CHARLOTTE, N.C.-- Kenny Chapman should have been hospitalized when he showed up at a local emergency room saying he wanted to kill his wife and displaying obvious signs of mental illness, four psychiatrists told the Observer.

The psychiatrists from around the country say they probably would have hospitalized Chapman - even against his will - if they had been called on to treat him.

Chapman twice sought help at CMC-Randolph, once in February and once on March 16 - the same day he killed his wife and two of his children.

Chapman told clinicians at the Billingsley Road psychiatric hospital that he had access to firearms and wanted to kill his wife, according to records obtained by the Observer. He later backed away from his threat, saying he would not hurt his wife, Nateesha. But he also told staff he was hallucinating, had a history of alcohol abuse and depression, and had a volatile relationship with his wife.

Both times, clinicians released Chapman from the emergency room within hours, giving him prescriptions and instructions to call back for an appointment. Records show no attempt to hospitalize him.

There's no question that Chapman should have been hospitalized, says Dr. Janet Taylor, a New York psychiatrist and former clinical instructor of psychiatry at Harlem Hospital. He's definitely a danger to himself and others.

Officials at Carolinas Medical Center, which runs the psychiatric hospital for the county under a $16 million contract, say confidentiality laws prohibit them from discussing Chapman's case. But hospital officials are reviewing how staff at CMC-Randolph handled Chapman's treatment.

The 33-year-old Fed-Ex package handler ultimately killed himself, two weeks after the initial killings.

Chapman's mother, Ruby Cosby, says she's outraged that her son was allowed to leave the hospital when he needed help.

I lost my son and granddaughter, and other lives were taken because the hospital was negligent, she says. That negligence cost a lot of lives. What do you have to do or say before anyone pays attention to you crying out?

Psychiatrists nationally say the decision about hospitalization hinges on whether they believe a patient is dangerous to himself or others. They use a variety of tools to evaluate the risk - including interviews and observation of the patient, consultation with family, and a review of patient medical and behavioral history.

But doctors say they can't be certain who will turn violent, and the decision is ultimately a judgment call.

Five psychiatrists interviewed by the Observer said they couldn't determine whether Chapman should have been hospitalized because they didn't personally evaluate him.

But four other psychiatrists, recommended by professional associations and well-known medical schools, agreed they would have hospitalized Chapman, based on a detailed description of his hospital visits.

The doctors did not review Chapman's medical records. And, to avoid influencing their answers, the Observer didn't mention Chapman's eventual killings until they had offered opinions.

The four psychiatrists agreed that the toxic combination of risks in Chapman's case - depression, alcohol abuse, threats of violence and access to guns - suggested a need for immediate intervention.

If the person is depressed, angry with his wife and wanting to kill her, and has access to firearms, I'd certainly be inclined to hospitalize, said Dr. Bernadette Cullen, director of the Johns Hopkins Community Psychiatry Program.

It's not unusual for patients to threaten suicide, psychiatrists say, but explicit homicidal threats are rare and always get their attention.

Dr. Anil Godbole, chairman of psychiatry at Chicago's Advocate Illinois Medical Center, says patients threaten homicide two or three times a month at his psychiatric emergency department, which sees about 250 patients monthly.

Godbole, who served on President George W. Bush's Commission on Mental Health, said if a patient like Chapman refused to enter the hospital voluntarily, I would insist ... if he likes it or doesn't like it.

Growing calls for help

Like other mental health facilities in North Carolina, Charlotte's psychiatric hospital is under stress. With calls and visits steadily climbing, the hospital's 44-bed adult inpatient unit has been above capacity for more than a year.

It's unclear whether any beds were available on March 16. CMC couldn't provide a daily patient count last week. But the occupancy rate for March overall was 105 percent.

Area Mental Health Director Grayce Crockett won't discuss Chapman's treatment. Her department manages the county's mental health care providers, including CMC-Randolph, although the hospital has its own leadership team.

