When a woman with developmental disabilities drowned in the bathtub, state investigators took two months to conclude she had suffered no neglect.
But even then, the investigators missed critical information: Two state-provided caregivers were supposed to keep the woman in sight at all times. Instead, they had once let her go to McDonald’s on her own – and left her alone in the tub for as long as seven minutes.
The case reflects a disturbing pattern detailed in a new report on Georgia’s behavioral health system: untimely, superficial death investigations that lead to dubious conclusions.
“The findings and recommendations in certain investigations cause concerns about thoroughness and, even more importantly, the legitimacy of the conclusions drawn from the investigation,” a court-appointed monitor, Elizabeth Jones, wrote to U.S. District Judge Charles Pannell.
In the drowning, Jones wrote, “multiple elements … are consistent with a finding of neglect. It is disturbing that that conclusion was not reached. … There should have been further investigation into how such an accident could have happened to an individual with enhanced staffing requirements.”
Officials with the state Department of Behavioral Health and Developmental Disabilities declined a request for an interview on Wednesday. In a statement, spokeswoman Angelyn Dionysatos said the department “is focused on sustaining the significant system gains that have been achieved and addressing remaining areas of required compliance.”
“The independent reviewer continues to provide reflections and recommendations that are valuable to DBHDD,” Dionysatos said.
How Georgia treats people with disabilities and mental illness has been under scrutiny since The Atlanta Journal-Constitution published a series of investigative reports 10 years ago. The articles detailed dozens of suspicious deaths in state hospitals and a lack of community services for people under state care.
A settlement agreement with the U.S. Department of Justice in 2010 required the state to spend millions of dollars on new services and to move hundreds of patients out of psychiatric hospitals.
But Jones, who monitors compliance with the agreement, found that more than 350 people with disabilities remain in state hospitals and that the state has made “scant” progress in providing homes for people with chronic mental illness.
In addition, her report suggests that preventable deaths still occur and don’t always receive appropriate scrutiny.
During the year that ended June 30, officials reported 160 deaths among people receiving state disability services. The top cause of death was heart disease. But the second- and third-most prevalent causes were “disability” and aspiration pneumonia, a condition often associated with choking on food.
By the time Jones submitted her report last month, investigations had been completed on 68 of the 160 deaths, she wrote. Such inquiries are supposed to be finished within 30 days.
Among the unresolved cases: the Jan. 24 death of a man who reportedly had been neglected previously; the March 24 death of a man with a bowel obstruction; the April 3 death of a woman with sepsis and pneumonia; and the unexplained death on June 7 of a man who lived in a group home where three other residents had died since 2014.
“It would seem that the death of anyone living in a residence under the responsibility of a provider where there have been documented concerns about the quality of care would prompt even closer monitoring in the homes to ensure that proactive and promptly reactive measures are taken to meet the individualized needs of those still living in the same residence, especially those similarly situated who are in decline or crisis,” Jones wrote.
Jones noted progress in other areas, including clearer strategies to prevent injury or illness for former state hospital patients on a list of “high-risk” group home residents. She also said no patients younger than 18 had been admitted to a state hospital since the settlement agreement took effect.
But she said other problems persist. State facilities, including Georgia Regional Hospital/Atlanta, continue to discharge patients to homeless shelters or extended-stay motels. Many of them, Jones wrote, were “lost to follow-up (treatment) almost immediately.”
“This is unacceptable,” she wrote. “It is not known whether they are experiencing another negative outcome, such as street homeless or incarceration,” or worse.
“There are major gaps in the state’s performance that must be addressed,” Jones wrote to the judge. Noting that the settlement agreement is scheduled to expire next June, she said she felt “compelled to stress the urgency needed to demonstrate substantial progress in achieving outcomes that have not been realized so far.”