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• • • • • •

-Senate. January 20. 1983.

RE 0 PECIAL ~J."'.LL",."",,,,A~.a:",

roo ........TATE EST ATE ORnE O. 1'7810 1 o TRECE TLYRE

CONTINUED BY SENA NO. 1988 OF 1982) TO ."&.l"...a..~

INVESTIGATIO T AND STUDY 0 CIRCUMSTANCES SURRO DING COMMITMENT OF VERNAL W "l4Y\vn

TIIENORTHAMPTONSTATEHO P 19'74, IDS RELEASE, THE UBSEQW"T'W>'O''''T'''

MURDER OF ARNOLD ZELEZNICK MIAMI, FLORIDA, AND RELATED

MATTERS

Senator Pa ci

nator

elLoPreSenator

senator Arthur Lewis

Senator P er ebber

co TTEESTAFF

Gregory Torre ,Staff Director Eliza th Creme CommIttee O>unsel Rita D Giovanni, soclate Counsel Joanne yers, Secretary Mark Fo~ere. Intern John Wilson: -Intern

8 '~ENATE - 0.1822. [ r.

Arthur LeWis of Suffolk,and Norfolk; and Senator Peter Webb r of Berkshire.

BACKGROUND AND METHODOLOGY After severafplcinn1ng m~tingsin March_and April of this year.

Spec1a1 Committee decided to pro~eedin two phases: (1) PHASE ONE ,

It was agreed that the first phase of the Special Olm­~tt~e's investigation would focus solely on e 1974 release

. of Vemai WaIford-trOm-the1'l'OTthampton'State HospitaL.As. such, the Committee planned first, to reco struct the cir­cumstances surrounding the release through the

.examination of witnesses in public hearings; second, to determine the appropriateness of the release; third, to use the Walford case as a "window into the system" in place during 1974 and examine matters of policy. procedure, and

, overall facility management; fourth, to de ermine whether the Walford case reflects a breakdown in the decision-. making of ,..several individuals or whether it is indicative of systemic flaws which may remain unaddressed and have implications for the future; and, fifth. to review the internal investigation of the WaUord case conducted by the Depart- ' ment of Mental Health in january of 1975. ,It was further agreed that the Committee would complete the

-----~Dha.se__eHein¥eStigaUon an.!! issue its findings and con­clusions prior to initiation of Pha e Two. (2) PHASE TWO . It was agreed that the second phase of th,e Special Com- '

'm1ttee's investigation would focus on the present practices of . . the Department of Mental Health. particUl~lyas they rel~te

to the commitment, treatment, and release of potentially dangerous and assaultive pat1ent~ by the Commonwealth's

- state hospital system: , The Committee then proceeded with the hiring of staff, the

identification of witnesses, a review of documents, the develop­mertt of Rules of Procedure (see appendiX I) for the investigation.

. and preparation for a series of stenographically recorded public hearings.

Beginning in June, the Committee held a series of eight full d~y

J:1e , seven of which were held in Boston and one which was held at. the Northampton State. Hospital. A list of witnesses who

1

I the facility. to inform that he had igned c ( ote: According to day. to evalua e Word. If, determined to be a dang r to h elf or 0

Omental 1llness, the hospital ould then petition for an involuntary ocommitment. The pe 1t1 n patient from leaving the hospital until after h c the Court).

Meanwhile, the I}ursmg staff, . ho had witn assault by Walford, attempted to convince 0

transfer Walford to M.e.I. Bridgew t r. Altho ch a er was clearly permissable under th I w, the recommendation of the nur ing staff was denied.

Walford's physician, who assum d that a three day notice had actually been submitted. began to discuss the possibility of release with the patient.

Although Walford spent the rest of the day and night in a fairly lucid state. he was observed the following morning ( ovember 27. 1974.) chanting incoherently in the direction of the exit door at one end of the ward.

