A HIDDEN SHAME: DEATH IN GEORGIA'S MENTAL HOSPITALS
Sarah Crider was among 115 patients
in the state's care who might have lived.
First in an occasional series
Alone in the darkness of a state mental hospital, Sarah Crider, 14, lay slowly dying.
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
I hope nobody killed her, Dobson blurted out.
In fact, what happened to Sarah was beyond anything Dobson could have imagined.
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.
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
In an additional 24 cases, the agency says, "we agree the hospital system should make improvements."
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."
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.
newspaper could find no information on 16 of the 115 deaths, except
that state officials classified them as "unexplained/suspicious."
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
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.
was a healthy 14-year-old -- healthy," says Dobson, Sarah's maternal
grandmother and guardian, whose family 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
loved cartoons. Given the choice, she would have eaten ice cream with
every meal. She gardened with her grandmother, but teased about the
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.
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
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.
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.
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.
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.
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.
at Ridge-view, 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
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.
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
Over the next three months, Sarah's condition, as well as her behavior, deteriorated.
"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
Many of the drugs shared a common risk: constipation.
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.
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
"She was sedated," Joyce Dobson says, "like a zombie."
demeanor so upset Dobson that she began looking into an alternative
treatment program in Florida. She hoped to send Sarah there in the
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.
Sundays, Dobson and Sarah's other grandmother, Bobbie Crider, visited
her together. The second weekend in February, they went on Saturday
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
"She didn't talk much," Bobbie Crider recalls. "I thought she couldn't understand us well."
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
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
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.
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.
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.
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
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
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
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.
ordered a suppository for Sarah's nausea and a Tylenol for her
headache. Then she went back to work elsewhere in the hospital.
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.
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
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."
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.
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.
the medical chart, though, Gibb would note that Sarah was "cold, blue
and without a pulse" when she arrived. "Rigor mortis had already set
Gibb added, "The patient was unable to be revived, and expired."
An avoidable death
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.
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.
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.
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.
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."
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.
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."
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
For other hospital employees, the consequences of Sarah's death appear to have been minimal.
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
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.
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."