Brisbane Report TOC

The Brisbane Report, Nancy D. Feldman, J.D. for New Jersey Protection and Advocacy, Inc.

PART 2 -- BRISBANE'S HISTORICAL BACKGROUND

Brisbane’s Shortcomings Long-Identified, Still Remain

In 1947, Brisbane opened as a state hospital for the observation, care and treatment of children with mental illness between the ages of 5 and 12. The hospital continued serving as an inpatient psychiatric facility for children under age 14 until the late 1980's. At that time, the Adolescent Unit at Trenton Psychiatric Hospital was closed as a result of the Slocum v. Perselay litigation and Brisbane began functioning, as it currently does, as an acute, psychiatric inpatient facility for youth ages 11 to 17 years.

Slocum v. Perselay Litigation

Following the death of an adolescent patient in the Adolescent Unit at Trenton Psychiatric Hospital, the Public Advocate filed the Complaint in Slocum v. Perselay on June 27, 1986, in New Jersey Superior Court, Law Division, Mercer County. The action, in lieu of prerogative writ, sought declaratory and injunctive relief to prevent further harm to the children hospitalized there caused by improperly trained staff, lack of proper supervision, improper use of restraints, overuse of chemical restraints, lack of fresh air and exercise, and the failure to identify or develop appropriate and less-restrictive placements.

On May 20, 1988, a Consent Order with Partial Stipulation of Settlement and Dismissal was filed, requiring the complete closing of the Adolescent Unit at Trenton Psychiatric Hospital by December 31, 1988. Incorporated into the Consent Order was the State Plan for the Establishment of Regional Psychiatric Programs for Seriously Mentally Ill Children and Adolescents, dated February 1987. This Plan called for the development of: 40 additional CCIS beds statewide to serve all children who required inpatient care at the regional level for the first 28 days; post-28 day inpatient care; mental health services for 5 to 10 year olds; mental health services within the Division of Developmental Disabilities and in the Department of Corrections at Jamesburg; and a 40-bed unit at Brisbane to serve as a "Statewide Back-Up Unit" for severely mentally ill adolescents in need of extended hospitalization.

Documented Severe Deficiencies at Brisbane in May 1989

As the Adolescent Unit at Trenton Psychiatric Hospital was closed and Brisbane was transformed from a children's psychiatric institution to one serving adolescents, the focus of the Slocum v. Perselay litigation moved to Brisbane. In May 1989, the Public Advocate filed the report of their expert, Dr. Barry Nurcombe, who evaluated whether New Jersey was providing adequate treatment services at Brisbane in accordance with the May 1988 Consent Order.

According to Dr. Nurcombe’s Report:

• Although the population at Brisbane was to be no higher than 40, it had climbed to approximately 80.
• The Administration Building was shabby and depressing, and the admissions unit located there was grossly overcrowded. The cottages were poorly designed as hospital units. He noted that with its attractive grounds, Brisbane could function as a residential group home, but could not function as a hospital without extensive rebuilding.
• Staff members verbally intimidated and hectored the patients. Staff was especially provocative with patients that they perceived to be "out of line," possibly seeking to set up a physical encounter that would allow them to assert their dominance over the patient.
• There were serious deficiencies in diagnostic, therapeutic and educational services. Brisbane was unable to separate youths with conduct disorders from adolescents who were psychotic. In addition, the hospital was not providing separate treatment programs for patients with substance abuse disorders and developmental disabilities or for patients who had been traumatized by sexual abuse.
• There had not been adequate training in reliable methods of safe manual restraints. As a result, explosive patients had sustained avoidable injuries because of inept efforts by the staff to restrain them.
• There was confusion about the goal of Brisbane: Was it short-term stabilization or long-term reconstruction? Many patients were ready for discharge and had nowhere to go. As they waited for placement, some patients regressed and then needed to be re-committed to the hospital.

Based on Dr. Nurcombe's Report, the Public Advocate moved in May 1989, to reopen the matter because of violations of the Consent Order resulting from overcrowding at Brisbane, the failure of the hospital to separate adolescents with conduct disorders from those who were mentally ill, and the failure of 11 of the 33 required regional programs to be in operation.

In August 1990, A Recommendation that Brisbane Be Closed

In response to the Public Advocate's motion, the Court appointed Robert M. Friedman, Ph.D., to advise the Court on conditions at Brisbane and on the role of Brisbane in the broader juvenile mental health system. Dr. Friedman’s Report, dated August 1990:

• Recommended that Brisbane be closed as of January 1, 1992. He concluded that Brisbane was not adequate as an inpatient acute care facility due to its physical layout and that it should not be renovated to use as a residential treatment facility because of its physical isolation, making it difficult to hire and retain an especially qualified staff.
• Documented, as had Dr. Nurcombe, many major problems at Brisbane, including severe overcrowding, with a census of over 70 at the time of his investigation; absence of a clear mission; an inadequate treatment program and behavioral management system; lack of adequate discharge/aftercare plans; lack of staff training, particularly in the management of aggressive behavior; failure to provide strong linkages to community providers; and lack of family involvement.

Dr. Friedman described the overall system of mental health care for children and adolescents in New Jersey as over-centralized and fragmented. He noted that New Jersey was moving toward the creation of a crisis-oriented system in which it was necessary to have a mental health crisis in order to receive services. Then, when a crisis did occur, there were inadequate services and fiscal incentives to treat the child at home or in a clinic setting rather than in an inpatient setting.

