He was choked until his last breath. Blood pooled beneath his skin from two wounds to the back of his head. His body lay in an ignominious sprawl: facedown on the floor of a state psychiatric hospital.
Georgia's chief medical examiner ruled his death a homicide. So did a coroner's jury.
Yet no one ever faced criminal charges for killing Rickey Dean Wingo. No one was even disciplined.
In Georgia's state mental hospitals, even the most egregious cases involving employees --- patient deaths, assaults, beatings --- usually result in penalties no harsher than firing, and sometimes no punishment at all, an investigation by The Atlanta Journal-Constitution shows.
Hospital administrators both investigate the most serious incidents on their grounds and pass judgment afterward, the Journal-Constitution found. They decide whether to call in the local police, whether to notify prosecutors, and whether to punish employees who harm the patients in their care.
The medical examiner said the injuries that killed Rickey Wingo at Northwest Georgia Regional Hospital in Rome appeared to have come from blows by a fist and from a chokehold.
But prosecutors say they could not have proved criminal intent by any of the three employees involved in the fatal restraint.
None of the three was fired or faced other disciplinary action, despite state hospital rules forbidding "any form of abuse, neglect or exploitation of patients."
One of the workers had been charged a month earlier with battery for allegedly striking a female acquaintance. After Wingo's death, he got a job transfer and a small raise. A few months later, the hospital gave him an award for "faithful service."
The way the state hospitals handle cases of abuse and neglect illustrates the lack of public accountability in a system that has experienced at least 115 suspicious deaths of patients and more than 190 substantiated assaults since 2002, the Journal-Constitution found.
No outside state or federal agency routinely studies patient deaths or injuries. Reviews by the hospitals' medical staffs of serious incidents remain secret under state law. While Georgia law unseals complete files on children who die in foster care, officials restrict access to documents about deaths in state mental hospitals. They heavily edit hospital reports, including those describing patients' deaths from abuse or neglect.
But officials who oversee the state hospitals say they conduct thorough investigations in all cases.
"When an incident occurs, we take action --- whatever action is required, " said B.J. Walker, commissioner of the Georgia Department of Human Resources, which operates the state hospitals. Outside authorities, she said, aren't always needed to deal with suspected mistreatment of patients. "Everything that is at the level of being looked at might not rise to the level of calling law enforcement."
Advocates for people with mental illness, however, suggest that independent police officers and prosecutors are better arbiters in cases involving violent deaths or assaults.
"Otherwise, the message is that these people are subhumans, and are not worthy of the protections of the rest of society, " said Ron Honberg, legal director of the National Alliance on Mental Illness.
For Wingo, justice in Georgia's mental health system was elusive.
"They beat the living crap out of him, and then they strangled him, " said John Klonoski, an attorney for Wingo's family.
Klonoski's law partner, Sharon Rowen, added, "And then they tried to cover it up."
Rickey Wingo had been in and out of Northwest Georgia Regional for two decades. When his schizophrenia was under control, sometimes he lived on his own, in a trailer near Rome. Other times, he stayed in a group home for people with mental illness.
Wingo, 53, was living in such a facility in May 2002 when he quit taking his anti-psychotic medicine. The group home sent him back to the state hospital.
Wingo refused medication there, too. So after five days, his doctor ordered that he receive an injection by force. But, according to attorneys for Wingo's family, he never received a second medication that could have eased the agitation that was one of the side effects of the first drug.
The morning of May 25, hospital workers were letting patients outside for a smoke break. As technician Lonnie Wofford opened the door, he saw Wingo fast approaching.
"Mr. Wingo was coming down the hall and he was yelling he was the police and screaming, " Wofford, then 29 years old, later testified during a coroner's inquest. "And I told him --- I said, 'Mr. Wingo, you know if you keep yelling out loud the nurse probably won't let you go outside, you know, you need to calm down.'
"Well, about that time he just started swinging and pushing at me and hit me in the head. And I backed back and he was coming forward towards me and we fell down. He fell on top of me and then I rolled over on top of him and was just holding his arms to keep him from, you know, hitting him."
Wingo stood 5 feet 5 inches and weighed 330 pounds. An autopsy report would later describe him as "morbidly obese." As Wofford struggled with him on the floor, two other staff members joined in. The other workers held Wingo's lower body, records show, while Wofford stretched across his shoulders.
His face to the floor, according to medical records and an autopsy report, Wingo struggled about two minutes.
When his struggling stopped, the hospital workers turned Wingo onto his back. "He was unconscious, " Wofford said, "and that was pretty much it."
