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Spotlight Follow-up

A depleted state system fails many with serious mental illness

James Boyd Jr.’s death is one of seven recent incidents involving Department of Mental Health clients living in the community, frequently without proper supervision. Marilyn Boyd, his sister, looked through a bag of his belongings for the first time. Suzanne Kreiter/Globe staff

James Boyd Jr. was supposed to be one of the fortunate ones.

Within Massachusetts’ broken mental health care system, he was among those sick enough to be named clients of the state Department of Mental Health. State workers, accordingly, were tasked with watching over Boyd, who had chronic paranoid schizophrenia, and keeping him safe.

Yet just before sunrise one morning last August, he sat naked on a bench at a South End mental health center. The 49-year-old was agitated and had just gone to the bathroom outside the building, according to an internal state report obtained by the Globe.

Boyd had been released from a hospital psychiatric unit just days earlier, and it was clear to his immediate caregivers that he still required inpatient care, the report shows. But after two facilities refused to take him — a common problem for people with serious mental illness — the Department of Mental Health opted to keep Boyd in a less secure residential program that allowed him the freedom to come and go.

Boyd was jumpy after a night on the streets, and after spending days before that trying to get admitted to local emergency rooms. When he heard a nearby security officer call 911, he apparently got spooked and left Solomon Carter Fuller Mental Health Center.


Half a block up East Newton Street, a car struck him.

Boston police found him writhing in pain in a crosswalk, with severe lacerations to his back and scrapes on his head, legs, and arms, according to the police report. He was pronounced dead at Boston Medical Center at 6:37 a.m. on Aug. 24.

“He fell through the cracks,” said Boyd’s sister, Marilyn Boyd, who lives in Framingham. “I’m disgusted.”

James Boyd Jr.’s death is one of seven recent incidents involving Department of Mental Health clients that illuminate a growing concern inside the state agency: that the department is releasing a steady stream of people with serious mental illness to live in the community without proper supervision.


While thousands with serious mental illness struggle to get any help, the roughly 21,000 Department of Mental Health clients are promised treatment at state-run facilities and state-funded programs in the community that are operated by private vendors. Having successfully completed an onerous application process, they’re supposed to have access to the best care the state has to offer.

The funeral program for James Boyd Jr.Suzanne Kreiter/Globe Staff

But the string of incidents raises questions about whether the department is doing enough to ensure the safety of its clients and the public.

One state client on a watch list for sexual misconduct was found hiding in a Brookline family’s home. Another allegedly stabbed a stranger as the victim left a movie theater, while a third, known to have violent tendencies, allegedly assaulted a stranger with a brick. Still another client who was supposed to be monitored for suicidal behavior fell or jumped out of a group home window, broke his neck, and was not found until the following morning.

Current and former Department of Mental Health employees, along with clinicians who work closely with the department, say the chronically underfunded agency too often fails to properly manage those in its care. Community treatment has been outsourced to private vendors, whose staff are often underpaid and have limited training. State budget cuts have decimated the ranks of case managers, who oversee treatment for individual clients.


“I’m ashamed of the treatment we provide some of our most vulnerable, forgotten neighbors,” said one veteran Department of Mental Health employee, who asked to remain anonymous.

State investigators in at least three of the cases examined by the Spotlight Team, including Boyd’s, concluded that the agency or its contractors bore no fault. However, Department of Mental Health officials declined to comment on any of the cases, leaving many questions unanswered.

People like James Boyd Jr. are among the most difficult and challenging to care for. They have severe illnesses, often don’t take their medications, and can expertly mask how sick they’re feeling. It only takes a moment — one unsupervised decision — to bring about life-altering consequences.

Part of the problem, employees say, is the continuing pressure to move patients from inpatient units into the community. Managers are even evaluated on how many people they divert from psychiatric hospitals, employees say, reflecting a top goal of the state since it began closing hospitals in 1973.

