Willowbrook State School Case Analysis
Root Cause Analysis: Willowbrook State School
Maddalena Roseto
New York City College of Technology
HSA Health Service Management II
Dr. Katherine Gregory
March 12, 2017
PROBLEM: The residents of the Willowbrook State School live in absolutely unacceptable conditions:
Why1: Why were there so many clients admitted into Willowbrook State School?
The Willowbrook State School had become increasingly populated in the 1960s with residents of mental disabilities. Many physicians first recommendation of a child who suffered from delayed developmental growth, received a low score on IQ testing, or showed signs of a disability, was for the child to be initialization (NPR, 2008). This idea that children with mental disabilities …show more content…
With an exponentially large patient to caregiver ratio, feeding time reduction was one of the many results of understaffing. Patients were forced to a decrease from 30 minutes of feeding to 2-3 minutes, one of the many daily routines that suffered at the hands of underemployment (FilmRise, 2014). According to former Senator Robert Kennedy, residents were “living in filth and dirt, their clothing in rags, in rooms less comfortable and cheerful than the cages in which we put animals in a zoo” (Disability Justice, 2017). Not only were the residents, who were initially admitted because of the severity of their condition which required assistance, experiencing neglect, former resident of Willowbrook Bernard Carabello describes other instances where the lack of attendant care was reflected in abuse towards the patients, “I got beaten with sticks, belt buckles. I got my head kicked into the wall by staff … most of the kids sat in the day room naked, with no clothes on. There was a lot of sexual abuse going on from staff to residents, also.” This form of treatment is a reflection on not only the lack of numerical attendants working at the facility, but a reflection as well on the lack of humanizing importance these attendants identified the individuals residing at the Willowbrook State School …show more content…
(2014, October 15). The horrifying truth uncovered: Willowbrook State School. Retrieved March 13, 2017, from http://www.rootedinrights.org/the-horrifying-truth-uncovered-willowbrook-state-school/
Corrigan, P. W., & Watson, A. C. (2002, February). Understanding the impact of stigma on people with mental illness. Retrieved March 13, 2017, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1489832
Disability Justice. (2017). The Closing of Willowbrook. Retrieved March 13, 2017, from http://disabilityjustice.org/the-closing-of-willowbrook/
[Film Rise]. (2014, May 15). Unforgotten: Twenty-Five Years After Willowbrook. [Video File]. Retrieved from https://www.youtube.com/watch?v=FcjRIZFQcUY&feature=youtu.be
Levine, R. J. (1988). Ethics and regulation of clinical research. New Haven: Yale University Press.
NPR. (2008, March 07). Remembering an Infa ous New York Institution. Retrieved March 13, 2017, from
Maddalena Roseto
New York City College of Technology
HSA Health Service Management II
Dr. Katherine Gregory
March 12, 2017
PROBLEM: The residents of the Willowbrook State School live in absolutely unacceptable conditions:
Why1: Why were there so many clients admitted into Willowbrook State School?
The Willowbrook State School had become increasingly populated in the 1960s with residents of mental disabilities. Many physicians first recommendation of a child who suffered from delayed developmental growth, received a low score on IQ testing, or showed signs of a disability, was for the child to be initialization (NPR, 2008). This idea that children with mental disabilities …show more content…
With an exponentially large patient to caregiver ratio, feeding time reduction was one of the many results of understaffing. Patients were forced to a decrease from 30 minutes of feeding to 2-3 minutes, one of the many daily routines that suffered at the hands of underemployment (FilmRise, 2014). According to former Senator Robert Kennedy, residents were “living in filth and dirt, their clothing in rags, in rooms less comfortable and cheerful than the cages in which we put animals in a zoo” (Disability Justice, 2017). Not only were the residents, who were initially admitted because of the severity of their condition which required assistance, experiencing neglect, former resident of Willowbrook Bernard Carabello describes other instances where the lack of attendant care was reflected in abuse towards the patients, “I got beaten with sticks, belt buckles. I got my head kicked into the wall by staff … most of the kids sat in the day room naked, with no clothes on. There was a lot of sexual abuse going on from staff to residents, also.” This form of treatment is a reflection on not only the lack of numerical attendants working at the facility, but a reflection as well on the lack of humanizing importance these attendants identified the individuals residing at the Willowbrook State School …show more content…
(2014, October 15). The horrifying truth uncovered: Willowbrook State School. Retrieved March 13, 2017, from http://www.rootedinrights.org/the-horrifying-truth-uncovered-willowbrook-state-school/
Corrigan, P. W., & Watson, A. C. (2002, February). Understanding the impact of stigma on people with mental illness. Retrieved March 13, 2017, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1489832
Disability Justice. (2017). The Closing of Willowbrook. Retrieved March 13, 2017, from http://disabilityjustice.org/the-closing-of-willowbrook/
[Film Rise]. (2014, May 15). Unforgotten: Twenty-Five Years After Willowbrook. [Video File]. Retrieved from https://www.youtube.com/watch?v=FcjRIZFQcUY&feature=youtu.be
Levine, R. J. (1988). Ethics and regulation of clinical research. New Haven: Yale University Press.
NPR. (2008, March 07). Remembering an Infa ous New York Institution. Retrieved March 13, 2017, from