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.


MURDOCH DEVELOPMENTAL CENTER
Residential facility for patients with developmental disabilities, Butner
Opened 1948
Annual Budget: $87 million
575 patients
1,735 employees


HEIDI ELAINE WITCHER, 47
Died: Jan. 19, 2007
Hometown: Address listed as center
Manner: Unspecified
Investigation: No
Autopsy: No
Cause: Pneumonitis due to food and vomit; septicemia
Summary: Witcher, admitted to Murdoch in 1973,was having severe breathing difficulty on Jan. 7, 2007. The oxygen levels in her blood were low. The center's report indicates she had inhaled hood or vomit into both lungs. Transferred to a nearby hospital, she developed a bacterial blood infection. Though treated with antibiotics, she died Jan. 9.


LEONARD KNOX, 65
Died: June 17, 2005
Hometown: Address listed as center
Manner: Unspecified
Investigation: No
Autopsy: No
Cause: Inhalation of objects causing obstruction of respiratory tract
Summary: Admitted to Murdoch in 1965, Knox had been fed through a tube inserted into his stomach for about 9 years. On June 3, 2005, staff noticed he was wheezing and grunting. He was very congested, had a fever and his blood pressure elevated. Over the next few days, the center's report said he seemed to get better. But on June 15, his symptoms returned and the level of oxygen in his blood was low. He was transferred to a nearby hospital where he was treated with antibiotics for aspiration pneumonia. He died two days later.


GABRIEL EVAN LOWDER, 36
Died: March 20, 2007
Hometown: Louisburg
Manner: Unspecified
Investigation: No
Autopsy: No
Cause: Adult respiratory distress syndrome
Summary: Admitted to Murdoch in 1994 with mental retardation and quadriplegia, he was fed pudding-thick meals. The center's report says he did "not seem his usual self" on March 1, 2007. The level of oxygen in his blood was low and he was transfer to a nearby emergency room with a diagnosis of aspiration pneumonia likely the result of inhaling food or vomit into his lungs. He was placed on a ventilator but did not improve. After two weeks, on March 20, he was taken off the ventilator and died.


THOMAS PRESTON FERRELL, 65
Died: Oct. 12, 2005
Hometown: Address listed as center
Manner: Unspecified
Investigation: No
Autopsy: No
Cause: Gastrointestinal hemorrhage; volume depletion
Summary: Admitted to Murdoch in 1960, Ferrell began vomiting dark material on Oct. 11, 2005. He was given an enema to relieve a suspected intestinal blockage. Later he was noticed to have blue lips, a sign of not enough oxygen in the blood. His pulse was weak. EMS was called and efforts to resuscitate him started. He expelled a "large amount" of dark fluid from his mouth and died. The cause of death indicates he had massive bleeding in his upper digestive tract that had gone unnoticed.


CHARLES GOLDSTON, 55
Died: Nov. 1, 2005
Hometown: Address listed as center
Manner: Unspecified
Investigation: No
Autopsy: No
Cause: Abdominal hernia with gangrene
Summary: Admitted to Murdoch in 1975, Goldston was noticed on Oct. 24, 2005, to have increased drooling and difficulty breathing. He was transferred to a nearby emergency room. At the hospital, it was determined he had a bowel obstruction as a result of an untreated hernia. It was determined surgery could not repair the extensive damage and he was moved back to the Murdoch Center on Oct. 27. He died five days later.