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Though Williams had become suddenly still, hospital staffers apparently were not concerned. A nurse told investigators the staff thought Williams was "playing possum."

Notes in her medical records describe her condition as "quiet" and "resting" for nearly an hour. Her medical condition was not evaluated by a nurse, as required. Though no longer conscious, she was not released from the straps.

It was nearly three hours after she was first placed in restraints, about 8:40 a.m., when the health-care technician who was supposed to be observing Williams checked on her and realized she was no longer breathing.

A pledge to improve

Following their investigation, state regulators filed a scathing 30-page report in March 2006 that identified nine major conditions and standards violated in Williams' care and concluded that her individual rights had been violated. The federal Centers for Medicare & Medicaid Services gave the hospital 30 days to come up with a plan to fix the problems or lose millions in government insurance reimbursements.

As a result, the hospital fired one nurse for "gross inefficient job performance." Two staff members were suspended for five days without pay, and two others received written warnings.

Cherry Hospital administrators promised changes in procedures and remedial training in how to safely restrain patients and monitor their medical condition. The federal regulators accepted the plan.

It was not the first time Cherry's leaders avoided punishment by making pledges to improve.

Two years before Williams' death, in February 2004, Delores Franklin died after being restrained at the hospital. An investigation found that Franklin, who had paranoid schizophrenia and a history of heart problems, was given multiple injections of Thorazine. The drug can cause abnormally low blood pressure, which can lead to death in patients with heart disease.

Franklin went limp and was left alone for more than three minutes before anyone noticed she wasn't breathing.

When a nurse called a "Code Blue," the signal that scrambles help in a medical emergency, staffers retrieved the ward's "crash cart," a dolly where life-saving medical supplies are stored. As they tried to revive Franklin, they found no face mask for a mechanical breathing device. A drawer holding other needed items was jammed and could not be opened.

Three more crucial minutes passed before a crash cart was retrieved from another ward.

"We weren't told any of that," said Barbara Lewis Briggs, Franklin's aunt. "They just told us she had a massive heart attack."

When the hospital reported Franklin's death to regulators, boxes were checked on a form indicating that she had not been in physical restraint or seclusion within 24 hours of death, which was not true. A subsequent federal investigation showed that she was in a seclusion room.

Investigators cited the hospital with six violations and threatened a cutoff of federal aid. However, there's no mechanism in state law for punishing a hospital for erroneously reporting the circumstances of a death. As after Williams' death, a nurse lost her job. Hospital bosses promised to make changes and retrain staff in proper procedures.

'We got suspicious'

Williams' mother and siblings met with Cherry Hospital administrators in the spring of 2006 in an attempt to learn more about her death, but they were not told of the hospital's internal review or the federal investigation.

"They didn't talk too right, and they didn't look too right," Calvin Williams said. "That's how we got suspicious there was something wrong."

The family hired a lawyer, Lynne Holtkamp of Chapel Hill, who filed a subpoena that yielded copies of the investigative reports. She then turned those documents over to state pathologist Deborah Radisch, along with 15 pages of medical records from Cherry that administrators had not provided to the medical examiner.

In August 2006, Radisch determined that Janella Williams most likely suffocated as the result of "improper restraint."

"The history of prolonged attempt at physical restraint, with a sudden change in the patient's activity from noisy to combative to quiet and limp is consistent with an asphyxial death," Radisch wrote in the autopsy, suggesting Williams may have stopped breathing before she was carried to the restraint room and strapped down for nearly an hour.

Radisch said she would not have been able to accurately determine why Williams died had the additional medical records and investigative reports not been provided by the family's attorney.

There is no law or policy requiring that the reports on institutional deaths made by investigators for the Division of Health Service Regulation be forwarded to the pathologists performing the autopsies, though both work within the same department.

Though Williams' death was ruled a homicide, the district attorney for Wayne County says he was never informed of her death.

"It's extremely unusual to find out about something like that from the newspaper," Branny Vickory said after searching his office's files for any mention of Williams' death. "But I'm going to find out what's going on."

State institutions and employees can't be sued in civil court for official acts. The families of those seeking compensation for deaths in state institutions are required to apply to the N.C. Industrial Commission, where the cases are reviewed by commissioners appointed by the governor.

In Williams' case, officials conceded the government was negligent. Williams' family settled the case in January for $275,000. As part of the agreement, Cherry Hospital administrators once again promised to make changes and retrain staff to ensure patients are restrained safely.

Though the money is a comparative fortune around Acre Station, Williams' mother says the settlement is little consolation for losing a child. She finds it too difficult to visit her daughter's grave, which lies under a small gray stone in a cemetery not far from home.

"They did her wrong," Calvin Williams said. "My daughter had a life. Sometimes it seems like she's still alive in me, we were so close together. We understood each other. She was my baby."

(News researcher David Raynor contributed to this report.)

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