SHARE Special Report Chronic Crisis: Milwaukee County's mental health system focuses less on continual care and more on emergency treatment than any in the nation. Despite scandals, studies and promises of reform, the system is like many of its patients: It never gets better. Go to section

By of the

Gov. Scott Walker has authorized an investigation into a report on the deaths of four patients at the Milwaukee County Mental Health Complex.

It's not about how the patients died or the conditions there that led to their deaths.

It's an investigation about how the public learned about the claims of substandard care.

The state will investigate whether Disability Rights Wisconsin violated patient confidentiality rules by widely distributing copies of the report — even though it already had been covered by the Milwaukee Journal Sentinel. The investigation would determine whether the organization should be stripped of its role as the state's official advocate for people with disabilities.

The report found that doctors at the complex failed to provide basic medical care, leading to the deaths of four patients in 2012. It was written by William Knoedler, a Madison psychiatrist, based on patient records given to him by Disability Rights Wisconsin.

In the wake of the Journal Sentinel coverage, the county moved to discredit Disability Rights Wisconsin, and asked Walker to investigate the agency. Walker assigned the review of the patient advocacy group to lawyers at the state Department of Health Services on March 12 and notified Milwaukee County of the move this week.

Knoedler on Thursday called the move to undermine the organization "an utter deflection of responsibility."

"Clearly, they care more about their own embarrassment and looking for ways to divert attention than they do about patient care," Knoedler said.

In the report, Knoedler found that conditions at the complex were so poor that the facility should be closed until improvements could be made. Failures were both in psychiatric care — "the area of specialty and presumed expertise" of the staff at the complex — and in basic medical treatment, he found. In some cases, patients went days without adequate medical attention.

Disability Rights Wisconsin gave the report to state and federal officials, County Executive Chris Abele and two county officials last summer, but did not release it to the public or share it with the County Board.

The Journal Sentinel wrote about the report in January.

Disappointed in county

Knoedler said Thursday that no one from the state or county contacted him after the report was made public to ask his advice on what needs to be done to correct the problems that he found.

Jonathan Safran, a lawyer who represents the family of a man who died of complications from a broken neck at the complex, said he, too, is disappointed in the county and state's focus on whether Disability Rights Wisconsin should be disciplined.

"You would have expected them to immediately launch an investigation into the care there, especially given the grave concerns in the report," Safran said.

Brendan Conway, spokesman for Abele, said the county had moved to correct any errors in care before Knoedler's report became public.

Disability Rights Wisconsin has been a key player in pressing for more resources and better patient care at the complex. A Disability Rights official in late 2012 publicly called for state intervention at the complex, a move that prompted criticism from county officials. The group joined with other organizations last summer in calling for an increase in the county budget for more community mental health programs.

State legislation passed last week transfers oversight of the complex to a new board of mental health professionals and advocates appointed by the governor. Walker is expected to sign that into law soon.

The Journal Sentinel's "Chronic Crisis" investigation prompted the state legislation. The series told how Milwaukee County's mental health system focused more heavily on emergency treatment rather than continual care than any system in the country.

Patient identification

County Corporation Counsel Paul Bargren confirmed the governor's action came in response to a request by the county. Bargren said it was a consensus decision of Abele, county supervisors and administrators at the Mental Health Complex to seek the state investigation of the rights group.

County officials have complained that the rights group's report led to identification of some dead patients, even though no names or other personal information were used in the report.

Walker's action calls for a determination of whether Disability Rights Wisconsin should have its role as the state's official patient protection and advocacy agency revoked over the report's dissemination.

Before that could happen, the state would have to issue a formal finding of "good cause" to strip the patient advocacy designation from Disability Rights and give interested parties a chance to comment on the move.

Disability Rights Wisconsin is a nonprofit that operated on a$4.5 million budget in 2013. Losing the patient advocate designation — something Disability Rights Wisconsin has held since its founding in 1977 — would mean the loss of federal grants comprising about 40% of its total budget, said Dan Idzikowski, executive director of the rights group.

Walker directed Sandra Rowe, the chief legal counsel for the state Department of Health Services, to conduct the investigation of Disability Rights Wisconsin. He didn't give a time frame for completion of the investigation and a department spokeswoman did not immediately respond to a question on the time frame for the probe.

Cognitive Dissidence, a local blog authored by Chris Liebenthal, first reported the Disability Rights investigation Wednesday. Liebenthal is a human services worker for the county in the same department that runs the Mental Health Complex.

The rights group investigates reports of patient abuse and has access to hospital and other patient records.