Several hours later. apprOXimately forty hours after he had been involuntarily commited while in a psychotic state. and onl twenty-four hours after \;olently as aulting several staff mem~

ber, Vernal Walford was released from the Northampton State Ho pital. He was given a prescription tor thorazine: he was told to contact the community care center tor additional treatment; and he left the hospital in a taxi. His caSE> was. never followed by the

ita! even after a representative of Walford's employer tele­p ed the hospital several days later to report bizarre and

pti e behavior on the part of Walford. and sought to return ord to Northampton. December 2. 1974, Walford turned himself in to the Spring­

ld office of the Immigration and Naturalization Service. ord claimed to be following instructions from God and d to being an mega! allen. He handed over an megal passport

birth certificate in the name of Robert Miller Grant, identified hllrns:elf Vernal Walford and confessed his tnvol emen in cJ1tmllULl actvity, provided his current address and summary of

vitles over recent months. and left the office. His case

[Mar.SENATE - No. 1822.

ce tly promulgated "Manual on the Conduct of Investigations" as t followed. Eyewi sses to several important incidents

ch occurred during alford's stay ~t the hospital (including the assault) were never contacted by the investigating com·

ee. In some .instances, key witnesses were interviewed in a group meeting. No e~ort was· made to question witnesses ~l""-l''A.telyand explore confUcting testimony.

--pre11mJnary _~rt of the investigating committee is replete with fac.tual errors-; -an secUons-oflhe-report-are-unsigne<l

·:and BOrne are'"'!lot dated; and the Department of Mental Health failed to issue a final report of the investigating committee's findings. ­

CONCLUSIONS- . ,

F:or.the purposes of the Executive Summary, the Committee's conclusions and recommendations are presented in their entirety.

Upon review of the facts and findings established by an in· vestigation pursuant to Senate Order 1761, the Special Senate Committee concludes as follows: (l) e patient Vernal Walford was diseJla.l!ge4 from the North.

ampton State Hospital lJ.t a pr.,ecipitoUs and inappropriate fashion. The patient should not have been released.

(2) The operation of the Northampton State Hospital during 1974· was characterized· by· a pattern. of gross institutional negli.

. gence .which contributed significantly to· the inappropriate release of Vernal Walford. ,

(3) The actions and deClstons of those individuals responsible for the release of Vernal Walford were the inevitable result of a system characterized by organtzational chaos and neglect_. ,.. .

'l"heir actions must be viewed and ultimately judged in this· . larger context.

(4) The policies and procedures of the Department of Mental Health which governed the commitment and release of state hospital ·patients in 1974: were not adequate to protect, the

tient and ensure the safety of the public. (5) The circumstances surrounding the release of Vernal Walford

have implications for the present as well as the future. The Jack of organizational stabiltty and programatic account· abll1ty reflected In the operation of the Northampton State Hospital in 1974, raises serious questions about- the Common·

15SENATE - No. 1822.

W 's menial health delivery system ...:. a sy tem- w!Uch, eve- as early as ~71, has been widely acknowledged to be a model of reform antIinnovati()n. .

(6) Theintemallnvestigatien into the patient's release·conducted by the Department bf Mental Health in 1974, unpro­fessionally conducted, factually incorrect and extremely mIs­leading.. This thoroughly deficient effort places in doubt the ability of a state agency to conduct effective, timely and 1m­pa.rtiaI bivestigations into its own internal operations.

('l) ·Xhe- eentrai ufffce-of ilie DePartment o~ Mental Health failed to exercise its authority and responsibility with regard to the establishment of Policy, procedure, standards of care, an,d the . monitoring of quality of care -:- thereby creating or sig1l1fi­cantly coiltributing to the operational chaos and substandard care w~hexisted at the Northampton State Hospital in 1974.

(8) During 1914, the central office of the Department of Mental Health pursued a policy of rapid deinstituti~nallzationin an unplanned and irresponsible fashion. The department's exclu­Stve focus on the provision of community-based care resulted in the 1napproprta~andlegally quest! e removal of

L--xo.ln;;;o;;rtty and resoUrces from the· state hospital system. Although officials in the central office expressed a strong de­Sire for improved practices in the provision of mental health services, the strategy employed to implement this new policy reflecteda callous disregard for the department's employees; the department's patients; and the safety of the public.

