Hospital mistakes kept secret

The short, troubled life of Matthew Reese ended in what should have been a safe haven: the psychiatric hospital treating him for depression.

Reese, 27, was transsexual and preferred his identity as a woman: Sonya Michelle. As a man, he served prison time in his late teens after molesting a younger boy. By the time he entered SummitRidge Hospital in Lawrenceville, friends say, he was intent on taking his own life, and on Sept. 24 he hanged himself with a sheet from his hospital bed.

State officials will investigate whether mistakes by the hospital enabled Reese’s suicide. But their conclusions, and even how they conduct their inquiry, may remain forever confidential.

Reese’s death highlights a curious facet of hospital regulation in Georgia, according to an examination by The Atlanta Journal-Constitution. In an increasingly transparent era in health care, such data as the incidence of post-surgery infections and heart attack survival rates flood the Internet. Georgia, however, has tightened the secrecy surrounding some of the worst mistakes that occur in hospitals: patient suicides, sexual assaults and surgical errors.

The state does not allow public review of reports that hospitals submit following such episodes. It divulges little information even when it concludes a facility violated regulations. It withholds all uncorroborated allegations of wrongdoing, along with details of its investigations.

This lack of disclosure leaves medical consumers with no systematic way of learning whether a particular hospital has a history of complaints that might signal a pattern of inadequate care. It also prevents taxpayers from assessing the quality of state investigations into medical errors.

Georgia’s Open Records Act does not exempt the hospital reports from public disclosure requirements. But rather than seek a change in the law, a state regulatory board instead declared the reports confidential by adopting administrative rules — an approach that open government advocates find of questionable legality.

“The public has a keen interest in this kind of data,” said Hollie Manheimer, executive director of the Georgia First Amendment Foundation, “and the public needs to be informed.”

State officials and hospital industry executives contend public disclosure would cause more harm than good. Pam Keene, a spokeswoman for the state Department of Community Health, which regulates Georgia hospitals, said the secrecy promotes “candor” among medical professionals that helps facilities correct mistakes. If they don’t feel free to speak up, Keene said, serious deficiencies could go undetected.

The chief executive at SummitRidge did not respond to requests for an interview.

Whatever the hospital told the state about Matthew Reese, it will never come to light, regardless of whether the hospital or its staff was at fault.

The state, Keene said, “is not aware of any repository of public information about Georgia hospital errors.”

‘Suicidal thoughts’

A report by Lawrenceville police is the only public document that describes the events surrounding Reese’s death. It says he checked into SummitRidge on Sept. 18 to deal with depression, schizophrenia and “suicidal tendencies.” He moved into room 209 — on the male ward — and was placed on several medications.

The extent of Reese’s psychiatric problems cannot be determined. However, other public documents detail a long history of troubling behavior.

Reese dropped out of school in the ninth grade, according to court records, and by age 17 found himself in serious trouble with the law. In September 2001, Marietta police charged him with armed robbery; he had waved a knife at a clerk while stealing 20 packages of beef jerky from a convenience store just off I-75. Days later, police lodged a more serious charge: aggravated child molestation. Authorities said that, for a year, he repeatedly sodomized a younger boy at the Marietta apartment he shared with his mother.

Reese spent 11 months in the Cobb County Jail before pleading guilty in August 2002 to reduced charges in both cases. He was free on probation until late 2003 when he violated the terms of his release. A judge sent him to prison for a year and a half.

When he entered SummitRidge, Reese was living in Gwinnett County in a group home for people with mental illness, according to another patient who befriended him in the hospital. The patient spoke with The Atlanta Journal-Constitution on condition of being identified only by her first name, Mechille, to protect her family’s privacy.

Early on Sept. 24, a Saturday, Reese emerged from his room into a common area where hospital employees check patients’ vital signs, Mechille said in an interview. As he did most days, Reese had applied facial makeup, but wasn’t wearing the long-haired wig he brought to the hospital.

Later in the morning, Mechille said, she saw Reese in an outdoor smoking area, doubled over against a concrete wall. She said he was distraught over an encounter with a hospital employee who asked why he was wearing makeup.

“That’s what I choose to do,” Reese said he responded. “It’s what I do on the outside.”

The employee, Reese told Mechille, responded: “You look like a clown.”

“Hold your head up high,” Mechille said she told Reese. “You go tell him to go to hell.”

“A few hours later,” she said, “he was found dead.”

The police report does not mention Reese’s exchange with the hospital employee. It quotes another worker who told officers that at 9:45 a.m., he directed Reese to report to a regularly scheduled group therapy session. But Reese refused to go, according to the police report, and instead returned to his room.

An hour passed before another employee entered Reese’s room, the police report said. She found Reese hanging on the bathroom door, a white bed sheet tied around his neck, draped across the door and tied to the doorknob.

