A consultant who led the troubled effort to overhaul California's public psychiatric hospitals has played a lead role in federal reforms in at least five other states, where critics have raised similar concerns about cronyism and the quality of his work.
Nirbhay Singh, a psychologist from Virginia, abruptly resigned from his California post last year after The Times asked state officials about rising violence in the hospitals and the state's hiring of Singh's family members.
State mental health officials are now eliminating treatment approaches and elaborate paperwork that Singh imposed in a costly effort to satisfy a legal settlement between the state and the U.S. Department of Justice. Two of four hospitals targeted for reform by the department — in Napa and Norwalk — remain under federal court supervision because of concerns about patient safety and treatment.
In interviews, clinicians and others who worked with Singh around the country raised criticisms similar to those that surfaced in California: that excessive documentation requirements detracted from patient care and that close relationships among consultants and Justice Department lawyers appeared to compromise the process.
Singh, his relatives and his close associates have again and again received contracts to advise states and monitor reforms for the federal courts — often with the endorsement of Justice Department lawyers. The department itself retained Singh as a consultant over more than a decade, beginning in 1989, before he branched out to more highly paid work for states and courts.
Since 2002, when he began working in California, Singh has been hired in more than half the 23 states and territories where federal officials had reached court-supervised settlements intended to improve care at public mental hospitals and centers for the developmentally disabled, often playing a pivotal role.
Even as Singh's efforts were foundering in California, he obtained contracts to work on federal reforms in Connecticut, Georgia and Washington, D.C.
"The things that are being undone in California should be undone here," said Vittorio Ferrero, a former psychiatrist at Connecticut Valley Hospital, where since 2009 Singh has been the federally approved court monitor, earning $2,500 a day. "Everything they have done has resulted in less care."
Stuart Forman, Connecticut Valley's former medical director, said "meaningless garbage" was "required of hundreds of people all the time." Both men said they left last year in frustration.
In response to written questions from The Times, Singh said paperwork in Connecticut is being reduced as the hospital improves. He said the criticism in that state and elsewhere reflected staffers' discomfort with changes that were necessary. "In each case, the work that we did in partnership with staff ... improved patient care and will continue to improve patient outcomes," he said.
In 2010, officials in Georgia awarded Singh a no-bid, $3.5-million contract to reform seven mental hospitals and allowed him to hire staff through American Health and Wellness Institute, a company owned by Singh and his son and run by his daughter-in-law.
Two former employees of the firm said they were told by higher-ups not to provide guidance to hospital caregivers but simply to fill out checklists gauging their performance. "My concern from a clinician's perspective was: What are we really doing to make a difference? And how are we measuring it?" said Karen Foxworth, a licensed counselor who said she was terminated after Singh learned that she had offered a suggestion during a treatment session.
Singh said that employees were encouraged to offer feedback and that data showed significant gains "in all aspects of care."
Dr. Frank E. Shelp, commissioner of Georgia's Department of Behavioral Health and Developmental Disabilities, said last year that a Justice Department lawyer had urged the state to bring in outside expertise and recommended Singh, among others. A spokesman wrote in a recent email that the state is "pleased with the contribution Dr. Singh and his team have made."
Concerns about Singh's performance had emerged earlier in his career. In 2002, when he was the Justice Department's representative on a consulting team at Hawaii State Hospital, a federal court magistrate found him ineffective and asked him to resign, according to two sources with knowledge of the decision who declined to be identified because it was a confidential matter.
"He was the weakest link in the chain," said a third official, former hospital administrator Paul Guggenheim, who did not have direct knowledge of the magistrate's action.
Singh said he left for personal reasons.