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The Woman Who Died in the Waiting Room
Instead of helping her, they ignored her.

The story behind the videotape that shocked the country.

Jeneen Interlandi
NEWSWEEK
Updated: 1:43 PM ET Jul 12, 2008

Esmin Elizabeth green fell out of her chair in the waiting room of
Brooklyn's largest psychiatric hospital nearly an hour before anyone
realized she was in trouble. For 20 minutes, she writhed and twisted
between two chairs under the watchful eye of a security camera whose
footage would later be broadcast across the country, spurring a public
outcry. Two security guards and two other staff members passed through
the room and glanced at the 49-year-old woman, without bothering to
check her vital signs or help her up. The sight of patients like
Green, wearing a urine-stained hospital gown and lying face down on
the floor, was hardly uncommon in the psychiatric emergency room of
Kings County Hospital Center. Neither was the fact that by the time
she collapsed, she had been waiting almost 24 hours for a bed. At that
moment Green was in line with 32 other patients, some of whom had been
waiting just as long, if not longer.

In fact, the hospital's psychiatric unit, also known as the G
Building, was notorious for being both overcrowded and indifferent to
its patients. A lawsuit filed in 2007 by the New York Civil Liberties
Union charged staff members with beating and handcuffing patients and
injecting them with psychoactive drugs when they complained. And the
Commission for Quality of Care, a state agency, found that instead of
trying to locate available psychiatric beds at other area hospitals
when the facility reached capacity—as required by state law—G Building
employees had falsified documents to hide a persistent overcrowding
problem. Last year Alan Aviles, president of the Health and Hospitals
Corp. (HHC), which oversees Kings County, called the NYCLU allegations
"grossly inaccurate, irresponsible and an affront to the dedicated and
caring staff." Hospital leaders insisted that the facility's troubles
stemmed from space constraints, not staffing issues, and promised that
a new building still under construction would help alleviate that
problem. In an e-mail to NEWSWEEK, the embattled hospital says it has
made "significant reforms" since then, and promises more changes are
coming. But any such improvements will come too late for Green. Nearly
40 minutes after she stopped moving, a nurse walked over and lightly
kicked her. By then, she was already dead. Last week the city's
medical examiner cited blood clots in her legs as the official cause.

As disturbing as the circumstances of Esmin Green's death were, they
should not have come as a surprise. Public hospitals across the
country have struggled to provide acute psychiatric care to the poor
and uninsured since the early 1960s, when large mental hospitals began
closing their doors en masse. Rather than lock them away in cold,
uncaring institutions, the thinking went, the mentally ill should be
offered a place in society. But with insufficient outpatient services
and a dearth of community-based support, the least fortunate of them
have ended up in already overtaxed emergency rooms. They are the poor,
the uninsured and the undocumented. Many of them suffer from chronic
conditions that could potentially be treated with medication and
regular counseling, luxuries most of them cannot afford. With just
50,000 inpatient psychiatric beds for tens of millions of people
across the country, the mentally ill typically wait twice as long for
treatment as other patient populations do. "It's like landing
airplanes at O'Hare airport," says Ken Duckworth, medical director of
the National Alliance on Mental Illness. "For psychiatric patients in
particular, every day is the Wednesday before Thanksgiving at O'Hare.
There is just no place for them to go."

On June 18, as Green waited for help, the American College of
Emergency Physicians released a nationwide survey of emergency-room
directors. More than 80 percent of them said psychiatric patients
should be placed in dedicated emergency psychiatric facilities, like
the ones New York established in the late 1980s. The G Building at
Kings County, where Green died, was the city's largest such facility.
But if her story tells us anything, it's that isolating psychiatric
patients from everyone else will not solve the problem. In New York,
at least, this approach seems only to have fostered an environment
conducive to abuse and neglect.

Green came from a rural village near St. Catherine, Jamaica, in 2000,
and made her home among Brooklyn's Caribbean diaspora and the Jesus Is
Lord Sabbath Day Adventist Church, where she sang, prayed and
sometimes lived. The eldest of 12 children and a mother of six, Green
assumed the role of matriarch when she was just 20, after her own
mother died. In Jamaica, she had been a shrewd businesswoman,
establishing a successful dress shop, a wholesale fishing business and
a small import company over the course of a decade. Family and friends
remember her as outspoken, vivacious and generous to a fault, with a
voice that could wake the dead and a love for church and children that
surpassed all else. "She was the light to us," says her eldest
daughter, Trecia, who is suing the hospital and the city for $25
million. "She had a strength that drew everyone to her."

In Brooklyn, Green struggled with poverty and bouts of depression that
friends say were triggered by a profound home-sickness.Having left her
own children, including a 6-year-old son, in Jamaica, she immersed
herself in the church's youth programs, where she ran activities and
led prayer sessions, and area day-care centers, where she worked on
and off over the years. Without a green card, a permanent job or any
health insurance, Green relied on her pastor, Marilyn Johnson, and a
patchwork of friends to see her through dark times. But a fierce pride
compelled her to hide her illness from most of, them, so that even
after she died, only a handful knew the full extent of her suffering.

In January 2007, Green began acting erratically. She would eat very
little, pace the floors all night long and fall silent for days. She
would appear, disheveled and out of sorts, at the doorstep of this
friend or that one, in the middle of the day or late at night, asking
for a place to sit quietly. And she had taken to running around the
apartment over the church, where she lived with two other women,
gathering dresses, plates and other items into large trash bags and
putting them out onto the street. Her roommates would call Pastor
Johnson, and Johnson and her husband would come over and carry
everything back upstairs. "Her best clothes, her roommates' valuables,
would all be out there," Johnson says. "Sometimes she would not
remember doing it; other times she would remember but have no
explanation."

