Five years, 115 patients dead who might have lived

Different versions of how sisters died

State hospitals were the only homes Gloria and Dorothy Edenfield ever knew. Institutionalized since they were toddlers in Jesup in the 1940s, both "seemed to do very well" in recent years at Southwestern State Hospital, says Linda Hires, their younger sister. Hires didn't suspect anything out of the ordinary when her sisters died nine months apart --- Gloria, 63, in December 2003 and Dorothy, 60, the following September. The hospital told Hires both died of pneumonia. In fact, according to death certificates and state reports, Gloria died after aspirating the contents of her stomach into her lungs, and Dorothy choked to death from a foreign object in her respiratory tract. Although they spent their lives together in institutions, they had lived in separate rooms for years, Hires says, and Dorothy seemed not even to know Gloria had died.

Nearly blind, but allowed to wander

The world was becoming progressively darker for Donald Moore. In and out of institutions for years as he battled mental illness, Moore, 49, also had a degenerative disease that was slowly taking away his eyesight. Although he was nearly blind, the staff at Northwest Georgia Regional Hospital allowed him to wander from room to room, says his brother, Garry Moore of Cartersville. That freedom, his brother says, indulged Donald Moore's fixation with swallowing found objects, particularly coins. In August 2004, he swallowed several coins, some of which lodged in his esophagus. He died a short time later in a Rome hospital's emergency room.

Former staff writer Joe Geshwiler contributed reporting for these articles.

SUSPICIOUS DEATHS

From 2002 through late 2006

19: Georgia Regional Hospital/Atlanta

34: Central State Hospital in Milledgeville

23: East Central Regional Hospital in Augusta

16: Northwest Georgia Regional Hospital in Rome

6: Georgia Regional Hospital/ Savannah

14: Southwestern State Hospital in Thomasville

3: West Central Georgia Regional Hospital in Columbus

BY THE NUMBERS

44: Rank of Georgia among 50 states in per capita spending on mental health services.

97: Average percentage occupancy rate in Georgia's state psychiatric hospitals.

85: National standard for occupancy rate.

2.09: Number per 1,000 Georgia residents who will receive treatment in a state psychiatric hospital.

0.62: Number per 1,000 U.S. residents who will receive psychiatric hospital treatment.

44: Percentage of Georgia's mental health budget that goes to state hospitals.

29: Percentage of all states' mental health care spending on psychiatric hospitals.

13: Percentage of Georgia patients readmitted to psychiatric hospitals within 30 days after discharge.

9: National percentage of patients readmitted within 30 days.

Sources: National Alliance on Mental Illness; Georgia Mental Health Gap Analysis, APS Healthcare, May 2005; U.S. Department of Health and Human Services, Center for Mental Health Services' Uniform Reporting System, 2004.

CAUSES

Suspicious deaths from 2002 --- late 2006

36: CHOKING (includes patients who died after aspirating food or vomit into lungs)

15: INFECTIONS

12: SUICIDES

8: DEHYDRATION OR MALNUTRITION

8: BOWEL OBSTRUCTIONS

3: MEDICATION ERRORS

2: PHYSICAL RESTRAINTS

15: OTHER (includes undetermined causes)

16: UNEXPLAINED/SUSPICIOUS (as classified by Department of Human Resources)

ABOUT THIS SERIES

This is the first in a series of reports on Georgia's system of state psychiatric hospitals, focusing on the suspicious deaths of 115 patients. Future articles will look at patient abuse, escapes and inadequate planning for the treatment of discharged patients.

Today's main article is based in part on interviews with members of Sarah Crider's family and others familiar with her hospitalization and death. Reporters also reviewed medical records, reports from two state inquiries into her death, and a medical examiner's investigation. Direct quotations not taken from documents or heard by reporters appear in italics.

The Georgia Department of Human Resources, which operates the seven state hospitals, refused to identify any current or past patients, including the 364 who have died in state custody in the past five years.

Citing federal privacy rules and other laws, the agency's attorneys heavily edited incident reports and other documents concerning patients' deaths. By contrast, the agency releases complete files on deaths of children in its foster care system, as required by a 2000 state law.

