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Families trusted this hospital chain to care for their relatives. It systematically failed them

Carol and Warren Chesley with a memory quilt honoring their son, Jason. They won a change in procedure after Jason’s death at Arbour Hospital in Jamaica Plain in 2002. They were incensed to hear of a similar death in Pembroke in 2015.Craig F. Walker/Globe Staff

When state inspectors walked into the Westwood Lodge psychiatric hospital at 5 a.m. in April of last year, they found a heart-wrenching scene. Children slept on bare, plastic mattresses in filthy rooms; dust and dirt collected in the corners. When the young patients woke up, staff sat them in front of a television.

Caregivers had taken away the toys and stashed them in inaccessible piles at the nurses’ station, according to the state’s report. Trash was strewn about a rancid-smelling bathroom. And when inspectors questioned the only nurse on duty, a temp, about the location of the fire alarm or even how she would evacuate her eight small charges, all 12 and younger, she did not know.


Hospital executives ordered bedsheets that fit, brought out the toys, and gave the children’s unit a thorough cleaning and fresh paint. But when inspectors returned seven weeks ago, they found even more disturbing evidence of substandard care: a 9-year-old boy with a severely bruised face who had not been taken to the emergency room for six days after the injury.

The 89-bed hospital in Westwood is one of seven operated by Arbour Health System, which Massachusetts relies on to treat many of its sickest and most fragile mentally ill children and adults. The state Medicaid program pays the company more than $100 million a year, fueling its growth into an indispensable provider of mental health care in a system desperately short of psychiatric beds. Arbour now admits more than 20 percent of psychiatric patients in the state.

While some other hospitals have lost money providing psychiatric care, Arbour has reaped some of the most robust profits in the industry. A Boston Globe review of its Massachusetts hospitals, as well as interviews with several dozen patients, families, and employees, found that it has done so while repeatedly and sometimes egregiously shortchanging patient care.


The hospitals, which serve about 16,000 patients annually, were cited again and again in state documents reviewed by the Globe for failing to provide enough staff to care for patients, properly monitor them, devise treatment plans, run therapy groups — or even keep its units clean.

But on many occasions, after state — and occasionally federal — regulators have criticized the hospitals, a similar pattern has unfolded: The company promises fixes and the state Department of Mental Health, which licenses the units, accepts their reassurances, but there seems to be little lasting improvement for patients.

Complaints then resume. State inspectors descend. And the cycle repeats.

During at least 19 visits to Arbour-operated hospitals since 2013, inspectors found filthy conditions — split, ripped, and stained mattresses, walls covered with food, obscene graffiti, and an overpowering smell of urine in bathrooms. When told to address these failings, hospital officials have sometimes pushed back.

One former chief executive of Arbour’s Pembroke Hospital wrote regulators in 2014 that he could not immediately replace broken window shades and bathroom vanities because it would cost “several thousand dollars’’ — this at a hospital that, with its sister hospital Westwood Lodge, earned a 24 percent profit that year, according to figures posted on a state website that year. The company eventually scheduled the repairs.

Since 2010, regulators have cited the hospitals at least 23 times for not having enough staff to care for patients, and at least 31 times for failure to properly monitor patients, according to inspection reports and complaint investigations obtained by the Globe through public records requests, and information from sources and several media reports.


Mental health advocate Karen Gromis said that even though the citations are spread across a large system, they are troubling nonetheless. “They need to put some quality control into effect that they clearly don’t have,’’ said Gromis, interim executive director of the Massachusetts chapter of the National Alliance on Mental Illness.

Lapses such as those inspectors found seem to have led, at times, to chaos in Arbour hospital wards, alarming failures of management that have been cited in state reports as possible factors in sexual assaults, escapes, injuries, and at least five patient deaths.

Michael Bakios (left) and his brother, Brandon.handout

One of those patients was 32-year-old Michael Bakios, who had struggled with depression since he was a teenager. Too sick to work, he received Medicaid and lived with his younger brother and his family. When he arrived at Westwood Lodge in April 2015, Bakios was suicidal and required safety checks every five minutes, according to a police report.

But Arbour staff failed to do this even though the nurses’ station was just 10 feet away, state inspectors said. When the one employee on duty returned from her break at 3:20 a.m., Bakios was no longer breathing. She began CPR, and a co-worker grabbed the oxygen. But the equipment that might have saved Bakios’s life was not working properly, delaying possible treatment.