As a result, some patients are released before they’re ready, employees say, and, once back in the community, they get little oversight despite a Department of Mental Health pledge to actively monitor clients at risk of harming themselves or others.

Another longtime Department of Mental Health employee said that too many treatment decisions are “being made because of numbers, not what is clinically appropriate.” The employee initially saw promise in the election of Governor Charlie Baker and his appointment of Marylou Sudders, a social worker, as state health and human services secretary.


“I was hoping it would change,” said the employee, who asked to remain anonymous out of fear of retaliation. “It really hasn’t.”

.  .  .

Chad Kirby, 36, who has paranoid schizophrenia, had been under the care of South Shore Mental Health and living in an apartment. He allegedly attacked a man leaving a Newton movie theater.handout

Walking back to his car after a movie at West Newton Cinema, a man felt someone grab his forearm from behind. The alleged assailant, 36-year-old Chad Kirby, then struck him in the head with the blunt end of a knife and stabbed him in the forehead, according to a Newton police report on the Feb. 14 attack.

Kirby has paranoid schizophrenia, according to his mother, who asked not to be identified. He told police that he believed the man had “stolen his girl and drugs a long time ago,” even though the two were strangers. Kirby reported being off his medications for weeks and going days without eating, walking aimlessly around Newton and nearby communities.

Discharged from Medfield State Hospital in 2001 or 2002, he had been under the care of South Shore Mental Health, a nonprofit provider in Quincy, and living in an apartment, according to his mother and police records. Her son broke off contact with her five years ago, she said, but she cannot understand how he was allowed to deteriorate so badly.

“What is the protocol when a patient who is not able to differentiate between reality and delusional thoughts and needs daily medication and supervision has gone missing?” his mother said.

South Shore Mental Health said through a spokeswoman that privacy restrictions prevent the agency from commenting on specific cases. In a statement, the agency said it assists more than 200 people referred by the Department of Mental Health, which “engages us to provide care to some of the most vulnerable individuals living with mental illness.”


In another telling case, a Brookline family returned home on a Monday afternoon last August to find Harry Castillo-Pujols, a 27-year-old on a Department of Mental Health watch list for “problematic sexual behavior” and “significant violent behavior,” hiding under a bed, according to court files and state records obtained by the Globe. The mother saw his sock poking out and screamed. Castillo-Pujols — wanted by police for allegedly stealing packages from houses — fled out the back door and was later arrested.

“It was your worst fear — someone under the bed,” said the mother, who asked not to be identified.

The Brookline mother, a longtime nurse who has worked with people with mental illness, said the incident confirms her own experience with the declining quality of mental health care in Massachusetts. She said she remembers when state case managers used to carefully manage prescriptions and treatment.

“The case managers would call me and say, ‘They need a refill,’ ” she said. “And that just doesn’t happen at all anymore.”

Castillo-Pujols has been involved with the Department of Mental Health since at least 2010, according to the records, which do not detail his diagnosis or specific treatment plan. Nor do the records illuminate the possible cause of his behavior or the circumstances of his supervision. He had recently been in a community mental health program in Boston operated by North Suffolk Mental Health Association.

North Suffolk CEO Jackie Moore declined to address the case directly but said in a statement that safety is a top priority of her agency. She said her staffers are “persistent and diligent” and often successful in their efforts, but that there are limits to what they can do.

“Services and treatment are voluntary, and while we encourage people to engage in services that will support recovery, we cannot require it,” said Moore, whose agency also ran the group home where a resident with severe mental illness fatally stabbed counselor Stephanie Moulton in 2011.

An attorney for Castillo-Pujols declined to comment.

A few weeks before the arrest of Castillo-Pujols, on Aug. 6, Mehmet Beyaztas, a 28-year-old Level 2 sex offender whom a court had ordered confined to a secure unit at Lemuel Shattuck Hospital, slipped away during a supervised bathroom break and went missing for 15 days, according to another state report obtained by the Globe. He returned to the hospital on his own.

