Hospital workers weren't supposed to let Ezzard White out of their sight.

But they didn't notice when he closed the door to his room at the state mental hospital in Atlanta. Alerted later by a loud noise, a staff member found White, 45, choking another patient. The second man went to the emergency room with serious injuries.

A month later, in March 2007, workers lost track of White again. This time, they found him on his bed, surrounded by bloody vomit. He had ingested a foreign object, the medical examiner said after White's death five weeks later.

His case underscores a central theme in an investigation of Georgia Regional Hospital/Atlanta by the U.S. Justice Department: Again and again, hospital officials have failed to investigate or correct dangerous errors in patient care.

The hospital has promised regulators twice in the past six years that it would make improvements. But patients continue to suffer horrible fates — even with the facility under intense scrutiny from federal authorities and other investigators.

As many as 21 patients died under suspicious circumstances in the seven state-run psychiatric hospitals during 2007, according to an investigation last year by The Atlanta Journal-Constitution. Preventable deaths and injuries continued after federal authorities announced their investigation in April, began gathering records from the hospitals during the summer and started visiting facilities in September.

White was one of several patients whose cases were highlighted in a letter May 30 from the Justice Department to Gov. Sonny Perdue, demanding an overhaul of Georgia Regional and, by implication, the six other state-run mental hospitals. The letter referred to White only by initials; the Journal-Constitution identified him through public records.

The Justice Department's investigation documented widespread abuse and neglect, unchecked self-injurious behavior by patients, frequent assaults inside the hospital, and medical care that fell far short of minimum standards.

The findings echoed those presented in a series of articles in the Journal-Constitution last year. At least 136 state hospital patients died under suspicious circumstances from 2002 through late 2007, from such preventable causes as suicide, choking and bowel obstructions that went undetected, the newspaper reported. During the same period, the newspaper found, officials substantiated nearly 200 cases of physical or sexual abuse of patients by hospital employees.

By late July, Georgia must tell the Justice Department how it plans to correct deficiencies or face a lawsuit that could force expensive reforms and strip away control of the mental health care system.

State officials say they had already begun improving Georgia Regional and the other hospitals before the federal investigation began. They say they've hired nurses, appointed new administrators and assembled a better medical staff.

But with detailed descriptions of life inside the hospital, the 65-page Justice Department report makes clear that, whatever the state was doing in 2007, it wasn't enough to keep patients safe.

Ralph Ibson, vice president of government affairs for Mental Health America, an advocacy group based in Alexandria, Va., said the Justice Department and others have uncovered "incident upon incident upon incident."

"It is difficult to understand why it has been tolerated for so long," Ibson said, "given the investigations that have occurred."

'I told you'

"A.A." entered Georgia Regional in the spring of 2007. Two days later, two patients assaulted him, injuring his right eye. They attacked him again less than a week later, this time injuring his left eye.

Then, on May 8, hospital workers left the man alone in his room with a razor. When they returned, he had slashed his neck and arms and blood was spattered on the walls.

He shouted at the workers, "I told you I was suicidal."

Investigators found "a troubling number of patients" who attempted suicide despite being admitted for trying to kill themselves.

In August 2007, a few weeks before the investigators' visit, "G.G." was admitted after running into traffic with broken glass in her hand, threatening suicide.

A week later, Georgia Regional discharged the 21-year-old woman to a homeless shelter. She returned to the hospital three days later, again threatening to kill herself. Within 32 hours, the federal report says, she "had the means and opportunity to make a serious suicide attempt."

A hospital employee found the woman face down in a pool of blood, a cord wrapped tightly around her neck. She was sent to an emergency room and survived.

Federal investigators later determined that the cord was made from shoelaces or a robe belt that the hospital gave her. They also learned that staff members were supposed to have observed the woman at least once every 15 minutes; instead, they hadn't checked on her for more than half an hour.

Unidentified risks

A failure to identify risks — actual or potential — plagues Georgia Regional, investigators found.

Their report cited two patterns of deaths that should have raised alarms but did not: three patients who died with colon or bowel obstructions, and three more who died after choking or aspirating food. The hospital didn't properly monitor the first group's bowel movements, the report said. For the second group, it didn't have an effective plan in place to assist patients who have trouble swallowing.

When deaths or injuries from assaults, suicide attempts or accidents occur, investigators said, the hospital doesn't always look for the cause.

"I.I." had been found incompetent to stand trial for child molestation. At Georgia Regional, he was placed on "sexual protocol" – meaning staff members were supposed to observe him at all times, and he was supposed to be assigned to a bedroom by himself.

On June 24, 2007, though, the staff put "I.I." in a room with four other patients. That night, he sexually assaulted one of them.

"I.I." was still on a constant-observation status a month later when, somehow, he stuck a bottle of deodorant into his rectum.

When he returned from the emergency room, the federal report said, "the only intervention by [Georgia Regional] staff appears to have been an instruction not to insert objects in his rectum again."

Such lackluster responses are common, the report said.

"F.F." attacked patients or staff members seven times in five weeks – but the hospital didn't develop a plan to control his behavior.

"M.M." reported on Jan. 2, 2007, that her roommate had sexually assaulted her. But federal officials found no sign that the hospital investigated her allegation.

And "L.L.," a suicidal patient admitted in August 2007, was physically and sexually assaulted twice in 20 days – by the same person, apparently another patient. But "neither assault was investigated or addressed," the federal report said. The second assault, the report said, "was arguably preventable."

'Merely observing'

Even the presence of federal investigators did not quash what a Georgia Regional doctor called "continuing clinical chaos."

When they toured the hospital's adolescent unit last September, investigators watched as a patient ripped a water cooler out of the wall. Staff members had to restrain the boy before they locked him in a seclusion room.

During the same tour, a patient suffered a seizure in the cafeteria. The investigators watched as a few staff members fetched multiple emergency carts – none of which contained a complete set of equipment or medications.

As those employees tried to help the patient, others gathered in the cafeteria.

"Most of the assembled staff appeared not to be assisting," the federal report said, "but merely observing."

To patient advocates, that episode serves as a metaphor for the state's response to crises in its psychiatric hospitals. Often, officials do little more than appoint panels to conduct studies.

"This information has been brought to the state repeatedly," said Ruby Moore, executive director of the Georgia Advocacy Office, which investigates complaints about institutional care. "Their response this time has to be more than form a committee."