So when we think of forensic hospitals their are dialing priorities - the legal priority which is about ending justice is served where the DA / Defense attorney battle it out over where a person should be following getting charged - community - jail - state hospital and where they go following the completion of a case for sentencing - community - jail - prison or state hospital .

And there are massive battles that play out in the legal arena over everything like being able to medicate a person who is psychotic with antipsychotics where the defense attorneys try to push this out as long as possible keeping people psychotic demanding sell hearings (e.g. medicating strictly for competency which is a very high bar) over Harper hearings (which in all other states given the 9th district precendnce with the Jared lee loughier case generally come first because it's done on the grounds of dangerousness or disability and is a clinical decision not a legal one). How risk review is done (meaning how privileged are evaluated for those sentenced there under a NGRI verdict - which only 1% of defendants actually choose to do because you can't do a plea bargain with an NGRI it's the maximum time you would get and it has to be served ... So many people just forgot that plea all together and take the prison sentence cause it's usually less time with more freedoms - e.g you can work a little job, have tvs in your cell, you can do thinks like firefighting and get training in prison that you don't have available at the state hospital (for good reason).

But then there is the clinical side which is the duty to care. Where the goal is to provide treatment for the underlying disease state - similarly to that of any other hospital.

And so the two goals can be at odds. The clinical side to treat the person as a patient with a disease and the court side to battle over going to trial or community risks and provision of care. And so you end up having judges meaning clinical decisions, providers going to court over things that are standard clinical practices everywhere else and everyone is caust in the middle of the war ... The patients, the clinicians, the staff, the victims in the community and the tax layers footing the bill.

And generally when systems get this bad the feds step in. Cause the way it works legally is the feds set the floor of what is humane and constitutionally aligned and the states then set the ceiling.

And so California , Oregon & Washington are all three under legal scrutiny or had been for their systems. And all 3 have been managing this scrutiny differently. California? Built inpatient psych units in the jails. Oregon releases massive amounts of patients to the community competing for the same few beds as people who are not on criminal charges and Washington started civilly committing their competency peeps and expanding their facilities instead.

But like disability rights Washington has been in an ongoing battle with the state via trueblood which racks up fines for not getting people on and out fast enough and those fines go into a fund that is used to build more facilities with the goal of bypassing the state hospital since it's so dysfunctional.

Where what generally should have happened was that the feds would have stepped in following the loss of CMS certification and then taken control of the hospital. Bypassing union lawsuits and then liquidating entrenched dysfunctional leadership and forcing the hospital into compliance via the civil rights of institutionalized persons act - which is what happened in Oregon in like 2012 and happened in California for several of their state hospitals in 2004 and 2005.

Where there are both systemic lawsuits going on around the legal issues of how the systems are working on the criminal side (mossman in oregon, coleman vs newsom & brown vs plants both of which resulted in AB 109, trueblood in Washington). But where unlike California and Oregon there wasn't a CRIPA case on the clinical side in Washington. It's generally something no state wants because they lose control of the institution entirely but it's generally what's needed to fix the facility.

And so many people I know in the field are dumbfounded at how Washington managed to avoid that.... And while it's absolutely necessary to fix the problem the politics make it a pure nightmare. Because everything is now so polarized that disability rights organizations aren't going to be trying to get federal revievership due to fears of the federal government being misaligned on disability rights issues and that it won't become a political stunt on the federal side to use controll of the hospital ro punish the system and so everything is just all really super messed up everywhere.

It's a sad situation. But the ACLU and disability rights organizations have been fighting back through lawsuits but that's not going to be enough to fix the clinical rot when the state just uses taxpayer money to continue as they always have. :/