Report Assails VA Psychiatric Unit Over Five Suicides : Health care: An investigator says the Long Beach facility failed to recognize dangers to patients. He says the ward functions today ‘in name only.’

An investigator studying conditions at the Veterans Affairs Medical Center in Long Beach concluded in a preliminary report that the hospital’s psychiatric unit failed to recognize when suicidal patients were in danger and neglected to review their cases after they killed themselves.

Psychiatric patients at the hospital were committing suicide on the average of one every three months, but the death rate apparently “escaped the notice” of administrators at every level at the hospital, according to the investigator’s report obtained by The Times.

The hospital’s revamped locked psychiatric intensive care ward, where the most disturbed patients are to be kept safe from themselves and others, functions today “in name only,” said Dr. Donald E. Widmann, a consultant hired to investigate the suicides.

The intensive care unit--reopened in July with fewer beds, retrained staff members and new supervisors--still does not serve the needs of those who are suicidal, violent, homicidal or gravely disabled, Widmann said in his report. He criticized doctors at the unit for weeding out the sickest and sending them to a nearby private hospital for care.

Widmann, who could not be reached for comment, prepared his report in conjunction with an investigation ordered by the Department of Veterans Affairs in Washington last spring after The Times reported that five psychiatric patients had committed suicide between March 22, 1989, and April 17, 1990--four of them on the hospital grounds.

“It is all the more surprising,” Widmann wrote, that the growing number of suicides “appears to have escaped the notice of all levels of hospital administration until the issue was raised by the press.”

In a little more than a year, one man wandered away from nurses and jumped off a hospital roof, two patients hanged themselves with bed linen and a fourth shot himself in the mouth at his desert home after the hospital allegedly refused to admit him. When the fifth man died--a troubled 27-year-old Marine who hanged himself with the laces from his combat boots--alarmed staff members began to complain that the psychiatric unit was in chaos.

“These reviews are helpful and we welcome the review teams coming here,” medical center spokesman Gabriel Perez said Monday in response to Widmann’s findings. He said the psychiatrist’s preliminary report was being examined by hospital administrators and that the findings “will be acted upon.”

Widmann is part of a three-member team assembled by the VA’s Office of the Inspector General--the agency’s investigative arm--to probe the psychiatric unit and its suicides. The other two members, a VA nurse and an administrator, spent three weeks at the hospital in May.

Widmann, the only psychiatrist on the team and the only member not affiliated with the VA, spent three days at the hospital in late July and submitted his early findings last month. No results have been made public.

A reference in Widmann’s report suggests that his team members are equally critical of the hospital’s failure to keep patients safe, saying that the hospital apparently failed in its duties to flag the suicidal tendencies of its patients.

In his own highly critical, 17-page report, Widmann concludes that the hospital’s oversight committee, set up to ensure high-level care, never reviewed the suicide rate that experts have since called alarming.

State officials have said that the five suicides recorded at the Long Beach hospital in 13 months equals the number reported at all five state mental hospitals in two years’ time.

“It apparently did not occur to anyone that there might be a need for a . . . standardized process for the assessment of suicidality of all patients, especially once the patient had voiced suicidal (intentions) to staff or had made an attempt,” the report says.

Widmann likened the locked ward where two of the men died to a “tight little island” with a forceful chief nurse, a divided staff and an atmosphere occasionally hostile to patients who did not “fit in.”

That ward--part of the psychiatric unit at the 1,368-bed medical center, was abruptly shut down in May for six weeks to retrain the staff and upgrade equipment. It reopened in July with new leadership, one-third the beds and the administration’s promise of the “highest-level care.”

Widmann said problems persist today: The new head psychiatrist’s experience is superficial; the most gravely ill patients are transferred to a private hospital for care at federal expense; and a television monitor set up to watch patients in seclusion displays shady images at best, with no staff member assigned to monitor it.

Psychiatrist Steven Johnson, who took over as the locked ward chief in July, took exception to Widmann’s findings, saying the leadership is well-trained and that gravely ill patients are transferred only when the ward’s 10 beds are full.