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Danvers State Hospital

In 1989, a day program reported to the DPPC that X, a patient at Danvers State Hospital, appeared at their program with serious injuries. These injuries consisted of a bruise to the right cheek, a bruise below the right eye, right side of the jaw red and swollen, complaints of pain in right side of neck, left arm bruised on inner elbow (1.5 inches by 1.5 inches), a 1 inch bruise on forearm, left leg bruised on inner aspect of knee, left shin small bruise, right leg bruised and slight swelling in inner aspect of knee, 2 inch bruise on outer aspect of left knee, 2 inch bruise on outer aspect of right knee, red area on right shin, and a dark red mark over left eyelid under brow. The client stated that, while in restraints, he had been assaulted by a staff member at the hospital, first name A, last name unknown.


DPPC screened the case in and referred it to the Department of Mental Health (DMH) for investigation in accordance with the provisions of M.G .L. c. 19C §4(b ). DMH investigated the case, concluded that abuse had occurred, and immediately terminated the staff person.

Several months later, a DPPC investigator received a phone call from a staff member at the same state hospital. This person stated that the incident involving patient X was the third case of abuse by staff person A and the two previous cases, witnessed by senior staff at the hospital, had not been reported to DPPC. Commission investigators examined DPPC case files and confirmed that no reports had been received on the previous cases. The DMH Office of Internal Affairs was notified by DPPC that DPPC would conduct an investigation of the matter. DMH Internal Affairs also conducted their own investigation.​

A review of the DMH investigators' files and interviews with the DMH investigators revealed that, in fact, there had been two previous cases of abuse committed by the same abuser, Mr. A, on two other clients within weeks of the assault on patient X. Both of these prior incidents had been witnessed by hospital staff. Witnesses to the prior cases included direct care staff, nursing staff, and a hospital administrator, none of whom reported as required.


DPPC investigators reviewed the full hospital case files, interviewed the initial DMH investigators assigned to the case, interviewed staff witnesses to all three events, reviewed patient records, reviewed staff personnel records, and reviewed hospital memos and other records regarding the incidents. As a result, the following sequence of events was determined.

Incident 1:

Nurse D at Danvers State Hospital witnessed employee A escort a female patient to the quiet room. The patient, L, was not presenting difficulties. Mr. A pushed Ms. L into the quiet room from behind with both hands. Ms. L fell to the floor. Nurse D characterize the incident as abuse and indicates that she spoke to A about the incident and that she wrote a "verbal warning" to A about "unnecessary roughness". A copy of the letter was sent to the Assistant Director of Nurses. (Neither Nurse D nor the Assistant Director of Nursing reported the incident to DPPC or to other internal staff; nor was a complaint form filled out as required by DMH regulations.)


Incident 2:

Three weeks after the first incident, Mr. A was assisting in the restraint of patient H. Mr. H was tied to a bed at the time of the incident. Mr. A was pumping forcefully on H's chest. The Chief Hospital Supervisor, a registered nurse, witnessed this and told Mr. A to stop. Mr. A did not stop until his hands were removed by the Supervisor. This was also witnessed by another staff member, a Mental Health Worker III and supervisor on the unit. The Chief Hospital Supervisor stated in his interview that he could not decide if this constituted abuse, but later decided that it was and "wrote up" A; however, he did not report the incident to DPPC.

Incident 3:

According to the written complaint filed by a day program, this incident occurred in the evening on a ward porch. Client X and another patient were playing chess and were swearing at Mr. A. Mr. A then placed a "help" call, took off his glasses, pointed to the two patients and said "You guys, come here." The patients did not move. Mr. A then began throwing chairs and approached the two patients. Mr. A grabbed client X around the neck, at which point X fell over a chair. Mr. A then swung a chair at X, hitting him in the right knee. A fight then ensued in which the other patient knocked Mr. A to the floor. Staff from other areas began to arrive and restrained the two clients involved in the altercation and other patients in the area. According to Mr. X, while he was restrained to the gurney, Mr. A was kneeling on his face. According to other staff involved in the restraint, it did not require an excessive amount of force from the four to five staff to restrain Mr. X. Another patient who was present at the time stated that Mr. A smashed her head into the floor in the process of trying to restrain her and sat on her head when she was restrained. There was no evidence if the statements that she required restraint.

