467 Poisoned at Oregon State Hospital
November 18, 1942
One of the most tragic incidents in Salem’s history was the poisoning of nearly 500 patients and staff at the Oregon State Hospital, on the evening of November 18, 1942. Many who ate the scrambled eggs served for dinner that evening would later claim that they had tasted funny, some saying they’d been salty, others saying they tasted soapy. Within five minutes of consuming them, the diners began to sicken, experiencing violent stomach cramps, vomiting, leg cramps, and respiratory paralysis. Witnesses described patients crawling on the floor, unable to sit or stand. The lips of the stricken turned blue, and some vomited blood. The first death came within an hour; by midnight, there were 32; by 4 a.m., 40. Local doctors rushed to the hospital to help out staff doctors. The hospital morgue, outfitted for two to three bodies, was overwhelmed.
Eventually 47 people would die; in all, 467 were sickened. Though five wards had been served the suspect eggs, all the deaths occurred in four; in the fifth, an attendant had tried the eggs, found them odd tasting, and ordered her charges not to eat them.
Officials were baffled, and immediately focused on the frozen egg yolks which all the victims had been served, and which had come from federal surplus commodities. It was thought that the eggs might have spoiled due to improper storage, or even that they might have been deliberately poisoned by a patient who could have gotten a hold of a poison while on furlough. The biggest fear, however, was the fear of sabotage: with the country engaged in World War II, this possibility loomed large. Oregon Governor Charles Sprague ordered all state institutions to stop using the eggs. The federal government issued a similar order, and the Agriculture Department ordered an investigation into the handling of its frozen eggs.
But the eggs were part of a 36,000-pound shipment which had been divided between schools, NYA projects and state institutions in Oregon and Washington, 30,000 pounds of which had already been consumed with no ill effects. State officials confirmed that the eggs had been properly stored, and the president of National Egg Products Inc. pointed out that eggs bad enough to kill would be so obviously spoiled that no one would eat them.
The day after the poisoning, with dozens still ill, pathologists determined that the sickness and death had been caused by sodium flouride, an ingredient in cockroach poison; pathology reports showed large amounts of the compound in the stomachs of the dead victims. Five grams–the size of an aspirin–would have been fatal; some of the dead had eaten more sodium flouride than eggs. Cockroach poison was known to be available at the hospital, kept in a locked cellar room to which only regular kitchen employees had keys. State Police launched an investigation, and began interviewing staff and patients at the hospital.
Finally, several days after the poisonings, two cooks at the hospital, A.B. McKillop and Mary O’Hare, admitted that they knew what had happened, that they had realized soon after the symptoms had struck, but had not come forward for fear of being charged. McKillop took responsibility, saying he had been the one to send a patient trusty, George Nosen, to the cellar to get dry milk powder for the scrambled eggs he was preparing. He had given Nosen his keys to the cellar, and Nosen returned with a tin half-full of powder, an estimated six pounds of which were mixed into the scrambled eggs at McKillop’s direction. When people had begun getting ill, he had questioned Nosen about where he’d found the powder, and discovered he had brought roach poison.
Despite McKillop’s insistence that O’Hare bore no responsibility for the poisoning, and over the objections of the State Police, who had determined that the poisoning was accidental, District Attorney M.B. Hayden ordered both cooks arrested. A grand jury declined to indict them; the patient George Nosen was never charged. Considered by many of his fellow patients to be a mass murderer, he became something of a pariah at the hospital where he spent the rest of his life. Two brief attempts at life outside the institution failed, and he died at the State Hospital 41 years later, after suffering a heart attack during a fight with another patient.
Compiled and written by Kathleen Carlson Clements
Bibliography:
Capital Journal, November 19-December 1, 1942
Oregon State Hospital has been in trouble for some time.
This from 2004, Oregon Bar Association-
Oregon State Bar Bulletin — DECEMBER 2004
By Bob Joondeph
There is trouble at Oregon State Hospital. So what else is new? The Oregonian’s reports of sex-abuse and hush money in the 1990s may seem like old news, but the hospital’s problems are not: deteriorating buildings, some of which are over 100 years old; chronic over-crowding with patients sleeping in closets and seven to a room; chronic under-staffing with nursing, psychiatric and therapist positions remaining vacant for months and years. And don’t forget the 70-plus patients who have been found clinically ready to leave the hospital but can’t because of the lack of step-down community living arrangements. Despite recent efforts to bring relief, things are getting worse.