After his death, hospital executives promised to retrain staff in the proper way to check on sleeping patients: They must enter the room with a flashlight and witness the chest rise and fall for three respirations.


But four months later, a 20-year-old woman admitted to Pembroke Hospital with depression was found unresponsive in her bed at 5 a.m. She was supposed to have been checked on every 15 minutes, but Amber Mace was found “in full rigor mortis,’’ state officials said. In communications with the state, the hospital defended its care in this case, saying she was checked on appropriately.

Arbour declined the Globe’s request to interview executives and said it could not, because of privacy restrictions, discuss specific patient cases. But in a written statement, Dania O’Connor, director of the company’s Massachusetts division, pointed out that “serious adverse events’’ account for a “very, very small percentage’’ of patients treated at the facilities. She said most hospitals that care for very sick, complex patients “will regrettably face occasional unforeseen incidents.’’

Despite the expanding list of problems identified by inspectors, O’Connor said the company works diligently to ensure that “positive changes are monitored and sustained over time to benefit all future patients.’’

The company, in a prepared statement, did say it has been spurred by the adverse inspection results to make significant changes to its operations.

“We have recognized a need for a new approach to day to day operations,” a company spokeswoman said. “Change management has been a significant part of leadership over the past year. Efforts have been made to update and improve the system including new leadership, development of a new nursing hierarchy, a focus on training, and new housekeeping protocols.”


The Arbour hospital chain is owned by Universal Health Services Inc., the largest psychiatric hospital company in the country, which earned $702 million in profits last year. Arbour, which state officials said is the largest mental health provider in the state, is also a money-maker for its corporate parent.

The seven Massachusetts inpatient facilities — located in Attleboro, Brookline, Boston, Lowell, Quincy, Pembroke, and Westwood — earned between 8 and 14 percent in profits in 2015, according to financial information collected and posted online by the state.

By way of comparison, the Harvard-affiliated, nonprofit McLean Hospital in Belmont earned 2 percent in profit that year. Of the four other for-profit psychiatric hospitals in the state, one lost money, one broke even, and two earned profits less than all but one Arbour hospital.

Universal’s national strategy to aggressively expand its psychiatric business has enriched founder and chief executive Alan Miller, who drew $20 million in compensation last year. During a conference in March, Miller told investors that “our quality care’’ is the reason for UHS’s success. “Our reputation is very important to us,’’ he said.

But the company is under growing scrutiny; 24 of its 188 US psychiatric hospitals are under federal investigation for potential fraud, including those in Massachusetts, according to company filings with the US Securities and Exchange Commission.

Meanwhile, quality of care problems in Massachusetts have escalated, requiring the mental health department to focus extraordinary resources on the hospitals, including 73 inspections over the past two years and the appointment of a monitor dedicated to riding herd on Arbour properties.

Arbour says its special expertise is in serving some of the sickest and neediest of mentally ill patients. But its employees at times have seemed in over their heads, unable to manage such demanding cases.

One night in April of last year, inspectors found patients too scared to leave their rooms and staff members too intimidated to venture out of the nurses’ station at the Arbour Hospital in Boston’s Jamaica Plain neighborhood. Several patients rampaged around the unit, fighting, yelling, and smashing a phone. One patient slept on a pool table, covers pulled over his head.

Staff acknowledged they could not handle the severity of the patients’ symptoms — either because of inadequate training, too little help, or both. Two patients told state investigators that they had not seen their psychiatrists in days.

The hospital responded by promising to reeducate staff about deescalation techniques and the process for requesting assistance.

Janet Ross, director of licensing for the mental health department since November 2015, defended the state’s efforts to improve conditions at the Arbour properties since Governor Charlie Baker took office in 2015. She noted that the department has taken action against the hospitals 12 times in the past two years, often temporarily closing units to new admissions.

The hospitals have seen periods of improvement and employ some excellent staff, Ross said, which is why the state continues to work with them rather than shut them down.

The state has tried to use tools at its disposal to force Arbour to provide better care. Last July, the state Medicaid program withheld $1 million in payments from the Arbour system and then released the money when the hospitals showed improvements in five specific areas. A large Medicaid-managed care program also decided in May to terminate its contract with Westwood Lodge to provide care for teenagers.

