RALEIGH - Nearly two years after Donald Michael Jones swallowed 28 antidepressants at a state mental hospital, a medical examiner has ruled he died by suicide -- not the heart attack originally listed on his death certificate.

Jones, who had bipolar disorder, died July 27, 2006, after a stay at Cherry Hospital in Goldsboro. Though internal reports from 2006 show hospital officials knew Jones' death was linked to an overdose, that information was not shared with the medical examiner -- a potential violation of a state law requiring deaths by accident or suicide to be reported.

No autopsy was performed before his body was sent home to be buried by loved ones who were assured he died of natural causes.

Jones was one of 82 state hospital patients whose questionable deaths The News & Observer highlighted in a series on North Carolina's failed mental health reform. The Office of the Chief Medical Examiner in Chapel Hill is re-examining some of those deaths.

Jones' case is the first in which the cause of death has been reclassified.

His mother said the conduct of Cherry Hospital's staff and administrators was unconscionable.

"I was never told about the drug overdose," said Dody McMillen, a physician assistant and clinical professor on the medical faculty at East Carolina University. "To lose my son and be stabbed in the back by people in my own profession just rips my heart out."

McMillen has filed a wrongful death claim against the state Department of Health and Human Services, which operates a system of four mental hospitals.

A request for an interview with Cherry Hospital director Jack St. Clair was declined through a departmental spokesman who cited the pending litigation.

Jones, who was 32, is survived by four children.

Doctors make report

John D. Butts, the chief medical examiner, said it is rare for his office to issue new findings after a death certificate is complete.

In March, Gov. Mike Easley announced a change in policy: Administrators would have to report all deaths at state hospitals to the medical examiner by telephone.

Often the very doctors responsible for a dead patient's care make that report. If the medical examiner is told the patient died of natural causes, as happened with Jones, the issue is often not pursued. A pair of bills under consideration in the state legislature would require the medical examiner to review all state mental hospital deaths.

"When someone is in our custody, we owe them safe harbor," said Sen. Martin Nesbitt, an Asheville Democrat who is the primary sponsor of the Senate bill. "The loophole is that if you called and said it was a natural death he [the medical examiner] wouldn't go. I don't think someone telling the medical examiner why a patient died is sufficient. We want the medical examiner to go and determine why they died."

Jones' troubled life

Donald Jones, who was called Donnie by his family, started getting into trouble with drugs and alcohol when he was 15, according to his mother. Those with bipolar disorder sometimes are drawn to street drugs to dull the symptoms of their illness.

"He loved his children and loved his family," McMillen said. "He was fun to be around -- when he was clean."

Jones was admitted to Cherry Hospital on July 15, 2006, for drug dependence and a lack of impulse control, according to a report later compiled by federal regulators investigating the death. Five days later, on July 20, hospital staff told Jones he was being sent home.

Though Jones told the staff he wasn't well enough to leave, he was told to pack and given a bottle with 28 pills of the antidepressant Elavil to take after his discharge. He missed the bus leaving the hospital, however, and was sent back to his room with his bag, which included the pills.

According to the federal report, Jones took the entire bottle within minutes of being left alone. He was rushed to nearby Wayne Memorial Hospital and treated.

Two days later, however, he was returned to Cherry. Though he soon started complaining of chest pain and shortness of breath, Jones was not examined by a doctor.

A physician assistant who examined Jones failed to take his vital signs or listen to his heart, according to McMillen's review of her son's medical records. The staff member determined he was just seeking attention.

A known side effect of an Elavil overdose is an irregular heartbeat. Still, the staff member gave Jones an antipsychotic drug, Geodon, that the FDA warns should not be given to anyone with an irregular heartbeat.

"He had every symptom of acute coronary syndrome that is in any textbook," McMillen said. "I am livid at the medical care he did not receive. These are symptoms we are well educated on."

Hospital staff later found Jones unconscious. He was transferred to Pitt Memorial Hospital, where he lay in a coma until he died. His organs were harvested for transplant.

Overdose omitted

A doctor from Pitt called the local medical examiner and reported that Jones had died of a heart attack, making no mention of the overdose, said Butts, the chief medical examiner.

Though Cherry Hospital filed a written report within DHHS that said Jones' death was the result of an Elavil overdose, that document was never shared with the medical examiner.

In August 2006, federal regulators cited Cherry Hospital for allowing Jones access to the pills that led to his death. That report, however, was also not shared with the medical examiner's office or Jones' family.

Butts said his office would have likely assumed jurisdiction over the case two years ago had it been told about the overdose or received either written report.

"We're always at the mercy of someone who reports the death to us," Butts said.

John Rittelmeyer, the director of legal services for the advocacy group Disability Rights North Carolina, said Jones' death shows why the current standard of making oral reports to the medical examiner is insufficient. A new law is needed, he said.

"If there is any question a failure of care caused or contributed to a death of a person who was in the custody of the state, then an autopsy must be conducted," Rittelmeyer said.

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