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Letter regarding the Mental Health Crisis in Georgia



Dear Legislators:

I am writing to you regarding the recent reports of deaths, abuse and neglect in Georgia’s State hospitals by the Atlanta Journal Constitution. The harm that people are suffering in these institutions is horrific and unacceptable, and is symptomatic of a larger systemic failure of Georgia’s mental health system. The Georgia Advocacy Office regularly investigates abuse, neglect and death in the state hospitals, and we are writing to inform you of some of the preliminary findings we have made regarding the lack of care and lack of oversight that are endemic to the hospital system and to suggest how the discussion of an appropriate response to this crisis might begin.

The Georgia Advocacy Office is the designated Protection and Advocacy System for people with disabilities and mental illnesses in Georgia. We are a private, non-profit organization that is federally funded to provide protection and advocacy to people with disabilities in Georgia. Our mandate is statewide and encompasses any setting where people with disabilities live or are being served. See 42 U.S.C. §15041 et seq.; 42 U.S.C. §10801 et seq.; 29 U.S.C. §749e et seq.

Our federal mandate permits us to investigate deaths, abuse and neglect in the community as well as institutional settings. During the past year, we provided protection and advocacy to 479 people with disabilities statewide where abuse or neglect had been alleged. Of these, 45 involved deaths of people with disabilities and 84 required a formal investigation by this office. We also responded to 3,845 additional allegations of rights violations and discrimination. Additionally, we do “look-behinds” of other investigative bodies such as the Office of Regulatory Services, DHR’s Office of Consumer Affairs and internal investigations unit and the Centers for Medicare and Medicaid.

We are currently investigating 27 deaths that have occurred at the state hospitals. These are deaths of individuals with mental illness or developmental disabilities. Our investigations have revealed a system that has recurring breakdowns in the most basic forms of medical care, and that these breakdowns are system-wide. Additionally, when these breakdowns occur there is no effective system of safeguarding and accountability to address these recurrent problems in care. In short, these facilities are causing great harm and, in some instances, death to some of Georgia’s most vulnerable people, and there is no effectively working system of oversight to address these harms. What follows are four stories of Georgia citizens who have been killed or seriously injured due to medical neglect by state hospitals, and a description of how the investigatory and oversight system has failed to respond. We believe these stories are representative of many of the problems found in the state hospital system. We have altered identifying information to maintain confidentiality.


15-year-old Georgia Citizen

A teenager with developmental disabilities is admitted to a state hospital. He has autism, does not speak and is displaying behavior that is injurious to himself. Rather than being admitted to a unit designed to treat people with developmental disabilities, the teenager is improperly admitted to a psychiatric unit which is not designed to meet his needs. The hospital treatment team fails to assess and develop an appropriate treatment plan for his self-injurious behavior. It does not call for a functional analysis to determine the cause of the self-abuse and does not call for the development of positive interventions to address the behavior. Additionally, the treatment plan is not individualized and uses “canned” language such as calling for the teenager, who is non-verbal, to give verbal responses. Over the course of 11 days, the teenager develops open wounds that become infected. The nursing staff fails to document the wounds or request appropriate interventions to treat the wounds or the behavior that is causing them. It is only once the teenager’s medical condition had declined significantly (i.e., he became lethargic, dehydrated, and could only walk with staff assistance), do the medical staff feel it is necessary to intervene.

They call a non-emergency ambulance. Upon admission to the emergency room at Hughes Spaulding Hospital, the teenager is found to have cellulitis, osteomyelitis, sepsis secondary to infected wounds, renal failure, liver dysfunction, MRSA, and profound malnutrition. The hospital staff at Hughes Spaulding document abuse and neglect and notify the Georgia Department of Family and Children Services, the Office of Regulatory Services and the state hospital itself. The teenager is hospitalized for a month due to his injuries and requires surgery to treat his wounds.