But some Arbour employees question whether enforcement efforts have been hampered by the state’s reliance on the system’s 550 beds. Internal memos obtained by the Globe show the mental health agency trying to ensure that aggressive oversight doesn’t lead to a loss of badly needed beds.

“DMH does not want to step on their toes because if they do, where are they going to put their patients?’’ said one mental health worker who spent a decade at Arbour’s Pembroke Hospital, which was perpetually short-staffed. She spoke on condition of anonymity because she may want to return to the field. “The state should not answer to [Arbour].’’

Certainly, in the Westwood Lodge children’s unit, the state’s attempts to crack down and the company’s promises to do better have not done enough to change the culture of neglect.

A year after the young patients were found sleeping without sheets, state inspectors returned to find the badly bruised 9-year-old boy; he had been pushed off a chair by another patient, and hit his forehead on a door jamb. Inspectors found no nurses’ notes about his progress for two days in his medical record, and learned that staff did not take him to the emergency room for a brain scan until a week after his injury.

The hospital defended its actions, saying they did not take the boy to the hospital right away because the Arbour medical director did not believe he needed emergency care, based on an exam. When the child’s bruising worsened, another doctor decided to send him to the emergency room, but the boy’s CT scan turned out to be normal, the hospital said. The same child had also been given the wrong medication for nine days, according to a state report.

That mistake led Arbour to change. A spokesman said in a statement that Arbour has launched a “thorough review” of its medication administration safeguards and that officials “have made corrections to mitigate any future risk of recurrence.”

The nine-year-old was not the only injured child discovered by inspectors. A girl, also 9, had knocked a bottle off her dresser, one that had been inadvertently left there by a doctor, and had superficial cuts on her wrists, hands, and foot from shards of broken glass.

Regulators closed the unit to new admissions on the spot and then quickly suspended its license. Three days later, they stopped new admissions to the rest of the hospital. Arbour spokeswoman Judy Merel said the company will not seek to reopen the children’s unit now. State officials expect to decide this month whether to renew Westwood Lodge’s overall license.

Security breach

The state recently shut down the children’s unit at Westwood Lodge. Arbour says it will not seek to reopen the unit. John Tlumacki/Globe Staff

It was just past midnight on Oct. 17, 2015, when a teenager at the Arbour Hospital in Jamaica Plain ripped the ID badge from around a nurse’s neck. Two other teens rushed forward and then used the badge to unlock two doors. The three patients ran into the night.

It was an extraordinary security breach. Sheila Lee, nursing director for the licensing division at the mental health department and herself a former Arbour executive, sent a terse e-mail the next morning to then-Arbour chief executive Laura Ames.

“Good morning, I am totally perplexed how 3 adolescents escaped from this unit at midnight,’’ she wrote. Given the hospital’s concern about one boy on the unit, who had a history of aggressive outbursts, “did you staff up? If not why not?’’ she asked.

Lee demanded names of the employees on duty. “There will be many more discussions around this issue,’’ she vowed.

About two months later, the agency sent the hospital a letter saying an investigation found that it did not have enough employees on the unit, one in an expanding pile of such notices. There was just one nurse on duty and two mental health workers, and each of the mental health workers was assigned to watch a specific patient. That left the nurse “present with multiple patients,’’ the department said.

Understaffing also contributed to horrific consequences for another patient, Michael Monroe, his attorneys argued in a negligence lawsuit. Monroe lived in a group home in Boston and was so mentally disabled that he required a legal guardian to make medical decisions for him. Over five years, he had had five admissions to Arbour hospitals. Each time, his medical record noted his allergy to Bactrim, a powerful antibiotic, the suit said.

Yet, during an admission to Westwood Lodge in February 2011, he was given two doses of the drug to treat a cough — a mistake perpetuated by the psychiatrist who prescribed it, the pharmacist who filled it, and the nurse who administered it, all of whom had access to the allergy warning.

Monroe’s reaction to the drug was immediate and severe. His skin burned and blistered from the inside out, requiring a prolonged stay in the Massachusetts General Hospital burn unit, and permanently scarring his torso and face.

The pharmacist had been required to stay late because her department was perpetually short-staffed. Tired and rushed, she failed to notice Monroe’s allergy warning, according to court documents in the lawsuit Monroe filed in Suffolk Superior Court. The nurse who gave the drug was part-time and was not familiar with Monroe’s medical history. Due to the demands of treating too many patients at once, he did not check Monroe’s medical record, the lawsuit alleged.

