The state treats patients with drugs, brutality and death
Farview State Hospital, in the rolling wooded countryside north of Poconos, looks almost like what is was once intended to be – a benign circle of three-story brick buildings where the mentally ill who have committed crimes are treated and, if possible, cured. A passerby driving through the anthracite region could almost mistake it for a small cottage or resort hotel room monastery. It is none of those things.
WAYMART, Pa. – Farview State Hospital, in the rolling wooded countryside north of the Poconos, looks almost like what is was once intended to be – a benign circle of three-story brick buildings where the mentally ill who have committed crimes are treated and, if possible, cured.
A passerby driving through the anthracite region could almost mistake it for a small cottage or resort hotel room monastery.
It is none of those things. Over and over, those who have been patients at a Farview and to have been lucky enough to get out describe it as living hell on earth.
And there is a wealth of evidence from others – guards, administrators, scholars and even government investigators, whose findings have been suppressed – but the description is chillingly accurate.
A three-month investigation by The Inquirer has revealed that:
Farview State Hospital is a place where men have died during or after beatings by guards and by patients egged on by guards.
It is a place where men who have died that way have been certified as victims of heart attacks.
It is a place where men have been pummeled, bloody and senseless – for sport.
It is a place where an unwritten code requires all the guards present to hit a patient if one guard hits him.
It is a place where patients have been forced to commit sodomy with guards and other patients.
It is a place where men have been forced to live naked for years on end, sometimes handcuffed on icy floors.
It is a place where guards have sponsored patients in human cockfights and bet on the outcome.
It is a place where there is virtually no treatment aside from the use of mind-altering drugs, some of which other institutions abandoned a decade ago.
It is a psychiatric hospital without a board-certified psychiatrist.
It is a place where a man under a 30-day sentence for disorderly conduct can wait 30 years for his freedom.
It is a place where for decades – 26 years, in one case – can a lapse between the time a patient is admitted and the time he gets a psychiatric evaluation.
It is a place where men have been denied such basic amenities as toilet paper.
It is a place where staff members and patients alike must live in a system based on hustles, extortion and theft.
These are some of the findings that The Inquirer's investigation – an investigation prompted by the complaint of an embittered former patient, and based on stories of interviews and on the study of numerous documents previously not made public. Those interviews included former and present guards, administrators and state officials, as well as patients who have been freed or transferred to prison.
The main findings – homicide, cover-up, neglect, corruption, brutality, sodomy – form a pattern that spans the last three decades and possibly longer.
The current administration at Farview, interviewed last week, says it is trying and succeeding in stamping out many past abuses.
But the pattern of crime and neglect at Farview has easily survived all past attempts at reform, and two high-level staff members interviewed in recent days said that any new attempts at reform have yet to penetrate the guard structure that runs the hospital.
State law enforcement authorities have long known about the abuses at Farview. The files include strong evidence of crimes, including murder, and yet nothing has been done.
The files also include admissions from investigators that their work was superficial in crucial ways.
In November 1974, State Attorney General Israel Packle ordered an investigation of "allegations of threats, beatings, illegal contraband and deaths at the institution" at the request of Helene Wohlgemuth, then Secretary of the Department of Public Welfare. Most of the investigation was done by the Bureau of Investigations, but the State Police also conducted inquiries about deaths at Farview.
By the time the results came in, Packel was no longer Attorney General. On April 16, 1975, his successor, Robert P. Kane, wrote his conclusions on the matter to Frank S. Beal, then the secretary of public welfare. He said, "... there have been a multitude of occasions where staff has used force against patients," but concluded that such force had not been "excessive or unlawful."
"There is no evidence supporting allegations of criminal violations at the hospital," King said, but he did conclude that "there are serious problems caused by patients' possession of money and other contraband ... and that there has been a lack of administrative resolution of these problems..."
How was that conclusion reached?
By listening to guards and ignoring patients, according to an accompanying letter by Cecil H. Yates, director of the Bureau of Investigations.
Yates cited two predicaments that, he said, made his department's investigation "superficial." One problem, he said, was that the credibility of patients certified as both criminal and insane "must be viewed as questionable."
However, Robert Hammel, current acting superintendent at Farview, says that fully 30 percent of the 453 patients at the hospital have never been convicted of a crime. And the records at Farview are filled with accounts of patients who were admitted not because they were "insane," but because they were troublemakers elsewhere or, in some instances, because a court somewhere simply made a bureaucratic error.
