End-2 on Record of Proceedings of Board

of Investigation of May 23, 1949.

(JAG:I:4:WS:edn, A17-25/LL(Forrestal,

James V.) Bnd. #45181 of 7 June 1949.

H. L. Pugh

H. L. PUGH

Rear Admiral (MC) USN

Acting Chief of Bureau

O. V. Bergren

[20] RECORD OF PROCEEDINGS IN REVISION



of a



BOARD OF INVESTIGATION



Convened at the



NATIONAL NAVAL MEDICAL CENTER, BETHESDA, MARYLAND,



By order of



The Medical Officer in Command, National Naval Medical Center, Bethesda, Maryland.



To inquire into and report upon the circumstances attending the death of the late James V. Forrestal,

that occurred on May 22, 1949, at the U. S. Naval Hospital, National Naval Medical Center, Bethesda, Maryland.





July 13, 1949 [21] A17-25 / LL (Forrestal, James V.) HEADQUARTERS POTOMAC RIVER NAVAL COMMAND

UNITED STATES NAVAL GUN FACTORY

WASHINGTON, D. C.



RC1/A17-25(140)

Code 22



Serial No. [stamp: 10074 ] [stamp: 6 JUN 1949 ] [stamp: RECEIVED 2342

17 JUN 1949

OFFICE OF JUDGE ADVOCATE GENERAL ] RC1/A17-25(140)Code 22 The proceedings and finding of facts of the board of investigation in the attached case, and the action of the convening authority thereon, are approved.



G. B. Davis

G. B. DAVIS

Bound

45181

CARDS MADE

FINDING OF FACTS.

RECORD OF PROCEEDINGS



of a



BOARD OF INVESTIGATION



Convened at the



NATIONAL NAVAL MEDICAL CENTER, BETHESDA, MARYLAND,



By order of



The Medical Officer in Command, National Naval Medical Center, Bethesda, Maryland.



To inquire into and report upon the circumstances attending the death of the late James V. Forrestal,

that occurred on May 22, 1949, at the U. S. Naval Hospital, National Naval Medical Center, Bethesda, Maryland.







May 23, 1949.

Record of Proceedings

of a

Board of Investigation

Convened at the

National Naval Medical Center, Bethesda, Maryland,

By order of

The Medical Officer in Command, National Naval Medical Center, Bethesda, Maryland

To inquire into and report upon the circumstances attending the death of the late James V. Forrestal

that occurred on May 22, 1949, at the U. S. Naval Hospital, National Naval Medical Center, Bethesda, Maryland.



May 23, 1949.



Index

Page

[sic]

EXHIBITS

Introduced on Page No.

[sic]

NATIONAL NAVAL MEDICAL CENTER

BETHESDA, MARYLAND

22 May 1949



From: The Medical Officer in Command. To: Captain Aclpfar A. Marsteller, MC, U. S. Navy (Ret.) Active,

National Naval Medical Center

Bethesda, Maryland Subj: A Board of Investigation to inquire into and report upon the circumstances attending the death of Mr. James V. Forrestal.

M.D. Willcutts

M. D. WILLCUTTS,

REAR ADMIRAL, MEDICAL CORPS, U. S. NAVY

MEDICAL OFFICER IN COMMAND, NATIONAL NAVAL MEDICAL CENTER

BETHESDA, MARYLAND

SENIOR OFFICER PRESENT



FIRST DAY

NATIONAL NAVAL MEDICAL CENTER

BETHESDA, MARYLAND.



MONDAY, MAY 23, 1949.



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SECOND DAY.

NATIONAL NAVAL MEDICAL CENTER

BETHESDA, MARYLAND.



TUESDAY, MAY 24, 1949.



O. V. BERGRENRear Admiral, U. S. NavyCommandant, Potomac River Naval CommandDeath of Mr. James V. Forrestal.1. That the body found on the ledge outside of room three eighty-four of building one of the National Naval Medical Center at one-fifty a.m. and pronounced dead at one fifty-five a.m., Sunday, May 22, 1949, was identified as that of the late James V. Forrestal, a patient on the Neuropsychiatric Service of the U. S. Naval Hospital, National Naval Medical Center, Bethesda, Maryland.2. That the late James V. Forrestal died on or about May 22, 1949, at the National Naval Medical Center, Bethesda, Maryland, as a result of injuries, multiple, extreme, received incident to a fall from a high point in the tower, building one, National Naval Medical Center, Bethesda, Maryland.3. That the behavior of the deceased during the period of his stay in the hospital preceding his death was indicative of a mental depression.4. That the treatment and precautions in the conduct of the case were in agreement with accepted psychiatric practice and commensurate with the evident status of the patient at all times.5. That the death was not caused in any manner by the intent, fault, negligence or inefficiency of any person or persons in the naval service or connected therewith. Organization of board . . . . . . . . . . . . . . 1Board met . . . . . . . . . . . 1, 2, 33, 56 and 59Identification of body . . . . . . . . . . . . . 1View of Rooms sixteen eighteen and sixteen twentyBuilding one, National Naval Medical Center,Bethesda, Maryland . . . . . . . . . . . . . . . . . . 1View of scene of landing of the body. . . . . . . 1Board recessed. . . . . . . . . . . . . . 1, 7,18 38Board reconvened. . . . . . . . . . . . . 1, 7,18 38Introduction of photographs of the body of the deceased. . 2Introduction of photographs of scenes of Room sixteeneighteen and room sixteen twenty and outside ofbuilding one, National Naval Medical Center, Bethesda,Maryland. . . . . . . . . . . . . . . . . . . . 4Introduction of clinical record of the deceased. . 8Introduction of bathrobe cord. . . . . . . . . . . 37Introduction of photographs of external injuries takenimmediately preceding autopsy. . . . . . . . . . 55Introduction of letter of Doctor William C. Menninger. . 57Introduction of letter of Doctor RobertW. Waggoner. . . 57Board adjourned. . . . . . . . . . . . . 2, 33, 56 58Investigation finished. . . . . . . . . . . . . . 61Finding of facts. . . . . . . . . . . . . . . . . 61- - - - - - - - - - - - - - - - - - - - - - - - - - -Name of Witnesses Page- - - - - - - - - - - - - - - - - - - - - - - - - - -Harley F. Cope, junior, Aviation photographer’s matefirst class, U. S. Navy. . . . . . . . . . . 2, 3John Edward McClain, Hospitalman chief, U. S. Navy . . 3, 4George N. Raines, Captain, Medical Corps, U. S. Navy5 through 1456 through 60John E. Nardini, Commander, Medical Corps, U.S. Navy. .14 through 18David P. Hightower, Commander, Medical Corps,U. S. Navy. . . . . . . . . . . . . 18 through 23Robert Reynolds Deen, Commander, Medical Corps,U. S. Navy. . . . . . . . . . . . . 23 through 28Page one of two pages. Page two of two pages.- - - - - - - - - - - - - - - - - - - - - - - - - - -Name of Witnesses Page- - - - - - - - - - - - - - - - - - - - - - - - - - -Stephen M. Smith, Captain, Medical Corps, U. S. Navy 29 through 33William Eliades, hospitalman second class, U. S. Navy34 through 36Willie Ray Barnett, Lieutenant junior grade,Medical Service Corps, U. S. Navy. . . . . . . . 36, 37John Lawrence Mego, Hospitalman chief, U.S. Navy. . 37, 38Leslie O. Stone, Rear Admiral, Medical Corps, U.S.Navy . 38, 39Bartholomew W. Hogan, Captain, Medical Corps, U.S.Navy . 39Francis Whitney Westneat, Lieutenant junior grade,Medical Corps Reserve, U. S. Naval Reserve. . . 40, 41William Charles Mulry, Lieutenant Commander, MedicalCorps, U. S. Navy. . . . . . . . . . . . . . . . 42Robert Wayne Harrison, junior, Hospital apprentice,U. S. Navy. . . . . . . . . . . . . . . . 43 through 46Edward William Price, Hospital apprentice, U.S. Navy 47, 48Regina M. L. Harty, Lieutenant, Nurse Corps, U.S.Navy. . . . . . . . . . . . . . . . . . . .49,50,51Edwin Utz, Hospital apprentice, U.S. Navy. . . . . . . 51, 52Dorothy Turner, Lieutenant junior grade, U. S. NavalReserve. . . . . . . . . . . . . . . . . . . . . 53, 55William M. Silliphant, Captain, Medical Corps, U.S.Navy. . . 54, 55- - - - - - - - - - - - - - - - - - - - - - - - - - -Pictures of body of deceased,Exhibits 1 A through 1 J. . . . . . . . . . . . 2Photograph of Rooms sixteen eighteen andsixteen twenty and outside of buildingone, National Naval Medical Center,Bethesda, Maryland. . . . . . . . .Exhibits 2 A through 2 K. . . . . . . . . . . . 4Clinical record of the deceased,Exhibit 3. . . . . . . . . . . . . . . . . . .. 8Bathrobe cord, Exhibit 4. . . . . . . . . . . . . 37Photographs of external injuries takenimmediately preceding autopsy,Exhibit 5. . . . . . . . . . . . . . . . . . .. 55Letter of Doctor William C. Menninger,Exhibit 6. . . . . . . . . . . . . . . . . . . 57Letter of Doctor Raymond W. Waggoner,Exhibit 7.. . . . . . . . . . . . . . . . . . . 571. A Board of Investigation consisting of yourself as Senior Member and Captain Vincent Hernandez, MC, U. S. Navy, Captain Harold J. Cokely, MC, U. S. Navy, Commander William W. Ayres, MC, U. S. Navy, and Lieutenant Commander James D. Wharton, MC, U. S. Navy, as recorder, will convene at the U. S. Naval Hospital, National Naval Medical Center Bethesda, Maryland, at the earliest opportunity for the purpose of inquiring into and reporting upon the circumstances attending the death of Mr. James V. Forrestal, which occurred on May 22, 1949, at the U. S. Naval Hospital, National Naval Medical Center, Bethesda, Maryland.2. The Board is hereby empowered and directed to administer an oath to each witness attending to testify or depose during the course of the proceedings of the Board of Investigation.3. The proceedings of the Board will be conducted in accordance with the provisions of Chapter X, Naval Courts and Boards, and a complete Finding of Facts submitted.4. The attention of the Board is particularly invited to the provisions of sections 731, 732, 733, 734 and 735, Naval Courts and Boards.5. By copy of this precept, the Commanding Officer, U. S. Naval Hospital, National Naval Medical Center, Bethesda, Maryland, is directed to furnish the necessary clerical assistance.The Board met at 11:45 a.m.Present:Captain Aclpfar A. Marsteller, Medical Corps, U. S. Navy (Ret.) Active, Senior Member;Captain Vincent Hernandez, Medical Corps, U. S. Navy,Captain Harold J. Cokely, Medical Corps, U. S. Navy, andLieutenant Commander James D. Wharton, Medical Corps, U. S. Navy,members; andLieutenant Robert F. Hooper, Medical Corps, U. S. Navy, recorder.Mrs. Margaret H. Garrett, Civilian, was introduced as reporter.The convening order, hereto prefixed, was read, and the board determined upon its procedure and decided to sit with closed doors.No witnesses not otherwise connected with the investigation were present.The board announced that it would adjourn to the Morgue at the U. S. Naval Medical School, National Naval Medical Center, Bethesda, Maryland, for the purpose of viewing the body.The members of the board examined the body and identified it as that of the late James V. Forrestal, and recommended that an autopsy be made.The members of the board then proceeded to Room sixteen eighteen, tower sixteen, building one of the National Naval Medical Center, Bethesda, Maryland, and viewed the room occupied by the late James V. Forrestal and then proceeded to Room sixteen twenty, the galley on tower sixteen of building one of the National Naval Medical Center, Bethesda, Maryland, for the purpose of viewing that room.The members of the board then proceeded to the scene of the landing of the body. It was noted that the body landed on the roof of the second deck, on a level with the third deck, striking first a ledge of the fourth deck on the northeast corner of building one of the National Naval Medical Center, Bethesda, Maryland.All the members of the board returned to the regular place of meeting where the board was reassembled.Present: All the members, the recorder, and the reporter.The board then, at 12:30 p.m., took a recess until 1:30 p.m., at which time it reconvened.Present: All the members, the recorder, and the reporter.No witnesses not otherwise connected with the investigation were present. The board then, at 2:18 p.m., adjourned until 9:00 a.m., tomorrow, May 24, 1949.The court met at 9:07 a.m.Present:Captain Aclpfar A. Marsteller, Medical Corps, U. S. Navy (Ret.)Active, Senior member;Captain Vincent Hernandez, Medical Corps, U. S. Navy,Captain Harold J. Cokely, Medical Corps, U. S. Navy,Commander William W. Ayres, Medical Corps, U. S. Navy, andLieutenant Commander James D. Wharton, Medical Corps, U. S. Navy,members; andLieutenant Robert F. Hooper, Medical Corps, U. S. Navy, recorder.Mrs. Margaret H. Garrett, Civilian, reporter.The record of proceedings of the first day of the investigation was read and approved.No witnesses not otherwise connected with the investigation were present.A witness was called, entered, was duly sworn and was informed of the subject matter of the investigation.Examined by the recorder:1. Q. State your name, rate and present station of duty.

