An ongoing pattern of medical errors and neglectful care contributed to as many as 21 deaths this year in Georgia's state psychiatric hospitals.

These deaths occurred amid intense scrutiny of the hospitals' performance, an investigation by The Atlanta Journal-Constitution shows. The seven state-run facilities remain overcrowded and understaffed, and patients still are dying under circumstances similar to those that led to more than 100 other questionable deaths in the previous five years.

One patient died this year after doctors prescribed enough anti-psychotic medication to possibly kill a person. Those doctors "were not practicing the standard of care," another physician wrote.

Another man died from a misdiagnosed bowel obstruction. "I thought maybe it was something he ate," a nurse said later, explaining why the patient's symptoms went untreated. "We were not monitoring his intake or output."

In yet another case, nurses and aides disregarded a doctor's instructions to take a vulnerable patient's vital signs — more than 700 times. When he died, hospital staff members were merely guessing his body temperature.

The continuation of preventable deaths in 2007 — at a pace similar to that of recent years — underscores the scope of the troubles that have plagued the state hospitals for years.

The facilities have been under a spotlight since January, when the Journal-Constitution reported that at least 115 patients had died from neglect or abuse or under other suspicious conditions from 2002 through 2006. State authorities substantiated almost 200 reports of patient abuse during the same period.

The newspaper reported that poor care persisted in the hospitals during those years even as federal regulators cited widespread deficiencies. In 2002, for instance, regulators ordered Georgia Regional Hospital/Atlanta to correct overcrowding and patient care problems. But in a 2006 inspection, the regulators found that many of the same failings still existed.

In response to the Journal-Constitution's articles, the U.S. Justice Department is investigating whether conditions at the hospitals violate patients' civil rights. The agency could ask a federal judge to appoint a monitor to supervise the facilities. It also could force the state to spend millions of dollars expanding services, creating space for more patients or otherwise improving the hospitals. The results of the federal inquiry are expected to be released in 2008.

Meanwhile, consultants hired by the state have produced scathing reviews of hospital performance. And a commission created by Gov. Sonny Perdue is studying ways to overhaul the state's mental health care system.

Officials at the Georgia Department of Human Resources, which operates the hospitals, declined to comment late last week. Over the past several months, they have said they are trying to improve all aspects of mental health care. They speak of "rebalancing" the system to emphasize community-based treatment rather than hospital admissions. But they acknowledge that community services often don't exist or, when they do, are not plentiful enough.

Georgians with serious mental illness remain about three times more likely to end up in a state hospital than residents of other states. Georgia's state hospitals readmit a significantly higher percentage of patients than the national average. And at any time, nearly 100 hospital patients are ready for discharge, but have no place to go.

Citing privacy regulations, state officials refuse to identify deceased patients or to explain why they died. The Journal-Constitution relied on hospital reports, autopsies, death certificates, a database of vital statistics and interviews with patients' families and the families' lawyers to compile a picture of conditions inside the facilities.

The newspaper's review indicated that the state hospitals are arguably as dangerous as they were a year ago. In all, 55 hospital patients died of all causes this year through mid-November, the latest date for which reports are available. Of those, as many as 21 died after what appears to have been negligent care by physicians, nurses, aides or technicians, the Journal-Constitution's examination found. They died from causes that have become familiar in the state hospitals in recent years.

At least three choked on food, vomit or foreign objects. Two died from medication errors. Two developed fatal intestinal blockages, the same condition that killed 14-year-old Sarah Elizabeth Crider at the Atlanta hospital in 2006. Her death, highlighted in the Journal-Constitution in January, prompted hospital officials to create new policies requiring staff members to monitor patients' bowel movements.

But, as the deaths from intestinal blockages show, hospital workers still often failed to recognize symptoms of life-threatening illnesses or to provide adequate emergency treatment for injuries.

A missed clue

When Keith Ross developed a high fever last April, caregivers at Southwestern State Hospital in Thomasville thought he had the flu. "His condition was not life-threatening," a nurse manager said later.

But Ross, 19, a patient in Southwestern's forensic unit, which houses criminal defendants for mental illness, died shortly after hospital workers sent him to a local emergency room. The cause of death: appendicitis and a heart inflammation.

