Five years later, he entered a Charlotte psychiatric hospital, depressed and threatening suicide. He was supposed to stay at The Willows for three months.
Out of sight in an isolation room, where he had spent three days alone, Cameron tied a bedsheet over the door and knotted the other end around his neck. Then he hanged himself.
Though crucial details about what happened that night are in dispute, and experts question why the hospital left Cameron unsupervised, no regulator investigated his death.
Not the state agency that licensed The Willows, part of Carolinas HealthCare System. Not the state agency that investigates patient abuse and neglect. Not the national commission that accredits psychiatric hospitals.
Since 1994, at least 34 people with mental or developmental disabilities have died in questionable circumstances while under the care of N.C. mental health facilities. And the system set up to protect them has often failed to notice.
They died from suicide, murder, scalding and falls. They suffocated, starved, choked, drowned. Twenty-four were patients at state-run facilities; 10 were under the care of hospitals and group homes operated by private companies and other organizations.
Of the 34 deaths, regulators confirmed that they investigated just 10.
"It's almost been like the mentally ill are worth nothing, and that's sad," says Karen Murphy, advocacy administrator with the Governor's Advocacy Council for Persons with Disabilities, one of the cash-strapped agencies empowered to investigate psychiatric hospitals. "I always tell people, `If this were your family member, how would you want them treated?'"
Every year, about 700,000 people with mental illness, developmental disabilities and substance abuse problems turn to North Carolina's mental health system - tens of thousands requiring sustained care at a hospital or group home. But the system lacks the resources and coordination to supervise a troubled collection of state-run institutions and thousands of smaller mental health facilities that have opened in the past decade.
The job is complicated by rules that let untrained people open residential facilities, and state laws that limit regulators' authority to punish negligent caregivers.
States across the country are pushing to strengthen mental health care, and last month, the U.S. surgeon general released a widely publicized report calling for easier access to services and better trained caregivers.
But in North Carolina, the mental health agenda for more than a year has focused almost entirely on concerns that have little to do with patient safety.
State and federal investigators say mental health officials have mismanaged more than $100million in federal money. The Division of Mental Health, which runs the state mental hospitals, is trying to overhaul its operations. Director John Baggett stepped down last month after three years, citing stress.
The new director, Dr. Iverson Riddle, says his first priority is simply to figure out how much money he has to work with.
"The budget appears to me to be a rather amorphous glob of money," he says. "I can't operate like that."
No single government agency in North Carolina, meanwhile, knows how many people are dying in mental hospitals and group homes. Regulators have files on a few fatalities, including several that have drawn media attention, but many cases have slipped through the safety net.
The Observer identified deaths of the mentally ill and developmentally disabled by searching 370,000 N.C. death records from 1994 through mid-1999, along with hundreds of police and autopsy reports. The search turned up 34 deaths that were sudden, unexpected or involved circumstances that could raise questions about care. More than a third involved patients age 35 and younger.
Cameron Cullen was the youngest.
On an April evening in 1996, Doug and Nancy Cullen kissed their 13-year-old son goodbye in the isolation room where he had spent three days for disrupting his ward at The Willows. He cried and told them he loved them. After a month in the hospital, the Cullens say, Cameron looked hopeless for the first time.
"I think he'll try to kill himself tonight," Nancy Cullen told Cameron's psychotherapist, according to both their accounts. The Cullens begged her to watch their son, then walked to the parking lot in tears.
Someone leaving the hospital said there was an emergency inside, and the Cullens ran back in.
They saw Cameron unconscious on the floor, face blue, two staffers crouched beside him. The sheet was still around his neck.
He never regained consciousness, and died three days later.
"We will never get over this," Doug Cullen says. "The only thing you keep telling yourself is that we were only doing what was in Cameron's best interest."
Officials at The Willows won't comment on Cameron, citing a lawsuit filed by his parents. But in sworn depositions, Cameron's psychotherapist and her boss say the teen's frequent suicide threats and the Cullens' warnings did not convince them he really meant to kill himself.
