Overview
- The department's 13-page internal audit, released Wednesday, found gaps in spotting and managing high‑risk patients with unclear rules on how to report threats and who should respond.
- The report urged weapons screening at Ward 86, panic or duress buttons, restricted entrances at Buildings 80/90, stronger lighting, more video monitoring, and reliable emergency call boxes and phones.
- Investigators outlined November warnings about Wilfredo Tortolero-Arriechi, the dispatch of one deputy after a clean warrant check, his walk into a clinic without metal detectors, and the stabbing of social worker Alberto Rangel.
- The audit said at least eight minutes passed before staff called a Code Blue and about 11 minutes before paramedics arrived, while clinic workers gave care throughout.
- In response, the health department added four security staff and created a 24/7 threat‑management team, while Ward 86 employees dispute claims a deputy stopped a mass attack and seek counseling and more staffing.