The Suicide of Mr. A

A Mentally Ill Inmate Slips Through the Cracks—Into the Path of a Subway Train

SPMI inmates, as they are called, are particularly vulnerable to the loss of Medicaid and Supplemental Security Income that comes with being locked up for more than a few days. Inmates are considered to be in the state's care, and in New York it takes at least 45 days after release for the benefits to be reinstated. Discharge planners, who work for the city health department, are now required to visit prisoners receiving mental health care within a week of incarceration and offer their services. The planners must complete new benefit applications for the inmates, screen them for Medicaid eligibility, and make them an initial appointment with a support organization for when they get out. Finally, SPMI class members are supposed to be released in daylight hours, with the medication they need in hand, a place to go, and transportation there. A special Medication Grant Program begun in 1999 provides ex-prisoners with psychiatric meds until their benefits kick in.

Brad H. was named for a man with psychotic and depressive symptoms who has been cycling in and out of Rikers Island, homeless shelters, and state prisons for over 30 years now. The suit "sets a very high standard," says Hank Steadman of the National GAINS Center, which runs jail-diversion programs for the mentally ill. "But the court recognized that it wasn't too high to be realistic."

Steadman describes Brad H. as a groundbreaking attempt to address jails' new social service role. Just as public emergency rooms have become the expensive front line of care for people without insurance, so U.S. jails, which now book about 11 million people a year, are the catchall for the homeless, the mentally ill, and those with substance-abuse problems. There are now far more mentally ill people in the nation's jails and prisons (200,000) than in state mental hospitals (61,700). With an estimated 3,000 mentally ill inmates on Rikers Island at a given time, 800 in hospital beds and the rest in the general population, the New York City jail is, in effect, the state's largest psychiatric facility, and vying with the Los Angeles County jail for the status of largest inpatient psychiatric facility in the country.

George Nathaniel Atkinson was arrested after he called a suicide hotline threatening to shoot himself.
photo: Shiho Fukada
George Nathaniel Atkinson was arrested after he called a suicide hotline threatening to shoot himself.

"Because of the failure of community-based mental health care, people who should be getting it are getting jail-based care," says Mary Beth Anderson, whose Mental Illness and Chemical Addiction Project represents many Brad H. class members. "And the corrections environment, needless to say, is not a therapeutic one. This is not just about discharge planning—it's a systemwide failure."

Atkinson, of course, was not homeless or schizophrenic, just a man in need of help. He had been jailed once before, briefly, as a young man, and he found the rowdy Rikers Island environment unsettling. "He said, 'It's just crazy here,' " reports Andrew Smith. " 'I'm just falling back. It's a madhouse.' "

At Barr's request, within a week of Atkinson's plunge, the court-appointed Brad H. compliance monitors, attorney Henry Dlugacz and Dr. Erik Roskes, had begun a special report for the New York State Supreme Court. The first response by the city's counsel, Jeffrey Dantowitz, was a letter to Debevoise and Plimpton, dated October 15, protesting the investigation. "We disagree with any suggestion that the Compliance Monitors have a wide mandate to investigate the circumstances of Mr. A's death," Dantowitz wrote, using the moniker Atkinson received in court documents. The letter closed, "The mere fact of Mr. A's death, while tragic, does not alter the scope of the Compliance Monitor's authority as negotiated by the parties and set forth in the Settlement Agreement."

Nevertheless, Dlugacz and Roskes found that they did have jurisdiction to interview Atkinson's medical workers, his Legal Aid attorney, and prison staff. His plight comes through despite the report's dry, neutralized language.

While Atkinson was waiting to go before the grand jury on his weapons charge, the errors piled up. Upon his release from Kings County, his discharge plan was listed as "Rikers Island," meaning that no meaningful planning had taken place. The staff of the Community Referral Unit, the Rikers Island discharge planning office, unaccountably expected Legal Aid to make arrangements for Atkinson's follow-up care, while his Legal Aid attorney believed "it was taken care of." A fax from Legal Aid requesting plans, medications, and a referral letter for aftercare was lost because of a machine that stayed broken for weeks. His Rikers Island discharge planner, interviewed by the compliance monitors, could not remember him—she had a caseload of 200 at the time, about average. Her notes showed that she saw Atkinson and gave him three brochures about his rights under Brad H.

Most puzzlingly, after Atkinson had spent 25 days taking antidepressants, yet another mental health professional saw him and downgraded his diagnosis to "adjustment disorder with depressed mood, polysubstance abuse, and antisocial personality disorder." By her determination, he no longer belonged in the "seriously and persistently mentally ill" class that Brad H. covers. "This finding is difficult for the monitors to understand," reads the report. "Our discussion with the clinician who determined Mr. A to be not SPMI indicated a deficit in her understanding of the SPMI definition. . . . Her understanding of SPMI reflects what we believe to be a common misperception among clinicians."

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