A soccer player waded into thick brush and woods at the edge of Atlanta's Piedmont Park to relieve himself. Glancing up an embankment, he spotted something hanging from a tree.

It was a body.

The young man appeared to have been dead for some time. He wore a blue T-shirt, khaki pants and canvas deck shoes. His lips clenched a burned cigarette.

Authorities on that Friday afternoon in September 2003 found no identification in his pockets. They listed him as a John Doe.

Several blocks away, at 10th and Peachtree streets in the heart of Midtown Atlanta's high-rise office towers, lawyer Stanley S. Jones Jr. was coordinating a search for his son.

Thomas Madden-Jones, 19, had run away from Georgia Regional Hospital/Atlanta the previous Sunday, Sept. 21, 2003.

The state psychiatric hospital in DeKalb County was the latest stop in Madden-Jones' odyssey of treatment and relapse, confinement and escape as he fought dual demons of substance abuse and mental illness.

Family photo (ENLARGE)

Patient Thomas Madden-Jones (top) was a youth hockey goalie.

Keith Hadley/Staff (ENLARGE)

Holding a photo of his son at age 8, Atlanta lawyer Stanley S. Jones Jr. reflects on the young man's suicide after an escape from Georgia Regional Hospital/Atlanta. 'Tom's story is tragic,' Jones says, 'but I hope telling it can help the mental health system get more focus and resources.'

ABOUT THIS PROJECT Federal probe: • Justice Department finds 'critically deficient' conditions | Report PDF • Patients' safety slighted • Remedy will be costly • Feds hit Columbus hospital Call for reforms: • Mental hospitals under review • Consumer advocates seek tighter controls Part 1: A young Sarah Crider is among the victims Part 2: Suicide exposes neglect Part 3: A fatal struggle -- but no punishment Part 4: Lax security, easy escape, tragic ending Part 5: Rapid decline at hospital shatters family Part 6: Patients shunted to inns, shelters, streets • Two who lived — and two who died Part 7: Children housed with alleged offenders Part 8: A lonely end to a life of madness Part 9: Unlicensed homes can pose deadly dilemma Justice delayed?: Worker charged in 2004 sex case still not tried Questionable deaths: • A look at cases around the state Verification: Over 190 abuse cases verified 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

Stan Jones knew that cycle well. Since long before his son was born, Jones had been a volunteer advocate for people with mental illness.

As long ago as the early 1970s, he had worked on a panel studying mental health care in Georgia, appointed by then-Gov. Jimmy Carter.

Officials at Georgia Regional told him they had reported Tom's escape to the police, Jones remembers. But he initiated his own search anyway. He hired a private detective and, with help from a Midtown security group based in his office building, posted missing-person fliers.

The detective didn't find Tom. But he spoke to people who had just seen him near one of his favorite places, Piedmont Park.

Understaffing a factor

At Georgia Regional and the state's six other psychiatric hospitals, escapes such as Tom's occur with matter-of-fact regularity — at least 250 times since 2002, records show. The Atlanta hospital alone accounted for 63 of them.

These escapes reflect the systemic neglect of patients that results from insufficient hospital staffing, an investigation by The Atlanta Journal-Constitution found. Patient-to-staff ratios that often run higher than most experts recommend have contributed not just to the escapes, the newspaper discovered, but also to many of at least 115 suspicious deaths of state hospital patients since January 2002.

"If they have low staffing, [escapes] happen more frequently," says Dr. Alfred Herzog, a Hartford, Conn., psychiatrist and chairman of the American Psychiatric Association's patient safety committee.

Escapes can put both patients and the public at risk.

In April 1998, Ulises Olvera, 22, who had been admitted to Georgia Regional with paranoia and hallucinations, was allowed to go to a fenced area outdoors to smoke a cigarette. He jumped the fence and ran onto nearby I-285. Almost immediately, he was struck and killed by a car.

In February 2004, Earlie Murphy, then 44, a Central State Hospital patient serving a life sentence for a violent crime spree in DeKalb County, was sent to an Augusta medical center for a sleep apnea test. Central State arranged for Murphy to have a "sitter" accompany him at the sleep lab, but no security officers, records show. After the overnight test, police reports say, Murphy walked out of the lab, waving goodbye to an unsuspecting employee. A few hours later, police captured him after he allegedly assaulted a woman while trying to steal her car in a grocery store parking lot.

