Local hospitals say restraint use is down

From the Portland Tribune

Some facilities institute Salem-style changes, but not all users convinced

Donita Diamata (with daughter London and dog Bella) says she was secluded and tied to a bed four years ago at Providence Portland Medical Center. Area hospitals say they’re adopting policies that reduce the use of restraints, but Diamata says that if she ever needs to be hospitalized, she wants to be taken to Salem instead.

Donita Diamata, who has suffered from depression and an eating disorder and is now a mental health advocate, has had inpatient stays at Providence St. Vincent Medical Center, Providence Portland Medical Center and at Oregon Health & Science University, as well as Salem Hospital.

And even though she lives in Portland, Diamata says she has instructed friends that if she ever needs to be hospitalized for psychiatric care again, they should make sure she is not taken to a Portland hospital.

That’s because of what happened to Diamata four years ago, she says.

Diamata says she was secluded in a room in the emergency department at Providence Portland for four days and friends later told her that when they came to visit her in the psychiatric unit after the seclusion, her hands were tied to the bed.

She says she cannot recall the alleged restraint because medications had put her in a hallucinatory state.

She says books were taken away from her if she didn’t do what nurses instructed. She says she’s seen patients end up in restraint for talking too loudly at OHSU.

“I was in a room where restraints were hanging over the bed,” she says. “It was like a reminder that if I didn’t behave that would be my fate, too.”

In fact, she recalls a nurse at a Portland hospital who she says tried to convince her that physical restraint could be a positive experience.

“She said, ‘No, no, it can actually be a beautiful thing,’ ” Diamata says. “She said restraint is like getting a group hug.”

Officials at several of Portland’s six hospitals with inpatient psychiatric units – and some independent observers – say Portland hospitals have changed since Diamata was last a patient, and that they have significantly reduced their use of restraint and seclusion.

But exactly how much is a bit of a mystery.

None of the Portland hospitals is willing to say how many restraints and seclusions they do each year, despite repeated requests by the Portland Tribune.

The closest they’ve come is an e-mail from the Oregon Association of Hospitals and Health Systems, the lobbying organization for the state’s hospitals.

That e-mail said that the Portland-area hospitals had combined their data on restraint of mentally ill patients. The e-mail said that data showed the use of restraint in Portland facilities had dropped “about 60 percent” in the past five years.

“A typical Portland-area psychiatric unit would use restraint about once a month,” according to the e-mail.

When the Tribune asked that seclusion data also be sent, the association representative said that would not be possible because each hospital kept its seclusion data in a different form.

But recent revelations following the August death of 50-year-old psychiatric patient Glenn Shipman Jr. at Legacy Emanuel Hospital & Health Center raise questions about how far Legacy and the other area hospitals have come in changing their culture of care.

Shipman was asphyxiated at Legacy Emanuel’s psychiatric unit after staff there held him face down against the floor for at least 10 minutes in a position called prone restraint.

Shipman, who weighed 450 pounds and suffered from schizophrenia, refused to cooperate with nurses prior to his takedown and death, according to the federal report.
Restraint called a last resort

To many who work in the psychiatric units of hospitals, restraint and seclusion are necessary tools to deal with patients who often are out of control and frequently dangerous.

Restraining a patient, either by physical force as occurred in Shipman’s case, with leather or plastic cuffs that tie a patient to a bed, or with a special device called a Posey vest, often is partnered with seclusion, which usually refers to putting a patient in an isolated, locked room, often for long periods.

In the past five years there have been 136 attacks on staff by patients at Legacy Emanuel, according to John Reid, director of security at the hospital. The majority of those were staff members being punched, kicked or spit upon, Reid says.

“Health care workers don’t complain about those things,“ Reid says. “Unfortunately, it’s become part and parcel of being a health care worker. When you’re trying to get control of a situation, you do what you need to do to control a patient and protect the patient and the staff.”

Reid says that restraint is used only as a last resort, and that every time a restraint takes place the hospital follows up with a full analysis of the events.
Salem system used as model

Deborah Gaspar, chief nursing officer at Legacy Emanuel, says that Emanuel has looked at the model that Maggie Bennington-Davis helped institute at Salem Hospital – where restraints and seclusions were reduced from 260 to zero in just two years – and incorporated many of its principles.

Cindy Scherba, manager of the psychiatric care unit at OHSU, says that her hospital uses “a person-centered model” to engage patients that uses many of the same elements as the Salem program, including changes in the physical space to present a more comforting environment and twice-a-day community meetings that involve both staff and patients.

“Sometimes patients scare each other,” Scherba says. “(The community meetings) are a place they can feel safe and talk about real issues.”

According to Herb Ozer, who directs Behavioral Health Services for Providence Health and Services, both Providence Portland Medical Center and Providence St. Vincent Medical Center have trained their psychiatric staff in the same model Salem uses.

Jeff Rogers, a civil commitment investigator for Washington County Behavioral Health Program, is a frequent visitor to all the area psychiatric units, and he says he’s seen tremendous positive change in the way patients are treated.

But he also says that the flood of psychiatric patients coming to the hospitals through emergency departments has increased the stress level on the people who work in the psychiatric units.