There was a complete breakdown in the system of oversight and accountability in the hospital’s treatment of this young man. The state hospital did an internal investigation and found no neglect. Accordingly, the hospital took no disciplinary action against any of the medical staff responsible for the teenager’s care and failed to take any corrective action such as policy changes, staff discipline or appropriate training. At the time this young person was admitted to the state hospital, the Division of Family and Children Services (DFCS) had an open case related to possible neglect in his home. After he had been at the state hospital for a week, the DFCS caseworker made a visit there to see him. She noted that the teenager was in a state of undress except for a pair of sweatpants and that he looked as though he had been “whipped” due to all of the wounds about his body. The caseworker simply documented this in her file and left. She did not question the care the teenager was receiving at the hospital and failed to report the neglect to anyone at the hospital or within DFCS. After he had been admitted to Hughes Spaulding, the same caseworker went back out to the state hospital to investigate and still failed to make a finding of neglect. The Office of Regulatory Services conducted an investigation of the state hospital and found no deficiencies. ORS did not observe the teenager, review any of his records or interview any of his treating staff at Hughes Spaulding. The Division of Mental Health, Developmental Disabilities and Addictive Diseases (MHDDAD) decided not to investigate since ORS was already investigating.


14-year-old Georgia Citizen

A 14-year-old girl is admitted to a psychiatric unit at a state hospital in October 2005 for treatment of acute symptoms of her mental illness. She is prescribed a variety of psychotropic medications, all of which have a known side effect of constipation. One evening in February 2006, the teenager begins to complain of stomach pain and discomfort and is lethargic. The nurse gives her Tylenol, and she continues to complain about her stomach. The nurse assumes the problem is related to the young woman’s menstrual cycle and does not check her vital signs. Later that evening, the teenager begins to vomit. The nurses do not document critical information such as the teenager’s input and output of fluids. They eventually call the on-call physician. The physician, without doing a physical exam, prescribes something for the vomiting. At the 11:00 p.m. shift change, the new nurse begins to assess input and output of fluids but does not document every instance of vomiting. In interviews conducted later, staff admits that, although the medical records do not reflect it, this young woman vomits throughout the night.

The required bed checks are not conducted properly, and there is effectively no further medical monitoring through the night. The teenager is discovered the next morning at approximately 6:12 a.m. with no pulse. A Code Blue is called by the nurse, and CPR is started. The on-call physician arrives but does not take charge of the Code. The teenager is pronounced dead shortly thereafter.

MHDDAD investigated the death of this young woman and found neglect. They recommended a Corrective Action Plan (“CAP”) be developed by the hospital by April 20, 2006. The hospital did not develop a CAP until May 12, 2006. The CAP addressed retraining direct care staff on bed checks, reevaluation of standing orders for medications, the ordering of appropriate lab work when indicated, tracking intake and output for any patient taking anti-cholinergic (medications that dry you out and put you at risk of constipation), increased tracking of intake and output for non-verbal patients and appropriate personnel actions. Per division policy, the enforcement of the CAP is the responsibility of the Regional Office and not the MHDDAD investigative unit. The Regional Office reviewed the hospital’s Corrective Action Plan and found it to be sufficient to address the problems identified. It did not follow-up further to determine if the CAP was actually implemented. Our office has requested information regarding the follow-up on the CAP and any disciplinary action taken against any hospital staff as a result of this teenager’s death and have been provided none. We are unable to determine if any of the recommendations in the CAP have been implemented. Amazingly, ORS investigated and failed to cite neglect.


35-year-old Georgia Citizen

A young man with mental retardation and a moderate risk of choking is admitted to a state hospital. His risk of choking is assessed and documented. However, no plan is put in place to address the risk. The young man is allowed to eat without supervision. He leaves the dining room by himself without any check to see if he has eaten and swallowed all of his food. Shortly thereafter, a care worker finds the young man in the day room with his head back and non-responsive. Rather than initiating CPR immediately, the care worker who finds him walks to the nursing station and indicates that the young man is non-responsive. The nurse calls a Code Blue. However, CPR is still not initiated until a full three minutes after the code has been called. The young man is admitted to a local hospital where he is eventually taken off life support several days later after it is determined that there is no hope of recovery.

The state hospital’s internal investigation found no neglect and did not impose any disciplinary action upon any of the direct care staff. The MHDDAD investigations unit investigated and found neglect. At the behest of MHDDAD, the care worker who found the young man and failed to initiate CPR received a warning but was told it would be removed from his file if there were no further incidents for a year. MHDDAD failed to develop a corrective action plan even though they found neglect. ORS also investigated this matter and failed to cite the lack of supervision of the choking risk and failed to find neglect.


