The failure by the Department of Health to place a high priority on addressing conditions that led to the suicides and deaths of 16 mentally ill Hawai'i residents earlier this year reflects a "serious lack of judgment and questionable leadership," a federal magistrate said in a blistering report yesterday.

U.S. Magistrate Kevin Chang called the failure "appalling."

In his report, Chang said the 16 deaths — six by suicide — from Feb. 17 to March 26 are what troubled him most in reviewing the state's efforts to provide services for the mentally ill.

The magistrate cited remarks by a court-appointed evaluator, Kenneth Minkoff of Massachusetts, who expressed frustration with the adult mental health division's inability to respond to problems, even when "the system dysfunction may be resulting in unnecessary deaths."

Chang said that because the care and protection of the mentally ill are of "great importance," he is directing a special monitor, Kris McLoughlin, and a doctor to review all deaths among mentally ill residents this year and prepare written findings.

Chang's 50-page report is the latest review of state's and the Department of Health's effort to comply with a federal mandate to implement a plan to provide treatment and care for Hawai'i's estimated 9,000 mentally ill residents by June 30, 2006.

His criticism underscored his concern that the consequences of the state's failure to make progress on developing the plan could be a life-and-death situation for some of the mentally ill.

Janice Okubo, department spokeswoman, said that the agency had just received the report and that officials hadn't thoroughly reviewed it yet.

"We take all reports from the court very seriously and the department will be going over the report with our legal counsel, the attorney general, to determine the next step," she said.

The community mental health plan was developed under a federal consent decree as a result of a U.S. Justice Department lawsuit filed in 1991 against the state alleging violations of the civil rights of patients at the Hawai'i State Hospital.

The federal oversight of the state hospital was lifted last year, but the state must still comply with the plan as part of a strategy to provide services to the mentally ill in and out of the hospital.

The original deadline for implementing the plan was January of this year.

Assistant U.S. Attorney Harry Yee could not be reached for comment yesterday and Chang's report did not mention what he might recommend if the state fails to meet the deadline.

If the state doesn't comply, the federal court could appoint a receiver to take over the department, or parts of it, to ensure that it provides adequate services to the mentally ill.

Chang made it clear he doubts the state can meet the deadline.

He said the state has made some progress, but it remains "far behind" in implementing the plan and is "not close to establishing a sustainable system of mental health care statewide."

A mental health advocate agreed that it's critical the state meet the deadline, given the number of mentally ill people is higher than those with cancer, heart disease, diabetes and arthritis combined.

"We need to go faster," said Bud Bowles, executive director of United Self Help, a nonprofit group helping the mentally ill. "We need to treat everything like a crisis."

In his report Chang harshly criticized the leadership of the department's adult mental health division. He said its lack of progress is "disappointing and frustrating" because it "depreciates the extraordinary efforts of individuals throughout the state of Hawai'i who are committed to achieving the goals of the community plan and work hard every day to provide mental health services to consumers."

In one point in the report, Chang says the adult mental health division's leadership at times in the past two years has "appeared to be dazed and ineffective."

"Defendants, and particularly, (adult mental health division) leadership must step up, pick up the pace and do the hard work necessary to succeed and achieve compliance," the magistrate said.

Chang was critical of Thomas Hester, head of the adult mental health division.

Chang said the responsibility for the failure to adequately respond to the apparent suicide of a 42-year-old woman and the 15 other deaths should be focused on the chief of the division, Hester, and the former medical director for the division, Alan Radke, who recently resigned.

Last month, Hester said he would resign from his $300,000-a-year job because he understood that his authority would be taken away before he could complete putting the plan into effect. He withdrew his resignation after talking to Gov. Linda Lingle, who praised his work.

At a public hearing held by Chang last week, the magistrate said there was no move to oust Hester. Chang also said media coverage of Hester's remarks caused confusion and "unnecessary and unwarranted" fear among the mentally ill that they would be abandoned or would not receive services.

Lingle could not be reached for comment yesterday.

Chang said the evaluation team comprising Minkoff, Gail Hanson-Mayer of Massachusetts and Paul Gorman of New Hampshire will return in December. By then, McLoughlin and Dr. Chad Koyanagi will complete their review of the deaths and submit their reports.

The magistrate said he "urges defendants and (adult mental health division) leadership to put forth their absolute maximum effort to achieve timely substantial compliance with the community plan."

He also said a 1995 court order prohibiting retaliation against anyone reporting problems is still relevant today.

"There shall be no retaliation in any form against any person that reports or provides information regarding deficient conditions in the community mental health system or allegations of (mental health) consumer abuse and neglect," he said.

Chang, who is acting as a special master assisting Chief U.S. District Judge David Ezra, asked that the judge set a hearing and allow the parties, including the state and the Justice Department, a chance to file comments and objections.