“The acuteness of the cases seems to be greater, the complexity of the cases seems to be greater, and the pressure on the system from intake to discharge seems to be higher on everyone,” Rogers says. “There’s a lot of pressure on people to make really quick decisions.”

Reporting has had effect

As far as Diamata is concerned, Portland hospitals may have improved in the ways they deal with psychiatric patients, but they haven’t changed enough.

Diamata, who was director of consumer services at Cascadia Behavioral Healthcare until 2006, says that within the past year she has visited friends at Portland hospitals, and the change didn’t impress her. And, she says, the local psychiatric units still use seclusion.

Seclusion, she says, can be nearly as bad as restraint. “It’s traumatic and it’s insulting, and you feel like you’re in a cage,” Diamata says of seclusion.

Diamata and a host of national experts agree that hospital psychiatric units should be required to report their restraint and seclusion data to state health authorities, and that those numbers should be available for public comparison.

Susan Stefan, senior staff attorney for the Center for Public Representation, a Massachusetts-based organization that advocates for people with mental illness, says that the few states that have required hospitals to report their restraint and seclusion data have all experienced a similar result – the numbers of restraints and seclusions dropped.

“You’ve got comparisons so you can look across at the hospitals and say one is way out of line. It drives the rates down,” she says.

Beckie Child, board president of Mental Health America of Oregon, a statewide advocacy group, says she would welcome the data being made public, along with more change at Portland hospital psychiatric units.

Child, who was secluded a number of years ago at the now-closed Woodland Park Hospital in Northeast Portland, says she’s visited friends in many of the Portland psychiatric units, and the staff members “still don’t get it.”

“It’s not just about not using seclusion and restraint; it’s about making personal connections with individuals,” she says.

State’s helpful attitude gives us a glow

From The Portland Tribune

If local hospitals have a morale issue or a thorny potential lawsuit, the state agency that regulates them is there to help.

In the wake of a Dec. 4 Portland Tribune article reporting federal scrutiny of Legacy Emanuel Hospital over the death of Glenn Shipman Jr., records obtained by Sources Say show that state Department of Human Services health care licensing manager Ron Prinslow immediately fired off a note to his boss expressing concern that statements attributed to him in the article “could harm my needed relationships with … hospital providers.”

He claimed that some of the information did not come from him, and he questioned how his words were paraphrased – though he said the article was “basically true” and “the information is basically correct.”

Sources Say has noticed that such reactions are common when people later realize they were a little too honest with a reporter. And by all appearances, Prinslow is a conscientious public servant. What happened next, however, was interesting.

Told of Prinslow’s reaction, top Legacy officials requested that the department send a formal letter of complaint to the Tribune to help with the hospital’s “internal morale issues.”

Internal department e-mails show one state official suspected another motive: Legacy wanted help with “potential legal issues” – in other words, a lawsuit by Shipman’s family.

In the end, top state health officials wrote the letter for Prinslow; it claimed unspecified “inaccuracies.”

Asked by the Portland Tribune to detail the inaccuracies so they could be corrected, the state did not respond. The letter was hand-delivered to Legacy and circulated widely there before arriving at the Tribune.

Outsiders quick to judge

My View • Psychiatric staffs cope with chaos compassionately

From the Portland Tribune, Opinion by Jeff Rogers

Glenn Shipman Jr., who had schizophrenia, died three days after being admitted to Legacy Emanuel Hospital & Health Center in August. Investigations have attributed his death to asphyxiation from the use of a nontypical form of restraint.

The death of Glenn Shipman Jr., a psychiatric patient at North Portland’s Legacy Emanuel Hospital & Health Center, is a tragedy by any measure. At the same time, the resulting public discussion concerning the nature of inpatient psychiatric care has disturbed me.

Many have opined that inpatient psychiatric units are dark places where the staff is primarily concerned with controlling patients, rather than helping them. In my experience, nothing is further from the truth.

Inpatient psychiatric units are, by their very nature, studies in controlled chaos. They consist of a mixture of voluntary patients who recognize they need treatment, and involuntary patients held against their will after being deemed dangerous to themselves or others.

Patient ages range from 18 to the elderly. Men and women are segregated by room but mix freely in day-to-day interactions and therapy groups.

On any given day, the mixture consists of angry and manic individuals, withdrawn and depressed persons, and people suffering from psychotic symptoms and delusions.

Occasionally, developmentally disabled adults with psychiatric diagnoses are hospitalized, compounding the already stressful environment.

To add to the difficulties, the mixture changes daily as the stressed mental health system attempts to move people out of the hospital as quickly as possible to make room for the growing numbers awaiting admission.

Every day, inpatient psychiatric staff members walk into this setting armed only with their experience, training and compassion. It is a rare day when a potentially violent situation isn’t defused solely through the use of those three key elements.

Many times, I’ve watched in amazement while staff members stood serenely in the presence of an angry, physically agitated, and often delusional individual, calming him or her merely by remaining connected when the intuitive action would be to retreat to safety.

Their willingness to do that every day is what helps the people in their care get better. When others might avoid contact with these patients, the staff members sit quietly and talk with them, meet with them privately, and encourage them to find better ways to deal with their many issues.

