"Whistleblower reveals serious injuries, lax oversight at Central City Concern’s Sobering Station"

News Article
Article from The Oregonian. June 27, 2020.
Published

By: Maxine Bernstein

One man was seated naked on the floor of a cell at Central City Concern’s Sobering Station, attempting to choke himself with his pants tied around his neck.

Another man removed the zipper from his pants to cut himself and was pounding and kicking the door to his cell. Neither police nor emergency medics were willing to enter the cell to take him to a hospital.

Yet another person bit chunks of their own flesh off their arm in a cell where the walls and door were streaked with blood.

These are among dozens of accounts of people who seriously harmed themselves after they were placed in the Sobering Station’s so-called isolation safety cells, which were supposed to provide a “safer, more compassionate and cost-effective place” for intoxicated people to sober up than the street, jail or emergency room.

Central City Concern abruptly shut down the Portland facility and the Police Bureau stopped sending people there in late December, shortly after the city ombudsman became aware of the egregious safety problems that a whistleblower brought to her attention last fall.

City Ombudsman Margie Sollinger soon discovered a lack of safety checks or any rigorous state regulation as well as lax oversight by the Police Bureau of its contract with the nonprofit.

“It was an across the board failure,” Sollinger said. “We were supposed to be making sure that we were providing a safe environment to people taken into custody on a civil hold and we weren’t doing that.”

Even while police were dispatched to the Sobering Station on emergency medical calls to take patients to hospitals because of injuries they suffered at the facility, the state was giving glowing reports to state lawmakers that all was well.

“From what I could tell, there’s zero state oversight or regulations of these types of facilities,” Sollinger said. “It’s a paper registration system and that is it.”

The Sobering Station served the Portland metro area since 1971, and Central City Concern took over its operations in 1985. In 1991, the city of Portland began funding the program and last signed a four-year contract agreement with the nonprofit in 2016, paying $6.8 million to support the station and its transport vans.

In 2017, the city paid $30,000 to replace one of two vans Central City Concern used to transport intoxicated people to the Sobering Station. The van, though, was improperly outfitted with a wheelchair lift and lacked a liquid barrier or a reinforced back door. It was never used to transport patients, yet the city paid nearly half a million dollars for its hours of service, according to Sollinger.

Some of the problems should not have been surprising as prior work groups and audits highlighted safety concerns and a lack of oversight at the facility more than a decade earlier.

A workgroup in 2007, for example, signaled that the Sobering Station's population was growing to include more people with mental health and drug problems who were harming themselves and becoming a physical threat to staff.

The workgroup, made up of city, county, police and sheriff’s staff and others, recommended a different model of care, finding the Sobering Station was out of date and unequipped to properly handle clients. Thirteen years ago, the group urged enhanced training for staff, a redesign of the physical space and the need for a mental health crisis triage center on site.

Alarming reports

Staff jot notes as they see a man in an isolation safety cell tearing up his shirt, then tying the strips around his neck, attempting to strangle himself. Staff call 911, but don't enter cell until after noticing man "goes unconscious.''

Sollinger examined 911 logs on emergency medical calls from the Sobering Station and asked Central City Concern in November to turn over incident reports on about two dozen calls that referenced significant injuries to clients between 2017 and 2019.

Among those calls were reports of a man with a self-inflected cut to his head and bleeding uncontrollably at 2:19 a.m. on Jan. 27, 2017; a client with a chunk of their lip missing and in need of stitches at 6:25 p.m. on Dec. 18, 2018 ; at least four instances of clients with head injuries between April 4, 2019 through July 17, 2019, one who repeatedly was
banging their head on the floor very hard, another hitting head against safety room window and bleeding and yet another who, kneeling, pounded his head into the toilet and then latter slammed his head against the door.

No. 25 on the list was particularly disturbing but Sollinger was unsure of the date or time it occurred: “person bit large chunks of arm off, blood all over door and walls.‘'

Miles Sledd, Central City Concern’s associate director of primary care, assembled and provided copies of the incident reports to the city, yet he found nothing that fit the last one on the list. Sledd informed Sollinger in a letter that he had checked with staff who didn’t recall any such incident involving someone biting off pieces of their arm.

“Based on staff’s responses,” Sledd wrote to her on Dec. 5, 2019, “I believe this event to be fictional.”

"I believe this event to be fictional,'' Sledd said, when initially asked about an incident where a person had bitten off pieces of flesh in a Sobering Station isolation cell.

The next day, Sollinger shared with Sledd a photo she had received from the whistleblower of the gruesome injury, clearly depicted in one of the Sobering Station’s isolated safety rooms.

Sollinger had alerted Portland police of her findings about serious injuries at the facility early in her inquiry and shared some bloody photos for proof. One blurry photo was a screenshot from a cell phone video that showed a client’s infected foot with ants burrowing into the wound.

