At a six-hour health committee hearing, Department of Behavioral Health Director Barbara J. Bazron said the hospital replaced the chair of its outpatient forensic review board and added a psychiatrist after a former patient allegedly shot a man in March. The agency had acknowledged a day earlier that it failed to properly monitor 46-year-old Hilman Jordan, accused of killing a neighbor in an unprovoked shooting in the parking lot of their Southeast Washington condominium complex.
Jordan spent 17 years at St. Elizabeths after being acquitted by reason of insanity in an unprovoked fatal shooting in 1998. In March, he allegedly shot and killed Javed Bhutto, 63, in another unprovoked attack.
Jordan was released in 2015 but wasn’t returned to the hospital after testing positive for marijuana use in 2018 — a condition of his release, according to court clinical reports, as marijuana was a trigger for his paranoia.
Bazron announced Wednesday the hospital had developed a new tracking system for court orders and has started to supervise urine tests “to ensure the integrity of test results.” In addition, Bazron said the hospital will hire an forensic expert to review outpatient procedures.
She said the agency had also reviewed the cases of 65 former patients found not guilty by reason of insanity to ensure compliance with court-ordered release conditions.
With Bhutto’s widow, Nafisa Hoodbhoy, in the audience, committee chairman Vincent C. Gray (D-Ward 7) asked Bazron whether St. Elizabeths was responsible for his death. In the public summary of a confidential report on its handling of the case, the Department of Behavioral Health assumed no blame for the attack, saying any attempt to link its lax supervision of Jordan to the fatal shooting of Bhutto “would require undue speculation.”
But in comments this week to The Washington Post, Wayne Turnage, the District’s deputy mayor for health and human services, said: “We made mistakes, and the mistakes were pretty egregious, and a resident of the city was horribly murdered.”
“It’s such a stark difference in the two statements,” Gray said.
Bazron didn’t explain the discrepancy, but responded, “I think it’s tragic. . . . We have put a process in place.”
Hoodbhoy, who filed a wrongful-death lawsuit against the city in Superior Court last week, said after the meeting that Bazron “pretty much was on script.”
“I got a sense that they sounded like they were serious in reforming,” she said. “My loss is so great that there is nothing that can replace that, and it’s very sad that it had to come to this to get them to act.”
At the hearing, Iqbal Tareen, who knew Bhutto, called Turnage’s comments “a confession.”
“The agency has acknowledged it was their error,” he said, waving a copy of The Post article at the committee. “This speaks louder than anything else.”
Bazron also was called upon to address other recent problems at St. Elizabeths.
After legionella bacteria, which can cause Legionnaires’ disease, was discovered in the water system Sept. 26, the hospital remained without potable water for about four weeks. The facility, with about 270 patients, continued to admit patients as portable showers and sanitary wipes were brought in. No patients or staff became ill.
The hospital faces a class-action suit filed in U.S. District Court for the District of Columbia on behalf of four patients, alleging care was compromised amid unsanitary conditions.
Gregg Kelley, director of development and communications at the Washington Lawyers’ Committee for Civil Rights and Urban Affairs, which prepared the lawsuit, said in an email that the hearing showed “the Department of Behavior Health could not answer the most basic questions on how it would ensure a safe water supply for its patients.”
Bazron said the city hired a water expert to make recommendations and to develop a water management plan for the hospital. It’s not known how the bacteria was able to enter the system.
“We’re reviewing everything that happened during the water emergency,” Bazron said. “Based on that review, we will come up with what we do moving forward.”
She also responded to allegations of abuse involving three patients at St. Elizabeths from Disability Rights DC, which advocates for patients at the hospital. In a July report, the nonprofit said the patients were improperly restrained, including one whose arm and hip were fractured.
Andrea Procaccino, a staff lawyer for Disability Rights DC, said patients were restrained at “alarming rates” at the facility — 782 times in 2018.
“This is not a therapeutic intervention,” she said.
St. Elizabeths staff members, meanwhile, expressed concerns about their ability to manage violent patients after a nurse was assaulted in January. Susan Nelson, a St. Elizabeths nurse and president of the nurses’ union at the hospital, said more nurses were needed to maintain safety.
“Our staffing is very short,” she said. “The hospital has a lot of volatile patients.”
Bazron said an investigation from the D.C. Department of Health found “no patient abuse took place,” but a review of compliance with restraint and seclusion policies showed additional staff training was needed.
Gray said he was optimistic that Bazron, who took over the department about six months ago, will bring needed reforms to the hospital.
“This stuff with Hilman Jordan would not have occurred under her leadership,” he said in an interview after the meeting. “She seems to have a pretty thorough understanding of the pieces she needs to put in place.”