A key provision of Dr. Friedman's report was the recommendation that multi-agency teams (CART program) be established to facilitate the development of services on a local basis. He also called for New Jersey to reorganize the system away from a model of central statewide institutionalization and residential placement and focus resources instead on community-based services.

While Dr. Friedman's recommendation that Brisbane be closed was not implemented by the Court, it did order the establishment of the county-based inter-agency teams to review the needs of high priority children and adolescents with mental illness. This Order, dated January 24, 1991, was the final order in Slocum v. Perselay, except for the appointment of Jeanne Warnock on February 21, 1991, as an expert to monitor the State's compliance with the requirement to develop the CART program. In Warnock’s Report of September 1991, she documented that the State was launching the Youth Incentive Program to develop cross-system planning, client assessment, and service development at the county level to reduce the reliance on out-of-state placements and to reduce the time that patients ready for discharge waited at Brisbane for placement. Although interim CART programs had been established in every county, the CART process had not yet had an impact on the population at Brisbane, which remained in the mid-60's. Of this population, approximately half were ready for discharge.

Mental Health Association of Monmouth County's White Paper Detailed Critical Shortcomings at Brisbane

As the quality of care at Brisbane became the focus of the Slocum v. Perselay litigation, the Mental Health Association of Monmouth County issued a detailed and critical White Paper entitled Report on Investigation into Quality of Care at Arthur Brisbane Child Treatment Center in December 1989.

The White Paper's findings and conclusions:

• Brisbane failed to provide a safe and therapeutic environment for the children in its care.
• Brisbane violated the court-ordered separation of children based on diagnosis, leading to victimization and violence.
• Brisbane did not have a clinical director, nor did there seem to be clear clinical organization and policy.
• There was little continuity of care. Long-term placement and/or discharge planning were inadequate.
• Staff was not properly trained to deal with the current population.
• Brisbane was overcrowded and had many fire hazards. The environment was depressing, bleak and anti-therapeutic.
• Infirmary facilities were non-existent.
• The school had many vacant teaching positions. Teachers did not participate sufficiently in treatment-planning meetings.

The White Paper recommended that the State:

• Hire independent consultants to perform an in-depth review of Brisbane's clinical and management operations, policies and procedures;
• Appoint a qualified clinical director;
• Mandate multi-disciplinary attendance at treatment-planning meetings and assign a permanent treatment team to each child upon admission;
• Allow municipal authorities to inspect Brisbane for fire hazards on a regular basis and correct the deficiencies immediately;
• Create a less depressing, more therapeutic environment and redesign units for maximum patient surveillance;
• Separate children by diagnosis;
• Create an infirmary;
• Hire sufficient staff to eliminate mandatory overtime, and develop staff training;
• Hire teaching staff and assign a liaison between the residential units and the school; and
• Beyond Brisbane, develop a comprehensive system of care for New Jersey's seriously emotionally disturbed children as detailed in the "New Jersey State Mental Health Plan for Children and Adolescents."

State Acknowledges Problems and Issues Workplan

The Department of Human Services responded to the Mental Health Association’s investigation and White Paper with its own investigation into operations at Brisbane. In March 19990, in a report entitled, Report of the Arthur Brisbane Management Team, the Department acknowledged that there were problems at Brisbane that could be traced to both internal and external factors. At that time, according to the Department's Report, neither the CCIS units nor the local and regional short-term children's services in the State Plan were fully operational. As a result, Brisbane was handling both patients who needed intense, long-term psychiatric care and those who needed short-term screening and stabilization that should have been provided on a local or regional basis. The internal problems at Brisbane were attributed to the poor planning for transitioning Brisbane to become the "Statewide Back-Up Unit" after the Adolescent Unit at Trenton Psychiatric Hospital was closed and to Brisbane’s lack of a clearly defined mission. The Report documented in detail both system-wide and internal deficiencies and provided specific recommendations for changes.

The Workplan to Implement Recommendations of the Management Team for the Arthur Brisbane Child Treatment Center supported the Report and was issued at the same time. It included a time-table for changes in the following areas: organizational structure/administration; therapeutic environment; clinical services; programming; discharge process; risk management/ incident reporting; patient advocacy; medication (included restraint issues); quality assurance; staff training; and systems issues.

July 1991, Follow-up Report Finds Persisting Problems

The following year, in July 1991, the Mental Health Association of Monmouth County released the Follow-up Report on Investigation into Quality of Care at the Arthur Brisbane Child Treatment Center. It found significant improvements as well as continuing problems. The Follow-up Report included a new set of detailed recommendations in the areas of: quality of psychiatric care, abuse of children, facility, staffing, and education. In conclusion, the Follow-up Report noted:

Conditions at Brisbane have improved significantly in many areas; however, there are still many serious unresolved problems. Considering the high cost of care, quality of treatment is not as good as it could or should be.

New Jersey continues to fail to provide a responsive, coordinated system of care for its seriously emotionally disturbed children and adolescents. A restructuring of children's services is essential to establish Brisbane's rightful place within the system of care. At this time many children are inappropriately placed at Brisbane or remain there beyond the appropriate time. It is important to develop alternatives for children with serious mental illness who need intensive, long-term treatment.