A family shattered by failure in care

IN 2002 INSPECTORS FOUND:

> "Overcrowded environment."

> Patients sleeping on rollaway cots.

> Language barriers of non-English-speaking patients not addressed.

> Investigation of sexual assaults by patients.

> Patients fighting with patients and staff.

> Therapy groups for patients didn't meet individual needs and were held inconsistently.

> Failure to prevent patient escapes.

> Failure to protect patients from hazardous chemicals.

IN 2006 INSPECTORS FOUND:

> "Chaotic, unsafe environment."

> Overcrowded units.

> Possible language barrier with patient not assessed prior to his death.

> Patient sexually assaulted two staff members on the same day.

> Patients assaulting patients.

> Sex between patients in a "seclusion room."

> Failure to provide consistent active treatment or therapy groups to patients. "Nurses have no time to run groups, " physicians said.

> Failure to employ adequate numbers of nurses and social workers.

> "15 filled and 14 vacant RN positions; 10 filled and 5 vacant LPN positions; 43 filled and 18 vacant HST [health services technician] positions."

Source: Centers for Medicare and Medicaid Services

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$2 million sought in teen's death

Michael Webb is one of at least nine patients at Georgia's state mental hospitals who have died with bowel obstructions or similar intestinal problems since 2002, according to autopsy reports, death certificates, medical records and other documents reviewed by The Atlanta Journal-Constitution. Three of the deaths occurred at Central State Hospital in Milledgeville during a seven-week span in 2003. Many of the psychotropic drugs administered at the state hospitals can cause constipation that, if left untreated, can result in fatal intestinal conditions.

Webb's death after a three-week stay at Georgia Regional Hospital/Atlanta came 10 months after 14-year-old Sarah Elizabeth Crider (at left, at 12 years of age) died under similar circumstances at the same hospital.

Crider, a seventh-grader from Cobb County, died after an intestinal blockage went undetected by a physician at the hospital. Her death was highlighted in the Journal-Constitution in January.

Since then, Crider's family has filed a legal claim against the state, seeking $2 million in damages for her death. The family's attorney, Alwyn Fredericks of the Atlanta firm Cash, Krugler & Fredericks, said he is waiting for a formal response from state officials. If the state doesn't offer to settle for a satisfactory amount, Fredericks said, the family can then file a wrongful-death lawsuit.

OTHER PATIENTS WHO DIED WITH SIMILAR CONDITIONS INCLUDE:

> A 55-year-old man, 2003, at Central State.

> A 49-year-old man, 2003, at Central State.

> A 71-year-old man, 2003, at Central State.

> A 19-year-old man, 2003, at Georgia Regional/Atlanta.

> An 80-year-old woman, 2005, at Central State.

> A 41-year-old man, 2006, at East Central Regional Hospital in Augusta.

> A 30-year-old man, 2006, at East Central.

Source: AJC staff research

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ABOUT THE SERIES

This is the fifth in an occasional series of reports on Georgia's state psychiatric hospitals. Previous articles reported on the suspicious deaths of at least 115 patients from 2002 through 2006, on more than 190 substantiated cases of patient abuse, on patient suicides and on escapes.

Future articles will examine inadequate planning for the treatment of discharged patients and how the state handles mentally ill defendants from the criminal justice system.

Today's main article on Michael Webb is based in part on interviews with members of his family and experts on psychiatric treatment, as well as a review of the state's investigation into Webb's death. Webb's family obtained his complete medical files from Georgia Regional Hospital/Atlanta, Grady Memorial Hospital and Gwinnett Medical Center and shared them with reporters. Direct quotations not taken from documents or heard by reporters appear in italics.

Articles in this series were reported by staff writers Alan Judd and Andy Miller. To share your experiences with the mental health system, call 404-526-2640.

Upstairs, two sheriff's deputies waited with papers committing Michael to a state psychiatric hospital. But first his sister had to coax him out of the basement, the refuge for his increasingly bizarre behavior.

Once Michael lived to fish, and he dressed the part. In crisp khakis and fly fisherman's waders, he looked like a character from a Hemingway story. In recent years, though, the Vietnam War veteran had retreated even from his elderly, ailing parents, who worried he might hurt them. He refused to bathe, to shave, to cut his salt-and-pepper hair, to put on clean clothes. He ate nothing but hot dogs.

Now, the day before last Thanksgiving, on the brick hearth by the cold basement fireplace, he told his sister he wasn't leaving.

