Sky Schaudt/KJZZ

The entrance of the Arizona State Hospital in Phoenix.

Concerns about oversight at Arizona’s state-run psychiatric hospital are re-emerging less than four years after a federal investigation found alarming deficiencies. The hospital provides court-ordered treatment for people with serious mental illnesses.

In 2015, amid reports of abuse and misconduct, Gov. Doug Ducey replaced those in charge of the hospital and ordered a probe into why some incidents went unreported. Now a lawsuit is raising new questions about safety at the facility.

It’s unclear why a patient who was prone to violence was walking the halls of the Arizona State Hospital before dawn on Oct. 3 last year.

But the consequences would be bloodshed for Aaron Wallace, a patient asleep in his room.

“When the nurse opens Aaron’s door, this convicted murderer rushes in, attacks Aaron in his bed and stabs him multiple times,” said Phoenix-attorney Holly Gieszl.

Wallace managed to escape the man’s grip and flee from the room.

“Where the assailant then tracked him down and attacked him a second time,” she said.

Wallace was taken to the emergency room with stab wounds on his face, and neck, requiring surgical exploration.

Gieszl is now representing Wallace and says he’s lucky to be alive.

His attacker was a towering figure who had been brought back to the psychiatric hospital after a protective order was filed against him while he was on release.

The weapon he used against Wallace? A sharpened pencil he somehow obtained at the locked facility.

Gieszl says there was no security on the unit that morning.

“It is the equivalent of being attacked in your own home, in your bed sound asleep with people upon whom you are completely dependent for everything in life," said Gieszl.

Wallace is now suing the State of Arizona in superior court for negligence and failure to protect him.

The complaint alleges Wallace repeatedly brought up the attack in the following months to hospital staff, but wasn’t offered appropriate follow-up care. It wasn’t mentioned in his treatment plan, either.

“Now you ignore something like this either because of gross incompetence or gross indifference,” Gieszl said.

Weeks before the attack, patients on the unit even gave hospital staff a letter indicating their fear of the man who attacked Wallace and asking for him to be moved.

Gieszl said the failure to keep Wallace safe and follow proper procedures for monitoring patients is concerning given the hospital’s troubling history.

“It looks like second verse of the same song,” Gieszl said. “This incident would not occur if the hospital was competently run in a manner that demonstrates care and compassion for patients.”

The state-run facility provides court-ordered psychiatric treatment for people with mental illnesses who are considered a danger to themselves or others, as well as for those declared guilty except insane.

In 2015, a federal investigation found mismanagement at the hospital was endangering patients and limiting its ability to render adequate care. That came after reports of assaults, deaths, sexual abuse and efforts to cover up misconduct. Gov. Doug Ducey ordered a probe into why some incidents went unreported.

That same year, the hospital came under new management.

Dr. Cara Christ took over as director of the Arizona Department of Health Services, which both licenses and runs the hospital.

Speaking to KJZZ in 2015, Christ said the hospital was committed to reform.  

“Obviously, we want to have a culture of transparency and bringing things forward,” Christ said. “If you don’t know about problems, you can’t fix them.”

These efforts to improve transparency came as welcome news to Jim Gillcoatt.

“I came into this very wide-eyed and hopeful,” Gillcoatt said.

A psychiatric nurse, Gillcoatt serves on an all-volunteer committee — created by state law — that’s charged with independent oversight of the hospital. They hear patient complaints and investigate conditions at the hospital.

Sky Schaudt/KJZZ

Arizona State Hospital on 24th and Van Buren streets in Phoenix.

“I thought we were going to work hand in hand, that we could see things and say, ‘By the way, let’s look at this, let’s make it better.’”

But over the past year, the relationship between the oversight committee and the state has soured, according to members like Gillcoatt, as well as documents reviewed by KJZZ.

“I’ve been disillusioned,” Gillcoatt said.