“It was pretty alarming,” Police Deputy Chief Chris Davis said. “And it was really obvious to me that we needed to do something about this real quick.”

Police Bureau brass also realized that a former commander, who was a project manager for its Central City Concern contract, had retired and was never replaced, providing a gap in any oversight.

Later, in a Dec. 12, 2019 email to then-Portland police Lt. Chuck Lovell, Sollinger shared other staggering information:

  • Roughly 200 of the Sobering Station’s medical calls to 911 each year have required an ambulance and sometimes a Portland police response to help transport a client to a hospital. By late December 2019, the medical calls already had exceeded 200.
  • Many of the medical calls involved clients who harmed themselves, sustaining injuries while at the Sobering Station.
  • On multiple occasions, staff did not intervene when they saw someone harming themselves in an isolation room but instead called 911 and waited for an ambulance or police before entering, Sollinger discovered in reports. In 2018, for example, one client pulled a light fixture from the ceiling and hung himself from it using his pants. No staff entered the room until police arrived. The client survived. In 2017, staff watched as a man tore up his shirt, then tied the strips from his shirt around his neck and tried to strangle himself. Staff called 911, then noticed the man went unconscious. That’s when staff entered the room to cut off the shirt strips. The man regained consciousness and medics arrived.
  • Nearly half of the people who were the subject of 911 medical calls in the last 2 years of its operation were dropped off by public safety personnel from outside of Portland, yet Portland police had to respond to help transfer them to a hospital.

A man sat naked on the floor of an isolation safety cell, his pants wrapped around his neck. He then attempted to fit his head in the toilet, the report says.

In early December, as Sollinger was still investigating, Central City Concern adopted a more restrictive admission policy. But by late December, the Police Bureau was ready to halt its use of the facility and the Sobering Station decided to close.

Dr. Amanda Risser, Central City Concern’s senior medical director since June 2019, said the agency couldn’t properly handle the growing number of patients arriving in the midst of a mental crisis, agitated from opioid or meth use or a combination of both, leading to increased safety risks. She said they needed either medication or a higher level of monitoring that the station couldn’t offer.

“Safety is why we closed,” she said. “The program design and the physical space of the facility were no longer appropriate for the increased number of patients that were taken to the center, many dealing with both intoxication, drugs and psychiatric crises. It just became clear we couldn’t design our way out of unsafe situations without a new redesigned space and new policies and procedures.”

Risser said emergency medical technicians on staff aren’t required to put themselves at risk to provide medical care.

She said the ombudsman’s list of 911 medical calls from the station were reviewed by her office. “The descriptions listed in the 911 calls don’t always match up with what ended up being discovered,” she said.

But Sollinger, who reviewed the associated incident reports, said she found few disparities. “Call-takers generally write down what someone is telling them. I didn’t notice any major discrepancies.”

“I was having a hard time seeing how the city could, in good conscience, continue using this program,” Sollinger added. “I was relieved when leadership at the Police Bureau and Central City Concern came to the same conclusion and ceased its operation.”

A new design

Risser said the work group’s recommendations from 13 years ago is what is needed today, including a redesign of the physical space with padded rooms and an on-site mental health crisis triage center.

The Police Bureau earlier this year issued a request for proposals for other agencies interested in providing the service. Not one response was received. The mayor’s office has since tapped Bob Day, a retired police deputy chief, to consult on ways to move forward with a new system.

Meanwhile, the Police Bureau asked Central City Concern this spring to submit revised invoices to account for the services it didn’t offer that the bureau paid for, dating back to 2016. The nonprofit’s chief financial officer Sarah Chisholm responded that the nonprofit’s monthly invoices have accurately reflected the Sobering Station’s costs and services performed by contract.

Oregon Health Authority, under a bill that became law in 2017, is required to report to the legislature each regular session on how sobering facilities registered with the agency have provided safe, clean and appropriate environments for police officers to take intoxicated people.

The Sobering Station in Portland is one of only four registered in the state; the others are in Eugene, Medford and Grants Pass. Two more – one in Douglas and another in Klamath counties -- are seeking registration.

In its two-page 2019 report, the state’s health authority informed lawmakers of “no reports of extreme critical incidents such as deaths or aggravated assault or battery” in any of the registered sobering facilities.

The authority also reported that each of the sobering facilities registered in the state, including Central City Concern’s Sobering Station, have “developed successful strategies to manage intoxicated individuals to protect the health, safety and wellbeing of the intoxicated individual, peers, and staff.” The state agency largely relied on the facilities’ self-reporting.

“We can’t do anything unless we get an actual complaint and we didn’t get anything,” said Jeanne Windham, a spokeswoman for the Oregon Health Authority.