The state Department of Human Resources, which operates the state hospitals, says such escapes occur less frequently in Georgia than in many other states.

But the routine nature of escapes from Georgia's hospitals, as well as the circumstances surrounding many of the cases, raises questions about how well the state hospitals secure patients deemed to be a threat to themselves or others.

At Georgia Regional in Atlanta, adult mental health patients spend most of their time behind locked doors, but many are allowed outside on the 174-acre hospital campus to walk to the cafeteria or for recreation. Nearby 6-foot-high chain-link fences around the campus perimeter look fairly easy to scale.

At Central State Hospital in Milledgeville — where three patients escaped during a single week last summer — no fence encloses the vast campus.

Escapes at the Atlanta hospital in fiscal year 2005 increased 27 percent over the previous year, according to a report by the hospital. In July 2004, the first month of that fiscal year, nine patients escaped. Four of those patients left at one time from the forensic unit, which evaluates and treats people charged with crimes. They walked out through a gate that a staff member had left open while retrieving a ball.

The same month, and continuing into the following month, one patient managed to escape four times. "He was found unharmed on each occasion," the report said.

The hospital reported that 70 percent of patients either returned on their own or were retrieved by hospital staff or law enforcement. The report does not say what happened to the rest. In the previous year's report, Georgia Regional said most escapes could be "attributed to staff's failure to follow procedures and protocols."

Each Georgia hospital has its own policy on handling escapes. The Atlanta hospital's policy for patients considered a risk to themselves or others calls for the campus police to "coordinate the search efforts with the appropriate law enforcement."

Searches are much less urgent for patients who are in the hospital voluntarily and who aren't considered a risk, hospital policies show.

If an escape involves forensic patients, the hospital is supposed to report it to local law enforcement, says Gwen Skinner, director of the state's mental health division. If escapes are not reported, it may mean outside law enforcement wasn't needed, she adds; for instance, the patient may have been located just outside the hospital gates.

Escapes should be rare, says Carole Farley-Toombs of Rochester, N.Y., immediate past board member of the American Psychiatric Nurses Association. Except in some cases when a patient is close to discharge, escapes should prompt an aggressive response, she says. "If they're at risk of harm to themselves or to others, you call the police — you want to get them back."

But Georgia Regional's reporting to local police appears to be spotty, at best. The DeKalb County Police Department, which patrols the area around the hospital, said late last year it had taken just three written reports on escapes from Georgia Regional in the previous five years.

The department's files contain no formal reports on escapes since July 2002 — including Tom Madden-Jones'.

'Don't know what to do'

Madden-Jones was a gifted writer and a hockey goalie for youth all-star teams. He also had a history of running away.

When he was a senior at the Paideia School in Atlanta, severely depressed and dabbling in illegal drugs, he ran away over Thanksgiving break. He took a bus as far as Memphis before returning home.

Soon he told his family he felt suicidal. He entered a succession of treatment programs, where he responded well to antidepressant medications. But he usually left those programs, including by escape.

It was a frightening time for the family. They watched the teenager, who wrote poetry and loved mountains, descend further into drugs.

"We knew the drug use was increasing," Stan Jones says. "It was very scary. We were desperate for help. We tried everything we could think of. You look for any resource you can find."

While at home in the summer of 2002, Tom swallowed a whole bottle of Tylenol PM.

At that point, Stan Jones says, "you don't know what to do."

Tom entered treatment again. But in December 2002, he was arrested for possession of cocaine and methamphetamine, and for trying to run away from arresting officers.

He spent a few months in Atlanta's city jail before a psychiatrist there recommended sending him to the forensic unit at Georgia Regional, where his competency to stand trial would be evaluated.

Tom spent 90 days there, his father says. During that time, another patient got into a fight with Tom in the bathroom and bit off the tip of Tom's right ring finger. A Georgia Regional employee accompanied Tom — who was in leg shackles — in a taxi to Grady Memorial Hospital in downtown Atlanta.