The Atlanta Journal-Constitution used other sources --- including a database of state vital records, death certificates, autopsy reports and claims filed against the state --- to identify about 80 percent of the deceased patients and the causes of their deaths.

Articles in this series were reported by Journal-Constitution staff writers Alan Judd and Andy Miller. To share your experiences with the mental health system, contact Judd at 404-526-5029.

Alone in the darkness of a state mental hospital, Sarah Crider, 14, lay slowly dying.

She complained of stomach pain at 4:30 p.m. She vomited about 8:30. When the only physician on call at Georgia Regional Hospital/Atlanta came at 9:20, Sarah had vomited again, but the doctor did not examine her, medical records suggest. She threw up around midnight and once more about 2 a.m., this time a bloody substance that resembled coffee grounds. But hospital workers did not enter Sarah's room again until 6:15 a.m. By then, it was too late.

A few hours later, two hospital employees drove to Cobb County to tell Joyce Dobson, Sarah's grandmother. Dobson adored Sarah for all her complexities: artistic but troubled, challenging but comic. Now she could think only of two nights earlier, when she had last visited Sarah and heard another patient's haunting scream.

“I hope nobody killed her,” Dobson blurted out.

In fact, what happened to Sarah was beyond anything Dobson could have imagined.

Sarah was one of at least 115 patients from Georgia's state psychiatric hospitals who have died under suspicious circumstances during the past five years, according to an investigation by The Atlanta Journal-Constitution. The newspaper assembled a list of questionable deaths by examining state and federal inspection reports, a database of vital records, autopsies, medical files, court papers, state insurance claims and other documents.

This study revealed a pattern of neglect, abuse and poor medical care in the seven state hospitals, as well as a lack of public accountability for patient deaths. The findings for 2002 through late 2006 --- from employees beating patients with aluminum pipes to doctors widely prescribing sedatives just to maintain order --- evoke images from the mid-20th century at the state hospital in Milledgeville. There, thousands of patients lived and died amid horrific conditions that became synonymous across the nation with mistreatment of people with mental illness.

Several experts in psychiatric care concur with the Journal-Constitution's findings. They include patient advocates, as well as a Connecticut physician who heads the American Psychiatric Association's patient safety committee and another psychiatrist who helps conduct inquiries into deaths at mental hospitals in Illinois. All say the investigation shows significant problems with care provided in the Georgia hospitals.

State officials generally do not dispute the newspaper's conclusions. But a statement released by the Georgia Department of Human Resources, which operates the hospitals, says 82 of the patients identified by the Journal-Constitution had underlying medical problems "that were appropriately treated."

In an additional 24 cases, the agency says, "we agree the hospital system should make improvements."

Officials say they have been working to improve mental health care by shifting resources and patients, especially those with developmental disabilities, to community-based services.

"We have a whole system of care that we have to build and balance, " says B.J. Walker, the state's human resources commissioner. The Georgia facilities, she says, compare favorably with those in other states on several key indicators, such as escapes, deaths of patients restrained by hospital workers, and medication errors.

"Our hospitals are overcrowded and overused, " she says. But "we're not just throwing our hands up and hollering we can't do anything about it."

The Journal-Constitution documented 364 deaths of state hospital patients from January 2002 through mid-December 2006. Two-thirds apparently died of natural causes.

Among the 115 cases the newspaper determined to be suspicious, the greatest number of patients --- 36 --- died from choking on food, vomit or foreign objects, or by aspirating those substances into their lungs. A similar number died for lack of emergency treatment or from questionable medical care. Twelve committed suicide. At least two died under physical restraint by hospital workers.

The newspaper could find no information on 16 of the 115 deaths, except that state officials classified them as "unexplained/suspicious."

Experts say relatively simple measures could have prevented many deaths: More staff members to observe choking-prone patients during mealtime and to react to emerging medical problems. One-on-one monitoring of patients who threaten to kill themselves. More training in nonviolent methods to control unruly patients.

