Articles:June 18, 2007 -
Georgia to pay $1.25 million
in wrongful death suit
January 7, 2007 -
A hidden shame: Death in Georgia's mental
hospitals
The Atlanta Journal-Constitution
A HIDDEN SHAME: DEATH IN
GEORGIA'S MENTAL HOSPITALS
Sarah Crider was among 115 patients in the state's care who might
have lived
January 7, 2007
By Alan Judd and Andy Miller
Alone in the darkness of a state
mental hospital, Sarah Crider, 14, lay slowly dying.
She complained of stomach pain at
4:30 p.m. She vomited about 8:30. When the only physician on call at
Georgia Regional Hospital/Atlanta came at 9:20, Sarah had vomited
again, but the doctor did not examine her, medical records suggest.
She threw up around midnight and once more about 2 a.m., this time a
bloody substance that resembled coffee grounds. But hospital workers
did not enter Sarah's room again until 6:15 a.m. By then, it was too
late.
A few hours later, two hospital
employees drove to Cobb County to tell Joyce Dobson, Sarah's
grandmother. Dobson adored Sarah for all her complexities: artistic
but troubled, challenging but comic. Now she could think only of two
nights earlier, when she had last visited Sarah and heard another
patient's haunting scream.
I hope nobody killed her, Dobson
blurted out. In fact, what happened to Sarah was beyond anything
Dobson could have imagined.
Sarah was one of at least 115
patients from Georgia's state psychiatric hospitals who have died
under suspicious circumstances during the past five years, according
to an investigation by The Atlanta Journal-Constitution. The
newspaper assembled a list of questionable deaths by examining state
and federal inspection reports, a database of vital records,
autopsies, medical files, court papers, state insurance claims and
other documents.
This study revealed a pattern of
neglect, abuse and poor medical care in the seven state hospitals,
as well as a lack of public accountability for patient deaths. The
findings for 2002 through late 2006 -- from employees beating
patients with aluminum pipes to doctors widely prescribing sedatives
just to maintain order -- evoke images from the mid-20th century at
the state hospital in Milledgeville. There, thousands of patients
lived and died amid horrific conditions that became synonymous
across the nation with mistreatment of people with mental illness.
Several experts in psychiatric care
concur with the Journal-Constitution's findings. They include
patient advocates, as well as a Connecticut physician who heads the
American Psychiatric Association's patient safety committee and
another psychiatrist who helps conduct inquiries into deaths at
mental hospitals in Illinois. All say the investigation shows
significant problems with care provided in the Georgia hospitals.
State officials generally do not
dispute the newspaper's conclusions. But a statement released by the
Georgia Department of Human Resources, which operates the hospitals,
says 82 of the patients identified by the Journal-Constitution had
underlying medical problems "that were appropriately treated."
In an additional 24 cases, the
agency says, "we agree the hospital system should make
improvements."
Officials say they have been
working to improve mental health care by shifting resources and
patients, especially those with developmental disabilities, to
community-based services. "We have a whole system of care that we
have to build and balance," says B.J. Walker, the state's human
resources commissioner. The Georgia facilities, she says, compare
favorably with those in other states on several key indicators, such
as escapes, deaths of patients restrained by hospital workers, and
medication errors.
"Our hospitals are overcrowded and
overused," she says. But "we're not just throwing our hands up and
hollering we can't do anything about it."
The Journal-Constitution documented
364 deaths of state hospital patients from January 2002 through
mid-December 2006. Two-thirds apparently died of natural causes.
Among the 115 cases the newspaper
determined to be suspicious, the greatest number of patients -- 36
-- died from choking on food, vomit or foreign objects, or by
aspirating those substances into their lungs. A similar number died
for lack of emergency treatment or from questionable medical care.
Twelve committed suicide. At least two died under physical restraint
by hospital workers.
The newspaper could find no
information on 16 of the 115 deaths, except that state officials
classified them as "unexplained/suspicious."
Experts say relatively simple
measures could have prevented many deaths: More staff members to
observe choking-prone patients during mealtime and to react to
emerging medical problems. One-on-one monitoring of patients who
threaten to kill themselves. More training in nonviolent methods to
control unruly patients.
No independent agency routinely
investigates or analyzes these deaths, the Journal-Constitution
found. In New York and Illinois, any death in a state hospital
triggers a review by an outside group. In Georgia, the agency that
runs the state hospitals polices itself.
