Whiting Forensic Hospital is located in Middletown Connecticut adjacent to Connecticut Valley Hospital. The Hartford Courant
Whiting Forensic Division in Middletown on Tuesday, Oct. 13, 2020. The hospital provides treatment and evaluation services for patients with mental health conditions who are involved in the criminal justice system, or are not ready to be safely treated in less restrictive settings.

After two check-ins with staff in the late evening of Aug. 15, 2020, a patient at Whiting Forensic Hospital pulled a sheet from a dirty laundry bin, tied one end in a knot and threw it over the top of their door. The patient, whom the hospital had already determined was at risk of self-harm, then tried to hang themself.

Two different hospital employees walked by the patient’s room over the next four minutes. They did not notice the sheet over the door. It took about eight minutes before a third employee walked past the patient’s room and saw the sheet, found the patient and called for help. The patient survived.

The incident was uncovered in an investigation of Whiting conducted by the state Department of Public Health between October 2019 and March 2021. The resulting report, acquired by the CT Mirror via a Freedom of Information request, found multiple violations of state law, requiring the Department of Mental Health and Addiction Services, which runs Whiting, to submit a plan of correction.

That corrective action plan, which the CT Mirror also acquired, sheds light on ongoing legal proceedings between the state and patient advocates over the closure of a hospital unit at Whiting in May 2021. Dr. Tobias Wasser, Whiting’s chief medical officer, testified in court on June 8 that he had “zealously advocated” to close the unit because having so few staff available to work put patients at risk.

“In theory, if one patient started assaulting another patient, there could be seriously grave harm that could come to that patient by the inability of staff to respond in a timely manner,” said Wasser.

The report underscores how a stubborn staffing shortage at the state’s sole maximum security psychiatric hospital can erode patient safety and exposes the state agency’s failure to fully address that shortage. For example, while DMHAS created a corrective action plan that included a commitment to hire 47 nursing staff employees between March 19 and Aug. 13, it hired only 20.

Whiting’s staff shortage could worsen in the near future. Data released on Oct. 7 showed 112 DMHAS employees — 4% of the agency’s workforce — are not in compliance with the governor’s executive order that they either get vaccinated against COVID-19 or submit to weekly testing. Those Whiting employees who remain in non-compliance could be suspended, potentially further straining the hospital.

We have had multiple instances, particularly in the past six months, where the amount of staff available to us to, even after mandating everyone possible to perform overtime, was drastically below minimum staffing levels.”— Dr. Tobias Wasser, Whiting 

When asked how many of the 112 noncompliant DMHAS employees work at Whiting, agency spokesman Art Mongillo did not provide an exact number.

“A very small number of employees at Whiting are currently noncompliant. We do not believe it will impact staffing,” Mongillo said.

The DPH investigation recounts several serious incidents that lend weight to Wasser’s claims about how dangerous the hospital was becoming, from attempted to suicides to attacks by patients on staff and on each other.

The concerns ultimately led to about a dozen patients — some of whom had lived on unit 6, the unit that officials closed, for years — getting moved to another unit within the hospital. Advocates contend that that movement has made it harder for patients to get the care they need.

“I do not feel safe because I have had conflict with persons on Unit 4 and we will be packed into a smaller unit with almost twice the number of patients,” Hal Bassow, a patient at Whiting who was committed for 13 1/2 years, said in a declaration in the ongoing legal case.

Susan Werboff, a conservator for Anthony Henry, a patient at Whiting who is diagnosed with an intellectual disability, anxiety, depression and autism, said in a declaration filed with the court that Henry had been teased by patients in the unit where they were moving him.

“I do not feel Mr. Henry is safe on Unit 3,”Werboff said. “I also believe that he is at risk of returning to a situation in which he is lethargic or sleeping 24 hours per day and that his health and rehabilitative skills will, in turn, regress.”

Low morale among employees is not a new problem at the Middletown Hospital. In June, members of the CVH Whiting Task Force discussed the results of a survey that suggested staff at Connecticut Valley and Whiting Forensic hospitals feel they work in an under-resourced, overworked environment.

