Piece of Mind

Jackson's mental health unit fails Miami.

When John's bruised cadaver arrived at the medical examiner's office the next morning, a blue anklet was fastened around his right leg. It read, "34778."

Dipnarine, the 28-year employee, says she believes some staff members were not properly educated or trained. "We weren't tightly structured," she says. "We missed a lot of red flags."

After the death, conflict boiled. Mental health administrators blamed Freiberg, a then-45-year-old nurse manager, for trying to hide the suicide. He was placed on administrative leave in June 2005. According to a lawsuit he later filed, the bosses accused him of "falsifying, stealing medical records, and destroying hospital property."


Freiberg says someone else "doctored the records" in order to hide the fact that John had threatened suicide before release. Indeed, Jackson administrators soon learned the nurse manager wasn't responsible. After reviewing evidence, authorities rehired him two years later. (The lawsuit was eventually dropped.)

Jackson did not respond to inquiries about the stolen records noted in the lawsuit.

Today, Florida spends more than $789 million per year on mental health treatment, roughly the budget for natural disaster preparation and highway safety combined. Though the Sunshine State is among top spenders, it repeatedly ranks among the lowest in terms of care, according to the National Alliance for People with Mental Illness. A 2009 report graded Florida's system with a D. It dropped from a C in 2008.

"I'm surprised more hasn't happened," Freiberg says. "[Jackson] got away with murder."

Jackson spokesperson Lorraine Nelson couldn't speak specifically about John Hampton's case. "Due to confidentiality laws, we cannot comment on the care provided to a patient without consent." She added, "Jackson Health System complies with all regulatory laws and guidelines for the treatment and reporting of patient care."

But more tragic tales would surface.


A circle of men with wild hair and ripped clothes drinks beer from cans on a sidewalk half a block from Jackson's Highland Park psychiatric unit. The lonesome mud-colored building stands across from the main mental health center on the eastern outskirts of the mammoth medical complex. Inside a vacant lobby, a pretty security guard with bright pink nails gabs on her cell phone. "Oh, nothing," she says. "Just at work, bored."

Hospital policy states the facility should be tightly monitored to prevent escapes and intrusion, but a New Times reporter strolls by the guard and over to a set of locked elevators. After a few minutes, the doors squeak and then spontaneously part, and New Times climbs in. Brown paint peels off the elevator walls like dead tree bark.

On the fourth floor, a few staff members chat behind a desk. Nearby, a large rectangular window shows several patients in a locked room. One of them — a tall, restless man with the build of a point guard — wears black scrubs and an intense facial expression. He paces, stops in front of the window, and stares out with a wrinkled brow. Next to him, a sign with a smiley face reads, "Only smiles and good attitudes." New Times doesn't enter the patient area. But the point is made: Oversight is weak.

Or perhaps negligence is just the beginning. Over the past two years, state health investigators have found everything from a failure to prevent abuse to illegal shackling of patients. Other complaints range from urine stench to physical abuse from an aide. Things were so bad that on March 28, 2007, authorities threatened to pull the plug on Jackson's Medicare funding.

"The conditions at your hospital pose an immediate and serious threat to the health and safety of patients," reads a letter to Jackson CEO Marvin O'Quinn from Sandra Pace, the associate regional administrator for the Centers for Medicare & Medicaid Services. "The Medicare provider agreement... is being terminated at the close of business April 15, 2007."

The letter was prompted by a state inspector's three-day unannounced visit to the unit. In 62 pages of never-before disclosed notes, the report describes dreadful conditions. Altogether, the findings expose a disregard for patients' rights, safety, and personal privacy. Many were suicidal. Others were delusional, homicidal, or paranoid.

It began on a Tuesday morning. The inspector, Marlen Morales, arrived at the center March 20, 2007, after an anonymous tipster called to complain. That day, Morales checked the records of a 29-year-old woman with a borderline personality disorder. She had slashed both wrists and swallowed 60 muscle relaxant pills. Though nurses recorded the young woman was sleeping, documents revealed she was in an emergency room "attempting to leave," Morales wrote. The patient should have been under "constant observation."

She was discharged the following day, although medical records state "she continues to have thoughts of killing herself."

The same day, a female patient with chronic depression and no health insurance told doctors she would kill herself and her abusive husband if she were sent home. Even so, a physician ordered she be discharged in less than 24 hours. Morales determined she hadn't met "the criteria for an appropriate discharge."

The next day, the inspector noticed an out-of-touch female patient in the communal area of the crisis center. Her gown was on backward and her "breast and chest were exposed." Male patients were present, but "no staff intervened" to help.

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