A. Harley F. Cope, junior, Aviation photographer’s mate first, U. S. Navy, Navy Medical School, Bethesda, Maryland.

2. Q. What are your duties at the Naval Medical School?

A. I am attached to – am finishing work done on the African Expedition that was sent from here.

3. Q. Were you called upon recently to take some pictures?

A. Yes, sir.

4. Q. What were the nature of those pictures?

A. They were of somebody who had fallen from the sixteenth floor to the outside of the third deck and they wanted pictures of the position of the body.

5. Q. I show you ten pictures, can you identify them?

A. Yes, these are the pictures I took.

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The ten pictures of the body were submitted by the recorder to the board and offered in evidence. There being no objection, they were so received and marked “Exhibits 1 A through 1 J.” Examined by the board:6. Q. Can you tell us at what time you arrived on the scene and at what time you took the pictures?

A. Yes, the pictures – that series of pictures were taken between three and three fifteen. The last picture was taken at three fifteen, as a matter of fact.

Neither the recorder nor the members of the board desired further to examine this witness.The board informed the witness that he was privileged to make any further statement covering anything relating to the subject matter of the investigation which he thought should be a matter of record in connection therewith, which had not been fully brought out by the previous questioning.The witness said that he had nothing further to state.The witness was duly warned and withdrew.A witness was called, entered, was duly sworn, and was informed of the subject matter of the investigation.Examined by the recorder:1. Q. State your name, rate and present station of duty.

A. John Edward McClain, hospital corpsman chief, U. S. Navy; station, National Naval Medical School, Bethesda, Maryland.

2. Q. What are your present duties at the Naval Medical School?

A. Instructor in medical photography in the photo lab.

3. Q. Were you called upon recently to take pictures concerned with the death of the late James. V. Forrestal?

A. I was asked to shoot a series of pictures of his room, diet kitchen and up and down of the outside of the building.

4. Q. I show you eleven pictures; can you identify them?

A. Yes, sir. This picture was taken from the diet kitchen window shooting down toward the ground, toward this ledge. The camera was held on the outside of the building.

Examined by the board:5. Q. What ledge – the ledge of where?

A. There apparently was an arm extending out several decks below, sir.

6. Q. What floor would that correspond to?

A. The third floor. Right below that ledge was a roof like in proportion to the second floor; bunch of swabs, racks and looks like a screen there. This second picture was taken standing on a chair in the diet kitchen; I believe that is on the sixteenth floor. I had a man with me who pushed the screen back. You can see the upper corner of the screen, upper right hand corner, gives you a black appearance there. The dots were running diagonally across. Upper portion of picture is building, wing in back of this. This is out of focus. We were shooting for finger prints [sic] which we were requested to get and that is what we have, sir. This third picture was taken standing on the deck with the screen, letting the screen of the window come back in place as near as it would of its own accord

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[sic] ; only thing we could use as identifying mark was the bowl; our object was to show this was a special screen with lock that worked with a key, sir. Picture eight was taken on the sixteenth deck in room sixteen eighteen. We took it of the outboard window front showing this screen would only open to that distance, sir. Picture nine was taken from the roof of the third deck shooting straight up to the diet kitchen window showing the height of the tower, and giving windows and the corner. Number ten is a picture of the room on tower sixteen standing in the outboard left hand corner shooting diagonally across it showing the bed and placement of chair. Picture eleven is the picture from the entrance again showing the screen as far as it will open and the arrangement of that side of the room, sir. which also gave us some fingerprints. The fourth picture is a picture that was shot of the ledge of the third deck. It has identifying marks where it joins into the building. The fifth picture is a picture of a rug with some broken glass on it, taken approximately two feet from the end of the bed. We were unable to get any identifying marks except the rug; couldn’t pick up the bed because the glass wouldn’t show. It was room sixteen eighteen. This is the sixth picture, a picture of the interior of the diet kitchen on the sixteenth floor; we were standing in the hallway shooting into the diet kitchen. That’s all we have, just a picture of that. This is a picture in the bathroom on the sixteenth floor. We set up in the bathrub; only thing we could use as identifying mark was the bowl; our object was to show this was a special screen with lock that worked with a key, sir. Picture eight was taken on the sixteenth deck in room sixteen eighteen. We took it of the outboard window front showing this screen would only open to that distance, sir. Picture nine was taken from the roof of the third deck shooting straight up to the diet kitchen window showing the height of the tower, and giving windows and the corner. Number ten is a picture of the room on tower sixteen standing in the outboard left hand corner shooting diagonally across it showing the bed and placement of chair. Picture eleven is the picture from the entrance again showing the screen as far as it will open and the arrangement of that side of the room, sir.

Examined by the board continued:7. Q. You mentioned picture eight showed that the screen could open; was the screen open when you took the picture or did you open it to see how far it would open?

A. The screen was approximately in that position; I believe I did pull on it, sir, but as far as my opening it or unlocking it I just pulled it on back taut.

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The eleven pictures were presented by the recorder to the board as an exhibit. There being no objection, they were so received and are appended marked “Exhibits 2A through 2K.”Neither the recorder nor the members of the board desired further to examine this witness.The board informed the witness that he was privileged to make any further statement covering anything relating to the subject matter of the investigation which he thought should be a matter of record in connection therewith, which had not been fully brought out by the previous questioning.The witness said that he had nothing further to state.The witness was duly warned and withdrew.A witness was called, entered, was duly sworn, and was informed of the subject matter of the investigation. Examined by the recorder:1. Q. State your name, rank and present station of duty.

A. George N. Raines, Captain, Medical Corps, U. S. Navy, Chief of Neuropsychiatry, U. S. Naval Hospital, Bethesda, Maryland.

2. Q. Captain Raines, would you state your qualifications as a neuropsychiatrist?

A. I am a diplomate of the American Board of Psychiatry and Neurology, certified in psychiatry nineteen forty and in neurology nineteen forty-one. I am a fellow of the American Psychiatric Association, Chairman of the Committee of Nomenclature and Statistics of the American Psychiatric Association, member American Neurological Association, fellow of American College of Physicians, member of the American Academy of Neurology. I have been in psychiatric work since the completion of my internship in nineteen thirty-one with the usual interruptions occasioned by sea duty.

