The following people are among 82 who have died since December 2000 under circumstances that raise questions about their care while patients or immediately after discharge from a state mental institution, according to a News & Observer investigation aided by several medical professionals, including Harold Carmel, a psychiatrist and the former clinical director of Umstead Hospital.

The following information is drawn from death certificates and autopsy reports, as well as redacted copies of state death reports and regulatory reports where deficiencies in care were found. The manner of death cited is from the state's death certificate database, but, in some cases, the finding does not match the circumstances of death. Doctors at the hospital where the individual died typically designate the manner and cause of death unless there is a subsequent autopsy.

Investigations are conducted by the state Division of Health Service Regulation, which oversees medical facilities in North Carolina.

BROUGHTON HOSPITAL
Psychiatric facility, Morganton
Opened 1883
Annual budget: $77.4 million
313 patient beds
1,269 employees

ANTHONY DAWAYNE LOWERY, 27
Died: Feb. 1, 2007
Hometown: Clover, S.C.
Manner: Accident
Investigation: Yes
Autopsy: Yes
Cause: Compressional asphyxia
Summary: Lowery, who had schizophrenia, was seen rummaging through a dining room garbage can during lunch. When told to stop, he became agitated and threw the trash can. He was then tackled by several staff members and taken to the floor. He suffocated while being physically restrained on his back, with staff members sitting on his limbs and one on his chest. Federal officials found his care to be so deficient, they cut off Medicaid and Medicare payments to the hospital, costing state taxpayers at least $7 million so far.

SHAUN TOBIN LLEWELLYN, 22
Died: Jan. 27, 2004
Hometown: Concord
Manner: Accident
Investigation: Yes, no deficiencies found
Autopsy: Yes
Cause: Acute methadone toxicity
Summary: Admitted Jan. 21 with suicidal thoughts and suspected drug use, Llewellyn was found on the floor of his room six days later. Another patient told the staff he and Llewellyn had taken numerous pills containing methadone the night before his death. Methadone is a synthetic opiate often used as a painkiller and to stem the cravings of drug addicts. The autopsy report does not say how he was able to get the intoxicating pills, which are not listed among his prescribed medications.

EMORY KIRKLEE ROSSER, 28
Died: Feb. 25, 2003
Hometown: Candler
Manner: Accident
Investigation: Yes, no deficiencies cited
Autopsy: Yes
Cause: Acute methadone toxicity
Summary: Rosser was admitted Feb. 24 for drug dependency. He was prescribed high doses of methadone three times a day, as well as the painkiller Vicodin. He was found in his bed at 6:45 a.m. the next morning with large amounts of vomit around his face. An autopsy determined he died from ingesting toxic levels of his prescribed medication.

CARL WAYNE TOURNEAR, 37
Died: Aug. 3, 2007
Hometown: Mooresville
Manner: Suicide
Investigation: Yes, no deficiencies cited
Autopsy: None indicated
Cause: Gunshot wound to head
Summary: Tournear is reported to have taken about 100 pills of Valium and then barricaded himself in a house, resulting in his being Tasered by police. Involuntarily committed to Broughton July 31, he was discharged the following day with a prescription for antidepressants. Two days after he left the hospital, Tournear went to a sporting goods store and bought a gun. He then shot himself.

DEBORAH LYNN BISHOP, 45
Died: Oct. 18, 2001
Hometown: Address listed as mental hospital
Manner: Suicide
Investigation: Yes, deficiencies found
Autopsy: Yes
Cause: Asphyxiation by hanging
Summary: Bishop was a long-term resident with schizophrenia. She was found in her room, hanging from a bra looped over the bar in her clothes locker. She had been left alone, unsupervised, despite a history of suicide attempts, including a self-performed amputation of her forearm.

DARRELL ORLANDO PATTERSON, 39
Died: March 6, 2002
Hometown: Address listed as mental hospital
Manner: Accident
Investigation: Yes
Autopsy: Yes
Cause: Drowning
Summary: Patterson, who had schizoaffective disorder, was found at 4:50 a.m. lying in a bathtub filled with about a foot of water with his head fully submerged. He was reported not to be suicidal and an investigation found no evidence of foul play.

KATHLEEN ANNE HARPER, 33
Died: Nov. 17, 2005
Hometown: Indian Trail
Manner: Suicide
Investigation: Yes
Autopsy: Yes
Cause: Intentional self poisoning
Summary: Admitted Nov. 12 for depression and alcohol dependence, she was discharged Nov. 14. She was found dead in her car three days later.

TRINA SUZANNE HANNAH, 59
Died: July 11, 2001
Hometown: Maggie Valley
Manner: Suicide
Investigation: Yes, no deficiencies found
Autopsy: Yes
Cause: Suicide by handgun
Summary: DHHS officials could not find the written report with details of Hannah's death, but a database entry indicates she died less than a week after leaving the hospital. A medical examiner's review indicates she shot herself in a public street.

