SEATTLE -- The state says what happened in August 2006 was all recorded by a surveillance camera: A 15-year-old girl sits in a conference room waiting to be admitted to the psychiatric unit of Children's Hospital. She's suicidal, but has been left all alone.

There is a knock at the door, and when the girl opens it a 17-year-old male patient shoves past her. He gets her under the table and proceeds to fondle her.

According to documents obtained by the Problem Solvers, hospital staff looked at the tape but didn't save it. And a subsequent report from Child Protective Services points to additional mistakes, broken rules, poor supervision and lax security at the hospital's psychiatric ward.

"There truly was some confusion as to who was suppose to be doing what that night," said Kyle Smith with the state Department of Social and Health Services.

Smith said as CPS investigators dug deeper, they discovered a series of blunders by nurses and staff members who were on duty at the time of the assault.

The first was leaving the girl alone in the conference room, which was a violation of hospital protocol.

Investigators said hospital workers knew about the boy's "aggressive.... and sexually inappropriate behavior," but the report indicates that hospital staff disengaged from the boy in order to stop his attention-seeking behavior.

They put the boy in his room and relied on security cameras and motion sensors to make sure he didn't leave. But, in a letter to the victim's parents, Children's Hospital administrators admit the system failed.

Someone forgot to turn on the motion sensors.

The boy was out of sight for about 20 minutes and, during that time, attacked the female patient.

The state's investigation was inconclusive with regard to neglect, as hospital staff claimed they didn't know who was responsible for monitoring the children and turning on the motion sensors.

Smith said their investigation concluded that mistakes were made, but they couldn't determine who made them.

It's not the first time that someone has failed to set the sensors on the door.

A year before, a 13-year-old claims she was assaulted in the middle of the night by a male patient. Her lawsuit against Children's Hospital claims he got out of his room because hospital staff failed to engage the door alarms.

The hospital settled that lawsuit late last year.

Officials with Children's Hospital said they couldn't comment on the specifics of the case, but said they take any allegation of misconduct or abuse very seriously.

After the assault in the conference room, hospital staff moved quickly to isolate the boy and give the victim a bodyguard, and the hospital has put additional safety measures in place.

Smith said she feels that the psychiatric unit at Children's is safe.

"I believe that they would take our recommendations and make some changes," she said. "I believe they're pretty diligent in that."

More Information:

Read the statement issued by Children's Hospital in its entirety