In the early hours of July 15, 2006, Crystal Marshall, 17, cried out for her mother.
A nurse at Psychiatric Solution Inc.'s Cumberland Hospital in New Kent, Va., rushed to the girl's side as she began vomiting. Her head snapped to the right. Her legs jerked in seizure. Her pants soaked through with blood.
The doctor on call heard Crystal's moans over the phone and told staffers to check whether she was faking the seizure, according to an inspection report filed by Virginia's mental health department.
Almost an hour ticked by as Crystal's blood pooled on the floor. When staffers ultimately decided to summon paramedics, the doctor said, "Make sure it's non-emergency," according to the investigative report.
Crystal died later that morning of a rare blood disorder, a coroner's report said.
She had been scheduled to leave the hospital and return to her foster mother's Delaware home within days.
PSI officials said they could not comment on specific cases, but said they seek to learn from any mistakes and make needed changes. The facility reported to the state that it would in the future allow nurses to call 911 in an emergency instead of relying on a doctor's determination.
After Marshall's death, state regulators discovered that missteps in the teen's care started months before, including failures to arrange appointments for cardiac and neurological care that had been ordered by doctors.
Officials cited the hospital for neglecting to get Crystal routine and emergency medical care.
"I'll never see her graduate, try to further herself in school," said Denise Marshall, Crystal's foster mother. "Weddings, becoming a grandmother -- we're both missing out on a whole lot."
Jewett and Fields are writers for ProPublica.