Why? One cause may be state budget cuts that have left thousands of Oregonians without community mental health and chemical dependency treatment. Another contributor may be Oregon’s methamphetamine epidemic that has created a new cadre of psychotic and neurologically damaged individuals. Some observe that Measure 11 has changed the calculus used by defendants who are deciding whether to assert an insanity defense. Traditionally, a successful insanity defense resulted in more time in custody. Now, due to longer sentences and the sanctions of prison discipline related to behavior problems, a defendant cannot count on a shorter ride in the custody of the Department of Corrections.
One tool that the hospital used for years to control its population was taken away by the Ninth Circuit Court of Appeals in Oregon Advocacy Center v. Mink, 322 F.3d 1101, (2003). ORS 161.370 requires defendants who have been found mentally incapable of facing criminal charges to be committed to a state hospital or released. It was the practice of OSH to refuse transfer of such inmates from jail for weeks or months in order to control the hospital census. The Ninth Circuit upheld Judge Panner’s determination that this practice violated the substantive and procedural due process rights of the inmates and his injunction requiring OSH to admit mentally incapacitated criminal defendants within seven days of a judicial finding of incapacitation. In is interesting to note that OSH still employs a similar tactic for inmates who are awaiting a determination of their fitness to proceed under ORS 161.365.
Whatever the cause, we do know that Oregon’s jails and prisons have recently been flooded with mentally ill inmates and that state hospital admissions of “criminally insane” patients have grown three times faster than planned. Despite the efforts of state and county officials to create new community placements with the money at hand, they are being overwhelmed by the numbers of new customers and hamstrung by the need to use scarce resources to maintain the crumbling infrastructure of Oregon State Hospital. (And no, the problem is not that Dammasch Hospital closed. We would have even fewer services available if Dammasch were still around.)
The solution? This is not a case of not knowing what to do. Nor is it a case of competing interests: staff working conditions, patient treatment and the public purse would all benefit from the changes suggested by the just-released report of the Governor’s Mental Health Task Force. Among key task force recommendations are the following:
- The Legislature should appropriate sufficient funds to permit the orderly restructuring of Oregon State Hospital and the construction and operation of community facilities to support populations of individuals who will no longer be hospitalized.
- Local mental health authorities with support from the state will continue to accept increasing responsibility for assisting individuals to leave state hospitals.
- State and local mental health authorities will create a rolling three-year plan for the construction and operation of community facilities.
The good news is that the governor and the legislature have gotten the message. In November, the legislature’s Emergency Board permitted the shifting of funds within the Department of Human Services to support the creation of 75 new community placements for OSH patients and to go forward with a planning process for addressing the hospital crisis. The question remains whether the 2005 legislature will maintain its resolve to tackle the OSH problem in light of the massive budgetary shortfalls. Not doing so, to paraphrase hospital-speak, would constitute self-harming behavior.
The task force recommendations will take strong leadership to achieve. They will require a short-term influx of money to construct a smaller and/or refocused modern hospital and community facilities needed to accept the present residents of Oregon State Hospital. They will require collaboration among state agencies including the Department of Corrections and the Oregon Youth Authority to assure that acute psychiatric services are available for their inmates.
It is worth the investment. Transforming OSH and accompanying changes in how we use state hospitals will free our mental health system of a gigantic financial weight and allow the dedicated OSH staff to work in safer, more efficient environments. Patients will be safer and receive better treatment. The 25 percent of the state mental health budget that is dedicated to state hospitals will be more available to leverage federal matching funds. Compassionate care and community safety will be best realized by implementing a more modern, cost-effective approach to mental health treatment. The governor and legislature deserve our support to get this job done.
© 2004 Bob Joondeph
ABOUT THE AUTHOR
The author is the executive director of Oregon Advocacy Center.
Right about the same time as the article above, State Senator Gordly requested a Federal Investigation of the Hospital.
Another article made it to the blog Alas, A Blog:
Posted by Ampersand | October 15th, 2004
Sheelzebub at Pinko Feminist Hellcat comments on this Oregonian article, documenting a pattern of abuse and rape by Oregon State Hospital workers at Ward 40, a treatment center for children and teenagers. Even worse, the hospital had a pattern of hushing up these crimes.
The article itself is a litany of horrors, such as a fired hospital staffer using his knowledge of the hospital’s scheduling to kidnap and rape a teenager. (This same staffer apparently raped or molested five other patients; two later committed suicide). The most distressing thing for me, however, is the hospital staff’s apparent refusal to treat sexual abuse of patients as a serious problem. For example, regarding hospital employee and rapist/molester/abuser Ronnie LaCross:
On Valentine’s Day 1991, a day before [supervisor] Brakebill observed “No problems!” with LaCross’ behavior, the psychiatric aide, in violation of hospital policy, gave Darcey [a patient] a red and white teddy bear with a plastic tag that said, “I love you.”