About an hour later, doctors at a nearby emergency room officially pronounced Wingo dead.
Later in the day, according to medical records from Redmond Regional Medical Center, a physician from Northwest Georgia Regional called the emergency room to discuss Wingo. Attorneys for Wingo's family now describe the call as an attempt to conceal the truth about the death.
An emergency room doctor wrote about the conversation: "He states that the patient was agitated about smoking, then lay down and [died]. He denies that the patient was being restrained."
Aluminum pipe beating
When a state hospital patient dies or is assaulted, the hospital investigates itself.
Each of the seven state hospitals employs its own police force, and those officers conduct most initial investigations. Other hospital workers and officials at the Department of Human Resources also may get involved.
The Georgia Bureau of Investigation assists, when asked. But GBI officials said the hospitals do not systematically notify them of deaths or of other serious incidents.
And GBI agents with a task force that investigates abuse in nursing homes and other institutions said they could recall handling no more than two cases from state hospitals this decade.
Before hospital officials are allowed to call the GBI, they first must notify their department's headquarters in Atlanta. This extra step, the agency said in a 2000 memo establishing the policy, is intended "to improve and streamline our responses to incidents."
From January 2002 through late 2006, state officials recorded 934 allegations of physical or sexual abuse of patients by employees, according to the Journal-Constitution's analysis of hospital incident reports. Officials substantiated 194 allegations.
The newspaper could find criminal charges in no more than a handful of incidents.
Officials at the Department of Human Resources said they do not track the number of cases that result in prosecutions. However, they said they had identified nine instances in 2006 in which hospitals sought charges against employees accused of abusing patients.
During that year, the agency substantiated 31 cases of physical and sexual abuse in the seven hospitals.
A state policy has long mandated that hospitals fire workers if the "greater weight" of available evidence indicates they abused patients.
Under that policy, a hospital's administrator decides whether to ask prosecutors to file charges. That request may be made only if "evidence beyond a reasonable doubt shows that an employee has abused a patient."
That is the standard required for a criminal conviction. In most prosecutions, authorities apply a less stringent measure --- probable cause that a person committed a crime --- in deciding whether to file charges.
Consequently, for state hospital employees caught abusing patients, firing often is their only punishment.
That sometimes is true even when outside investigators get involved.
Officials at East Central Regional Hospital near Augusta learned in 2002 that a patient had been beaten with an aluminum pipe. Investigators later determined that one or more employees had stashed as many as 22 pipes throughout the hospital. Officials found 12 --- hidden on shelves in patients' rooms, in closets and drawers, and in day rooms where patients congregated.
A state report says that when authorities showed one of the pipes to a 32-year-old patient who had welts on her buttocks, she flinched.
Based partly on her reaction, investigators expressed concern that "there may have been widespread abuse, both physical and psychological, by the staff toward the consumers."
After a GBI investigation, prosecutors sought charges against an employee who had been one of the patient's caretakers. But a grand jury declined to indict the woman.
The hospital fired both that worker and another who had witnessed the beating but failed to report it promptly. Other employees denied using the pipes, so hospital administrators took no additional disciplinary action, said Dena Smith, a spokeswoman for the Department of Human Resources.
Hospitals sometimes seem slow to ask outside authorities to investigate, the Journal-Constitution found.
Last May at Georgia Regional Hospital/Atlanta, a 32-year-old patient dialed 911 to report that an employee had raped her. Before dispatching a DeKalb County police officer, the 911 operator called Georgia Regional.
"We informed them that our facility police would handle the investigation, " a hospital employee later told state investigators.
A hospital employee accompanied the patient to Grady Memorial Hospital in downtown Atlanta for a rape examination. On the way, the patient later told investigators, the employee asked her: "Are you sure you want to do this?" The accused worker "has new twin boys and a beautiful fiancee and is getting married. Do you want to ruin his life?"
When the hospital's administrator, Ronald Hogan, learned the patient's rape examination confirmed she had been assaulted, he fired the accused employee, Jermaine Ahmad Watson, 30, of Atlanta.
But six days passed before the hospital notified either the Department of Human Resources headquarters or the GBI, records show.
"The person responsible for submitting the incident report was absent for that amount of time, " said Gwen Skinner, director of the department's mental health division. "That delayed it."
The GBI arrested Watson on May 23, three weeks after the incident. Charged with rape and sexual assault on a person in state custody, Watson posted $15,000 bond and was released June 13. No trial date has been set.
