The Woman Who Died in the Hospital Waiting Room

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.