Kendra’s Law Was Meant to Prevent Violence. It Failed Hundreds of Times.

After John Skeene served prison time for beating his mother to death with a chair leg, after he attacked a man with a radiator cover and threatened to murder his therapist, New York State placed him in its gold-standard program for treating mentally ill people at risk of committing violence.

The program, which grew out of legislation known as Kendra’s Law and has been held up as a national model, was supposed to ensure that Mr. Skeene complied with a court-ordered treatment plan despite being homeless and living with schizoaffective disorder.

But by late 2018, there were signs that he was once again becoming unstable. He terrorized workers in his Queens transitional housing program, records show, banging on desks and kicking doors until they called 911. After subsequent outbursts, and while he was off his medications, the workers tried to send him for a hospital psychiatric evaluation, but he refused.

Under Kendra’s Law, his treatment team could have forced him to go anyway, but it apparently did not take that step, records show. Soon after, Mr. Skeene cornered a mental health worker in her office and punched her 30 times in the face, fracturing her eye socket and damaging her brain. She spent the next six months in the hospital, and, when she emerged, had to relearn how to walk. Mr. Skeene, then 59, went to prison.

For years, New York has used Kendra’s Law to force the seriously mentally ill people it has judged to be most at risk of committing acts of violence to receive psychiatric treatment, with the goal of protecting the patient and the public alike. Enacted in 1999, the law was designed to ensure that dangerous breakdowns never occurred again.

But a New York Times investigation has found that people under Kendra’s Law orders have been accused of committing more than 380 subway shovings, beatings, stabbings and other violent acts in the past five years alone.

More than a third of them took place in New York City.

The state would not disclose the details of the serious crimes, citing laws that protect patient privacy. But a Times review of breakdowns in New York City’s mental health care system for homeless people, based on tens of thousands of pages of confidential treatment records and hundreds of interviews, turned up ready examples of the program’s failures.

At least five people who were or had been under the court-ordered monitoring pushed people onto the subway tracks — the very act, carried out by a man with untreated schizophrenia, that led to the creation of Kendra’s Law in the first place.

Another seven people committed brutal beatings or slashings on the streets, in an apartment building or on subway cars.

One man assaulted a Connecticut lawmaker following a prayer service earlier this year.

The random victims were not the only ones harmed. More than 90 people have killed themselves while subject to Kendra’s Law orders in the past decade, state records show.

The overwhelming majority of people who were placed under Kendra’s Law have not committed violent acts while in the program, and most had access to at least some stability in the form of housing. But among those who remained — homeless New Yorkers with severe mental illness — The Times found a pattern of troubling failures by the program to spot signs of an impending crisis and respond appropriately.

Together, their cases suggest that the program has often struggled to treat those who are the most difficult to reach, even though that population in recent years has repeatedly posed threats to themselves and others.

Many of the failures trace to a lack of funding that has left treatment teams overworked and underpaid.

“These teams have caseloads that are unmanageable and unreasonable, and that’s why you see people fall through the cracks,” said Matthew Shapiro, a senior director of government affairs at the National Alliance on Mental Illness in New York. “Is Kendra’s Law working the way it should? Unfortunately, it is not.”

Other failures stemmed from a reluctance among some teams to seek involuntary hospitalizations for people who go missing or stop taking their medications — the part of Kendra’s Law that gives it its teeth. In interviews, some providers said doing so destroys rapport with clients and is ineffective.

Treatment team members who do try to force hospitalizations described pleading with hospitals to admit patients who were psychotic only to see the patients released within hours. Eighty-five percent of the attempts to use Kendra’s Law to hospitalize people against their will in New York City did not result in hospital admissions, records show.

The law has also been softened by legal challenges from groups who have successfully argued that it infringes on individual rights, The Times found, making it more difficult for people to be placed in the program without their consent. In 2020, about 40 percent of all requests to get mentally ill people into court-ordered treatment in New York City failed, records show.

Brian Stettin, who helped draft Kendra’s Law in the 1990s and is now the senior adviser for severe mental illness in Mayor Eric Adams’s administration, said the program was not foolproof but remains “remarkably effective.”

“No one is suggesting that it completely eliminates any risk of criminality or that arrests have been reduced to zero,” Mr. Stettin said in an interview. “These things are still going to happen, and we’re still dealing with a highly challenging population.”