Carolinas HealthCare System this month announced plans to close The Willows, citing financial problems and a shift toward outpatient mental health care.
State mental health officials know nothing about Cameron's death, but they point out that psychiatric hospitals treat fragile patients.
They acknowledge some deaths in the four state-run hospitals could have been prevented, but they say it's impossible to stop every suicide or injury. The state hospitals admitted more than 16,000 patients last year. State facilities for substance abusers and the developmentally disabled served several thousand more.
"We're dealing with very sick people," says Baggett, who became the state hospitals' strategic planner after leaving the director's job. "I think any suicide or any death that happens in a hospital is a terrible tragedy. But when you consider the odds, our staff is doing an outstanding job."
Critics of North Carolina's mental health system agree the mentally ill and developmentally disabled are prone to accidents and suicides. But even if the state can't guarantee safety, they say, it should at least investigate every suspicious death, including all suicides.
Without a dependable way to monitor injuries and deaths, North Carolina has little chance of punishing negligent caregivers, changing faulty procedures or learning from mistakes. And patients' families often are left wondering what happened.
"Basically what you have is an unregulated system," says attorney Deborah Greenblatt of Carolina Legal Assistance, a nonprofit agency that represents people with mental disabilities. "There simply is not a system in place that is designed to effectively protect people from abuse, nor is there a system in place to require true accountability."
Among the concerns:
Of the 24 questionable deaths The Observer found in state mental institutions, the advocacy council investigated five, a top official said. In all those, it found negligence. The council is investigating a sixth death now.
Facility Services has records on just three of the 10 questionable deaths The Observer found in licensed facilities. It investigated two of them and found negligence in both.
Mental health advocates worry that little will change because so many other costly problems - flood relief, schools, roads, crime - crowd the state's agenda.
"If government is to do anything, it should support its most vulnerable citizens," says Dave Richard, executive director of The Arc of North Carolina, a nonprofit advocacy agency for the mentally retarded. "They can be productive. They can have meaningful lives, and they can touch us all. But that won't happen if we don't support them."
Some of the people in residential care have disabilities severe enough to require lifelong institutionalization. But many need residential treatment only for days or weeks at a time. When a crisis ends, or when they are stabilized on medication, they often resume normal lives.
That was the plan for Cameron Cullen.
Finding help for Cameron
A skinny kid from Charlotte's suburbs, he could dissect Civil War battles and identify any airplane in the sky. He played soccer and baseball, and had little trouble making friends. He qualified for Dilworth Elementary School's gifted program.
When Cameron was 7, the Cullens divorced. He and his younger brother divided their time between both parents.
At age 8, Cameron grew sad and withdrawn. He stopped playing with the dog. He wouldn't go outside. He talked about dying.
"He said he wanted to hang himself," Nancy Cullen recalls. "I just asked him, `Why would you want to hurt yourself? We love you.' He said, `I just can't take it anymore.'"
The Cullens took Cameron to a psychiatrist, and worked with his guidance counselor at school. He got better, but by age 11 he had become withdrawn and surly. He slammed doors and cursed his mother.
When Cameron was 13, Nancy Cullen suspected he was abusing drugs. She took him to Presbyterian Hospital, where doctors diagnosed depression. Doctors also were concerned about Cameron's claims that he had used drugs and tried to kill himself, but they couldn't confirm that he was telling the truth. A drug screening found nothing.
A psychiatric hospital for adolescents had opened a week earlier in Charlotte, on the same campus as Amethyst, a psychiatric and substance abuse hospital for adults. Both are owned by Carolinas HealthCare System, where Nancy Cullen works as a health-care manager.
Psychologist Herbert Shriver, The Willows' program director at the time, told the Cullens the hospital could treat Cameron.
In their sworn depositions, the Cullens say Shriver also promised Cameron would be safe there. Doug Cullen says Shriver told them: "You can't watch him 24 hours a day. We can watch him 24 hours a day, and we can guarantee his safety."
Shriver acknowledges telling the Cullens the hospital provided 24-hour care, but he denies promising them nothing could go wrong.
