The NYPD’s Poor Judgment With the Mentally Ill


On the evening of March 15, Shauna Francis called 311 looking for some information. She wanted to call an ambulance for her 30-year-old sister, Shereese, but wasn’t impressed by the quality of care at Queens General, the nearest hospital. Shauna wanted to know if she could ask the ambulance to take Shereese to a Long Island hospital.

The 311 operator told Shauna she would have to take that question up with the EMTs when they arrived and asked Shauna about the nature of the problem. Shauna explained that Shereese, a person with schizophrenia whose illness was well-controlled by her medication, had been refusing to take her meds for some time, and the family wanted doctors at a hospital to help persuade her to resume taking them.

The operator transferred Shauna to a 911 dispatcher, who listened to Shauna’s story and promised to send someone over. Shauna hung up and traveled the short distance from her home to the small, single-story house in Rochdale where her mother lived with Shereese.

As she drew up to the driveway, she saw a police cruiser had already arrived, and four officers were approaching the front door. That wasn’t unusual: On other occasions when the family had called an ambulance for Shereese, police often arrived along with the EMTs. Assuming an ambulance was probably on its way, Shauna led the officers into the house, where her mother, Eleen, explained that Shereese was in her bedroom in the basement.

What happened in that basement after the police went downstairs to talk to Shereese isn’t fully known. Shauna and Eleen saw and heard some of what transpired, but not everything. Citing an ongoing internal investigation, the police department isn’t commenting.

Police logs record the four officers arriving at the Francis home at 10:20 that night. Shauna and Eleen saw the officers wrestle Shereese onto a bed, all four of them piling onto her as they pressed her facedown into the mattress and handcuffed her. Within 20 minutes of the police arriving, Shereese Francis had stopped breathing, and Emergency Services personnel were attempting to revive her.

When Shereese was finally taken to Jamaica Hospital Medical Center at 12:25 a.m., she was pronounced dead. Hospital staff told the family she likely had been dead for at least 90 minutes before she arrived. The death certificate signed by the medical examiner listed Shereese’s death as a homicide and cited the immediate cause of death as “compression of trunk during agitated violent behavior (schizophrenia) while prone on bed and attempted restraint by police officers.”

Shereese’s father, George Francis, is more succinct. “The bottom line is, they come there and kill her,” he says. 

The death of Shereese Francis has rekindled a decades-long debate over the NYPD’s treatment of the mentally ill. As the first responders to all sorts of emergency calls, police officers are on the front line for just about every social problem in the city, and mental illness is no exception. The department estimates that it handles nearly 100,000 calls for “Emotionally Disturbed Persons” every year—hundreds a day. Every few years, one of those calls goes so badly that somebody dies.

Determining who bears responsibility for those deaths and whether and how they can be prevented isn’t always easy. But with a growing international consensus on the best practices for police interactions with the mentally ill—practices the NYPD has so far resisted adopting—the story of how Shereese Francis died once again raises the question of whether the NYPD is doing everything it can to train its officers on how to do the delicate work of serving New Yorkers with mental illness.

Francis Grace Day Care and Learning Center stands in a two-story white stucco building on a stretch of Merrick Boulevard in Queens surrounded by used-car lots, a Quick Lube, and roti restaurants. The front is covered with gaily painted balloons, rainbows, and alphabet blocks. It’s a hot summer day when I meet the Francis family there to talk about what happened to Shereese, and the air-conditioning isn’t keeping up, so we drive down the block in George Francis’s Mercedes minivan to another location he’s renovating. It’s cooler there, and settling around a folding table, the family members begin to tell their story.

George Francis came to Queens in 1985 from Kingston, Jamaica, and soon brought his family—Eleen and their two young daughters, Shauna and Shereese—to join him. Along with other members of the family, they began building a child care center. The enterprise was successful, and soon they were running a small constellation of centers. In 2000, The New York Times included their business in a trend story about 24-hour child care centers targeted at shift workers with off-hour needs.

Shereese and her sister helped with the business and worked hard at school, her parents say. After high school, Shereese spent two years at Nassau Community College, where she studied to be a physical therapist.

