Deep Dive into California's Mental Hospitals Reveals More Questions Than Answers

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Napa State Hospital where a staff member was murdered by a patient in 2010. (Lisle Boomer: Flickr) (Lisle Boomer via Flickr)

My nine-month investigation into California's state mental hospitals began with a simple question: "What happens to people found 'not guilty by reason of insanity' or 'incompetent to stand trial'?"

Turns out the answers -- and the issues raised -- are complicated.

This week marks a grim anniversary for Napa State Hospital.  Five years ago Saturday, hospital psychiatric technician Donna Gross was murdered  by a patient there. I focused my reporting in Napa, as opposed to the other four state mental hospitals (Atascadero, Coalinga, Metropolitan and Patton) because I wanted to know what impact Gross's murder had on the hospital and how security and policies have changed since then. I needed to talk to hospital staff, patients and their families to find out.

It wasn't easy.

In some ways Napa is a very troubled institution. And the trouble started long before Donna Gross was murdered.


In 2004, the hospital denied access to the U.S. Department of Justice (DOJ), which was investigating conditions at the hospital. The DOJ was looking at potential violations of the Civil Rights of Institutionalized Persons Act. Denying the U.S. Attorney General access -- that's rather astonishing. Despite this lack of access, the DOJ interviewed hospital staff and others and found, among other things, failure "to protect patients from harm and abuse."

In 2010, a few months before Donna Gross was murdered, the hospital's executive director Claude E. Foulk was fired after being arrested and charged with child molestation. He was later sentenced to 248 years in prison.

His replacement, Dolly Matteucci, was soon confronted with Gross's brutal murder by a patient, Jess Massey, who had been allowed to walk around unattended on hospital grounds even though he had a history of violence. He later pleaded no contest to one count of murder and is now in Corcoran State Prison.

Less than two months later another hospital therapist was severely beaten as he escorted a different patient on the grounds.

I reported earlier this week that since these incidents, there have been many changes at the Napa hospital:

  • Personal distress alarms with GPS replaced the old alarms, which didn't work outside where Gross was murdered
  • More hospital police have been hired
  • Policies have been changed to protect vulnerable staff, and
  • Gov. Jerry Brown signed AB 1340, which will allow Napa and other state hospitals to segregate the most dangerous patients and give them "enhanced treatment" -- including risk assessment for violent behavior and concentrated clinical therapy --  in a secure setting. Construction has not yet started on this additional housing.

It was in this context that I asked to interview hospital director Matteucci. At first I was told "maybe," then I was told she could only do the interview on the phone. After pushing, I was granted an in-person interview with her in the administration building "outside the security fence."

The hospital had more than 1,800 physical assaults last year. To be fair, "assault" can be anything from pushing away the hand of a nurse who's giving out medication to  getting punched or worse.

Yet it is patients, not staff, who are usually the victims of this violence from other patients. A small number of them cause most of the problems.

I wanted to visit the hospital and talk with a patient. The public information officer for the Department of State Hospitals told me I was free to write to any patient I knew was there (such as perpetrators of very high profile crimes, like One L. Goh, the shooter at Oikos University in Oakland in 2013) to ask if they would talk to me.  I knew this would be a long shot, so instead I reached out to the hospital's family support group. Eventually I visited Napa with Frank and Barbara Brackin, as I described in my story on Friday.

Their son Shawn ended up in Napa after a tragic incident in a Roseville. During an attempt by Shawn of "suicide by cop," he walked into a police station waving a gun. In the melee, a police officer shot and killed another policeman by mistake.

Shawn was found not guilty by reason of insanity and sentenced to time in a state mental hospital.

In the nearly 20 years he's been there, Shawn has been brutally assaulted, most recently in 2014 when another patient slammed his head into a wall so hard his hair was stuck in the wall. The Brackins are suing the hospital for failing to protect him.

One thing emphasized to me over and over is that people sent to state mental hospitals are patients, not prisoners. That means they have certain rights and privileges, even if they're violent.

I'll never forget my visit to Napa with the Brackins. It felt like I had entered a kind of "forbidden zone" where outsiders rarely went.  And meeting Shawn after hearing so much about him from his parents was very poignant.

On my visit, we were met in the parking lot by a media representative from the Department of State Hospitals. We were warned not to videotape or photograph the barbed-wired security fence, the tight security at the main gate, or people coming and going (including reporters, like me).

We passed through multiple locked gates, doors and a metal detector before we were told to surrender cell phones and wallets.

I was warned not to talk to or interview any other patients. I was asked to turn over my audio recordings of Shawn Brackin so the Department of State Hospitals could review them to make sure he didn't say anything compromising the privacy of other patients. I negotiated a much more narrow accommodation.

I was also denied any access to record audio of music therapy classes. I was told this could jeopardize patient privacy.

I found all these requests to be overly strict. I've been to numerous state prisons, including San Quentin. The Department of Corrections has allowed me to freely photograph the gate, inmates, the cell blocks -- pretty much anything except Death Row.  I have attended classes, religious services and therapy classes and was allowed to record, videotape and take photos.

To keep us away from other patients at Napa (who were meeting with family members nearby) the four of us were escorted to a tiny (perhaps 10 feet by 10 feet) room with no air conditioning and no apparent ventilation. (I was told this is where attorneys can meet privately with patients and their families.) At one point Shawn, who appears to have severe brain damage from assaults he suffered at Napa, asked to open the door to let some air in.

But not all families criticize Napa. Some say their loved ones are finally getting the treatment they should have gotten in the community before they committed tragic crimes.

And even strong critics acknowledge there’s a role for state hospitals to play in our criminal justice system, especially for violent defendants.


But some advocates for the mentally ill say we need to make more treatment available in the community whenever possible -- rather than in locked state hospitals like Napa.