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A new report from Disability Rights Florida raises urgent concerns about patient safety inside Florida’s state-run mental health treatment facilities, concluding that staff negligence played a significant role in at least six patient deaths over the past five years.

The deaths occurred at Florida State Hospital, Northeast Florida State Hospital, North Florida Evaluation and Treatment Center, and South Florida State Hospital. In each case, investigators found that required patient safety checks were missed, poorly performed, or falsely documented — failures that contributed to deaths from suicide, assault, or untreated medical emergencies.

People treated in these facilities are typically involuntarily committed, meaning the state has taken custody of them because they are considered a danger to themselves or others. Under Florida and federal law, the state assumes responsibility for their safety and medical care.

At the center of the report is a practice known as patient safety checks, sometimes called “face checks.” These are routine, scheduled observations meant to confirm that patients are alive, breathing, and not in distress. In most psychiatric hospitals, patients are checked at least every 15 minutes. In Florida’s state hospitals, however, the default is typically every 30 minutes, unless a doctor specifically orders more frequent monitoring.

Disability Rights Florida found that even these minimum checks were often not happening.

In one case, a woman at Florida State Hospital died by suffocation after staff failed to check on her for hours and later falsified records claiming they had done so. In another, a patient with a head injury was supposed to be monitored every 15 minutes overnight but was left unobserved for nearly three hours before being found dead. In other cases, patients were assaulted by roommates or were able to access plastic bags, sheets, or unlocked rooms that allowed them to take their own lives.

Video footage reviewed during investigations repeatedly showed staff either skipping checks altogether or performing them so briefly that they could not confirm signs of life — sometimes shining a flashlight through a door window for only a few seconds or not stopping at all.

While hospitals typically fired or disciplined the employees directly involved, the report concludes these actions are not enough. Most safety checks are performed by low-paid, non-clinical staff with high turnover, and the hospitals lack meaningful systems to supervise their work or catch problems before someone was harmed.

The report also highlights aging facilities as a major risk factor. Many of Florida’s state hospitals were built decades ago and lack modern, ligature-resistant design features now standard in psychiatric care, such as doors, fixtures, and hardware designed to prevent hanging or self-harm.

Disability Rights Florida is calling on the Florida Department of Children and Families, which oversees the hospitals, to take immediate statewide action. Recommendations include comprehensive safety audits of all facilities, increased nighttime staffing, more frequent and standardized safety checks, improved suicide risk screening, and routine video audits to ensure checks are actually being performed.

“These deaths were not isolated or unavoidable,” the report concludes. “They were the predictable result of systemic failures that continue to put patients at risk.”