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Investigators found 16 Unity Center cases should have gone to cops. County employees scrutinized.

TRIBUNE FILE PHOTO - Unity Center has been the subject of scathing state reports in recent months, but was recently cleared by state and federal officials to keep operating. Now, however, a preliminary Multnomah county review sparked by the Unity controversy has found numerous abuse complaints were not forwarded to police as required.An internal review of how Multnomah County employees handled cases of alleged abuse and neglect of mentally ill people from greater Portland has spawned a criminal investigation, the Portland Tribune has learned.

Among the issues that appear to be under review by prosecutors and the Multnomah County Sheriff's Office are whether the alleged abusers cited in complaints can be indicted. Prosecutors also will determine whether any Multnomah County mental health employees could be charged for their improper handling of complaints.

Emails obtained under Oregon's public records law indicate county employees improperly failed to report to police as many as 16 cases of alleged abuse of mentally ill people at the Unity Center for Behavioral Health, a troubled Northeast Portland mental health facility that opened in January 2017. It is unclear how many other cases of alleged abuse, at locations other than Unity, were not followed up on by county employees.

The public relations director for Legacy Health, which oversees Unity Center, said his employer has not been contacted by law enforcement and is unaware of abuse complaints that the county should have reported to police. State investigators have said Legacy has made significant safety improvements at the mental health facility since the time frame that is now under review by sheriff's investigators.

"We have made significant improvements to our environment of care, and our policies and practices," Brian Terrett said.

County and law enforcement officials largely declined to comment other than to confirm the criminal investigation is underway. County Chair Deborah Kafoury, whose administration launched the review, said through a spokeswoman she is waiting until the the investigation is done and "she has the facts."

No protocols, no follow up

The Multnomah County review was sparked in August by an internal whistleblower's account in the Portland Tribune, as well as a critical state report. Both blasted unsafe conditions at the Unity Center.

Greg Monaco, a newly retired investigator, told the Tribune that top county mental health officials tolerated a complete absence of protocol, guidelines and training to ensure abuse complaints are propertly handled.TRIBUNE FILE PHOTO - Former Multnomah County investigator Greg Monaco accused mental health managers of failing to investigate abuse. Now prosecutors are trying to find out if laws were broken.

"People didn't know to whom to report things, because nobody really has responsibility for doing anything. And they have abdicated oversight," he said at the time.

In addition to the account of Monaco and the state's findings that echoed him, top county officials, including Chief Operating Officer Marissa Madrigal, were motivated to launch the review after apparently deciding they could not trust information provided to them by their own managers, who'd been overseeing Monaco.

Two top county mental health officials were placed on leave and the county has acknowledged that information previously released to the Tribune and The Oregonian — claiming that the county could not investigate abuse complaints — was false.

In addition, records obtained by The Oregonian in August showed the complaints about Unity Center received by the county included multiple sexual assaults.

While the county review of its Mental Health and Addiction Services Division operations is not complete, records show that managers overseeing the internal review have shared information with the Multnomah County Sheriff's Office, which is overseeing the investigation. And a criminal investigation is now pending.

Now that sheriff's investigators have pinpointed the cases of alleged abuse at Unity Center and elsewhere that were not properly acted on by county employees, authorities intend to forward those to police for documentation.

Were expecting more at Unity

Following earlier reports that county mental health managers had not properly followed up on complaints, law enforcement had braced for an even higher number.

"The highlighted yellow incidents are the ones that (a county manager) had identified as should have had police reports filed, but we cannot locate a report anywhere," wrote Multnomah County Sheriff's Captain Harry Smith in a Sept. 13 email, which referred to an attached spreadsheet. "Thankfully that number is relatively low compared to what we feared we may find.

"I would like to get together with you to review these incidents to see if we have anything to base a criminal investigation upon," Smith wrote in the email, which was addressed to Deputy District Attorney Melissa Marrero, who is overseeing the review. "In the meantime, I will try to have data extracted regarding the victims to see if we have any concerning patterns."

Smith forwarded a spreadsheet compiled by investigator Daniel Felix of the Sheriff's Office. Felix, in an email, told Smith that 16 cases had been highlighted. Most should have led to referrals to police, but did not, Felix wrote, and with "a couple" of them, it was unclear if law enforcement needed to be told.

'Sensitive inquiry'

The details of the 16 incidents and the allegations Smith referred to are unclear. However, in an email the day before to his subordinate, Felix, Smith described them all as relating to Unity Center, and indicated some cases were "PREA-style." PREA appears to refer to the Prison Rape Elimination Act that was adopted in 2003 to protect people in custody from sexual assault.

"This is a very sensitive inquiry so we need to keep this within the unit," Smith cautioned Felix in the Sept. 12 email.

The scope of the investigation may be larger than just 16 cases. Emails obtained by the Tribune refer to another batch of potential abuse cases, likely other than the Unity Center ones. Moreover, the scope of the initial county review that preceded sheriff's involvement included whether adult mental health abuse reports in general were properly handled by county personnel.

Staff under scrutiny

Emails indicate potential county employee culpability is a focus of the criminal review as well. Specifically, investigators are reviewing county policies on abuse complaints to see if employees had followed them.

On Nov. 7, Capt. Harry Smith wrote that as "we look at this larger picture" for the investigation, sheriff personnel wanted to see "relevant policies, training products/standards, and emails between the supervisors and call screeners."

The union representing county mental health employees was briefed on the review in early September, records show.

The Multnomah County District Attorney's office confirms that a criminal investigation is underway.

"We're not going to go into specifics," DA spokesman Brent Weisberg said on Tuesday morning. "We're trying to determine if a crime has occurred at all ... We are looking at a very broad level of material here. There's a lot of information we need to go through to determine if a crime has occurred."

Prosecutors on Monday cited the pending criminal probe to withhold several public records requested by the Portland Tribune regarding the law enforcement review of the county's complaint-handling.

It is unclear whether any county employee could be subject to investigation for official misconduct, a criminal statute that can be used to punish officials who don't do their job.

Officials at the county largely declined to comment on the investigation, reiterating that they have screened 1,300 reports of abuse to see if they were handled properly and to make sure any adults suffering abuse are now safe.

County officials say they've also made sure proper processes are in place to ensure abuse complaints are properly handled now.

"The county has worked to assure the staff has been trained by the state in the process. A manager and supervisor have been appointed to oversee their work and 100 percent of the new reports are being reviewed by those senior folks," wrote Multnomah County Communications Director Julie Sullivan-Springhetti in an email.

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