Dangerous conditions in the
hospitals arise from decades of disregard by public officials,
chronic overcrowding and understaffing, and public indifference, the
newspaper found.
In 2000, state legislators created
an ombudsman's office to investigate abuse and neglect -- but never
appropriated money for the office and never filled the job. And the
problems have become even more intractable. Since 2004, the state
has cut the hospitals' budgets by 12 percent.
Meanwhile, officials project, the
daily average number of adult mental health patients will have risen
12 percent by the end of this fiscal year. This is the combustible
atmosphere that Sarah Elizabeth Crider, a seventh-grader from the
suburbs, encountered in the fall of 2005 when she entered Georgia
Regional.
The way a girl with no history of
serious physical illness died more than three months later
illustrates not just the breakdown of care in her case, but also a
systemic failure that has escaped scrutiny for decades.
"She was a healthy 14-year-old --
healthy," says Dobson, Sarah's maternal grandmother and guardian,
whose family has hired an attorney to pursue a claim against the
state. "She had never been sick in her life.
"Why wasn't something done for this
child?"
A girl's life unravels She loved
cartoons. Given the choice, she would have eaten ice cream with
every meal. She gardened with her grandmother, but teased about the
results.
Meemaw, Sarah Crider would tell
Dobson in the yard, why don't you just admit it -- everything you
touch dies anyway.
Sometimes, though, Sarah's
disposition darkened.
One day in February 2003, she
claimed to be seeing large spots on a wall that had no spots. Her
family took her to an emergency room, where a doctor at first
suspected meningitis. A spinal tap ruled out that diagnosis. But
Sarah's hallucinations worried the doctor, who thought she might
hurt herself. He sent her to the nearest state psychiatric hospital:
Georgia Regional.
The 38-year-old facility sprawls
across 174 acres in south DeKalb County, near the I-285 interchange
with Flat Shoals Road. It resembles a small college campus, with
low-slung buildings clustered amid grassy fields. Sarah entered a
unit for children and teenagers, segregated from adults with mental
illness and retardation.
She was 11 years old.
Doctors treated her for autism, for
which she had been previously diagnosed.
After two weeks, she returned to
Dobson's house in Acworth acting as if nothing had happened and
quickly resumed her regular life: Girl Scouts, youth groups at
church, special education classes at school.
In November 2004, her sixth-grade
class from Lost Mountain Middle School planned to attend a Disney on
Ice performance at Philips Arena in downtown Atlanta. Sarah, by then
13, often had trouble getting out of bed on school days. But she
awoke early the morning of the field trip, she was so excited.
At school, as her classmates
boarded a bus, Sarah went back inside to retrieve her coat. The bus
was on I-75, well on its way downtown, before anyone noticed Sarah's
absence. Missing the trip devastated Sarah. In a fit of anger, she
shredded an antique book belonging to Dobson. The outburst was a
preview of what would become routine behavior -- "acting up," as
family members describe it.
Sarah lived with her grandmother,
as did her younger brother, Wesley, and her mother, Leslie Dobson.
Sarah's parents no longer lived together, and several relatives had
helped care for her. Now, no one could control her. So on Nov. 19,
2004, her family reluctantly admitted her to Ridgeview Institute, a
private psychiatric hospital in Smyrna.
There, Sarah received a new
diagnosis: schizophrenia.
The brain disorder, which can cause
hallucinations and delusions, among other symptoms, affects about 1
percent of the population, according to the National Institute of
Mental Health. In children, the institute says, the disease often is
misdiagnosed as autism.
Sarah improved at Ridge-view, her
family says, becoming less anxious, less frenzied. But the economics
of psychiatric health care quickly intervened. Her mother's medical
insurance policy, which covered Sarah, paid for not quite a month of
inpatient psychiatric care. So Sarah became one of many mentally ill
Georgians who, facing similar insurance restrictions, or lacking
coverage altogether, have only one real option: a state hospital.
Sarah spent two weeks at Georgia
Regional in February and March 2005, shortly after leaving
Ridgeview. Back at her grandmother's house, she continued having
severe, disruptive tantrums despite being heavily medicated. By the
fall, Sarah's family realized they needed help again. On Oct. 24,
2005, Sarah returned to Georgia Regional.