They promote a sense of community among people who may never have had any sense of belonging in their personal lives. In an almost magical way, that community then provides its members with an alternative social reality where everyone can see that everyone else has problems. It reminds them that they aren’t alone.

At that point, the patients begin to help one another recover, which is perhaps the most magical thing of all.

Few people ever personally experience this process. Only those whose presence is required or invited are allowed on inpatient units, because psychiatric patients retain their rights to privacy and choice of who they want involved in their lives.

If this were not the case, perhaps people would not be so quick to criticize the actions of staff members faced with hundreds of decisions on every shift, any one of which might result in a physically dangerous situation to themselves, the patient or other patients in the environment.

I see it in my work on psychiatric wards every day. But I’ve also seen situations where nothing could prevent a person from escalating to violence or self-harm.

Because of that, I have to reserve judgment in Shipman’s case — I don’t have all the information. I would encourage others to do the same.

I can only say that in my own experience, compassion and dedication to helping people whose mental illness often robs them of the ability to help themselves are the driving emotions behind the vast majority of psychiatric staff I know.

Jeff Rogers is a mental health professional in the Portland metropolitan area.

Mentally ill are not criminals

Letter to the Editor of the Portland Tribune

Glenn Shipman Jr.’s death (Patient dies after being restrained, Dec. 4) is simply one more in a growing legacy of failures by those charged to serve and protect in North America, now long touted as the most advanced civilization of all time.

In October, we saw (literally, accessible worldwide on YouTube) the killing of a clearly mentally disturbed Robert Dziekanski at the Vancouver, British Columbia, International Airport.

And last year James P. Chasse Jr., another schizophrenic man, died after an encounter with police, who, according to Willamette Week, claimed he was “doing something suspicious or acting just, um, odd.”

There are other examples, too. Such incidents are becoming all too common, and, in every such case, mentally disturbed people are being dealt with as lethally dangerous criminals, even though in every case unarmed, essentially by those presumably professionally trained to serve and protect.

Were it not so tragic, it would be a farcical drama. Were it not so pathetically reflective of the ubiquitous failure of so-called education in North America, it could be analyzed as intentional terrorization of the citizenry.

At the end of the day, it’s simply one more example of a civilization at the precipice of its fall.

Serious artists now are telling this story more frequently by the day. Major media (present company not excluded) are essentially ignoring it, choosing to pump fatuous feel-good glitz and fluff, which fits the tenor of the epoch perfectly.

The cities are burning, Idols are singing and everyone’s dancing with the stars … awesome!

Jackie T. Gabel - Southeast Portland

Hospitals rarely tell all

from Portland Tribune

Legacy death highlights reluctance to admit medical mistakes

READ - Report on the death of Glenn Shipman - Statement of Deficiencies and Plan of Correction, created by HCLC on 10/3/07 (PDF 1.8 MB)

When Kathy Shipman was shown an Oregon Department of Human Services report that said Glenn Shipman, her brother, had died after being restrained face down on the floor by the staff at Legacy Emanuel Hospital & Health Center, she said it was a blessing to finally know the truth.

But Shipman, who saw the DHS report last Friday, said she and her family would have liked to know the truth much earlier — and wished Legacy would have been willing to tell them.

Glenn Shipman died Aug. 26.

Kathy Shipman said that from the day her brother died until an Oct. 23 meeting with hospital officials that the family requested, the hospital had no contact with Shipman’s family except for a call from a nurse who wanted to send flowers.

At that Oct. 23 meeting, both Kathy Shipman and Glenn’s mother, Elaine Shipman, said hospital officials never told them that Glenn died from asphyxiation, as stated in the state medical examiner’s death certificate. They said hospital officials told them Glenn had been restrained and that he had died of cardiac arrest.

“They did say they were sorry for our loss,” Kathy Shipman said.

But, she said, hospital officials did not acknowledge the death was related to their restraint of Shipman — which is what a DHS official believes.

“They pointed to Glenn’s weight (over 400 pounds) and said he had apnea,” she said. “It feels like Glenn is no longer the victim here but he’s the perpetrator. That’s the impression I got out of it.”

Hospital officials said they could not comment on the case while it is under investigation.

Asked for the hospital’s policy on disclosure of accidents or mistakes to patients or their families, a Legacy spokeswoman wrote in an e-mail statement that the hospital had “clearly defined protocols” it followed when unanticipated events occurred.

Asked through an e-mail for more details on those protocols, Legacy officials did not respond.

Legacy’s response to the unexpected death of Glenn Shipman is hardly unusual.

Despite a national movement to encourage hospitals and doctors to tell patients what they know after unexpected events, most, fearing lawsuits, reveal little, according to experts in the field of medical disclosure.

Lawrence Wobbrock, a Portland malpractice attorney for 31 years, isn’t convinced that there’s been all that much change in hospitals and doctors willing to admit their mistakes.

“In general (hospitals in Portland) rarely disclose what happens,” Wobbrock said.

The Oregon Legislature approved a law in 2003 that requires hospitals to disclose serious events in writing to patients, but the law doesn’t say what or how much they have to disclose.

