Part Five of N&O series on Mental Health Reform

http://www.newsobserver.com/2771/story/976809.html

Published: Mar 02, 2008 12:30 AM Modified: Mar 02, 2008 05:11 AM

Patients die from poor care; families don't hear full story Since December 2000, at least 82 patients have died in ways that raise questions, including homicides and suicides

Michael Biesecker and Brooke Cain, Staff Writers

Janella Williams begged her mother never to send her back to Cherry Hospital.
Having struggled with paranoid schizophrenia since her late teens, Williams, 35, had been admitted to the state-run mental institution in Goldsboro 18 times. After a five-month stay, she was discharged in March 2005 to her family home in rural Beaufort County with a cast on her leg.

Williams told her mother the staff had broken her bone while restraining her, though her official medical file offers no explanation for the fracture other than to say it was the result of a "twist."

"She said, 'Cala, I don't want to go back to Goldsboro,' " remembered Calvin Williams, Janella's mother. "She said, 'If I go back to Goldsboro, they're going to kill me.' "

On her 19th admission to Cherry Hospital, Janella's prediction came true.

She was one of at least 537 patients of the state's 14 mental institutions who have died since December 2000.

Most died of natural causes, but a News & Observer investigation shows that
82 of those patients died under circumstances that raise
questions: homicides, suicides, accidents, inadequate treatment or mistakes.

Family members of the deceased, who have a legal right to receive complete information about how their loved ones died, often are not told the full details or provided access to internal reviews that would raise concerns.

State reviews, death certificates and autopsy reports confirm the death toll.

Jimmy Clifton Davis, 52, died after he was beaten by another patient and then restrained at Dorothea Dix Hospital in Raleigh.

Anthony Dawayne Lowery, 27, suffocated while being held down by staff at Broughton Hospital in Morganton.

Delores Ingram Franklin, 47, died after three injections of an antipsychotic drug at Cherry.

Suicidal patients -- such as Deborah Lynn Bishop, 45, at Broughton and Darnell Jamarr Harrell, 22, at John Umstead Hospital in Butner -- were unsupervised and hanged themselves.

Alphonzo Leonard Hicks, 53, suffered severe and painful constipation while a patient at Umstead and died from from a resulting infection.

At least four patients died of urinary tract infections that were not treated effectively, while three died of blood infections resulting from improperly maintained feeding tubes and catheters. Some died shortly after discharge because of conditions related to their state hospitalization.

Though the names of the dead and their causes of death are available to the public at county courthouses, officials at the state Department of Health and Human Services contend that federal patient privacy laws forbid them from disclosing the names of those who died in their care.

The N&O assembled its list by cross-referencing redacted copies of internal state documents and computer databases with such public records as death certificates and autopsy reports -- matching birth and death dates, locations of death and the circumstances. In several cases, confidential medical records were released with the cooperation of the deceased patient's family.

Those records were reviewed in consultation with physicians, psychiatrists, pathologists and other medical experts.

The deaths occurred in state hospitals and homes for people with developmental disabilities that have struggled for decades, but particularly since 2001. That year, the state started cutting the numbers of beds and staff to help pay for a plan that would use private outpatient providers to treat mentally ill people closer to home.

But those reforms have not provided the expected levels of community treatment, and the demand for state inpatient services has risen. The mental hospitals have been turning patients away.

Death rates at the hospitals generally have held steady since 2001, except for a significant drop last year. The psychiatric hospitals have reduced the numbers of beds for elderly patients and stopped accepting patients when hospitals become overcrowded.

"These are not snake pits where people come in and they're dying right and left," said James Osberg, who heads the state system of mental hospitals and developmental centers. "Do you know how many referrals we get of elderly people who come in from a nursing home who are about to die, and it's a nice little dump job, but we have to take them?"

Of the 82 deaths questioned, 20 were above the age of 65.

Osberg said deaths similar to those questioned by The N&O occur in all hospitals. However, neither he nor his staff consistently tracks or analyzes why their patients die.

A review of conditions in North Carolina's state mental hospitals by the U.S. Department of Justice in 2004 concluded that employees routinely violated patients' civil rights. The inappropriate use of physical restraints and seclusion were cited as major problems, as were inadequate mental-health treatment, unsafe building conditions and the failure to "ensure the reasonable safety of patients."

Legislators and administrators at the state Department of Health and Human Services have focused on closing aging facilities in favor of new, smaller buildings.

The new Central Regional Hospital in Butner was set to open last month; Dorothea Dix and John Umstead were set to close. But opening the $120 million hospital has been delayed because of design flaws, such as open stairwells where suicidal patients could jump and door fixtures that might be used to anchor a noose.