She was the sole resident of Room
1123 on the adolescent unit. The only door had a long, narrow window
that had been covered. The only furnishings were a bed and a wooden
desk with the drawers removed. A slim window on the outside wall
offered her a view of a trailer on the hospital grounds.
Over the next three months, Sarah's
condition, as well as her behavior, deteriorated. She "frequently
experienced hallucinations, talked or mumbled to herself, and was
combative and uncooperative with directions and schoolwork," a state
report says. She rarely spoke, according to another report, and when
she did, she seemed fixated on such topics as getting pregnant and
the singer Britney Spears.
Doctors prescribed an assortment of
medications: Ativan to reduce anxiety. Benadryl for sedation. Geodon,
Risperdal and Seroquel to treat schizophrenia and psychosis.
Thorazine to control hallucinations. Cogentin to counteract the
Thorazine's side effects.
Many of the drugs shared a common
risk: constipation.
Sarah had entered the hospital with
an elevated white blood cell count, a sign that she was fighting an
infection. But medical records indicate no doctor at Georgia
Regional ordered additional blood tests right away. They
concentrated instead on Sarah's mental illness.
At Christmas, two months later,
Sarah left for 13 days to visit her family. Her homecoming was far
from joyful.
She barely spoke to anyone. She
frightened her younger cousins with a fixed stare. Her family
couldn't leave her alone, for fear that she would run away.
"She was sedated," Joyce Dobson
says, "like a zombie."
Sarah's demeanor so upset Dobson
that she began looking into an alternative treatment program in
Florida. She hoped to send Sarah there in the spring.
When Sarah returned to Georgia
Regional after Christmas, the hospital staff was supposed to take
blood to test for anemia and infection. Sarah refused, and no one at
the hospital ever asked Dobson for permission to take blood by
force. So the tests were not done.
Most Sundays, Dobson and Sarah's
other grandmother, Bobbie Crider, visited her together. The second
weekend in February, they went on Saturday night instead.
Sarah met them in a waiting room --
the hospital does not allow visitors on the wards -- dressed in a
white hospital gown, rather than the jeans and shirts she had worn
during earlier visits. Her shoulder-length brown hair needed
washing. She had put on weight during her hospital stay, about 30
pounds, up to 156, possibly a side effect of her anti-psychotic
medications.
She was withdrawn and seemed ill.
"She didn't talk much," Bobbie
Crider recalls. "I thought she couldn't understand us well."
Dobson noticed that Sarah's ears
were bright red; usually that meant she had a fever. Dobson also
wondered about a red streak across Sarah's forehead and about the
girl's swollen feet. She told a member of the medical staff that her
granddaughter needed attention.
Just before she left, Dobson heard
a loud, prolonged scream from behind the locked door to Sarah's
unit. A hospital employee explained that a patient was being
restrained.
I just hate to send her back into
that kind of environment, Dobson told Bobbie Crider. Sarah embraced
Dobson one last time before returning to her room. It was a ritual
between grandmother and granddaughter. Sarah had always called it a
"squeezy hug."
Staff under pressure
The next night, Feb. 12, 2006,
Sarah Crider was one of 22 patients in Georgia Regional's adolescent
unit. Boys slept on one hall, girls on the other. A nursing station
that connected them served as a base for the staff working the
overnight shift: one nurse and four technicians.
"There was chaos on the unit," a
nurse who went off-duty at 11:30 p.m. would later tell an
investigator.
The nurse in charge overnight had
responsibilities both on the adolescent unit and elsewhere in the
hospital. He had to administer medications to patients and fill out
paperwork. He had to respond to emergencies on other units in other
buildings and process the admission of new patients. He had to
assign staff members to cover patients' needs.
The nurse sent two male technicians
to the boys' hall; one supervised a patient who required individual
monitoring, while the other cared for the remaining eight boys. As
the shift began, the nurse assigned another male technician to the
girls' hall to work with a female colleague. She would later say she
wasn't able to look in on all 13 girls on the unit because, with so
many patients, "I wouldn't have time to do anything else."
High patient-to-staff ratios are
hardly unusual at the state hospitals. The occupancy rate in adult
mental health units averaged 109 percent last fiscal year, well
above the national standard of 85 percent. Staff turnover is heavy,
made worse by pay for many technicians of less than $20,000 a year.
Nurse and technician jobs go unfilled for weeks or months at a time.