Nor are threats to patient safety unheard of, though hospital leadership said in 2019 that incidents of harm and abuse were trending down. Employees repeatedly kicked, hit and tormented patient William Shehadi Jr. for at least a decade, according to his brother, before state police, in 2017, ultimately charged 10 employees with abuse after reviewing video footage from Shehadi’s room in unit 6 — the same unit hospital officials decided to close last May. Thirty-seven other staffers were placed on administrative leave because of the abuse.

Wasser testified that he was “gravely concerned about the safety of the hospital” because of “dangerously low staffing levels,” which ultimately led to the decision to close the unit.

“We have had multiple instances, particularly in the past six months, where the amount of staff available to us to, even after mandating everyone possible to perform overtime, was drastically below minimum staffing levels,” he said.

The DPH investigation highlights several serious incidents that lend weight to Wasser’s claims. In June 2020, a patient shoved a pen into his penis; a nurse said she was so “short staffed” that it was difficult to monitor him one-on-one.

If the incidents recounted in the investigation highlight the dangerous situations created by low staffing levels, they also underscore the difficulty in hiring and retaining employees in a high-stress setting like a maximum security psychiatric hospital.

Wasser also testified that the department is “trying desperately to hire” to bolster its number of employees.

“But for anyone who is familiar with hiring in a state system, it’s a highly bureaucratic system that can take an extensively long period of time,” he said.

On April 22, 2020, a patient slapped a nurse in the face and pulled her ponytail. Another hospital employee pinned the patient to the ground. The patient, still holding a scrunchy and a clump of the nurse’s hair, was then placed in four-point restraints. The employee was later placed on administrative leave because of an improper use of a restraint technique.

The DPH report found that the hospital did not ensure adequate staffing levels, as required by its approved staffing plan.

For instance, on May 9, 2021, 21 employees at the Whiting maximum security building called out of work. The Director of nurses immediately notified hospital leadership and relocated patients on one unit to other units in the building. The report notes there were “no negative patient outcomes related to staffing issues.” 

The chronic staffing shortage led to the decision on May 18, 2021 to transfer patients from one unit to others at Whiting. Wasser said that move would reduce the number of units where they had to have staff present, making it safer for patients and ultimately reducing the number of staff mandated to work overtime.

In the corrective action plan submitted to DPH on July 30, 2021, DMHAS officials said they planned on hiring 47 people to their nursing staff by Aug. 13. Mongillo said in an email that the department hired 20 people for a variety of nursing staff positions between March 19 and Aug. 13, the period specified in its corrective action plan.

“DMHAS has hired nursing staff to fill positions at Whiting Forensic Hospital (WFH). DMHAS will continue to recruit and hire nursing staff for WFH as needed,” said Mongillo.

Another method to add staff: luring former employees out of retirement to work. According to state records, the state brought back four people from retirement to work at Whiting, three of whom started in 2020paying them between $25 and $35 an hour, according to state payroll records.

As of Aug. 31, 2021, there were 94 nurses working at Whiting, eight more than were working there as of Sept. 21, 2020.

In the June hearing, Wasser testified that Whiting officials noticed about a year ago staff were leaving the job faster than they could be replaced, and they started a new process to recruit more people to join the hospital.

He offered a few reasons for why people left: “fiscal incentives in the union contract” that motivate employees to retire by 2022, and an executive order the governor issued in September 2020 that state agencies subject prospective hires to greater scrutiny.

Wasser also said that the merging of the Whiting units didn’t solve all their issues.

“We continue to struggle with the same grave staffing shortages and safety concerns that we did that prompted this decision three weeks ago,” Wasser testified in June, explaining that the previous weekend, they had a shift where the hospital was 12 workers short of its minimum staffing level, even after mandating staff for overtime. “There were staff that had to work on a unit with upwards of 15 patients with only two staff present.”

Dave does in-depth investigative reporting for CT Mirror. His work focuses on government accountability including financial oversight, abuse of power, corruption, safety monitoring, and compliance with law. Before joining CT Mirror Altimari spent 23 years at the Hartford Courant breaking some of the state’s biggest, most impactful investigative stories.

Kelan is a Report For America Corps Member who covers the intersection of mental health and criminal justice for CT Mirror. Before joining CT Mirror, Kelan was a staff writer for City Weekly, an alt weekly in Salt Lake City, Utah, and a courts reporter for The Bryan-College Station Eagle, in Texas. He is originally from Philadelphia.