Records show that staff confiscated the tag when Darcey used it to carve bloody wounds on her arms.
About a month later, two teenage patients demanded that staff stop LaCross from abusing Darcey. But hospital officials failed to take action.
The hospital waited almost three days before calling her caseworker at the state’s children’s services agency. The hospital did not inform police as required by law. After pestering the hospital for two days to report the suspected abuse, the caseworker called state police herself, records show.
Five months later, Mazur-Hart, the hospital superintendent, ruled that Darcey’s allegations were true. LaCross, who spent several months on paid leave, was eventually fired and convicted of second-degree sexual assault.
The girl who made the first complaint about LaCross more than a year earlier was named as an “additional victim” in police reports in the Darcey case. She told police that besides fondling her breast, LaCross had sex with her three times on the ward. LaCross was never charged in that case.
KATU’s story (based on the Oregonian’s reporting) includes this tidbit:
Records also suggest that one of the hospital’s whistle-blowers was demoted from his job as a mental therapist and made to scrub pots and pans in the hospital kitchen after he came forward in an affidavit saying he had warned the hospital about the ongoing abuse, The Oregonian reported.
The only reason most of this is known is that sealed court records from 1994 were misfiled in a public-records area. There’s good reason to worry that Ward 40 has continued to be a home for rapists, pedophiles and abusers since 1994. The Oregonian discovered seven cases of alleged child sex abuse in the last four years that were never reported to the chief DHS investigator.
Needed security measures that have become standard at other hospitals have not been taken:
A former worker who has since been convicted of attacking young boys, however, said the hospital was a pedophile’s dream.
In a letter to The Oregonian, Frank Milligan detailed a litany of oversight problems at the hospital, including “far too many blind corners” and a “lack of cameras or even simple surveillance equipment.”
“Should a staff member be so inclined, he/she need only wait for an emergency situation, or a patient to act out and draw the attention of the other staff, to take advantage of the chaos and slip away with a victim.”
Hopefully, the Oregonian article will be a start towards getting Ward 40’s appalling conditions fixed (or better yet, towards getting Ward 40 closed down and replaced with modern small-group homes). If you’d like to write Governor Ted Kulongoski a note asking him to take action, here’s his contact information.
Some useful links:
http://en.wikipedia.org/wiki/Oregon_State_Hospital
http://www.youtube.com/watch?v=jKEeavx3GfI
http://www.historycooperative.org/journals/ohq/109.2/brown.html
http://www.kirkbridebuildings.com/blog/oregon-state-hospital-the-library-of-dust
http://www.flickr.com/photos/photoinference/2994136725/
http://blog.oregonlive.com/politics/2008/01/feds_oregon_state_hospital_con.html
http://www.oregonlive.com/politics/index.ssf/2009/07/federal_investigators_return_t.html
http://www.statesmanjournal.com/article/20090920/NEWS/909200355/1001
Special Master’s Report from last February
The Governor appointed someone to oversee the process of improving conditions at OSH- this is an excerpt, followed by a pdf file of the full report:
Culture
Every organization develops its own culture; how it sees and responds to its world. The hospital is no different. Successfully changing the culture of this organization is the single most important factor in achieving the goal of establishing the Oregon State Hospital as a first rate hospital for the mentally ill.
For many decades the hospital has been under-funded, under-staffed, over-populated, under-managed, and housed in inadequate facilities. It is no wonder that over time it has become a highly calcified organization lacking in incentive to change and burdened by learned helplessness. It has been clear from working with a variety of people in the hospital that many problems have been well known and have existed for years with little or no attempt to solve them. There appears to never have been a culture in the organization that was supportive of people taking responsibility to do problem solving at the level where the problem is occurring.
Another aspect of the hospital culture that deserves mentioning is what I might call the “ward ” view as opposed to a “hospital” view. Largely, I believe, because of the original design of the hospital, staff and patients alike have tended to see each ward as a separate hospital and have tended to operate from that perspective. This has made the management of the hospital as an integrated whole a very difficult task. The centralized model for delivering treatment in the new facility should eliminate the “ ward” view and help facilitate the shift to a “hospital” view. This shift should enable the hospital as an organization to become much better managed and operated. This will be an extremely important transition and one that will be quite difficult for many in the hospital to make.
It also appears that the rather pervasive view of the hospital by staff has been to see it as a long term care facility instead of viewing it as an intensive treatment facility. These two different views produce two very different approaches to dealing with patients. The current view seems to be characterized by a general belief that most patients are going to be hospitalized for a long time and that there is no great urgency about moving them through treatment as rapidly as possible. The culture of the hospital needs to be one of viewing itself as an intensive treatment facility that is part of a treatment continuum. There needs to be an attitude by all management and staff and instilled in patients, that the hospital’s role is to complete their portion of the treatment of the patient as quickly as possible, consistent with best medical practice, so that the patient can move on to the next stage of recovery and return to the community as rapidly as possible.
