Hospital Deaths

The Office of the Chief Medical Examiner has reclassified the cause of death of a patient whose death was among 82 questionable hospital patent deaths highlighted in a News & Observer series on failed mental health reforms. Donald Michael Jones, who had bipolar disorder, died July 27, 2006, after a stay at Cherry Hospital. He swallowed 28 antidepressants. His original death certificate indicated he died of a heart attack. Though internal reports from 2006 show hospital officials knew Jones' death was linked to an overdose, that information was not shared with the medical examiner — a potential violation of a state law requiring deaths by accident or suicide to be reported.
No autopsy was performed before his body was sent home to be buried by loved ones assured he died of natural causes. His death has now been ruled a suicide. The Office of the Chief Medical Examiner's office is re-examining the deaths highlighted by the newspaper, and Jones' is the first to be reclassified. John D. Butts, the chief medical examiner, said it is rare for his office to issue new findings after a death certificate is finalized. In March, Gov. Mike Easley announced that hospital administrators would have to report all deaths at state hospitals to the medical examiner by telephone. Often the very doctors responsible for a dead patient's care make that report. If the medical examiner is told the patient died of natural causes, as happened with Jones, the issue is often not pursued.
A pair of bills under consideration in the legislature would require the medical examiner to review all state mental hospital deaths. "When someone is in our custody, we owe them safe harbor," said Sen. Martin Nesbitt, D-Buncombe, the primary sponsor of the Senate bill. "The loophole is that if you called and said it was a natural death he [the medical examiner] wouldn't go. I don't think someone telling the medical examiner why a patient died is sufficient. We want the medical examiner to go and determine why they died." (Michael Biesecker, THE NEWS & OBSERVER, 6/26/08).