Arizona State Hospital Facts of Life #3. Systemic Abuses of Authority and Breach of the Public Trust. Of overt retaliation and grossly unlawful subjection to grave risk of harm on the basis of patient generated advocacy. 

Since her appointment to the highest ranking position in Arizona’s public health care system in 2015, Arizona Department of Health Director Dr. Cara Christ has repeatedly stated that there have been “great improvements” in the state’s sole long term public mental health care facility, Arizona State Hospital (ASH). To date however, January 2018, Dr. Christ has never provided any evidence or information about just what these “improvements” at ASH are, in fact. This is of very real concern to the staff of this publication, given that Dr. Christ’s immediate predecessor (Will Humble ADHS Director 2009-2015) willfully relied upon producing a pattern of overt and untruthful propaganda that served to delay a subsequent process of critically needed oversight and accountability at ASH. Propaganda that defied the realities specific to the ASH operation, including but not limited to several preventable patient deaths, the tragic murder of a young Phoenix woman, and the suppression of a wide range of patient generated concerns expressed in grievance submissions; as such, granting the former administrators of ASH further opportunity to continue operating ASH in a manner deeply harmful to the welfare of the Hospital’s patient community. 

These issues have been exemplified by the information provided in this blog since 2012, as well as in a number of scathing investigative findings of the staff of ABC Ch15 circa 2013-2015. The following article was originally published sometime in the first twelve months of the life of this blog, PJ Reed The Arizona State Hospital Patient Abuse. We are republishing this information as one means to remind our readers of how dismally substandard the operation at ASH was circa 2010-2012, and in order to raise consideration as to whether in fact any legitimate improvements have in fact come about since Dr. Christ was granted directorship over Arizona’s public health care system.

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I don't want to risk being overindulgent in terms of simply bitching and moaning about my personal opinion about the Arizona State Hospital (ASH). It's a safe guess that nobody in their right mind (no pun intended) would find much pleasure in being hospitalized for 13 months, and of course, no hospital is perfect. But indeed, ASH is like no other hospital that I have ever spent time in, and this includes the other psychiatric hospitals I spent time in prior to my arrival at ASH. In my opinion, ASH is nothing short of a safe haven for abusers and incompetents, truly a place where otherwise unemployable mental health professionals can go in order to get away with all sorts of unlawful conduct. I have in recent weeks come upon a number of well researched critiques showing that state mental hospitals  are "snakepits" for patient abuse and substandard practices, as follows:

              "Numerous state psychiatric hospitals have recently been exposed for violations and/or deficiencies in patient care and safety, including several that have come under U.S. Department of Justice (DOJ) investigation. The reports show that these facilities are not safe, sanitary or rehabilitative places." (S. Wagner, Director of Litigation and Prosection, The Citizens Commission on Human Rights. November 24, 2007)

The time has come for the citizens of Arizona to be made aware of the vast irresponsibility of ASH administrators and clinicians. Each and every patient at ASH is  a human being, and as such, somebody's son or daughter, father or mother, brother or sister, and so on. To allow the wrongdoing to continue is simply wrong, and I encourage anybody who is interested in looking more closely at these issues to get in touch with me. I have a very reasonable body of sound evidential material that supports all aspects of my allegations, and in time, I will do what I can to get it all on-line.

But at the moment, as a matter of getting to the meat of my current situation as a recently discharged ASH patient who has ongoing business with the rat bastards who are most responsible for the wrongdoing there, I am going to sum up four important examples of my experiences at ASH, as follows via ASH Facts of Life #3:

Fact #3) Willful unlawful retaliation; criminal abuse of administrative authority; abridgments of internal codes of policy and procedure; blatant denial of patients rights, privileges, and liberties as defined by federal and state law; willful exposure to undue threats to safety; complicity and intent to do harm. 

(Originally published April 09, 2012.)

INTRODUCTION: Arizona State Hospital administrators, physicians, nurses, and behavioral health technicians will as often as not openly abuse the rights of their patients in order to preserve substandard practices, rather than risk being held accountable for their wrongdoing The problem is systemic and endemic in all senses, and no matter how much good faith effort any one patient puts into trying to address wrongdoing when it occurs, Hospital staff will engage in systematic suppression of and even retaliation against that patient for taking such action. 

In my first six months at the Arizona State Hospital, circa early January 2011-June, 2011, I was pretty freaking amazed to learn that not only were there constant occurrences of staff misconduct at ASH, but even more so that my good faith efforts to report the worst of the things that I witnessed or experienced first hand were only leading to clear resentment and overt retaliation from numerous members of the staff most close to my flow of treatment during that period of time. Initially, I very ignorantly presumed that my reports would be appreciated by the higher ranking staff that I sincerely cooperated with via the suggested procedures in this regard. But even my first primary attending psychiatrist, Dr. Laxman Patel, openly tried to dissuade me from reporting wrongdoing, which in fact created a conflict specific to conscientious between the two of us. The whole experience was mind blowing at times, and my ability to comprehend how it is that such substandard practices could still exist given the many years of health care reform specific to state mental hospitals, etc., was very limited from day one.

