A suicidal patient, but no safe haven

Not when the hospital completed his psychological examination about two weeks later. A physician noted, "Client stated he did not feel like living."

And not when hospital workers discussed his treatment plan in the days before his scheduled discharge. Miller, a staff member wrote, "cannot offer a reason to live."

Still, when Miller, 43, stormed off to his room the evening of Aug. 1, 2002, no one checked on him, although staff members later claimed they had. By the time a hospital worker found him hanging by his shoelaces from two screws in the wall, he had been dead two hours, a coroner determined.

Miller's is one of a dozen suicides involving patients from Georgia's mental hospitals during the past five years, an investigation by The Atlanta Journal-Constitution has found. An additional 60 patients attempted suicide.

Each case represents a specific failure to provide a safe haven for a person with serious mental illness. Taken together, the suicides and attempts also reflect a broader neglect that was a key factor in most of the 115 suspicious deaths among state hospital patients identified in the Journal-Constitution's inquiry.

Staff shortages, inadequate assessment and treatment, and, in cases such as Miller's, human error played significant roles in many of the suicides, just as they did in other deaths, the newspaper determined from state reports, autopsies and other documents.

State officials accept a share of blame for suicides. "If someone is ill enough, depressed enough, without supports enough that they commit suicide, it's a failure, " says Gwen Skinner, director of the state Department of Human Resources' mental health division, which operates the hospitals. "It's a failure of the mental health system. But it's a failure of a lot of systems."

Patient suicides inside and outside the state hospitals were the third-highest identifiable cause of suspicious deaths since 2002, according to the Journal-Constitution's review. Comparing Georgia's suicides to those in other states is all but impossible, given the different structures of each state's mental health system and the lack of consistent reporting on incidents in state psychiatric facilities.

Regardless, Dr. Kris Sperry, Georgia's chief medical examiner, says every suicide in a state hospital amounts to "a gross dereliction of duty."

Suicidal patients must be observed constantly, Sperry says. But, in part because of staffing shortages, many of those patients are checked no more than every quarter- or half-hour or at even greater intervals.

"A check every 15 minutes is pointless, " Sperry says. "A suicide watch is all or nothing."

Even a momentary lapse can have fatal consequences.

Last April at Northwest Georgia Regional Hospital in Rome, two staff members were supervising 29 patients on an outdoor break. One of them was a 42-year-old woman who had been admitted the previous day and had not yet undergone a psychological evaluation. With the hospital employees standing nearby, the woman, who was not identified in state reports, climbed about 25 feet up a tree. Then, as employees dispersed a group of onlookers, the woman placed her arms behind her back and dived headfirst to the ground. She died instantly.

A plea for help

Sandra Mayfield had heard from her son in times of crisis before, when he couldn't handle his alcohol abuse and depression. On the telephone this night in June 2002, Mark Miller pleaded for specific intervention. He wanted to go to a mental health facility near his home in Barnesville.

Mom, he said, I need help.

"I said, 'If you need help, I will take you, ' " recalls Mayfield, 66, who lives in Zebulon, about 50 miles south of Atlanta. "Your first-born son --- no matter what your kids do, you love them."

Mayfield drove her son to a hospital emergency room in Spalding County. Workers there arranged for Miller to receive psychiatric treatment, first at the facility in Barnesville, then at West Central Georgia Regional.

Miller, who was divorced and had no children, had a history of depression and of suicide attempts, his medical records show. He also lived with chronic back pain from a workplace accident in the early 1980s.

He managed his pain in either of two ways, says Larry Keith Evans, the attorney for Miller's family: When he was working and had health insurance, he took prescription medications. When he wasn't working and didn't have insurance, he drank.

Mayfield described her son as a master of trades. He worked construction. He drove big trucks. He painted buildings.

"There wasn't too much he couldn't do, " she says. "He made excellent wages. He didn't take care of them, but he made excellent wages."

When he entered the state hospital, records show, Miller described himself to a social worker as "a good-hearted person who tries to help anyone he can." He said he enjoyed fishing and watching baseball and NASCAR races.

He also said he preferred death to living in pain.

Miller repeatedly threatened suicide during his hospital stay. At times, though, he promised therapists not to harm himself. By late July, after Miller had spent more than a month in the hospital, his psychiatrist decided he had suppressed his suicidal thoughts enough to be discharged.

