NY State Finds Fatal Lapses in Lauded Mental Health Program


Poor oversight and bureaucratic delays in New York State’s gold-standard program for treating mentally ill people at risk of becoming violent has led in recent years to preventable injuries and even deaths, according to a state audit made public on Thursday.

The audit, performed by the state comptroller, found that the program, known as Kendra’s Law, sometimes dragged its feet in linking people to psychiatric care. In one case, it took nearly a month for a mental health provider to connect with a person in the program, even though such a connection was supposed to occur within a week. The provider did not schedule a required follow-up meeting, and soon after the person was arrested on a homicide charge.

The State Office of Mental Health, the agency responsible for ensuring that people in the program receive treatment, did not learn about the delay until the local health department alerted the office to the killing, the audit showed.

Overall, the audit found that in many instances Kendra’s Law was working effectively to connect people with psychiatric care. Still, it noted that the program, which compels mentally ill people into court-ordered treatment, needed to be improved to reduce delays and communication breakdowns that have sometimes led to grave results.

“When there are lapses,” the comptroller, Thomas P. DiNapoli, said, “the consequences can be fatal.”

Treatment providers and health officials are supposed to regularly share information about how people in the program are faring so they can coordinate care, such as noting if people have failed to take their medication, threatened to hurt themselves or been arrested. But in nearly a quarter of the cases auditors reviewed, there were data entry errors in reporting these serious events.

The audit did not identify any program participants by name, but the cases described were harrowing. One person in the program was hospitalized for suicidal thoughts 33 times over a year and a half, the audit found, yet none of the hospitalizations were recorded as required. The day the person was released from the hospital for the last time, the person died by suicide.

The audit echoes the findings of a New York Times investigation that identified serious breakdowns in Kendra’s Law. The program, launched in 1999 after a man with untreated schizophrenia fatally shoved a woman in front of a subway train, was designed to prevent similar attacks from occurring again.

But The Times found that people under this most heightened form of monitoring were accused of committing more than 380 subway shovings, beatings, stabbings and other violent acts in the past five years alone. At least five people who were or had been under Kendra’s Law orders pushed strangers onto the subway tracks. More than 90 people in the past decade killed themselves while in the program, The Times found.

One man diagnosed with schizophrenia was placed under a Kendra’s Law order about three years ago, but the group responsible for coordinating his care missed signs that he was becoming unstable, records and interviews show. For weeks, beginning in spring 2023, he expressed violent delusions as his mother begged his providers to get him more psychiatric help. Weeks later, he assaulted a state lawmaker in Connecticut. He remains in jail awaiting trial.

In another case identified by The Times, a man named Evan Guzman was under a Kendra’s Law order after being released from prison in April 2021, according to his mother, Lisa Guzman. But weeks after being released, when he was supposed to be receiving help for his schizoaffective disorder, he rarely saw his care team, was not meeting with a psychiatrist or getting his prescribed medications, and was becoming unstable, his mother said.

Ms. Guzman pleaded with officials in Monroe County, N.Y., to get him more intensive help before it was too late.

“Once again he is falling through the cracks,” she wrote in emails to officials with the State Office of Mental Health reviewed by The Times. “If the lack of care he is getting through his current providers continues, he will end up back in prison or worse.”

Two months later, in July 2021, Mr. Guzman was accused of knocking on a 52-year-old man’s door and stabbing him to death. He was charged with murder and is awaiting trial.

New York State spends about $29 million a year to run the court-ordered treatment program, formally known as assisted outpatient treatment or A.O.T., for some 3,800 people. Studies have shown that the program is largely effective at reducing incarcerations and emergency room visits, and officials consider it the best way to get the small subset of mentally ill people deemed to be dangerous into psychiatric treatment.

But the program has been underfunded, and treatment providers and health officials are often stretched thin, The Times found. It can take months or years for health officials to vet mentally ill people — who must either have recent histories of violence or repeated psychiatric hospitalizations — for acceptance into the program, the auditors found.

In about half the cases reviewed, it took from six months to more than two years for local mental health officials to screen people for admission into the program — despite requirements that the screenings be conducted in a “timely” manner. In the interim, people ended up hurting themselves or others, the audit found.

In one case, health officials took about two years to evaluate a person for the program, during which time the person was hospitalized five times, including after assaulting someone.

Another person was referred to the program after threatening a family member with a knife while hallucinating, the audit found. But the local mental health agency took almost two years to review the person’s eligibility for the program and did not follow up after requesting the person’s medical records to complete the process. Despite the person’s psychiatric history, the person was never placed under a Kendra’s Law order, the audit showed.

State mental health officials said they largely agreed with the auditors’ findings and were working on ways to enhance monitoring. They said that some of the delays in getting people into the program stemmed from a court decision in 2011 that makes it more difficult to obtain the necessary medical records to compel people into treatment, if the people do not consent to sharing them. Health officials said most people do not consent, so officials must file subpoenas for the records, significantly delaying the process.

Auditors also faulted local health officials for failing to take necessary steps to renew peoples’ Kendra’s Law orders, leading to avoidable lapses in care. The treatment orders typically expire after one year, but can be renewed, and studies have shown that longer monitoring periods increase compliance with treatment and lead to better outcomes.

Auditors reviewed 37 cases and found that in more than 60 percent of them, health officials did not conduct the required case review before peoples’ court-ordered treatment was set to lapse. In one case, a person in the program was showing signs of delusion and had become aggressive toward hospital staff, but local health officials did not attempt to renew the treatment order. In another instance, health officials allowed a person’s treatment order to lapse, and, soon after, the person tested positive for drugs and was kicked out of a homeless shelter.

The Times found other cases in which Kendra’s Law orders were not renewed — with disastrous results.

Luis Rodriguez was placed under a Kendra’s Law order in 2015 after attacking his family members while in the grips of a paranoid delusion, records show. While in the program, he received monthly injections of an antipsychotic drug and showed such improvement that health officials determined his order should not be renewed.

But without the court-ordered monitoring, he unraveled over the next 18 months. He barricaded himself in his room and insisted that spirits were haunting his television before grabbing a kitchen knife, bursting into the hall of his mother’s apartment building and stabbing two of her neighbors, records show.

Mr. Rodriguez pleaded guilty to attempted murder in 2022 and was sentenced to eight years in prison.



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