A lack of oversight and bureaucratic delays in New York state's gold standard program for treating mentally ill people who are at risk of becoming violent have led to an increase in preventable injuries and cases in recent years, according to a state audit released Thursday. In some cases, it can lead to death.
An audit conducted by the state comptroller found that the program, known as Kendra's Law, can sometimes be a drag in connecting people with psychiatric care. In one case, it took him nearly a month for a mental health provider to connect with a participant in the program. Such a connection was supposed to happen within a week. The provider did not schedule the required follow-up meeting, and the individual was arrested on suspicion of murder shortly after.
The state Department of Mental Health, which is responsible for making sure program participants receive treatment, didn't know about the delay until the local health department reported the homicide to the department, the audit found.
Overall, the audit found that Kendra's Law is often effective in connecting people to mental health care. Still, the group said the program, which forces mentally ill people into court-ordered treatment, needs to be improved to reduce delays and communication breakdowns that sometimes lead to serious consequences.
Comptroller Thomas P. DiNapoli said, “Any negligence can have deadly consequences.”
Treatment providers and health authorities regularly share information about how program participants are faring, and ensure that people are forgetting to take their medications, are at risk of self-harm, are being arrested, etc. They are supposed to be able to make adjustments to their care, such as pointing out if they are doing something wrong. However, in almost a quarter of the cases auditors investigated, there were data entry errors when reporting these significant events.
Although the audit did not identify program participants by name, the incidents described were harrowing. One participant in the program was hospitalized for suicidal thoughts 33 times over a 18-month period, but the hospitalizations were not recorded as required, the audit found. The last day the person was discharged from the hospital, the person died by suicide.
Justin Mason, a spokesman for the state Department of Mental Health, said the audit focused on some cases involving “the most difficult clients,” but added that the department is working to make improvements.
This audit echoes the findings of a New York Times investigation that identified significant failures in Kendra's Law. The program was launched in 1999 after a man with untreated schizophrenia fatally shoved a woman in front of a subway train, with the aim of preventing similar attacks from happening again. There is.
But the Times reveals that those under the most intense surveillance regime have been accused of more than 380 subway shovings, beatings, stabbings and other acts of violence in the past five years alone. I made it. At least five people who were or were under Kendra Law orders pushed a stranger onto the subway tracks. Over the past 10 years, more than 90 people have committed suicide while participating in the program, the Times reported.
A man diagnosed with schizophrenia was placed under a Kendra Law order about three years ago, but the group responsible for coordinating his care noticed signs that he was becoming unstable. Records and interviews revealed that this was overlooked. Over several weeks in the spring of 2023, he expressed violent delusions as his mother begged medical providers to get more psychiatric help. A few weeks later, he assaulted a Connecticut state lawmaker. He is still in jail awaiting trial.
In another case revealed by the Times, a man named Evan Guzman was placed on a Kendra Law order after being released from prison in April 2021, according to his mother, Lisa Guzman. But weeks after his release, he was supposed to receive treatment for schizoaffective disorder, but he barely met his care team, saw no psychiatrist, and took no prescribed medication. His mother said he was mentally unstable.
Guzmán implored authorities in Monroe County, New York, to get more intensive help before it's too late.
“Once again, he is falling into a corner,” she wrote in an email to state Department of Mental Health officials seen by the Times. “If the lack of care he is receiving from his current health care providers continues, he could end up back in prison or worse.”
Two months later, in July 2021, Guzman was charged with knocking on a 52-year-old man's door and stabbing him to death. He has been charged with murder and is awaiting trial.
New York state spends about $29 million a year running court-ordered treatment programs, formally known as outpatient assisted treatment, or AOT, for about 3,800 people. Studies have shown that the program is largely effective in reducing incarceration and emergency room visits, and officials say the program provides psychiatric treatment to a small number of mentally ill people deemed dangerous. I think this is the best way to get them to accept it.
But the program is underfunded, and treatment providers and health officials are often stretched to their limits, the Times reported. It can take months or years for health authorities to vet mentally ill people (who must either have a recent history of violence or repeated psychiatric hospitalizations) to admit them into programs. This was revealed by the auditors' investigation.
In around half of the cases investigated, local mental health authorities took anywhere from six months to two years to screen people for entry into the program, despite the requirement that screening be carried out in a “timely” manner. It took more than that. During that time, people ended up hurting themselves or others, the audit found.
In one case, it took health officials about two years to evaluate a person for the program, during which time the person was hospitalized five times, including for assault.
The audit revealed another person was referred to the program after he allegedly threatened a family member with a knife while hallucinating. However, the local mental health agency took nearly 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 audit found that the person had never been placed under a Kendra Law order.
State mental health officials said they generally agree with the auditor's findings and are working on ways to strengthen oversight. They said in 2011 that part of the delay in people's participation in the program is that it makes it more difficult to obtain the medical records needed to force people into treatment if they don't agree to share their medical records. He said this was due to the court's decision. Health officials said most people disagree, forcing authorities to file subpoenas for records and significantly slowing the process.
The auditors also accused local health officials of not taking the necessary steps to renew people's Kendra Law orders, leading to avoidable lapses in care. Treatment orders typically expire after one year but can be renewed, and studies have shown that longer monitoring periods increase treatment compliance and lead to better outcomes.
Auditors investigated 37 cases and found that in more than 60% of them, health authorities did not conduct the required case review before court-ordered treatment expired. In one case, a person featured on the show showed signs of delusion and became aggressive towards hospital staff, but local health officials did not renew the treatment order. In another example, health officials allowed a person's treatment order to lapse, and shortly after that person tested positive for drugs and was removed from a homeless shelter.
The Times also found other cases where Kendra Law orders were not renewed, with disastrous results.
Records show Luis Rodriguez was placed under a Kendra Law order in 2015 for attacking a family member while in the grip of a paranoid delusion. During his time in the program, he received monthly injections of antipsychotic medication and showed enough improvement that health officials decided his order should not be renewed.
But without court-ordered monitoring, symptoms became apparent over the next 18 months. Records show the man barricaded himself in his room and claimed the TV was haunted, then burst into the hallway of his mother's apartment building with a kitchen knife and stabbed two of his neighbors. It is said that he did.
Rodriguez pleaded guilty to attempted murder in 2022 and was sentenced to eight years in prison.
Laura Olivieri Robles Contributed to the report.
