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Death rates at the hospitals generally have held steady since 2001, except for a significant drop last year. The psychiatric hospitals have reduced the numbers of beds for elderly patients and stopped accepting patients when hospitals become overcrowded.

"These are not snake pits where people come in and they're dying right and left," said James Osberg, who heads the state system of mental hospitals and developmental centers. "Do you know how many referrals we get of elderly people who come in from a nursing home who are about to die, and it's a nice little dump job, but we have to take them?"

Of the 82 deaths questioned, 20 were above the age of 65.

Osberg said deaths similar to those questioned by The N&O occur in all hospitals. However, neither he nor his staff consistently tracks or analyzes why their patients die.

A review of conditions in North Carolina's state mental hospitals by the U.S. Department of Justice in 2004 concluded that employees routinely violated patients' civil rights. The inappropriate use of physical restraints and seclusion were cited as major problems, as were inadequate mental-health treatment, unsafe building conditions and the failure to "ensure the reasonable safety of patients."

Legislators and administrators at the state Department of Health and Human Services have focused on closing aging facilities in favor of new, smaller buildings.

The new Central Regional Hospital in Butner was set to open last month; Dorothea Dix and John Umstead were set to close. But opening the $120 million hospital has been delayed because of design flaws, such as open stairwells where suicidal patients could jump and door fixtures that might be used to anchor a noose.

While money has been spent on bricks and mortar, employee pay in the hospitals has remained low, contributing to heavy turnover and unfilled positions. Those overseeing the hospitals have used short-term staffers and temporary employees to fill many vacancies.

"The staffing and crowding conditions that may have contributed to the deaths are a consequence of reform," said Harold Carmel, president of the N.C. Psychiatric Association and the former clinical director at Umstead. "Mental-health reform in North Carolina was a grandiose plan, with great-sounding rhetoric about how well things would go, but with little substance behind it."

'We lost her'

Each patient death has a story. Janella Williams' shows how hard it can be for loved ones to learn the truth.

Williams worked part time as a cashier at a Wal-Mart in Greenville and had recently moved from her mother's house to a small apartment in the Eastern North Carolina town.

The youngest of seven children, she grew up in Beaufort County a couple of miles north of the rural crossroads of Acre Station. On a recent visit, the road to Calvin Williams' house was lined with bolls of fresh-picked cotton that blew off on the way to the gin.

Janella Williams loved gospel music and attended church nearly every Sunday, taking detailed notes on the sermon in spiral notebooks she also scribbled full of poems.

"Though the storms of life may come," she wrote, "I shall not murmur and complain. The devil's job is to try to have kept me insane."

Williams had been out of the state hospital for nearly a year and, according to her family, was doing well when her mind again descended into chaos and fear.

On Feb. 16, 2006, she dialed 911 and pleaded with the dispatcher for help, saying someone was after her. She was taken to Pitt County Memorial Hospital, where a doctor signed a petition to involuntarily commit her to Cherry Hospital -- the designated state psychiatric hospital for a region that includes 33 eastern counties.

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