(~)The Department of Mental Health holds the·r.responSibility . ,.b­

for corrective action in those instances where. the systemic problen\.a relfected in the Walford case continue to exist to­day.

RECOMMENDATIONS ~c1al Senate Committee to Review .Commltment and

Release Procedures of the Department of Mental Health makes following recommendations: . .

) That the General Court consider legislation which (a) ledges the precipitous and inappropriate release of the pattent; (b) ac l~dges the gross institutional negligence which contributed to the release; and (c) authorius compensation to the family of Arnold Zeleznik

"

..

16 SENATE - No. 1822. r:r4ar.

in the amount~9ffifty thousand dollars $50.000) in recognition of their eight ar effort to bring the facts of this case to the

.;, public's attention. . (2) That; the General Court consider legislation aimed at ensur­

ing effectivd, timely and impartial investigations of unusual I

incidents within state human service agencies. (3) That the Department of Mental Health provide the Special

Committee with a "Written response to each of the above find­- /

ings related to· deficiencies in policy, procedure~_a:nd. _ standar.~ of -practice, and -that -the-Department include in each response the following: .(a) A statement as to whether or not a policy, procedure, or

stand':U"d of practice is curr ntly in place; (b) the-date that said policy, procedure, or standard of prac­

tice was developed; . (c) the process followed in order to circulate the policy, pro- .

.cedure, or standard of practice; (d) a description of all training offered to those responsible

for i.mplementing the policy, procedure, or ~tandard of practice; and . -- - - - ---­

. (e)-a. description of the monitoring system used by the de­partment ta-ensure that the policy, procedure or stan<!ard of practice is regularly followed.

AFTERWORD Re: The UnitedStates Immigration and Narurali:..afibn Service

After in~dvertently discovering evidence .to the effect that· Vernal Walford was known to the United State Immigration and Naturalization Service (INS) as early as 1972, and that Walford' had attempted to turn. himself in to the INS shortly after his re­lease from the Northampton State Hospital in December, 1974, the S c1al 9<>mmittee conducted a limited fact finding effort into the hand11ng of the Walford case by the INS.

On October 4, 1982, during its eighth and final public hearing (Phase One), the Special Committee introduced Walford's INS file into the record. and took testimoQY from two former· em­ployees and one present employee of the INS.

In the matter of the INS involvement with the Walford case the· Special Committee makes no specific findings, conclusions, or recommendations. To do so after such a 111Tlited fact finding effort

c

o 1

vesltlglaticm. During ln1 the following BgJ::eementl

Sinc Senate Order 1761 con mittee agreed to structure 1 p . I, centering apeclftcall 0

ford cue in 1974 and Phase n. foctlS1J1tg tlce of the Department of Men I H

(2) It was agreed that during PIth Oomml the Walford case as a "WIndow into th in 1974 and examine matters of policy. procedure, d overall facility management in addition to individual d clio mak­ing usoclated with the release. It as agreed that the Committ would make every eft< rt to avoid the simple "scapegoatlng" of individuals and attempt to consider the more fundamental que - "Does this case represent a breakdown in the decision m several professionals or is it ind cattve of systemic s which may remain unaddressed and have lmplicat10ns or the ~ture?"

f) It was agreed that the Committe auld compJete-1 I '" -investigation and issue its findings on Phase I prior to initiat ­

ing .the Phase II effort. Furthermore, the Commi ee ould use its findings from Phase I to identity areas of concern on which to focus the Phase II investigation. It as agreed that public hearings would be an essential com­ponent of the process and that at least one hearing during Phase I would be held at the Northampton State Hospital.