Patients in the group therapy session saw police and paramedics enter the hospital, Mechille said, and then watched authorities remove a body.

“When we saw the body bag being rolled out, we all said, ‘It’s Matthew,’” Mechille said. “We all immediately started crying. We knew — we just knew — that it had to be him.”

In Reese’s room, a police officer found two black notebooks: Reese’s journals. In one, the officer wrote, “there was a note where Mr. Reese wrote down that he was having suicidal thoughts.”

Whether anyone else had seen the note is not known.

Critical confidentiality

The state requires hospitals to report any “unanticipated” death that is not related to the reason for a patient’s admission: suicides such as Reese’s, as well as fatal drug overdoses, medical errors, or falls and other accidents. Hospitals also must notify the state of surgeries performed on the wrong patient or the wrong body part, along with reported rapes that hospital officials have corroborated.

The Department of Community Health’s regulatory division maintains an online database of hospital inspections. The database, however, offers somewhat sketchy accounts of incidents that violated state or federal rules.

The vast majority of reports contain just a few sentences that give no hint of the alleged irregularities that were investigated or how officials determined that complaints were not legitimate.

A 2010 report on Atlanta Medical Center is typical: “An off-site medical records review was conducted. ... Allegations could not be substantiated. No deficiencies were cited.”

Another report details the plight of a patient who went to Athens Regional Medical Center for knee surgery; the hospital operated on the wrong knee. Another says a patient who committed suicide at Cartersville Medical Center wasn’t properly supervised in the emergency room while awaiting admission to a psychiatric hospital. Another report blames a patient’s death at the Medical Center of Georgia in Macon on inadequate training for workers assigned to observe heart monitors.

In these cases, as in most others, the state levied no penalties after the hospitals voluntarily corrected deficiencies.

Many of the citations listed in the database involve situations that might happen, not incidents that actually did happen. Last year, following an annual inspection, the state cited Jenkins County Hospital in Millen for not having a policy in place to prevent the kidnapping of pediatric patients. No one had actually been kidnapped; the hospital just didn’t have the right policy on its books.

When serious incidents occur, most hospitals immediately begin their own investigations, said Temple Sellers, general counsel of the Georgia Hospital Association.

“You want to know right away, No. 1, if there was a mistake and, No. 2, what was the cause of that,” Sellers said. “Is it an isolated mistake or is there some type of pattern?”

Even at that early stage, she said, confidentiality is critical. Physicians, nurses and other hospital employees need to know they’re protected from public embarrassment and from litigation, she said.

“People are reluctant to speak out if they are going to be blamed. That’s really harmful to patient safety and quality.”

The state’s confidential treatment of these reports dates to 2003, when the board of what was then the Department of Human Resources adopted new rules governing hospitals (drafted with the industry’s help, Sellers said).

The reports, according to state officials, amount to “peer review” — by law, a private self-examination of bad outcomes, often associated with a deliberative appraisal typically conducted weeks or months afterward.

In a statement last week, the Department of Community Health said: “By affording peer-review protection, the law promotes candor in determining why an incident occurred by removing the fear that the information disclosed will be used by the practitioner/facility, etc., in subsequent litigation. By fostering greater candor in reviewing an incident, the problem/failure that led to an incident is more likely to be resolved and less likely to occur again, resulting in overall higher patient care.”

If such reviews were made public, “nobody would investigate anything,” said Evelyn Baram-Clothier, executive director of the American Medical Foundation for Peer Review and Education, based in Philadelphia. “They’d bury everything under the carpet. This gives an opportunity for fresh air to get into the system.”

The state won’t say whether SummitRidge submitted a report on Reese’s death.

Two former patients, however, filed a complaint, alleging hospital employees should not have left Reese alone so long. A few days later, regulators wrote back to acknowledge they had received the complaint. Nearly two months after Reese’s death, the former patients have heard nothing more.


How we got the story

The Atlanta Journal-Constitution learned about Matthew Reese’s suicide from two former patients at SummitRidge Hospital in Lawrenceville. While researching Reese’s background, a reporter discovered his criminal history, which included a child molestation case in Cobb County. Most details in the article about Reese’s death come from a report filed by the Lawrenceville police.

The state Department of Community Health answered questions about its regulation of Georgia hospitals. Its database of hospital inspections is online at


A Hidden Shame

In January 2007, The Atlanta Journal-Constitution began a yearlong series of articles that revealed more than 100 patients of Georgia’s state psychiatric hospitals had died under suspicious circumstances during the previous five years. In response to the articles, the U.S. Justice Department opened an investigation into whether the state was violating the civil rights of hospital patients and others in the mental health system. State and federal officials reached an agreement last year that calls for wholesale changes, including a new emphasis on community-based care. The agreement does not cover privately owned psychiatric hospitals in Georgia.