Audit finds fatal flaws in mental health program designed to curb violence

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

The audit, conducted by the state comptroller, found that the program, known as Kendra's Law, sometimes struggled to connect people to psychiatric care. In one case, it took almost a month for a mental health provider to connect with a person in the program, even though such a connection would occur within a week. The provider did not schedule a mandatory follow-up interview and shortly thereafter the individual was arrested on murder charges.

The state Office of Mental Health, the agency charged with ensuring people in the program receive treatment, only learned of the delay when the local health department notified the office of the killing, the audit found.

Overall, the audit found that Kendra's Law worked effectively in many cases in connecting people to psychiatric care. Still, it noted that the program, which forces mentally ill people into court-ordered treatment, needed to be improved to reduce delays and communication breakdowns that have sometimes led to serious consequences.

“When mistakes occur,” said the auditor, Thomas P. DiNapoli, “the consequences can be fatal.”

Treatment providers and health officials are expected to regularly share information about how people in the program are doing so they can coordinate care, for example if people haven't taken their medications, threatened to hurt themselves or have been arrested. But in almost a quarter of the cases reviewed by the auditors, there were data entry errors when reporting these serious events.

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

The audit reflects the findings of a New York Times investigation that revealed serious flaws in Kendra's law. The program, launched in 1999 after a man with untreated schizophrenia fatally pushed a woman in front of a subway train, was intended to prevent similar attacks from happening again.

But The Times found that people under this most heightened form of surveillance were accused of committing more than 380 subway shoves, assaults, stabbings and other violent acts in the past five years alone. At least five people who were or were under Kendra's law orders pushed strangers onto the subway tracks. According to The Times, more than 90 people have committed suicide during the program in the past ten years.

A 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 signals that he was becoming unstable, records and interviews show. For weeks, beginning in the spring of 2023, he expressed violent delusions as his mother begged his health care providers to get him more psychiatric help. Weeks later, he attacked a state lawmaker in Connecticut. He is still in jail awaiting trial.

In another case identified by The Times, a man named Evan Guzman was under a Kendra's Law warrant after being released from prison in April 2021, according to his mother, Lisa Guzman. But weeks after his release, when he was scheduled to receive help for his schizoaffective disorder, he rarely saw his care team, did not meet with a psychiatrist or receive prescribed medications, and became unstable, his mother said.

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

“He is falling through the cracks again,” she wrote in emails to officials at the state Office of Mental Health, reviewed by The Times. “If the lack of care he receives through his current health care 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 annually on the court-ordered treatment program, formally known as assisted outpatient treatment, or AOT, for about 3,800 people. Studies have shown the program to be largely effective at reducing incarceration rates and emergency room visits, and officials consider it the best way to get the small subset of mentally ill people considered dangerous to psychiatric treatment undergo.

But the program is underfunded and practitioners and health officials are often understaffed, The Times notes. It can take months or years for health officials to vet mentally ill people — who must either have a recent history of violence or repeated psychiatric hospitalizations — before admitting them into the program, the auditors noted.

In about half of the cases studied, it took six months to more than two years for local mental health officials to screen people for admission to the program – despite the requirement that the screenings be conducted in a “timely” manner. In the meantime, people have hurt themselves or others, the audit showed.

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 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 nearly two years to determine the person's eligibility for the program and made no progress 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 found.

State mental health officials said they largely agreed with the auditors' findings and were working on ways to improve monitoring. They said some of the delays in getting people involved in the program stemmed from a 2011 court decision that makes it harder to obtain the necessary medical records to force people into treatment if people don't agree to receive them. to share. Health officials said most people don't give consent, so officials have to file subpoenas for records, significantly slowing the process.

Auditors also accused local health officials of failing to take the necessary steps to renew the public's Kendra's Law orders, leading to avoidable deficiencies in care. Treatment orders typically expire after one year but can be extended, and studies have shown that longer monitoring periods increase treatment compliance 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 review of the case before the people's court-ordered treatment would expire. In one case, a person in the program showed signs of being delusional and had become aggressive toward hospital staff, but local health officials did not attempt to renew the treatment order. In another case, health officials let a person's treatment order lapse, and soon after, the person tested positive for drugs and was kicked out of a homeless shelter.

The Times uncovered other cases in which Kendra's law enforcement orders were not renewed — with disastrous consequences.

Luis Rodriguez was placed under Kendra's Law Order in 2015 after attacking his family members while in the grip of a paranoid delusion, records show. During the program, he received monthly injections of an antipsychotic drug and showed such improvement that health officials decided his treatment should not be extended.

But without court-ordered supervision, he fell apart over the next eighteen months. He barricaded himself in his room and insisted ghosts were haunting his television before grabbing a kitchen knife, storming into the hallway 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.