3. Q. Captain Raines, how long have you been Chief of the Neuropsychiatric Service at the Naval Hospital?

A. Since May third, nineteen forty-five.

4. Q. Have you recently had a patient under your care by the name of James V. Forrestal?

A. Yes.

5. Q. When was Mister Forrestal admitted to this hospital?

A. At about seventeen hundred on Saturday, April second, nineteen forty-nine.

6. Q. Under what circumstances was Mister Forrestal admitted to the hospital?

A. On Thursday, March thirty-first, about noon, shortly before noon, the Surgeon General called and said that I was to get packed immediately and dressed in civilian clothes and meet Admiral John Gingrich at the Naval Air Station, Anacostia, for a flight south to see a patient. He was quite uncertain as to how long I would be gone or what the situation was or even where I was going. He said that the patient was Mister Forrestal but there were no details concerning the nature of his difficulty. Admiral Gingrich and I landed at Stuart, Florida, at about eight o’clock that evening and were met and taken to the home of Mister Robert Lovett. Mister Lovett, and subsequently Mr. Artemus Gates who was also at the resort town of Hobe Sound [,] gave us some information of what had been going on with Mister Forrestal who had arrived there two days previously. In general, they described an individual who was quite depressed, sleepless and restless. They also told us, which we had not known before, that Mister Ferdinand Eberstadt had been requested by Mister Forrestal to come to Hobe Sound with a physician and Mister Eberstadt was arriving the following day with Doctor William C. Menninger. Under the circumstances I considered it unethical to take any part in the case despite our having been sent there because Mister Forrestal had designated a physician of his own choice. As a result, I remained completely out of the picture and Doctor Menninger arrived late the following afternoon, April first. He examined Mister Forrestal and Doctor Menninger, Mister Eberstadt, Admiral Gingrich and I then had dinner together to discuss the situation. Menninger was of the opinion that Mister Forrestal had a

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severe depression which was primarily on a reactive basis and had resulted from excessive work with a lot of very difficult responsibilities. He and Mister Eberstadt discussed hospitalization for the patient at some length, paying particular attention to what type of hospital should be employed and where that hospital should be located. Admiral Gingrich and I didn’t participate in this discussion but were present. Doctor Menninger and Mister Eberstadt then arrived at the conclusion Mister Forrestal should be treated in a general hospital, that the Naval Hospital, Bethesda, provided the best possible facilities available. Among other things that entered in their consideration was that Mister Forrestal was suffering with a recoverable illness, that recovery could be expected in a reasonably short period of time, three to six months, that recovery probably would be complete and that attention should be paid to protecting him from unnecessary stigma or any intrusion on his illness that might subsequently interfere with his life. I had been instructed by the Surgeon General to bring Mister Forrestal back to the hospital if he wished to come so that I accepted him as a patient the following morning, April second. I went back on the evening of April first and simply spoke to him along with Doctor Menninger but actually took responsibility for him the following evening. We were flown back and he was admitted here that afternoon.

7. Q. Will you tell the Board the results of your observations and treatment of Mister Forrestal, especially in reference to his mental status?

A. Mister Forrestal was obviously quite severely depressed. I called the hospital from Hobe Sound on the morning of the second and asked that they have two rooms available, one on the officers’ psychiatric section and the other in the tower. At that time I had not examined Mister Forrestal, was not at all sure how much security he needed. On the flight up I had opportunity to talk to Doctor Menninger at great length and to see the patient briefly. As a result, I felt he could be handled in the tower satisfactorily, provided certain security measures were taken. Consequently, he was admitted to the tower with a continuous watch when he arrived here. The history indicated that Mister Forrestal had had a brief period of depression last summer but that this had cleared very rapidly when he went on a vacation. His present difficulties seemed to have started about the first of the year, perhaps a little earlier, with very mild depressive symptoms beginning at that time and a good many physical symptoms, noticably [sic] weight loss and constipation. The depression had been rather marked from about the fifteenth of February nineteen forty-nine but had not become actually overwhelming until the week-end preceding admission which would have been approximately March twenty-fifth and twenty-sixth. At that time he became very depressed and I believe as a result of that relinquished his office some three days earlier than had been previously planned. He was seen by Mister Eberstadt on the Monday before admission and on his advice immediately relinquished his office and went to Florida for a rest. The physical examination was done by Doctor Lang immediately after admission which showed nothing remarkable except some elevation of blood pressure. The neurological examination was negative except for small, fixed pupils which, so far as I know, had no significance. Mister Forrestal was obviously exhausted physically and we postponed any complete studies until such time as his physical condition could

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be alleviated. He was started immediately on a week of prolonged narcosis with sodium amytal. His physical condition was so bad we had difficulty adjusting the dose of amytal because of his over-response to it. About the third night his blood pressure dropped to fifty-five systolic under six grains of amytal. To prevent any confusion in the orders on the case I selected two of the residents [,] Doctor Hightower and Doctor Deen, and put them on port and starboard watch to begin at five o’clock each evening. The doctor on watch slept in the room next to Mister Forrestal. On Monday after admission on Saturday security screens were provided for the room that Mister Forrestal occupied and for the head connected with it by moving them from tower five. At the same time a lock was placed on the outer door of the bathroom and strict suicidal precautions were observed. I saw Mister Forrestal for interviews daily during the morning of that first week when he was allowed to come out of his narcosis for short periods of time. These interviews were devoted primarily to history-taking. His response to that early treatment was very good and he gained about two pounds during the course of the weeks’ [sic] narcosis. The following week, beginning the eleventh of April we started Mister Forrestal on a regime of sub-shock insulin therapy combined with psycho-therapeutic interviews. This was continued about four weeks but his response to it was not as good as I had hoped it to be. He was so depleted physically he over-reacted to the insulin much as he had to the amytal and this occasionally would throw him into a confused state with a great deal of agitation and confusion so that at the end of the second week I had to give him a three day rest period instead of the usual one day rest period. I am not sure that that was the end of the second or third week. At the end of the fourth week again he was over-reacting to the insulin and I decided to discontinue it except in stimulating doses. From that time on he was carried with ten units of insulin before breakfast and another ten units before lunch with extra feedings in the afternoon and evening. In spite of this he gained only a total of five pounds in the entire time he was in the hospital. His course was rather an odd one, although in general it followed the usual pattern of such things. The odd part came in the weekly variation of the depression. I can demonstrate it and explain. Instead of the depression lightening, instead of straight up in a line he would come up until about Thursday and then dip, hitting a low point on Saturday and Sunday and up again until the middle of the week and down again Saturday and Sunday. Each week they were a little higher. He was moving upward steadily but it was in a wave-like form. In addition, he had the usual diurnal variation, the low point of his depression occurred between three and five a.m. so that the course towards recovery was double wave-like motion, the daily variation being ingrafted [sic] on his weekly variation. The daily variation is very common, the weekly variation is not so common and that was the portion of the course that I referred to as “odd”.

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The board then, at 10:10 a.m., took a recess until 10:18 a.m., at which time it reconvened.Present: All the members, the recorder, and the reporter.No witnesses not otherwise connected with the investigation were present. George N. Raines, Captain, Medical Corps, U. S. Navy, the witness under examination when the recess was taken, entered. He was warned that the oath previously taken by him was still binding, and continued his testimony.Examined by the recorder continued:8. Q. Captain Raines, I show you a clinical record, can you identify it?

A. This is the nursing record of Mister Forrestal. The only portion I don’t recognize is this poem copied on brown paper. Is that the one he copied? It looks like his handwriting. This is the record of Mister Forrestal, the clinical record.

The clinical record was presented to the board as an exhibit. There being no objection, it was so received. A photostatic copy is appended marked “Exhibit 3.”9. Q. Captain Raines, would you continue your testimony?The witness requested permission to refer to the clinical record which has been introduced as an exhibit so as to refresh his memory.The permission was granted.

A. In addition to the further therapeutic measures which have been mentioned we established a rather strict regime of isolation from the outside, primarily because the patient felt quite unable to tolerate visitors. Throughout most of the course of treatment only four physicians were allowed to write orders and it was generally understood that all orders were to be referred to me if I could be reached. The resident medical officers, Doctor Hightower and Doctor Deen, were allowed a certain amount of discretion on the evening watch towards carrying out the orders in detail. As late as the twenty-ninth of April the patient was still quite suicidal and personnel were reminded of this by an order in the chart. A week later the insulin therapy was discontinued and beginning on the eighth of May the patient was placed on the stimulating doses of insulin which I previously mentioned. He continued to improve in the irregular fashion which I have described and by the ninth of May I felt it safe for Mrs. Forrestal to make her plans to go abroad but didn’t think he should go with her. My reason for objecting to his going was, ironically enough, that I knew in the recovery period which seemed at hand the danger of suicide was rather great. The son returned to his work in Paris on May thirteenth. The family was at all times kept fully advised as to the patient’s progress but I didn’t warn them continuously of the suicidal threat nor did I mention it to any one except my immediate colleague, Doctor Smith. By that I mean that I felt my job was to accept responsibility for the patient and that the family should not be unnecessarily troubled or worried by the continual suicide threat. By the end of that week, that is by the fourteenth of May, I felt that daily interviewing could be discontinued and that I could be absent from the city for a period of a week or ten days without disturbing the course of the patient’s recovery. From the ninth of May until the eighteenth which was the last time I saw Mister Forrestal, I had encouraged

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him to see people and to extend his activities. He had reached a point in treatment at which it seemed advisable for him to socialize more. I believe he did see a few people that week. He had planned on having some of his friends in this week and saw his business manager momentarily on the afternoon of May twenty-first. The chances on suicide were taken rather deliberately as a part of his treatment. There comes a point in any depressive illness to put some relaxation on restrictions, it has to be given if a patient is to make a complete recovery. Mister Forrestal had reached that point. I was fully aware of the inherent danger but felt that that had to be accepted as a portion of the treatment. That is the general course.

Examined by the board:10. Q. When you left the city on your temporary additional duty, whom did you leave in charge of the case?

A. Doctor Nardini was in direct charge. The situation was a little complicated because Doctor Smith had to be out of town. I introduced Doctor Nardini to the patient on Monday, the sixteenth. On the afternoon of Tuesday, the seventeenth, I spent quite a long time in interview with Mister Forrestal, perhaps two hours and a half. I saw him again on Wednesday morning for about an hour and my purpose in those visits was, in part, to see what danger might have to be faced while I was away. At the time he was not suicidal and in that considerable period of interviewing I felt well assured that there was no suicidal preoccupation at the moment. That didn’t mean, of course, that it wouldn’t come with the weekend because Tuesday and Wednesday were his best days. Nonetheless, on Wednesday he was better than he had been on the previous Wednesday. Because of the weekly variation in his condition I could never compare day to day but I would have to compare the day to the same day of the previous week.