33-year-old Georgia Citizen

A man is admitted to a state hospital in November 2005. He is noted to drink excessive amounts of water. The admitting physician orders that the man’s water intake be restricted to 40 ounces per day and that he be supervised every 15 minutes. This order is not followed. In mid-December 2005, the physician changed the supervision to a level that would require hourly checks with no mention or consideration of the excessive water drinking. In the beginning of January 2006, a physician orders that the man be put in seclusion for up to two hours because of his constantly pushing himself into the bathroom or the water fountain to drink water. The nursing staff fails to communicate the excessive water drinking to the treatment team during routine treatment meetings. The physician never orders lab work to rule out polydipsia, polyuria or diabetes, conditions known to cause excessive water drinking. Rather than develop appropriate interventions to address the excessive water drinking, the staff illegally use forced intramuscular injections to control the man’s behavior. Over the course of his confinement at the state hospital, the man is forcibly injected eighteen times with powerful psychotropic medications as a means of behavior control. At no point is there a finding as required by Georgia law that the man is a danger to himself or others such that forced medication would be appropriate. The man dies in February 2006. An autopsy concludes the probable cause of death to be idiopathic cardiac dysrhythmia. The autopsy notes the record of polydipsia and polyuria while in the hospital.

MHDDAD investigated and concluded that the hospital management and staff followed all policies and procedures. ORS also investigated and found no deficiencies. At a minimum, ORS should have cited the failure to develop an appropriate treatment plan for this man’s excessive water drinking, and they should have cited the use of forced medication where there was no finding of danger to himself or others.

In addition to the three deaths mentioned above, we are currently investigating 24 other suspicious deaths at the state hospitals. Most of these deaths are due to causes that would tend to indicate medical neglect such as sepsis secondary to megacolon and sepsis secondary to pressure ulcers and choking. We will be publishing our findings regarding these deaths in the coming months.

Clearly, we must reassess how we meet the needs of Georgians with mental illness or developmental disabilities currently confined to state hospitals. It would be a disservice to people with disabilities, though, if our legislature misread the recent call for a complete overhaul of Georgia’s mental health system as a mandate to simply pour more money into a broken and outdated institutional system of care. More staff and new paint are not going to fix this problem. Georgia needs a functioning community-based mental health system. Many people are unnecessarily confined to the state hospital system simply because there are insufficient community-based supports and services available to them to live in their own homes and communities. This has lead to an over reliance on a very expensive and harmful institution-based system of care. We know that people are not getting what they need, and worse, they are being harmed, and in some cases, killed

Georgia’s current model of institutional care is outdated. Research has long shown that most people with mental illness and developmental disabilities can and should be supported to live in their own homes and communities. Additionally, most other states are moving toward community-based mental health services. The United States Supreme Court has ruled in L.C. v. Olmstead, a case that originated in Georgia, that states have an obligation to provide mental health services in the most typical community setting appropriate for the individual. Many states such as Arizona, Massachusetts and Ohio have successfully transformed their systems of support and services for people with mental illness and developmental disabilities from one based in institutions to one based in the community. To its credit, Georgia’s Division of Mental Health, Developmental Disabilities and Addictive Diseases has begun its Children’s Initiative to bring children home from state hospitals and other institutional settings. Adults who have mental illness or developmental disabilities do not need to live in institutions either. A hospital is not a home, and Georgia needs to better support the community services for individuals with mental illness or developmental disabilities instead of continuing to finance institutions that can never pretend to be a real home where a person can experience some of the comfort and safety we all need.

Finally, the internal and external safeguards needed to keep people safe are woefully inadequate as demonstrated by the stories above. We need to establish multiple and redundant safeguards to protect people from harm, especially unnecessary and painful deaths in the hospitals and other institutional settings. We urge you to consider mandating and funding an external entity to specifically review all deaths in hospitals and other settings where people with disabilities are congregated and segregated, as well as doing a thorough analysis of what internal and external safeguards are necessary on a systemic level to keep Georgians with disabilities protected from harm. States that have done this most comprehensively (e.g. New York, Illinois) have a commission established and funded directly through the governor’s office to look at all deaths in the psychiatric hospitals, analyze trends, and make recommendations for needed change. They work effectively with the designated Protection and Advocacy System in their respective states, as well as other external review entities (e.g. Ombudsman Program, State Bureau of Investigations).

I look forward to working with you as we try to protect some of Georgia’s most vulnerable citizens. If you have any questions or need further information, please do not hesitate to contact us.



Ruby Moore
Executive Director

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