Here is how the first of Debbie Cenziper's series begins:

Cameron Cullen was 8 years-old when he first told his mother he wanted to die.

Five years later, he entered a Charlotte hospital, depressed and threatening suicide. He was supposed to stay at the Willows for three months.

He never came home.

Out of sight in an isolation room, where he had spent three days alone, Cameron tied a bedsheet over the door and knotted the other end around his neck. Then he hanged himself.

Though crucial details about what happened that night are in dispute and experts question why the hospital left Cameron unsupervised, no regulator investigated his death.

Not the state agency that licensed The Willows, part of Carolinas HealthCare System. Not the state agency that investigates patient abuse and neglect. Not the national commission that accredits psychiatric hospitals.

Since 1994, at least 34 peop1e with mental or developmental disabilities have died in questionable circumstances while under the care of North Carolina mental health facilities. And the system set up to protect them has often failed to notice.

They died from suicide, murder, scalding and falls. They suffocated, starved, choked, drowned. Twenty-four were patients at state-run facilities;10 were under the care of hospitals and group homes operated by private companies and other organizations.

Of the 34 deaths, regulators confirmed that they had investigated just 10.

"It's almost been like the mentally ill are worth nothing, and that's sad," says Karen Murphy, advocacy administrator with the Governor's Advocacy Council for Person's with Disabilities, one of the cash-strapped agencies empowered to investigate psychiatric hospitals. "I always tell people, ‘If this were your family member, how would you want them to be treated?"

Every year, about 700,000 people with mental illness, developmental disabilities and substance abuse problems turn to North Carolina's mental health system—tens of thousands requiring sustained care at a hospital or group home. But the system lacks the resources and coordination to supervise a troubled collection of state-run institutions and thousands of smaller health facilities that have opened in the past decade.

The job is complicated by rules that let untrained people open residential facilities, and state laws that limit regulator's authority to punish negligent caregivers.

States across the country are pushing to strengthen mental health care, and last month, the U.S. surgeon general released a widely publicized report calling for easier access to services and better-trained caregivers.

But in North Carolina, the mental health agenda for more than a year has focused almost entirely on concerns that have little to do with patient safety.

State and federal investigators say mental health officials have mismanaged more than $100 million in federal money. The Division of Mental Health, which runs the state mental hospitals, is trying to overhaul its operations. Director John Baggett stepped down last month after three years, citing stress.

The new director, Dr. Iverson Riddle, says his first priority is simply to figure out how much money he has to work with.

"The budget appears to be a rather amorphous glob of money," he says. "I can't operate like that."

No single government agency in North Carolina, meanwhile, knows how many people are dying in mental hospitals and group homes. Regulators have files on a few fatalities, including several that have drawn media attention, but many cases have slipped through the safety net. The Observer identified deaths of the mentally ill and developmentally disabled by searching 370,000 N.C. death records from 1994 through mid-1999, along with hundreds of police and autopsy reports. The search turned up 34 deaths that were sudden, unexpected, or involved circumstances that could raise questions about care. More than a third involved patients age 35 and younger

Cameron Cullen was the youngest.

On an April evening in 1996, Doug and Nancy Cullen kissed their 13-year-old son good-bye in the isolation room where he had spent three days for disrupting his ward at The Willows. He cried and told them he loved them. After a month in the hospital, the Cullens say, Cameron looked hopeless for the first time.

"I think he'll try to kill himself tonight," Nancy Cullen told Cameron's psychotherapist, according to both their accounts. The Cullens begged her to watch their son, then walked to the parking lot in tears. Someone leaving the hospital said there was an emergency inside, and the Cullens ran back in.

They saw Cameron unconscious on the floor, face blue, two staffers crouched beside him. The sheet was still around his neck.

He never regained consciousness, and died three days later.

"We will never get over this," Doug Cullen says. "The only thing you keep telling yourself is that we were only doing what was in Cameron's best interest."

Officials at The Willows won't comment on Cameron, citing a lawsuit filed by his parents. But in sworn depositions, Cameron's psychotherapist and her boss say the teen's frequent suicide threats and the Cullen's warnings did not convince them he really meant to kill himself.

Carolina's HealthCare System this month announced plans to close The Willows, citing financial problems and a shift toward out-patient mental health care.

State mental health officials know nothing about Cameron's death, but they point out that psychiatric hospitals treat fragile patients.