11. Q. Did Mister Forrestal, throughout his illness, have access to outside communications through the radio, telephone, newspapers, correspondence or people?

A. He had full freedom in everything except telephone and people. We took the telephone out of the room, not because of outgoing calls, but because so many people were calling in and asking and I didn’t want to take the risk of his being disturbed by cranks and what not who could get the calls through. We kept visitors out in part at his own request because he didn’t feel able to tolerate them. One of the last orders I left, however, was to the effect if he wished he could have his telephone in his room at any time and he could use the pay station on the ward at any time. Concerning the security measures if you would like those in more detail, we began relaxing them. I first eased the regulations as a test on the twenty-sixth of April but found that the patient was not ready for it and that resulted in an order on the twenty-ninth of April that the watch was to remain in the room at all times, that the patient was still quite suicidal. The relaxation on the afternoon watch was only a few days later, on May first, which indicates how abruptly his condition would change at times in these undulating moments in the illness. I allowed the special watch to be out of the room from the evening meal until twenty-one hundred beginning the first of May. Five days later

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[,] over and above the written order and this was simply authorization in writing for them to be out. We actually encouraged him to leave his room. It was not our assumption that he would be wandering around the hospital at two o’clock in the morning, that was his own idea. He ordinarily slept with the aid of sodium amytal right through the night and on Friday night I had been told by the resident that he slept through the night without medication. He was in that stage of improvement. we left the door open into the patient’s room because of the heat in Mister Forrestal’s room. On the seventh of May we allowed the day watch to relax somewhat and an order of that date states that the watch need not remain in the room at all times. It is impossible to put into writing what a special watch needs to know in detail; usually the men were always instructed personally, either by Doctor Smith or myselfover and above the written order and this was simply authorization in writing for them to be out. We actually encouraged him to leave his room. It was not our assumption that he would be wandering around the hospital at two o’clock in the morning, that was his own idea. He ordinarily slept with the aid of sodium amytal right through the night and on Friday night I had been told by the resident that he slept through the night without medication. He was in that stage of improvement. He was very close to well actually. When I saw him on the eighteenth I felt we could, didn’t tell him, but felt hospitalization for another thirty days would probably do the trick. He was that close to the end of it. That, of course, is the most dangerous time in any depression.

12. Q. What date did you leave Washington and turn the case over to Doctor Nardini?

A. On May eighteenth. I should say that throughout the conduct of the case while I was in full charge and had full responsibility for it, it was a joint effort by four of us because I didn’t feel that any one person could possibly find his way through that entire matter. As a result of this there was a morning conference with Doctor Smith, Doctor Hightower and myself each day. In addition, Menninger came out in the beginning, twice, looked over the situation. I talked over the course of therapy with him and he concurred in it. I subsequently saw him around May first, the exact date I am not sure of, went over the case with him again and he felt that it was moving along about as was expected.

13. Q. Those residents that were on the port and starboard; were they there in case of emergency or did they have a routine of visiting the patient during the night?

A. They were there primarily for the evening sick call, to be sure that medications, orders, were carried out and in event he needed anything; not limited to emergencies. The night time was a bad time with him always and the two residents were fully as aware of of [sic] his case and how to handle the things he would bring up. His depression began to get deeper in the late evening and very frequently he needed someone to talk to and I felt he had enough of me during the day and there should be someone else during that time. During my absence Hightower spent some afternoons with him in interview but not with any very deep psychotherapy, simply superficial support.

14. Q. Did Mister Forrestal make any attempts at suicide while he was under your care?

A. None whatsoever. The matter of suicide in Hobe Sound, he told Doctor Menninger that he had attempted to hang himself with a belt. Menninger and I were both very skeptical of that and both he and I were of the opinion it was sort of a nightmare. The man

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had no marks on him and there was no broken belt. Very frequently a depressed person has a fantasy of dying and reports it as real. So far as I know he never made a single real attempt at suicide except that one that was successful. He was the type of individual, fast as lightening, [sic] of extremely high intelligence and one reason I doubt previous attempts [,] I knew if he decided to do it he would do it and nobody would stop him. He was a boxer in college and his movements, even when depressed, were so quick you could hardly follow them with your eye. In the course of psychotherapy he talked a great deal about his suicide; he would tell me when he was feeling hopeless and had to do away with himself. At those times we would tighten restrictions. He would tell me in symbolic language. One morning he sent me a razor blade which he had concealed. When I interviewed him I said “What does this mean?”. He said “It means I am not going to kill myself with a razor blade”. Of course, he had the blade and could have done it. A man of that intelligence can kill himself at any time he desired and you can’t very well stop him. He is my first personal suicide since nineteen thirty-six, thirteen years ago. The last one was on a locked ward at St. Elizabeth’s [sic] Hospital under immediate supervision of an attendant. We discussed, whenever he felt badly enough, he would talk about the possibilities of killing himself and I am sure that when I left here on the eighteenth he had no intention at that time of harming himself.

15. Q. Had he, in the course of your interviews, either symbolically or otherwise, suggested his method if he committed suicide?

A. Yes, I am sure he didn’t jump out of the window. My interviews with him were for one to three hours a day over a period of eight weeks; can’t go into all the material that makes me think that but by the time he had been here four weeks I was certain there were only two methods he would use because he had told me, one was sleeping pills. He said that was the one way he could do it and the other was by hanging which made us feel somewhat more comfortable about the period of risk, knowing that he wasn’t going out one of the windows. I haven’t gone into all the details of what happened, but personally feel he tried to hang himself. I don’t think he jumped; he may have; don’t think it was out the window; think he meant to hang. For some time he had had complete access to the open windows in the residents’ room and for a short period of time he even slept in there for two or three nights. There were two beds in the residents’ room and he would sleep in one of those until about three o’clock and then go back to his own bed. That was the one thing that puzzled me, when he [Nardini] called me, as to what had happened; I couldn’t believe it because of the window, until I got back and found out about the bathrobe cord.

16. Q. Would you tell us, Captain Raines, the nature of the watch that was maintained in Mister Forrestal’s room?

A. It was a psychiatric watch. I didn’t know the corpsman who was on watch at the time of the suicide. However, I left the selection of the corpsmen entirely up to Doctor Smith and Doctor Hightower who knew them personally much better than I. All of our men have had training in psychiatric safeguards and procedures although only very few of them are certified psychiatric technicians. We conduct a course of our own which runs for six months. I don’t know how long the man on watch had even been here or whether he had had all of that course but know he must have been considered satisfactory to Doctor Hightower or he wouldn’t have been on watch.

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17. Q. How many times did Doctor Menninger visit at the hospital?

A. Twice. He was here April third and April sixth.

18. Q. Will you please state Doctor Menninger’s qualifications briefly?

A. Doctor Menninger is one of the most prominent psychiatrists in the country. He is just completing a term as the President of the American Psychiatric association, the American Psychoanalytic Association and the Central Neuropsychiatric Association, probably the only man in history to hold all three offices simultaneously. He has so many governmental appointments as consultant that I don’t know all of them; on the training committee of Public Health Service, hundreds of them, Veterans committee of National Research Council, etc. Incidentally, for the information of the board, I was with Doctor Menninger at the time I was notified of Mister Forrestal’s death. His attitude was that it was the type of casualty which comes with therapeutic psychiatry; he knew all of the steps that had to be taken. I spent about thirty minutes with him on Sunday morning after the suicide; reviewed the case and he felt that the conduct of the case had been in accord with the principles which had been followed throughout. As a matter of fact, I also have a large number of telegrams and telephone calls from some twenty to thirty psychiatrists throughout the country, including Braceland who is Chief of Psychiatry at Mayo Clinic, beside the people here on my staff and Doctor Menninger. Braceland was the only other individual that know in detail the conduct of the case. He was a personal friend of Mister Forrestal’s and thought very highly of him and I had spent two days with Braceland, on May nineteenth and twentieth, and during that time had brought him up to date on the course of Mister Forrestal’s case. He was at that point in complete accord with what we were doing and called last night, unfortunately I was out, but left word that he would be happy to appear if it were necessary, which was what Doctor Menninger said – if the board of investigation would like to talk to him he would come down. I would personally hesitate to ask Doctor Menninger to come until the end of the week because he is in charge of the meeting of American Psychiatric Association which is having some internal trouble and really should not be here but I am certain if the board wanted a telephonic communication with him he would be glad to help out any way he could.

19. Q. Did Doctor Menninger, at any time, discuss, suggest or agree on the relaxation of safety precautions when the time was appropriate?

A. Yes, sir, we spent a great deal of time talking about the danger period and in trying particularly to find some way of transition from complete strict security to recovery. Mister Forrestal’s prominence was such that it imposed a great burden on trying to make any arrangements in which he could have some freedom of movement. Literally hundreds of people who called about him, who knew about him, and some of those were friends, others were people whose primary interest seemed to be in what they could get out of him. He wasn’t in any position to be exposed to any exploitations by crack pots, [sic] screwballs and whatnots and Menninger and I, and his family and I, and Mister Eberstadt and I, at various times did