No independent agency routinely investigates or analyzes these deaths, the Journal-Constitution found. In New York and Illinois, any death in a state hospital triggers a review by an outside group. In Georgia, the agency that runs the state hospitals polices itself.

Dangerous conditions in the hospitals arise from decades of disregard by public officials, chronic overcrowding and understaffing, and public indifference, the newspaper found.

In 2000, state legislators created an ombudsman's office to investigate abuse and neglect --- but never appropriated money for the office and never filled the job. And the problems have become even more intractable. Since 2004, the state has cut the hospitals' budgets by 12 percent. Meanwhile, officials project, the daily average number of adult mental health patients will have risen 12 percent by the end of this fiscal year.

This is the combustible atmosphere that Sarah Elizabeth Crider, a seventh-grader from the suburbs, encountered in the fall of 2005 when she entered Georgia Regional.

The way a girl with no history of serious physical illness died more than three months later illustrates not just the breakdown of care in her case, but also a systemic failure that has escaped scrutiny for decades.

"She was a healthy 14-year-old --- healthy, " says Dobson, Sarah's maternal grandmother and guardian, who has hired an attorney to pursue a claim against the state. "She had never been sick in her life.

"Why wasn't something done for this child?"

A girl's life unravels

She loved cartoons. Given the choice, she would have eaten ice cream with every meal. She gardened with her grandmother, but teased about the results.

“Meemaw,” Sarah Crider would tell Dobson in the yard, “why don’t you just admit it -- everything you touch dies anyway.”

Sometimes, though, Sarah's disposition darkened.

One day in February 2003, she claimed to be seeing large spots on a wall that had no spots. Her family took her to an emergency room, where a doctor at first suspected meningitis. A spinal tap ruled out that diagnosis. But Sarah's hallucinations worried the doctor, who thought she might hurt herself. He sent her to the nearest state psychiatric hospital: Georgia Regional.

The 38-year-old facility sprawls across 174 acres in south DeKalb County, near the I-285 interchange with Flat Shoals Road. It resembles a small college campus, with low-slung buildings clustered amid grassy fields. Sarah entered a unit for children and teenagers, segregated from adults with mental illness and retardation.

She was 11 years old.

Doctors treated her for autism, for which she had been previously diagnosed. After two weeks, she returned to Dobson's house in Acworth acting as if nothing had happened and quickly resumed her regular life: Girl Scouts, youth groups at church, special education classes at school.

In November 2004, her sixth-grade class from Lost Mountain Middle School planned to attend a Disney on Ice performance at Philips Arena in downtown Atlanta. Sarah, by then 13, often had trouble getting out of bed on school days. But she awoke early the morning of the field trip, she was so excited. At school, as her classmates boarded a bus, Sarah went back inside to retrieve her coat. The bus was on I-75, well on its way downtown, before anyone noticed Sarah's absence.

Missing the trip devastated Sarah. In a fit of anger, she shredded an antique book belonging to Dobson. The outburst was a preview of what would become routine behavior --- "acting up, " as family members describe it.

Sarah lived with her grandmother, as did her younger brother, Wesley, and her mother, Leslie Dobson. Sarah's parents no longer lived together, and several relatives had helped care for her. Now, no one could control her. So on Nov. 19, 2004, her family reluctantly admitted her to Ridgeview Institute, a private psychiatric hospital in Smyrna.

There, Sarah received a new diagnosis: schizophrenia.

The brain disorder, which can cause hallucinations and delusions, among other symptoms, affects about 1 percent of the population, according to the National Institute of Mental Health. In children, the institute says, the disease often is misdiagnosed as autism.

Sarah improved at Ridgeview, her family says, becoming less anxious, less frenzied. But the economics of psychiatric health care quickly intervened. Her mother's medical insurance policy, which covered Sarah, paid for not quite a month of inpatient psychiatric care. So Sarah became one of many mentally ill Georgians who, facing similar insurance restrictions, or lacking coverage altogether, have only one real option: a state hospital.