, durtrig th1 period, a Counsel to the Committee and Staff Dlrec::tor ere appointed to begin preparation for a serles of pUbl1c .."""__.....gs. Staffing patterns and other Department of Mental

th documents were reviewed to identify potential witnesses. ies, procedures. and standards of practice in effect at the

rthampton State Hospital in 19U were 'reviewed tor backJgtclUnd information and ca~ogued as exhibits for introduc­

into the record. Potential witnesses were located and inter­vt.:!:w,ed. Arrangements were made for the establishment ot a

graphic record of all public hearings, and Committee collD.l!lel prepared Rules of Procedure (see Appendix I) to be

y Committee during the coul'!le of the investigation. ce of the Massachu8et~ Psychiatric ci ty,

'­

SEN ' TE - No. 1822. [ ar.

mii in h18 speech." The Nursing Supervisor's Report for the evening shift states:

When awake (Walford) appears contUsed. At time speaks very loudly which he says i&because of his he

(12) November26, 1974, 4:00A.M.: Walford wakes up and has a lengthy conversation"-with night shift nurse Phyllls Da.ndineau. Walford admits living under an alias as well as involvement in criminal activity (trans­porting aild/or smuggling weapons, drugs and false docu­mEmtS). 'Nurse-:DamUneau records a 9.etalled summary of

• --- 4 .)

this conversation in both the Nursing Service Supervisors' Report and the Nurses Notes form. ­ J

(l3) November26, 1974, 8:30A.M.: 'Walford attends a "ward meeting" of all patients on the floor. Northampton State Hospital staff in attendance were Carol Bombard, Head N~e, Janet James, LPN, and At­tenda1lts J'ack Bourgeois and-Ed Kubasek. Walford attempts

--:-:---rU.UlI~akout of tum and is requested to wait his tum by Carol Bombard. Walford becomesenraged-and attempts, to ass-==ul=-=t'---_ Nurse Bombard. Jack Bourgeois and Ed Kubasek attempt to restrain Walford and are both violently assaulted. Several male patients come to the aid of the two attendants and after a violent struggle, Walford is restrained and placed In seclu­sion. Both attendants suffer minor injuries in the struggle . .-,'

(14) November 26, 1974, late morning: -. " Doctor Shirley Gallup, Medical Assistant ,Superintendent. is contacted by both Carol Bombard and'Janet ia~e8. Both Bombard and James inform Dr. Gallup 6f Wa:lford~s as- _ saulUve behavior and r-ecommend Walford's transfer to the maximum security State Hospital at M.C.I. Bridgewater. Dr. Gallup promises to send Dr. Angelina SupBh to the Spring­field Unit to evaluate Walford.

(lIS) November 26, 1974, lale morning: Doctor Angelina Supan, Medical Director of the Holyoke­Chicopee Unit, arrives on the Springfield Unit and conducts an interview with Walford lasting approximately fttteen minutes. During'the interview Walford appears to be re­sponding to voices, makes bizarre facial grimaces and seems to make mention of God instructing him to klll. Wal­ford complains of a foreign body in his eye. The interview is

SENATE - 0.1822. [Mar.

(4.) F dings relative to the release of Vernal alford from the Northampton State Hospital

(5) -Findings relative to tl].e administration and or Uon of the Northampton Stat~Hospitalin1974.

(6f Fbi4ings relative to the integrity of the in rnalthv stiga­tion

<

conducted by the Department of Mental aeal 197ts SecUon One: Findings Relative'lo the Invollintur. " Comml/ nt of

Vernal Walford . (1J The comm1tting physician at the Springfield H pi ,Dr.

WUJ,ta.rn Linson, -made- an appropriate clinical jlldgment 1ri or4er1i1g the involuntary cbmmitment of Vernal Walford to the Northampton State Hospital under M.G.L., Ch.l23, sec. 12.

(2) Dr. Linson precisely followed the statutory procedure for carrying out the involuntary commitment of a patient when he committed Vernal Walford to the ~orthampton State Hospital. .

(3) Dr. Linson acted responsibly when he contacted Dr. GallUp, ~cal Assistant Superintendent at Northampton State HOspital, by-telephone. and warned Dr. Gallup C?! Walford's "

-,--- ­dangerousness.