According to one staff who arrived at the scene, Mr. A was on top of a patient with his hands around the patient's neck and appeared to be "applying excessive force and endangering the safety and welfare" of the patient. This employee assumed that the person doing the choking was a patient and broke the choke hold because "I saw the danger". Mr. A screamed and said "I'm staff." Later in the incident the second employee also witnessed Mr. A straddling a patient's legs, whose arms were already in restraints, "twist the patient's left foot in a clockwise direction to the point of almost snapping. I yelled at him to stop." Mr. A then twisted the patient's other foot until the second employee again yelled at him to stop.


Ms. G, a registered nurse and Chief Hospital Supervisor, responding to the "help" call, found Mr. X on his back in a gurney in four-point restraint. "Four or five" MHW's were transferring the gurney to the corridor. Mr. X attempted to sit up, which he was unable to do because of the restraints. At that point, Ms. G observed Mr. A "jump into the air and land with his full body weight, left knee first, on [X's] mid sternum. Following that deliberate force Mr. [A] once again lifted his knee and with harmful intent forced his knee down on [X]'s chest in the mid sternum area. In both instances the force applied was severe enough to push Mr. [X's] back into the mattress." In an interview with DPPC investigators, Ms. G described the incident, "I've never seen anything like it. It was disgusting to see. Terrible." Ms. G did not report this incident to the DPPC.


 Two other staff involved in the incident signed statements that they saw no abuse.

Mr. A left work that evening saying that his wrist had been injured in the incident. Mr. A was not allowed to return to work and was terminated.

Danvers State Hospital

All of the staff involved in all three incidents are required by law to report abuse to the· DPPC. All of the staff involved are required by DMH regulations to file complaints whenever an illegal, dangerous or inhumane incident or condition occurs. None of the staff involved in any of the incidents called the DPPC hotline to report the abuse. None of the staff involved filed a formal complaint as required by DMH regulations. Some staff did report the matter to their supervisors.


If the first incident of abuse had been reported to the DPPC, an immediate investigation would have resulted, and the fact of an investigation would have possibly prevented the other two incidents from occurring due to the scrutiny and protective actions which an investigation would have brought. Had the second incident been reported, it is possible the third could have been prevented. However, it was not until client X arrived at an outside day program that an employee of that program acted appropriately, notifying the DPPC and filing a formal complaint with the hospital.


The DMH Office for Human Rights had prepared a video tape describing employee reporting requirements for abuse and other human rights violations. This tape was shown extensively to staff at Danvers State Hospital. In interviews with DPPC investigators, the staff witnessing the events indicated that, at the time of the incidents, they did not know that they should have reported the matter to DPPC. However, according to Danvers State Hospital personnel records obtained by DPPC investigators, the list of individuals recorded as having viewed the tape regarding DPPC includes two of the witnesses to the abusive incidents involving client X. Two of the witnesses are listed as having attended training on incident reporting. Two other witnesses are listed as having attended orientation training, which, according to staff interviewed, contained abuse reporting requirements. Thus, records show that at least five of the witnesses to the abuse of client X by Mr. A had, in fact, received formalized training regarding their reporting responsibilities, including DPPC reporting.


DPPC staff began investigating the failure to report matter at Danvers State Hospital soon after learning the extent of the abuse of Mr. X.


Approximately two weeks later, at the direction of the Danvers State Hospital Chief Operating Officer at the time, a memo was issued to all hospital staff which described in detail each employee's obligations to report abuse to the DPPC and to Elder Affairs (for patients aged 60 and over). At the time of the conclusion of the DPPC investigation into failure to report at Danvers State Hospital, DPPC investigators interviewed the then-Chief Operating Officer. The COO stated that the staff members who were involved and who failed to report abuse had been the subject of various disciplinary actions, including suspension without pay. He also stated that since the DPPC investigation began, staff were much more vigilant about their duty to report abuse. This was confirmed by a marked increase in the number of reports received by the DPPC from that hospital.


The DPPC review of this matter notes the high quality of the DMH investigations into these cases when finally reported, as well as the fact that DMH investigated the failure of the staff to report. The Commission further notes the exemplary actions of the Danvers State Hospital Chief Operating Officer to remedy the problem after the failures to report were revealed.

Disabled Persons Protection Commission. (1992).Boston, MA. 

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