Sarah spent two weeks at Georgia Regional in February and March 2005, shortly after leaving Ridgeview. Back at her grandmother's house, she continued having severe, disruptive tantrums despite being heavily medicated. By the fall, Sarah's family realized they needed help again.

On Oct. 24, 2005, Sarah returned to Georgia Regional.

She was the sole resident of Room 1123 on the adolescent unit. The only door had a long, narrow window that had been covered. The only furnishings were a bed and a wooden desk with the drawers removed. A slim window on the outside wall offered her a view of a trailer on the hospital grounds.

Over the next three months, Sarah's condition, as well as her behavior, deteriorated.

She "frequently experienced hallucinations, talked or mumbled to herself, and was combative and uncooperative with directions and schoolwork, " a state report says. She rarely spoke, according to another report, and when she did, she seemed fixated on such topics as getting pregnant and the singer Britney Spears.

Doctors prescribed an assortment of medications: Ativan to reduce anxiety. Benadryl for sedation. Geodon, Risperdal and Seroquel to treat schizophrenia and psychosis. Thorazine to control hallucinations. Cogentin to counteract the Thorazine's side effects.

Many of the drugs shared a common risk: constipation.

Sarah had entered the hospital with an elevated white blood cell count, a sign that she was fighting an infection. But medical records indicate no doctor at Georgia Regional ordered additional blood tests right away. They concentrated instead on Sarah's mental illness.

At Christmas, two months later, Sarah left for 13 days to visit her family. Her homecoming was far from joyful.

She barely spoke to anyone. She frightened her younger cousins with a fixed stare. Her family couldn't leave her alone, for fear that she would run away.

"She was sedated, " Joyce Dobson says, "like a zombie."

Sarah's demeanor so upset Dobson that she began looking into an alternative treatment program in Florida. She hoped to send Sarah there in the spring.

When Sarah returned to Georgia Regional after Christmas, the hospital staff was supposed to take blood to test for anemia and infection. Sarah refused, and no one at the hospital ever asked Dobson for permission to take blood by force. So the tests were not done.

Most Sundays, Dobson and Sarah's other grandmother, Bobbie Crider, visited her together. The second weekend in February, they went on Saturday night instead.

Sarah met them in a waiting room --- the hospital does not allow visitors on the wards --- dressed in a white hospital gown, rather than the jeans and shirts she had worn during earlier visits. Her shoulder-length brown hair needed washing. She had put on weight during her hospital stay, about 30 pounds, up to 156, possibly a side effect of her anti-psychotic medications. She was withdrawn and seemed ill.

"She didn't talk much, " Bobbie Crider recalls. "I thought she couldn't understand us well."

Dobson noticed that Sarah's ears were bright red; usually that meant she had a fever. Dobson also wondered about a red streak across Sarah's forehead and about the girl's swollen feet. She told a member of the medical staff that her granddaughter needed attention.

Just before she left, Dobson heard a loud, prolonged scream from behind the locked door to Sarah's unit. A hospital employee explained that a patient was being restrained.

“I just hate to send her back into that kind of environment,” Dobson told Bobbie Crider.

Sarah embraced Dobson one last time before returning to her room. It was a ritual between grandmother and granddaughter.

Sarah had always called it a "squeezy hug."

Staff under pressure

The next night, Feb. 12, 2006, Sarah Crider was one of 22 patients in Georgia Regional's adolescent unit. Boys slept on one hall, girls on the other. A nursing station that connected them served as a base for the staff working the overnight shift: one nurse and four technicians.

"There was chaos on the unit, " a nurse who went off-duty at 11:30 p.m. would later tell an investigator.

The nurse in charge overnight had responsibilities both on the adolescent unit and elsewhere in the hospital. He had to administer medications to patients and fill out paperwork. He had to respond to emergencies on other units in other buildings and process the admission of new patients. He had to assign staff members to cover patients' needs.

The nurse sent two male technicians to the boys' hall; one supervised a patient who required individual monitoring, while the other cared for the remaining eight boys. As the shift began, the nurse assigned another male technician to the girls' hall to work with a female colleague. She would later say she wasn't able to look in on all 13 girls on the unit because, with so many patients, "I wouldn't have time to do anything else."

