Kedren Community Health Center’s acute psychiatric hospital in South Los Angeles is under scrutiny, after reports and records show failures of oversight in care of patients. This comes after the Los Angeles Times reviewed inspection reports and court records, and revealed allegations of misconduct, sexual assault and mistreatment at the facility. 

Among the cases that raised concern were: A patient allegedly killed by his roommate, another patient reported to have been choked by a staff member, as well as a third patient who said she was sexually assaulted by her roommate. The reports also show that the hospital allegedly did not follow up with an investigation following the complaints.

 Records also indicate that former employees have filed lawsuits for being wrongfully fired for reporting misconduct, as well as malpractice at the hospital, which Kedren has denied in legal documents.

The Community Health Center was founded in the wake of the 1965 Watts riots, by a group of Black psychiatrists to address, discrimination, violence and education gaps, and poverty in underserved communities. For more than 50 years, Kedren has served as a central component of primary care, education and other family services, as well as mental health in the South Los Angeles region.

Media reports reveal that local, state and federal regulators say the hospital made numerous reforms and is competent enough to provide quality care for its patients. However, the reviewed records by The Times may raise questions in regard to the hospital’s performance, as well as their leadership and lack of response in regards to safety concerns.

After the death of Jacob Masters, the patient reportedly strangled by his roommate, the hospital’s board of directors agreed to review the incident, which happened two weeks after Masters’ death. They advised to have a psychiatrist on duty for after-hours, to immediately evaluate patients who arrive at a later hour.

However, reports indicate that inspectors learned that the hospital still didn’t have an after-hours psychiatrist on duty, eight months after the board’s suggestions. Inspectors also found that the chief executive and president of the hospital, Dr. John Griffith, was reportedly unaware of the postmortem finding in the case. There was also no mentioning of the failure to provide psychiatric evaluations and patient monitoring in the report.

According to a follow-up survey—one year after Masters’ death—another patient, who was reportedly never given an initial evaluation nor subsequent treatment for mental illness, attacked a security guard with a broken toilet. After that, the hospital decided to have a 24-hour full psychiatric clinical care.

Experts in the mental health field say that incidents of violence in psychiatric hospitals are nothing out of the ordinary, but hospital homicides done by another patient are rather uncommon, experts say.

California Department of State Hospitals has said that 3,500 incidents of patient-on-patient violence in 2017, as well as 3,300 involving staff were disclosed statewide.