No, I don't do that. I'll stay here. You go with them.

Janie said: Michael, you trust me. I would never do anything to hurt you. I would never let anybody hurt you.

Finally, the Gwinnett County deputies took Michael away in handcuffs, first to a nearby hospital for a physical examination, then to Georgia Regional Hospital/Atlanta, the state-run psychiatric facility in south DeKalb County.

Three weeks later, he was dead.

Michael Ernest Webb, 59, died from cardiovascular collapse caused by a bowel obstruction, medical records show, after more than two weeks of constipation that apparently went untreated at Georgia Regional.

Webb died under circumstances that closely resembled those surrounding the death of 14-year-old Sarah Elizabeth Crider at the same hospital 10 months earlier.

In all, at least nine patients in Georgia's mental hospitals died with bowel obstructions or similar intestinal problems between 2002 and 2006, according to an investigation by The Atlanta Journal-Constitution.

The newspaper found at least 115 suspicious deaths in the seven state institutions during that period and little public accountability for mistakes in those cases.

Webb's death in particular illuminates one of the most vexing problems in Georgia's state hospitals: the failure to learn from, and prevent, fatal errors.

Many anti-psychotic drugs are widely known to cause acute constipation. And at Georgia Regional, Sarah Crider's death from an intestinal blockage after she received several of those drugs had prompted officials to establish a policy for keeping track of patients' bowel movements.

The policy instructed hospital workers to document each patient's daily output, and required supervisors to audit employees' compliance with the new rules.

When Webb entered Georgia Regional on Nov. 23, nurses noted his risk for constipation. If he went three days without a bowel movement, his medical chart shows, they were supposed to notify his doctors.

Hospital workers did record Webb's failure to have a bowel movement --- for 18 consecutive days.

On the 19th day, a doctor finally prescribed a laxative, although one that can take days to act.

On the 20th day, Webb died.

At least one physician knew Webb was constipated but failed to treat it, an inquiry by the chief of the hospital's police force found. The chief, Gloria Boyd, wrote in a report that information in Webb's file "should have served as a catalyst for medical intervention, but it did not."

Nevertheless, no hospital staff members have faced disciplinary action over Webb's death, officials say.

The Georgia Department of Human Resources, which operates the state hospitals, accepts no blame for Webb's death, says a spokeswoman, Dena Smith.

"There are a number of reasons a person could have had a bowel obstruction, " she says.

Noting that no autopsy was performed on Webb, she says, "If you don't know how they died, what could you do?"

On Dec. 31, two weeks after Webb died, however, the agency issued a directive to hospital employees: "Effective immediately, each patient's bowel functions will be monitored each day and shift."

For Webb's family, his death culminated one tragedy and preceded another.

His parents had created a suburban idyll on a lake in Duluth for their four children, born across a span of 17 years.

In just a month, this world shattered.

First, Michael, the eldest sibling, died unexpectedly. Then the parents moved out of the family home into an assisted-living facility. Finally, another death stunned the family.

For Janie Webb-Miller, the cause of her brother Michael's rapid decline remains a mystery. And the state hospital, she says, has done little to clear it up.

"He was physically OK, " she says. "I don't know how he went from being OK in November to dying in December."

Reclusive behavior

Michael Webb's family never really thought of him as mentally ill, just eccentric.

After graduating from high school in 1965, he attended Young Harris College, then the University of Georgia. His sister Janie, three years his junior, describes him as smart, well-read, fascinated by politics. In college, though, "he loved to drink beer, " she says. "He loved to party."

He displayed little ambition, his family says, except to fish. That was especially true after he returned from Vietnam, where he operated a radio on an Army helicopter. Back home, he never spoke about his war experiences. He was so stoic and so reclusive that his family sometimes wondered whether he suffered from post-traumatic stress, although the disorder was never diagnosed.

Webb spent several years in Florida, working nights at fancy resorts to free up his days for fishing.

He returned to Duluth in the late 1980s. He moved into his parents' basement and frequently cast a line in Cardinal Lake, a favorite fishing hole since his family became the first residents of the surrounding subdivision when he was 13. He worked several years at Bass Pro Shops in Gwinnett County, using the expertise he gained in Florida to advise customers about saltwater fishing. He even answered fishing questions on a radio call-in show on occasion.

The store let him go in 2004; his family says store managers told them he was aloof and rude to customers, especially those of Asian descent. He began to hibernate in the basement, generally emerging only if his parents were in the house alone. For a time, he ate only TV dinners --- Salisbury steak. Then he switched to hot dogs, but they had to be a certain brand, and they had to be stored in the same spot in the refrigerator.