Every year, the state Office of Mental Health collects but does not publish data on how often people in the Kendra’s Law program are accused of committing “serious crimes” — violence including homicides, sex offenses and arson.

To learn more about the incidents, Times reporters filed records requests for the serious crimes data, and Times lawyers negotiated the release of some of the information.

The records, which were bare-bones and included no details of the violent acts, show that the alleged crimes were committed by less than 2 percent of all people in the program.

But an earlier Times examination of nearly 100 subway shovings, beatings, slashings and other violent acts found that it was not uncommon for such acts to have been carried out by homeless mentally ill people who had already been subject to Kendra’s Law. Sixteen of the incidents reviewed by Times reporters involved people who were being monitored or had recently been monitored by the program.

Diagnosed with schizophrenia, Andrey Desmond was placed under intensive monitoring about three years ago, Mr. Desmond said in interviews. But by spring 2023, it was clear the nonprofit contractor tasked with coordinating his care, the University Consultation & Treatment Center for Mental Hygiene, was not aggressively responding to signs that he was becoming unstable.

In several conversations with a Times reporter in May and June, he expressed bizarre and sometimes violent delusions.

“I think people are raping me in my sleep and touching me with their brains,” Mr. Desmond said during one call. “They think things are going to turn out well? If this country puts me out on the street?”

Soon after, Mr. Desmond left his housing program in the Bronx, saying in a text message that he was headed to Connecticut, where he grew up. For weeks, beginning in late May, Mr. Desmond’s mother, Lynsey Desmond, frantically called and texted a member of the team coordinating his care. She sent a last urgent text in late June, imploring the worker to find her son. A read receipt suggested the worker had reviewed the message but never responded.

Two days later, Mr. Desmond attacked a Connecticut state lawmaker, Maryam Khan, while she was with her children outside a prayer service in Hartford, Conn., slapping her face, placing her in a chokehold and throwing her to the ground, Ms. Khan said in an interview.

“A lot of lives that day were impacted,” said Ms. Khan, adding that she and her children were still suffering from the attack. “This exposed a lot of holes in our system.”

Mr. Desmond, 30, was jailed on an assault charge and is awaiting trial.

A lawyer for the coordinating team said the organization was limited in what it could tell Ms. Desmond because of privacy constraints but had relayed her concerns to the city health officials who run the Kendra’s Law program.

In other cases, people deemed no longer to be in need of Kendra’s Law monitoring quickly spiraled out of control.

Samuel Junker was placed under monitoring after years of troubling episodes caused by his schizoaffective disorder. While off his medications, he believed his parents were space aliens, and he had tried to kill himself by banging his head against the floor until his sinuses bled, his mother wrote in letters to judges and city and state agencies. On another occasion, he had set his apartment ablaze so he could “burn for Jesus.”

While under monitoring, Mr. Junker had found stability, and his dangerous delusions were kept at bay, his mother wrote. If he ever resisted taking his medications, the police could be called to take him to the hospital for an antipsychotic injection — a trip he never refused, she wrote, because he respected police authority.

Concerned somebody might get hurt if the order were lifted, Mr. Junker’s mother, Bonnie Dean Junker, begged a judge in Westchester County to extend it in summer 2018.

Without a Kendra’s Law order, Ms. Junker wrote to the judge, “we are looking at a future train wreck.”

The judge released him anyway, and the case was sealed, making it difficult to learn why he determined Mr. Junker no longer needed monitoring.

Mr. Junker quickly unraveled, his brother said. He refused to take his medications, had severe delusions and tried to set his mother’s mailbox on fire. Then, in August 2023, Mr. Junker appeared to be in the grips of a psychotic episode when he shoved a 34-year-old woman onto the subway tracks in Lower Manhattan, breaking her leg. Mr. Junker, 41, was charged with assault and is awaiting trial.

Kendra’s Law was named after Kendra Webdale, who was 32 in January 1999 when a man shoved her in front of a subway train, killing her instantly.

Soon after, it emerged that the man, Andrew Goldstein, had lived with schizophrenia for years. In the weeks before the random attack, he had deteriorated on the watch of the city’s mental health care system.

In response to public outrage, Gov. George Pataki signed Kendra’s Law the same year. It allowed doctors, family members and others to petition a judge to force mentally ill people into treatment if they met certain criteria. They had to have lashed out once within the previous four years or been hospitalized twice for failing to follow treatment plans in the prior three years. If a judge granted the petition, the person could receive medication and monitoring by a team of dedicated, vigilant specialists.