In time, I made the choice to remain actively dedicated to advocating for myself as well as on behalf of all the patients at ASH, by doing all that I could to report wrongdoing in as loud a manner as I could muster given my circumstances. Please note- before I continue with my summary descriptions of some of the ongoing grievance issues- that I am still trying to meaningfully resolve the fact that on a day to day basis, I experienced myriad incidents involving a variety of patient abuse, often fairly low key stuff, but too often events that clearly bordered on brutality and blatant criminal conduct. The plain fact is, I found it impossible to go about my day to day treatment without encountering some or another form of unlawful conduct. It was really bizarre at times how rampant the incidents cropped up. All the while, I was doing what I could with the minimal resources afforded patients to keep up my best efforts as self advocate, and it was very trying, at times, because many staff members became aware of my efforts in this context, and I was thus challenged and even harassed by staff in ways that I know would shock any reasonably ethical person. Such staff members very clearly resented the fact that I was not willing to simply ignore the crap that I saw and experienced, and I came to realize that the issues as a whole are endemic to the very culture of ASH employees.

The accounting of these grievance issues is rather long, and hopefully not too convoluted or otherwise onerous in terms of reading them. That said, I very much appreciate any time and energy taken to consider the full breadth of my concerns as they stand today. The wellbeing of the patients still at ASH, as well as anybody effected by the shortcomings at ASH or throughout the state managed care system, is very much at stake.   

As described above in Arizona State Hospital Facts of Life  #1, an advocate from the state office for human rights initiated and  prepared a formal grievance on my behalf in relation to the events of late May, 2011, wherein I was unlawfully subjected to coercion, undue restriction, and other like administrative misconduct. He conducted a very well founded investigation, and in late summer,  submitted the grievance in the form of a  lengthy document containing very serious and well researched allegations specific to the matter, including elements of wrongdoing that featured the actions of Dr. Pervais Ahkter and ASH Chief Medical Officer, Dr. Steven Dingle. 

ASH received this grievance document on Friday, September 2, 2011. Only four days later, on Tuesday, September 06, 2011, which was one business day (due to the Labor Day holiday) after ASH had received the grievance document, I was advised in a very short letter signed by Dr. Dingle, as well as the new ASH Chief Executive Officer, Corey Nelson, that I was being moved from the unit on which I had been accommodated to that point (Palo Verde East unit, for a total of seven full months) and over to another unit (Desert Sage East unit).

No explanation for the move was provided to me nor to the most critical members of my treatment team, which flies in the face of requisite hospital procedure and several provisions of the Arizona Administrative Code; and no consideration at all was granted on my behalf in terms of how the move would be therapeutically beneficial to me, which essentially contradicts the basic mission of legitimate medical practice, and is also in violation of not only hospital procedure, but of state law, as well.

By virtue of this questionable action, I was to be assigned an entirely new treatment team, including a new primary attending physician (thus removing Dr. Ahkter as my psychiatric doctor), medical (physical) doctor, social worker, rehabilitation therapist, and so on; and any concerns  that I raisd about continuity of care were also discarded for no justifiable reason.

But most significantly, the move amounted to me being physically removed against my express wishes from Palo Verde East unit, which is without doubt one of the most peaceful units at ASH and an environment where for over 7 full months I had established healthy peer relationships with patients and at least some staff, and transplanted to Desert Sage East unit, which is without doubt one of the most violent units at ASH.

Now, I did not initially realize that Desert Sage was so violent at first, and I was somewhat willing to trust the patient advocate and several other staff members who (I realized later) lied to me by advising me that Desert Sage East unit was both quieter and more peaceful than Palo Verde East. I knew already that I was placed on Palo Verde East unit upon my admission to ASH in late January, 2011, as per good faith discussions that my attending/referring psychiatrist in Tucson, Dr. Stoker of University of Arizona Medical Center, had conducted on my behalf.  In those discussions, and before the decision to send me to ASH had been made, Dr. Stoker had talked to me about the possibility that ASH could be a dangerous place, and he assured me that he had been in touch with ASH administrators, who had in turn assured him that ASH was set up in such a way that consideration was always given to the established personality and behavioral characteristics of incoming patients. Specifically, ASH had told Dr. Stoker that there were units designed to accommodate the more peaceful patients (vs. the more violent, etc.), and based on my characteristics, Dr. Stoker had very clearly directed ASH to place me in the most peaceful setting available. And indeed, in the seven months that I was on Palo Verde East, I had not been physically assaulted in even the slightest degree except by the rogue staff technician Elaine Traylor (see ASH Facts of Life #2).

But, again, I was not initially aware of the violent atmosphere on Desert Sage East. As matter of practicality, I was preparing to file a grievance merely relating to the fact that no explanation had been offered to me concerning why I had been transferred to Desert Sage East, or how the move would benefit me therapeutically, because it was very, very obvious from the timing of the move that it had everything to do with the grievance document that had been submitted on my behalf exactly one business day before the decision was made to move me.