Consequently, the hospitals often call on employees to perform
heroically under virtual combat conditions.
And when employees are overworked,
distracted or disengaged, patients may suffer.
At East Central Regional Hospital
in Augusta in 2002, patient Larry Mansfield asked a technician to
help him buy corn chips from a vending machine. Like many patients
in the state hospitals, Mansfield, 53, had a history of choking, was
restricted to a diet of ground food, and needed supervision while
eating. The technician got Mansfield the chips anyway, then left to
help subdue another patient. Alone with the chips, Mansfield choked
to death.
By comparison, Sarah Crider's
stomachache apparently didn't seem like much of an emergency, at
first, on a hectic Sunday night at Georgia Regional.
Hours of distress
One physician was on duty for the
entire hospital that night: Dr. Ginari Gibb, a 32-year-old medical
resident in psychiatry. Unlike most other residents, who work at
Georgia Regional under an attending physician through arrangements
with medical schools, Gibb was a free agent, according to state
personnel records, hired for a 12-hour overnight shift at $60 an
hour.
After Sarah vomited about 8:30
p.m., the nurse then on the adolescent unit paged the doctor. Gibb
arrived about 9:20, and wrote in Sarah's chart that she was "found
lying in bed in vomitus" and "complained of stomach cramps over
several hours." Medical records don't indicate whether Sarah was
able to describe the extent of her pain. Regardless, Gibb noted,
Sarah appeared to be in no distress.
But Sarah's medical records contain
no indication that Gibb actually examined her. The doctor did not
document whether she listened for bowel sounds with a stethoscope,
or checked whether the abdomen and bowel area were firm, or felt for
masses.
Gibb ordered a suppository for
Sarah's nausea and a Tylenol for her headache. Then she went back to
work elsewhere in the hospital.
No one summoned Gibb when Sarah
vomited at least two more times between midnight and 2 a.m. The
overnight nurse had been occupied with other duties since 12:35,
then returned at 2 to document that Sarah was lying in "extra large
amounts" of vomit. A technician would later tell investigators it
resembled coffee grounds, a sign of a medical emergency: She was
vomiting partly digested blood.
For the next several hours, though,
hospital employees showed no urgency in their assessments of Sarah's
condition.
3:15 a.m.: Sarah was "in bed and
awake." 4:15 a.m.: Sarah's breathing was "even and unlabored." 5:30
a.m.: "No complications noted."
In fact, the employees had no idea
how she was doing.
As the male technician working the
girls' hall later would explain to state investigators: "We're not
supposed to go into the female rooms at night. We just stand at the
door and make sure that they're in the room."
When he looked in on Sarah, the
overhead light was off and she was facing away from the door, the
technician said. She was quiet, he said, but he "couldn't
necessarily tell if she was breathing." At 6:15, a nurse entered
Room 1123 and found Sarah, unconscious, without a pulse, still lying
in vomit. The staff declared a "code," a hospital term for medical
emergency.
A nurse who raced to Sarah's room
from another unit noted that her abdomen was enlarged, rounded and
firm to the touch, and that a thick brown substance was coming out
of her mouth. Her skin was so discolored that staff members who
hadn't seen Sarah before assumed she was black. Another nurse placed
a defibrillator to Sarah's chest, hoping to restart her heart.
"Where [is] the medical doctor?"
the nurse asked, according to notes later inserted in Sarah's
medical chart.
Gibb, still the only physician on
duty, arrived at Sarah's room a few minutes later, records show. She
stood in the doorway, other hospital workers would later report, and
watched as they tried to resuscitate Sarah.
In the medical chart, though, Gibb
would note that Sarah was "cold, blue and without a pulse" when she
arrived. "Rigor mortis had already set in."
Gibb added, "The patient was unable
to be revived, and expired."
An avoidable death
Joyce Dobson at first assumed
another patient had assaulted her granddaughter. But she says
Georgia Regional employees assured her that Sarah died peacefully,
in her sleep.
Sarah's autopsy provided a far more
horrific account.
The medical examiner found Sarah
had developed a severe intestinal blockage that caused her colon to
stretch almost to the point of bursting. Her lungs had filled with
vomit. And she had developed bacterial sepsis, an infection of the
bloodstream.
The day after Sarah died, the state
opened two investigations -- both by the Department of Human
Resources, the same agency that runs the hospitals.