The statute also says that statements made by a physician in disclosure to a patient cannot be used against the doctor should a case be taken to court.

Wobbrock says the law is weak.

“I’m finding that occasionally they’ll apologize, but they know it is not admissible,” Wobbrock said. “I have seen no change in hospitals informing patients when a bad thing happens, that it’s someone’s fault.”

Nationally, a 2003 study by University of Washington School of Medicine assistant professor Thomas Gallagher discovered that only one in three doctors who as patients were victims of unexpected events were told about the problem by their own doctors.

“It’s not what we’d like it to be,” Gallagher said of physicians’ willingness to disclose.

Move toward disclosure

Gallagher and other national experts say that hospitals could and should tell patients everything they know, and more hospitals are starting to do just that.

“This is not about preventing lawsuits,” said Jim Conway, senior vice president for the nonprofit Institute for Healthcare Improvement in Cambridge, Mass. “People will do what they do. This is about the organization honoring their moral and ethical responsibility to disclose.”

Kathryn Wire, a St. Louis-based attorney and risk management consultant to hospitals, said she advises hospitals that telling harmed patients or their families what they know is not only right for the patients, but also good business for the hospitals.

A number of studies in recent years, Wire said, have reported that when hospitals and doctors are more open and honest with patients who are victims of “unexpected events,” the hospitals don’t suffer financially because potential lawsuits get resolved more quickly.

Wire said that, after reading the Portland Tribune’s Tuesday stories about the Glenn Shipman case, she would have advised Legacy Emanuel to disclose details to the family before the release of the DHS report.

That report cited the hospital for failure to meet federal standards for patient safety.

The DHS report said that the hospital failed to adequately monitor Shipman’s condition while he was being restrained.

The DHS report also cited the hospital for a locked door that kept a resuscitation team from getting to Shipman, and for a staff worker not knowing how to operate a medication dispenser after Shipman had stopped breathing.

Wire said the hospital could have revealed some of those facts to the family without knowing, or saying, if they contributed to Shipman’s death.

She said family members often just want to hear from the hospital that measures have been taken so that those problems don’t occur with future patients.

Jim Conway agrees, and he has experience in patient disclosure that few hospital administrators can match.

Conway was brought in as executive vice president of the Dana-Farber Cancer Institute in 1995 to deal with what probably was the most highly publicized medical mistake in recent history.

Case brought spotlight

In 1994 Betsy Lehman, a Boston Globe health columnist, was killed by an overdose of chemo-therapy drugs at Dana-Farber, considered one of the country’s pre-eminent cancer hospitals. Lehman’s death made headlines around the country, and focused attention on hospital mistakes.

Dana-Farber, Conway said, fully disclosed to Lehman’s husband all that they knew, and quickly reached a legal settlement with him.

“Our board of trustees said there was no conflict over what happened, so let’s settle with the family and spend the time making sure it never happens again,” Conway said.

Conway said that full disclosure yields patient trust. Every patient that has been harmed by an unexpected event at Dana-Farber and has been provided full disclosure has remained at the hospital as a patient, he said.

Conway said hospitals are beginning to change, slowly.

“This is a cultural change, and you don’t change cultures overnight,” he said. “People have been living in this shame and blame, keep it quiet, don’t disclose (environment) for most of the tradition of health care. It’s like trying to turn a ship around.”

Peter Bernardo, a Salem surgeon who is vice president of the Oregon Medical Association, said telling patients just makes good sense.

“Most patients are not accusatory, and most of the time they’re going to find out about it anyway,” he said. “In this day and age it doesn’t do you any good to lie about it.”

Patient dies after being restrained

Hospital says cardiac arrest; medical examiner says asphyxiation
Feds: Legacy Emanuel doesn’t meet safety rules; probe continues

The Portland Tribune

A state medical examiner has ruled that Glenn Shipman Jr. died of asphyxiation three days after being admitted to Legacy Emanuel Hospital & Health Center in August. Investigations since then have pinned his death on the unmonitored use of a nontypical form of restraint and identified other areas of concern.

Elaine Shipman liked to think that the one place her son, Glenn, would be safe was in a hospital with professionals trained to take care of him.

Glenn, who suffered from schizophrenia, had been in and out of a number of local hospitals since his disease was diagnosed when he was 30.

But a hospital was the last place Glenn wanted to be.

“Glenn said he was deathly afraid of hospitals,” said his mother, a Scappoose resident. “He’d rather be in prison than a hospital.”

Glenn Shipman Jr.’s fear of hospitals turned out to be warranted.

On Aug. 24, his 50th birthday, Glenn Shipman suffocated after hospital workers at North Portland’s Legacy Emanuel Hospital & Health Center restrained him by pressing the 450-pound man onto the floor, his arms underneath him, his face down.

They held him there for at least 10 minutes before discovering that Shipman had stopped breathing, according to an investigation conducted by the Oregon Department of Human Services a few weeks after Shipman’s death.

Hospital workers tried to revive Shipman, but he never regained consciousness. He was kept on life support for two days and died Aug. 26, according to the DHS investigation.

Legacy officials did not contact the Shipmans about their son’s condition until more than 18 hours after the Aug. 24 incident, when they told Elaine Shipman that her son had suffered a cardiac arrest.