At first, Webb-Miller and her sister, Cindy Berwick, thought he was exhibiting a misguided sense of entitlement.

But "it began to seep into our heads that he was depressed, different, " Webb-Miller says, "that something was happening."

His decline coincided with that of his aging parents, who were struggling with health issues. They had come to perceive Michael as a threat, especially, they said, after awakening to find him standing beside their bed. They couldn't help him, and he couldn't care for himself. As a veteran, he could have checked into the Veterans Affairs hospital in Decatur. But he refused to go there, or elsewhere, for treatment.

"We were out of options, " Webb-Miller says.

Early last Nov. 22, the police came to the Webbs' home to deal with the friction between Michael and his parents. The sisters later went to the Probate Court in Gwinnett County, signed affidavits swearing that their brother had become physically threatening, and waited while a judge signed papers committing him to the state hospital.

The deputies came for Michael about 2 p.m. When Janie went to the basement, she found him sitting on the hearth, drinking a glass of water. His hair was a wild bush. His beard fell to his belly. His smell, she says, is best described as "musty."

At Gwinnett Medical Center in Lawrenceville, doctors examined Michael to make sure he was physically strong enough to enter the state hospital. A security guard stood watch over Michael in the emergency room as he sat with Janie. Michael would take her hand and motion toward the door, or pick up her purse.

Get your keys, he told her. Let's go.

She left her brother about 10 p.m., a few hours before deputies returned to take him to Georgia Regional. She never saw him again.

'No medical intervention'

Michael Webb arrived at Georgia Regional at 4 a.m. Thanksgiving Day. An admissions form said he "smells of urine, mild tremors in hands noted, speech incoherent, pacing the day area, in need of stabilization."

Paperwork in his hospital file, later obtained by his sister Janie, said Webb was malnourished because of his diet. The hospital's overall assessment, though: "No medical problems noted."

His prescribed medications made Webb a "high risk for constipation, " a nurse wrote in his file. The chart instructed nurses on every shift to document whether Webb had bowel movements; if he went three days without one, doctors were supposed to examine his abdomen thoroughly.

Webb had never taken psychotropic drugs, and had never received psychiatric treatment, his family says. Now, having diagnosed him as psychotic, doctors immediately started him on a regimen of strong medicines.

During Webb's first nine hours at Georgia Regional, hospital employees gave him two doses of three medicines so commonly combined that they're known as "the cocktail": Ativan, an anti-anxiety drug; Benadryl, a sedative; and Haldol, an anti-psychotic. Together, the three drugs can calm agitated patients. The latter two also can cause the same side effect: constipation.

Over the next few days, Webb began an inexorable decline.

He spoke so little that an activity therapist wrote that he was "mute." He wandered in and out of other patients' rooms, or paced and mumbled. As he received even more medication, he spent more time in bed. Nurses' notes in his file described him as "sleepy, " "drowsy, " "still sedated."

Webb ate parts of some meals throughout his stay at Georgia Regional, his file indicates. But his last recorded bowel movement was on Nov. 26, three days after he entered the hospital.

After that, on a form to record his output, hospital workers marked down "0" or "Refused." These notations repeated for 18 days.

On Dec. 6, 10 days after Webb's last recorded bowel movement, a physician noted the suspected constipation in his medical chart. Yet, as the hospital's police chief later concluded, "there was no medical intervention."

Exactly what happened is difficult to determine. Webb's file contains no detailed notes from nurses or others for several periods, including almost 48 hours on Dec. 5 and 6. On the 6th, a nurse made a passing reference to changing Webb's diaper --- the first mention of his having been placed in one.

Webb's file does not make clear how much medication he received over three weeks. But experts say multiple medications can lead to severe intestinal problems.

"No one drug with one administration is going to cause an obstruction, " says Charles Reynolds, a psychopharmacology consultant in Los Angeles. "This is the chronic effect of medication."

Hospital staff should take action if a patient goes several days without a bowel movement, says Dr. J.R. Elpers, a psychiatrist and retired professor at the UCLA medical school.

"You should know you have a problem, " Elpers says. Both Elpers and Reynolds spoke in general terms without reviewing Webb's medical records.

It wasn't until Dec. 15, more than a week after Webb's constipation was first noted in the chart, that a doctor ordered him a laxative. The medication, MiraLax, normally takes two to four days to be effective, according to the prescription drug guide Physicians' Desk Reference.

