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North Carolina Newspaper Reports 35 Questionable Deaths: Is This Is A Complete System Failure?

For Immediate Release, 24 Jan 00
Contact: Chris Marshall

The Charlotte Observer (Charlotte, NC), is publishing a five-part series which documents North Carolina's inability to protect its most vulnerable citizens from abuse and premature death. The series started yesterday, January 23, 2000 and will run through Thursday, January 27, 2000. Since 1994, at least 35 people with mental or developmental disabilities have died in questionable circumstances while under the care of North Carolina's mental health facilities. And the system set up to protect them has often failed to notice. They died from suicide, murder, neglect, scalding and falls. They suffocated, starved, choked, drowned.


There were twenty eight deaths in JCAHO (Joint Commission on Accreditation of Healthcare Organizations) facilities. JCAHO knew of just two of these.


No North Carolina state agency knows how many people die in psychiatric facilities. A state official is quoted as saying: "We don't know anything about what's really happening" in private facilities. Another state official says that oversight of state hospitals is "negligible." The State says it is "impossible" to stop every death and injury.


Most deaths reported to the state's Protection and Advocacy Agency are not investigated. The North Carolina P & A is not an independent agency - it reports to the state's Department of Administration. NAMI NC executive director Beth Melcher calls their performance "pitiful."


Anyone, apparently, can be a Residential Treatment Center. There are no requirements to be an RTC and licenses are issued by the state without site visits. Submission of photographs is sufficient to be granted an RTC license.


Not only are deaths and serious injuries not reported, no one knows where the money goes. The state mental health director says "the budget appears to me to be a rather amorphous glob of money."


1. Share this with your own newspapers. Ask them to launch a similar investigation.

This is the third major newspaper investigation since the series in the Hartford Courant in Connecticut in October 1998. In that series, the Hartford Courant reported on 142 deaths resulting from restraint and seclusion in psychiatric treatment facilities. In November 1999, the Orlando Sun-Sentinel (Florida) reported in a series abuse and neglect in Residential Treatment Centers. Now, we have the Charlotte Observer series.

2. Write your U.S. Congressional Delegation.

Ask them to support proposed legislation (S. 736, S. 750, H.R. 1313 and H.R. 3010) to regulate the use of restraint and seclusion in psychiatric treatment facilities. These proposed legislative bills would mandate the reporting of deaths and serious injuries and require that all restraints and seclusion be ordered by the treating physician or licensed independent mental health practitioner after a face-to-face evaluation. Details are available on the NAMI website at Contact information is available by clicking on "Write to Congress" on the policy page of the NAMI website.

3. Write your U.S. House Representative

Ask them to support NAMI's Mental Health Block Grant accountability amendments to the Substance Abuse and Mental Health Services Administration (SAMHSA) reauthorization legislation. Passed by the Senate late last year, S. 976 is currently pending before the House Commerce Committee. NAMI advocates every public mental heatlh system use an unduplicated count of persons served by diagnosis, age, gender, race, and services utilized. Following a data-based understanding of where dollars are spent, NAMI advocates targeting Mental Health Block Grant and public mental health dollars on persons with the most severe and persistent mental illness through replication of evidence-based programs such as PACT, programs for assertive community treatment. Refer to the NAMI E-News of December 20, 1999 (00-74) for more details on the issues associated with S. 976.

To download yesterday's and today's articles, visit the newspaper's web site at


Broken Trust: How North Carolina Fails the Mentally Ill

Five-part series by Debbie Cenziper, Investigative reporter
The Charlotte Observer
January 23 - 27, 2000

Day 1:

Twenty-four were patients in state-run facilities; 11 were under the care of hospitals and group homes operated by private companies and other organizations. Of the 35 deaths, 25 were never investigated by regulators. 'It's almost been like the mentally ill are worth nothing and that's sad," says Karen Murphy, advocacy administrator with the Governor's Advocacy Council for Persons with Disabilities, one of the cash-strapped regulatory agencies empowered to investigate psychiatric hospitals.

The Observer spent six months researching deaths, and analyzed more than 370,000 death certificates. The paper found that each year, more than 50,000 people with mental illness, developmental disabilities and alcohol and drug addictions turn to North Carolina's mental health system. But the system lacks the resources and coordination to supervise a troubled collection of state-run institutions and thousands of smaller mental facilities that have opened in the last decade. The job is complicated by rules that let untrained people open residential facilities, and state laws that limit regulators' authority to punish negligent caregivers.

Day 2:

Hiring and training standards guide North Carolina's four state-run psychiatric hospitals, but the law gives almost complete staffing freedom to the 12 hospitals not operated by the state and 3,300 smaller group homes. The regulation gap risks patients' lives. The Observer reviewed hundreds of state files and found that sporadic investigations have cited dozens of N.C. mental health facilities for failing to teach employees such skills as restraining violent patients and administering medication. They found nurses and technicians who didn't k now how to conduct suicide searches, investigate reports of abuse or teach patients basic living skills.

Day 3:

Each year, North Carolina denies mental health services to thousands of sick or severely abused children because there's little money to cover the costs and little coordination between state agencies to provide care. The state spends $250 million annually treating 76,000 children, about 2,500 in residential care. Mental health officials estimate another 84,000 need treatment but don't get any -- enough kids to fill 153 elementary schools.

Day 4:

Patients are dying unnoticed in mental health facilities across North Carolina, and tens of thousands are living without treatment. But North Carolina's mental health officials are focusing almost exclusively on another overwhelming issue: money management. Auditors and advocacy groups repeatedly have cited the N.C. Division of Mental Health for financial mismanagement and inefficiency. The federal government has demanded repayment of $30 million and might seek $87 million more. And the N.C. legislature has hired consultants to study spending at the division's four psychiatric hospitals and 39 local mental health offices.

Day 5:

The struggles of the mentally ill and developmentally disabled are drawing greater attention nationwide, but some states have been working for years to build better, safer, more efficient mental health programs. They've tackled the challenges that still overwhelm North Carolina by raising more money, passing tougher laws and better managing mental health operations.