“She was a very happy person, a very loving, spiritual person,” her sister says. “Everybody loved her. She was always very happy, very concerned about everyone.”

In college, Shereese became quieter, depressed and withdrawn. “She began seeing things,” her father says. Eventually, she was diagnosed with schizophrenia and prescribed Risperdal, an antipsychotic.

The medication worked well. When she took it, Shereese was functional and outgoing. She attended a Catholic Charities outpatient program that offered psychotherapy, which helped her manage her illness. But the Risperdal also “made her fat,” in her father’s words, a side effect about which Shereese was painfully self-conscious.

Beginning in November, Shereese stopped taking her medication, at first with minimal effect. “The first month was fine,” Eleen remembers. But by November, things were getting worse. Shereese spent entire days in her bed, under the covers, refusing to talk to anybody. The family became increasingly concerned. Social workers from Shereese’s program came by a couple of times to check on her. “She wasn’t that bad at the time,” Eleen says. “She spoke to them.”

It got worse. “She stopped eating, she wasn’t sleeping,” Eleen says. “She spent her days combing her hair. Combing her hair and putting on makeup.”

On the morning of March 15, things seemed even worse. “She hadn’t slept the night before,” Eleen says. “I went down there to check on her, to see if she wanted to sleep.” Abruptly, Eleen pauses her retelling, dissolving into silent tears. Shauna, sitting next to her, takes up the story.

“I got back from school around 8, and my mother told me, ‘I’ve never seen her act this way,'” Shauna says. “‘She accused me of taking her makeup, and then she was pulling my hair.’ Mom said, ‘I think we need to take her to the hospital before anything gets any worse.'”

Shauna went back to her own house, nearby, had her conversation with the 311 operator and the 911 dispatcher, and returned to her mother’s house, where the police were just arriving. After explaining the situation, Shauna and Eleen followed the police down into the basement. Shereese was in her bedroom, but the police spoke to her through the closed door.

“They were basically telling her, ‘We’re going to take you to the hospital,'” Shauna says. Shereese wasn’t having it. “She was arguing with them,” Shauna says. “She was like: ‘What are you doing here? You’re not taking me anywhere!'”

It wasn’t clear that Shereese actually understood the situation. “It didn’t seem like she knew they were the police,” Shauna says. “She was saying, ‘I’m going to arrest you,’ just all kinds of crazy things to them.”

After a few minutes, Shereese opened the door and tried to push through the crowd, down the basement hallway, and up the stairs.

“The police officers say, ‘Do not let her go,'” Shauna says. “That’s when all the tackling began.”

Police managed to keep Shereese from making it to the stairs and instead pushed her into another bedroom that opened off the hallway.

“One of the officers initially said, ‘Why don’t you just use the Taser?'” Shauna says. “I said, but they didn’t hear me, ‘That isn’t necessary.'” As the police piled into the bedroom, Shauna got a partial glimpse of the struggle. She thought she saw one of the officers making hand movements as though he might have been hitting Shereese, but she couldn’t be sure.

“Then they got her onto the bed,” she says. “All four of them were on top of her. They were trying to get handcuffs on her.”

Shauna heard one of the police officers cursing at Shereese. “‘Give me your effing hand! Give me your effing hand!’ I was like, ‘What kind of police officers are these?'”

Shereese managed to resist for a while, Shauna says. “At first, she was fighting them off, fighting them off, fighting them off. But then I didn’t hear her anymore, and she wasn’t moving.”

Recognizing that something wasn’t right, the police took the handcuffs off and moved Shereese to the floor, Shauna says.

Sixteen or 17 minutes after the police showed up, the EMTs arrived and rushed downstairs. The police were keeping the family out, and the basement door was locked.

Eleen, back upstairs at this point, heard one of the EMTs run upstairs and talk into the radio, and mention something about arrest. “She thought that meant they wanted to arrest her,” Shauna says. “Later, we realized they were talking about cardiac arrest.”