DWIGHT SPURGEON SNIPES, 69
Died: Sept. 28, 2003
Hometown: Address listed as mental hospital
Manner: Unspecified
Investigation: No
Autopsy: No
Cause: Septicemia
Summary: Admitted March 3, 2003, Snipes was sent to the medical ward the morning of his death for lethargy and low blood pressure, Snipes was given an IV antibiotic but did "not respond to therapy." Report from hospital provides little detail, but listed cause of death indicates widespread blood infection that apparently went untreated until immediately before death.

DEBORAH KAY RICHMOND, 45
Died: Oct. 17, 2003
Hometown: Pinnacle
Manner: Accident
Investigation: Yes, no deficiencies cited
Autopsy: No
Causes: Multiple injuries
Summary: Admitted for anxiety and expressing suicidal thoughts, Richmond was discharged after a nine-day stay on Oct. 16. The following day, Richmond was driving on U.S. 52, a busy four-lane highway, when she stopped her vehicle and got out. She then stepped into the path of an oncoming tractor-trailer, according to medical examiner's report.

MONICA EILEEN SANDBORN, 37
Died: July 19, 2004
Hometown: Hendersonville
Manner: Suicide
Investigation: Yes, no deficiencies indicated
Autopsy: No
Causes: Multiple trauma
Summary: Admitted July 12 after a suicide attempt. Discharged July 16. A medical examiner's report indicates that three days later she jumped in front of a tractor-trailer on Interstate 26 and was subsequently run over by several vehicles.

TINA CAROL GRIBBON, 36
Died: Sept. 23, 2004
Hometown: Brevard
Manner: Unspecified
Investigation: No
Autopsy: No
Causes: Delirium; obstruction of respiratory tract
Summary: Transferred to Broughton Sept. 16 for treatment of an overdose of psychiatric drugs and alcohol withdrawal, Gribbon went into respiratory distress two days later and was transferred by ambulance to a local emergency room. Hospital report provides little detail of why Gribbon was having trouble breathing, but suggests she suffered severe brain damage due to lack of oxygen.

JERRY PARKER, 56
Died: March 13, 2005
Hometown: Washington, D.C.
Manner: Unspecified
Investigation: No
Autopsy: Yes, private
Cause: Staphylococcus
Summary: Parker, who was schizophrenic, was sent to Broughton's acute medical ward March 12 coughing up blood and short of breath. A chest X-ray showed signs of an infection in his lungs. Antibiotic treatment was started and he was transferred to another hospital where he died the next day. Cause of death indicates staph infection was likely present well before he received treatment. A box is also checked on the report indicating he was in restraints within 24 hours of death.

JERRY RODRIQUE LOVE, 36
Died: Aug. 16, 2005
Hometown: Pineville
Manner: Suicide
Investigation: Yes, no deficiencies cited
Autopsy: Yes
Cause: Hanging
Summary: Admitted Aug. 9, Love suffered from severe depression and said he heard voices in his head urging him to drink. He was sent home Aug. 11 after he said his hallucinations had stopped and hospital staff deemed him "capable of making responsible decisions." He hanged himself with a vacuum cleaner cord a week later. Tests showed he had toxic levels of alcohol in his blood when he died.

STEVEN RHYMER EARLEY, 47
Died: Aug. 31, 2007
Hometown: Forest City
Manner: Natural
Investigation: No
Autopsy: Yes
Cause: Cardiovascular disease
Summary: Earley, who had schizoaffective disorder, was admitted to Broughton Hospital Aug. 26. The hospital's report indicates he was restrained by staff and placed in a seclusion room on Aug. 27 and 28. When staff checked on him the morning of the 29th, he was in bed and unresponsive. Rushed to a local acute care hospital, his brain had been starved of oxygen and, with his family's consent, he was taken of life support and died three days later. A test on his urine at the hospital was positive for oxycodone, a powerful painkiller that was not among his prescribed drugs. Blood tests later failed to confirm the earlier result and a pathologist determined Earley's history of heart disease most likely caused his death. The autopsy -- which notes signs of blunt trauma such as bruises and burst blood vessels on his back, torso, hips and legs -- makes no mention of Earley's restraint in the mental hospital, and the pathologist said he wasn't aware of the incident. Earley's Aug. 31 death came days after Broughton was cut off from federal funding following the restraint death of Anthony Lowery. But because Broughton is still cut off from federal money, the regulators say they have no jurisdiction to investigate the circumstances of Earley's death.

MAE PEARL MULLINAX, 79
Died: March 26, 2001
Hometown: Address listed as hospital
Manner: Unspecified
Investigation: No
Autopsy: No
Causes: Pulmonary disease; anemia
Summary: DHHS officials said they no longer have the written report of Mullinax's death, but an entry in a state database indicates she may have died while in psychiatric restraints.

RUTH ELIZABETH LANE, 80
Died: July 28, 2002
Hometown: Morganton
Manner: Unspecified
Investigation: No
Autopsy: Yes, private
Causes: Pneumonia; obstruction of respiratory tract
Summary: Lane, who had dementia, was confined to a wheeled reclining chair and was fed through a tube inserted in her nose. Report from hospital indicates she frequently inhaled food or vomit into her lungs, resulting in pneumonia and respiratory distress.

