Why Did 14 Yr Old Crider Die?

January 10, 2007

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A HIDDEN SHAME: DEATH IN GEORGIA'S MENTAL HOSPITALS

Crider was among 115 patients in the state's care who might have

lived.

By ALAN JUDD and ANDY MILLER

The Atlanta Journal-Constitution

Published on Jan. 7, 2007

First in an occasional series

Alone in the darkness of a state mental hospital, Crider, 14, lay

slowly dying.

She 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,

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 '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, 's grandmother. Dobson adored for all her complexities:

artistic but troubled, challenging but comic. Now she could think only of

two nights earlier, when she had last visited and heard another

patient's haunting scream.

I hope nobody killed her, Dobson blurted out.

In fact, what happened to 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.

State 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

appropriately treated. "

In an additional 24 cases, the agency says, " we agree the hospital system

should make improvements. "

Officials 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. , 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. "

The 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.

The newspaper could find no information on 16 of the 115 deaths, except that

state officials classified them as " unexplained/suspicious. "

Experts 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 found.

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 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.

" She was a healthy 14-year-old -- healthy, " says Dobson, '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

She loved cartoons. Given the choice, she would have eaten ice cream with

every meal. She gardened with her grandmother, but teased about the results.

Meemaw, Crider would tell Dobson in the yard, why don't you just admit

it -- everything you touch dies anyway.

Sometimes, though, 's disposition darkened.

One 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

'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.

entered a unit for children and teenagers, segregated from adults with

mental illness and retardation.

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.

In 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. , 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, went back inside to

retrieve her coat. The bus was on I-75, well on its way downtown, before

anyone noticed 's absence.

Missing the trip devastated . 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, Dobson. '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, received a new diagnosis: schizophrenia.

The 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.

improved 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 , paid for not

quite a month of inpatient psychiatric care. So became one of many

mentally ill Georgians who, facing similar insurance restrictions, or

lacking coverage altogether, have only one real option: a state hospital.

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, 's family realized they needed help again.

On Oct. 24, 2005, returned to Georgia Regional.

She 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 hospital grounds.

Over the next three months, 's condition, as well as her behavior,

deteriorated.

She " 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 effects.

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 's mental illness.

At Christmas, two months later, left for 13 days to visit her family.

Her homecoming was far from joyful.

She 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

away.

" She was sedated, " Joyce Dobson says, " like a zombie. "

's demeanor so upset Dobson that she began looking into an alternative

treatment program in Florida. She hoped to send there in the spring.

When returned to Georgia Regional after Christmas, the hospital staff

was supposed to take blood to test for anemia and infection. refused,

and no one at the hospital ever asked Dobson for permission to take blood by

force. So the tests were not done.

Most Sundays, Dobson and 's other grandmother, Bobbie Crider, visited

her together. The second weekend in February, they went on Saturday night

instead.

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 seemed ill.

" She didn't talk much, " Bobbie Crider recalls. " I thought she couldn't

understand us well. "

Dobson noticed that 's ears were bright red; usually that meant she had

a fever. Dobson also wondered about a red streak across '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 's unit. A hospital employee explained that a patient

was being restrained.

I just hate to send her back into that kind of environment, Dobson told

Bobbie Crider.

embraced Dobson one last time before returning to her room. It was a

ritual between grandmother and granddaughter.

had always called it a " squeezy hug. "

Staff under pressure

The next night, Feb. 12, 2006, 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.

The 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.

The 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.

At 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, 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

One physician was on duty for the entire hospital that night: Dr. ri

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 vomited about

8:30 p.m., the nurse then on the adolescent unit paged the doctor. Gibb

arrived about 9:20, and wrote in '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 was able to describe the extent

of her pain. Regardless, Gibb noted, appeared to be in no distress.

But '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.

Gibb ordered a suppository for 's nausea and a Tylenol for her

headache. Then she went back to work elsewhere in the hospital.

No one summoned Gibb when 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 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 's condition.

3:15 a.m.: was " in bed and awake. "

4:15 a.m.: 's breathing was " even and unlabored. "

5:30 a.m.: " No complications noted. "

In fact, the employees had no idea how she was doing.

As 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 room. "

When he looked in on , 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. "

At 6:15, a nurse entered Room 1123 and found , unconscious, without a

pulse, still lying in vomit. The staff declared a " code, " a hospital term

for medical emergency.

A nurse who raced to '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 before assumed she was black.

Another nurse placed a defibrillator to 's chest, hoping to restart her

heart.

" Where [is] the medical doctor? " the nurse asked, according to notes later

inserted in 's medical chart.

Gibb, still the only physician on duty, arrived at '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 .

In the medical chart, though, Gibb would note that was " cold, blue and

without a pulse " when she arrived. " Rigor mortis had already set in. "

Gibb added, " The patient was unable to be revived, and expired. "

An avoidable death

Joyce Dobson at first assumed another patient had assaulted her

granddaughter. But she says Georgia Regional employees assured her that

died peacefully, in her sleep.

's autopsy provided a far more horrific account.

The medical examiner found 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 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 '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.

In 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 " 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.

Gwen Skinner, who heads the mental health division of the Department of

Human Resources, describes the investigations as " strong, thorough. " ,

the human resources commissioner, says the department " takes whatever action

is required. "

In 's case, investigators from the department's regulatory section

struck a critical tone.

They 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 's consumption of food and liquids or

her bowel movements.

Furthermore, investigators said, '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. "

's condition 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 's death was avoidable.

" Our 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. "

The state fired Dr. Ramesh Amin, '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,

s, says Amin should not be " singled out " for blame. " It was a

tragedy that had nothing to do with his abilities as a doctor. "

For other hospital employees, the consequences of 's death appear to

have been minimal.

ri Gibb, the doctor on duty the night 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

's 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, " , you're my best friend, and I'm

going to miss you. "

About a month later, Joyce Dobson called Georgia Regional to ask for 's

clothes.

" They said, well, if they could find them, " she recalls. She eventually

received 's gown and robe, both stained by what appeared to be vomit or

blood.

Dobson was furious. 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

's death.

" I was angry because I felt like it could have been prevented, " Dobson says.

" It just seemed like such carelessness. "

AN INVESTIGATIVE SERIES

• About this project

• Part 1:

A young Crider is among the victims

• Part 2:

Suicide exposes neglect in state hospitals

• Questionable deaths:

A look at cases around the state

• Workers:

Volatile environment also threatens staff

• Solutions:

Experts offer ideas

Feds can step in

• Interactives:

Map: Locate Georgia's mental hospitals

• Video: Reporter discusses findings

• By the numbers:

Quick facts about hospitals

• How to report problems

• Reach reporters Alan Judd and Andy at 404-526-2640

• Additional AJC

investigative reports

Cassandra Dawn Casey

If you’re not outraged, you’re not paying attention.

http://www.scientific-misconduct.blogspot.com

Utah Director, ICFDA

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it's a matter of political will to put the public health first, commercial

considerations second.

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January 10, 2007