S.ection TWo: Findings Relative to the Admission of Vernal Walford to the Northampton State Hospital

(1) The physical examination given to Vernal Walford by Dr. Villacorte upon his admission to the hospital was inadequate. The laws of the cOmmonwealth and Department Of Mental, Health Regulations require that all patients admitted to a s~te hospital receive a full and complete physical exami- .... nation. Although .Walford's record contained evidence of a

.phYlUcal exam having been completed', it would appear from' the record that the physical was conducted in ~ pei'functory fashion. The fact that Walford repeatedly' complained of a foreign body ~,his eye prior to his admissiqn, and 1Jlat the Particle was not removed from his eye until two days after his release supports the finding tha( his physical examination . was less than thorough. :' 4

(2) .Dr. -Vmacorte made. no effort to collect relevant bacltgro~d

infonnation on Vernal 'Yaltord dUring the admission prbcess. The admitting physician (Dr. Villacorte) ,did not contact the committing physician (Dr. Linson) f~r additional informa­tion on Walford, despite the fact that Walford arrived at the

SENATE - No. 1822.

boapt,talin a psychotic state and was unable to communicate logical, co~erent manner. li'urthermore, the name and

) phone number 9f Dr. Selden, the Milton Bradley physician' had sent -WaUord'to Dr. Linson, as clearly recorded

W.gLlford's commitment papers under the head1n~: "Other evant data. which -may assist the' admitting physician."

Thus, two sources of additional information, Dr. Linson and Dr. Belden, were never contacted by the Northampton State HospttaL I~ is entirely possible that had contact been made

th the medic8.l staff at the Milton 'Bradley Company.. North­ampton staff wQUld have been informed of Walford's threat to ­JtW a fe ow employee several day~ earlier. Walford's health me at MiltOn Bradley,contained a report of the doll incident on U/21174 which stated, in part, "(Walford) became enraged

stood there and said 'I don't play, I believe in, God, I'll you.' "

'(3) Pollcies and. procedures regarding the admission of in­luntary patients, in, effect at the. Northampton State:

--IHo~S"'pMi~in 1974, were completely inadequate.---,,-LIttle or no procedural direction was given to professional staff relative to how an admission was to be conducted. The responslbillty of the admitting nurse versus the role of the ad­mitting physician was not clearly defined. The scope of the psychiatric examination to be conductetl was not clearly de­scribed and the procedure for how background information on .

patient was to be collected. verified, and recorded was vague.

5ectJIoDThree: Findings /?Ielath'e to the Treatment and E\'aluation Received by Vernal Walford aT the' Northampton State Hospital.

(l) The "Treatment" Vernal Walford receIved while a patient at Northampton Siate Hospital consIsted' almost exclusively

f shelter, m~d1cation,and restraint. Virtually no psych18.tric atment was given to the patlent. '

emal Walford was not afforded the opportunity to benent a therapeutic c11n1cal relationship with either a psychia­

trist or a trained cl1n1clan. Walford was medicated, given a room, arid placed in seclusion after e~bitlng assaultive be­

vtor. He was not evaluated ,by ~ treatment team and his contact with the doctor assigned to his case was of an ad

SENA .1

hoc nature. Furthermore, h charge planning, an inte

tient treatment, supports th patient did not recei';e

neurological examina or ever, which further reflects , treatment.

(2) The only treatment received by V . alford ither met or exceeded standard was that provided b ing ataU. The evidence suggeltts that th nu f establish contact with Vernal Walford and so c t val ble information regarding his personal ry. 'Ibis informa­tion was recorded, in detail, in the N s Progre ot • and was available to the ph clan igned to case. Furthermore, the nursing staff strongly recommend that Walford be transferred to a higher security instituti . Un­fortwlately, the observations and recommendations the nursing staff were all but 19RO

Section Four: Findings Relative to lh Rele of Vernal Walford from the 'orthampton State H05pual

(1) Vernal Walford was inappropriately released from the Northampton State Hospital approximately forty hours atter his admission and approximately twenty-four hours atter violently assaulting members of the ho pita! staff.