HENRY ELLIOTT RUPPE, 72
Died: Aug. 1, 2002
Hometown: Shelby
Manner: Natural
Investigation: No
Autopsy: Not indicated
Cause of Death: Alzheimer's disease
Summary: A long-term resident of the hospital, Ruppe was fed with a tube inserted into his stomach through a small incision in the abdomen. He was sent to the acute care ward July 6, vomiting and feverish. Tests later showed his feeding tube opening was infected with strains of bacteria resistant to antibiotics. He was discharged to a private nursing home July 25 and died six days later.

BETTY JEAN SPARKS, 71
Died: Dec. 9, 2003
Hometown: Address listed as mental hospital
Manner: Unspecified
Investigation: No
Autopsy: No
Causes: Renal and perinephric abscess
Summary: Sparks, who had bipolar disorder, broke her right hip and had recurring urinary tract infections from a drug-resistant bacteria often associated with poor wound care. Though treated with antibiotics, the infection spread. Abscesses formed in her kidneys and Sparks died of blood poisoning. The hospital's report provides no explanation of how Sparks fractured her hip.

NETTIE LUCILLE FORREST, 66
Died: March 25, 2004
Hometown: Pilot Mountain
Manner: Unspecified
Investigation: No
Autopsy: No
Cause: Urinary tract infection
Summary: While in the hospital, Forrest contracted recurring urinary tract infections. On March 25, she was sent to the acute care ward due to trouble breathing and a rapid heart rate. She was dehydrated and was given IV antibiotics. An ambulance was called to transfer her to a nearby emergency room, but her heart stopped as she was moved onto a stretcher for transport.

RONALD JAMES WILSON, 55
Died: Nov. 27, 2004
Hometown: Shelby
Manner: Unspecified
Investigation: No
Autopsy: Not indicated
Cause: Septicemia
Summary: Wilson, who had schizoaffective disorder, was paraplegic and used a colostomy bag. While in the hospital, he developed reoccurring urinary tract infections, a bone infection in his right hip and a persistent bedsore on his left foot -- conditions often indicative of poor medical care. Uncontrolled, the infections resulted in a 103-degree fever and Wilson went into septic shock. He was transferred to an acute care hospital, where he died.

OPHELIA A. FORNEY, 74
Died: Sept. 6, 2005
Hometown: Spindale
Manner: Unspecified
Investigation: No
Autopsy: Not indicated
Cause: Septicemia; renal failure
Summary: Forney, who had schizophrenia, was admitted Aug. 22. She soon became dehydrated and an examination on Sept. 5 indicated her kidneys were failing and a serious imbalance of electrolytes in her blood. She was also had a urinary tract infection and vomited fecal material, which suggests severe constipation or an intestinal obstruction. She was transferred to an acute care hospital but died the same day.

KENNETH RAY HEDRICK, 43
Died: Oct. 1, 2005
Hometown: Statesville
Manner: Unspecified
Investigation: Yes, no deficiencies indicated
Autopsy: No
Causes: Motor neuron disease; cardiac arrest
Summary: Hedrick, who had Lou Gehrig's disease, was fed through a tube in his stomach and was prone to inhaling food and excess amounts of saliva into his lungs. He died after inhaling stomach contents, raising questions about whether standard precautions were in place to prevent aspiration.

MORRIS NEAL SUTHERLAND, 84
Died: Nov. 9, 2002
Hometown: Mount Airy
Manner: Unspecified
Autopsy: No
Causes: Septicemia; pneumonitis due to food and vomit
Summary: Sutherland, who had dementia and needed assistance to eat, was admitted Oct. 12 and sent to the hospital's acute care ward Nov. 7 for dehydration and pneumonia. He died two days later. Listed causes of death indicate Sutherland died of a blood infection after inhaling food and vomit into his lungs, raising concern about whether effective precautions were in place to prevent aspiration.

UNKNOWN NAME, 58
Died: Oct. 27, 2007
Hometown: Not known
Manner: Not known
Investigation: No
Autopsy: No
Cause: Urosepsis
Summary: According to redacted copy of hospital report, the male patient had serious depression and was addicted to methadone. On Oct. 24, there "was difficulty in placing a suprapubic catheter," a tube inserted into the bladder through an incision made a few inches below the navel. The following day he was transferred to an acute care hospital with abnormally low blood pressure and urosepsis, a serious urinary tract infection that has spread to the bloodstream. He died two days later.

UNKNOWN NAME, 71
Died: Nov. 14, 2007
Hometown: Not known
Manner: Not known
Investigation: None indicated
Autopsy: None indicated
Cause: Cardiac arrest following electric shock treatment
Summary: A male patient with schizoaffective disorder and prostate cancer was restrained in a wheeled recliner. According to a redacted hospital report, he was transferred by Broughton on Nov. 9 to a clinic in Asheville to receive electroconvulsive therapy. The report indicates the patient was "medically stable." After his first shock treatment he stopped breathing and was moved to an intensive care unit, where he died Nov. 14.