Studies soon showed that Kendra’s Law significantly reduced the number of arrests and hospitalizations of mentally ill people and saved taxpayers money on emergency room visits and other bills associated with untreated mental illness.

But civil liberties groups, who argued that the law deprived mentally ill people of their rights, won a major court ruling in 2011. In that case, the State Court of Appeals significantly limited the program’s reach by barring those seeking to place someone under Kendra’s Law from accessing that person’s medical records without their consent.

The ruling made it more difficult to obtain the records necessary for an involuntary treatment order. By 2020, city records show, an attempt to have someone monitored under Kendra’s Law was more than three times as likely to fail if it came from a family member or other member of the community than if it came from a hospital worker with access to medical records.

And despite its success, Kendra’s Law has often been treated as an afterthought by city and state officials, lawmakers and former program workers said.

When Amy Holman started as the director for the Kendra’s Law program under the city’s Department of Health and Mental Hygiene in 2001, her team was given a sprawling third-floor office to run the program, she said in an interview. But within a couple of years, she said, she and her team were moved into a cramped, dark work space in the basement.

The program, she said, “took a backslide.”

At the state level, said Catharine Young, a former Republican state senator who championed the program while in office, the Legislature has repeatedly failed to invest in Kendra’s Law.

“We were constantly fighting for more financial support,” Ms. Young said in an interview. “It wasn’t enough.”

New York State now spends about $29 million a year to run Kendra’s Law for some 3,800 people — less than 1 percent of what the state spends to operate its prison system.

The lack of funding has sometimes led to uneven care, The Times found.

When Erika Menendez was growing up in Queens, she was a sweet, sunny girl who once took a part-time job to help her family when money got tight, recalled her mother, Maricela Mera.

But as a teenager, her behavior took a turn. She tried to kill herself by swallowing a bottle of Tylenol and became convinced she was being followed by the F.B.I. At 22, she was diagnosed with schizophrenia and put on a strict regimen of psychotropic drugs.

The pills evened her out enough for movie nights and cups of tea on the couch, Ms. Mera said, but the medication’s side effects were harsh — weight gain, fatigue, uncontrollable twitching — and she never stuck with them for long.

Off the pills, she would cry in her room all day and refuse to shower. She became paranoid and accused people of being spies, became manic and destroyed everything in the house, and ultimately devolved into violence, saying that voices in her head were telling her to harm other people.

After one such cycle, Ms. Menendez was placed under Kendra’s Law in July 2012 and assigned to the care of a nonprofit called Federation of Organizations. The team was supposed to meet with her six times a month, deliver her medications and ensure she was taking them and have her hospitalized if she was not, her treatment plan showed.

But soon, the team was behaving like an organization that was stretched beyond its capacity. Its members skipped visits, and when they did visit it would be for only about 15 minutes, Ms. Mera said. They did not conduct required tests to determine whether Ms. Menendez was taking her medications. Instead they simply took her word for it, records show.

A spokesman for Federation of Organizations declined to comment, citing privacy concerns.

By fall 2012, Ms. Menendez was once again showing signs she was about to break down, giggling uncontrollably, blowing off appointments from the treatment team and using marijuana, which aggravated her symptoms. In December, she disappeared, leaving behind a pile of unopened packets of the pills that kept her stable.

In a panic, Ms. Mera begged the treatment team to find Ms. Menendez before it was too late. The team could have sought an order to send the sheriff’s office out to locate Ms. Menendez and take her to a hospital. But nothing in her treatment records indicate that the team ever took that step.

On Dec. 27, 2012, Ms. Menendez was on a subway platform in Queens when she shoved a 46-year-old man named Sunando Sen onto the tracks as a train barreled into the station — just as Mr. Goldstein had shoved Kendra Webdale about a decade earlier. Mr. Sen died instantly.

Ms. Menendez, 33, pleaded guilty to manslaughter and was sentenced to 24 years in prison.

“It is a shame that an innocent man had to die due to the negligence of people in charge of the care and monitoring of the mentally ill,” Ms. Mera wrote to the judge overseeing her daughter’s criminal case. “All my efforts to get her help all these years were in vain.”

Susan C. Beachy and Peter Franceschina contributed research.