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.


O'BERRY NEURO-MEDICAL CENTER
Residential treatment center for people with developmental disabilities, Goldsboro
Opened 1957
Annual Budget: $49.7 million
340 patients
1,035 employees


TONYA SUE ZIMMERMAN, 43
Died: April 23, 2002
Hometown: Address listed is that of center
Manner of Death: Accident
Investigation: No
Autopsy: Yes
Cause: Aspiration of gastric contents
Summary: Zimmerman, who could not speak or walk, had lived at the O'Berry Center since 1965. She had seven teeth pulled on Feb. 28 and was hospitalized for a resulting infection. She was discharged back to the group home March 7 and appeared to be doing well. On the day of her death, she refused to eat lunch but was still taken on a group outing to a local Wal-Mart. A staff member thought Zimmerman "didn't look right" and the group started back. Upon arrival at O'Berry, she was found in the back of the van in cardiac arrest. An autopsy determined she choked to death on her vomit. The state then placed a lien against her estate for "services rendered."


CHRISTOPHER EIDE, 57
Died: Oct. 17, 2002
Hometown: Pinehurst
Manner: Accident
Investigation: No
Autopsy Performed: Yes
Cause: Aspiration of gastric contents
Summary: Admitted to the O'Berry Center in 1994, Eide had developmental disabilities but was otherwise in good health. Report says Eide went to his room following dinner and collapsed. Attempts to revive him were unsuccessful. An autopsy found he died after choking on his own vomit.


PEGGY JEAN THOMPSON, 39
Died: March 14, 2003
Hometown: Chadbourn
Manner: Unspecified
Investigation: No
Autopsy: No
Causes: Septicemia; fistula of intestine
Summary: Thompson had developmental disabilities due to spinal meningitis and had lived at O'Berry since 1970. She was fed through a tube inserted through an incision in her abdomen into her stomach. In March 2003, she developed an infected abscess at the site where the feeding tube entered her body. The infected pocket was drained and she was treated with antibiotics. On the morning of March 10, staff members noticed Thompson was "not looking right." She was sent to an acute care hospital where she was found to have another large abscess in her abdomen. A section of her small intestine was so badly infected and perforated that it could not be surgically repaired. She was treated with antibiotics and pain medication and died on March 14 from blood poisoning associated with her bowel infection. Her symptoms raise concern her feeding tube was not properly maintained or cared for over a long period of time.


STEVEN ANDRE CAMPBELL, 40
Died: Feb. 2, 2003
Hometown: Southern Pines
Manner: Unspecified
Investigation: No
Autopsy: No
Cause: Septicemia due to streptococcus
Summary: A resident of the center since 1970, Campbell could not speak or walk. On the evening of Jan. 25, 2003, he vomited large amounts of undigested food but the report does not indicate what precautions the staff may have made to prevent aspiration. The following morning, he vomited again and was noted to have a fever. A chest X-ray showed he had inhaled food or vomit into his right lung, causing respiratory distress. Transferred by ambulance to a nearby acute care hospital, he died of infection a week later.


RICHARD CORNELIUS ARTIS, 51
Died: Nov. 15, 2003
Hometown: Knightdale
Manner: Natural
Investigation: No
Autopsy: No
Cause: Intestinal obstruction
Summary: Artis, who had lived at O'Berry since 1967, had chronic bowel problems. He was admitted to the center's medical ward for a suspected obstruction of the small bowel. An X-ray quickly confirmed the diagnosis, however he was not taken to an acute care hospital for treatment for two weeks and then only for further tests. By then, he had a complete small bowel obstruction with a "massively" stretched intestine. Immediate surgery was required and complications from that procedure led to Artis' death. The sequence of events raises questions about whether the staff at O'Berry could have treated his obstruction more urgently.


BARBARA JEAN LITTLE, 44
Died: Sept. 17, 2004
Hometown: Address listed as that of center
Manner: Unspecified
Investigation: No
Autopsy: No
Cause: Pneumontis due to food or vomit
Summary: A resident of the O'Berry Center since 1969, Little had profound mental retardation and minor but chronic medical problems, including recurring urinary tract infections. On the morning of Sept. 9, 2004, she was having difficulty breathing and was transferred to a nearby acute care hospital. Tests indicated she had a urinary tract infection from a type of aggressive bacteria typically contracted in an institutional setting. The infection had already spread to her bloodstream and was carried to other parts of the body. She died about a week later.


ROSETTA GAY, 58
Died: June 5, 2004
Hometown: Address listed as center
Manner: Unspecified
Investigation: No
Autopsy: No
Cause: Septicemia
Summary: Gay, who was admitted to the O'Berry Center in 1958, could not speak, depended on staff to feed her and used a wheelchair. She received medication through a catheter surgically implanted in a vein through an incision in her skin. On May 30, 2004, she was sent to a nearby hospital with a fever that was suspected to have been caused by an infection at her catheter site. She was treated with antibiotics, but died of a blood infection six days later.


LARRY MAXWELL SIMPSON, 66
Died: Dec. 19, 2003
Hometown: Address listed as center
Manner: Unspecified
Investigation: No
Autopsy: No
Cause: Urinary tract infection
Summary: Simpson, who had lived at O'Berry since 1984, was sent to a nearby hospital on Oct. 28, 2003, with shortness of breath and low levels of oxygen in his blood. He was diagnosed with a drug-resistant strain of bacterial infection in his lungs, intestines and kidneys. He died Dec. 19.