Beyaztas, who has been diagnosed with schizophrenia, has had multiple arrests since 2009 for open and gross lewdness and lascivious behavior, having been repeatedly caught masturbating in front of women in public. He was arrested on the same charge
again last April, after allegedly following a woman into the Symphony MBTA station at 5:20 a.m. He was found incompetent to stand trial, ending up at the Shattuck.

A state investigation into his flight from Shattuck concluded that hospital staff were not at fault, although Beyaztas told investigators he found it “incredibly easy” to sneak away, just as he had on a group outing to the Museum of Fine Arts last June. Beyaztas reported hearing voices telling him to leave the hospital, court records show, raising the possibility that he wasn’t taking medications at the time. The hospital had no specific policy for supervising sex offenders, according to the investigators’ report.

Mehmet S. Beyaztas, a 28-year-old Level 2 sex offender in a secure unit at Lemuel Shattuck Hospital, slipped away for 15 days. He told investigators he found it “incredibly easy” to sneak out.Massachusetts Sex Offender Registry Board

Beyaztas’s attorney did not respond to requests for comment.

Two days before Beyaztas went missing in August, another man who has been under the Department of Mental Health’s care, Stephen Fusco, allegedly asked a commuter at North Station if he spoke English, then struck him in the forehead with a brick, opening up a five-inch gash.

“I didn’t like the way he spoke to me or looked at me,” Fusco, then 48, told MBTA police, court records show.

It was Fusco’s third alleged violent offense in 2016 alone. Fusco, who’s been diagnosed with schizoaffective disorder-bipolar type and has an extensive criminal record, has been caught in a revolving door between jail and the streets, unable to get consistent care, according to one of his attorneys, Lauren Thomas. Without medication, she said, his condition deteriorates swiftly.

“Maybe if we had better services, he wouldn’t be where he is,” said Arnold Abelow, a lawyer for Fusco in Suffolk Superior Court, where Fusco faces assault and civil rights charges. He has pleaded not guilty.

Two recent incidents involved people living in group homes, a key part of the community care system that allowed Massachusetts to close so many public psychiatric hospitals over the last 40 years. There are 408 such homes, granting many with mental illness significant freedom. But they can also expose residents and the surrounding community to risk.

In September, Edward Hennessey, 24, was discharged from Solomon Carter Fuller Mental Health Center and sent to live in a group home in Roslindale operated by Bay Cove Human Services, a Boston-based nonprofit agency. Two days later, Boston police were called to the residence because Hennessey, whose impairments include bipolar disorder and mild mental retardation, had two knives and was making threats, according to police and court records.

Hennessey, who has a history of assaulting mental health workers, fled before police arrived; he was later spotted walking into a nearby Stop & Shop armed with a knife.

Approached by an officer who had been working a detail, Hennessey raised the knife to his neck and then pointed it at his stomach, screaming at the officer to “go ahead, just shoot me,” according to a Boston police report. The officer assured the troubled man that he would not be shot, and Hennessey eventually agreed to drop his weapon and go to the hospital.

The outcome could have been much worse: More than 50 times statewide since 2005, the Spotlight Team found, police involved in similar confrontations have shot people who were suicidal or mentally ill.

Attempts to reach Hennessey’s lawyers and family members were unsuccessful.

The task of caring for people with serious psychiatric illnesses is complex and unforgiving. Still, there are often warning signs long before the crisis. The staff at a Dorchester group home, for example, chronicled the deterioration of a Department of Mental Health client with schizophrenia for months after he was discharged from Shattuck Hospital in the spring of 2015.

Three times that summer, records show, crisis clinicians were called to the Maple Street group home to address concerns about Shaheid Ware’s adjustment to the less structured setting, given his long criminal record and history of suicidal actions, including once jumping from a window. By December 2015, he had stopped sleeping at night, according to records, and was seen fighting an invisible opponent.

At 2 a.m. on Dec. 7, 2015, a staff member discovered Ware was missing. That wasn’t unusual, according to a state report; Ware sometimes wandered the neighborhood at night. The staffer checked his room again at 3 a.m. and again at 4:30.