High patient-to-staff ratios are hardly unusual at the state hospitals. The occupancy rate in adult mental health units averaged 109 percent last fiscal year, well above the national standard of 85 percent. Staff turnover is heavy, made worse by pay for many technicians of less than $20,000 a year. Nurse and technician jobs go unfilled for weeks or months at a time. Consequently, the hospitals often call on employees to perform heroically under virtual combat conditions.

And when employees are overworked, distracted or disengaged, patients may suffer.

At East Central Regional Hospital in Augusta in 2002, patient Larry Mansfield asked a technician to help him buy corn chips from a vending machine. Like many patients in the state hospitals, Mansfield, 53, had a history of choking, was restricted to a diet of ground food, and needed supervision while eating. The technician got Mansfield the chips anyway, then left to help subdue another patient. Alone with the chips, Mansfield choked to death.

By comparison, Sarah Crider's stomachache apparently didn't seem like much of an emergency, at first, on a hectic Sunday night at Georgia Regional.

Hours of distress

One physician was on duty for the entire hospital that night: Dr. Ginari Gibb, a 32-year-old medical resident in psychiatry. Unlike most other residents, who work at Georgia Regional under an attending physician through arrangements with medical schools, Gibb was a free agent, according to state personnel records, hired for a 12-hour overnight shift at $60 an hour.

After Sarah vomited about 8:30 p.m., the nurse then on the adolescent unit paged the doctor. Gibb arrived about 9:20, and wrote in Sarah's chart that she was "found lying in bed in vomitus" and "complained of stomach cramps over several hours." Medical records don't indicate whether Sarah was able to describe the extent of her pain. Regardless, Gibb noted, Sarah appeared to be in no distress.

But Sarah's medical records contain no indication that Gibb actually examined her. The doctor did not document whether she listened for bowel sounds with a stethoscope, or checked whether the abdomen and bowel area were firm, or felt for masses.

Gibb ordered a suppository for Sarah's nausea and a Tylenol for her headache. Then she went back to work elsewhere in the hospital.

No one summoned Gibb when Sarah vomited at least two more times between midnight and 2 a.m. The overnight nurse had been occupied with other duties since 12:35, then returned at 2 to document that Sarah was lying in "extra large amounts" of vomit. A technician would later tell investigators it resembled coffee grounds, a sign of a medical emergency: She was vomiting partly digested blood.

For the next several hours, though, hospital employees showed no urgency in their assessments of Sarah's condition.

3:15 a.m.: Sarah was "in bed and awake."

4:15 a.m.: Sarah's breathing was "even and unlabored."

5:30 a.m.: "No complications noted."

In fact, the employees had no idea how she was doing.

As the male technician working the girls' hall later would explain to state investigators: "We're not supposed to go into the female rooms at night. We just stand at the door and make sure that they're in the room."

When he looked in on Sarah, the overhead light was off and she was facing away from the door, the technician said. She was quiet, he said, but he "couldn't necessarily tell if she was breathing."

At 6:15, a nurse entered Room 1123 and found Sarah, unconscious, without a pulse, still lying in vomit. The staff declared a "code, " a hospital term for medical emergency.

A nurse who raced to Sarah's room from another unit noted that her abdomen was enlarged, rounded and firm to the touch, and that a thick brown substance was coming out of her mouth. Her skin was so discolored that staff members who hadn't seen Sarah before assumed she was black.

Another nurse placed a defibrillator to Sarah's chest, hoping to restart her heart.

"Where [is] the medical doctor?" the nurse asked, according to notes later inserted in Sarah's medical chart.

Gibb, still the only physician on duty, arrived at Sarah's room a few minutes later, records show. She stood in the doorway, other hospital workers would later report, and watched as they tried to resuscitate Sarah.

In the medical chart, though, Gibb would note that Sarah was "cold, blue and without a pulse" when she arrived. "Rigor mortis had already set in."

Gibb added, "The patient was unable to be revived, and expired."