But the state medical examiner determined in an Aug. 27 autopsy that Shipman died of “compression asphyxia” – asphyxiation.

Ron Prinslow, the official who has overseen the DHS investigation and a follow-up investigation relating to Shipman’s death, told the Portland Tribune, “It is my understanding that what the people (Legacy staff) were doing led to his death.”

A Legacy spokeswoman said late last week that the hospital could not comment on Glenn Shipman’s care or death due to federal privacy regulations.

After Elaine Shipman offered to sign a release that would legally allow Legacy Emanuel staff members to talk to the Portland Tribune, the hospital spokeswoman said even with that permission, they would be “unable to comment” because the case still was under investigation.

Portland police are reviewing Shipman’s death to see if any crimes occurred.

Meanwhile, Prinslow says, the report from the initial investigation following Shipman’s death found Legacy Emanuel out of compliance with the standards that hospitals must meet to be eligible for Medicare and Medicaid payments.

A second investigation of the hospital was conducted last week by DHS to determine if the hospital has made changes that it promised after the first report, or whether a process will continue that could cost Legacy Emanuel its ability to collect Medicare and Medicaid payments.

No door opens for code team

Legacy Emanuel failed Glenn Shipman in a number of ways, according to the initial DHS investigation, which was prepared for the federal office that oversees Medicare and Medicaid payments.

The investigation by DHS began because hospitals are required to report to federal authorities all restraint-related deaths.

The DHS report cites the hospital for not properly transferring Shipman from the hospital’s emergency department to the hospital’s psychiatric unit.

The facility also failed to have a “crash cart,” used to restart hearts, on the psychiatric unit. The hospital denies that charge.

According to one hospital staff member interviewed by investigators, the hospital code team, which responds to life-threatening emergencies and which was called by pychiatric ward staff, was pounding on a locked door leading to the psychiatric unit where Shipman lay on the ground, not breathing.

The members of the code team were unable to get in to provide help, and staff members who were surrounding Shipman could not hear them.

Another hospital staff member, unidentified in the report, told investigators that he or she was unable to access medication for Shipman because they did not know how to properly operate the hospital’s automatic medication distribution system in an emergency.

But the most explosive finding in the report deals with how Legacy Emanuel staff members restrained Shipman after he came out of his room in the psychiatric ward, ignored requests to return to his room, and pushed a nurse.

The investigation found that hospital workers pressed Shipman’s face to the floor for at least those 10 minutes, until they noticed one of his hands turning blue.

The investigation found that while Shipman was down, no one was monitoring his condition, not even checking to see if he was breathing until it was too late.

‘Prone restraint’ put to use

The only available record of what occurred at the hospital comes from the DHS investigation report.

Shipman had been brought to the Legacy Emanuel emergency department late in the evening of Aug. 23 by Scappoose police responding to a call from Elaine Shipman.

Her son had been acting agitated and “out of control,” and believed his sister was trying to kill him, according to the DHS report.

Six officers responded, and a resisting Shipman was Tasered as officers wrestled him into a squad car and delivered him to the hospital.

According to the investigation record, Shipman was alert and cooperative when he reached Legacy Emanuel. He was admitted to the emergency department talking about the world coming to an end and saying that “Satan is coming.”

He slept unobserved in the emergency department, and the next evening he was transferred to the hospital’s psychiatric unit, where the events that would lead to his death transpired.

According to the DHS report, at about 6:30 p.m. Aug. 24, Shipman refused to cooperate with staff in the psychiatric unit in changing his gown, and he started walking down the hall toward the nurses’ station.

A hospital employee (the report does not distinguish between nurses, doctors and security personnel) tried to block Shipman’s way.

Shipman pushed one staff member, according to the report, and squeezed that staff member’s hand.

Staff members then took Shipman facedown into a prone position on the floor, with hospital security staff arriving to help.

According to the report, “Staff asked the patient if he could walk to the quiet room. There was no verbal response.”

After at least 10 minutes with his face to the floor, according to the report, one staff person “noted that the patient’s left hand was blue.” A staff member asked another if Shipman was breathing.

In checking, they “noted the patient’s face to be cyanotic (bluish) and the patient’s tongue was protruding from his mouth.” By that time, according to the report, Shipman had no pulse.

He never regained consciousness.

The face-down technique used to subdue Shipman, which in the end killed him, is called prone restraint.

According to Bob Joondeph, executive director of the Oregon Advocacy Center, a nonprofit organization that advocates for people with disabilities, the use of prone restraint is well-known for increasing the danger of asphyxiation.

He also said that staff should have known that using it on a 450-pound patient was even riskier.

Joondeph said that most hospitals have trained staff to try to eliminate prone restraint, or restrict its use to only the most dire situations – when an out-of-control patient might bite staff or spit on them.

And when it is used, Joondeph said, patients’ vital signs need to be constantly monitored.

“A person is not going to talk to you if they can’t breathe,” Joondeph said. “You can’t rely upon them to say, ‘Hey, down here, I’m not breathing.’ ”

Patient called a ‘gentle giant’

Glenn Shipman’s mother and his sister, Kathy, also question whether any such restraint was necessary, with Kathy calling Shipman “a gentle giant.” He had no record of violence or violent arrests.