Yates also noted that his investigators had perused the medical records of guards injured by patients, but not those of patients who claimed to have been injured by guards. To do the latter, he said, would be "legally questionable."
Thus it was, he said, that "no attempt was made ... to thoroughly analyze the problem," or to recommend "corrective actions."
The narrower, simultaneous State Police investigation into three deaths did turn up strong evidence of murder in one case – the death of Robert (Stonewall) Jackson in 1966. In two other cases, there was conflicting evidence. In yet another three cases, not involved in the investigation, questionable circumstances surround the deaths. In none of the cases were charges lodged or reforms proposed.
To moviegoers who saw "One Flew over the Cuckoo's Nest," the circumstances under which "Stonewall" Jackson died at age 36 may have a familiar ring.
But Jackson died, and law enforcement officials were told how, long before the film was made. It is a death that illustrates a pattern described by many former Farview patients – beatings, murder, incorrect records at the hospital and indifference from legal authorities.
Jackson's mother, Mrs. Alma Jackson of Southwest Philadelphia, says she visited him at Farview about three months before his death on Sept. 24, 1966.
Stonewall, she told The Inquirer, had acquired the nickname because of his formidable size and strength, and that when she saw him at Farview his body was weak and twisted.
"He walked with his stick," she recalled. "He was all bent over. He told me that they were going to kill him, that he didn't have long to live."
She said she asked the doctor why her son was being mistreated. "He told me that my son wouldn't talk. He said that he was stubborn, and that 'we are going to break him.'"
According to William, 57, who spent 22 years at Farview and now lives in Philadelphia, Jackson quarreled with guards on "D." Ward one evening on or about Sept. 21, 1966. It was near midnight, Ash says, when the guards "dragged" Jackson out.
Jackson ended up in a medical ward. A patient there, William James Wright, who is currently in prison at Dallas, Pa., awaiting sentencing for murder, was interviewed by State Police investigators 18 months ago.
"As a patient, I witnessed Robert Jackson beaten," he related. "He was cuffed by his hands and legs to a bed with leather restraints.
"It was late in the evening sometime between 10 p.m. and 6 a.m. Jackson was making a lot of noises. He was disturbed. The guard told a patient to stop Jackson from making noises.
"The patient then went out of the office and struck Jackson in the throat with the back edge of his right hand. He struck him only once, and Jackson started to gag, and about 20 minutes later he died."
Another former patient, William Franklin Sipes, 30, of Philadelphia, told the State Police he also saw a male nurse strike Jackson in the throat after Jackson knocked a tray off his bed with his knee, spilling some of the food on the nurse.
"As soon as I seen what was going on, I got away," Sipes said. "I was worried about what could happen."
Another inmate, Clayton Allen Terhune, told the investigation that he witnessed Jackson's final moments. "Jackson's arms and legs were cuffed," he said. "He was restrained to a bed ...
"This is how it happened. The inmate working in the ward placed a pillow against Jackson's face while he was cuffed to the bed. The pillow was held against his face for a long time. In fact, the patient got on top of Jackson and put his weight on the pillow against (Jackson's) face. During this time the nurse was standing beside the bed. He was watching and did nothing about it."
The hospital's official paperwork on the death mentions none of this.
The cause of death, entered on the death certificate by Dr. Joseph D. Moylan, a staff physician, who is now dead, was acute coronary occlusion with myocardial infarction – a heart attack.
No autopsy was performed, and the body was embalmed by a guard who is also a registered mortician.
Jackson's mother recalls the condition of the body when she received it.
"His neck was crooked," she said, "his arm looked bent out of shape."
A year ago, Dr. Halbert E. Fillinger, Jr., assistant Philadelphia Medical Examiner, concluded in a letter was part of the State Police report:
"The police investigation involving the circumstances surrounding the man's death, as substantiated by several witnesses would certainly cast doubt on this diagnosis (death by heart failure). As a matter of fact, the information supplied to the police by several witnesses would strongly suggest that this man's death was of a highly suspicious nature.
"There are certainly several allegations that the deceased may well have been suffocated with a pillow and that the cause of death given on the death certificate is a totally erroneous one.
