In the latest of a long string of dominoes to fall, a former Multnomah County mental health investigator filed a whistle-blower lawsuit April 1 in Multnomah County Circuit Court.

For more than 25 years, Monaco worked for the Multnomah County Mental Health and Addiction Services Division as a pre-commitment investigator, evaluating whether patients should be hospitalized.

That work placed him deep inside the workings of the public and private sector mental health systems within the county.

In early 2017, with support from OHSU, Kaiser and Multnomah County, Legacy Health opened a specialized facility called the Unity Center for Behavioral, which was aimed a coordinating and improving the delivery of services to people facing psychiatric crises, who were often left untreated in hospital emergency rooms or the streets.

But in his lawsuit, Monaco says from the beginning, staff at the Unity Center, where he often went to evaluate patients, shared concerns with him.

"On or about January 31, 2017, Unity finally opened," the lawsuit says. "Within several days of its opening, Monaco arrived on site to fulfill his [per-commitment investigation] duties. There, Monaco observed significant problems with the facility in areas including structure, staffing, staff training, and other areas threatening patient safety."

The lawsuit says that he shared his concerns about patient safety, including at least one death at Unity, with his superiors in the Multnomah County Health Department. They reportedly ignored his concerns, he says.

Monaco also shared his concerns with former Multnomah County Steve March and the director of the Unity Center but rather than addressing those concerns, the lawsuit says, Unity officials complained to Multnomah County that Monaco was a causing problems.

"By early 2018, Monaco continued to learn of serious problems and continuing health and safety issues at Unity, including conditions and practices dangerous to patients and staff, and a pattern of retaliatory action at Unity against whistleblowing staff members," the lawsuit says.

"Despite a continuing policy asserted by County managers to not provide oversight over issues raised about Unity, Monaco again raised concerns about Unity to the Auditor as well as managers and leadership. When Monaco raised concerns, he faced significant pushback. This pushback included criticism when Monaco elevated reports to higher managers, and instructions that he instead report to direct supervisors who had already shown, by direct statements as well as conduct, that they would take no action on those reports."

Eventually, after extensive reporting by the Portland Tribune which first reported Monaco's lawsuit, state officials and later, federal officials moved in and found Monaco's concerns were valid. That validation wasn't enough to save his job at the county, however, according to the lawsuit. He says in the lawsuit he was pressured to leave his job and took early retirement July 31, 2018.

Multnomah County continues to investigate why Monaco's superiors ignored his complaints but last week, the county abruptly fired its two top mental health officials.

Monaco is seeking $1.1 million in damages.

Brian Terrett, a Legacy spokesman said Legacy hadn't seen the lawsuit yet.

"Legacy Health has not been made aware of this litigation and no chance to review it in detail, Terrett said. "It is Legacy Health's practice not to comment on legal matters or litigation, but rather let the process occur in the appropriate venue."

Multnomah County declined to comment.