“He was like a puffer fish,” mother Elaine Shipman said. “I think what he tried to do was look as big and tough as he could to intimidate people, but he wouldn’t hurt a thing.”

Elaine Shipman said that in an Oct. 23 meeting requested by the family in search of an explanation for Shipman’s death, hospital staff gave no indication that her son had been acting violently or out of control before they took him down.

“They said he clenched his fists and moved in the direction they didn’t want him to go, toward other patients,” Elaine Shipman said. “I think he had a panic attack.”

While hospital officials acknowledged they restrained Shipman at that point, according to Elaine Shipman, they never acknowledged in the Oct. 23 meeting that their restraint of him was in any way responsible for his death.

Prinslow said that there were reasons he doubted the need for hospital staff to use prone restraint on Shipman. He points out that Shipman had been in the hospital a full day without observation and with no problems before the altercation.

“They left him in an unlocked room by himself, so I would question the violence,” Prinslow said. “On the other hand, my experience tells me that sometimes a mental patient is subdued just by the presence of a show of force.”

Prinslow said that he talked to the DHS nurse investigator who compiled the report about the incident. “She’s been trained never to restrain a patient prone on the floor,” he said.

Investigators had doubts

Prinslow said state officials were suspicious of the version of events initially presented by hospital officials, including that Shipman died of cardiac arrest.

In fact, according to the DHS report, a hospital worker told the DHS investigator, “Procedurally, we didn’t do anything wrong.”

Prinslow and his investigators disagree. “We took all the facts, and it just didn’t add up,” he said. What appeared most inexplicable, according to Prinslow, was the hospital’s insistence that Shipman died of cardiac arrest.

In essence, everybody has cardiac arrest when they die because their hearts have stopped beating.

But cardiac arrest is not necessarily the cause of their death. Their hearts may have stopped beating for any number of reasons, including asphyxiation.

Prinslow said he believes the actions of the hospital workers – not cardiac arrest – are what killed Shipman.

“I would say the restraint process led to the patient suffocating,” Prinslow said.

And that is something Prinslow said he finds hard to reconcile. “If a hospital is in the business of taking care of psychiatric patients, then I just don’t see how this happens,” he said. “I just don’t understand it, because they’re the experts.”

Prinslow’s job is to oversee hospital inspections and certification for Oregon.

In 20 years of working in the hospital inspection field in Oregon, he can’t remember another case of a patient dying while being restrained in one of Portland’s hospitals.

Hospital not forthcoming

Elaine Shipman now says she never really believed that her son died of cardiac arrest. She cites a number of reasons.

The family went to the hospital, Elaine Shipman said, and found Glenn Shipman on life support. But what they heard didn’t sound right to them, Elaine Shipman said.

“The doctor didn’t say he had a heart attack,” she said. “He just said his heart stopped beating.”

Two months after Shipman’s death, Elaine Shipman, Kathy Shipman, friend Jim Morud and a pastor from the family’s church went to Legacy Emanuel and met with staff members at the hospital.

According to Elaine Shipman, across the table were the chief of the hospital’s psychiatric department, a patient safety representative, a nursing supervisor, the hospital’s head of security and a nurse.

Elaine Shipman couldn’t understand why the physician across the table from her didn’t talk about what had happened in his department.

“The doctor never had anything to say,” she said. “It was like it was canned. The head doctor sat there, and his expression never changed. He just sat there looking at everybody. I felt like he was monitoring the situation to make sure nobody said anything out of turn.”

But someone did say something out of turn, she now thinks. According to Elaine Shipman, a nurse called her from the hospital, shortly after Glenn Shipman’s death.

“She said, ‘We’re sorry,’ ” Elaine Shipman said. “But what I thought kind of strange is she said, ‘In cases like this the hospital likes to send flowers, unless the family objects.’ What does she mean, ‘In cases like this?’ ”

The hospital’s flowers were on display at Glenn Shipman’s Sept. 9 memorial service.

Elaine Shipman and her family did not know the details of what caused Glenn Shipman’s death until Friday, when the Portland Tribune showed them a copy of the DHS report. That report was completed sometime after Sept. 19.

On Friday, having read the investigation report, Elaine Shipman, Kathy Shipman, and Morud stood around a kitchen table, bowed their heads and said a prayer of gratitude that finally the truth had come to them.

And Elaine Shipman said that the family had no intention of seeking out an attorney to file a lawsuit against Legacy Emanuel.

“Glenn’s memory isn’t for sale, and we aren’t either,” Kathy Shipman said.


TIMELINE - Truth slow to come

Glenn Shipman Jr. is brought to Legacy Emanuel Hospital & Health Center in North Portland in handcuffs by police “after becoming out of control at home,” according to a report from the Oregon Department of Human Services. He is admitted to the emergency department.

6:15 p.m. Aug. 24

Shipman is transferred to the hospital’s psychiatric unit.

Between 6:15 p.m. and 6:30 p.m.

