Report Faults St. E's for 'Needless' Suffering

About 20 percent of the hospital's patients "are sick and aging," in addition to being mentally ill, Nickles said. "My understanding is, the number of deaths we've had -- and obviously every death is a terrible situation -- the number is not out of line with what psychiatric in-patient hospitals experience around the country."

The hospital is at the core of a troubled mental health system in the District. As part of a settlement last spring with the Justice Department, which had threatened to sue the city over conditions at St. Elizabeths, Mayor Adrian M. Fenty (D) agreed to a long list of improvements, with deadlines ranging from a year to three years.

Among other steps, Fenty promised better supervision of patients and to curb patient-on-patient violence and self-inflicted injuries. In October, the city agreed to pay $650,000 to the family of 55-year-old Frank Harris Jr., a schizophrenic patient at St. Elizabeths who gouged out his eyes. In return, Harris's guardian dropped a lawsuit that said that hospital staff members should have monitored him more closely.

University Legal Services said the medical files it reviewed suggest that several patients lingered in pain for days without adequate treatment before their deaths.

Citing the case of a 63-year-old woman identified as Ms. H, who died July 17, the report says, "Throughout the medical records, [a physician's] monthly notes are typically very brief and, at times, contain no evidence that the doctor physically examined Ms. H."

Although her ailments included Crohn's disease, chronic diarrhea, lung disease, congestive heart failure, leukocytosis and anemia, the report says, "the nurses at the hospital failed to adequately assess and monitor" her condition. "Nursing notes are infrequent; there are times when the medical records do not contain any . . . progress notes for many consecutive days."

In addition to those who died, "other patients also were the victims of staff incompetence," the report says. "One patient mistakenly received an excessive dose of his medication, resulting in a three-month hospitalization. . . . Another patient's medication was discontinued after causing serious side effects, yet it was mistakenly prescribed again.

"A third patient with multiple, serious medical conditions, including late-stage HIV disease, spent up to 25 days in medical isolation without a plan to address the extreme seclusion of being confined to his room," the report says.