One inquiry began in response to an
anonymous complaint about Sarah's treatment. The other resulted from
a 2005 policy requiring agency employees to look into the death of
every state hospital patient.
In many instances, employees of the
hospital where a death has occurred investigate their colleagues'
actions -- and, records show, rarely find fault.
In one case, hospital officials
assigned a death investigation to a music therapist on their staff.
At another hospital, a patient advocate with no professional license
in any medical field conducted numerous inquiries. His report from a
2005 investigation was typical: 58-year-old Henry Jenkins "was loved
and admired by all who knew him," the advocate concluded. "Someone
said to me, 'Everyone liked Henry.' We can all hope to be remembered
in that way."
Physicians and other medical
professionals often critique the handling of death cases by
conducting peer review. But the state refuses to release records of
those reviews, even to the families of deceased patients.
Gwen Skinner, who heads the mental
health division of the Department of Human Resources, describes the
investigations as "strong, thorough." Walker, the human resources
commissioner, says the department "takes whatever action is
required."
In Sarah's case, investigators from
the department's regulatory section struck a critical tone.
They found she had become lethally
constipated partly because of her medications, some of which were
known to cause severe constipation in many patients. The problem,
they discovered, was exacerbated by dosages that sometimes exceeded
the amounts prescribed. They also documented that hospital employees
did not record Sarah's consumption of food and liquids or her bowel
movements.
Furthermore, investigators said,
Sarah's impacted bowels developed over time and could have been
detected by more careful observation.
Georgia Regional "failed to
adequately monitor and assess the patient," the investigators wrote.
"Medical professionals are left with the responsibility to develop
systems to collect information related to the patient's wellness, to
recognize symptoms related to impaired health, and to obtain and
provide prompt and appropriate treatment."
Sarah's condition should have been
recognized as a medical emergency requiring immediate surgery, says
Dr. Kris Sperry, Georgia's chief medical examiner. "People should
not die of obstructed intestines."
Skinner agrees that Sarah's death
was avoidable.
"Our take on it was the situation
with the child was not something that occurred on one night or one
shift," Skinner says. "I would say that anytime you have a child
die, the system has failed." The state fired Dr. Ramesh Amin,
Sarah's primary psychiatrist for much of her hospitalization, citing
"negligence and inefficiency." Amin, who has contested his firing,
declined to comment for this article. His attorney, Sandra Michaels,
says Amin should not be "singled out" for blame. "It was a tragedy
that had nothing to do with his abilities as a doctor."
For other hospital employees, the
consequences of Sarah's death appear to have been minimal. Ginari
Gibb, the doctor on duty the night Sarah died, continues to practice
at Georgia Regional. Gibb, who did not respond to requests for an
interview, received no punishment from hospital officials, just a
letter from the facility's clinical director outlining her mistakes.
The letter's purpose, the clinical
director wrote, was for "coaching and counseling."
The final indignity
Sarah's funeral was Thursday, Feb.
16. Her special education classmates brought red heart-shaped
balloons to a Marietta cemetery on a warm winter afternoon. One
child read aloud, "Sarah, you're my best friend, and I'm going to
miss you."
About a month later, Joyce Dobson
called Georgia Regional to ask for Sarah's clothes. "They said,
well, if they could find them," she recalls. She eventually received
Sarah's gown and robe, both stained by what appeared to be vomit or
blood.
Dobson was furious. Sarah was
meticulous about her clothes, sometimes changing three or four times
a day. Dobson knew her granddaughter never would have chosen to stay
in soiled clothing. She saw this as one last indignity, one last
symbol of neglect surrounding Sarah's death.
"I was angry because I felt like it
could have been prevented," Dobson says.
"It just seemed like such
carelessness."
Cassandra Dawn Casey
Georgia to pay $1.25 million in
wrongful death suit
14-year-old Cobb County girl died
in mental hospital
June 18, 2007
By Alan Judd and Andy Miller
State officials have agreed to pay
$1.25 million to settle the case of a 14-year-old Cobb County girl
whose death became a touchstone for serious problems in Georgia's
state psychiatric hospitals.
Sarah Elizabeth Crider's family
will be paid $1 million for her wrongful death and her estate will
be paid $250,000, according to lawyers for the family and the state.
The payment apparently represents the largest compensation in at
least a decade for family members of patients who died in one of the
state's seven mental hospitals.