Webb had vomited earlier that morning and "smelled of feces, " a technician noted in his chart. Notes in the medical file indicate a nurse checked Webb's abdomen and told Dr. Joe Browning, the only physician on duty at the time, that the patient might be constipated.

Browning told the nurse to "pass on information to treatment team this morning, " she wrote in the file.

Browning later told an investigator he disputed the nurse's contention that she had told him about Webb's condition. Efforts to reach Browning were unsuccessful.

Shortly after lunch that day, another nurse discovered that Webb had vomited a bloody substance the consistency of coffee grounds --- a strong indication of intestinal breakdown. Such a problem typically requires emergency treatment.

By then, Webb's primary physician at Georgia Regional, Dr. Mahendra Dave, was on duty. But his response lacked urgency, the nurse said later. The doctor's instructions, according to the nurse: Monitor the patient.

The nurse, Justin Vassell, later told an investigator he "at least twice insisted" that Dave send Webb to Grady Memorial Hospital's emergency room in downtown Atlanta. Dave agreed only to page another physician for a second opinion, Vassell told the investigator. That doctor never answered the call.

After several minutes, the nurse called for an ambulance to take Webb to Grady, he told the investigator. It arrived at Georgia Regional about 1:45 p.m., nearly eight hours after the first nurse notified a doctor of Webb's condition.

Dave did not respond to requests for an interview. He told an investigator he had been on leave during part of Webb's hospital stay and didn't learn until Dec. 15 that Webb was constipated. Webb's medical file, however, included charts documenting his failure to have bowel movements.

At Grady, an escort from Georgia Regional told nurses that Webb had been found unconscious on the floor of his room, a detail not contained in his medical file.

A report by the ambulance crew said Webb appeared to be in pain and "only moaned en route" to the hospital before he stopped breathing. Emergency room workers resuscitated him.

Doctors at Grady told Webb's family he needed emergency surgery to clear his intestines. But he was so sick, they couldn't operate. He died late the next afternoon, Dec. 16.

Two days later, Janie Webb-Miller delivered the eulogy at Michael's funeral. She drew from the book "A River Runs Through It, " Norman Maclean's semi-autobiographical story of his vain effort to save his self-destructive brother, a gifted fisherman.

She quoted the narrator's father, reflecting on the son's death and his failure to help him:

"It is those we live with and love and should know who elude us."

A tragedy compounded

Webb's family declined to have an autopsy performed. But a few weeks after he died, Webb-Miller and her husband, Richard, read about the death of Sarah Crider and recognized similarities to Michael's case. They decided they needed to learn more about what happened.

Webb's family knew little about his hospital stay. Webb-Miller and her husband had gone to Georgia Regional several times, but staff members always warned that a visit might upset Michael. So they left each time without seeing him.

In mid-January, they met with Georgia Regional's clinical director, Dr. Mark Rowles. He told them the hospital staff had no reason to monitor Michael's bowel movements, Webb-Miller recalls. And, she says, Rowles disputed that Michael had received any combinations of medicines.

They asked to see Michael's medical chart, which sat on Rowles' desk. He declined, citing Michael's privacy rights, they say. Five weeks later, after a judge approved Webb-Miller's request to be appointed administrator of Michael's estate, the hospital turned over the documents --- along with a $202 invoice for copying and other fees.

After reviewing the file, Webb-Miller does not believe Rowles accurately described her brother's care.

Rowles did not respond to requests for an interview.

The night before the meeting with Rowles, Webb-Miller had received a frantic call from her sister, Cindy.

Their other brother, Bill, had committed suicide.

Bill, 42, idolized Michael. He also had struggled with depression and was devastated when Michael died. Cindy discovered Bill's body in his apartment in Duluth on Jan. 18. He had been dead for about six days.

"Bill clearly made a lot of bad choices, " Webb-Miller says. "He had a lot of problems. But I definitely link the timing of Bill's death to Michael's."

In a month, she and her sister lost two brothers and saw their parents give in to the demands of aging. The series of events began when they committed Michael to Georgia Regional and quickly spun out of control.

"Never in my wildest nightmares could I have imagined these outcomes, " she says. "We were so desperate for help."

She wipes a tear, and mentions that she and her husband had considered inviting Michael to live with them when he got out of the state hospital.

"What haunts me now is that this will happen to somebody else, " she says. "And it will, if someone doesn't do something."