After doctors tried unsuccessfully to reattach the fingertip, Tom ran from his escort. Outside the hospital, he bolted into a nearby MARTA station and, still shackled, hopped over the turnstile and made his way into the track well. The MARTA police stopped the trains and captured Tom.

When his 90-day commitment was up, Tom returned to court, where he asked the judge to be sent to prison. The hospital recommended another 90 days in the forensic unit. But the judge said others were waiting in jail for Tom's spot in that unit and, according to Stan Jones, admitted Tom involuntarily to an adult mental health unit at Georgia Regional.

Security in the new unit was looser than in forensics. His father noticed that doors separating the visiting area from the outside were not being locked and unlocked in the correct sequence; they were opened both at once, instead of one at a time, which would enhance security.

One day Tom followed his grandfather out of the hospital building. "Where are we going?" he asked his startled grandfather, who walked Tom back inside the building.

His failed escape attempt in the MARTA station had left Tom hopeless.

"He felt like he couldn't get out," his father says.

About two weeks after transferring to the adult mental health unit from forensics, Stan Jones says, "he pretty carefully said goodbye to everybody."

He told his grandfather how deeply depressed he was. He told his mother he wanted to be cremated when he died.

Tom was on line-of-sight observation, meaning that he was supposed to be within view of a staff member at all times.

On Sept. 21, 2003, Tom was in a group of patients allowed to go outside for recreation. When the group came in for lunch, Stan Jones says he was told, a staff member asked, "Where is Tom?"

Repeated searches

The family started searching for Tom almost immediately — in downtown Atlanta, in Piedmont Park.

Nothing.

The next day, Stan Jones hired a private detective, who located people who had seen Tom near the park. The same day, Tom called his father's office twice. Jones was on the phone both times and missed his calls. On voice mail, Jones recalls, "he was very upset."

Over the next several days, Jones went to Piedmont Park daily looking for his son.

Again, nothing.

It was Friday, Sept. 26, when the soccer player spotted the young man hanging in a tree by a thin white wire fashioned into a noose. Authorities took the body to the Fulton County Medical Examiner's Office, where an autopsy determined the man had died by suicide. Lab tests showed he had cocaine in his bloodstream.

A week later, an Atlanta police officer who had seen both Stan Jones' missing-person flier and a report on the John Doe from Piedmont Park was the first to make the connection. Fingerprint tests confirmed the body's identity.

At a memorial service, another patient from Georgia Regional, who had been released since Tom's escape, told the family Tom had left by slipping under a fence.

Later, Stan Jones delivered flowers from the funeral to the hospital's forensic unit. As he drove up to the campus, he spotted maintenance employees working along the fence.

His son's death is easier to talk about now. The family has healed, he says, though he still deals with feelings of guilt and sadness.

He sits on the top floor of his law firm's office building and ponders a question: Does he blame the hospital for Tom's death?

"That's a hard one for me," he says.

On one hand, he says, Tom was a known escape risk who was deeply troubled. On the other, he acknowledges, his son's death shows that even a child of privilege — a child of an advocate who knows the mental health system and how to get the most out of it — can fall into a pit that has no bottom.

"I think anybody who goes to the hospital deserves the hospital services to be provided competently," Jones says. "The basic obligation of the state is to deliver quality services. The citizens have a right to insist on that — rich and poor."

BY THE HOSPITALS

Georgia's seven state psychiatric hospitals reported 250 escapes by patients from July 2002 through late 2006. Here's how the numbers break down by hospital:

63: GEORGIA REGIONAL HOSPITAL/ATLANTA

50: CENTRAL STATE HOSPITAL, MILLEDGEVILLE

34: EAST CENTRAL REGIONAL HOSPITAL, AUGUSTA

45: NORTHWEST GEORGIA REGIONAL HOSPITAL, ROME

25: GEORGIA REGIONAL HOSPITAL/SAVANNAH

15: SOUTHWESTERN STATE HOSPITAL, THOMASVILLE

18: WEST CENTRAL GEORGIA REGIONAL HOSPITAL, COLUMBUS

Source: AJC analysis of Critical Incident

Reports filed by the Georgia Department of Human Resources