"If the allegations of the several witnesses interviewed by the State Police have a basis in fact, the only conclusion one can draw is that a felonious death had occurred and a thorough investigation must be conducted to pinpoint the person responsible for this man's death and see that he is brought to justice."
No charges have been filed in the death and no evidence has been presented to a grand jury, as far as The Inquirer can determine. Several years after Jackson's death the male nurse was fired for allegedly smuggling a pistol to an inmate.
Since The Inquirer began looking into Jackson's death, however, the State Police has shown a renewed interest. Mrs. Jackson said she was called last week.
"They asked me questions about his death," she said. "I tried so hard to get someone to listen to me back in 1966. No one would help us. I knew that whoever killed him would never have any rest, never have any peace."
The death of Calvin Bush on Oct. 11, 1973, may or not have been a murder. In either case, it says a great deal about what passes for medical care at Farview.
Bush, 32, died of a heart attack. At the time of the death, he was being subdued by eight guards, one of whom weighed nearly 200 pounds and was sitting on his chest.
The incident apparently began shortly after breakfast that day, when Bush returned to the minimum-security ward where he had been living for about a year. A guard, who later testified before State Police investigators, said that Bush threatened to kill him, called him a "goddamn white man" and then threatened to knock his "block" off.
The guard said that Bush had frequently been abusive, but that this time it was decided to transfer him to either the "N" or "D Ward, which the guard characterized as an "a little rougher than the ones I have (worked on)."
But Bush refused, saying that he wasn't "going no place," the guard recounted. Bush then picked up a chair, but was persuaded to put it down. When he walked out of the day room, eight guards dragged him to the floor and began fastening his arm in a leather restraining device.
While the guard, who estimated to State Police that he weighed 197 pounds at the time, sat on Bush's chest, a doctor ordered a 100-milligram injection of Sparine, a tranquilizer, to calm Bush down.
But Bush died first.
That, however, did not prevent guards from rolling him over and pulling his trousers down to allow a male nurse to administer the injection.
An autopsy by Marvin E. Aronson, Philadelphia's medical examiner, disclosed that the dose of Sparine was indeed given that remained concentrated in the left buttock near the point of injection. It was never circulated because Bush's heart was no longer beating.
The official cause of death was "cardiac arrhythmia due to hypertension aggravated by excitement."
Corner Robert Jennings of Wayne County told The Inquirer: "I know he died of a heart attack, but I also feel that such things are brought about by unusual stress, and that struggling with and being restrained by eight men, some sitting on the chest, could cause enough anger and stress."
The indiscriminate use of drugs was also manifest in the death of John Rank, 68.
Last March, 2, Rank was given a ham sandwich by a guard. In quick succession, according to the post-mortem, Rank "developed bizarre, agitated behavior, jumped up from where he was sitting, ran, head lowered, smashed into a wall and fell to the floor."
He was soon dead.
An autopsy disclosed that rank apparently had choked to death on part of the ham sandwich – an unremarkable fact, except for the fact that he had earlier been heavily sedated with a drug that inhibits swallowing.
When John Rank died, there was no nurse on his floor and no doctor in the hospital. Dr. Bernard J. Willis, the hospital's assistant superintendent and clinical director, told The Inquirer, "The doctors got tired of being here all the time."
When a nurse from another floor arrived, she tried to give aid, then telephoned Dr. Willis at home.
According to a preliminary investigation by Coroner Jennings, Dr. Willis ordered the body removed to the hospital morgue and placed on a table.
The body remained on the table for 14 hours and was never placed in refrigeration. Eventually it was picked up by the coroner's office and an autopsy was performed.
By the end of last month – three months after his death – John Rank had yet to be officially pronounced dead by any official associated with Farview State Hospital, according to the corner.
A toxicological report on the thin, pale elderly man was performed by National Medical Services Inc., of Willow Grove, Pa. Dr. Richard D. Cohn disclosed these findings:
"The level of chlorpromazine (Thorazine) detected in this individual's blood is more than double the usual maximum therapeutic level. It is reasonably certain that at the level of (Thorazine) found to be present in the blood, pronounced central nervous system depression was obtained and that coordinated and reflex actions were significantly impaired.
"The blood level (of Thorazine) found is not inconsistent with an acutely toxic (Thorazine) concentration, which is in the absence of similar or more competent causes, could be competent, independent causes of death."