"Can't guarantee anybody's safety," Shriver says in his deposition.
Frightened but hopeful, the Cullens took Cameron to The Willows.
He was supposed to stay for three months, then return home.
Private facilities abound
The state runs one. The other, generally called the private system, is a massive collection of facilities controlled by different owners - corporations, nonprofit groups, individuals. A handful are operated by local governments or public hospital authorities like Carolinas HealthCare System, but they're guided by the same rules that apply to private-sector facilities.
First, the private system.
Taxpayers contribute at least $500million to North Carolina's private mental health industry annually, largely in Medicaid money, but the state has little say over the industry's operations and little knowledge about patient care.
The system consists of 12 psychiatric hospitals, including The Willows, and 3,300 smaller facilities such as group homes and outpatient centers.
To do business in North Carolina, each facility must get a license from the Division of Facility Services, a regulatory agency within the N.C. Department of Health and Human Services. Licenses are good for two years, and the agency is responsible for monitoring everything from staffing levels to sanitation.
But the task has overwhelmed Facility Services.
The number of group homes and smaller mental health facilities in North Carolina has tripled in the past decade, fueled by a push to get patients out of state institutions and back into their communities.
Until this year, a staff of four licensed the 3,300 facilities. Instead of making site visits at new facilities, officials at times accepted photographs. Regulators rarely visited facilities before renewing their licenses. Some abuse and neglect investigations were delayed up to three months.
"All we could do was the paperwork," says Jim Upchurch, who oversees licensing for the facilities. "There was no routine monitoring."
Mental health advocates say the lapse jeopardizes patients.
Sporadic state and federal investigations of group homes detail a frightening list of infractions across the state.
In one Monroe home, a patient was found lying on the living room floor soiled with feces and urine, and playing with feces, as caregivers walked in and out of the room. In another Monroe home, a staff member hit a severely retarded man with a belt after the man urinated on the floor. According to investigators, the staffer told a colleague: "I got him good with that belt."
In Charlotte, staffers failed to give children prescription medications. And in Fayetteville, residents in a halfway house for substance abusers were kept from participating in religious services.
Advocates worry many other troubling cases regularly slip past regulators.
This year, the group home licensing staff will grow to 16 - but that's still significantly smaller than staffs in many nearby states. South Carolina has 32 staffers licensing 1,500 facilities, including those for the mentally ill.
"It is right now a system that is absolutely full of holes," says John Tote, executive director of the N.C. Mental Health Association. "There are too many beds, too many operators, too many people being served to have the necessary oversight."
The staff that regulates North Carolina's 12 private hospitals is similarly stretched.
State licensing officials say they don't need to provide strict oversight because two other regulatory groups, both of them national, have some authority over private hospitals and facilities that receive Medicaid money.
But the regulators' effectiveness is often questioned.
The Joint Commission on Accreditation of Healthcare Organizations, a private body funded by hospitals, accredits about 80percent of the country's 6,200 general and specialized hospitals. Accreditation, though, is voluntary, and the commission does not require facilities to report deaths.
A two-year study released last year by the U.S. Department of Health and Human Services sharply criticized the commission for failing to detect substandard care in hospitals.
Of the 34 questionable deaths identified by The Observer, 28 occurred in facilities that had earned commission accreditation. The commission has records on just two. In one case, the commission asked the facility to explain how the death occurred. In the other, the commission asked the facility to improve such things as staff training.
The federal Health Care Financing Administration also conducts on-site hospital reviews. It visits facilities at random and looks into serious complaints, but doesn't provide routine oversight. The agency recently began requiring some psychiatric hospitals to report deaths involving restraint or seclusion.
Even Dr. David Bruton, secretary of the N.C. Department of Health and Human Services, agrees that no regulator keeps close enough watch on private facilities to ensure that patients are safe.
"We don't know anything about what's really happening (in the private system)," says Bruton, whose department oversees Facility Services and the Division of Mental Health. "It's a lack of resources, a lack of people."