'Recipe for disaster'
After Rickey Wingo's death during the restraint, a GBI agent interviewed several employees at Northwest Georgia Regional. All suggested he died from natural causes.
"I think it was a blood clot or some type of massive heart attack that caused Rickey to die, " nurse Patrick Andrews told the GBI. "I did not see anyone holding Wingo in a manner that would cause him to choke."
Wofford, the first employee involved in the altercation, said: "I never did put my arms around his neck in a chokehold. I don't think anyone here did anything to cause Wingo's death."
Dr. Kris Sperry, Georgia's chief medical examiner, reached a different conclusion.
On the back of Wingo's head, Sperry found two wounds he later described as being consistent with blows from a fist. Both caused "extensive" internal bleeding, Sperry said later.
On the front of Wingo's neck, Sperry found another injury that caused even more internal bleeding and apparently cut off oxygen to the brain.
Testifying in a deposition for a lawsuit filed by Wingo's family, Sperry said he could think of no cause for the neck injury other than a chokehold.
Being strangled causes "some of the most intense panic that human beings can sustain, " he testified. "The feeling of not getting enough to breathe is extremely anxiety-producing."
Although Wingo obviously struggled, Sperry said, it's not clear whether Wingo was fighting to get loose or simply to catch his breath.
"There comes a point ... where the struggle that is being observed reflects the person's inability to breathe adequately and get enough oxygen to their brain, " he said. "Certainly before the person lapses into unconsciousness, what is being seen is the panic because the person cannot breathe."
Sperry found two breaches of accepted standards in Wingo's restraint.
First, holding a person facedown on the floor is "a recipe for disaster, " he said, because it can block breathing passages.
Second, he said, a chokehold should be used only in life-or-death struggles, not in restraining a mental hospital patient.
Sperry ruled Wingo's death a homicide --- that is, caused by another person's actions.
"This was more than an incidental, unfortunate death, " Sperry said in an interview. Wingo, he said, died because of "the exertion of physical violence."
On June 19, 2002, almost a month after Wingo's death, the Floyd County coroner impaneled a six-person jury to sort through the case.
A GBI agent and the county's chief deputy coroner told the jury they agreed with the medical examiner's findings. But four hospital employees testified they were not responsible for Wingo's death.
Still, Wofford told the jury he regretted the incident: "It's so scary, you know. . . . Things just ain't the same working, you know, when something like that happens."
In the end, the coroner's jury unanimously classified Wingo's death a homicide. The panel, however, had no authority to file charges.
A few weeks later, the GBI turned the case over, without comment, to the Floyd County district attorney's office. A file in the office says prosecutors declined to charge Wofford, citing "insufficient evidence."
"They could not prove criminal intent or criminal negligence, " District Attorney Leigh Patterson, who did not work in the office at the time, said last week.
To the criminal justice system, the case was closed.
"I don't think it was done criminally, " said Barry Henderson, the Floyd County coroner. "The guy had to be restrained."
Wingo's head wounds didn't sway Henderson.
"People like that tend to bump into things, " he said.
Sperry, the medical examiner, said that, in contrast to most homicide cases, prosecutors never asked him about Wingo's autopsy or his opinion on whether the hospital workers were criminally negligent.
In an interview, Sperry was asked what he would have said.
He paused several seconds. Then he answered: "It's a very difficult question. It's a hard question. It amazes me sometimes what things get prosecuted and what things don't get prosecuted. That's all I can tell you."
Officials at Northwest Georgia Regional did not punish any worker involved in Wingo's restraint because criminal investigations established no abuse or neglect, said Smith, the Department of Human Resources spokeswoman. "There was no misconduct."
About six months after Wingo's death, the hospital honored Wofford for five years' service. The following March, prosecutors put the unrelated battery case against him on indefinite hold; the alleged victim was in the U.S. Army and had been deployed to Kuwait, according to court records.
Wofford remained at the hospital as a clerical worker until last summer. Efforts to reach him by telephone and in person at his last known address were not successful.
With the criminal investigation finished, all that remained was a lawsuit filed by Wingo's son and daughter, from whom he had been estranged.
Shortly after Sperry's deposition outlining his findings, the state settled the case for $850,000 --- the largest payment of its kind in an abuse or neglect case from the state hospitals. Since 2002 the state has paid $239,000 to settle five other abuse cases from the psychiatric hospitals.
The state admitted no fault in Wingo's death. Employees involved in the restraint were not parties to the settlement.
Wingo's son, Rusty, said recently he and his sister believe the payment failed to make up for the violence of their father's death, or for the lack of justice afterward.
"It was like they just wrote it off."