The medical director for the state's mental health division at the time determined later that the hospital staff should have sought emergency treatment much sooner. Ross' persistent fever, she wrote, should have been "a big clue."

Ross' grandmother, Beatrice Wilson of Albany, said doctors at Southwestern State gave him antibiotics for several days before seeking emergency treatment. She still wonders why they waited, and what made her grandson so sick.

"Those questions have not been answered for me," Wilson said.

Questions also remain about the death of a 71-year-old patient last May at Central State Hospital in Milledgeville.

The woman fell to the floor as a nursing assistant put her to bed. But the patient received no medical treatment for her injuries for five days – until just a few hours before she died. The aide apparently never told the patient's physician about the fall.

The woman's "right to appropriate medical treatment was violated," a state investigation concluded. The hospital fired the nursing aide.

Breakdown

The death of a 55-year-old patient at Central State in July shows how a breakdown in communication between physicians and other staff members could result in a breakdown of care.

The patient had been blind and mute since birth. He needed a safety belt and a lapboard to keep him from falling out of his wheelchair. He came to the state hospital, a report said, when his family in DeKalb County could no longer handle his "uncontrollable and destructive behavior."

The man was prone to dangerously low body temperatures. In April, his physician at Central State instructed nurses to take the patient's temperature rectally every two hours for 90 days, and to notify him if it fell below 96 degrees.

The nurses and aides rarely followed the doctor's orders. During the last three months of the patient's life, records show, they failed to record his vital signs as instructed 739 times.

Late on July 3, according to state records, the patient had been vomiting continually for more than 24 hours. His condition worsened overnight. He vomited at least three more times, twice throwing up what nurses and aides described as "coffee-ground" material – most likely, blood from his gastrointestinal system.

The hospital staff called the doctor at 2 a.m., but he did not come to examine the patient. The staff, he said later, assured him the man's vital signs were "stable." However, a nursing aide later said she merely thought the man's temperature was 97.6 degrees — or "somewhere around there," as she put it.

The doctor ordered a suppository for the patient and told the staff to disconnect his feeding tube until morning.

Records indicate the staff next checked on the patient at 4 a.m. He had vomited again. At 5, an aide returned and found the man "just lying there," she told investigators. A nurse issued an emergency code and attached a defibrillator device to the man's chest. Nine efforts to force his heart to beat failed. At some point, a nursing aide dialed 911 to summon paramedics to the hospital.

The doctor arrived at 5:26 a.m. and pronounced the man dead 12 minutes later. Officials performed an autopsy, but the report won't be finished until January.

The state's investigation found the man's vital signs had last been checked 13 hours before he died. A report on the inquiry concluded that one nurse and one aide had been neglectful in the patient's care.

The report's recommendation for avoiding future lapses: training for the hospital staff in how to follow physicians' orders.

A barrier to care

The deaths in Georgia's state hospitals, psychiatric experts say, show the need to focus not just on patients' mental conditions but also their physical ailments.

High-quality medical care in psychiatric facilities is "extraordinarily important," said Dr. Charles Nemeroff, chairman of the psychiatry department at Emory University School of Medicine.

As a member of the commission examining Georgia's mental health care system, Nemeroff heads a subcommittee that will study quality of care issues for the hospitals, including the credentials of state-employed physicians. The state hospitals, he said, should hire physicians who have been certified by the boards overseeing specialties such as internal medicine, not just psychiatry.

Of the 190 doctors employed by the state hospitals in the fiscal year that ended June 30, just 88 had any board certification, according to the Journal-Constitution's analysis of medical licenses. Thirty-six of the 88 were certified in areas other than psychiatric medicine.

Nemeroff said people with serious mental illnesses are prone to medical disorders, such as heart disease, stroke and diabetes. They often receive poor, or no, medical care in the community. And, he said, they have "a fundamentally shorter life span" than other adults.

"This conspiracy of reasons comes together to, unfortunately, present a barrier for psychiatric patients — particularly state hospital patients — to get good medical care," said Nemeroff.

"It's a reason," he said, "to consider them an at-risk population that ought to get more attention, not less attention."