Having struggled with paranoid schizophrenia since her late teens, Williams, 35, had been admitted to the state-run mental institution in Goldsboro 18 times. After a five-month stay, she was discharged in March 2005 to her family home in rural Beaufort County with a cast on her leg.

Williams told her mother the staff had broken her bone while restraining her, though her official medical file offers no explanation for the fracture other than to say it was the result of a "twist."

"She said, 'Cala, I don't want to go back to Goldsboro,' " remembered Calvin Williams, Janella's mother. "She said, 'If I go back to Goldsboro, they're going to kill me.' "

On her 19th admission to Cherry Hospital, Janella's prediction came true.

She was one of at least 537 patients of the state's 14 mental institutions who have died since December 2000.

Most died of natural causes, but a News & Observer investigation shows that 82 of those patients died under circumstances that raise questions: homicides, suicides, accidents, inadequate treatment or mistakes.

Family members of the deceased, who have a legal right to receive complete information about how their loved ones died, often are not told the full details or provided access to internal reviews that would raise concerns.

State reviews, death certificates and autopsy reports confirm the death toll.

Jimmy Clifton Davis, 52, died after he was beaten by another patient and then restrained at Dorothea Dix Hospital in Raleigh.

Anthony Dawayne Lowery, 27, suffocated while being held down by staff at Broughton Hospital in Morganton.

Delores Ingram Franklin, 47, died after three injections of an antipsychotic drug at Cherry.

Suicidal patients -- such as Deborah Lynn Bishop, 45, at Broughton and Darnell Jamarr Harrell, 22, at John Umstead Hospital in Butner -- were unsupervised and hanged themselves.

Alphonzo Leonard Hicks, 53, suffered severe and painful constipation while a patient at Umstead and died from from a resulting infection.

At least four patients died of urinary tract infections that were not treated effectively, while three died of blood infections resulting from improperly maintained feeding tubes and catheters. Some died shortly after discharge because of conditions related to their state hospitalization.

Though the names of the dead and their causes of death are available to the public at county courthouses, officials at the state Department of Health and Human Services contend that federal patient privacy laws forbid them from disclosing the names of those who died in their care.

The N&O assembled its list by cross-referencing redacted copies of internal state documents and computer databases with such public records as death certificates and autopsy reports -- matching birth and death dates, locations of death and the circumstances. In several cases, confidential medical records were released with the cooperation of the deceased patient's family.

Those records were reviewed in consultation with physicians, psychiatrists, pathologists and other medical experts.

The deaths occurred in state hospitals and homes for people with developmental disabilities that have struggled for decades, but particularly since 2001. That year, the state started cutting the numbers of beds and staff to help pay for a plan that would use private outpatient providers to treat mentally ill people closer to home.

But those reforms have not provided the expected levels of community treatment, and the demand for state inpatient services has risen. The mental hospitals have been turning patients away.

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