Editor’s note: this article was originally published by Law Week Colorado in print in its January 20, 2020, issue. It has been digitized now for the first time.
From its founding in the early 1880s to its rebranding in 1991, the Colorado Mental Health Institute at Pueblo, previously known as the Colorado State Insane Asylum and the Colorado State Hospital, was frequently the center of criticism for operational issues and patient welfare. The state investigation into the institute’s operations in January of 1899 would have long-lasting impacts on the medical treatment of the criminally insane in Colorado.
Over the course of the first 20 years of its operation, the then-Colorado State Insane Asylum was run by Superintendent Dr. Pembroke Thombs, who ran the facility with minimal staff and funding for decades before the state began investigating conditions, services, operations and staffing after several exposés came out in 1898 by the Denver Evening Post.
According to the San Juan Prospector, the January 1899 investigation began in earnest after the state board of charities and corrections and Gov. Alva Adams visited the facility in September 1897 and three members of the board were accidentally locked in one of the wards. The Prospector went on to note that “unknown to the management, these members conducted an investigation on their own account. They found cases of grossest neglect. One patient was found dead in his cell. Further investigation disclosed that a room with the capacity for 50 patients was wholly unused, and that the oft-repeated excuse of Warden Thombs that the asylum was already overcrowded, covered up a story of mismanagement and neglect.”
Newly appointed Attorney General David Campbell released a scathing indictment against Thombs, who was given a chance to address the findings of the board and the investigative panel on Jan. 20 and was unable to adequately explain his behavior or justify the operations of the facility under his reign as superintendent.
The full findings of the investigation were published state-wide, including the discovery of inhumane conditions similar to that of a poorly maintained prison, lack of appropriate treatment to patients for their medical conditions, lack of oversight to the administration of medical treatment, administration of medical treatment by unqualified personnel, lack of appropriate staffing per patient quota and the lack of operational management including the absence of an appropriate tracking, financial and reporting system for state funding and assets.
In addition to these findings, the state also noted that the investigation overturned other much more troubling incidents like a female patient giving birth in the facility. Upon further probing into this specific incident, Thombs simply noted that his staff were unable to watch all the patients at all times and that the child had been born ill and had died.
According to the Pagosa Springs News in December 1898, Thombs was immediately removed from the position of superintendent and was replaced by the temporary placement of Dr. Hubert Work of Pueblo, pending a full investigation of the charges against Thombs by the legislature.
Thombs resigned in July 1899 and was officially replaced by Dr. A. P. Busey, who reformed the facility’s practices and increased the operational procedures of the hospital including an increase in qualified staff and medical treatment oversight.
Under his direction and influence, the hospital began appropriately receiving patients and discharging cured patients, adhering to the hospital’s intended purpose. With these changes, the focus of the hospital shifted toward rehabilitation and competency restoration instead of imprisonment