Several patient deaths, including a suicide that could have been prevented and a case of overmedication, have led to greater scrutiny and calls for change at the Colorado Mental Health Institute in Pueblo. One patient died in August while restrained, one killed himself in September 2009 after signing a petition to ask for programming to be restored, and another died in 2007 after receiving too much medication, leading to a settlement of more than $223,000. Inside the hospital, staffing is low, along with morale, and the organizational structure is in “disarray,” according to a new report (via Westword). “There appeared to be a significant disconnection between administrative decisions and clinical care,” investigators found. Even the hospital’s metal mirrors, used for security, are problematic, presenting a “funhouse” image to patients.

The report, produced by three independent evaluators who interviewed staffers and reviewed records in the wake of the deaths, recommends that the hospital cut back on its use of physical restraints and seclusion of patients by half, notes The Denver Post.