What Happens When New Yorkers With Mental Illness Slip Through the Cracks

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February 26, 2019
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by Marcia Robiou Abrams Journalism Fellow, FRONTLINE/Columbia Journalism School Fellowship

Snow had already begun falling, but Carmen Pacheco and her children — on a quest for snacks — had bundled up to face New York City’s biggest blizzard of 2016. As Pacheco navigated her apartment building’s dark hallway using the flashlight beam of her phone, her daughter made a gruesome discovery downstairs: a man, stark naked and curled in the fetal position, lay dead in the foyer.

“A lot of things went through my mind,” Pacheco said. “I didn’t hear anybody fall down the stairs. I was scared.”

Pacheco alerted her neighbor Nestor Bunch, who confirmed that it was the body of his roommate, Bernard Walker. Pacheco was shocked. The 54-year-old Bernard, affectionately known as Benny, had been kind to her family, frequently greeting them and volunteering to take out their trash.

But there had been warning signs that something was wrong. In the months leading up to his death in January 2016, Bernard began to exhibit increasingly bizarre behavior. He banged on Pacheco’s door wearing only underwear, offering to sell her cereal and soda. Another neighbor described seeing Bernard, half-naked, practicing karate in the street days before he died.

Bernard — who had schizoaffective disorder — was one of hundreds of New York residents who made the transition from adult homes, centers that have long housed the poor and disabled, to independent living. Bernard and Nestor, his roommate, were both beneficiaries of a landmark 2014 court settlement that allowed psychiatrically disabled residents in about two dozen New York adult homes to move into affordable apartments.

The case was a major coup for disability rights advocates, who believe that those with severe mental illness should be given the chance to live on their own with support from caregivers.

But as the FRONTLINE documentary Right to Fail shows, for some, the transition from tightly-controlled settings to the lower levels of supervision in supported housing can have dire consequences. The FRONTLINE-ProPublica investigation found that at least six people in the program died under questionable circumstances, including a woman who was choked to death and left in a bathtub. More than two dozen ended up in dangerous or inhumane conditions, including one who went missing and another who landed in jail.

Right to Fail finds that there is a systemic lack of coordination among the network of agencies responsible for implementing the program, making it easy for some of the most vulnerable people to fall through the cracks. Until recently, the Office of Mental Health, the New York state agency primarily in charge of the program, had no system in place to track the outcomes of people once they moved into an apartment. After months of questioning from FRONTLINE and ProPublica, OMH revealed that of the 770 who have moved out so far, 33 have died and 39 have returned to adult homes.

“There’s no one single point of responsibility that you could point to,” Sam Tsemberis, the founder of a supported housing model and expert witness in the court case, told FRONTLINE. “Where does the buck stop? Where’s that desk that says the buck stops here on the adult home case? That’s what I’d like to know.”

Michael Walker has been on a search for what, exactly, happened to his brother Bernard leading up to his death. But the former New York City police officer has been met with deflection and secrecy from the agencies responsible for Bernard.

“I experienced a lot of anger and grief because I didn’t know exactly what was going on,” Michael said. “The information we got was very sketchy.”

Michael’s search for answers — which has stretched on for years — exposes the flaws at the heart of the program. Medical records show that Bernard was struggling with independence after a month of moving into his apartment. He had trouble keeping up with a battery of anti-psychotic medication. The last time a case worker visited him was two days before his death. The entire encounter lasted 15 minutes.

The Office of Mental Health conducted an investigation into Bernard’s death, but has refused to disclose the findings to the Walker family, claiming it would be an unwarranted invasion of his privacy and that it is a “quality assurance record,” which is exempt from public records requests.

“I can’t understand why the agency is not freely giving the information,” Michael said. “How far did they go? Or was it just a cursory investigation?”

In response to reporting by ProPublica and FRONTLINE, the judge overseeing the New York court case has ordered an investigation into the state’s incident reporting system. But this offers little solace to Michael, who may never know what happened to his brother before he was found alone in an unheated foyer.

Right to Fail premieres Tuesday, Feb. 26 at 10 p.m. EST/9 p.m. CST on PBS stations (check local listings) and online.

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