Confident of compliance

After the Journal Sentinel wrote about the report, the rights group distributed copies to about 60 members of the county's Mental Health Task Force and hundreds of others on a task force mailing list. The report also was posted on the rights group's website.

Names and other personal patient information were blacked out.

According to a Jan. 20 letter by Bargren, those actions violated a confidentiality agreement Disability Rights Wisconsin signed with the county in 2011, when it was investigating earlier allegations of patient abuse at the Mental Health Complex.

The distribution of Knoedler's report also may have violated federal law protecting patient privacy, Bargren wrote in a Feb. 11 letter to Walker and other state officials.

"Such a disclosure constitutes a grave breach of DRW's statutory and ethical patient confidentiality obligations and should prompt reconsideration of its role as Wisconsin's protection and advocacy agent," the Feb. 11 letter says.

Idzikowski said Thursday there was no violation of patient confidentiality.

"We redacted any names or any other protected health information, in compliance with all the laws on patient confidentiality," Idzikowski said. "We are very confident that we complied with all laws regarding confidentiality."

The agency took an additional step and obtained permission from relatives of two of the deceased patients to publicly use any part of those patients' records Disability Rights thought might be useful, he said.

Kristin Kerschensteiner, managing attorney for the rights group, said in a letter to the county that the group did not breach its confidentiality agreement with the county or break any state or federal patient confidentiality laws.

She said no one from the rights group leaked the report to the Journal Sentinel. But once the Journal Sentinel posted the report on its website in January, it "became generally available to the public," Kerschensteiner said.

Furthermore, Disability Rights "has complied with all relevant provisions of these (patient confidentiality) laws and properly protected the individuals' identity," Kerschensteiner wrote.

Knoedler's report didn't name any of the patients who had died at the complex, but discussed some details of poor care they received there.

Names of those patients had been publicly disclosed in medical examiner and law enforcement reports. One of the patients who died in 2012, Brandon Johnson, was the subject of an open Joe Doe investigation into circumstances surrounding his death from complications of a broken neck.

Twitter: twitter.com/SteveSchultzeJS

How to contact county and state officials

Gov. Scott Walker: (608) 266-1212, govgeneral@wisconsin.gov

Milwaukee County Executive Chris Abele: (414) 278-4244, chris.abele@milwaukeecountywi.gov

Hector Colon, Milwaukee County health and human services director: 414-289-6481, hector.colon@milwaukeecountywi.gov

James Kubicek, acting administrator for Milwaukee County Behavioral Health Division, (414) 257-4823, james.kubicek@milwaukeecountywi.gov

Supervisor Deanna Alexander, (414) 278-4259, deanna.alexander@milwaukeecountywi.gov

Supervisor Mark Borkowski, (414) 278-4253, mark.borkowski@milwaukeecountywi.gov

Supervisor David Bowen, (414) 278-4265, david.bowen@milwaukeecountywi.gov

Supervisor Gerry Broderick, (414) 278-4237, gerry.broderick@milwaukeecountywi.gov

Supervisor David Cullen, (414) 278-4263, david.cullen@milwaukeecountywi.gov

Supervisor Marina Dimitrijevic, (414) 278-4232, marina.dimitrijevic@milwaukeecountywi.gov

Supervisor Jason Haas, (414) 278-4252, jason.haas@milwaukeecountywi.gov

Supervisor Willie Johnson Jr., (414) 278-4233, willie.johnson@milwaukeecountywi.gov

Supervisor Patricia Jursik, (414) 278-4231, patricia.jursik@milwaukeecountywi.gov

Supervisor Theo Lipscomb Sr., (414) 278-4280, theodore.lipscomb@milwaukeecountywi.gov

Supervisor Michael Mayo Sr., (414) 278-4241, michael.mayo@milwaukeecountywi.gov

Supervisor Khalif Rainey, (414) 278-4278, khalif.rainey@milwaukeecountywi.gov

Supervisor Peggy Romo West, (414) 278-4269, peggy.romowest@milwaukeecountywi.gov

Supervisor Jim "Luigi" Schmitt, (414) 278-4273, james.schmitt@milwaukeecountywi.gov

Supervisor Russell Stamper II, (414) 278-4201, russell.stamper@milwaukeecountywi.gov

Supervisor Anthony Staskunas, (414) 278-4247, anthony.staskunas@milwaukeecountywi.gov

Supervisor Steve F. Taylor, (414) 278-4267, steve.taylor@milwaukeecountywi.gov

Supervisor John Weishan Jr., (414) 278-4255, john.weishan@milwaukeecountywi.gov