112 Preventable Deaths at State Mental Hospital

She complained of stomach pain at 4:30 p.m. She vomited about 8:30. When the only physician on call at Georgia Regional Hospital/Atlanta came at 9:20, Sarah had vomited again, but the doctor did not examine her, medical records suggest. She threw up around midnight and once more about 2 a.m., this time a bloody substance that resembled coffee grounds. But hospital workers did not enter Sarah's room again until 6:15 a.m. By then, it was too late.

A few hours later, two hospital employees drove to Cobb County to tell Joyce Dobson, Sarah's grandmother. Dobson adored Sarah for all her complexities: artistic but troubled, challenging but comic. Now she could think only of two nights earlier, when she had last visited Sarah and heard another patient's haunting scream.

I hope nobody killed her, Dobson blurted out.

In fact, what happened to Sarah was beyond anything Dobson could have imagined.

Sarah was one of at least 115 patients from Georgia's state psychiatric hospitals who have died under suspicious circumstances during the past five years, according to an investigation by The Atlanta Journal-Constitution. The newspaper assembled a list of questionable deaths by examining state and federal inspection reports, a database of vital records, autopsies, medical files, court papers, state insurance claims and other documents.

This study revealed a pattern of neglect, abuse and poor medical care in the seven state hospitals, as well as a lack of public accountability for patient deaths. The findings for 2002 through late 2006 -- from employees beating patients with aluminum pipes to doctors widely prescribing sedatives just to maintain order -- evoke images from the mid-20th century at the state hospital in Milledgeville. There, thousands of patients lived and died amid horrific conditions that became synonymous across the nation with mistreatment of people with mental illness.

Several experts in psychiatric care concur with the Journal-Constitution's findings. They include patient advocates, as well as a Connecticut physician who heads the American Psychiatric Association's patient safety committee and another psychiatrist who helps conduct inquiries into deaths at mental hospitals in Illinois. All say the investigation shows significant problems with care provided in the Georgia hospitals.

State officials generally do not dispute the newspaper's conclusions. But a statement released by the Georgia Department of Human Resources, which operates the hospitals, says 82 of the patients identified by the Journal-Constitution had underlying medical problems "that were appropriately treated."