Many other states have the same problem. Just six states have a system for reporting deaths at private mental health facilities. New York is the most aggressive. Its quality-assurance office reviews every case, particularly suicides, and is creating a database to track trends.
In almost all cases, N.C. law doesn't require private caregivers to report questionable deaths to the licensing or mental health divisions. Several state agencies are in a position to know about some deaths, but few procedures ensure that they share the information.
Medical examiners, for example, learn of questionable deaths. But they don't regularly tell mental health or licensing officials, even though such information routinely goes to other agencies, such as the Occupational Safety and Health Administration.
The Division of Mental Health oversees 39 community-based mental health offices across the state, and those offices hire private caregivers for patients who seek state help. Caseworkers learn about deaths, but don't regularly report problems to licensing or mental health officials in Raleigh.
The lack of oversight outrages families.
"I cannot believe these places are not more accountable," says Cheryl Pettyjohn, whose daughter committed suicide one day after being released from the private, for-profit Holly Hill/Charter Behavioral Health System hospital in Raleigh. "How else are we going to get things changed unless there is someone looking over their shoulder?"
Pettyjohn's daughter, Wendy Klenotiz, played basketball and made the honor roll at UNCPembroke, studying to become a special education teacher. In fall 1996, she became depressed for the first time. Klenotiz, a diabetic, tried to kill herself by purposely taking too much insulin.
She went to Holly Hill for treatment, and spent two days there. The day after she came home, Klenotiz hanged herself in her mother's attic. Pettyjohn sued, saying a doctor released Klenotiz prematurely. The case was settled out of court.
Dr. Gary Henschen, chief medical officer for Charter Behavioral Health Systems, won't talk about Klenotiz's case, but he says predicting suicide is difficult.
"Patients who are really seriously suicidal could suddenly have a flight into health, or appear that they're doing well and they're really not," Henschen says.
Regulators never had a chance to determine if Holly Hill was at fault because, just as in Cameron Cullen's case, they didn't know Klenotiz had died.
`I'm drowning'
Two weeks into his stay, Cameron was put on suicide watch after he scratched his wrists on a bathroom pipe. Program director Shriver and psychotherapist Naomi Drucker-Herndon concluded it wasn't a serious suicide attempt, according to their depositions.
"They went ahead and dismissed it as an attention-getting type of device," Doug Cullen says.
Cameron talked about four previous suicide attempts, but staffers didn't believe him. He also said he was seeing flying goldfish, and that Satan was in his room and fire was jumping out of his bed.
The Cullens had no evidence that Cameron had tried to kill himself before entering the hospital.
In their depositions, the staffers say Cameron talked about drugs and suicide largely to alarm his mother. Nancy Cullen, they say, overreacted, giving him the attention he wanted.
Soon after he scratched his wrists, Cameron panicked the ward by telling patients that gang members were planning to break into the hospital to steal drugs. He was sent to an empty room with his mattress, a bedsheet, some coloring books and his stuffed animal, a Wyle E. Coyote he named Odie.
The room had been used before as a time-out room, where patients are locked away for brief periods. When Cameron was there, staffers say the door was unlocked and he could leave to use the bathroom.
The isolation room was tucked into an alcove and staffers could not see inside from the hall. Shriver's deposition says he recommended putting a mirror in the alcove sometime before Cameron died so staffers could see into the room. But there was no mirror during Cameron's confinement.
During his stay in the room, Cameron wrote a poem he called "The Window and Beyond."
"I'm stuck. I'm smothering. I'm drowning. The happiness of life outside my window is eating away at my thoughts," he wrote. " I'm in here against the white brick wall with a polyester green blanket draped over my soul, corroding my hope."
State system swamped
The $1.2billion-a-year state system, operated by the Division of Mental Health, consists of four psychiatric hospitals, 39 community-based mental health offices and centers for substance abusers and the developmentally disabled.
State hospital administrators for years have complained about a lack of resources.
At Broughton Hospital in Morganton, where Charlotte-area patients are sent, severe crowding and staff turnover create a chronic "crisis mode," says hospital director Seth Hunt. In the admissions division one recent day, 206 patients squeezed into a space built for 140.
