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Milwaukee County Must Take Immediate Action to Ensure Patient Safety

DRW re-emphasizes its recommendations to improve conditions at the Milwaukee Mental Health Complex.


Disability Rights Wisconsin (DRW) is the federally mandated Protection and Advocacy Agency for the State of Wisconsin, charged with protecting and advocating on behalf of individuals with mental illness to address abuse, neglect, or other violations of their rights including independently investigating instances of abuse and neglect at mental health facilities. One of DRW’s highest priorities has been protecting the rights of people served at the Milwaukee County Mental Health Complex.

The recent death of a patient at the Milwaukee County Mental Health Complex adds to the alarming toll of patient deaths at the Complex in the past several years and reinforces our grave concerns regarding the quality of care provided at the Complex. Over the years Disability Rights Wisconsin has conducted investigations at the Complex regarding a range of complaints and concerns about patient safety and the quality of care provided there. In 2012 DRW commissioned an independent expert review of inpatient medical care, psychiatric treatment, and patient safety at the Complex. Federal and state regulatory investigations have documented a number of recurring administrative and treatment inadequacies that have resulted in formal citations, including multiple findings of immediate jeopardy to patient safety. The time to act to ensure patient safety is long overdue. We once again call on Milwaukee County to move forward with the recommendations advanced by Disability Rights Wisconsin in our most recent report, delivered to state and local officials in June of 2013.

Specifically, we urge Milwaukee County Executive Abele and the Milwaukee County Board to immediately:

  • Close or reduce admissions at the Complex until improvements are made in medical care.
  • Put safeguards in place to monitor the treatment of medically ill patients. The effectiveness and adequacy of these safeguards must be assured through independent oversight.
  • Deploy an independent interdisciplinary team (including a psychiatrist, psychiatric nurse, systems/policy expert, and a human resources professional familiar with this type of facility) to review current treatment protocols.
  • The interdisciplinary team must have authority to initiate specific policies, procedures, and personnel decisions to effectively ameliorate the current situation.

Additionally, we urge the Wisconsin Department of Health Services to take an active role in the implementation and oversight of these recommendations. This would require positive involvement in crafting a solution to the problems at the Complex, not only investigating each tragedy as it occurs.

To be successful this plan must be actively promoted with the medical and professional staff at the Complex. Implementation of the recommended changes should be monitored by the independent interdisciplinary team to ensure quality improvement and patient safety.

Our continuing concern regarding patient safety at the Complex underscores the necessity of expanding community-based mental health services that can provide an alternative to inpatient care. Private providers also bear responsibility for the decline of alternative inpatient mental health capacity. They too must contribute to the solution. Patients with mental health issues can be far better served through comprehensive services that support their life in the community. Individuals with mental illness and their families deserve no less. As a community we must demand the highest standard of care. Those that have the duty and ability to act must act now to prevent needless deaths and move toward a system of high quality community care.