The nurse made troubling comments to investigators from the Massachusetts Disabled Persons Protection Commission who were looking into Monroe’s care. He said the hospital had a “high turnover of staff and patients” and was “very chaotic,’’ the lawsuit said.

The lawsuit sought $2.5 million for Monroe’s pain and suffering; a settlement was reached in 2013 for an undisclosed sum.

The company denied the allegations in court documents and would not comment specifically on Monroe’s case.

Requirements unmet

The mental health department requires psychiatric hospitals and units to provide a minimum of six hours of direct care from nurses and mental health workers to each adult patient each day; that mandate rises to seven hours for adolescent and geriatric patients, and eight hours for children.

Arbour has often fallen short of those requirements, state records show. The company has indicated that it is challenging to find enough psychiatrists, nurses, and mental health workers to fill jobs caring for mentally ill patients who increasingly have addiction and medical issues. But some employees, families, and lawyers believe the company intentionally keeps staff levels low to maximize profits, despite caring for extremely vulnerable patients

Last year, Massachusetts General Hospital provided an average of 9.32 hours per day of direct care to each patient on its adult psychiatric unit, while Baystate Medical Center, Beth Israel Deaconess Medical Center, Carney Hospital, and Melrose-Wakefield Hospital provided between 7 and 8 hours, according to reports made public on the Massachusetts Health & Hospital Association’s website.

Direct comparisons among hospitals are imprecise, officials warn, because some may employ more staff because they care for sicker patients, or may provide fewer staff because the staff they do have are highly experienced. But mental health officials said they have found that acute-care hospitals generally have more staff on their psychiatric units than stand-alone psychiatric hospitals such as those that Arbour runs.

Staff levels at the state's stand-alone psychiatric hospitals are not publicly reported.

Ross, the state licensing head, said her department has found staffing and other violations at psychiatric hospitals other than Arbour’s, though not as frequently as have been discovered at Arbour hospitals in the last two years.

In its statement to the Globe, Arbour said it routinely adjusts staffing to account for patient severity and only accepts patients it knows it can care for.

But a review of state inspection records makes clear that this is not always true.

During an August 2014 inspection, state investigators found that on four of 14 days, Arbour HRI in Brookline was not providing the bare minimum of six care hours per patient. Even when these minimal expectations were met, “the units were not adequately staffed to meet the needs of the patients and the acuity of the unit,’’ the inspector wrote. The report pointed out that one patient was not seen by a doctor for nearly eight hours after arriving. The hospital promised to increase staff.

Staff fears unanswered

Arbour-HRI Hospital in Brookline.Aram Boghosian for The Boston Globe/File/Globe Freelance

Working at a psychiatric hospital carries with it certain risks. Patients often can be psychotic, paranoid, and aggressive. They may have stopped taking their medications or lost hold of reality. Arbour executives have long defended their record by contending that they admit some of the sickest and most troubled patients in Massachusetts. O’Connor indicated that Arbour keeps an open door to patients whom other hospitals might turn away, such as those with “intellectual disabilities, co-occurring addiction disorders, and assaultive or aggressive behavior.’’

Many employees agree that is true but add that it is all the more reason to ensure adequate staff. Nurse Paula Price said that when she raised concerns about not having enough help, her pleas were ignored — and she ended up injured.

On Christmas Eve 2015, Price, a nurse at Pembroke Hospital, was feeling uneasy about a patient. She couldn’t put her finger on why. When he began pacing the halls at 5:30 a.m., she picked up the phone. “I called my supervisor and said we need another person up here. She said ‘I’ll see what I can do,’ ’’ said Price, 63. “That was always their response.’’

Price was on the unit with two mental health workers; one was walking room to room checking on the 20 patients on the unit. The other was assigned to watch one specific patient. As Price opened a binder of lab results at the nurses’ station, the patient, Darren Johnson, ran up behind her.

He shoved her to the floor, she said. As he kicked and punched her, Price curled up into a ball.

“We did not have enough staff on the unit,’’ she said in a recent interview. A fourth staffer on the ward might have spotted Johnson coming, she said.

“It was never about the patients and the employees,’’ said Price, who did not return to work after the attack. “It was about the numbers and about the money.’’