While money has been spent on bricks and mortar, employee pay in the hospitals has remained low, contributing to heavy turnover and unfilled positions. Those overseeing the hospitals have used short-term staffers and temporary employees to fill many vacancies.

"The staffing and crowding conditions that may have contributed to the deaths are a consequence of reform," said Harold Carmel, president of the N.C. Psychiatric Association and the former clinical director at Umstead.
"Mental-health reform in North Carolina was a grandiose plan, with great-sounding rhetoric about how well things would go, but with little substance behind it."

'We lost her'

Each patient death has a story. Janella Williams' shows how hard it can be for loved ones to learn the truth.

Williams worked part time as a cashier at a Wal-Mart in Greenville and had recently moved from her mother's house to a small apartment in the Eastern North Carolina town.

The youngest of seven children, she grew up in Beaufort County a couple of miles north of the rural crossroads of Acre Station. On a recent visit, the road to Calvin Williams' house was lined with bolls of fresh-picked cotton that blew off on the way to the gin.

Janella Williams loved gospel music and attended church nearly every Sunday, taking detailed notes on the sermon in spiral notebooks she also scribbled full of poems.

"Though the storms of life may come," she wrote, "I shall not murmur and complain. The devil's job is to try to have kept me insane."

Williams had been out of the state hospital for nearly a year and, according to her family, was doing well when her mind again descended into chaos and fear.

On Feb. 16, 2006, she dialed 911 and pleaded with the dispatcher for help, saying someone was after her. She was taken to Pitt County Memorial Hospital, where a doctor signed a petition to involuntarily commit her to Cherry Hospital -- the designated state psychiatric hospital for a region that includes 33 eastern counties.

Williams' medical records, released at the behest of her family, say she arrived at the institution in the back of a squad car shortly after midnight, agitated and refusing to take medications. She was deemed combative and is reported to have attempted to assault a staff member.

About 5:45 a.m., four people carried Williams into a room where she was strapped to a table and injected with a powerful tranquilizer and other medications. When the drugs failed to calm her, the records show she was forcibly medicated again.

About 8:40 a.m., Williams' medical records say she was still in restraints when a staff member checked on her and found she was no longer breathing and had no pulse. She was rushed by ambulance to Wayne Memorial Hospital, where she was declared dead.

Calvin Williams got the news of her daughter's death by telephone.

"The doctor called and said, 'We lost her,' " she said. "That's all he'd say. 'We lost her.' "

Rules for restraints

Physically restraining patients can endanger them and staff members.
Those who work at mental hospitals are instructed to use nonconfrontational methods to calm patients and to use force only as a last resort.

When physical intervention becomes necessary, hospital staffers are trained to use holds designed to limit patients' ability to move while not injuring them. If a patient continues to resist, sedatives may be administered with the approval of a doctor, and the patient will be carried by staff members holding the arms, legs and head into a special "restraint" room.

There, the patient is strapped to a steel bed with wide leather bands on the person's arms and legs. Regulations require that the patient must be released "at the earliest possible time."

Though specific procedures for restraining patients in state hospitals vary by institution, Cherry Hospital's policy is that no patient should be strapped down for more than 30 minutes. The restrained patient must be under constant observation by at least one staff member.

On the confidential forms used to report mental-hospital deaths to the state Division of Health Service Regulation, staffers are required to indicate when a patient died after being physically restrained or locked away in a seclusion room. At least five have died after being placed in restraints since 2003.

In Williams' case, however, no such report was made by Cherry Hospital, a violation of state and federal laws. Investigators learned of her death from an anonymous tip.

State investigators responded by making an unannounced visit to Cherry. They interviewed staff members about Williams' death and read the written records.

They found the accounts incomplete and, in some cases, contradictory.

Key point left out

Williams' medical records, as written by the staff at Cherry, didn't tell the full story of how she died. Not included was the key detail that she managed to get out of her restraints -- despite the requirement for constant supervision.

When she walked out of the restraint room on her own about 7:30 a.m., a staff member called for "male help," according to the federal investigative report. Health- care technicians, the least-trained and lowest-paid members of the hospital's medical staff, often are charged with tackling patients and restraining them.

About 15 people are estimated to have responded to the emergency page.
They held Williams face-down on the floor for about 10 minutes until she stopped resisting and went "limp," according to the investigative report.

She was carried back into the restraint room, where her gown was changed because she had urinated on herself. She was then put back in the leather straps without the approval of a doctor, a violation of procedures.