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[sic] some of those on pure impulse. That is supported by several things. [sic] DU [Diagnosis Undetermined] Medical Observation but the psychiatric diagnosis was reactive depression. Clinically, the depression was of mixed type but in the present nomenclature the best diagnostic term applicable is Reactive Depression. There were very strong reactive elements in it. It is the type of depression which we saw very frequently during the war; sixty to ninety day depressions in reaction to excessive work or complete change in a man’s life. He had reached a point at which the entire life had to reoriented with giving up of his job as Defense Secretary which he knew was coming some time back. Everything had to be changed; his whole method of living which had gone on for about nine years and at his age that sort of rearrangement is a difficult task. Many people go through this sort of thing in lesser degree. His, I think, was especially severe because he was worn out. a great deal of discussing as to what the move would be in this period of relaxation, how we would get him out of the hospital. I personally, my personal plans were, within the period after I came back, depending on his condition, to move him to tower seventeen where there are no security screens at all and to continue his watch about as it was being continued at the time I left, or more an attending basis than a basis of very strict supervision. It was this period that we were all worried about, as to how it could be accomplished and Menninger and I fully agreed that restrictions would have to be removed as rapidly as the patient’s condition justified. The only hope for recovery in people of that sort is to allow them to gradually take up socialization activities. The confinement of a man to strict isolation routine when he is depressed is very apt to fix the illness; there has to be something to break him away from himself and get him interested in the world outside and people outside. From the very first Mister Forrestal’s mail and other communications were handed to him unopened. He was allowed to see all of them on the theory no one can live in a vacuum and might just as well be exposed to whatever came along; that is the method of dealing with it; it would depend on how well he was or how sick he was. It was as simple as that. Actually, he dealt quite well with almost everything. It is my own feeling from what I know that the period of despondency which caused him to end his life was very sudden in onset and probably the whole matter was on an impulsive basis. That was the one thing I had feared, knowing of his impulsivity. Again I say he moved like lightening,some of those on pure impulse. That is supported by several things. I talked to Doctor Hightower last night and was glad to hear him say spontaneously and not just in agreement with me that he felt that this was an impulsive thing of sudden origin, but one of the main evidences is the complete absence of any suicidal note or expression of suicidal intent in any way. He left no message at all except this poem which I am sure was meant for me and was not a portion of the suicide. That is to say, I think he was simply writing that out to demonstrate how badly he felt. People who contemplate suicide almost invariably leave some note to someone and usually someone close. The absence of some note would make me feel this was a very impulsive act of the moment. Mister Forrestal was still being carried UnderDUMedical Observation but the psychiatric diagnosis was reactive depression. Clinically, the depression was of mixed type but in the present nomenclature the best diagnostic term applicable is Reactive Depression. There were very strong reactive elements in it. It is the type of depression which we saw very frequently during the war; sixty to ninety day depressions in reaction to excessive work or complete change in a man’s life. He had reached a point at which the entire life had to reoriented with giving up of his job as Defense Secretary which he knew was coming some time back. Everything had to be changed; his whole method of living which had gone on for about nine years and at his age that sort of rearrangement is a difficult task. Many people go through this sort of thing in lesser degree. His, I think, was especially severe because he was worn out.

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20. Q. Before he came to Bethesda while he was down south, did he make any attempt to slash his wrist?

A. No, he had a small scratch on his wrist which he told me was not a suicidal attempt but he was considering it and he was wondering what he could do to himself and he took a knife or blade and scratched his wrist, so superficial it was not even dressed, and wouldn’t come under the heading of “attempt” so far as I am concerned. There is one thing about the treatment. We considered the possibility of electro-shock but felt that the reactive portion of the illness was so prominent that we should withhold electro-shock for at least ninety days. In reactive depressions if electro-shock is used early and the patient is returned to the same situation from which he came there is grave danger of suicide in the immediate period after they return. Of the last two or three people who have jumped from bridges in town here two of them, to my knowledge, were electro-shock cures of short duration, so strangely enough we left out electro-shock to avoid what actually happened anyhow.

Neither the recorder nor the members of the board desired further to examine this witness.The board informed the witness that he was privileged to make any further statement covering anything relating to the subject matter of the investigation which he thought should be a matter of record in connection therewith, which had not been fully brought out by the previous questioning.The witness made the following statement:

I would like to stress one point and that is that the responsibility of the case was entirely with me. I had nothing but the most complete cooperation from the hospital authorities here, from Mister Forrestal’s friends, and from his family. I shared the conduct of the case with selected members of the staff because I needed their assistance but all of the direction of the case and the complete control of it was entirely in my hands. I would like to make that a matter of record. The problem of responsibility, the responsibility for its conduct was entirely mine.

Neither the recorder nor the members of the board desired further to examine this witness.The witness said that he had nothing further to state.The witness was duly warned and withdrew.A witness was called, entered, was duly sworn, and was informed of the subject matter of the investigation.Examined by the recorder:1. Q. State your name, rank and present station of duty.

A. John E. Nardini, Commander, Medical Corps, U. S. Navy. My station is Psychiatric Service; officer in charge of the officers’ neuropsychiatric service, U. S. Naval Hospital Bethesda, Maryland.

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2. Q. How long have you been in psychiatry and what are your qualifications?

A. I have had a special interest in psychiatry since nineteen thirty-two in college and have pursued the study with additional interest ever since. Technically, the first formal medical training period was from June nineteen forty-six to June nineteen forty-seven as Executive Officer and Resident in Training at the U. S. Naval Medical Unit, U. S. Public Health Service Hospital, Fort Worth, Texas. From July, 1947 to the present time I have been serving in my present assignment as officer in charge of the neuropsychiatric service of this hospital. My official status is on the staff.

3. Q. Would you please tell the board all that you know relative to your participation in the treatment of the late James V. Forrestal?

A. Just prior to Doctor Raines’ departure on Wednesday, May eighteenth he had indicated to me that he would like me to take administrative charge while he was gone. In preparation for this the first time that I met Mister Forrestal was for the purpose of being introduced to him on Monday afternoon, the sixteenth of May. I next saw him on Tuesday morning along with Doctor Smith briefly and then I saw him alone again for brief periods on the mornings of Thursday, Friday and Saturday. My primary administrative role was to handle all incoming calls, to decide whether or not visitors who wished to see Mister Forrestal should be permitted to see him, to take up with him directly his choice of wanting to see any particular visitors and to handle any inquiries that came from outside on either a professional or personal basis on all matters relative to his case. Since Doctor Hightower had been in more complete and earlier contact with the case and Doctor Hightower knew the case it was felt that he should continue to deal with the more personal aspects of the case and Doctor Hightower and I conferred at various times regarding Mister Forrestal’s condition. The feeling that I had regarding his condition, based upon my own observations and conferences with Doctor Hightower, was that his condition remained essentially the same. Most of my conversations with him were on a more or less impersonal nature with no serious attempt to enter into the actual therapeutic situation. I last saw Mister Forrestal on Saturday morning about ten o’clock at which time he seemed to be about the same as he had been on the preceding few mornings. About zero two ten Sunday morning I received a phone call from Doctor Deen in which he informed me that Mister Forrestal had gone through the window and his body was found below. I then called Doctor Raines in Montreal, Canada, and informed him of the situation and told him that I would come to the hospital immediately to do whatever was required.

Examined by the board:4. Q. Doctor, during your period of supervision of this case was it necessary for you to change or issue any new orders?

A. No, sir, I considered his condition to remain essentially the same and made no change of any of the existent orders.

5. Q. When you took over charge of Mister Forrestal were you familiar with the various aspects of his case?

A. Yes, sir, in a rather general way. I had a general understanding of his over-all clinical picture, although I had had no active participation in the case up to Monday, May sixteenth.

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6. Q. Were you aware of the possibility of suicide?

A. Yes, sir.

7. Q. You stated that he was about the same; over what period of time did you have reference to, did you mean from the time he entered the hospital or for the few days you were cognizant of his case?

A. That would only be from the period the first time I saw him on Monday the sixteenth up to Saturday the twenty-first.

8. Q. Saturday was the last time you saw him?

A. Yes, sir.

9. Q. What time?

A. Approximately ten o’clock Saturday morning.

10. Q. And you saw no change in his condition at that time; no evidence of any undue disturbance or agitation or depression?

A. No, sir, he continued his usual discussions; he was rather brief in his discussions. It was rather difficult to reach him in a sense of establishing close personal contact but his intellectual functionings seemed as usual. He gave no increased evidence of tension or depressive features; made no unusual references. Most of our discussions were conversations either of personal life, he usually directing questions toward me about my activities, or some of my background features but since I was not entering into the treatment situation I saw no reason for participating in personal discussions.

11. Q. Then you saw no reason whatsoever to make any change in orders, to tauten up security or take extra precautions?

A. That is correct.

12. Q. Doctor, in the preliminary testimony you stated that there was a dual function, that you, Doctor Nardini, were to handle the incoming inquiries and Doctor Hightower, because he was better acquainted with this case, to handle the professional aspect. In other words, Doctor Hightower handled the professional and you handled the administrative matters?

A. That is essentially true but at the same time the over-all responsibility was mine since I was placed in charge of his case and I conferred for that reason with Doctor Hightower as to his opinions of the more personal phase of the patient’s condition.

13. Q. But you actually didn’t have any psychiatric interviews with Mister Forrestal?

A. Not more than would be derived from conversations I had with him on the mornings of Thursday, Friday and Saturday.

14. Q. Did Mister Forrestal make any attempt at suicide while you had charge of the patient?

A. No, sir, none that I was ever informed of, became aware of, or suspected.

15. Q. Did Mister Forrestal indicate in any way to you that he might do harm to himself?

A None whatever.

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16. Q. Doctor Nardini, if you had – in your observations of this case and in the absence of Doctor Raines who was in immediate charge, would you have felt free to change any safety precautions that might be taken?

A. Yes, sir, it was understood between Doctor Raines and I if there was any question in the condition of the patient which required any further consideration or attention to get in touch with him immediately.

17. Q. To get in touch with him or take immediate action?

A. I would have assumed either way; if immediate action was indicated I would have felt free to take it or if I had any other questions about it I would have felt free to contact him.

18. Q. But you saw no indication at any time to take action or change any orders?

A. No, sir, I saw no specific indication for changing the course of management or treatment.

19. Q. There was a hospital corpsman on watch on Mister Forrestal, was there not?

A. Yes, sir.

20. Q. But he was not required to be in the room?

A. Not at all times at this stage.

21. Q. Did he have orders to check up on him every so often?

A. His orders were to be with the patient most of the time but that he could leave the room as desired for purposes which were indicated.

22. Q. Do you remember the man on watch between the midnight and two o’clock Sunday morning on the twenty-second?

A. Yes, sir, that was a corpsman by the name of Harrison.

23. Q. Is he designated as a neuropsychiatric technician?

A. No, sir, but he had had a degree of training on the neuropsychiatric service in the closed wards which would be enough to give him sufficient understanding of this type of problem.