Finally, at about 8 a.m., the same staffer raised the blinds in one room of the residence and saw the 34-year-old lying outside on the ground. Ware had either fallen or jumped from his bedroom window. He was unresponsive, fingers twitching, eyes rolling back in his head. According to state records, his neck and spine were fractured, requiring surgery, and his body temperature was between 80 and 85 degrees.

An investigator from the Department of Mental Health determined six weeks later that staff at the group home, also operated by Bay Cove, had not caused or contributed to Ware’s injuries, concluding, “there was no evidence of inattention to duty or failure to properly perform a duty by any BCHS caregiver in connection with this incident,” according to the investigation report obtained by the Globe.

Ware’s relatives did not allow Bay Cove further contact with him after his hospitalization and subsequent transfer to a rehab center, the report says. Attempts to speak with Ware’s family were unsuccessful.

Bill Sprague, president and CEO of Bay Cove, which runs the separate programs that Boyd, Hennessey, and Ware were sent to, declined to comment on individual cases, citing privacy restrictions. He said that while his agency has improved the lives of thousands of people, those efforts don’t always succeed.

“All of us at Bay Cove Human Services are committed to the well-being of everyone we work with, and we were deeply affected by these tragic incidents,” Sprague said in a prepared statement. “I can tell you that, in addition to our proactive efforts to minimize risk, we also carefully review all incidents to determine what we may have been able to do differently and to learn for the future.”

But the problem is bigger than that, said Dr. Charles Carl, who was a psychiatrist at the Department of Mental Health for 15 years. The state agency, which once specialized in direct treatment, has grown too removed from the mental health care system to manage it effectively, he said.

“The level of care is just not adequate to the degree of the problem,” Carl said. “The whole thing is just a circus.”

.  .  .

“He fell through the cracks. I’m disgusted,” said Marilyn Boyd, talking about her brother James.Suzanne Kreiter/Globe Staff/Globe staff

The death of James Boyd Jr. remained, as of late last year, under investigation by the Suffolk district attorney’s office as an unsolved hit-and-run case.

A separate, internal Department of Mental Health investigation obtained by the Globe, meanwhile, cleared caregivers in Boyd’s housing program, which is called Bay View Inn, of culpability.

Boyd was suffering prior to the accident, his sister and father said. Originally from New Jersey, like his family, he hadn’t been the same since he was shot in the stomach more than 10 years ago, they said. He had diabetes and had difficulty walking. He and Marilyn Boyd also lost their sister Veronica in a South End fire last March.

“He was going through hell,” said his father, James Boyd Sr.

In the days between leaving Shattuck and his death, Boyd — who was largely refusing his medications — tried to get himself admitted to multiple Boston hospitals, according to the state report and medical records shared by his family.

He had also openly threatened to lie down in the street and kill himself, the state report shows. Boyd’s sister and father both wonder — though they may never know — if he made good on the threat early on that summer morning.

“I don’t think he wanted to be here any more,” his father said.

On a recent afternoon, Marilyn Boyd sat in her apartment with a reporter and, for the first time, picked through her brother’s belongings, which were collected in a black trash bag with his name taped to the outside.

She found letters to Oprah Winfrey; stacks of $500 bills in Monopoly money; one Bingo Star Tripler lottery ticket (unused); unfilled prescriptions; a box of Irish Spring soap; and a paper titled “Russian Clock Words” with a clock drawing and an array of symbols resembling Cyrillic.

“He was smart, wasn’t he?” said Boyd, who is active in her Framingham church and hopes to start a support group for women who are victims of domestic violence. “Look at this!”

“Sometimes he would make sense and sometimes he wouldn’t,” she continued. “That’s why I think he shouldn’t have been out in the street like that.”

Maria Cramer of the Globe staff contributed to this report. Scott Helman can be reached at scott.helman@globe.com.