So began a slow deterioration marked by repeat visits to Kings
County's G Building. Each time it was the same: her roommates would
grow uneasy with some outburst or strange incident and call 911. The
hospital would admit her and keep her for a few days. When they
discharged her, Pastor Johnson would come to bring her home. It
remains unclear what type of treatment she received during these
stays. An autopsy released on Friday determined that untreated blood
clots had exacerbated a chronic paranoid schizophrenia. "Were she
examined, she could have been given an anticoagulant and instructed to
walk around," says attorney Sanford Rubenstein, who is representing
Green's family in their lawsuit. "If that were done, she might still
be alive today."

But over the past year, as Green's behavior grew more erratic, Johnson
was less concerned with Green's diagnosis than with keeping her under
control. After one hospitalization, she stayed with Johnson's sister
Babs while Johnson prevailed upon Green's roommates over the church to
take her back in. "They were nervous, and Sister Green didn't want
anyone else in the parish to know she was sick because she was
embarrassed," says Johnson. "So we couldn't really ask the others to
help." When it was time to leave Babs's and return to the church
apartment, Green disappeared. "It took us two hours before my husband
found her hiding in the back of a small coat closet," Johnson recalls,
laughing warmly. "She just flashed us this huge grin, like a little
child who'd been caught taking too many cookies."

On another occasion, Johnson went to visit Green at the hospital, but
Green refused to see her. "I stood there smiling and she walked right
up to me, looked, turned around and walked away like she didn't
recognize me," says Johnson. "A few hours later she called me at home
and asked why I had not come to see her. 'Everybody have visitors and
me have none,' she said. So I went back, and she was all hugs and
smiles."

The surveillance tape that captured Green's last visit to Kings County
was obtained by the NYCLU as part of a routine evidence request for
its ongoing lawsuit. The first thing attorney Beth Haroules noticed as
she watched the footage was how shiny the floors were. Haroules had
been working for more than a year on the lawsuit against the hospital,
and until now, progress had been glacial. Even with a Department of
Justice investigation spurred by the NYCLU's findings, the defendants
had only recently managed to paint the walls and clean the floors.
"Those floors used to be disgusting," Haroules says. "Not that their
being clean has made any difference here."

Haroules has been around long enough to watch her own efforts at
solving the psychiatric-care crisis come full circle.She joined the
NYCLU in the late 1980s, just as new laws that the organization had
pushed for were forcing the state to create separate emergency rooms
for psychiatric patients. But if those specially designated facilities
spare psychiatric patients from the trauma of a typical emergency
room, critics say that they also replace that trauma with a callous
approach to care. Haroules doesn't regret the establishment of these
facilities, known as Comprehensive Psychiatric Emergency Programs, or
CPEPs, but says much more is needed to protect psychiatric patients.
"This was supposed to be a whole new way of doing business, but we're
right back where we started from," she says. "Only it's worse because
now, the most vulnerable population is also the most isolated, and
that has led to poorer quality in terms of staff, infrastructure and
financial resources."

For Green, such was the final, flimsy safety net. By early June, she
had lost her job and her apartment, and was staying with a friend not
far from the church. On June 18 she woke at about 2 a.m., after
sleeping only an hour, and paced silently through the apartment's
small rooms. At 4 a.m. she headed out into the muggy predawn in search
of Pastor Johnson. Forty minutes later she knocked on the pastor's
door. "Oh, Pastor, my soul is in trouble," she said. "I need
forgiveness before I die, or I will have no mercy." Both the church's
bishop and Johnson's sister Babs had recently suffered strokes, and
Johnson had begun to feel the strain of helping them through recovery.
She quickly offered Green forgiveness, but it was not enough to calm
her. Green continued to bemoan the condition of her soul, working
herself into a frenzy as she repeated the same refrain over and over,
her voice rising each time, "Oh, my soul is in trouble, and I need
forgiveness before I die."

By the time she reached full volume, the neighbors were awake and
Johnson had sneaked back inside to call 911. "I had to tell her I was
going to change my clothes, so she wouldn't get even more upset," says
Johnson. "When Sister Green gets like this, she has the strength of 12
men." Before long, the police arrived, along with an emergency-
services van. The sight of them quieted Green instantly. "It was like
a switch went off," says Johnson. One officer ordered Johnson and her
husband to go inside and close the door, while another escorted Green
toward the emergency van. Johnson did not bother to protest—she knew
from previous experience that even if she had followed Green to the G
Building, she would not have been allowed to wait with her. "It's not
like a regular emergency room; you can't just walk in with the patient
and sit there," she says. "Once you turn them over, they go to a
separate area and that's it." Before turning into the house, Johnson
saw Green tap the side of her head three times and look up at the sky.
It was something she did often, and Johnson knew she was saying,
"Jesus, Jesus, Jesus." It was the last time she would see her friend
alive.

Green's funeral filled the church. In the weeks that followed her
death, footage of the incident had made its way through cyberspace,
and as hundreds of mourners spilled into the street and crowded around
windows to pray and sing, local politicians, immigrants' rights groups
and mental-health advocates expressed outrage and demanded change.

For what some say is the first time, Kings County has responded. Six
staff members, including the director of psychiatry and the four
employees who saw and ignored Green on the floor, were terminated. The
hospital has also agreed to check on patients every 15 minutes, and to
keep the number of patients in the waiting rooms down to 25.

Those changes bring a small measure of peace to Marilyn Johnson. The
pastor has faced the ire of many in her community who fault her for
not accompanying Green to the hospital. As the small brick church
began to empty and mourners made their way through the darkening
streets, Johnson stood alone. "I'm sorry," she said to more than one
straggling parishioner. "I did the best I could for your friend. There
was nothing more I could have done." The health-care system charged
with Green's care cannot say the same.

URL: http://www.newsweek.com/id/145870
©2008