Another horrifying case of staff raising a red flag to no avail ended up in court. One man admitted as a patient at Pembroke Hospital in April 2008 seemed to have his eye on a particular 35-year-old female patient, who had suffered through a bitter divorce, lost custody of her children, and was suicidal. He lay down on an extra bed in her room. When staff shooed him out, he told them he would “make babies all night long if he wanted to,” according to documents that are part of a lawsuit brought by the female patient in 2012.

A nurse called her supervisor to request more help watching the man. But she did not think a higher level of supervision was necessary, she told investigators from the Disabled Persons Protection Commission. “A lot of patients come in that way and we don’t have the manpower for it,’’ said the supervisor, whose name was redacted from the report filed in court.

The man came back to the patient’s room later, the female patient said, and raped her. A jury found the hospital negligent and awarded the plaintiff $107,000 five years ago.

In her letter to the Globe, O’Connor, the head of Arbour, said the company takes “pride in our service to the thousands of Massachusetts residents we have successfully cared for over the past decade.’’ The company also sent the Globe copies of letters from six patients and family members praising employees for the good care they provided.

Despite the incidents cited in state documents, some employees feel the pressure to accept severely ill patients has intensified.

On Feb. 18 of last year, when O’Connor was interim Westwood Lodge chief executive, she told employees during a staff meeting that 94 patients had been turned away over the previous two months because they were too sick, according to an internal document summarizing her remarks. Many should have been admitted, she said. Only criminals should be turned away.

“Years ago, we screened very carefully for patients with a violent history,’’ said one longtime Arbour HRI employee, who did not want her name used because she is worried she will be fired. Now “we have to accept any patient. All we heard is, ‘Fill the beds until we are full.’ ’’

It’s not only violent patients whom staff are worried about. It’s also patients with serious medical conditions that Arbour hospitals may not be equipped to handle, and whom nurses may not have the experience to treat.

Sometimes, however, the hospitals’ failings have nothing to do with the complexity of a case but about the failure to see to the most basic things. The Arbour HRI staffer said she felt particularly bad about indignities suffered by a patient with a serious medical condition who was admitted to the hospital several months ago.

The patient had a colostomy bag — a small pouch used to contain fecal matter in patients who have had bowel operations. The bag was full at 7 a.m. and the hospital did not have a replacement. It took more than a day for staff to go to a nearby emergency room to obtain a new bag, she said.

“He had to hold a towel to himself,’’ she said. “He was so embarrassed.’’

‘A bed crunch’

On Aug. 4, 2014, an employee from Arbour’s Lowell Treatment Center left a phone message for mental health commissioner Marcia Fowler. She did not leave her name, but her words were alarming. There are not enough staff, she reported. It’s unsafe.

The state’s response illustrates the bind it has found itself in with Arbour and its supply of critical beds.

The next day, Lee, the licensing division’s head nurse, walked into the hospital at 5 a.m. and discovered the anonymous caller was right — there were 38 patients in the building and only two staffers in each unit; no one else was available if there was an emergency. She decided they would have to close the 10-bed adolescent unit temporarily, reassigning its workers to two other short-staffed and unsafe adult units. She e-mailed her superiors about the plan.

E-mails flew back and forth. Lester Blumberg, the lawyer for the department, asked if closing the adolescent unit would create “a bed crunch’’ and whether Arbour management would “push back’’ on the decision.

While the demand for beds for teens is usually lower in summer, “downsizing the system by 10 adolescent beds on a permanent basis would pose a significant problem,’’ chimed in Joan Mikula, who was then deputy commissioner. She has since replaced Fowler as commissioner.

Lee stood her ground and told the hospital to close its teen unit. At 5:23 the next morning, Blumberg e-mailed her to say he’d gotten a call from Karen Braunwald, the hospital’s chief clinical officer, who questioned the state’s regulatory authority to close the unit, since the hospital believed it had met the six-hour staff minimum.

The hospital will “respond with an aggressive defense of its performance rather than immediate steps to change conditions,’’ he told Lee and others in an e-mail. He said he believed the company could decide to convert the teen beds to adult beds permanently — a result the state wanted to avoid.

Blumberg said the agency may need to consider allowing the hospital to immediately open the teen beds on a “probationary basis.’’

Sure enough, four days later, on Aug. 11, the unit began to accept patients again.

