Over three years, 350 troubling incidents — assaults, injuries, suicide attempts, escapes and sudden deaths — occurred at Washington’s six private psychiatric hospitals.

Yet, in the same time, the hospitals reported a total of only 15 “adverse events,” including suicides, escapes, sexual assaults and other assaults causing serious injury.

It is unknown how many of the 350 incidents uncovered by Times reporter Daniel Gilbert’s stunning investigation into the state’s behavioral health system ought to have been reported to state health officials. Even so, the catalog of incidents — mined from police, regulatory and court records, workers’ compensation data and emergency dispatcher notes — raise another set of troubling questions about Washington’s rapidly growing system.

Adverse event reporting is part of a Department of Health quality assurance process that is separate from inspections. It is intended as a tool for improvement; to document specific types of medical errors that may result in death or serious disability. State law requires health providers to notify the department within 48 hours of confirming an adverse event. Within 45 days, they must submit a report identifying root causes of the failure and outlining action plans to ensure it is not repeated. If adverse events go unreported, there is no assurance that such reflection or corrective actions have taken place.

Washington law explicitly prohibits using the reporting system to punish medical errors, but health inspectors may cite facilities for violations if, when reviewing internal incident reports during inspection, they discover events that should have been reported. The law does not establish specific penalties for noncompliance other than ordering the health department to “direct the facility to provide notification or to undertake an investigation of the event.”

Since Washington has no publicly searchable database for facility-level inspection reports or administrative actions, it would be extraordinarily difficult for the average person to determine whether a hospital had failed to report such a serious threat to patient health and safety, even if inspectors found the omission.


The Times has published many violation reports online as part of the investigative series, but the only way to examine a facility’s inspection history through the Department of Health is by making a public-records request.

Secretary of Health John Wiesman said in an interview that he is “appreciative” of the Times’ investigation and is committed to transparency. He said he agrees that inspection reports should be readily available for all facilities regulated by his department — including psychiatric and medical hospitals, and care facilities. A necessary technology upgrade was funded in the last legislative session but will take years to complete.

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As an interim step, staff members are working to post behavioral hospital inspection reports to the department website — a project he estimates will be completed before year’s end. Broader considerations of policy and enforcement are ongoing, including discussion with the governor’s office about short-term actions and a potential legislative proposal in 2020.

As soon as is practicable, health officials should invite the public into those discussions. Transparency is a key component of accountability. Patients, loved ones and Washington taxpayers deserve to know what’s going on.