In the past decade, a dozen Western State Hospital patients have killed themselves. More than a hundred others have tried. Megan Templeton was the most recent. In April, she hanged herself in her hospital room. She had turned 20 the day before. Suicide is the second leading cause of death for teenagers and young adults in Washington.
But inside the state's largest psychiatric hospital, patients are supposed to be safe, even from themselves. How did Megan Templeton slip through the cracks of the mental-health safety net? John Ryan brings us this public radio/KUOW investigation.
A warning: This story contains graphic descriptions of suicide and other violence.
Megan Templeton was living in Vancouver, Washington, when she ended up at Western State Hospital. But she spent most of her 20 years in a small town on the Chattahoochee River in Alabama. Her twin sister, Marley Shoffeitt, still lives there.
Shoffeitt: "I miss everything about Megan. Even though she had problems, she was always uplifting, and she lit up a room when she walked into the room. She gave very good hugs. She was just a very loving person."
Templeton [sings]: "No matter what I face, I will finish this race."
That's Megan Templeton singing and playing keyboard. She was in a Christian rock band with her brother in Alabama.
Templeton [sings]: "I will not give up. I will not give in."
Here's a bit of a home video Templeton made in February after she moved to Vancouver.
Templeton: "My name is Megan Templeton, and I have had a lot of stuff go on in my life. But I want to try out for American Idol. It's a dream of mine. I love singing. I love music, and I just want to show other people who have struggled that they can get through that, that there is hope."
Megan had a long history of abuse growing up. Her sister says Megan started showing signs of serious mental illness when she was about 14. She started cutting and burning herself.
Shoffeitt: "Personally, I don’t understand it, but feeling pressure being relieved—that's how she described it. It took her mind off her problems and her thinking about her past."
Megan's problems included abuse at the hands of a 26-year-old pastor at her Baptist church. After trying to kill herself, she was sent off to a Christian boarding school for troubled girls. There, her cutting got worse.
That pastor, Regina Chambers, was charged with sodomy and assault. The case meandered through the Alabama legal system for five years. The trial finally came last November.
After Megan Templeton testified against her former youth pastor, the lawyers made a deal. Regina Chambers pled guilty to assault in exchange for dropping the sexual charge. She got three years' probation.
After getting home from the trial, Templeton tried to kill herself with a mouthful of pills. Here's her twin sister.
Shoffeitt: "She didn't feel like she had done any good. I mean, she went through all of that, in telling strangers, basically, what happened to her, very personal things that happened to her, because she thought she was going to make a difference. Then Regina got off with probation."
Megan Templeton went in and out of various hospitals in Alabama. After all she'd gone through, the family decided a change of scenery would do her good.
Shoffeitt: "For her diagnosis, borderline personality disorder, we thought she'd get better treatment with better doctors in Washington."
So she moved in with family in Vancouver. She started classes at Clark College. But before long, Templeton's self-harming behavior landed her in a string of Washington hospitals. Mike Kuhns is her stepfather.
Kuhns: "She was here for four months before she was institutionalized out here."
Late on a rainy night in March, employees of a Walmart in Vancouver found her in a bathroom. She was lying in her own blood on the floor with a stolen razor.
Kuhns: "She was back in hospitals from then on out."
Even as she struggled with her mental illness, Megan Templeton had brighter moments. On her 20th birthday, her family visited her at Western State Hospital, near Tacoma. She'd been there about a week. They got permission to take her out for a junk-food picnic on the shores of Puget Sound.
Kuhns: "So we went down to a park there. That's where we had our birthday celebration. Real nice day, sunny and clear. It was a good day. Before we left the hospital, I recall one of the nurses asking us point blank if we thought we could keep her safe while she was out there. Of course, we told her yes. But looking back, it's pretty ironic. We kept her safe while she was out there, but what happened the very next day? How come you people couldn't keep her safe? You know, that's why she was there."
The next day, Western State Hospital provided Megan Templeton both the means and the opportunity to end her own life. The means came in the form of a bed sheet, a chair to stand on and the closure mechanism at the top of her bedroom door.
Hanging is the most common way patients in mental hospitals commit suicide. Western had identified its door closers as a hanging risk in 2010. Most of those closers are still in place today. The hospital requested funding in May to replace them. The opportunity came when nurses left Templeton unobserved for close to an hour after letting her out of restraints.
According to hospital records and police interviews obtained by KUOW, Templeton wound up in restraints twice that day: once after trying to jump over a nurse's station to grab a scissors. The second time, she asked for the ward's head nurse, Elvira Moore. Moore recounted the scene to Lakewood police detective Todd Jordan.
Moore: "She said, 'Yes. I won't do it again. I just want to go to bed and sleep.'"
Jordan: "'I won't do it again,' she said that?"
Moore: "I won't do it again. I just want to go to bed and sleep."
Moore OK'd removing the restraints. At midnight, Moore saw Templeton lying awake in bed. Fifty minutes later, a staffer doing hourly rounds found Templeton hanging from her door.
[911 tape] Voice 1: "911. What are you reporting?"
Voice 2: "This is Western State Hospital, and we have a code blue."
Voice 1: "What does that mean?"
Voice 2: "They're not breathing."
Hospital staff performed CPR until the ambulance came. Templeton survived the night but died two days later.
Elvira Moore, the head nurse, told police that Templeton had made a suicide pact with another patient. Some staff at Western heard about this pact, but the information failed to reach the right people until too late.
Moore: "Right during the code blue, one of my supervisors heard that she made a pact with another borderline patient that they will kill themselves, and I didn't know about that."
Jordan: "When did you find about that?"
Moore: "Right after the CPR."
Once word got out, the other patient was immediately put on a suicide watch. But it was too late for Megan Templeton.
The head nurses on both the evening and graveyard shifts told police if they'd heard about a suicide pact, they would have made sure Megan Templeton was watched more closely. Her twin sister, Marley Shoffeitt, says it wasn't the only warning the hospital missed.
Shoffeitt: "That day, you know, it was very obvious that she was upset. They had to put her in restraints more than once. So I don't understand how that hospital would take her out of restraints and just let her go to bed."
In May, a national health-care organization investigated Western. The Joint Commission found a dozen ways that the hospital failed to meet national standards for keeping patients safe. It also faulted Western's chronic under-staffing for the poor patient monitoring. In Megan Templeton's case, the commission said it was hard to know what actually happened, given the hospital's poor record keeping.
Templeton [sings]: "It gets so dark, I can barely walk." To add one bright note to this dark story: Megan Templeton was an organ donor. With her kidneys and her liver, she gave new life to three women -- two in Seattle and one in Spokane. Her death also spurred safety improvements at Western State Hospital.
Copyright 2012 Northwest Public Radio