"The state took responsibility for
the death of Sarah Crider," said Alwyn Fredericks, the lawyer for
the girl's family. "They did not choose to drag the family through
additional, protracted litigation. We still think it was a tragedy,
but [state officials] did the right thing."
Crider, a seventh-grader at Lost
Mountain Middle School, died Feb. 13, 2006, at Georgia Regional
Hospital/Atlanta. The Atlanta Journal-Constitution featured her
death in the opening article of a series, "A Hidden Shame," that
reported at least 115 state hospital patients died under suspicious
circumstances from 2002 through 2006.
Crider died from a severe
intestinal blockage that had gone undetected by doctors and nurses,
records show. On the night she died, she vomited several times, but
a doctor called to her bedside apparently chose not to perform a
physical examination. Hospital workers who were supposed to check on
her condition through the night failed to enter her room for as much
as four hours. They discovered her body early the next morning.
After Crider's death, hospital
officials mandated that employees monitor patients' bowel movements.
But less than a year later, the Journal-Constitution reported in
April, another patient at Georgia Regional, 59-year-old Michael
Ernest Webb, died after he went 19 days without a bowel movement,
and employees failed to intervene.
Articles on Crider's death and
other cases prompted the U.S. Justice Department to open an
investigation into whether the state hospitals are violating
patients' civil rights. Similar investigations in other states have
led to sweeping changes in the delivery of mental health care.
The General Assembly voted in April
to create a commission to study ways to transform the state's mental
health system. Gov. Sonny Perdue vetoed a resolution creating the
commission, saying he would issue an executive order forming a
similar panel that, unlike the legislative group, would include
officials from the executive branch, which oversees the hospitals.
Crider's family — including her
mother and father, her two grandmothers and two siblings — notified
the state this spring that it intended to file a lawsuit over her
death.
Lawyers from the state attorney
general's office agreed to settle the Crider case out of court after
a mediation session on June 4, said Fredericks, of the Cash, Krugler
& Fredericks law firm. State law caps wrongful-death settlements
from state agencies at $2 million.
Before the Crider case, the largest
settlement this decade stemming from a death in a state hospital was
the $850,000 paid to the family of Rickey Dean Wingo. The
53-year-old Rome man died in 2002 after employees at Northwest
Georgia Regional Hospital choked and beat him during an altercation.
Officials at the Department of
Human Resources, which runs the hospitals, did not comment Monday on
the Crider settlement. As part of the settlement, the agency
acknowledged no wrongdoing by its employees. The department fired
Crider's primary physician at Georgia Regional, but only "counseled"
the doctor who did not examine her the night she died.
In an interview last November,
however, the department's top officials described Crider's death as
a systemic breakdown.
"Our take on it was the situation
with the child was not something that occurred on one night or one
shift," said Gwen Skinner, director of the department's mental
health division. "I would say that any time you have a child die,
the system has failed."
Find this article at:
http://www.ajc.com/search/content/metro/cobb/stories/2007/06/18/0618meshmental.html
According to the
Alliance for Human Research Protection,
"If you think American mental patients' care has improved since the
"Snake Pit"--think again: What's more the current malpractice of
prescribing "an assortment" of psychotropic drugs to patients who
may be fighting infections is decidedly making a bad situation
worse."
The Atlanta Journal-Constitution
reports about the death of a 14 year old child--one of 115 patients
at Georgia Regional Hospital in Atlanta who died of suspicious
causes:
"Over the next three months,
Sarah's condition, as well as her behavior, deteriorated. She
"frequently experienced hallucinations, talked or mumbled to
herself, and was combative and uncooperative with directions and
schoolwork," a state report says. She rarely spoke, according to
another report, and when she did, she seemed fixated on such topics
as getting pregnant and the singer Britney Spears.
Doctors prescribed an assortment of
medications: Ativan to reduce anxiety. Benadryl for sedation. Geodon,
Risperdal and Seroquel to treat schizophrenia and psychosis.
Thorazine to control hallucinations. Cogentin to counteract the
Thorazine's side effects. Many of the drugs shared a common risk:
constipation.
Sarah had entered the hospital with
an elevated white blood cell count, a sign that she was fighting an
infection. But medical records indicate no doctor at Georgia
Regional ordered additional blood tests right away. They
concentrated instead on Sarah's mental illness."
Contact: Vera Hassner Sharav
212-595-8974
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