Hospital staff see Shipman walk out of his room and down the hall. Shipman pushes a staff member who tries to block his advance. That staff member and another staff member take Shipman to the floor.

6:40 p.m.

After several hospital security workers arrive and help restrain Shipman on the floor, a hospital staff member notices Shipman’s left hand has turned “blue” and he apparently has stopped breathing.

7:05 p.m.

After Shipman is given cardiac drugs through an intravenous line, Shipman has a heart rate of 130 beats per minute, and is transferred to the hospital’s intensive care unit.

Sometime on Aug. 25

Hospital officials perform a computerized scan on Shipman’s brain. The scan shows that Shipman’s brain was damaged by lack of oxygen.

2 p.m. Aug. 26

Doctors meet with Shipman’s family to “discuss the patient’s condition.” According to family, they say Shipman suffered cardiac arrest.

3:38 p.m. Aug. 26

Shipman dies.

Oct. 5

State medical examiner issues death certificate, listing cause of death as “compression asphyxia,” or asphyxiation.

Oct. 18

DHS report notes several failures in Shipman’s case, including that the “facility staff restrained a patient to the floor in the prone (face-down) position without adequate monitoring of the patient’s condition.”

Oct. 23

After the family’s request, the Shipman family, its pastor and another family friend meet with Legacy Emanuel staff and officials. Hospital staff say Shipman died of cardiac arrest and make no mention of the DHS findings.

Nov. 30

Shipman family learns for the first time that the restraint incident probably caused Shipman’s death — after being given a copy of the DHS report by a Tribune reporter.
‘Gentle giant’ had many soft spots

Glenn Shipman struggled with mental illness, building a life

Glenn Shipman Jr. struggled all his life not to be defined by his mental illness or his size, according to his family. In the end, his illness and size might have cost him his life.

Shipman was asphyxiated on his 50th birthday while a patient in the psychiatric unit of Legacy Emanuel Hospital & Health Center in Portland.

A schizophrenic, Shipman could be delusional, even paranoid, said his mother, Elaine Shipman. And he weighed well over 400 pounds, the result of weight gain that began when he started taking psychiatric medications at age 30, according to his mother.

Elaine Shipman thinks that the combination of her son’s size and his illness probably was frightening to Legacy Emanuel workers who, she said, might not have realized that he wasn’t a violent man.

Frightened, he might not cooperate with hospital staff, she believed. He would have tried to walk away from them, she said, but he would never attack them or intentionally try to hurt them.

But false assumptions had long been made about Glenn Shipman. Elaine Shipman recalled that a high school football coach, certain that a husky, teenage Glenn would excel at the sport, repeatedly asked her to convince Glenn to come out for the team.

But Glenn, she said, abhorred physical contact. Finally she persuaded him to try one practice, which he did before quitting.

Glenn Shipman’s talent was with computers — he set up and repaired computers for friends and family and for a while ran a small computer-repair business.

And he liked to cook. His mother recalled the first meal he prepared.

She said that she had gone back to work after a number of years staying home with her children. When she returned to the house one evening Glenn had made dinner — baked chicken with orange sauce, baked potatoes and a salad. He was 14.

When a family at Cedar Mill Bible Church had a baby, according to Elaine Shipman, Glenn on his own began preparing meals three times a day and delivering them to the new mother, without telling anyone.

Glenn Shipman attended a number of technical and computer schools but could never quite complete them. He even went to a technical school in Phoenix one year. But he returned home, unable to conquer his mental illness.

At his death Glenn Shipman was in debt from unpaid school loans. He was living on a $10 to $15 weekly allowance from his Social Security disability checks allocated by a credit counseling company.

His mother said that she went through his effects.

“I found his receipts,” she said. “As little money as he had, he had one receipt that was for 40 Bibles sent to Russia.”

And when he looked inward, Glenn Shipman seemingly faced the same problem that others did when they looked at him — he could not in his own mind construct a self-image free of his disease. He longed to have a relationship with a woman, his mother said, but never felt he was worthy.

“He never went on a date,” she said.

Death of Scappoose man questioned

Portland police, hospital officials have been slow to explain the events leading to the cardiac arrest of Glenn Shipman

The South County Spotlight

Questions linger for family and friends of a Scappoose man who died while in the custody of Legacy Emanuel’s psychiatric division in August, though the mother of the man has ruled out police Taser use as a cause of his death.

“The Scappoose police, their actions had nothing to do with it,” said Elaine Shipman of Scappoose.

Elaine, 76, said she arrived at her conclusion regarding the Taser and her son’s death based on information contained within the Multnomah County medical examiner’s report.

Exactly what did happen to Elaine’s 50-year-old son, Glenn Shipman, that led to his cardiac arrest and death remains unclear.

Legacy Emanuel Hospital staff and Portland police officials have made little effort to reach out to Shipman’s mother, who began to doubt whether her son’s death was being investigated as was stated in early media reports.

When first contacted by the Spotlight in mid-October, more than a month after Glenn’s death, Elaine had not been contacted by the Portland Police Bureau, and had received only one telephone call following Glenn’s death from a nurse with Legacy Emanuel who offered to send flowers, Elaine said.

“Nobody has said anything,” she said.