Mayfield, meanwhile, was caring for Miller's stepfather, who was terminally ill with a bone marrow disease. She could not take on another responsibility. So the hospital found a spot for Miller in a shelter operated by the Salvation Army.

On the day he was scheduled to go, however, the shelter had no available bed. At least temporarily, he would have to remain in the hospital.

Miller had been taking Darvocet, a narcotic, for his back pain. When his discharge was delayed, Miller's doctor was supposed to reauthorize nurses to give him the drug. Miller's medical records show the physician entered no such order. "She just clean forgot, " says Evans, the family attorney.

By the evening of Aug. 1, records show, Miller had gone 24 hours with no pain medicine. About 9 p.m., he demanded that a nurse call the doctor for more Darvocet. The nurse refused. Enraged, Miller threw other medications and a cup of orange juice at her and stomped into his room. He slammed the door behind him.

Two quick releases

Of the dozen suicides of state hospital patients since 2002, seven occurred within 14 days of the patient's discharge. One escaped and hanged himself in Atlanta's Piedmont Park.

Some had convinced doctors they were no longer suicidal. Others, though, had been released after minimal assessment or treatment, records indicate, raising questions about the hospitals' culpability.

In May 2002, Andres Martinez, 36, was hearing voices telling him to kill himself, according to a referral form used to admit him to Georgia Regional Hospital/Atlanta. Martinez was fluent only in Spanish, but no one brought in an interpreter to help communicate with him during treatment, according to hospital documents obtained by the Journal-Constitution. A nurse evaluated Martinez across that language barrier, the documents show, and failed to note his suicide risk. The hospital released Martinez after three days. A week later, in the basement of his Clayton County home, he hanged himself.

When Jimmy Aaron Williams, 25, of Covington, went to the Atlanta hospital in October 2003, he had already threatened to commit suicide by ingesting rat poison. During his seven days in the hospital, according to a medical examiner's investigation, he vowed at least once to kill himself soon. But his doctor released him with prescriptions for antidepressants and anti-psychotic drugs. Four days later, at a boardinghouse in southeast Atlanta, he drank antifreeze, fell asleep on his landlord's sofa and never awakened.

Skinner, the state's mental health director, says physicians weigh many factors in judging whether to discharge a patient.

"It's not an exact science, " she says. "It's someone's clinical opinion."

But Dr. Sidney Weissman, a trustee of the American Psychiatric Association who teaches at Northwestern University's medical school in Chicago, says short hospital stays are not enough to assess, much less stabilize, suicidal patients.

"Where have all the suicidal thoughts gone?" Weissman says. "The suicidal ideation doesn't evaporate.

"It takes a lot of knowing about a patient to really make a determination."

Angry and alone

The door that Mark Miller had slammed stayed shut.

His doctor's orders called for hospital workers to observe Miller at least once an hour. But an investigation by the chief of the hospital's on-campus police force later determined that no one entered the room between 9:10 p.m. and 11:25 p.m.

During that time, according to medical records, police reports and other documents, Miller tied together the nylon laces from his boots to form a 120-inch rope. He tied it around two 2-inch screws that were anchored into the Sheetrock 65 inches off the floor. Later investigation would determine that the screws, which had supported a framed picture of a globe, could withstand 200 pounds of force.

Miller, who weighed 144 pounds and stood 5 feet 7 inches, looped the makeshift rope around his neck. Then he dropped into a sitting position, falling just shy of the floor, strangling himself.

The Muscogee County coroner estimated that Miller died about 9:30 p.m. It was nearly two hours later when a technician who had just begun his shift discovered Miller's body.

Other hospital workers, however, falsified records to indicate they had been regularly checking Miller all evening, an investigation found.

One technician recorded nine false reports of observing Miller that night, investigators found. The technician later said he was merely marking down Miller's "routine." Further, according to a police report, the technician said he was working the second of two consecutive eight-hour shifts when Miller committed suicide and was "really tired."

The hospital fired that employee. Others were disciplined but kept their jobs.

Alleging negligence, Miller's family filed a claim against the state. Officials approved a settlement of $157,000.

But Mayfield never got what she says she really wanted from the state hospital: an apology.

"We thought he would be safe there, " she says. "We thought that would be a good, safe place for him to be, that they could help him."