An "unabated" failure to correct dangerous conditions at the state mental hospital in Atlanta has caused preventable deaths, injuries and illnesses for patients, federal investigators have found.

In a blistering 65-page letter to Gov. Sonny Perdue, the U.S. Justice Department detailed "critically deficient" conditions at Georgia Regional Hospital/Atlanta. Investigators have inspected two other state hospitals, finding comparable problems, and plan to visit another next week.

Continually failing to address hospital fatalities and violence, the letter said, caused similar deaths to multiply and left patients vulnerable to sexual assaults and other attacks.

Federal investigators, the letter said, found that medical and nursing care "substantially depart from generally accepted professional standards." They also determined that the hospital provides inadequate psychiatric treatment; uses seclusion and restraint, including sedatives, inappropriately; and fails to "adequately protect its patients from harm."

"The harm," the letter said, "can be fatal."

"We have concluded," the letter added, "that numerous conditions and practices at [Georgia Regional] violate the constitutional and statutory rights of its residents."

The Justice Department gave state officials 13 pages of necessary corrective measures, including the hiring of substantial numbers of medical and support staff members. If the state does not act by late July, the department said it could file suit to force the changes.

The department's letter, obtained Wednesday by The Atlanta Journal-Constitution, resulted from an investigation that began in April 2007. The inquiry's findings —- unnecessary patient deaths, abuse by staff members, uncontrolled fighting among patients, overuse of medications, poor planning for patient care after discharge, shoddy or nonexistent investigations of serious incidents —- echo a series of articles in the Journal-Constitution, "A Hidden Shame," published in 2007.

The newspaper reported that at least 136 patients died under suspicious circumstances at the seven state hospitals from 2002 through late 2007.

In addition, the newspaper said, state officials substantiated nearly 200 cases of patient abuse by hospital employees during that period.

Officials at the Georgia Department of Human Resources, which operates the hospitals, said the Justice Department findings were not surprising.

"We were already working on many of these [problems]," Gwen Skinner, head of the state's mental health division, said Wednesday. Georgia Regional has increased its nursing staff, as well as the number of hours of patient treatment, she said. A commission appointed by Perdue to study the state's mental health system issued a report Wednesday documenting problems in hospital care, community psychiatric services and state funding.

Skinner acknowledged "a sense of urgency" in correcting problems at Georgia Regional. But asked about the Justice Department's contention that immediate changes were required, Skinner said, "It speaks for itself."

Perdue spokesman Bert Brantley said the governor has already put more money into mental health and "is definitely determined to make progress."

"We are confident in the plan of action and the steps we're taking," Brantley said. "There's definitely some momentum toward making changes."

The federal investigators inspected Northwest Regional Hospital in Rome and Georgia Regional Hospital in Savannah late last year and will begin an inquiry at Central State Hospital in Milledgeville beginning Monday.

A Justice Department spokesman in Washington, Jamie Hais, declined to comment.

A tone of indignation, however, infused the agency's letter to Perdue.

By tolerating a chronic shortage of nurses, the letter said, Georgia Regional "routinely compromises" patient care. The adolescent unit is "highly dangerous," the letter said, quoting one staff member as saying patients "would be safer outside" the hospital and another who described "continuing clinical chaos."

"Many of these deficiencies," the letter said, "stem from a system that does not have clear, specific standards of care or an adequate number of trained supervisory, professional and direct care staff."

Deaths highlighted

Again and again at Georgia Regional, a 352-bed facility on Panthersville Road that opened in 1968, investigators documented a failure to respond to danger signs about hospital performance or at-risk patients.

In 2006, the letter said, federal regulators cited Georgia Regional for poor mental health treatment, nursing and health care. Last year, consultants hired by the state reported similar concerns. And, the letter said, the Journal-Constitution series reported that patients "often suffer preventable injuries and illnesses, some of which have been fatal."

"We found that these same conditions remain unabated, despite [Georgia Regional's] notice of the deficiencies," Grace Chung Becker, acting assistant attorney general in charge of the civil rights division, wrote to Perdue.

The hospital failed to react when staff mistakes resulted in patient deaths, the letter said.

It cited the February 2006 death of Sarah Elizabeth Crider, a 14-year-old Cobb County girl whose case was highlighted in a Journal-Constitution article. The day before she died, the letter said, Crider complained of stomach pain and had nausea and vomiting.

An on-call physician did not document whether she examined the girl, who died of an infection caused by a severely impacted colon that went untreated. The letter said impaction is a well-known side effect of many of the antipsychotic drugs prescribed for Crider.

