Dear Governor,

You didn’t know Jorge. He was just one of thousands of mentally ill patients living in one of your state mental health hospitals.

I wonder sometimes how his sister, his only surviving relative, is doing. I wonder if she knows the truth about how and why he died.

Jorge didn’t die from his heart disease, COPD, diabetes or long term dialysis treatments due to kidney failure. That’s how we all expected him to die. Fifty-five years old, in and out of hospitals much of his life, he was sure to die earlier than a healthy person his age.

Then he landed in one of your state mental hospitals. A few years after being admitted, his paranoia, his delusions and his lack of impulse control were somewhat improved. All we did to help him was of no help on his last day on earth. His last transport out of the hospital was in a body bag.

We told the patients, his peers on the ward, a couple of days later. Some already knew about it and some didn’t care. Some said “good riddance.” At the time of Jorge’s death, employees felt their own PTSD flare up again with increased respiratory rate, heart palpitations, and tears sneaking out during the unit de-briefing or later, in break room conversations.

Jorge’s dead because another patient killed him in the middle of the night when the unit was understaffed. He’s dead because your hospital refused to hire staff at appropriate patient levels based on the violent tendencies of many of our patients.

We know that the patient who killed Jorge will not be held responsible because of his own mental illness. Both men were mentally ill, both hospitalized for care and treatment. The hospital administration, and you—where the buck stops—is accountable for Jorge’s death. My colleagues know that. The doctors, the nurses, the janitorial staff all know it.

Yes, Jorge had a mean and nasty mouth on him, I’ll give him that. He could rile the calmest person in the room. That was his M.O. He was stingy. He was funny, flirty, kind at times, and very sad. He also played a wicked game of chess.

And now he’s dead.