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Safety Flaws Found At Western State Hospital

John Ryan

Investigators have found multiple safety problems at Washington state's largest mental institution. The inquiry into conditions at Western State Hospital was prompted by the violent deaths of two patients there this spring.


The national hospital–accrediting group known as the Joint Commission started looking into safety at Western after a suicide and a murder inside the mental hospital's walls in April.

The Joint Commission highlighted a dozen different ways that Western failed to meet national standards for keeping hospital patients safe from harm. Those included chronic understaffing, failures to monitor patients properly, and unsafe doors.

With too few nurses and psychiatrists working each shift, patients were able to harm themselves or their neighbors unseen.

Western officials had determined in 2010 that hundreds of door handles and those closing mechanisms above each door could be used by patients to hang themselves. Western officials say they requested but didn't get enough funding to address the problem at the time.

The hospital did begin to replace problematic door handles last October. But hundreds of dangerous doors were still in place this spring. A 20–year–old patient hanged herself from her door in April.

Ryan: "I guess my question is why would a mental institution have doors that people can hang themselves from at all, in the first place?"

Ando: "I think that's an excellent question."

Sandi Ando is with the National Alliance on Mental Illness in Spokane.

Ando: "It's very easy to become complacent sometimes until these tragedies happen. I think that's not the only safety issue that's in our state institutions. The fact is at some point, when we're looking at being penny–wise and pound–foolish, very often, human tragedy can ensue."

Western State Hospital CEO Jess Jamieson says the hospital has been working full–bore to fill its vacancies and finish upgrading its dangerous doors by the end of next month. He says the hospital is also exploring adding more hallway mirrors so nurses can keep an eye on more patient areas. But he says there are always tradeoffs.

Jamieson: "It's a hospital where we respect the privacy of our patients on their road to recovery. And then we need to balance that with our ability to observe people and make certain they're safe and actively engaged in their treatment as well."

The Joint Commission will conduct an unannounced follow–up inspection this summer to see if Western has made the safety improvements it has promised to.

I'm John Ryan, KUOW News.

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