New Decision Letter! Questions about accountability at Lemuel Shattuck

Hello, Human Family,

I started this petition in 2023 to call for an investigation into Jean Bash’s death and allegations from a staff member of systemic abuse of Queer patients at Lemuel Shattuck hospital in Jamaica Plain, Massachusetts. After learning about the deaths of Haywood Earl and CaSonya King, I expanded the petition to call on Massachusetts decision-makers to investigate whether marginalized patients are disproportionately affected by deadly medical neglect and to create laws to protect our community.

The lack of response to these allegations is representative of a failure to respond appropriately (or sometimes at all) to complaints big and small across the state mental health system overall.

As another example, I’m now writing to share a decision letter from a complaint I filed in 2024 about a psychiatrist at Lemuel Shattuck Hospital. The hospital’s investigation substantiated several of the facts I reported—but still classified the complaint as “unsubstantiated”, essentially because they felt that the name calling, dehumanization and invasion of privacy that occurred didn’t matter enough to qualify as “dangerous, illegal, and/or inhumane.”

What happened

On July 11, 2024, I filed a complaint about Dr. Voinov unexpectedly entering my treatment team meeting. He did not knock or initially introduce himself. My psychiatrist introduced him as “the doctor who will be taking over for me when I retire.”

Dr. Voinov addressed the medical team without making eye contact with me and said:

“I really feel most comfortable as a psychiatrist. I mean I use to work as an ER doctor and, as we all know, half of the patients in the ER are crazy anyway.”

I told him I was uncomfortable with him being in the room. He responded, “Will this patient be transferred to my care?” He referred to me as “the patient,” even though he knew my name. I felt objectified and humiliated.

What the hospital found

On August 5, 2024, the hospital issued its decision after interviewing six people and reviewing records. It substantiated these points:

• Dr. Voinov “was not expected to be in the Treatment Team meeting.”
• He “did not address the client by the preferred name.”
• He “used stigmatizing language by referring to other clients he's worked with in the past as crazy.”
• I “expressed discomfort with the presence of the PCO in the Treatment Team.” The letter uses “PCO” to refer to Dr. Voinov.

Even with those findings, the letter classified the complaint as “unsubstantiated,” saying there was “insufficient evidence” that the incident created a condition that was “dangerous, illegal, and/or inhumane.”

That distinction is at the heart of my concern: the investigation confirmed key parts of what happened, but the overall complaint was still labeled unsubstantiated.

Link to the decision letter HERE.

What happened to corrective action?

Under 104 CMR 32.04(5)(c), the regulation says the decision must identify any corrective actions to be taken and who is responsible for carrying them out.

The letter says the Director of Nursing could decide whether corrective action was appropriate, but does not state what action, if any, was selected or who would carry it out. Before the letter was issued, investigators told me Dr. Voinov would be moved to another floor. The decision does not confirm whether that happened. I’m left with questions about what, if anything beyond moving him to another floor, was decided.

For years, patients, advocates, and legal advocacy organizations have raised concerns about DMH’s complaint investigations and how they classify complaints. If this is what accountability looks like when there are witnesses and a paper trail, what does it look like when a patient has died and cannot file a complaint?

I believe the evidence points to a systemic problem at Lemuel Shattuck Hospital and DMH—in how patients are treated, how complaints are investigated, and whether anyone is held accountable. In this case, the investigation confirmed important facts, but left the rest unclear.

More documentation

If you missed any of the previous updates, they have included letters of concern including from a licensed clinical social worker who attended my treatment team meetings, a statewide organizer, and my psychologist, as well as a letter from the Disability Law Center documenting serious concerns about a restraint I experienced.

You can view these items here:

• A  letter from Thomas Brown, a statewide mental health advocate
• A letter from the Disability Law Center (DLC) documenting an unlawful and punitive restraint, that called on DMH leadership to review and update its restraint policies
• DMH's response, finding themselves blameless
• A letter from Ivy McCall, a licensed clinical social worker who has attended many of my team meetings
• A letter from Michelle Binford, my private psychologist
• A letter written by and signed onto by my advocates after another egregious restraint. 
• A complaint written by Sera Davidow that has yet to go answered 

Does this piss you off? It should.

If you want to help

• Sign, share, and donate to the petition.
• Write Governor Healey and Attorney General Campbell. Call for an independent investigation into Jean Bash’s death and the allegations of systemic abuse of Queer patients at Lemuel Shattuck.
• Write a letter of concern about my care, following the directions at the top of this previous update.

Your Human Family member,

And Steiner