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Families trusted this hospital chain to care for their relatives. It systematically failed them

Carol and Warren Chesley with a memory quilt honoring their son, Jason. They won a change in procedure after Jason’s death at Arbour Hospital in Jamaica Plain in 2002. They were incensed to hear of a similar death in Pembroke in 2015. –Craig F. Walker/Globe Staff

When state inspectors walked into the Westwood Lodge psychiatric hospital at 5 a.m. in April of last year, they found a heart-wrenching scene. Children slept on bare, plastic mattresses in filthy rooms; dust and dirt collected in the corners. When the young patients woke up, staff sat them in front of a television.

Caregivers had taken away the toys and stashed them in inaccessible piles at the nurses’ station, according to the state’s report. Trash was strewn about a rancid-smelling bathroom. And when inspectors questioned the only nurse on duty, a temp, about the location of the fire alarm or even how she would evacuate her eight small charges, all 12 and younger, she did not know.

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Hospital executives ordered bedsheets that fit, brought out the toys, and gave the children’s unit a thorough cleaning and fresh paint. But when inspectors returned seven weeks ago, they found even more disturbing evidence of substandard care: a 9-year-old boy with a severely bruised face who had not been taken to the emergency room for six days after the injury.

Michael Bakios (left) and his brother, Brandon. —handout
Jason Chesley, at age 16. —Craig F. Walker/Globe Staff
Carol Chesley displayed a Mother’s Day gift from her son Jason in her home. When Carol Chesley heard of other deaths at Arbour hospitals, she was enraged. She made an appointment with the state’s deputy mental health commissioner and demanded, “How long are we going to let them kill people?’’ —Craig F. Walker/Globe Staff

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