Crockett says even when all of the hospital beds are filled, patient care isn't compromised. If a patient needs to be admitted, she has said, the hospital can transfer him to the state psychiatric facility in Morganton. CMC also can send patients to the psychiatric units of general hospitals.

But experts nationally say psychiatrists may hesitate to order an admission if a hospital's beds are full.

It undoubtedly casts a shadow on the decision-making, says Dr. William Sledge, medical director of the Yale-New Haven Psychiatric Hospital.

The number of psychiatric beds nationally has declined, experts say, and insurance companies increasingly refuse to cover inpatient care except in the most severe cases.

Chapman first went to CMC-Randolph's emergency room on Feb. 28. During the two-hour evaluation, he told clinicians he had been fighting with his wife and thinking about harming her, records show. It was a chronically volatile relationship with verbal and physical conflicts, a doctor wrote. He was previously treated for depression, and had a history of alcohol abuse. He also had guns.

But Chapman later told staff he wouldn't hurt anyone. Clinicians sent him home with a prescription for medication to treat anxiety and depression. Those medications probably would have taken effect on Chapman within a few days or weeks, psychiatrists say.

Two weeks later, on the morning of March 16, Chapman again appeared at the emergency room.

He had a shouting match with his wife, and he told staff he wanted to kill her, records show. He also reported seeing shadows of people every day. But later in the visit, Chapman told a nurse and a doctor he wouldn't harm anyone.

A doctor thought Chapman had a depressive disorder and increased the dosage of anti-anxiety medication, records show. The hospital released Chapman around 6 a.m.

Later that day, police say, Chapman suffocated his wife and 1-year-old daughter and fatally stabbed his 13-year-old stepdaughter.

He spent the next two weeks living in his south Charlotte home with his two surviving children, ages 10 and 2 - while the bodies of his two dead daughters were locked in a bedroom. When police came to Chapman's home on March 29, they say he shot at them and then took his own life.

'Recipe for disaster'

Under N.C. law, doctors can involuntarily commit mentally ill patients they judge to be a threat to themselves or others.

Chapman's professed change of heart about killing his wife would have complicated a doctor's decision on whether to hospitalize him, psychiatrists say.

Dr. Marvin Swartz, interim chair of Duke University's psychiatry department, says he couldn't judge whether Chapman should have been admitted without evaluating him. But he says clinicians may have concluded they had adequately addressed Chapman's problems in the emergency room.

If you feel you've turned it around during that visit, sometimes you have to take that risk, he says, because you can't admit them all.

But Taylor, the New York psychiatrist, says she puts more weight on a patient's initial statements because later comments can be influenced by fears of being committed.

People start getting nervous about what's going to happen, and they change their tune, she says.

S.C. psychiatrist Gariane Gunter called Chapman's risk factors a recipe for disaster. A resident at the University of South Carolina School of Medicine, Gunter says she would not have been persuaded by Chapman's later claims that he wouldn't hurt anyone.

I don't know what else you need to be really scared for his wife, she says.

'He was reaching out'

It's unclear whether hospital staff made any effort to warn Chapman's wife. But the records show no indication that contact was made.

Several of the psychiatrists interviewed say clinicians, often by state law, have a duty to warn the targets of such threats. North Carolina has no such law.

Chapman's parents say they wish the hospital had alerted them about their son's troubles. The hospital failed their family, they say.

He was reaching out, says Chapman's mother, Ruby Cosby, and they didn't reach back.

The two surviving children are in the custody of the Mecklenburg Department of Social Services, temporarily placed with relatives until officials assign the kids a permanent home - or possibly separate homes.

Chapman's 10-year-old daughter keeps in touch with her grandparents with a cell phone the Cosbys gave her when she went to New Jersey for her father's funeral.

Chapman's 2-year-old son doesn't yet understand death, says Chapman's stepfather, James Cosby.

All he knows is that he misses his mother and father.

Staff writers Ely Portillo and April Bethea contributed.

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