They acknowledge some deaths in the four state-run hospitals could have been prevented, but they say it's impossible to stop every suicide or injury. The state hospitals admitted more than 16,000 patients last year. State facilities for substance abusers and the developmentally disabled served several thousand more.

"We're dealing with very sick people," says Baggett, who became the state hospitals' strategic planner after leaving the director's job. "I think any suicide or any death that happens in a hospital is a terrible tragedy. But when you consider the odds, our staff is doing an outstanding job."

Critics of North Carolina's mental health system agree the mentally ill and developmentally disabled are prone to accidents and suicides. But even if the state can't guarantee safety, they say, it should at least investigate every suspicious death, including all suicides.

Without a dependable way to monitor injuries and deaths, North Carolina has little chance of punishing negligent caregivers, changing faulty procedures or learning from mistakes. And patients' families often are left wondering what happened.

"Basically what you have is an unregulated system," says attorney Deborah Greenblatt of Carolina Legal Assistance, a nonprofit agency that represents people with mental disabilities. "There simply is not a system in place that is designed to effectively protect people from abuse, nor is there a system in place to require true accountability."

Among the concerns:

• When a patient dies under questionable circumstances in a state-run mental hospital, the Governor's Advocacy Council is responsible for investigating. But the state agency, empowered by federal law, has repeatedly failed to investigate deaths.
  
  
• Of the 24 questionable deaths The Observer found in state mental institutions, the advocacy council investigated five, a top official said. In all those, it found negligence. The council is investigating a sixth death now.
  
  
• Mental facilities not run by the state—12 hospitals and 3,300 group homes and smaller programs—get even less outside oversight. N.C. law doesn't require caregivers to report deaths to state mental health officials or the Division of Facility Services, the licensing agency that decides if the facilities are fit to operate.
  
  
• Facility Services has records on just three of the 10 questionable deaths The Observer found in licensed facilities. It investigated two of them and found negligence in both.
  
  
• North Carolina allows individuals with little or no training to open mental health facilities. And once a facility opens, the state offers little oversight. Licenses are often issued without site visits; abuse and neglect complaints sometimes sit untouched for months.
  
  
• Many other states, including South Carolina, have far tougher rules. Some have started issuing fines for serious safety infractions and granting only short-term licenses to new private facilities. North Carolina has strengthened its regulation of nursing homes and rest homes, but mental health facilities have largely escaped scrutiny.

Mental health advocates worry that little will change because so many other costly problems—flood relief, schools, roads, crime—crowd the state's agenda.

"If government is to do anything, it should support its most vulnerable citizens," says Dave Richard, executive director of The Arc of North Carolina, a nonprofit advocacy agency for the mentally retarded. "They can be productive. They can have meaningful lives, and they can touch us all. But that won't happen if we don't support them."

Some of the people in residential care have disabilities severe enough to require lifelong institutionalization. But many need residential treatment only for days or weeks at a time. When a crisis ends, or when they are stabilized on medication, they often resume normal lives.

That was the plan for Cameron Cullen.

Finding Help for Cameron

Cameron wanted to be a writer. A skinny kid from Charlotte's suburbs, he could dissect Civil War battles and identify any airplane in the sky. He played soccer and baseball, and had little trouble making friends. He qualified for Dilworth Elementary School's gifted program.

When Cameron was 7, the Cullens divorced. He and his younger brother divided their time between both parents.

At age 8, Cameron grew sad and withdrawn. He stopped playing with the dog. He wouldn't go outside. He talked about dying.

"He said he wanted to hang himself," Nancy Cullen recalls. "I just asked him, ‘Why would you want to hurt yourself? We love you.' He said, ‘I just can't take it anymore.'"

The Cullens took Cameron to a psychiatrist, and worked with his guidance counselor at school. He got better, but by age 11 he had become withdrawn and surly. He slammed doors and cursed his mother.

When Cameron was 13, Nancy Cullen suspected he was abusing drugs. She took him to Presbyterian Hospital, where doctors diagnosed depression. Doctors also were concerned about Cameron's claims that he had used drugs and tried to kill himself, but they couldn't confirm that he was telling the truth. A drug screening found nothing.

A psychiatric hospital for adolescents had opened a week earlier in Charlotte, on the same campus as Amethyst, a psychiatric and substance abuse hospital for adults. Both are owned by Carolinas HealthCare System, where Nancy Cullen works as a healthcare manager.

