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.




JOHN UMSTEAD HOSPITAL
Psychiatric Facility, Butner
Opened 1947
Annual Budget: $81 million
321 patient beds
1,298 employees

DARNELL JAMARR HARRELL, 22
Died: March 3, 2005
Hometown: Winston-Salem
Manner: Suicide
Investigation: Yes, deficiencies cited
Autopsy: Yes
Cause: Asphyxiation due to hanging
Summary: Admitted to Umstead Feb. 21 with a diagnosis of schizophrenia, Harrell was found dead in a shared hospital shower hanging from a belt attached to a handicapped handrail. Staff members indicated they were unaware he was suicidal, though records say he had bought a knife with plans to kill himself the day before he was admitted. An investigation later determined the hospital had failed to provide the services necessary to prevent Harrell from harming himself.

RUTH BRYAN TIDWELL, 84
Died: April 17, 2003
Hometown: Oxford
Manner: Accident
Investigation: None indicated
Autopsy: No
Cause: Sepsis
Summary: Tidwell is reported to have fallen while in the hospital's geriatric psychiatric ward. She was transferred to Durham Regional Hospital, where surgeons attempted to repair her shattered femur with metal plates and screws. The repair failed, and doctors amputated her leg. Tidwell then developed an infection. Though treated with antibiotics, she died.

<ALFONZO LEONARD HICKS, 53
Died: Feb. 12, 2002
Hometown: Winston-Salem
Manner: Natural
Investigation: Yes, deficiencies cited
Autopsy: Yes
Cause: Volvulus of the small bowel
Summary: Hicks complained of abdominal pain and constipation on Feb. 7. He received several doses of laxatives with "minimal results." On Feb. 11, he developed a high fever and was given a dose of antibiotics. He was found dead in the early hours of the next morning in his bed. An autopsy showed his abdominal cavity was filled with pus. An investigation determined Hicks received deficient nursing care and should have been sent to an acute care hospital. Critical X-rays that could have diagnosed his condition earlier went unread five days, until after Hicks' death, because a radiologist was contracted to come to Umstead only two days per week.

HENRY ELIAS LUTTERLOH JR., 75
Died: Dec. 30, 2000
Hometown: Address listed as mental hospital
Manner: Unspecified
Investigation: Yes, deficiencies cited
Autopsy: No
Cause: Atherosclerotic heart disease
Summary: Lutterloh, who had Parkinson's disease and several other medical problems, fell while a patient at Umstead on Dec. 28, 2000. He complained of abdominal pain and soon began vomiting material that looked like coffee grounds, a textbook sign of gastrointestinal bleeding. The following morning, he refused to eat and once again vomited blood. Lutterloh was transferred to Umstead's medical unit for X-rays. Due to the hospital's radiologist working part-time, a physicians' assistant interpreted the slides. Without consulting a doctor, she determined Lutterloh had impacted bowels and gave him a bottle of laxative. Lutterloh was then taken to the bathroom, where he again fell and the staff member failed to catch him. He continued to vomit and became too weak to stand. He was found dead about 5:50 the following morning. Investigators found numerous deficiencies in Lutterloh's medical care. The X-rays that could have lead to his receiving the correct diagnosis were not properly interpreted by a radiologist for four days, by which time the patient had already died.

THEODORE CICKIEWICZ JR., 48
Died: Dec. 6, 2004
Hometown: Chapel Hill
Manner: Accident
Investigation: Yes, no deficiencies cited
Autopsy: Yes
Cause: Oxycodone toxicity
Summary: Cickiewicz, who was homeless, was admitted to Umstead Nov. 23 with suicidal thoughts and multiple psychological and medical problems. He was discharged Dec. 2 with a prescription for Percocet, a pill that contains the painkiller Oxycodone. Cickiewicz was found dead four days later of an apparent drug overdose, a nearly empty bottle of Percocet among his belongings.

JAMIE JEANETTE CRANE, 37
Died: May 23, 2007
Hometown: Greensboro
Manner: Suicide
Investigation: No
Autopsy: No
Cause: Intentional self harm by hanging
Summary: Admitted to Umstead May 5 for depression and alcohol dependence, Crane was discharged May 17 with staff noting she showed no indication of suicidal thoughts. Crane hanged herself in a hotel room six days later.

CHARLES C. RIGSBEE JR., 60
Died: July 17, 2002
Hometown: Durham
Manner: Unspecified
Investigation: Yes, deficiencies cited
Autopsy: No
Cause: Anoxic brain damage; cardiac arrest
Summary: Rigsbee had a long history of mental illness. According to the hospital's report, he was booted from a group home after kicking another resident and was dropped off at a homeless shelter. Admitted to Umstead June 4, 2002, his decision-making skills were rated as "extremely poor." On July 7, he choked on food during a meal. For days later, at lunch on July 11, he was observed to stuff a whole roll into his mouth. He started to turn blue and staff attempted the Heimlich maneuver. What appeared to be pieces of a sandwich were removed from his throat and a tube was inserted to help him breathe. He was transferred to an nearby acute care hospital, where he later died. The listed cause of death suggests a loss of oxygen caused severe brain damage. An investigation determined the hospital failed to prevent Rigsbee's fatal choking episode by failing to properly supervise him during mealtimes following the first event.

FREDERICK TECMUSH JAMES, 47
Died: Jan. 28, 2003
Hometown: Durham
Manner: Accident
Investigation: Yes, deficiencies cited
Autopsy: Yes
Cause: Tracheal infusion of Kayexalate
Summary: James, who was diagnosed with paranoid schizophrenia, refused to take a medication used to treat high levels of potassium in his blood. A group of nurses inserted a feeding tube in his nose to forcibly give the liquid, which caused James "some discomfort," according to the hospital's report. The patient soon started to complain he felt sick, began wheezing and died. The hospital's initial report said James most likely died of heart disease, but an autopsy found the forced medication had flooded his lungs, rather than going into his stomach as intended. Investigators found five of the six nurses involved in the incident had not been trained in the procedure, along with numerous other problems.

TEENAGE PATIENT, 16
Died: Dec. 11, 2007
Hometown: Chapel Hill
Manner: Pending
Investigation: No
Autopsy: Pending
Cause: Pending
Summary: Patient admitted Nov. 16 with a diagnosis of major depressive disorder and drug dependence, as well as suicidal thoughts. He was discharged Nov. 21 and referred for outpatient treatment. He died Dec. 6 of what the hospital reported as an opioid overdose, though it is not clear whether the overdose of pain killers was the result of an accidental overdose or suicide attempt. A final determination by the medical examiner is pending.

JAMES ALBERT SLAUGHTER, 66
Died: May 3, 2007
Hometown: Eden
Manner: Unspecified
Investigation: No
Autopsy: No
Cause: Pneumonia
Summary: Slaughter, who had dementia, was admitted to Umstead Feb. 23, 2007. On April 26 he developed at temperature of 103 degrees and went into respiratory distress. He was transferred to an acute care hospital in Durham and treated with antibiotics, IV fluids and oxygen. He died a week later. His symptoms suggest Slaughter may have suffered an infection after inhaling food or vomit.