24. Q. Were you and Doctor Hightower in full accord that the safety precautions were adequate at the time?

A. Yes, sir, based on my understanding of the case as derived from Captain Raines and my conversations with Doctor Hightower that there had been no perceptible change in the patient’s condition and also my own observation. I had observed no perceptible change in the patient’s condition.

25. Q. You had had conversation with Doctor Hightower about it, is that right?

A. Yes, sir.

26. Q. Is this corpsman that had the watch from after twelve o’clock – was he aware of the suicidal tendencies of Mister Forrestal and had he been instructed to watch against suicide?

A. To the best of my knowledge he had been informed of the nature of the case and written instructions for the corpsmen were detailed in the chart, and, in addition, there was a doctor in constant attendance at the spot where he could obtain any additional information or understanding as desired.

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27. Q. Was Mister Forrestal permitted to go into the galley or the passageway of the sixteenth deck without supervision?

A. It is my understanding that the restrictions had been lifted to a degree where he was permitted to go out to the passageway to make phone calls or to enter the doctors’ room adjoining his.

28. Q. Did Mister Forrestal exhibit any abnormal behavior Saturday morning when you saw him?

A. No, sir, none that seemed to me any more different from his usual attitude of the preceding mornings.

Neither the recorder nor the members of the board desired further to examine this witness.The board informed the witness that he was privileged to make any further statement concerning the subject matter of the investigation which he thought should be a matter of record in connection therewith, which had not been fully brought out by the previous questioning.The witness said that he had nothing further to state.The witness was duly warned and withdrew.The board then, at 12:04 p.m., took a recess until 1:15 p.m., at which time it reconvened.Present: All the members, the recorder, and the reporter.No witnesses not otherwise connected with the investigation were present.A witness was called, entered, was duly sworn, and was informed of the subject matter of the investigation.Examined by the recorder:1. Q. State your name, rank and present station.

A. David P. Hightower, Commander, Medical Corps, U.S. Navy, presently attached to the U. S. Naval Hospital, Bethesda, Maryland.

2. Q. What are your duties at the Naval Hospital?

A. My duties are – I am a resident in neuropsychiatry.

3. Q. How long have you been a neuropsychiatrist in this resident status?

A. Since I reported to the Naval Hospital on October eighteenth, nineteen forty-six.

4. Q. Would you please tell the board all you know relative to your connection with the treatment of the late James V. Forrestal?

A. My first knowledge of Mister Forrestal’s case was on Sunday afternoon, April third, after his admission to this hospital on Saturday, at which time I was called at home by Captain Smith and told to report to the hospital that afternoon and be prepared to spend the night. I reported to the hospital and to Captain Smith and was informed that I was to stand a special watch, sleeping in the room adjacent to Mister Forrestal’s suite and that my duties, so far as the watch was concerned, were to handle any emergency that might come up during my tour of duty at night and also to keep Doctors Smith and Raines, who were handling the case, informed of what was going on. I continued to stand a regular watch at night with Mister Forrestal on alternate nights, to alternate with Doctor Deen. The hours to be covered were from the end of working hours, approximately sixteen thirty, until the beginning of working hours the next morning at zero eight-thirty. In the mornings Doctor

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Smith would visit Mister Forrestal briefly and Doctor Raines usually saw him in the afternoons. After Mister Forrestal was started on sub-shock insulin therapy my duties were increased to the extent that I was to report and remain in the room with the patient for the last thirty minutes of the insulin therapy period. This therapy period was usually started at eight o’clock and terminated at eleven hundred. So, on the days that he received insulin I was with him from approximately ten thirty to a few minutes after eleven hundred. After the insulin therapy was discontinued I went back to my old schedule of on every other night. When Doctor Raines left town he asked me to make a point of sitting with Mister Forrestal at some time during the day every day. This I took to mean in the afternoons at the times that Captain Raines had ordinarily been seeing him and on Wednesday, Thursday, Friday, I did sit with Mister Forrestal for anywhere from forty-five minutes to an hour and a half and sat with him briefly on Saturday morning. That about covers the whole time as to when I was actually there.

Examined by the board:5. Q. Were you fully aware of the various phases of Mister Forrestal’s condition from shortly after he was admitted as a patient to the hospital?

A. Yes, sir, Doctor Raines, Doctor Smith, Doctor Deen and I had discussed at intervals various procedures and therapeutic efforts that were being made during the course of the entire case.

6. Q. During the period of his stay in the hospital did you feel that he was making some gradual improvement?

A. Yes, sir, my feeling from the first was that he was pretty overly depressed, as evidenced by his lack of interest in his surroundings, interest in personal contact with me on the brief occasions that I saw him, whereas as the case progressed, particularly during the insulin period [,] he seemed to become more alert, more interested in his surroundings, and particularly interested in what was going on about the floor itself and the hospital.

7. Q. What was your feeling in regard to the possibility of suicide during the first few days of his stay in the hospital?

A. My feeling with regard to suicide during the first few days of his stay in the hospital was that it was potentially present, that being based on psychiatric experience with depressed patients. I had no actual factual evidence of any sort which would lead me to be able to say specifically that suicidal thoughts or ideas were present. However, I did feel and consider it a possibility on the basis of general psychiatric knowledge.

8. Q. What was your feeling in regard to the possibility of suicide at approximately the time that Doctor Raines left Washington?

A. At that time I felt that Mister Forrestal had made a definite improvement in the over-all picture from the time of his admission and that the possibility of suicide was much more remote than earlier in the case. There were several observations made during the course of the case which led me to feel this. About two weeks before Doctor Raines left I went up to stand the watch one night and stopped by the room to speak to Mister Forrestal, asked him how he was feeling. He said “About as usual”. We chatted briefly about my medical education and where I lived and what not; then later,

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when I came up to go to bed about twenty-two forty-five, he was awake and I asked him how he was feeling. He said “About as usual” but he felt his room was a little stuffy and in view of the fact that two of the windows were stuck and couldn’t be opened I agreed that the room was a little stuffy. He said that he thought possibly he would be able to sleep better if he slept in the room with me, - there being two beds in my bedroom and I said I thought that would be a good idea, it might be more comfortable over there. So he did sleep in the room that I slept in that night. My feelings at this time were that the patient was making an effort to broaden his horizons. I felt that he was lonely and felt the need for friendly contact with other people and also felt at the time that the suicidal possibilities had lessened sufficiently to make it safe for him to remain out of his own room. The danger of suicide had been discussed with Doctors Raines and Smith on several occasions prior to this and we had been encouraging the patient to broaden his activities even prior to this particular incident.

9. Q. At any time while Doctor Raines was away did he appear to you to be preoccupied, worried, disturbed or agitated more than usual?

A. To the contrary, he appeared less preoccupied, worried, disturbed, and particularly less agitated. On Wednesday afternoon after Doctor Raines left Wednesday morning I stayed with him about an hour. The relationship during that hour was as usual. We talked of superficial things such as the flowers in his room, a thorn I had removed from his thumb some time previously. Thursday night he said that he would like to attempt sleeping without his usual medication of sodium amytal and I agreed to that with him for a trial period but insisted that if he were not asleep within a reasonable length of time, I think about an hour, he should take his amytal. On Friday I sat with him for about an hour Friday afternoon. He was slightly more cheerful than he had been on Thursday. The impression that I had of him on Thursday was identical with the impression I had with him on the Sunday before which was a day that Captain Raines didn’t see him. That is to say, his appearance and my feeling for his condition was almost identical.

10. Q. Did you, at any time during Doctor Raines’ absence, discuss his condition with Doctor Nardini?

A. Yes, sir, we talked over almost everything that happened with Doctor Nardini and Doctor Deen.

11. Q. During this period did anything come up that made you think that you should tauten up on his privileges any?

A. No, sir, to the contrary. The things that did come up, the feeling I had was if anything, privileges should be extended. We didn’t increase any privileges during this period because we didn’t have Captain Raines or Captain Smith aboard to discuss the matter and we figured we would let the standing orders that they had left when they left remain. However, those orders were, we felt, relatively lenient and that Mister Forrestal was fully capable and able to go along on that line without any change either to increase or to decrease the restrictions that were in effect at that time.

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12. Q. Did you see him Saturday, May twenty-first?

A. Yes, sir, I saw him.

13. Q. Give us your impressions of him at that time.

A. Saturday morning when I woke up, having slept in the room next to his with both the doors opened through the bathroom with my bed arranged so that I could look directly into his room and he could look directly in my room, I got up, dressed, went in and spoke to him, asked him the kind of night he had. That night, Friday night, he had slept the entire night with no awakening periods that I know of at all without a sedative. On Friday night he had gone to bed while I was in the room sitting with him. While I was sitting with him Friday night he said he felt sleepy and got in bed. Shortly after he had been in bed for a little while I left and checked with the corpsman about nine o’clock to find out had he taken his amytal. The corpsman said he was sleeping so I said “Well, don’t wake him up to give him some amytal.” My understanding was that he slept the entire night.

14. Q. What was your final impression of him when you left him Saturday?

A. I saw him again Saturday morning at which time an old friend of his from New York came down to visit, a Mister Strieffler. We had been informed by Captain Raines on Thursday night that Mister Strieffler would be down Saturday morning and he had permission to visit. I had told Mister Forrestal on Friday afternoon that Mister Strieffler would be down Saturday morning. He had no comment. My impression Saturday morning was that his condition was about as it had been for the last several days. He didn’t appear to be particularly depressed, neither did he appear to be particularly cheerful.

15. Q. Then you left him Saturday feeling very comfortable about his condition?

A. Saturday noon I spoke to Doctor Deen as he was taking over the week-end watch and told Doctor Deen that I felt the week-end coming up would be about as usual which was my feeling and considered the possibility of dropping back by Sunday afternoon to sit with him as I had been doing along alright, that that would not be necessary and didn’t plan to come over on Sunday afternoon to sit with him.

16. Q. Did Mister Forrestal, in the times you would be with him, express anything about international affairs, discuss them with you?

