Mental health reformers split over strategy

Mental health advocates are challenging the settlement of a federal civil rights investigation of Georgia’s state psychiatric hospitals. Their objection, though, could create an unintended consequence: a way for the state to withdraw its potentially expensive pledge to overhaul the facilities.

The advocates understand the risk.

But they say the settlement allows too much time to improve care, while failing to hold the state accountable.

“We want teeth in the settlement agreement,” said Cynthia Wainscott, a former national chairwoman of the advocacy group Mental Health America, who is leading the objectors. But, she acknowledged, the state could withdraw from the settlement “if there is a change to a dot or a comma.”

The objection, filed in federal court in Atlanta, has brought together adversaries and divided allies. In the balance is a plan to correct chronic abuse, neglect, overcrowding and substandard medical care in the seven state hospitals.

Officials at the Georgia Department of Human Resources, which operates the hospitals, declined to comment. The U.S. Justice Department, which charged that dangerous conditions in the hospitals violate patients’ civil rights, did not respond to a request for comment.

Both, however, have asked U.S. District Judge Charles A. Parnell Jr. to approve the settlement agreement and dismiss the objection. At least one advocacy group, the National Alliance on Mental Illness, or NAMI, has broken ranks and supports the government’s position.

Parnell has said he will hold a hearing before reaching a decision.

The state hospitals have been under close scrutiny since 2007, when The Atlanta Journal-Constitution began reporting on dangerous conditions in the facilities. As many as 136 patients died under suspicious circumstances from 2002 through late 2007, the Journal-Constitution found.

The newspaper’s articles prompted the Justice Department to open an investigation in April 2007. After visiting one hospital, Georgia Regional in Atlanta, federal authorities wrote a blistering letter to Gov. Sonny Perdue, demanding immediate improvements and threatening to sue the state.

The state averted a lawsuit by reaching the settlement agreement with the Justice Department early this year. But the agreement cannot take effect unless both sides accept its terms and the judge approves. Neither party could be forced to consent to changes.

Even if the judge proposes changes supported by the advocates, the state may be unlikely to go along; any additional provisions could only make complying with the agreement more expensive.

If the judge rejects the agreement, the Justice Department would have to either sue the state or drop the case.

The agreement, signed Jan. 15, gives the state one year to improve efforts to prevent suicides, choking deaths and patient-on-patient assaults. The state also pledged to demonstrate improved medical and nursing care and better discharge planning within four years. The agreement further requires the state to find as much money as necessary —- millions of dollars, perhaps —- to transform the hospitals.

Similar settlements in other states included the appointment of independent monitors to supervise compliance with the agreements.

Georgia, though, would prepare its own compliance reports for the Justice Department.

Organizations that advocate for people with mental illness —- the Carter Center, among them —- complained in court papers that federal authorities would rely too heavily on the state to monitor its own performance.

With that degree of self-regulation, they said, the settlement “represents little more than a promise by Georgia to do better.”

In a separate filing, the Georgia Advocacy Office, a government-funded oversight group, said the agreement gives the state too long to address several critical issues.

“Persons who are confined in Georgia’s state institutions are vulnerable to ongoing and serious abuse, neglect and rights violations,” the advocacy office said. “They cannot wait four or five years for the state to comply with a settlement agreement to reach only what is constitutionally required.”

In a response filed in court last week, the state did not specifically address many of the advocates’ complaints, but questioned their legal standing to enter the case.

The Justice Department, however, defended the agreement, saying it would closely observe the state’s compliance.

Federal authorities plan to visit each of the seven hospitals once during the next year and may conduct additional inspections if necessary.

They also will review the state’s reports of patient deaths and other serious incidents.

In recent court filings, the department listed several provisions of the settlement agreement that provide oversight of the hospitals. However, each section actually counts on reports by the state.

Nevertheless, the department said, “the United States has taken it upon itself the role of monitor under the agreement to ensure that the state attains compliance with its terms in a timely manner… . Serving as monitor for the agreement permits the United States to intervene at an early stage if it believes that the state is not taking adequate steps to implement the measures required by the agreement.”

The case has divided advocacy groups, all of which pressed federal officials for a tough settlement agreement.

Departing from the objection by other organizations, NAMI has told the judge it is willing to accept what it considers to be a flawed plan to rehabilitate the hospitals.

“I guess we’re taking a more pragmatic approach that this is a good step in the right direction,” Eric Spencer, executive director of NAMI’s Georgia chapter, said in an interview. “We would like to see something done, rather than holding out for perfection and seeing nothing done.”

Justice Department officials have made it clear that Georgia would be likely to back out of the agreement if it were asked to submit to more stringent terms, Spencer said.

“There’s no renegotiating,” he said.

NAMI continues to criticize the quality of care in state hospitals, however. It recently blasted Georgia in its annual report cards on state mental health systems.

Georgia’s grade: D.

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. Here are the numbers of deaths by institution:

42 Central State Hospital in Milledgeville

26 East Central Regional Hospital in Augusta

22 Georgia Regional Hospital/Atlanta

17 Northwest Georgia Regional Hospital in Rome

17 Southwestern State Hospital in Thomasville

7 Georgia Regional Hospital/Savannah

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)

ON AJC.COM

> To view the Journal-Constitution’s series about the state’s mental hospital system: www.ajc.com/hiddenshame