Much of the dispute centers on what information the committee gets from the hospital about patient care.

Gillcoatt is in charge of reviewing such incidents for the oversight committee. He first heard about the attack on Wallace last year and wanted to learn more about why the patient wasn’t under closer supervision and how he found a dangerous object.

But Gillcoatt said he didn’t get a report.

“Then the next month came and I didn’t see it again. We wondered what was going on? Why are we not seeing these things?”

Over the past year, Gillcoatt said the committee has not been getting reports about other incidents, too, especially what he characterizes as “outlier events” like deaths and serious assaults.   

“If we are not hearing about this, what else are we not hearing about?”

Gillcoatt isn’t the only one asking that question.

At their most recent meeting, Laurie Goldstein, another committee member, raised the same concern about missing information, calling it “a little suspicious.”

The state tells KJZZ it’s begun looking into those concerns and how to resolve any issues. But earlier this year, the message coming from state health officials to the committee was quite different.

In February, a scathing letter alleged some members of the oversight committee were violating patient privacy and blurring the line between oversight and personal advocacy.

Calling the situation “untenable,” the health department imposed new, stricter rules for how the committee gets information from the hospital.

After a legal review, the state also determined the oversight committee no longer had jurisdiction over the forensic patients at the hospital — people with a mental illness who’ve been involved in criminal cases.

Aaron Wallace is one such patient.

“The sense I am getting is we are more of a thorn in their side,” Gillcoatt said.

The dispute between state health officials and the committee even reached the state Capitol. Earlier this year, state Sen. Nancy Barto sponsored Senate Bill 1450 that would have, among other things, restored the oversight committee’s access to forensic patients at the hospital.

At a March legislative hearing, Barto said she was worried about the health department’s “sweeping” and “unilateral” changes that “make it more difficult, it seems, to have functional oversight and effective oversight over these vulnerable populations by these groups.”

The bill did eventually pass, but not with the changes Barto had sought that would have restored the oversight of forensic patients.

At the hearing, Rep. Eddie Farnsworth seemed to reveal why to fellow lawmakers. He suggested the measure, as originally introduced by Barto, would not be signed by Gov. Doug Ducey, whose office sits on the 9th floor of the state’s Executive Tower.

“It’s the governor’s signature,” Farnsworth said. “The 9th floor has some concerns about the language. I have not been involved in all the conversations.”

Farnsworth added that Barto had requested the changes to her own bill because she knew it might not pass otherwise.

The department of health would not discuss Aaron Wallace’s assault for this story because it has not yet seen the lawsuit.

As for oversight, a spokesperson said there are other groups involved in looking after forensic patients, including “the Joint Commission, State Licensing, and the Arizona Health Care Cost Containment System’s Office of Human Rights if the patient has a serious mental illness.”

Sharon Ashcroft chairs the state hospital oversight committee. She said Wallace called into their meeting after the attack and asked them to look into what happened.

“He had not received any counseling, he had not been debriefed,” she said.

Ashcroft said she later asked the hospital’s CEO about the stabbing and was assured it was being investigated, and the committee would be kept in the loop.

“After a few months, when nothing was forthcoming, we had actually drafted a request for an investigation and that is when we were told we no longer would be able to access the forensic campus,” Ashcroft said.

The state’s crackdown on the oversight committee surprised Kim Scherek, too.

Like Ashcroft, she’s long advocated for patients at the hospital while also volunteering on the committee. But that is no longer allowed, according to the state’s new rules for the committee.

“The reason people are on the committee is because they care about these patients,” Scherek said.

“It feels like they were determined to silence us, and that’s exactly what has happened.”

The oversight committee isn’t the only group concerned about transparency. Last month, the Arizona Center for Disability Law also sued the state for withholding records related to the death of a patient in 2015.

According to the lawsuit, that came after years of asking for the information without success.

“It’s sad because this is a population of people that doesn’t have a lot of advocates,” Scherek said.