(2) Vernal Walford was released by Dr. Angelina Supan atter a brief telephone consultation with Dr. Shirley Gallup.

(3) Vernal Walford was released by the discharging ph clan without proper consultation with the cl1n1clan assigned to the case or nurses who had significantly more contact with the patient.

( ) The patient's hospital record. which contained his realna.me and suggestions of his involvement in crlmlnal activity, was· not reviewed by the discharging physl prior to his release.

(5) A three day notice. required by law in order for a conditional voluntary patient to be considered for release, may; never have been signed by the patient prior to his release. No witnesses testifying before the Committee had actually seen Walford's signature on a three day notice. Although several witnesses had been informed that such a document.

f the investigating comm

co CLU 10 po review of the facts and finding stabll h

a on pursuant to senat Ord 1761.. th mi tee concludes as follo

(1) The patient. Vernal Walford d1 charged rom the orthampton State Hospital in precipitous and ppro­

pri te fashion. The patIent sho ld have been led. 2) TIt operation of the • orthampto State Ho- Ita! during

197{ was characterized by a p tterm of gross institutional n 11 ence which contributed sign! icantly to th inappro­priate release of Vern;l.1 Walford.

3) actions and decisions of tho individuals responsible for the release of Vernal Walford w re the inevi bl result of a ystem characterized by organizational c os and n ect. Their actions must be viewed and ultimately j dged in this larger context.

H) The policies and procedures of the Department of (ental Health which governed the commitment and release of

'te hospital patients in 1974 were not adequate to protect Ute patient and ensure the safety of the public.

5) The circumstances surrounding the release of Vernal Wal­ford l\ave implications for the pr nt as well as the future.

lack of organizational stabUty nd programmatic ac­countability reflected in the operation of the orthampton S te Hospital in 1974. raises serious que tions about the Commonwealth's mental health delivery system - a

y tern which, even as early as 1971. has been Widely a knowledged to be a model of reform and innovation.

(6) Th internal investigation into the patient's release con­cted by the Department of Mental Health in 197~. as un­

prof ionally conducted, tactually i.rrcorrect d ex­tremely misleading. This thoroughly deficient effort places in oubt the ability of a state agency to conduct effective, ti ely and impartial investigations into its own internal operations.

(7 The central office of the Department of Mental Health failed to exercise its authority ani! responsib1l1ty with regard to

e ta,blishment of policy, procedure. standards of care.

SE A - o.

lding officer .as a {assachu GpnlPNll

La Chapter 3, sec 0 27. D Te timony of aU hearing 1 be r~('I'lrf:l~

sten grapher. The stenographic report shall in state library at the con lu ion of the mmittee' wor in accordance with chu etts G n r Chap er 3, section 29.

(E A ess may nave an attorn y ppear with hi or her at ah lng.

(F Wi s may be -question d by Committ members. The' presiding officer shall det~ine the or r in hlch Committee members question a wItness.

. .. e4

~- ~

(G) A tness shall be permitted to make an opening state­ment. after being s",·orn.

(H) A witness on his or her counsel may decline to answer a question on the ground of privilege or irrelevance. Ex­cept for the assertions of the privilege against self­incrimination. all objections shall promptly be nl1ed upon by the presIding officer, .and if the objections are over­roled the witness shall answer the question.

I) A witness may refuse to answer a question on the ground of his or her privilege against self-incrimination. If a wit,. ness claims the privilege, he or she shall not be required to answer the question at the time.

J) No other objections to the form or content of questions may be raised by a witness or his or her counsel. Strict roles of evidence applicable in a judicial proceeding shall not be applied.

(K) At My time before the close of questioning, the witness may submit to the presiding officer written questions

ch the presiding officer may, in his or her discretion. after consultation with the Committee members, ask the

tness. t e close of his or her testimony. a witness may make a

c g statement. A witness may be asked additional qtieS1t1ons after his or her closing statement.

tness may be recalled to appear before the Com­ee.

(N) If any person behaves in a disorderly or contemptu us manner at a hearing, or if any person behaves in a man·