Sharon Torgerson, spokeswoman for the Executive Office of Health and Human Services, said state officials would not comment on any incidents that took place during the previous administration.

But the complaints about staffing at Lowell have continued since Baker took office. Last year, on May 9, the mental health department received three complaints about unsafe staffing at the hospital. The allegations were confirmed during a 4:30 a.m. visit by Lee. There had been 14 resignations in the past 30 days. Staff complained that they were mandated to pick up shifts, and were burned out and tired, she wrote in an e-mail to colleagues.

After her visit, the hospital decided to close one unit until it could hire and train more workers.

This January, the clinical monitor for the mental health department, who had visited the hospitals 22 times over the previous eight months, reported to department officials that the Arbour system had made improvements and that new leaders have joined the system, which was encouraging, according to documents obtained by the Globe. But the monitor, whom the department would not name, was worried about constant staff turnover and the growing number of patients being put in restraints or given shots to calm them down. At Pembroke Hospital in particular, “the environment of care will rapidly deteriorate’’ without more state oversight, the report said.

Nevertheless, Mikula decided in February to renew the license for Westwood Lodge, Pembroke Hospital, and Lowell Treatment Center, which share a license, for another six months. Since then, Westwood Lodge has been closed to new admissions four times for repeated problems, and remains so today.

When the license for the three facilities expires next Saturday, the state will face a major decision — determining whether they have earned the right to continue operating.

The Joint Commission, the national organization that accredits hospitals, has been ineffective so far at forcing sustained improvement at the Arbour hospitals. Though its inspection reports are secret, the Globe obtained several reports contained in state files. The commission reaccredited Westwood Lodge, Pembroke Hospital, and Lowell Treatment Center last August during the same time period when the mental health department was finding repeated serious lapses.

‘Absolutely disgusting’

From her first minutes at Pembroke Hospital, Erin Rice found the care lacking. Aram Boghosian for The Boston Globe/Globe Freelance

Consumers who look on the commission’s website for guidance will find the organization’s gold seal next to each of the seven Arbour hospitals in Massachusetts.

But Erin Rice would not give Pembroke Hospital her seal of approval.

Rice, 34, began suffering serious anxiety and depression after graduating from the University of Massachusetts Amherst.

She would slice her arms with a razor because, she said, it calmed her. But over time, she learned to seek inpatient care when this desire flooded her mind — as she did one night in April 2016.

Her boyfriend drove her to the emergency room at Newton-Wellesley Hospital, where she had found help in the past. But the next morning, a nurse told her the hospital’s psychiatric unit was full. Pembroke Hospital, though, had an open bed.

From her first minutes there, Rice found the care lacking. Nurses too busy to give medications. Little meaningful group therapy. Sanitation was also a problem. Rice said the floors and couches were filthy and the bathrooms “absolutely disgusting.’’

One day she did not get her diabetes medicine, and she never got her blood tested — which is required daily to make sure her blood sugar is within safe levels — despite repeatedly requesting the test during her five-day admission, she said.

“There was a lot of ‘We will do it when we get to it. We are understaffed,’ ’’ Rice said.

A chance for some time outdoors — a patient right under Massachusetts law — was never offered. Therapy groups were sporadic and run by mental health workers, a lot of them college students, she said

“That was what psychiatric units were like long ago, not what they should be like now,’’ said Rice.

Her experience at Pembroke contrasted sharply with several admissions she had previously had at Newton-Wellesley. Occupational therapists ran groups on coping skills, substance abuse, communication, and eating disorders throughout the day, even on weekends. The hospital was clean. And staff called her regular psychiatrist to coordinate care before she was discharged, a step that did not happen at Pembroke, she said.

For the past three years, Newton-Wellesley said, it has provided between 8.5 and 10.25 hours of direct care per patient per day on its adult psychiatric unit, according to the hospital association’s website.

Rice, who earned a master’s degree in women’s health at Suffolk University, is feeling better these days She says she would never return to Pembroke.

A misdiagnosis

Rice said the floors and couches at Pembroke Hospital were filthy, and the bathrooms ‘absolutely disgusting.’John Tlumacki/Globe Staff

Carol Chesley, whose son died at Arbour Hospital in Jamaica Plain 15 years ago, was taking a break from advocacy. Jason was 18 years old when he stopped taking his medication for bipolar disorder, contemplated suicide, and ended up in the emergency room at Massachusetts General Hospital.