Psychologist Herbert Shriver, The Willows' program director at the time, told the Cullens the hospital could treat Cameron.

In their sworn depositions, the Cullens say Shriver also promised Cameron would be safe there. Doug Cullen says Shriver told them: "You can't watch him 24 hours a day. We can watch him 24 hours a day, and we can guarantee his safety."

Shriver acknowledges telling the Cullens the hospital provided 24-hour care, but he denies promising them nothing could go wrong.

<a onClick="window.open('/olcweb/cgi/pluginpop.cgi?it=jpg::::/sites/dl/free/0073511935/535051/Broken_Trust_p1.jpg','popWin', 'width=NaN,height=NaN,resizable,scrollbars');" href="#"><img valign="absmiddle" height="16" width="16" border="0" src="/olcweb/styles/shared/linkicons/image.gif"> (12.0K)</a>

Debbie Cenziper

"Can't guarantee anybody's safety," Shriver says in his deposition.

Frightened but hopeful, the Cullens took Cameron to The Willows.

He was supposed to stay for three months, then return home.

Here is one of the sidebar stories Cenziper wrote in her series:

Jean Allen loved the children no one else wanted.

She took them into her home, 18 in all, and gave some of the neediest kids in the foster care system a family of their own. At least temporarily.

Some came to Allen's house right from the hospital. Abused kids. Blind kids. Kids with cancer or neurological impairments.

Then there was Tristan.

He was neglected by his mother, developmentally delayed, partially deaf, hyperactive, small for his age.

First, Allen became his foster mother. Then she adopted him when he was 2.

The decision would take Allen on a frustrating 12-year search for mental health care in North Carolina, and eventually turn her into a nationally cited critic of children's services.

Tristan was a happy kid. He listened to Mariah Carey's music, and read about exotic cars. He climbed trees and rode bikes around his home in suburban Greensboro.

But he was manic-depressive, and a doctor prescribed lithium when he was 9. Tristan also took medications to control hyperactivity. He was in and out of public schools, special education programs, hospitals and treatment centers.

Allen and her husband, Richard, learned Tristan needed long-term residential treatment and searched the state for help. They found a program in Kinston, but it cost $6,000 a month.

Tristan, who was 11, didn't qualify for Medicaid, and the family had no medical insurance and couldn't cover the bills. So Allen did what she says social workers repeatedly suggested: She gave up parental rights.

It's a strategy families around the country pursue when they can't afford mental health care. Signing away parental rights turns the child into a ward of the state, and the state becomes responsible for treatment costs. Once in the foster care system, children from middle-income families become eligible for Medicaid, the federal health insurance plan for the poor.

"Can you imagine going in and telling someone, ‘I love my child, and my child's real sick, and I need your help.' And they say the only way they're going to take care of him is if I give him up?" says Allen, who has a doctorate in child development.

Once in the state's care, Tristan moved to Kinston. He was there three years and made the honor roll.

Then state officials said they wanted to place Tristan in a Greensboro group home. The Allens thought he was thriving in Kinston and fought in court to keep him there. But because they had given up custody, the Allens couldn't contest the move.

His stay in the new group home lasted less than a year. He became depressed and threatened suicide.

In February, 1998, Tristan was admitted to a charter hospital in Greensboro. On March 4, Allen got a phone call.

"They said Tristan was upset and stopped breathing, and we probably ought to go to Wesley Long Hospital," Allen says.

Tristan died when seven staff members restrained him by placing a bedsheet and towel over his mouth and nose. The medical examiner's office said the death was due to suffocation, and the case drew nationwide attention.

Dr. Gary Henschen, chief medical officer at Charter Behavioral Health Systems, says the company has dramatically reduced the use of restraints. He also says he's unconvinced Tristan's death was due to suffocation. He may have had a seizure, Henschen says.

Last year, former Charter worker Megan Duffany was tried on manslaughter charges. A Guilford County jury acquitted her.

Allen said she agreed not to sue Charter in return for an undisclosed payment. She has started an organization called Tristan's Quest to study the use of patient restraints, and to teach families how to get help.

She's also lobbying for more state oversight of private mental health facilities in North Carolina.

"We can't go back and undo what's happened," Allen says. "But in Tristan's name, we can work to make changes."

(Reprinted with permission from The Charlotte Observer. Copyright owned by The Charlotte Observer)