Thomas L. Garrett, 37, died at Farview in March 19, 1960, according to hospital records.
The cause of death, again according to the hospital records, was a sudden and unexpected pulmonary embolism which Garrett suffered after spending 17 days in the medical ward with a fever.
What killed Garrett, however, according to patients who say they witnessed it, was a sustained beating by guards that took place in the Farview dining room in February of that year.
Hospital records say that Garrett was confined to the maximum-security ward in February after "attacking guards," and was transferred to the medical ward on March 2 after he came down with a fever.
Hospital records, however, are contradictory on the subject, and an autopsy said to confirm the cause of death cannot be found.
Ward notes for the day in question say that an autopsy was performed by Dr. Harry Probst of nearby Wayne County Memorial Hospital. Dr. Willis, clinical director at Farview, also told State Police who investigated the incident 1975 that Dr. Probst performed the autopsy determining the cause of death.
Dr. Probst, however, told police that he could not recall any such autopsy.
The director of nursing at Farview told State Police that he was present, along with a lab technician in the guard, with Dr. John Perridge, at the time Wayne County coroner, performed the autopsy confirming the cause of Garrett's death. He said the copies of the autopsy report went to the county coroner, to the Department of Public Welfare, to two undertakers and to Farview itself.
However, Dr. Perridge told police that his records indicate that he had never performed any such autopsy, and all of the supposed recipients of the autopsy report told police that they never received it.
Dr. Willis, who signed the certificate of death attributing Garrett's death to a pulmonary embolism, told State Police on January 21, 1975, that he could remember nothing of the incident. Twenty-three days later, his memory had greatly improved. He told State Police that he remembered the incident "very well" and said that Garrett had appeared to be responding well to treatment for fever when, suddenly, he died.
Patients who were there remember it differently. They said that they believed Thomas Garrett died because he was brutally beaten by guards. They told State Police, that one day in February 1960, Garrett asked a guard for a job in the dining hall and was refused. Then, they said, Garrett slapped a guard, whereupon a number of guards attacked him and beat him. Heyward Speaks, a Farview inmate at the time, who currently is an inmate at the State Correctional Institution at Graterford, Pa., told The Inquirer that he witnessed the incident. "All the guards around kicked and stomped Garrett," he said. "They stomped and kicked him in the side of the head. Broke him up real good. Then they put him on "J" ward (Farview's maximum-security ward).
"I was one of the last to see him alive. I went on the ward to shave and cut the inmates' hair. When I went into Garrett cell, I saw he was busted up. His jaw was broken. He was semi-conscious. He was trying to say something, but he couldn't open his mouth. His ribs were busted up as well. I told the guards that I couldn't shave this man ... Ten days to two weeks after that, Garrett died. We were told that he died."
The Inquirer is not the only party to whom Speaks has told his story. In 1969, he wrote to the state Department of Public Welfare, detailing Garrett's incident. The department handled the matter properly. It mailed Speaks' letter back to Farview – namely to Dr. John Shovlin, the superintendent at the time. Later, Speaks said, he wrote to the state attorney general on the same subject. That letter, too, was referred back to Dr. Shovlin.
State police did look into the Garrett incident in the 1975 investigation after another patient told them that he had heard the story of Garrett's death from many inmates.
Nothing came of the investigation.
Russell Sell was 46 when he died at Farview on Jan. 7, 1963. The cause of death was recorded as acute coronary occlusion. On the death notice, Dr. Willis wrote that the body had no wounds, no fractures, and no dislocations.
However, an autopsy one day later by the Wayne County corner reported that Sell in fact had three broken ribs. And 11 years later, Clayton Allen Terhune, a fellow inmate, testified to Pennsylvania State Police investigating the incident that Sell actually died of a severe beating administered by a guard six days earlier in a hospital dining room.
Terhune said that Sell was beaten after he waived in the air a newspaper clipping reporting that Farview had purchased a large order of beef and complained that patients received little meat, because the guards were stealing most of it.
Guards told State Police investigators that there was in fact, a dining room fracas six days before Sell's supposed heart attack, and that he probably broke his ribs falling against the steam table.
The hospital ward notes of Jan. 7 tried to take a middle path. They noted that Sell "died this date, following injuries received while being subdued during a disturbed period during a work assignment in K-3 dining room. Contributing cause of death: acute coronary occlusion."
