A brick sign with the inscription "Montana State Hospital - 1877 Warm Springs" stands in a grassy area with leafless trees in the background. In the distance, snow-covered mountains can be seen under a clear sky.
Montana State Hospital in Warm Springs Credit: John S. Adams / MTFP

In a federal lawsuit filed this week, family members of one living and two deceased Montana State Hospital patients allege that state officials and staff should be held responsible for negligence and the violation of constitutional rights at the adult psychiatric facility in Warm Springs.

A photo of Lucio DiMauro, courtesy of his sister, Nina DiMauro. Credit: Courtesy photo.

Plaintiffs include the estates of former hospital patients Lucio DiMauro and David Patzoldt, through their personal representatives, and Lesley Jungers, a recent patient represented by her two guardians. DiMauro, who was admitted to the hospital in Sept. 2020, died in August 2021 after roughly a dozen documented falls, the lawsuit states. Patzoldt’s health also reportedly deteriorated over a little more than three months after he was admitted in October of 2021. He died the following January. 

Jungers, diagnosed with bipolar disorder and dementia, began residing at the hospital in August 2020. Since then, the lawsuit states that she has left her room without supervision multiple times despite staff being directed to monitor her closely. Jungers spent 14 days in locked seclusion in October of 2020, over the objection of her family members, following those elopements and her inappropriate conduct toward other patients. 

The lawsuit names the state of Montana, Gov. Greg Gianforte, the Department of Public Health and Human Services, health department director Charlie Brereton, and interim hospital administrator David Culberson as defendants, despite some of the alleged negligence and mismanagement occurring under the prior administration of Gov. Steve Bullock. 

“The Montana State Hospital at Warm Springs has been neglected by the Montana Legislature and governors for decades,” the lawsuit states. “Due to neglect from the top, the facility itself has run into disrepair, is unsafe for its residents, and is egregiously understaffed, with the not-surprising result being that Montanans with: (1) serious mental health problems and (2) lack of financial means are systemically abused and neglected. This case is about Montanans who suffered at Warm Springs because of the neglect of those in power.”

Jon Ebelt, a spokesperson for the state health department, declined to comment on the lawsuit Wednesday.

In recent statements to members of the media, lawmakers and other advocates for improved mental health care, Brereton and other officials have said the administration is prioritizing systemic reform at the Montana State Hospital after decades of mismanagement and underfunding. 

After the state facility lost its federal accreditation in April 2022 because of patient deaths, falls and other safety concerns, the Gianforte administration hired the global consulting firm Alvarez & Marsal Public Sector Services to oversee operations at the hospital and help it regain accreditation. A June report from the firm posted to the health department’s website said that the hospital is still struggling with a 37% staff vacancy, a 70-person waitlist for those charged with crimes and awaiting mental health evaluations, and a projected annual budget deficit of nearly $44 million.

“These were problems that needed to get fixed yesterday.”

plaintiffs’ attorney John Heenan

The administration also created a governing board for the hospital comprised of top health department staff members. The group began meeting this year to review updates and ongoing challenges and has another meeting scheduled for mid-November.

The state’s inadequate mental health system and the problems plaguing the public hospital also motivated lawmakers to push through legal reforms during this year’s legislative session. Among those, House Bill 29 requires the state to eventually stop admitting patients with a primary diagnosis of Alzheimer’s, dementia, or a traumatic brain injury to the Montana State Hospital in favor of medically appropriate, community-based placements. A committee to oversee the implementation of the new law, and the development of more local health care options for impacted patients, held its first meeting in October. 

Jon Heenan, a Billings attorney whose firm is representing plaintiffs in the case filed Tuesday, said in an interview Wednesday that the problems at the state hospital have been building for decades and that he agrees that the Gianforte administration “inherited a problem.” Regardless, he said, he hopes the legal challenge can result in a decision that compels the state to remedy short staffing and inadequate conditions at the facility, in addition to providing monetary damages to the plaintiffs.

“The people who [are] there right now, they can’t wait for someone to come back with solutions,” Heenan said, a reference to the state’s ongoing contracts with consultants. “These were problems that needed to get fixed yesterday.”

While Heenan and other attorneys are not pursuing the litigation as a class-action lawsuit, he said, the door is open to other potential plaintiffs who have suffered injuries at the state hospital to join the case.

Responding to the fact that the harm alleged in the lawsuit occurred between 2020 and 2022, Heenan pointed to recent state licensure reviews that he said indicate ongoing issues in various parts of the Warm Springs campus.

“Everything I’ve heard and understand is that the problems that we’re alleging lead to our clients to get hurt and injured, all those things are still happening,” Heenan said. “It’s still understaffed. There are still problems with staff turnover and morale.”

The lawsuit, which requests a jury trial, has been assigned to District of Montana Judge Brian Morris. The state had not filed a legal response as of Wednesday afternoon. 


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Mara writes about health and human services stories happening in local communities, the Montana statehouse and the court system. She also produces the Shared State podcast in collaboration with MTPR and YPR. Before joining Montana Free Press, Mara worked in podcast and radio production at Slate and WNYC. She was born and raised in Helena, MT and graduated from Seattle University in 2016.