An avoidable death

Joyce Dobson at first assumed another patient had assaulted her granddaughter. But she says Georgia Regional employees assured her that Sarah died peacefully, in her sleep.

Sarah's autopsy provided a far more horrific account.

The medical examiner found Sarah had developed a severe intestinal blockage that caused her colon to stretch almost to the point of bursting. Her lungs had filled with vomit. And she had developed bacterial sepsis, an infection of the bloodstream.

The day after Sarah died, the state opened two investigations --- both by the Department of Human Resources, the same agency that runs the hospitals.

One inquiry began in response to an anonymous complaint about Sarah's treatment. The other resulted from a 2005 policy requiring agency employees to look into the death of every state hospital patient.

In many instances, employees of the hospital where a death has occurred investigate their colleagues' actions --- and, records show, rarely find fault.

In one case, hospital officials assigned a death investigation to a music therapist on their staff. At another hospital, a patient advocate with no professional license in any medical field conducted numerous inquiries. His report from a 2005 investigation was typical: 58-year-old Henry Jenkins "was loved and admired by all who knew him, " the advocate concluded. "Someone said to me, 'Everyone liked Henry.' We can all hope to be remembered in that way."

Physicians and other medical professionals often critique the handling of death cases by conducting peer review. But the state refuses to release records of those reviews, even to the families of deceased patients.

Gwen Skinner, who heads the mental health division of the Department of Human Resources, describes the investigations as "strong, thorough." Walker, the human resources commissioner, says the department "takes whatever action is required."

In Sarah's case, investigators from the department's regulatory section struck a critical tone.

They found she had become lethally constipated partly because of her medications, some of which were known to cause severe constipation in many patients. The problem, they discovered, was exacerbated by dosages that sometimes exceeded the amounts prescribed. They also documented that hospital employees did not record Sarah's consumption of food and liquids or her bowel movements.

Furthermore, investigators said, Sarah's impacted bowels developed over time and could have been detected by more careful observation.

Georgia Regional "failed to adequately monitor and assess the patient, " the investigators wrote. "Medical professionals are left with the responsibility to develop systems to collect information related to the patient's wellness, to recognize symptoms related to impaired health, and to obtain and provide prompt and appropriate treatment."

Sarah's condition should have been recognized as a medical emergency requiring immediate surgery, says Dr. Kris Sperry, Georgia's chief medical examiner. "People should not die of obstructed intestines."

Skinner agrees that Sarah's death was avoidable.

"Our take on it was the situation with the child was not something that occurred on one night or one shift, " Skinner says. "I would say that anytime you have a child die, the system has failed."

The state fired Dr. Ramesh Amin, Sarah's primary psychiatrist for much of her hospitalization, citing "negligence and inefficiency." Amin, who has contested his firing, declined to comment for this article. His attorney, Sandra Michaels, says Amin should not be "singled out" for blame. "It was a tragedy that had nothing to do with his abilities as a doctor."

For other hospital employees, the consequences of Sarah's death appear to have been minimal.

Ginari Gibb, the doctor on duty the night Sarah died, continues to practice at Georgia Regional. Gibb, who did not respond to requests for an interview, received no punishment from hospital officials, just a letter from the facility's clinical director outlining her mistakes.

The letter's purpose, the clinical director wrote, was for "coaching and counseling."

The final indignity

Sarah's funeral was Thursday, Feb. 16. Her special education classmates brought red heart-shaped balloons to a Marietta cemetery on a warm winter afternoon. One child read aloud, "Sarah, you're my best friend, and I'm going to miss you."

About a month later, Joyce Dobson called Georgia Regional to ask for Sarah's clothes.

"They said, well, if they could find them, " she recalls. She eventually received Sarah's gown and robe, both stained by what appeared to be vomit or blood.

Dobson was furious. Sarah was meticulous about her clothes, sometimes changing three or four times a day. Dobson knew her granddaughter never would have chosen to stay in soiled clothing.

She saw this as one last indignity, one last symbol of neglect surrounding Sarah's death.

"I was angry because I felt like it could have been prevented, " Dobson says. "It just seemed like such carelessness."