Nobody stopped Bill Turnbull the night he turned himself into a battering ram and slammed his head repeatedly into a concrete wall.
Nurses and aides at the Minnesota Security Hospital stood and watched — in fear for Turnbull's life, but also in fear for their jobs if they dared to intervene. A state hospital once infamous for the overuse of patient restraints was now under new rules. To restrain Turnbull, they would need permission from their supervisor. But when they called her at home, records show, they were turned down repeatedly, and his ordeal went on until dawn.
The events that unfolded that night in August 2012, detailed in licensing reports and other documents, reflect breakdowns in patient care that continue to shadow the state's largest psychiatric hospital, Minnesota's core treatment facility for the mentally ill and dangerous.
Nearly two years after the hospital's professional psychiatric staff departed in a mass resignation, the state still has not hired a full complement of psychiatrists, documents show. Basic medical record-keeping has been neglected, employees have been placed in danger and patients have been discharged with inadequate safeguards, according to internal memos, federal records and agency files reviewed by the Star Tribune.
Dysfunction at the hospital, a sprawling facility that houses more than 300 patients on the outskirts of St. Peter, Minn., has rippled through the state's mental health system, contributing to backlogs in patient care and delays in court placement of the mentally ill. "The hospital infrastructure to care for the most sick and most dangerous people in Minnesota is broken," said Dr. Jennifer Service, who resigned as the hospital's medical director in 2012.
Top officials at the state Department of Human Services (DHS), which operates the hospital, say they're making progress, rebuilding the staff and changing the culture. Over the past four years, they note, more than 130 patients have been discharged and only 24 were ordered back by a judge, an indication of successful treatment. This year, 48 patients were discharged, records show.
"We've made some progress, but every time something isn't done in an exemplary way, we'll report it," said Deputy Commissioner Anne Barry, who now oversees reforms at the hospital. "The leadership feels strongly about accountability."
Barry says her mandate is to restore public confidence that Minnesota's most challenging mental health patients will receive the care they deserve and have realistic hopes of being discharged into stable living arrangements. "We want a more therapeutic environment, and we want to work on getting more capacity in the communities so that they have stable places to live," Barry said. "We are showing that people can recover and they can move on. For a long time we were not moving."