She was injected with Thorazine, a powerful antipsychotic drug not listed in her medical records among the medications she was prescribed by a doctor.

Though Williams had become suddenly still, hospital staffers apparently were not concerned. A nurse told investigators the staff thought Williams was "playing possum."

Notes in her medical records describe her condition as "quiet" and "resting"
for nearly an hour. Her medical condition was not evaluated by a nurse, as required. Though no longer conscious, she was not released from the straps.

It was nearly three hours after she was first placed in restraints, about 8:40 a.m., when the health-care technician who was supposed to be observing Williams checked on her and realized she was no longer breathing.

A pledge to improve

Following their investigation, state regulators filed a scathing 30- page report in March 2006 that identified nine major conditions and standards violated in Williams' care and concluded that her individual rights had been violated. The federal Centers for Medicare & Medicaid Services gave the hospital 30 days to come up with a plan to fix the problems or lose millions in government insurance reimbursements.

As a result, the hospital fired one nurse for "gross inefficient job performance." Two staff members were suspended for five days without pay, and two others received written warnings.

Cherry Hospital administrators promised changes in procedures and remedial training in how to safely restrain patients and monitor their medical condition. The federal regulators accepted the plan.

It was not the first time Cherry's leaders avoided punishment by making pledges to improve.

Two years before Williams' death, in February 2004, Delores Franklin died after being restrained at the hospital. An investigation found that Franklin, who had paranoid schizophrenia and a history of heart problems, was given multiple injections of Thorazine. The drug can cause abnormally low blood pressure, which can lead to death in patients with heart disease.

Franklin went limp and was left alone for more than three minutes before anyone noticed she wasn't breathing.

When a nurse called a "Code Blue," the signal that scrambles help in a medical emergency, staffers retrieved the ward's "crash cart," a dolly where life-saving medical supplies are stored. As they tried to revive Franklin, they found no face mask for a mechanical breathing device. A drawer holding other needed items was jammed and could not be opened.

Three more crucial minutes passed before a crash cart was retrieved from another ward.

"We weren't told any of that," said Barbara Lewis Briggs, Franklin's aunt.
"They just told us she had a massive heart attack."

When the hospital reported Franklin's death to regulators, boxes were checked on a form indicating that she had not been in physical restraint or seclusion within 24 hours of death, which was not true. A subsequent federal investigation showed that she was in a seclusion room.

Investigators cited the hospital with six violations and threatened a cutoff of federal aid. However, there's no mechanism in state law for punishing a hospital for erroneously reporting the circumstances of a death. As after Williams' death, a nurse lost her job. Hospital bosses promised to make changes and retrain staff in proper procedures.

'We got suspicious'

Williams' mother and siblings met with Cherry Hospital administrators in the spring of 2006 in an attempt to learn more about her death, but they were not told of the hospital's internal review or the federal investigation.

"They didn't talk too right, and they didn't look too right," Calvin Williams said. "That's how we got suspicious there was something wrong."

The family hired a lawyer, Lynne Holtkamp of Chapel Hill, who filed a subpoena that yielded copies of the investigative reports. She then turned those documents over to state pathologist Deborah Radisch, along with 15 pages of medical records from Cherry that administrators had not provided to the medical examiner.

In August 2006, Radisch determined that Janella Williams most likely suffocated as the result of "improper restraint."

"The history of prolonged attempt at physical restraint, with a sudden change in the patient's activity from noisy to combative to quiet and limp is consistent with an asphyxial death," Radisch wrote in the autopsy, suggesting Williams may have stopped breathing before she was carried to the restraint room and strapped down for nearly an hour.

Radisch said she would not have been able to accurately determine why Williams died had the additional medical records and investigative reports not been provided by the family's attorney.

There is no law or policy requiring that the reports on institutional deaths made by investigators for the Division of Health Service Regulation be forwarded to the pathologists performing the autopsies, though both work within the same department.

Though Williams' death was ruled a homicide, the district attorney for Wayne County says he was never informed of her death.

"It's extremely unusual to find out about something like that from the newspaper," Branny Vickory said after searching his office's files for any mention of Williams' death. "But I'm going to find out what's going on."

State institutions and employees can't be sued in civil court for official acts. The families of those seeking compensation for deaths in state institutions are required to apply to the N.C. Industrial Commission, where the cases are reviewed by commissioners appointed by the governor.

In Williams' case, officials conceded the government was negligent.
Williams' family settled the case in January for $275,000. As part of the agreement, Cherry Hospital administrators once again promised to make changes and retrain staff to ensure patients are restrained safely.