Consider, lastly, the way Farview cared for Alfred E. Miller, 61, an epileptic who died of natural causes this year, a week before Rank.
Miller's name came up about 18 months ago in an investigation by the State Department of Justice. John M. Fitzgerald, director of social services at Farview, told investigators that another patient had informed him about repeated mistreatment of Miller by guards.
Miller was known as "Jughead." According to the testimony, the guards on the second shift in his ward would get Jughead to strip and they would taunt him verbally until he would scream and carry on. The guards did this as amusement."
"Jughead" died in a bed during the seizure. According to Coroner Jennings, this is how Farview handled his death:
"Mr. Miller's death was reported to me by Dr. Hobart Owens, who was scheduled to have been the officer of the day and should have been on duty. But instead he called me from his home in Hawley, Pa., approximately 20 miles from the institution.
"Dr. Owens reported Mr. Miller's death to my office without examining him or determining that he was, in fact, deceased."
"Being a doctor on duty does not require my being at the hospital," Dr. Owen said in a telephone interview with The Inquirer. "Sure, I am supposed to check the body before he is pronounced dead, but when they (the hospital) called me he was already dead.
"How did I know he was dead? A nurse told me he was dead. A nurse pronounced him dead. But it's true, I am supposed to check the body."
The patient's plight is one side of the story, the guards say. The other is the attacks on guards, and indeed there is ample evidence of guards being injured.
One guard was shot and paralyzed from the waist down by a former inmate who returned seeking one of the doctors. Another guard was bitten by an inmate and lost part of a finger. There are many other instances.
It is a fact that some of the patients at Farview are among the most vicious criminals Pennsylvania has ever produced. It is also a fact that nearly half of them are blacks from the ghetto streets of Philadelphia and Pittsburgh, while the guards who deal with them are, almost without exception, whites from the rural area around Waymart.
Those facts and others have led several officials who have studied Farview to recommend, in private reports, that the facility be closed down altogether. But every time the suggestion has even been hinted at, both the guards' union and much of the local populace, who consider Farview a main industry, have objected.
Consequently, Farview continues – although it does shrink. Its current inmate population of 354 is down from a peak of 1,410 in 1962, largely because of court rulings on mental patients' rights. Even given those cases, however, Farview still harbors a surprising number of inmates with no evident criminal record and some with no documented classification of mental instability.
Farview officials say that as many as 100 inmates have never been convicted of a crime, but are men who have proved difficult to control at other mental hospitals. And about 10 inmates have been committed voluntarily, either by themselves or their families.
The officials also say, as noted earlier, that they are doing their best to stamp out the worst abuses of the past, and they assert that what goes on at Farview today bears no resemblance to what went on earlier.
It is impossible to confirm or altogether call into question that assertion, for news of conditions, abuse and even violent deaths seeps out of Farview slowly, carried by the handful of patients released each year who are brave enough and lucid enough to talk. The Inquirer, in its investigation, has been told of murders alleged to have taken place in 1946, 1950, 1954, 1958, 1960, 1962, 1963, 1967, 1968 and 1972. What goes on at Farview today cannot be accurately assessed until possibly a year or more from now.
According to the patients, violent deaths tend to happen in the same basic way. The victim, sometimes baited, gets into a fight with a guard or another patient. The guards respond by forcibly subduing the patient. A short time later the patient is pronounced dead. Usually the cause is listed as a heart attack.
But this is only what former patients say, and, as noted by Cecil Yates, Farview alumni have had a hard time persuading those in positions of authority to take them seriously. The very fact that they have been at Farview means that, whether they are or not, at one time they were branded as both criminal and insane.
That is one problem in plumbing the depths of Farview swamp. Another is the shoddiness of the records.
Many records were lost, officials say, when the basement at the hospital flooded in 1968. Some former officials add that the surviving records are not to be believed. And indeed in some cases, such as that of "Stonewall" Jackson is supposed heart attack, there is every reason to suspect that the records are misleading.
But there can be no question that inmates at Farview are, and have been treated with extraordinary brutality, of which the recurring deaths are only a symptom.
In 1975, Joseph Jacoby, a criminologist working on a study sponsored by the National Institute of Mental Health, gave the committee of the State Legislature a strong indication of the widespread cruelty.