A. No, sir.

17. Q. Do you think he was trying to get away from such things?

A. I didn’t have much feeling about whether he was or not. He never made any effort to talk along those lines when I was with him, no, sir. In fact, the basis of most of our conversations were relatively superficial, having to do with things of the moment; should he take his sleeping pills or not; was I going to sleep in the room next to him or not; how was the rose thorn in his finger getting along; or whether his constipation was being taken care of or not. Another one of my duties in the case was to write orders for his bowels and I had done that earlier in the course of the case.

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18. Q. During your conversations with him did he show any interest in discussing any current events or anything outside of himself?

A. Only once. He asked me on several occasions did I plan to remain in the service if the service treated me as well as it had in the past but with all of the changes in prospect relative to the Navy and the services I was standing by to see how some of those came out and keeping an open mind on the subject. He evidenced considerable interest at that time saying that he had been in on the unification deal and said that he felt that it was a good thing and would probably work out to everyone’s advantage. This was said in a rather round-about fashion and not specifically a direct quote. I don’t remember the exact words.

19. Q. Did he ever discuss any of the lighter things like baseball?

A. He discussed briefly golfing with me once, merely to say that he had been a golfer at one time and that’s about all so far as the lighter things were concerned.

20. Q. Were the windows in Mister Forrestal’s room locked on the Saturday morning that you last saw him?

A. Two of them were unlocked, two locked.

21. Q. Could those windows be opened to permit a person to go out through those windows?

A. No, the window screens on Mister Forrestal’s room were; there were a total of four security screens. In the room itself three screens, two on one side, one on one side, fourth in the head. In the installation of the security screens the two screens nearest his bed were warped and couldn’t be opened or closed without getting a part of the scale that was in the room and taking two people to prize and push and twist to open and close it. I know this because the corpsman and I tried one of them out about a week or week and a half before the case ended. In the entire area the overhead drops down about eighteen inches in front of the windows which were offset. These security screens open inward and hit on this overhead long before they can be opened and when we opened these two they were warped. One afternoon to raise the windows – it was a sultry day, one of the thunderstorm afternoons – the corpsman that was on, quite a small fellow, and I were working on it and I remember distinctly trying to get him to get behind the screen on the window side to try to raise the windows and he couldn’t get in there and following this I didn’t see any point in locking the two warped frames because their purpose of guarding the window was answered whether they were locked or unlocked; namely, they couldn’t be opened sufficiently for even a small person to get out even if they were unlocked. There were no security screens in the doctors’ bedroom and for a period of two or three weeks the door from the head to the doctors’ room had been left unlocked and frequently wide open to improve the ventilation in Mister Forrestal’s room. I tried to encourage him to move about the area after the general feeling among the staff was that his horizons needed to be broadened.

22. Q. At the time that you left him Saturday morning, May twenty-first, did you notice that the ashtray or Petri plate was broken in Mister Forrestal’s room?

A. To the contrary. I noticed that the ashtray Petri plate was not broken before because I recall distinctly using it for my cigarette while I was in there. That had been my usual ashtray when I went in. He had another one by the bed.

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Neither the recorder nor the members of the board desired further to examine the witness.The board informed the witness that he was privileged to make any further statement covering anything relating to the subject matter of the investigation which he thought should be a matter of record in connection therewith, which had not been fully brought out by the previous questioning.The witness made the following statement:

My impression of the entire case was that Mister Forrestal was admitted to the hospital in a definitely depressed condition, was quite ill and that during the course of his stay in the hospital his improvement was gradually upward at all times with minor day-to-day fluctuations in mood. My viewpoint during the entire case was a hopeful one and in all my contacts with the patient what few efforts I made to talk with him were aimed along hopeful lines for a complete return to his normal way of life.

Re-examined by the board:23. Q. Doctor, did you know the night corpsman who was on duty with Mister Forrestal Saturday night extending into Sunday morning?

A. Yes, sir.

24. Q. What was his name?

A. His name was Harrison.

25. Q. Did you regard him as being a suitable and competent watch for Mister Forrestal during those hours?

A. Yes, sir.

The board did not desire further to examine the witness.The board informed the witness that he was privileged to make any further statement covering anything relating to the subject matter of the investigation which he thought should be a matter of record in connection therewith, which had not been fully brought out by the previous questioning.The witness said that he had nothing further to state.The witness was duly warned and withdrew.A witness was called, entered, was duly sworn, and was informed of the subject matter of the investigation.Examined by the recorder:1. Q. State your name, rank and present station.

A. Commander Robert Reynolds Deen, Medical Corps, U. S. Navy, U. S. Naval Hospital, Bethesda, Maryland.

2. Q. What are your duties at the Naval Hospital?

A. Resident in second year training in psychiatry.

3. Q. What is your experience in training in neuropsychiatry?

A. I have been in residency status since December nineteen forty-seven when I reported here at Bethesda. Since that time I have been continually on the psychiatric service except for three months last fall when I was on neurology and I am at present again on neurology, having been on neurology since April first, nineteen forty-nine.

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4. Q. Will you please tell the board all you know relative to your connection with the late Mister Forrestal?

A. When Mister Forrestal first came to the hospital as a patient I was designated as one of the two residents to stand night calls, you might say. We were instructed by Doctor Raines that we would be on hand any time we were needed and that we should sleep in the room which adjoined the room of Mister Forrestal. The watch, or call, both apply, began on the days we had the call at four-thirty and extended through next morning until eight-thirty. On weekends, we split it port and starboard, would have week-end duty beginning at twelve noon on Saturday extending through ’til eight-thirty on Monday. Our duties were primarily to be at hand if any question arose in the carrying out of the orders that were written for Mister Forrestal, to give assistance to the corpsman or nurse if they so desired, to make our routine rounds and visit the patient and on any matter which we didn’t feel qualified to handle (I am referring to Doctor Hightower when I say “we”) we were to get in contact with either Doctor Smith or with Doctor Raines. The past week since Doctor Raines was away Doctor Nardini had been designated as the administrative officer-in-charge and in case of any difficulties during that period, the period when we couldn’t contact Doctor Raines or Smith, we were supposed to get in touch with Doctor Nardini.

5. Q. When was the beginning of that watch with reference to date?

A. I can’t say for sure so far as the date goes but Mister Forrestal came to the hospital on a Saturday. Doctor Hightower had the first duty on Sunday night and I had the duty on Monday night; one of the first week-ends in April but so far as definite day I am not sure.

6. Q. That watch has been continuous since that time up until this past Saturday night, is that right?

A. Yes, sir.

Examined by the board:7. Q. Were you fully aware of the various phases of Mister Forrestal’s condition?

A. I was not aware of anything that went on in therapy but I was informed and from my own observation had what I thought was a fairly good knowledge of his condition all the time.

8. Q. Did the matter of suicide ever occur to you?

A. It certainly occurred to me ever since the man has been here.

9. Q. How did you regard him from that standpoint for the first few days of his stay in the hospital?

A. Well, of course, on the first few days, it was much longer than the first few days, on admission to the hospital he was under almost continuous sedation and constant watch. After a few days they were able to get screened windows on the room and corpsmen were instructed to stay with Mister Forrestal at all times and if they needed anything from the nurse or corpsman on the outside or from Doctor Hightower and me they went through another corpsman, didn’t leave the room at any time. Following that he was on sub-shock insulin therapy for a period of something like three weeks, I believe, and the man was obviously depressed and any time a man is depressed there is always a consideration of suicide to be kept in mind.

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10. Q. How did you regard the progress of his condition from the time of admission to the hospital until the time that Doctor Raines left town?

A. Well, I think it is best to put it this way. From discussions with Doctor Raines, Doctor Smith and Doctor Hightower and from the changes in the orders which permitted Mister Forrestal to have more freedom of movement in that he could go into our bedroom and he could be in the room alone without the corpsman I presumed, I felt that improvement was going along or those measures would not have been put into effect. So far as my personal dealing with Mister Forrestal [,] on his original entry and at the time he was on insulin therapy it was always quite difficult to talk with Mister Forrestal, quite difficult because we had been instructed to try to stay away from things that bore on therapy and for a man like Mister Forrestal you couldn’t very well talk to him about the flowers and bees because he was not interested in them. I could ask questions about his Navy life and that sort of thing but always felt that would be getting into a field I should not be in, the psychotherapeutic field, and for that reason I say I found it difficult to talk with him; would discuss things, primarily me, at his questioning but as time went on there was the opportunity to maybe discuss other things. Don’t know just when it was but when Mister Douglas in London had that accident he talked with me about that. From time to time he would ask me questions about was the duty difficult, was I working hard and so on and so forth so that during the period of time he was here in the hospital I felt he was showing continually more interest in outside activities but, as I said, in the beginning the way I looked at it I felt sure things were going on in discussion with Doctor Raines probably I didn’t know about but which were indications that the man was improving considerably.

11. Q. You did, however, from objective signs form some opinion of your own that he was improving?

A. Yes, sir, I did, the night that this happened. Doctor Raines had encouraged Doctor Hightower and me to see if we could possibly get Mister Forrestal to go for a walk or maybe take him up to the television on the eighteenth floor and on Saturday two times, once about quarter of eight I asked him if he would be interested in going up to see the television and he said “No, thank you, I think I will let it go.” Then again at eleven o’clock or thereabouts I talked with him again. The television, strictly speaking, I think is supposed to be closed around ten-thirty, but is sometimes on a little later. When I came up to go to bed some time before eleven I asked him again if he would be interested in going to the television and he said “No, not tonight.”, but he made it sound like not tonight but a night near in the future I will go up with you.

12. Q. During Doctor Raines’ absence did you observe anything that made you think his privileges should be tautened up?

A. No, sir, I didn’t observe a thing.

13. Q. Did you discuss at any time his condition with Doctor Nardini or Doctor Hightower?

A. Saturday noon, May twenty-first, when I went on watch I saw Doctor Hightower in the chow hall and Doctor Hightower just having come off Thursday and Friday nights was pleased that he had the week-end free and said to me “You will have an easy time of it, everything is going fine.” That was the extent of any discussion. I knew Doctor Nardini had talked with Mister Forrestal on Saturday morning, May twenty-first, and there was very little discussion between us. If he said anything it was of so little importance I forgot what it was.

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14. Q. Saturday night, May twenty-first when you went to bed how did you feel about Mister Forrestal’s condition?