"We are so maxed out," Hunt says. "We hope that we're even doing the bare minimum, meaning we are trying to provide for people's safety."
Sometimes they fail.
At Broughton three years ago, 57-year-old Alzheimer's patient Bobby Creson was brutally beaten and strangled by another patient.
At Dorothea Dix Hospital in Raleigh, 37-year-old Debra Mitchell hanged herself with her purse strap in 1994, one day after she was admitted for trying to overdose on medication.
On the same campus two years later, Kitty Sue Gerlosky, 35, climbed unnoticed to the top of a piece of construction equipment on the hospital campus and fell 47feet to her death.
Bruton, secretary of health and human services, defends the state's hospitals. He acknowledges some deaths could be prevented, but says many are caused by complicated medical conditions, not negligence.
Some patients die from malnourishment because they choose not to eat and refuse feeding tubes. Some choke because their conditions make swallowing and chewing difficult.
Dr. Patrick Lantz, a forensic pathologist at Wake Forest University School of Medicine, agreed the mentally ill and developmentally disabled are fragile. But Lantz and other medical experts say mental health providers can prevent many accidents and deaths with adequate staffing and training.
Food can be chopped into small pieces to prevent choking. Bedsheets, ropes and string can be taken away from potentially suicidal patients. Patients prone to falls can be strapped into wheelchairs. Eating and drinking can be closely monitored.
"Whatever the institution is, they're trying to keep down the costs, and the biggest cost in any organization is people," Lantz says. "If you've hired someone who is low-end of the pay scale, and they don't know much about dehydration, they think that just putting the glass and pitcher on the bed stand or in the room is enough."
Unlike North Carolina's private mental health industry, the public system has created checks and balances to monitor safety. But those safeguards often fail.
When questionable deaths occur, the Governor's Advocacy Council is supposed to step in and guide families through an investigation.
But its oversight has been inconsistent.
Four patient advocates field hundreds of abuse and neglect complaints about the mentally ill each year, not only at state hospitals, but at nursing homes, rest homes and other medical facilities. Advocates are supposed to investigate suspicious deaths, including all suicides. But they have overlooked a number of cases over the years that officials now acknowledge they should have questioned.
The council said it didn't investigate the death of John Paul Hunt, who hanged himself in a shower stall at the state's John Umstead Hospital, north of Durham. Or Robin Durell Watson, who choked on feces at Dorothea Dix. Or Grace Maxine Bryan, who hit her head and died of a cerebral hemorrhage at Cherry Hospital, northeast of Fayetteville. Or Robert Sandlin, whose leaky feeding tube led to malnutrition at Broughton Hospital.
Even when the council does launch an investigation, critics worry the inquiries are compromised because the group is part of state government. In most other states, the groups are private, independent agencies.
The executive director of North Carolina's council reports to the Department of Administration, and legislative leaders appoint members to the group's governing board. In reviews by advocacy experts from other states, the council has been criticized for not filing lawsuits on behalf of abused or neglected mental patients.
"How do you sue your boss?" says Beth Melcher, head of the National Alliance for the Mentally Ill in North Carolina. "Their list of litigation is pitiful."
But Butch Elkins, the council's managing attorney, says being part of state government gives the agency more clout, not less.
"A lot of our counterparts spend a fair amount of money having to sue the state simply to get into a psychiatric facility," he says. "We've got people who have keys to the facilities."
Elkins added if the council failed to investigate deaths, it was because advocates didn't know about them or didn't get enough information, even though state hospitals give the advocates daily incident reports. The reports include all deaths and other injuries.
Similar information goes to the Division of Mental Health and to hospital human rights' committees. Baggett, the former mental health director, says the division sometimes reviews questionable cases, but officials wouldn't say which cases they have questioned or what conclusions they reached.They would not release information without permission from patients' families.
Riddle, the division's new director, calls oversight of the state hospitals "negligible."
He says the Governor's Advocacy Council needs more money and should be separate from state government. The division is considering hiring a private agency to provide advocacy services in the hospitals.