Shauna’s mother-in-law, who had now arrived, tried to poke her head in and see what was going on. “She looked at her and said, ‘She looks like she’s dead!’ They said: ‘Oh, no, no. Get outside.'” Eleen and Shauna’s mother-in-law circled around and tried to peer in a window but were again shooed away. For what felt like a long time—more than 45 minutes, they estimate—the family, worrying and making phone calls, waited anxiously on the lawn while the police and EMTs worked on Shereese in the basement.

“I didn’t know what to think,” Shauna says. “I was just wondering, why is she down there so long? What’s going on?”

At one point, a sergeant came upstairs with what seemed like good news. “He said: ‘We’ve got a pulse! But there are no guarantees,'” Shauna remembers. It was still a “long time after that” before she saw Shereese being taken out of the basement on a stretcher. The ambulance was parked across the street, but for some reason, the police and EMTs took her out a stairway that led to the backyard.

“I think maybe they wanted to avoid us,” Eleen says. The family asked to ride with Shereese in the ambulance, something they’d done on previous occasions, but were told they couldn’t. Shauna and Eleen got ready to drive to the hospital themselves, but as they were heading out the door, more recently arrived police, detectives in plainclothes, said they wanted to take recorded statements on what had happened. The women gave short statements and explained what had happened, trying to reconstruct the timeline. Finally, they were allowed to follow Shereese to the hospital. When they arrived, a nurse directed them into a room.

“They told us she was dead, and there was nothing they could have done,” Shauna says. Nurses showed her mother-in-law the readout from Shereese’s EKG from the time she arrived at the hospital. It was flat from the beginning.

In the following days, the family’s shock and grief began to settle into anger. Shereese didn’t have to die that night.

“They cut short the girl’s life,” George Francis says. “She had a lot to live for. She had a schizophrenic problem, but if she took her medication, she come right back, you know?”

“These police officers weren’t trained to handle this,” Shauna says. “Who restrains someone on a soft surface, facedown? Who would do that?”

Eleen agrees.

“Usually, when you talk to her, it may take a long time, but if you keep talking to her, she’ll listen,” she says. “The police officers in the past, they all talked to her. It seemed like they knew what they were doing.”

In the days afterward, police investigators kept calling, wanting to talk more about what had happened, but George Francis was tired of talking to police without a lawyer. The family hired Steve Vaccaro, a lawyer with experience suing the NYPD.

“We need justice for Shereese,” says George Francis, his Jamaican phrasing becoming more pronounced as he becomes more upset. “New York City got to pay for all our pain and suffering and compensate for our loss of life. Money won’t bring her back, but at least it would serve justice. That mean somebody got to pay. Somebody got to be accountable.”

Shereese Francis was hardly the first person with mental illness killed by police in New York City. Throughout the decades, there have been numerous such incidents, each provoking—to greater and lesser degrees—flurries of media attention, public dismay, and calls to reevaluate the NYPD’s approach to such encounters.

The first landmark incident came in 1984. Police broke down the door of 66-year-old Eleanor Bumpurs in an effort to evict her from public housing and hospitalize her for what a psychiatrist sent by the city deemed to be psychosis. Inside the apartment was Bumpurs, 275 pounds, naked, holding a 10-inch kitchen knife. Carrying shields and a Y-shaped restraining bar, police attempted to subdue Bumpurs, but in the scuffle, one of the officers was knocked to the ground. As Bumpurs stood over him with the knife, Officer Stephen Sullivan fired two shots from his 12-gauge shotgun. The first struck her hand. The second went into her chest and killed her.

Following the incident, Sullivan was indicted on manslaughter charges and acquitted. The city ultimately paid the Bumpurs family $200,000 to settle a civil suit, and the NYPD changed its guidelines to require a senior officer to be on hand before police confront an emotionally disturbed person. Police also began to carry less lethal weapons, including Tasers.

In 1998, Kevin Cerbelli, a 30-year-old who had been in and out of mental institutions, walked into the 110th Precinct in Queens carrying a screwdriver and a knife and attempted to stab an officer in the back. Police surrounded him and attempted to subdue Cerbelli with a Taser but were unsuccessful, and after he continued to lunge at officers, he was shot seven times.

