A Seattle Times investigation into the death of 78-year-old Rosemary Torgesen revealed the human agony of our state’s inadequate behavioral health services network. It raises questions and reveals system weaknesses not directly addressed by recent state commitments to behavioral health.

The investigation revealed poor record-keeping, chronic short staffing, and repeated violations of other standards for patient rights and safety at Smokey Point Behavioral Hospital. These shortcomings at the Marysville facility were the subject of repeated complaints and noted by government inspectors during 12 visits over 15 months.

But, of all the investigation’s troubling details, this should spark immediate action: “The Torgesens couldn’t have known that a week before Rosemary was admitted, in March 2018, state inspectors had found problems so grave that they created a ‘high risk of serious harm, injury and death,’ ” the article states.

In fact:

  • State regulators do not notify patients or families when inspections uncover problems, even for repeated or serious violations of patient health and safety standards.
  • Nor do they maintain any publicly searchable database for facility-level inspection reports or administrative actions. The only way to find out a facility’s inspection history is through a public-records request.

Such information should be freely available, both to help families and patients make informed decisions and as a measure of public accountability.

State Department of Health officials say they are discussing the idea, along with other potential procedure and policy fixes. They say inspectors followed proper procedure, evidenced by their frequent inspections and requirement that the hospital hire an outside consultant, approved by health officials, to provide oversight and identify deficiencies.

“Unfortunately in the case of Smokey Point, they’ve gone in and out of compliance more than other facilities,” said Kristin Peterson, assistant secretary of the department’s Health Systems Quality Assurance Division. A Smokey Point staff member referred an editorial writer’s request for comment to HealthVest’s corporate office, which did not respond.

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Clearly, patient safety and current standards of care must be regulators’ chief concern. But other questions cannot go unanswered. Namely, whether hospital management intentionally operated with insufficient staff and knowingly admitted medically fragile patients it could not properly care for, and whether officials properly vetted hospitals’ owner-operator, US HealthVest, before allowing the hospital to open its doors. The attorney general’s office declined to comment about whether it is investigating the incident. It should. In addition, the state’s chief law enforcement officer should hire an independent investigator to determine whether the Department of Health did its job. An AG spokeswoman referred to the Health Department as the AG’s “client,” almost as if that is a higher purpose than protecting the public. Who is watching out for the public here?

Finally, state lawmakers should take a hard look to ensure that regulations, oversight and workforce requirements are keeping up with the state’s rapidly growing system. For example, they should consider whether staffing requirements are specific enough to safeguard patient safety and ensure that free-standing hospitals are assuring integration of psychiatric and medical care.

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Last session, legislators made the most substantial investment in the behavioral-health system in at least a decade. It will take years for some of those investments to come online and yield results. A new 150-bed unit and psychiatric teaching hospital is in planning stages, for example. Funding and construction of facilities are only the first of many steps.

The system is in many ways unfinished, so all due care must be taken in development and oversight. But public information and transparency are critical.