CHAPEL HILL - A new dimension has been added to the ongoing inability of North Carolina's state mental health agency to meet its responsibilities competently. Recent news reports describe uncontrolled violence and unexpected deaths (including at least one associated with restraints), with significant incidents in three of our state hospitals. These incidents reflect deep management problems in the hospitals and at the state Division of Mental Health, Developmental Disabilities and Substance Abuse Services.

The state has a fundamental moral and legal responsibility to safeguard patients admitted to its state hospitals. This is all the more true when patients are restrained, since under those circumstances the state takes all autonomy away from the patient. Any harm that comes to a patient in the context of restraints is unequivocally the responsibility of the state.

North Carolinians must be shocked by recent revelations of a death (or deaths) associated with restraints, and of an assault on a restrained patient. We must ask ourselves: How can this happen? Who is responsible? How can this be prevented?

Providing a safe environment for patients and staff in a state hospital is not rocket science. The principles involved are well-known:

* Staff in sufficient numbers must be available. This means recruitment and retention of well-qualified staff must be a high priority. The shortage of RNs in some of our state hospitals is one example of a critical need the state faces. As a matter of safety, beyond a certain point, beds must be closed if they cannot be adequately staffed and supervised.

* Hospital staff must be well-trained and well-supervised. Every hospital ward must have its own nurse manager responsible for its functioning 24 hours a day. Supervisors, and their managers, must be responsible for the harm that comes to patients. This may seem self-evident, but it is possible for supervisors and managers to evade such responsibility.

* Transparency is critical. Within the limits of the requirements of patient confidentiality, what happens in a state hospital is not the sole property of the state hospital. A safety mechanism for unsafe conditions is the involvement of outside agencies -- outside the state Department of Health and Human Services' chain of command.

The N&O's reporting demonstrates the value of a vigilant press. The role of an active, independent protection and advocacy agency is also vital (in North Carolina, the recently designated Disability Rights North Carolina).

This agency should routinely receive reports on injuries in restraint and unexpected deaths. The public interest is not served by a state hospital director who strives to suppress the rights of employees and patients to provide information outside the institution, or a director who does not consider it his duty to report deaths to the Division of Health Service Regulation.

* Finally, if patient abuse occurs, it is not solely the responsibility of the individual employee. The supervisory and management structure must be held responsible for its failures. It is not enough to say, as a hospital CEO recently did, "We have good policies in place." Hospital management's responsibilities do not end with good policies. Ensuring that they are faithfully executed is far more difficult, far more important.

Finally, some questions.

So far as is publicly known, no supervisor or manager has been held responsible for these scandals. No word of apology for these deaths and abuses has been heard. Is it the state's position that these scandals do not require accountability and drastic, effective action?

Does the Division of Mental Health, Developmental Disabilities and Substance Abuse Services really think its role is that of an innocent bystander? True, some state hospitals have traditionally exerted independence from the division's oversight, and for practical purposes a state hospital director must have reasonable autonomy. But in exchange the hospital director must be held accountable.

Does Governor Easley feel any responsibility for these state hospital scandals, that like the botched mental health "reform" are part of his legacy? Will the governor act effectively to ensure the safety of our state hospital patients and staff?

(Dr. Harold Carmel is president of the N.C. Psychiatric Association and associate consulting professor of psychiatry at Duke. He was clinical director of John Umstead Hospital from 1998 to 2004. He was also medical director of Virginia's mental health agency.)