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.


CHERRY HOSPITAL
Psychiatric facility, Goldsboro
Opened 1880
Annual budget: $73.6 million
274 patient beds
1,120 employees


CLIFTON NAKAYA LARONE GENTRY, 27
Died: July 22, 2005
Hometown: Jacksonville
Manner: Suicide
Investigation: Yes, deficiencies cited
Autopsy: Yes
Cause: Gunshot wound to the head
Summary: While waiting in the hospital admission office, Gentry is reported to have grabbed a .45 caliber pistol from a sheriff's deputy and shot a staff member in the leg before shooting himself. Following his death, the hospital instituted restrictions on law officers taking their firearms into the hospital.


DELORES INGRAM FRANKLIN, 47
Died: Feb. 8, 2004
Hometown: Goldsboro
Manner: Natural
Investigation: Yes, deficiencies cited
Autopsy: Yes
Cause: Heart disease
Summary: Though Franklin's death was reported as natural, an investigation determined she stopped breathing while in a seclusion room immediately following a dose of the sedative Thorazine injected by a hospital nurse without a doctor's approval. She was then left unobserved, a violation of procedure. Thorazine can cause abnormally low blood pressure, which can lead to death in patients with heart disease. Attempts to revive her were complicated when the staff was unable to locate needed emergency medical equipment. The report filed by the hospital following her death indicates she was not in restraints and seclusion at any time in the 24 hours prior to her death, which was not true.


DONALD MICHAEL JONES, 32
Died: July 27, 2006
Hometown: Greenville
Manner: Natural
Investigation: Yes, deficiencies cited
Autopsy: No
Cause: Acute myocardial infarction
Summary: Though Jones is listed as dying of a heart attack, a subsequent investigation cited the hospital for allowing Jones access to a bottle of the antidepressant Elavil. He took 28 pills and overdosed while awaiting discharge from the hospital after pleading to stay. An inspection following Jones death found the staff had not properly secured potentially lethal drugs.


JANELLA WILLIAMS, 35
Died: Feb. 17, 2006
Hometown: Acre Station
Manner: Homicide
Investigation: Yes, deficiencies cited
Autopsy: Yes
Cause: Compressional asphyxia
Summary: Williams suffocated while being held down by more than a dozen staff members and then left unsupervised in restraints. Regulators later cited the hospital with numerous violations following her death, though the local district attorney says he was never notified of the homicide to conduct a review for potential criminal negligence. The state settled a wrongful death claim, paying $275,000 to Williams' mother.


MARCUS ANTHONY MILLER, 17
Died: June 1, 2003
Hometown: Wilson
Manner: Natural
Investigation: Yes, no deficiencies cited
Autopsy: Yes
Causes: Undetermined
Summary: Found dead next to his bed in the early morning. An autopsy was unable to determine the exact cause of death, but the report indicates Miller had been taking Geodan, a then new antipsychotic with the potential to cause heart problems and sudden death.


ROBERT EARL LEONARD JR., 19
Died: Dec. 25, 2006
Hometown: Rocky Mount
Manner: Accident
Investigation: Yes, no deficiencies cited
Autopsy: Yes
Cause: Asphyxia; inhalation of gastric contents
Summary: Admitted Oct. 22 with a diagnosis of schizophrenia and substance abuse, a hospital report says Leonard was hitting other patients and was placed on a close observation status that required at least one staff member to be in the same room with him. On Christmas Day at 4:15 p.m., Leonard went to his room to lie down, got in his bed and pulled the covers over his head, which is described as unusual behavior for him. He appeared to be asleep, the report says. When a staff member tried to rouse him about 5:10 for supper, he was no longer breathing and there was mucous on his pillow. An autopsy concluded he died after inhaling his own vomit.


BARBARA ANN WINSTEAD, 62
Died: June 24, 2004
Hometown: Wilson
Manner: Unspecified
Investigation: None indicated
Autopsy: Not known
Cause: Septicemia
Summary: Admitted to Cherry May 31 with a diagnosis of schizoaffective disorder, she refused to eat, drink or sufficiently bathe. She developed a urinary tract infection and 103-degree fever. She was treated with antibiotics, but the infection persisted. On June 21 she was transferred to Dix Hospital in Raleigh for more intensive medical treatment. Within minutes of arrival she was noted to be having difficulty breathing and had a rapid heart rate. She was transferred to a nearby acute medical hospital where she died three days later.


JOHNNY LEE INGALLS, 42
Died: Aug. 26, 2005
Hometown: Washington
Manner: Natural
Investigation: Yes, no deficiencies cited
Autopsy: Yes
Cause: Withdrawal state
Summary: Admitted to Cherry the evening of Aug. 25 with alcohol induced psychosis, an autopsy report says Ingalls was unruly and "required significant sedation during the night." The staff was unable to wake him at 8 the following morning and 911 was called. It took 30 minutes for paramedics to arrive, according the the hospital's report. The patient was declared dead upon arrival to a nearby emergency room. Ingalls' death, so soon after his arrival at Cherry, raises questions about whether his symptoms for alcohol withdrawal were adequately monitored.