All in all, as I saw it, the action was arguably wrong enough that it deemed at least some attention. And within 48 hours of my arrival on Desert Sage East, I was very seriously threatened by more than one patient on my new unit, and my concerns about the reasons underlying the transfer from Palo Verde East greatly deepened as I came to realize that I had been purposely placed in an extremely dangerous environment where the likelihood of me being attacked and possibly gravely injured was higher than any I had ever experienced, and only aggravated the well reasoned fear that I had about the staff sanctioned, radically dangerous conditions at ASH. The atmosphere on Desert Sage East is like night and day in comparison with the conditions on Palo Verde East. From the get go, e.g., there were men on the unit openly selling and arguing about illicit substances, including several who recognized me and openly resented me because of my prior involvement in advocating against the presence of illicit substances at ASH (see this blog “Of greed, contraband, felonious violations of state and federal law, and patient health” January 01, 2018), an activity that I had engaged in with full cooperation from Arizona Department of Health Services Office of Human Rights officials, and to my knowledge, ASH' administration was fully aware of that activity, which implies that they were fully aware of the hazard posed to me on Desert Sage East unit by such individuals. I was certainly aware of it, and I made this clear when I was advised that I was to be moved to Desert Sage, but the ASH patient advocate, Sonya Serda, ignored my statements to that effect.

I was also subjected to some very disturbing staff misconduct almost immediately after I arrived on Desert Sage East, including one situation wherein a clearly unstable staff nurse named Tracy literally incited several patients into attacking me, one of whom violently struck me on the shoulder, while another began a process of verbal harassment and threats that continued on for months and eventually led to the same man being criminally charged after he attacked me on the patient mall (this, too, another story in itself for a later time, wherein ASH staff went out of their way to try and and alter the truth of the incident in order to invalidly implicate me). This nurse openly stated to the involved patients that “This guy is out to get us all in trouble!”, at a level of volume that literally echoed throughout the whole unit. As stated, this incident was mind blowing, all but out of my comprehension, and consistent with the wider scope of issues that we will publish in due time.

On a more specific note clarifying the danger posed to me in this matter, I very recently learned that a man on Desert Sage East named Joe Saucedo Gallegos, whom by virtue of this unlawful unit transfer I was forced to share a bathroom with for the majority of my time on that unit, had in fact brutally beaten two young boys to death with a baseball bat only a 18 months years earlier in time. Gallegos was one of the patients involved in distributions of contraband that I know was smuggled into ASH by Hospital staff, and for the entirety of my time on Desert Sage East unit, he constantly and openly threatened me with physical harm and otherwise harassed me well to the knowledge of ASH staff.

Following my February, 2012, discharge form ASH, Gallegos was taken into custody by law enforcement and is now serving two life sentences in the state prison system.

IN CLOSING: These things did occur, as described, with respect for my thoroughly documenting such issues in my journal notes while at ASH. I am being 100% truthful about every aspect of this accounting. The good faith and entirely lawful self advocacy that I began engaging in at ASH as a matter of surviving the horrendously corrupt conditions there compelled ASH clinicians and administrative officials to subject me to malfeasant retaliation that put me in grave danger for my life, not to mention my state of mind as a patient. The basic fact that this whole process was carried out in such unbridled fashion only furthers my basic position that the conditions at ASH are absolutely out of control, and that the situation is deserving of nothing short of federal intervention. That said, I am again willing to offer my sincere plea for support from anyone who shares my concerns for the rights of mentally ill persons in the state of Arizona, with particular respect for the clearly egregious conditions at ASH. This has to stop, now. If you feel you are up to it, get in touch with me, please. 


(a)Retaliation

No person shall discriminate against any individual because such individual has opposed any act or practice made unlawful by this chapter or because such individual made a charge, testified, assisted, or participated in any manner in an investigation, proceeding, or hearing under this chapter.

DATELINE 2018: The Americans With Disabilities Act (ADA), U.S. Code 42 $12203 expressly prohibits retaliation or coercion in relation to any individuals included in that "special class" (disabled under state and federal law) who has cause to complain in any formal fashion about the care practices of medical providers (and/or the conduct of employers). Specifically, this is stated as follows: $12203 (a) "Retaliation. No person shall discriminate against any person because such individual has opposed any act or practice made unlawful by this chapter or because such individual testified, assisted, or participated in any manner in an investigation, proceeding, or hearing under this chapter." Unfortunately, I was not familiar with the provisions of the ADA during my time as an ASH patient, in large part due to me only being included in said special class after my discharge from ASH in February, 2012; had I been, I would have taken this issue further to task at that time. Knowing as I do the existence and significance of this law, I can only declare it a matter of good fortune that ASH administrators were not formally investigated by the US Department of Justice, which has full authority over the protections afforded to disabled Americans, as defined by this congressional act.

paoloreed@gmail.com