"We've got some good managers of the mental hospitals, but they absolutely have to have (advocates) who are independent," Riddle says.
Cameron says goodbye
During a family counseling session that night, Cameron asked when he could get out of isolation. The Cullens' depositions say psychotherapist Drucker-Herndon told him as long as six months. In her testimony, Drucker-Herndon says she doesn't recall making that statement.
Near the end of the session, Cameron started crying, and so did his parents.
The Cullens said goodbye to Cameron in the isolation room, and were so worried about the look on his face, they say they urged Drucker-Herndon to put him under suicide watch.
"I think in (Cameron's) mind, he already knew," Doug Cullen says.
He says he asked Drucker-Herndon why Cameron still had his shoelaces. Nancy Cullen told her Cameron would try to kill himself before morning, depositions say.
The timing of what happened next is in dispute.
The Cullens walked to the parking lot and paced in front of their cars, debating whether to take Cameron home.
Drucker-Herndon's deposition says she ordered suicide watch about 10 minutes after the Cullens left, but says she's not sure if she specified a level of supervision. Suicide watches generally range from 30-minute checks to constant supervision.
Drucker-Herndon says a few minutes later, about 8p.m., Cameron was found hanging in his room. The hospital called 911 at 8:02.
The Cullens question whether suicide watch was ordered. They say they were talking in the parking lot for at least 45 minutes. If Drucker-Herndon's account is true, they say, Cameron would have been under suicide watch for at least 35 minutes, starting about 7:25.
No one knows precisely when he hanged himself. But the Cullens reason that if he didn't do it before 7:25, he might not have been able to hang himself once suicide watch started.
Psychological assistant Nancy Vaughan says in her deposition that Drucker-Herndon told her to move Cameron to another room. Drucker-Herndon said she was thinking about putting him on suicide watch, but didn't sound urgent, Vaughan testified.
Vaughan went to see Cameron in the isolation room. She saw the sheet and the back of his head through a window in the door.
Doctors at Carolinas Medical Center pronounced him brain dead three days later, and the Cullens took him off life support. The bill for the four-week stay at The Willows was $14,800. Nancy Cullen's insurance paid for the treatment.
Guilt still overwhelms the Cullens almost four years later.
"I couldn't even help my own baby," Nancy Cullen says. "I didn't keep him safe."
After Cameron died, the Cullens discovered he had sold his Converse sneakers and sweatshirt to other patients and left his money, three small piles of change, to his parents and younger brother.
In a sworn affidavit, one hospital staffer says Drucker-Herndon knew Cameron had sold his things but thought he was just seeking attention. Drucker-Herndon's deposition doesn't address the issue.
Several mental health professionals say that simply keeping Cameron in an isolation room for so long is worrisome. The state hospitals don't let patients spend longer than one hour in isolation after they've gained control of their behavior. And when patients are isolated, supervision is constant. Similar rules apply at many private hospitals, including those run by Charter.
The Cullens have hired Fayetteville medical malpractice attorney Wade Byrd, and filed suit in November in Mecklenburg Superior Court.
"You think most doctors are omnipotent," Doug Cullen says. "You go ahead and you heed their advice, and you think they know best."
Nancy Cullen says: "I will never go on blind faith again."
The Willows did not report Cameron's death to state regulators because no law requires it, says Scott White, spokesman for Carolinas HealthCare System. White added the incident was reported to police and reviewed by hospital officials.
"If we were required to report deaths we would have done so," he says. "If you're not required to report it, you don't report it."
After Cameron, Christy Miller
She was 43, and had just attempted suicide by overdosing on medication. Miller stayed at Amethyst, the adult side of the psychiatric center.
Miller had two children, ages 13 and 14. She graduated from Charlotte's Garinger High School and had a master's degree from Appalachian State University.
While on suicide watch at the hospital, she hanged herself with a shoestring from the hinge of a bathroom door.
State regulators have no record of Miller's death, either.
Adults nationally who
experience severe mental
illness each year.
5.5 Million