Of Patient Safety. And/or, the lack thereof in terms of the substandard care practices and conditions at The Arizona State Hospital.

With all of the attention currently being directed to the fact that the senior psychiatric staff at The Arizona State Hospital have engaged in creating highly unsafe conditions at ASH that have led to thousands of staff and patient reports specific to the harms caused by this crisis, I felt it might be useful to recall the following.

I am a man affected by major depressive disorder. This condition initially manifested in my personal life when I was an adolescent. It was not until I was in my late 30s that the worst elements of this condition arose to such an extent that my personal life affairs began to unravel, and another decade before I was willing to turn to the public behavioral health care system in Arizona, this after I had survived several serious suicide attempts, and other like impacts of my diagnosed mental illness. My diagnosis, as such, has nothing to do with my actual character as a person. I have never been involved in any nature of serious criminal behavior, although I was cited for misdemeanor DWI in 1999. As importantly, I am in no way a violent man, and in fact have embraced peaceful approaches to conflict resolution for as long as I can remember. Relatedly, the presence in my childhood history of physical and psychological abuse does underlie my absolute distaste for violence as an adult, and also has direct bearing on the manifestation of mental illness in my life.

In this context, in the first 8 months of my time hospitalized in Arizona's public behavioral health care system (pre-ASH), the fact that I am a non-violent and in fact passive man was clearly established by my primary care physicians, an aspect of my character that did become a central feature in my formal medical records to that time. The primary psychiatric doctor who referred my case (and me) to  The Arizona State Hospital in late 2011 was well aware of this fact, and we discussed the optimum possibilities that I could reasonably expect once I was formally admitted to ASH, including my right to be treated in the most reasonably safe setting that might be available at ASH. In determining this possibility, that doctor (David Stoker) directly communicated with ASH's chief medical officer at the time (Steven Dingle) in order to ascertain what ASH could offer a man like me, with all aspects of my diagnosed needs and related personality/behavioral traits in mind, and he was advised that upon my admission to ASH, I would be placed into the most peaceful unit at ASH, as per these needs, etc. 

I was admitted to ASH on January 11, 2011. I was placed on the Palo Verde East unit at that time, and my first attending psychiatrist (Laxman Patel)  confirmed the fact that Dr. Stoker had requested I be placed on that unit, as per his communications with ASH prior to me transferred there. During the course of my first treatment team meeting at ASH, Patel stated in no uncertain terms that I had been directed to his care on the Palo Verde East unit as a direct result of these communications, saying "I am aware that you are a nonviolent man, and as per your referring doctor's wishes, we have placed you on this unit in order to keep you away from our most violent patients."  It was that simple. Or so I thought. 

On September 05, 2011, an Arizona Department of Health/Behavioral Health Services human rights advocate named John Gallagher submitted a formal grievance report on my behalf that identified a very questionable process of intimidation and coercion that a small range of ASH staff had imparted upon me in order to force me to do something I was not comfortable with, namely, to sign a legal document that I was not comfortably familiar with. Involved staff include Dr. Steven Dingle, Dr. Pervaiz Akhter, Dr. Lynn Lydon, and ASH's legal counsel, Joel Rudd.

On September 06, 2011- one business day after the submission of the above described grievance document- I was informed that I was to be transferred from the Palo Verde East unit, which I have already described as the most peaceful treatment unit at ASH, to one of the most violent, Desert Sage East. I was placed in a room with immediate adjacency to one of ASH's most infamously violent patients at the time, Joe Gallegos, who is now serving a life sentence in the AZ corrections system for bludgeoning to little boys to death, a case that I had no awareness of  when I was at ASH. There were also a number of other very violent men housed there on Desert Sage East, and as soon as I was relocated there, I found my myself repeatedly exposed to ongoing threats, actual assaults, and even an unabashed willingness of at least one charge nurse on that unit (Tracy) to subject me to patient aggression (including one very violent assault) in order to "keep (me) in line!" It was that bad, it was that obvious as a form of standard practice at ASH, and no degree of effort on my part to relate my fears and ongoing harms in this context made the slightest difference.

 And I can prove it.

I remained on the Desert Sage East unit the for remainder of my time at ASH. For the entirety of that phase of my experiences at ASH, I was constantly exposed to ongoing threats and related patient attacks that I contend were instrumented by ASH's highest ranking clinical and administrative staff. Instrumented as a means of direct retaliation for my having taken good faith action to expose the wrongdoing that I witnessed and personally experienced at ASH since the day I arrived there- literally (upon my admission to ASH on Jan. 11, 2011, a full and unopened bottle of prescribed medication that just so happens to have high street value was stolen from my property by some or another of the ASH staff who handled my admission at that time). Such tactics are utilized by many ASH staff in every imaginable way, but in this case, the evidence applies to the misconduct of some of ASH's highest ranking administrative and clinical staff, grossly egregious misconduct that occurs in utter defiance of all/any directly applicable state and federal law. And the only reason these people get away with it stems from the fact that the patient community at ASH are highly vulnerable to such forms of discrimination as a direct consequence of disability. It is that bad, and 100% consistent with the history of places like ASH. Bottom line.

IN CLOSING: By the time the associated issues in this matter played out in fall-winter 2011-12, even the brand new ASH supervisor, Cory Nelson , had become involved. I documented virtually all elements of my experiences at ASH in my records, and of course have full records specific to the details I have shared above. 

paoloreed@gmail.com