Doctors transferred him to Arbour. He called his mother the next day. “He sounded as high as a kite, like I have never ever heard him before,’’ Chesley recalled in an interview. “I said, ‘What kind of medications do they have you on?’ He said, ‘Methadone. They said I am a heroin addict.’ ’’

But he wasn’t, she said.

Jason Chesley, at age 16.Craig F. Walker/Globe Staff

Two days later, on Feb. 1, 2002, staff tried to wake up Jason at 7:30 a.m., but they could not rouse him. At 9:15 a.m., they looked in on him again and realized he had stopped breathing, according to an expert who reviewed the case for the Department of Public Health.

At first, the state did not fault the hospital. But Chesley appealed, and further investigation led to the conclusion that the hospital had misdiagnosed Jason with a serious heroin addiction, prescribing a dangerous dose of methadone and numerous other drugs that also depressed his central nervous system. At the same time, staff failed to properly monitor the impact of these drugs on his body; his vital signs were not taken for a full 24 hours prior to his death.

The hospital argued to the state that Jason’s treatment was appropriate.

Chesley successfully lobbied for the Arbour system to change its policy on patient safety checks. Rather than simply make sure that the patient was in bed, staff needed to witness three respirations.

So when she read last year in a local newspaper about Amber Mace, the young woman who had apparently been dead for a prolonged period before Pembroke staff discovered she was not breathing, Chesley was enraged. She made an appointment to see the deputy mental health commissioner, Dr. Kathy Sanders, who heads clinical and professional services.

“This should not happen,’’ Chesley recalled telling her. “How long are we going to let them kill people?’’

Sanders told her that the Arbour hospitals are now under very strict state oversight.

The new policy on safety checks also appeared to fail Michael Bakios, the 32-year-old who died at Westwood Lodge in 2015.

Bakios came of age under tough conditions in Lawrence. He was also diagnosed with schizophrenia, and because of his illness, he could not keep a job or an apartment or even cook for himself and leaned heavily on his younger brother, Brandon Bakios, the family said. Michael moved in with his brother and his brother’s partner, Katie Lavertue, and their children, sharing a room with their oldest son.

They took care of him, but Lavertue said he helped her, too. When Brandon was at work and she became overwhelmed, Mike would take one of their daughters to the playground and out for an ice cream cone, or walk her son to school. “We loved having him here,’’ she said.

He attended a program down the street from their apartment, and Lavertue could look out the window and see him walking home before noon. When he did not show up one morning, she began to worry. They did not know where he was until he called the next day from Westwood Lodge. They were shocked at how he sounded.

“I could not understand anything he was saying,’’ Brandon Bakios said. “I said ‘Mikey, what do they have you on?’ ’’

A few nights later, Mike called Brandon to tell him he was coming home, though he still did not sound like himself. Mike wandered back to his room at the hospital, fell asleep, and began to snore, according to state records obtained by the Globe.

Staff told police that they checked on him every five minutes. But when police and mental health department investigators reviewed videotape, they said that was not true. Between 2:25 and 3:15 a.m. he was not checked on as required, potentially delaying a response to what the medical examiner would later determine was a “probable cardiac dysrhythmia.’’

Two years later, his family is still stunned at how a physically healthy 32-year-old could die while closely monitored in a hospital.

In the weeks after his death, then-Westwood Lodge chief executive Gregory Brownstein called Brandon Bakios to express his condolences. “He said if something happened, he was going to get to the bottom of it.’’

A few months later, after his initial grief subsided, Bakios said he phoned Brownstein back with questions. But, he said, the CEO never returned his call. Reached by phone, Brownstein said he usually gets back to callers and might not have received the message.

Lavertue said she still is not at peace with what happened and wants the state to take stronger actions. “How many more times will they be cited before it’s too late again?’’

Carol Chesley displayed a Mother’s Day gift from her son Jason in her home. When Carol Chesley heard of other deaths at Arbour hospitals, she was enraged. She made an appointment with the state’s deputy mental health commissioner and demanded, “How long are we going to let them kill people?’’ Craig F. Walker/Globe Staff/Globe Staff

Liz Kowalczyk can be reached at kowalczyk@globe.com. Follow her on Twitter @GlobeLizK.