Piece of Mind

Dario Lupi awoke on a hot August morning two years ago and decided it was time to die. The 49-year-old Venezuelan businessman grabbed a bottle of sleeping pills, stuffed it into his jeans pocket, and disappeared from his upscale bayfront condo near the Julia Tuttle Causeway.

He looked remarkably average as he fled: thinning brown hair, a thick mustache, and the faded tan of a man who'd spent years working indoors. But inside he wasn't ordinary; something dark and nagging haunted him.

The date was August 28, 2007. Up in the Charter Club — a cheery salmon-colored building — his wife, Elizabeth Hubinger, began to worry. Elizabeth, an assertive 57-year-old with a soft South American accent, had good reason: Dario had attempted suicide three times before. He had recently talked about the pressures of work and his desire to kill himself.

And now this. Dario was gone and wasn't answering his cell phone. At 11:30 a.m., Elizabeth called Miami Police to report a missing person. She told them he was wearing a yellow T-shirt and had taken off in a 2003 PT Cruiser. Then she waited.

A few hours later, officers found Dario alone in the condo garage. He looked nervous and wouldn't speak or make eye contact. After speaking with Elizabeth, cops made a judgment call: They would take him to the mental health center at Jackson Memorial Hospital.

She was relieved. "I called a friend," Elizabeth remembers. "I said, 'We did it; we saved him. He's going to be OK.'" Then she headed to the hospital with the police.

At 6:42 p.m., Dario arrived at the center, a dreary peach-colored building on NW Ninth Avenue. Officers took him around back to the crisis unit — an emergency room for the mind, filled with dozens of the county's most fragile mentally ill patients.

As Elizabeth spoke to a doctor, a psychiatric aide checked Dario in and then took him to a small, sparse bedroom. Inside were a thin mattress, blank walls, and a cramped bathroom. The aide handed him a cotton shirt and pants, took his belongings, and left him alone. He sat silently on his bed, staring out the window.

An hour passed — according to Jackson documents obtained by New Times — and no doctor had assessed Dario. Though hospital policy states suicidal patients should be under constant supervision, no "safety observation rounds" were documented.

By 8 p.m., an aide returned to the bedroom and heard only the sound of running water. In the bathroom was Dario's lifeless body, dangling by the neck from the shower handle. He had fashioned his cotton pants into a noose and hanged himself.

The suicide is one of many tragedies — at least some preventable — that have plagued the deeply troubled unit of the nation's third-largest public hospital. After reviewing hundreds of pages of state health records, two recent lawsuits, and testimony from three mental health employees, one patient, and a former acting director of the unit, New Times has uncovered the following: rushed patient releases, inadequate supervision, undocumented use of restraints, and possible civil rights violations.

Among the most outrageous cases:

• John Hampton, a homeless 24-year-old, jumped from a parking garage at Jackson after being discharged prematurely in May 2004.

• Doctors ignored confirmed complaints that a woman had been sexually violated by fellow patients in March 2008.

• Shantavia Robinson, a 17-year-old with bipolar disorder, escaped after being shackled repeatedly in April 2008.

• Jacqueline Joyes, a 75-year-old former government secretary, died mysteriously in her bed in April 2008.

Though Jackson ranks at the top of US News & World Report's "Best Hospitals" list, in the past two years, the 172-bed mental health center has been cited for violating state health regulations at least 13 times — more than all ten of Florida's largest psychiatric facilities. (By contrast, Florida State Hospital, which has seven times the number of psychiatric beds, received one such violation in the same period.) State Agency for Health Care Administration (AHCA) findings note everything from the dangerous release of a homicidal woman to the sad story of a patient who lost eight pounds in eight days.

As the state cuts funding for mental health programs, and Florida continues to spend hundreds of millions on ineffective care, one thing is clear: Jackson is failing those who most need it. And state legislators recently pushed aside the only bill meant to fix the problem.

"It felt like a Third-World country," says Lisa Burton, former acting director of patient care, who was fired last year after protesting the shackling of children. "There were absolute atrocities."

Counters Jackson spokesperson Lorraine Nelson: "All regulatory findings are taken extremely seriously. At JHS, we are always looking for ways to improve on the services we provide. Our top priority is and always will be the well-being of our patients."

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Natalie O'Neill
Contact: Natalie O'Neill