Though the money is a comparative fortune around Acre Station, Williams'
mother says the settlement is little consolation for losing a child. She finds it too difficult to visit her daughter's grave, which lies under a small gray stone in a cemetery not far from home.

"They did her wrong," Calvin Williams said. "My daughter had a life.
Sometimes it seems like she's still alive in me, we were so close together.
We understood each other. She was my baby."

(News researcher David Raynor contributed to this report.)

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[The following page-one sidebar was not included in the on-line text]

The 82 Deaths

The News & Observer's review was assisted by several medical professionals, including Dr. Harold Carmel, president of the N.C.
Psychiatric Association. Now in private practice, Carmel served as clinical director at John Umstead Hospital from 1998 to 2004 and was chief of geriatric psychiatry at Dorothea Dix Hospital until 2006. A pathologist also reviewed the list, which includes deaths of such "natural" causes as urinary tract infections that were not treated effectively or patients with feeding tubes who inhaled food into their lungs. Our experts said such deaths are often avoidable.

The State's Response

"...[O]ur initial review of available materials shows that 40 of those deaths labelled as 'questionable' by the News and Observer do not appear to be 'questionable,'" state spokeswoman Debbie Crane wrote in a statement.
"We aren't sure what criteria the News and Observer used.
Our facilities house some of the most medically fragile people in the state, who are likely to die of a variety of causes that aren't related to staff or inadequate care."

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http://www.newsobserver.com/2771/story/976645.html

Law requires notice of deaths, but not all comply Reports missing on 165 patients

Michael Biesecker, Staff Writer

State mental hospitals often fail to accurately report critical details of patients' deaths to regulators charged with investigating suspicious cases.

Following an investigation by The Charlotte Observer in 2000 that highlighted 34 questionable deaths in state-run mental facilities, legislators passed a requirement that such deaths be reported to the state Division of Health Service Regulation.

Since Jan. 1, 2001, all public and private medical facilities have been required to file a report providing details of any death resulting from homicide, suicide, accident or unknown cause.

The report has to be made within three days of the death and must disclose whether the deceased patient had been kept in psychiatric restraints or locked in a seclusion room within the prior seven days.

It soon became clear, however, that some state hospitals were still not reporting questionable deaths -- wrongly classifying their causes as natural.

In response, an additional order was sent out in March 2001 that required nearly all state mental facilities to report all deaths, regardless of cause. Patient deaths that occurred within a week of discharge also had to be reported.

A review of more than 500 such deaths shows that state hospitals still often fail to comply with the law, more than seven years after the measure took effect.

Director demoted

Seth Hunt, the director of Broughton Hospital in Morganton, was demoted in December following The News & Observer's disclosure that his troubled facility had failed to report four deaths to the regulators.

According to a database maintained by the state, the death reports from its mental hospitals and developmental disability centers were received by regulators within the mandated three days only 8 percent of the time.

So far, officials with the state Department of Health and Human Services say they have been unable to locate copies of the required death forms for 165 patients who died in state facilities since December. State officials say they don't keep most reports more than five years but acknowledge they can't find some reports less than five years old.

The standardized forms on which state hospital deaths have been reported internally since 2001 have a box to be checked indicating whether the patient had been in restraint or seclusion within 24 hours of death, not the full week required by law. Those forms were not corrected until this January.

State hospitals director James Osberg contended there was no proof the facilities under his supervision had violated the law.

Though state law requires that all deaths occurring in prisons, jails or while in the custody of law enforcement be reported to the state Office of the Chief Medical Examiner for review, there is no such measure covering all deaths in mental hospitals.

Dempsey Benton, secretary of the state Department of Health and Human Services, said last week that he would support legislation requiring that all state hospital deaths be reported.

There is already a law requiring deaths that are the result of accidents, homicide, suicide and unknown or unexpected causes to be reported to the medical examiner for a possible autopsy.

The N&O's review found some examples of deaths in state hospitals or after an emergency transfer to an acute-care facility where that reporting requirement was not met.

An example is Ruth Tidwell, an elderly patient of John Umstead Hospital who died in 2003. Tidwell fell and shattered her leg while in the hospital's geriatric psychiatric ward.

She was transferred to Durham Regional Hospital, where surgeons tried to repair her shattered femur with metal plates and screws. The repair failed, and doctors amputated her leg. Tidwell then developed an infection and eventually died of blood poisoning.

Administrators at Umstead made no report to the state medical examiner. It was nearly five months before the medical examiner for Granville County learned of Tidwell's death, which was ruled to be the result of an accident.

By then it was too late to perform an autopsy. Her body had been cremated.