Audit Finds Fatal Lapses in Mental Health Program Meant 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 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.