He and his fellow researchers interviewed 269 former Farview patients who had been released or transferred to other mental institutions between 1969 and 1971 as a result of a federal court suit.
The patients were asked what they liked most and least about Farview and its staff. With no prompting at all, Jacoby reported 45 percent of those who gave "recordable responses" cited brutality at Farview. In contrast, less than 2 percent cited brutality in the hospitals or prisons to which they had been transferred.
Here are some of the responses, each from the different former Farview patient:
"The guards would knock you down and kick you if you talk."
"The way they beat them and kill them – I seen it done."
"They once beat up a guy so bad his mother couldn't recognize him. They said a patient beat him up."
"Beatings and stompings of the patients."
"Beatings they gave to the men. They beat them up about once a month or so."
"It's a butcher house – house of no return."
"Too brutal and cruel to you at Farview. They don't beat you here (the patient's current hospital)."
"At my prison hospital they have good guards who don't resort to brutality. At Farview, your life is in danger from the minute you enter to the minute you leave."
"The guards and attendants beat me up and didn't treat me like a human being."
"Sadistic guards terrorizing and beating up on patients."
"Beating guys for no reason. My friend was beaten, had his jaw broken, and was robbed. My face was busted. I been beaten up on every ward I been on."
And so on.
Jacoby said that the percentage of those citing brutality might have been even higher had not some patients still been in fear of their former guards.
"We have reason to believe," Jacoby said, "that a number of subjects refused to answer questions about Farview candidly because they feared retaliation if they complained about conditions and their identity were discovered. One patient confided, 'They, the guards, used to tell us we better not talk about Farview or else. But I ain't afraid.' This fear could have been a real factor in the way some patients fashioned their replies ..."
Another view of the violence was given to The Inquirer by John Naughton, who retired as a guard and secretary of the guards' union in December 1974 after eight years of Farview.
Naughton, now the assistant manager of a restaurant in Scranton, confirms the claim of former patients that the guards had a code that compelled them to join in on the beatings of inmates.
He said that there "absolutely was a code, an unwritten but well understood rule among the guards, that when the guard hit a patient you had to jump in. If you didn't, you were pulled off that ward immediately. You were branded as a coward, or just branded, period.
"I've seen the guards come to work and start out the shift picking on the patient and put him in the 'peanut' (a tiny room) for punishment – all for no reason, except that the guard can do it.
"There are guards there that just like to kick and stomp patients. I've seen them kick and stomp patients. There were people there that I just would not work with, because I knew I would spend all night pulling them off the patients."
Those who were kicked and stomped undoubtedly have even more vivid recollections.
Rayford Smith, who was a Farview patient from 1959 to 1964 and is now a prisoner at Graterford, told The Inquirer that he was kicked so hard in the genitals "that they ruptured my scrotum and I urinated blood for three months after the beating."
"They kicked me so hard in the stomach that I actually had a bowel movement right there. My intestines hurt for five years after that. ..."
Arthur Pitts, 49, served two terms of Farview, one from 1963 to 1964 and the other from 1966 to 1968, and is now at Western State Correctional Institution in Pittsburgh. During his second stay he attempted to escape but was caught hiding in a recreation area.
"The guards beat me and kicked me and stomped me," he said in an interview. "Then they stomped and jumped on my shin bones until they broke both of them. They kicked me in the face and kicked one tooth out."
Heyward Speaks, 55, a convicted rapist currently serving his sentence at Graterford, says he learned an important lesson in the first hour of his first term in Farview in 1956.
"The first night I got to Farview from Eastern State Penitentiary I was met by a guard who told me I had to take a shower first," Speaks recalls. "There was only one nozzle in the shower stall. I turned it on in the water was ice cold. I started to step out and complain, but I could see from out the side of my eyes that about seven guards were coming towards me into the stall.
"I sensed that I had better not complain. I held my breath and stayed under the shower until I got used to the cold water. Then I was given a nightshirt and told to sit on the bench outside the shower stall.
"I watched from the bench what happened to the next inmate, a white man who came up in the same car as me. The man turned on the water and it was cold. He jumped out and complained. They beat him and stomped and kicked ... him.
"When they finished beating him, his naked body looked like a piece of raw meat. I knew then I wasn't going to give anybody any trouble here."