Don Reese, a Multnomah County deputy district attorney, confirmed that it is an open investigation being headed by Detective John Rhodes of the Portland Police Bureau. Rhodes said he is currently reviewing Glenn’s medical records obtained from Legacy Emanuel through a district attorney subpoena.

“That’s where we’re kind of at, is just gathering as much information as we can about the case,” Rhodes said. “You can’t focus on anything in particular until you have the information.”

The police are handling the investigation at the request of the Oregon Medical Examiner’s Office, Rhodes said. The police report into Shipman’s Aug. 26 death is being held confidential as the investigation continues.

Elaine said that she received a telephone call from the hospital informing her Glenn had suffered a cardiac arrest nearly a day after it had occurred.

The news was shocking on several levels, including the revelation that injury had befallen her son while he was housed within the assumed safety of a hospital environment.

“That was part of how shocking it was,” she said.

Upon receiving the call, Elaine traveled to the Portland hospital with Jim Marud, a family friend.

Elaine hesitates to speculate on what might have caused Glenn’s death, and said she does not want to force the hospital or police into a defensive posture.

“We’re trying to work with the hospital, and I don’t want them to get defensive or anything,” she said.

Glenn was on life support and had no brain wave activity when Elaine and Marud arrived at the hospital.

Elaine said she and Marud spoke with the attending doctor while standing at Glenn’s hospital bedside. The doctor provided few details about the events leading up to Glenn’s cardiac arrest, she said.

“The only thing he said was that Glenn was very agitated and the security staff was called in, and then he said that Glenn had a cardiac arrest and stopped breathing and they weren’t able to revive him for 20 to 25 minutes,” Elaine said. “He didn’t give any details. Needless to say I was very stressed at the time, because they didn’t call us until practically a day had gone by.”

Elaine said that one possibility for why the hospital was slow to call was because Glenn was angry at the family for having been returned to the hospital.

A Legacy Emanuel spokeswoman said the hospital is prohibited from commenting on the cause of Shipman’s death due to restrictions outlined in the Health Insurance Portability and Accountability Act, a 2003 piece of broadly interpreted federal legislation that trumps disclosure of just about anything on anybody when it comes to medical records.

“In general, we have full disclosure about patient outcome with patients and their families,” the spokeswoman said.

History of caring, anguish

Glenn, who is a diagnosed schizophrenic, had been staying at his mother’s house because of his mounting feelings of paranoia he felt while living by himself in a Scappoose apartment.

Elaine said he had started to believe his medication was poison and that he had stopped taking it. He had also stopped eating regular meals and was living on popcorn and canned soup, she said.

“I had him stay here because I just didn’t feel he was safe to be alone,” Elaine said. Marud said the illness contradicted Glenn’s outward demeanor. He was a calm, gentle soul, Marud said, and was referred to by friends and family alike as a “gentle giant.”

“He was really a gentle soul, he really was,” Marud said. Glenn had attended a Bible study class taught by Marud, though the relationship between the two was mostly one of friendship.

“I met him at the church we attend, and he was just a really neat, good guy,” Marud said. “It was really, more than anything, just a friendship that we had.”

Marud recounted stories of Glenn sharing Christmas with him and his family, and that they held a large homecoming celebration, complete with a singing quartet, for Glenn after his release a couple of years ago from the psychiatric ward at Legacy Good Samaritan Hospital.

On the basketball court, his gentle touch translated into easy shots from three-point distance.

“He was a great big guy and kind of slow moving, but he could drain them from downtown,” Marud said of the 450-pound Glenn. On the football field, his demeanor was one of protector, not aggressor.

He was also a man of intelligence, Marud said, recounting how Glenn had a special knack for electronics.

“The guy was just way off the charts brilliant when it came to stuff like that,” Marud said. “He struggled mightily, but for a person who had such mental anguish from time to time, he dealt with it maturely, I think, and very carefully.”

On the evening of Aug. 23, Elaine called for Scappoose police assistance when Glenn began to act agitated at her house.

When police arrived, they discovered Glenn threatening to turn the power off to the house. But because he didn’t pose a threat to himself or others, the police determined, there was insufficient cause to take him into custody and they left.

A case worker from Columbia Community Mental Health called for Scappoose police assistance a second time at 10:20 p.m. This time, when police arrived they discovered Glenn acting combative.

Scappoose police Sgt. Doug Carpenter fired a Taser stun gun at Glenn, who responded by yanking the Taser prongs out of his chest. Officer Shaun Barrett fired a second Taser shot into Glenn, who wavered on his feet. While he was off balance, police tackled him and took Glenn into custody.

He was evaluated by paramedics prior to being transported to the hospital in a squad car.

Before departing, Elaine said she heard Glenn tell the police officer that he was sorry for causing a problem.

“I heard him say, I don’t want to hurt anybody, and the one officer said, I know you don’t,” Elaine said.

Elaine said she is hoping the truth comes out about the circumstances leading to her son’s death, not for the sake of vendetta, but to help protect others from experiencing a similar fate.

“I just want, like the lady who started MADD to protect other people from what happened to her daughter, and not so much a vendetta or anything like that, because that won’t bring him back anyway,” she said.