In 1999, Gidone Busch, a bipolar 31-year-old who lived in Borough Park, was shot to death by police responding to a complaint that he was threatening a local boy with a hammer. Busch, an observant Jew, was in his apartment when six police officers confronted him, but he backed out onto the sidewalk, where police used pepper spray on him. Police accounts afterward differed on whether Busch had first struck them with the hammer, a religious item used in prayer, but there’s no disagreement that after the pepper spray, Busch became more upset, striking out with the hammer. Four officers fired their guns, killing Busch.

In the space of a week in 2007, police officers shot and killed two emotionally disturbed men in Brooklyn. Khiel Coppin, 18, was holding a hairbrush under his shirt like a gun when police killed him in Bedford-Stuyvesant. David Kostovski, 29, was brandishing a broken bottle at police when he was shot in East New York.

In 2008, when police responded to a call from the mother of 35-year-old Iman Morales, who wasn’t answering his front door. When police arrived at the Bedford-Stuyvesant apartment, Morales, naked, retreated out the window and onto a ledge 10 feet above the sidewalk. Police called for an inflatable air bag to place on the sidewalk under Morales but didn’t wait for it to arrive before shooting him with a Taser. Morales went stiff, fell headfirst onto the sidewalk, and died. The entire episode was captured on video and prompted another round of public debate over the use of Tasers and police protocols in dealing with emotionally disturbed people.

Most recently, police officers fired 12 shots at Darrius Kennedy and killed him in the middle of Times Square last Saturday. Police first stopped Kennedy for smoking a joint, but he slipped free and began brandishing a large kitchen knife. Police pepper sprayed Kennedy four times, to little effect. When he lunged at police attempting to cut off his retreat down Seventh Avenue, officers opened fire.

Kennedy, 51, had been sent to Bellevue for a mental evaluation in 2008, but it isn’t known if he was diagnosed. Still, Mayor Bloomberg, defending the officers’ actions, said Kennedy “must have been mentally deranged” since “taking a knife and going after other people, particularly police officers, isn’t something that a sane person would do.”


New York isn’t unique for its steady stream of violent and fatal encounters between the police and what law enforcement calls “emotionally disturbed persons,” or EDPs. In their role of keeping the peace and handling situations beyond the capability of ordinary citizens, police have always been called upon to interact with people whose mental illness or emotional breakdowns are causing them to put themselves or others at risk.

That complicated responsibility has only become more difficult in the past half-century, as the institutions that once warehoused the mentally ill have closed in favor of a public health model that relies much more on outpatient treatment, home care, and integration.

In this new era, an increasing share of the responsibility for the mentally ill has fallen on the criminal-justice system. Police are often more likely to be called for help than a health professional. And in many places, poorly integrated services have left officers with few options once they arrive at an EDP call besides doing nothing and making an arrest. The result, research shows, is that prisons have become the new asylums, as more and more mentally ill people find themselves incarcerated.

Cities across the country have their own versions of stories like those of Bumpurs and Cerbelli, stories that show how, in the wrong circumstances, a person with mental illness can be dangerous, forcing police to make split-second decisions about how to protect themselves.  

It happened in Memphis in 1987, when a Memphis Police Department officer shot and killed a mentally ill person. In the outpouring of community dismay that followed, the MPD decided to revisit its policies for handling EDP calls and to reach out to mental-health professionals and to the mentally ill themselves and their families to craft a new strategy.

The result, soon termed the “Memphis Model,” was a revolution in policing. It relied heavily on Crisis Intervention Teams, or CITs, composed of police officers who had volunteered to undergo between 40 and 80 hours of extra training in responding to EDP calls. Enough Memphis officers were trained that when an EDP call came through, at any hour and in any part of the city, dispatchers could refer the call to a Crisis Intervention Team.

“The CITs aren’t specialized units in the sense that they only respond to one kind of situation,” says Major Sam Cochran, who helped develop and implement the model and has since become its chief evangelist. “They’re just part of the regular uniform patrol division. They’re the first responders, be it a domestic dispute, a bank robbery, or anything else.”

The difference is CIT officers have been trained in de-escalation. They know that shouting at people in mental distress doesn’t help, that surrounding them, threatening them, and rushing them is almost invariably counterproductive. More than their tactical expertise, