Written by DRO staff members Janice Perciano, Rick Vachio, Jonna Schuder, and Bob Joondeph
This report is the result of an investigation into the deaths of five patients at Dammasch State Hospital between June 25 and October 8, 1993. The investigation was begun in response to independent complaints about each death. The report was released in the hope that it would bring attention to the conditions that contributed to these deaths and prevent future harm to Dammasch patients. Dammasch State Hospital was closed in 1995.
Disability Rights Oregon (then known as Oregon Advocacy Center, or OAC) is a private, non-profit organization which advocates on behalf of people with disabilities. As Oregon’s “Protection and Advocacy System”, DRO is authorized by state and federal law to investigate complaints of abuse and neglect of patients in treatment facilities. In the course of this investigation, DRO reviewed the patients’ treatment records, interviewed family members and spoke to any staff members who would agree to do so.
This report contains a separate section for each patient. Background information is supplied for each patient so that his or her death can be understood within the context of life at Dammasch. The details surrounding each death is then set forth, followed by questions that DRO believes still need to be answered and DRO recommendations.
dro staff who prepared this report are investigators and attorneys. They are not formally trained in medicine or psychiatry. Many of the questions raised by this report regarding appropriate clinical practices need to be answered by qualified professionals who are not affiliated with Dammasch. These tragic deaths deserve expert objective review at state expense.
While the circumstances of the deaths differ, systemic deficiencies at Dammasch affect each one. Factors such as staff instability, budget reductions, inadequate physical plant, and poor training and oversight contribute to conditions that endanger patients who present special needs. These problems are not new to Dammasch, but the hospital’s ongoing process of transitioning to a smaller institution has made them more acute and, in our opinion, contributed to the deaths of five patients.