Three days later, the letter said, a 33-year-old patient died at the same hospital after his "medical concerns were mishandled," including the failure to monitor his bowel functions. And that December, 59-year-old Michael Webb died after more than two weeks without a bowel movement —- information never flagged on his medical chart, the letter said.

Georgia Regional's "failure to critically review the first death, which should have led to corrective actions that could have prevented the second and third fatalities, compounds the tragedy of these three deaths," the letter said.

The hospital's staff members, investigators found, "often fail to provide even the most basic care, opting instead for a reactive approach in which patients' medical needs are addressed only after problems develop."

Observations

Similarly, investigators documented a failure to break a pattern of physical assaults and aggressive behavior. The adolescent unit, the letter said, is "particularly disturbing."

Investigators touring the unit observed a patient tearing a water cooler from the wall before he was forcibly restrained by staff members. A week earlier, in September 2007, six patients started a disturbance in the adolescent unit, throwing tables and chairs, crashing through a secure door to the building's lobby and breaking furniture. One patient used a piece of broken plexiglass to cut his neck before staff members could react. What investigators now call a "melee" was controlled only after hospital officials summoned DeKalb County police.

Investigators said they found "troubling patterns" of patient aggression on adolescent and adult units: repeat victims, repeat assailants, multiple assailants ganging up on a single victim. Assaults frequently caused serious injuries that required emergency room treatment, the letter said, including broken bones and head wounds.

"The repeated and significant level of violence on the units suggests a fundamental failure to address the root causes of patients' aggression," the letter said, "and demonstrates a failure to intervene adequately to prevent future incidents."

Violations found

In many cases, investigators found, hospital officials simply don't investigate incidents —- or, if they do, they conduct woefully inadequate inquiries.

In one case, investigators found documents had been removed from the medical file of a patient who had attempted suicide. The documents described irregularities in the patient's care: Staff members had failed to watch the woman as a doctor had ordered, and one had gotten into a shouting match with the patient shortly before the suicide attempt.

Removing the documents from the file was "highly irregular," the Justice Department letter said. "Equally disconcerting," the letter added, was hospital officials' failure to investigate why the documents were removed.

Repeatedly, investigators documented situations in which hospital employees violated standard procedures. They cited the case of a patient who has been admitted to Georgia Regional 107 times; her treatment plan has rarely varied, and no one has assessed why she repeatedly returned to the hospital.

Patients routinely are discharged to places such as homeless shelters, motels and bus stops, the letter said, noting that the U.S. Supreme Court ruled in a 1999 case that shelters, for instance, were "inappropriate discharge locations."

State officials are more than familiar with that case. Georgia Regional, the Justice Department letter said, "is the very hospital where, nearly a decade ago, the United States Supreme Court made clear that the unnecessary institutionalization of persons with disabilities violates the law."

ON AJC.COM

> To view the report and read the Hidden Shame series about the state's mental hospital system. www.ajc.com/hiddenshame

OMINOUS NUMBERS

At least 136 patients died under suspicious circumstances in Georgia's state psychiatric hospitals from 2002 through 2007, according to a 2007 investigation by The Atlanta Journal-Constitution.

22: Georgia Regional Hospital/Atlanta

42: Central State Hospital in Milledgeville

26: East Central Regional Hospital in Augusta

17: Northwest Georgia Regional Hospital in Rome

7: Georgia Regional Hospital/ Savannah

17: Southwestern State Hospital in Thomasville

5: West Central Georgia Regional Hospital in Columbus

CAUSES

38: Choking (includes patients who died after aspirating food or vomit into lungs)

17: Infections

12: Suicides

10: Bowel obstructions

8: Dehydration or malnutrition

4: Medication errors

2: Physical restraints

1: Beating by patient

24: Other (includes undetermined causes)

20: Unexplained/suspicious (as classified by Department of Human Resources)

WHAT TO DO?

Among recommendations by the U.S. Department of Justice to fix problems at Georgia Regional Hospital/Atlanta:

> Improve reporting of injuries, assaults, abuse and neglect, and suicide attempts.

> Require comprehensive investigations of such events.

> Ensure there is sufficient nursing staff.

> Implement policies to preserve patient care records and address improper removal or destruction of records.

> Review and revise psychiatric assessment of all patients.

> Ensure treatment plans address the repeated hospital admissions of an individual.

> Begin systematic monitoring of medication use throughout the hospital.

> Establish effective physical and nutritional program for patients at risk for aspiration.

> Create a review process for discharges.