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MENTAL HOSPITAL DEATHS: State often ends probes without all the evidence
Key questions unasked: Autopsies frequently missing; reports conflict.

The Atlanta Journal-Constitution
Published on: 05/06/07

Despite intensifying scrutiny, Georgia's state mental hospitals continue to absolve themselves in patients' deaths while leaving key questions unanswered, or even unasked.

At least five times state officials concluded investigations into suspicious deaths in 2007 before receiving autopsy reports, a review by The Atlanta Journal-Constitution shows. In a sixth questionable case, the patient's family declined to have an autopsy performed.

The investigations into these six suspicious cases, detailed in reports filed during the first quarter of 2007, show that the state still completes inquiries without always fully examining factors that led to patients' unexpected deaths. The Journal-Constitution reported in January that at least 115 patients from the seven state hospitals had died under suspicious circumstances from 2002 through 2006 and that state investigations had often been incomplete.

In a January case, a patient at Central State Hospital died three days after a doctor warned that the man may have been prescribed a lethal dosage of an anti-psychotic drug. Yet the state investigation concluded without examining whether the medication contributed to the man's death.

In February, a 24-year-old patient at Southwestern State Hospital died in what the facility's clinical director described as "a medical mystery." The doctor added, "Twenty-four-year-old men don't die from unknown causes very often." But investigators cleared the hospital without waiting for autopsy results. State officials say their long-standing system of self-policing is effective and allows them to revisit conclusions about deaths if new information emerges.

Outside review sought

But in response to the Journal-Constitution's latest findings, advocates for mental health consumers and experts in psychiatric care said they had expected more thorough death examinations in response to the newspaper reports, subsequent criticism from state legislators and a recently announced investigation of the hospitals by the U.S. Justice Department.

"It can't be a definitive report if the autopsy has not been factored in," said Dr. Sidney Weissman, who teaches psychiatry at Northwestern University's medical school in Chicago and serves on a panel that reviews deaths in Illinois' state hospitals.

Ellyn Jeager, of the advocacy group Mental Health America of Georgia, said: "It's another reason why they shouldn't be investigating themselves . . . There needs to be independent oversight."

Gwen Skinner, director of the mental health division of the Georgia Department of Human Resources, which runs the hospitals, said at a recent meeting that she supported the idea of outside review. Last week she ordered the hospitals to request an autopsy on every patient who dies under state control. Previously, local coroners and patients' families had the discretion to request or decline autopsies.

Regardless, Human Resources officials contend the current system produces thorough, timely investigations.

Within 30 days of a patient's death, the mental health division's investigative unit is supposed to file what it calls a "final report." Those reports typically include a chronology of events leading to the death, interviews with hospital workers involved with the patient, and conclusions about whether the facility is culpable.

Neither autopsy reports nor death certificates, which also list the cause of death, generally are available in 30 days, said Mona Givens, who heads the investigative unit. The agency's medical director later goes over documents related to the cases, including internal reviews by physicians. The medical director then "makes the decision about the [quality of] medical care and can effect any changes that she thinks are necessary," Givens said.

Whether to conduct additional investigation is decided "case by case," Givens said.

'Mystery' death

Officials said late last week they could not say whether recent cases warranted further examination.

Among them was the "mystery" surrounding the death of the 24-year-old patient at Southwestern State in Thomasville.

The man had been hearing voices telling him to kill himself and others, the state's report says. The man's identity, like that of others who died during the first three months of 2007, was redacted from public documents; as a result, the newspaper could not obtain autopsy reports or other patient information.

The hospitals' policies call for complete physical examinations of newly admitted patients. But staff members at Southwestern State decided the 24-year-old was too agitated to provide samples for routine lab tests. Thus, reports say, doctors had no idea what was wrong with him about a day into his stay when he exhibited a "change in level of consciousness."

Still, before autopsy results came in, investigators concluded the hospital's staff acted "in accord with hospital policy and procedure."

Such conclusions are common, the Journal-Constitution found, even when the investigators' reports contain contradictory information.

When a 46-year-old patient at Central State died of an apparent intestinal obstruction in January, employees at the Milledgeville hospital told state investigators they had not been tracking the man's bowel movements. Many anti-psychotic medications cause severe constipation, and hospital officials acknowledge that monitoring bowel functions is crucial.

When the Central State patient became ill, "I thought maybe it was something he ate," a licensed professional nurse told investigators. "We were not monitoring his input or outtake. We would not have monitored unless he had a problem."

The investigators, however, reported only that forms recording the patient's bowel movements were missing from his medical chart. Their conclusion: "All policies and procedures were followed."

Conflicting conclusions

The failure to reconcile hospital employees' statements with the investigators' conclusions is among the glaring omissions in cases from 2007 that the newspaper reviewed.

The investigation into the death of the patient whose anti-psychotic dosage had been flagged by a physician made no attempt to determine what role the medication played, if any, documents indicate.

The 64-year-old man had been transferred to Central State from Georgia Regional Hospital/Atlanta three days earlier. The physician who examined him in Central State's admissions unit questioned whether doctors in Atlanta had prescribed too high a dosage of a medicine called Zyprexa. The Central State physician, Dr. Louis Barton, told investigators he disagreed with the patient's diagnosis and "could not reconcile or continue to recommend the medication prescribed" in Atlanta.

Even if he needed Zyprexa, Barton said, his dosage was potentially lethal for a person his age, especially one with dementia. Zyprexa is thought to increase the risk for a stroke in such patients.

His supervisor rejected his concerns, Barton told investigators.

"The referring physicians were not practicing the standard of care," Barton said. But "I have been instructed to order what the referring physicians recommend and [let] the client's attending physician make any adjustment."

At Central State, doctors instructed nurse's aides to keep the man within their sight at all times. On the man's third night there, he kept getting out of bed and, because of his unsteady gait, workers feared he might fall. So an aide sat with him in his room.

The aide told investigators the man said he used to be a math teacher and, to pass the time, he helped her with homework for a math class. She left after the man went to sleep. When she returned two hours later, he had died.

Investigators did not know what caused the man's death. But, their report concluded, "all policies and procedures were followed."

Except for one.

The investigators said the nurse's aide had engaged in "activities other than official business" by doing her math homework with the patient. They recommended that she be disciplined.


Beginning in January, the Journal-Constitution series "A Hidden Shame" has reported on overcrowding, understaffing and substandard care in Georgia's state mental hospitals. The newspaper found at least 115 suspicious patient deaths and more than 190 cases of physical and sexual abuse of patients from 2002 through 2006. The articles have prompted the U.S. Justice Department to open an investigation.

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