These and many more hospital culture issues need to be identified, explored and new cultural norms created as needed to see that the whole atmosphere of the hospital promotes
the best possible treatment of patients in the least time necessary. The hospital needs to develop and implement a comprehensive, long term change plan to accomplish this cultural change. This issue of culture is one that will be a large component in a Request for Proposal (RFP) that is currently being drafted to bring professional consulting services to the hospital transformation project.
Download the full report: specialmastersreport
I often wish that someone would make a serious effort to record the history of this place- from the patients’ perspective. I hear stories every day that would blow your mind. I heard about the story below from a patient who has been there for decades. He was not an eyewitness but he was around while some of the victims were still alive.
467 Poisoned at Oregon State Hospital
November 18, 1942
One of the most tragic incidents in Salem’s history was the poisoning of nearly 500 patients and staff at the Oregon State Hospital, on the evening of November 18, 1942. Many who ate the scrambled eggs served for dinner that evening would later claim that they had tasted funny, some saying they’d been salty, others saying they tasted soapy. Within five minutes of consuming them, the diners began to sicken, experiencing violent stomach cramps, vomiting, leg cramps, and respiratory paralysis. Witnesses described patients crawling on the floor, unable to sit or stand. The lips of the stricken turned blue, and some vomited blood. The first death came within an hour; by midnight, there were 32; by 4 a.m., 40. Local doctors rushed to the hospital to help out staff doctors. The hospital morgue, outfitted for two to three bodies, was overwhelmed.
Eventually 47 people would die; in all, 467 were sickened. Though five wards had been served the suspect eggs, all the deaths occurred in four; in the fifth, an attendant had tried the eggs, found them odd tasting, and ordered her charges not to eat them.
Officials were baffled, and immediately focused on the frozen egg yolks which all the victims had been served, and which had come from federal surplus commodities. It was thought that the eggs might have spoiled due to improper storage, or even that they might have been deliberately poisoned by a patient who could have gotten a hold of a poison while on furlough. The biggest fear, however, was the fear of sabotage: with the country engaged in World War II, this possibility loomed large. Oregon Governor Charles Sprague ordered all state institutions to stop using the eggs. The federal government issued a similar order, and the Agriculture Department ordered an investigation into the handling of its frozen eggs.
But the eggs were part of a 36,000-pound shipment which had been divided between schools, NYA projects and state institutions in Oregon and Washington, 30,000 pounds of which had already been consumed with no ill effects. State officials confirmed that the eggs had been properly stored, and the president of National Egg Products Inc. pointed out that eggs bad enough to kill would be so obviously spoiled that no one would eat them.
The day after the poisoning, with dozens still ill, pathologists determined that the sickness and death had been caused by sodium flouride, an ingredient in cockroach poison; pathology reports showed large amounts of the compound in the stomachs of the dead victims. Five grams–the size of an aspirin–would have been fatal; some of the dead had eaten more sodium flouride than eggs. Cockroach poison was known to be available at the hospital, kept in a locked cellar room to which only regular kitchen employees had keys. State Police launched an investigation, and began interviewing staff and patients at the hospital.
Finally, several days after the poisonings, two cooks at the hospital, A.B. McKillop and Mary O’Hare, admitted that they knew what had happened, that they had realized soon after the symptoms had struck, but had not come forward for fear of being charged. McKillop took responsibility, saying he had been the one to send a patient trusty, George Nosen, to the cellar to get dry milk powder for the scrambled eggs he was preparing. He had given Nosen his keys to the cellar, and Nosen returned with a tin half-full of powder, an estimated six pounds of which were mixed into the scrambled eggs at McKillop’s direction. When people had begun getting ill, he had questioned Nosen about where he’d found the powder, and discovered he had brought roach poison.
Despite McKillop’s insistence that O’Hare bore no responsibility for the poisoning, and over the objections of the State Police, who had determined that the poisoning was accidental, District Attorney M.B. Hayden ordered both cooks arrested. A grand jury declined to indict them; the patient George Nosen was never charged. Considered by many of his fellow patients to be a mass murderer, he became something of a pariah at the hospital where he spent the rest of his life. Two brief attempts at life outside the institution failed, and he died at the State Hospital 41 years later, after suffering a heart attack during a fight with another patient.
Compiled and written by Kathleen Carlson Clements
Bibliography:
Capital Journal, November 19-December 1, 1942
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