A. When I got up on tower sixteen I talked with the corpsman who was on duty. He told me that Mister Forrestal had been resting off and on all evening but that he still hadn’t taken his medication. I told the corpsman that I felt possibly my coming to bed would have some bearing on whether Mister Forrestal went to sleep or not and I thought he probably would go to bed and stay in bed after I came up. At no time has there been, in the past three weeks, any hard and fast rule about whether or not Mister Forrestal should take his sleeping medication although it was always ordered, the reason being that at least since I knew Mister Forrestal he had always complained that he didn’t like the sensation of the medication and always wanted to try to sleep without the medication. I viewed his taking or not taking medication just another indication of his gradual improvement and sort of a stepping-stone to further good health. For that reason at no time did I ever insist that Mister Forrestal would take the nightly medication but on numerous occasions I knew that even though he took his amytal he still would be up maybe one or two times during the night going into the bathroom or at least not sleeping. When I had the duty on Wednesday, the eighteenth of May, I went up about seven-thirty to make my evening rounds. Mister Forrestal was asleep, he hadn’t taken any medication and when I went up again to go to bed in the neighborhood of eleven-thirty he was still sleeping so that was proof enough for me he was able to sleep without taking nightly medication.

15. Q. Can you tell us a little more specifically your impression and what happened on the last night that you had the duty, which was Saturday, May twenty-first?

A. I mentioned previously that when I went up on tower sixteen around eleven the corpsman had mentioned that Mister Forrestal had not been sleeping and then I also previously mentioned that I had discussion with the corpsman at that time. I went in to see Mister Forrestal and that was the time I discussed again with him the possibility of going up and seeing the television. He implied not that night but in the future. I again reminded him if he were not sleeping and could not get to sleep he should take his medications, to which he answered “I will.” For the past, I think it was the second of May [,] I would have to check the record to make sure, since that time the adjoining bathroom door into my room has been left open from time to time. That particular night while we were talking about the television and his taking the medication he said “Are you going to close the door” and I said “Yes, because it is cold and I don’t want to catch another cold. [”] I had had a cold for a couple weeks previously and he knew about it and that was was [sic] one of our subjects of conversation from time to time and he said OK or perfectly alright or something like that so I went into my room, got undressed, went into the bathroom, came back, read the newspaper for a while and from here on in I’m not sure of any times but I would presume that I possibly went to bed about eleven thirty. I wasn’t sleeping and although I realized that these lessening of restrictions on the patient were a part of the treatment in his road to recovery, frankly, at times I was ill at ease about the fact that there were two open windows in my bedroom. Whether or not you realize that some restrictions are relaxed, that some risks have to be taken, I don’t think that removes the concern from the people who might be involved in those risks. This was something that had been discussed with both Doctor Hightower and Doctor Raines. Some nights the door would be locked, other nights the door would be closed, another night the door would be opened but on that particular night the door was closed when I

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went to bed but as I was lying in bed at one time I heard a little sort of thud and didn’t know whether the wind was coming through Mister Forrestal’s room and banging the door or venetian blinds banging against the window but anyhow I stayed awake just a short period of time and while I was awake Mister Forrestal walked into my room, stood in front of the window next to the bathroom door, looked out for a half-second, turned around, went back through the bathroom into his room and left the door open. I got up and walked over beside the other bed so I could look into the room and Mister Forrestal was lying in his bed. I got back into the bed again and then I started thinking that, well, I told him the door was supposed to be closed, he’s got the door open, now should I get up and close it or shouldn’t I. I finally decided with the air swishing through and the banging of the door I probably wouldn’t get to sleep at all unless I closed it so I got up to close it and was standing in front of the bathroom door with my back to the door which by that time was about three-quarters shut, I presume from the wind blowing it, and just as I was reaching to the knob to close the door Mister Forrestal who was evidently standing in the bathroom, I didn’t see him but we had a few words. He said “Are you going to lock the door” and I said “Yes, because the wind is coming up and it will be banging and it is getting cold here in my room” and he said “Well,” I’m not sure but something like well, that’s alright and then I said “Haven’t you been sleeping?” He said “Yes, off and on” and I said again “You better take your medication you need the sleep, it will do you good” and he said “Alright I will.” I locked the door, lit a cigarette and was standing there in the dark smoking the cigarette and thought – well, I’ll see if there’s something else in the paper I haven’t read. I turned the light on, put my white coat on – I use it as a sort of bathrobe – and started out to the nurse’s desk to get a drink of water. Just as I went by the galley Mister Forrestal and one of the corpsmen were standing in the galley door. As I went out to the desk I watched him going back into his room with the corpsman. I got the drink of water, came back into my room, read the paper for about three minutes and got back in bed. I didn’t have the slightest idea what time it was; didn’t hear anything else or wasn’t concerned about anything else. The light in the galley went on a couple of times but that [sic] not unusual and the next thing I knew was the corpsman, Harrison, came in, awakened me and said that Mister Forrestal still was not sleeping, what should he do about it. I said something like this – that Mister Forrestal knew that he should take his pills if he were unable to sleep without them and that the corpsman should again remind him that the pills were there and that he should take them if he felt he couldn’t go to sleep by himself. At the same time I told the corpsman to keep a close eye on Mister Forrestal. I don’t know what time that was but after all this happened and in talking with the corpsman and nurse I think it was about one thirty-five or something like that when the corpsman came and talked to me. I went back to sleep again because the next thing I recall was Miss Harty coming into the room; she flipped the light on, don’t know which I was conscious of first [,] and she said “Mister Forrestal is not in his room.” I sat up in bed and as I sat up the first thing that flashed through my mind was that he was wandering around the passageway somewhere and I said “Where is he” and she said “I think he’s out the window” so I quickly got up and by the time I was dressed everybody had been shocked about this thing but you can imagine how shocked I was. I went out once to the nurse’s desk in my white coat without any pants on and then came back into my room to get dressed. By that time there were numerous and sundry and many people, including the Officer-of-the-Day, Doctor Mulry, and I had gone in the galley and looked out the window and saw him down there and then went to the desk and called Doctor Nardini to tell him what had happened. Doctor

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Nardini said “Does the Officer-of-the-Day know about it” and I said “Yes, he has just been up here but now that I have called you I will go down to see if he has notified Admiral Stone.”

16. Q. When you retired for the night did you believe that any closer restriction should be exercised?

A. No, sir, I didn’t.

17. Q. Was it usual for Mister Forrestal to get up during the night and to walk around or was that an unusual happening on the night in question?

A. In the previous things I have said I hoped to convey the idea I didn’t think any of his activities that night were unusual in any respect. I knew nights he had a capsule and slept, nights he had capsules and didn’t sleep, nights that he slept without anything. It was not unusual for him in the middle of the night to get up, walk over into our room and walk back into his room. As a matter of fact, on, well, two nights with Doctor Hightower I think and one night I am sure of with me, Mister Forrestal asked if he could come over and sleep in the empty bed in our room which we permitted and discussed with Doctor Raines. Doctor Raines said “It is perfectly alright, the man is lonely and dependent and if you people don’t mind its’ [sic] perfectly alright.” On the nights that he didn’t do that he would, say on at least two occasions when I had the duty, he would come into my room, stand in the door and walk back into his own room. Other nights I have heard him in the middle of the night, three o’clock in the morning or something like that, in the bathroom and I could see nothing unusual, nothing different in the way that he had acted on many previous occasions.

Neither the recorder nor the members of the board desired further to examine this witness.The board informed the witness that he was privileged to make any further statement covering anything relating to the subject matter of the investigation which he thought should be a matter of record in connection therewith, which had not been fully brought out by the previous questioning.The witness made the following statement:

I think I have mentioned before but would like to add again that I was conscious of the fact that Mister Forrestal had not completely recovered. I was also conscious of the fact if we expected any recovery whatsoever the only way it would be brought about would be by gradual relaxation of the restrictions under which the patient had been originally subjected. In all depressed people there is that chance that has to be taken. It doesn’t leave a lot of people very happy about it but at the same time it is the only thing that can be done I feel in allowing the patient to gradually return to a previous better state of well being.

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Neither the recorder nor the members of the board desired further to examine this witness.The witness said that he had nothing further to state.The witness was duly warned and withdrew.A witness was called, entered, was duly sworn, and was informed of the subject matter of the investigation. Examined by the recorder:1. Q. State your name, rank and present station of duty.

A. Stephen M. Smith, Captain, Medical Corps, U. S. Naval Reserve, my station is U. S. Naval Hospital, Bethesda, Maryland.

2. Q. What are your duties at the Naval Hospital?

A. I am assistant chief of the Psychiatric Service.

3. Q. Will you give a resume of your qualifications as a psychiatrist?

A. I graduated from Tufts College Medical School in nineteen twenty, interned at Boston City Hospital. During the succeeding twenty-nine years I have spent a major portion of that time in the active practice of psychiatry. Among other positions which I have held are Physician in Charge of the Philadelphia Hospital for Mental Diseases; Clinical Director of the Polk State School in Polk, Pennsylvania; Medical Director of Halbrook Sanitorium, Greens Farms, Connecticut; U. S. Navy from April forty-two to August forty-six at which time I returned to the private practice of psychiatry in Westport, Connecticut, and returned to temporary active duty in the Navy September tenth, nineteen forty-eight. I am a Member of the American Psychiatric Association; the New York Society for Clinical Psychiatry; the Connecticut Psychiatric Society; for the past approximately fifteen years I have been an instructor in psychiatry at the College of Physicians and Surgeons at Columbia University, New York City. I am consulting psychiatrist to the Norwalk Hospital, Norwalk, Connecticut; Grace New Haven Hospital, New Haven, Connecticut; Stamford Hall in Stamford, Connecticut; on military leave from the indicated hospital appointments and at the present time I am also assistant Clinical Professor of Psychiatry at Georgetown University. I was also formerly on the teaching staff at the Medical School at Yale.

4. Q. Captain, will you please tell the board what you know relative to the treatment of the late Mister Forrestal?

A. Perhaps I should begin by saying that the treatment was directed by Captain George Raine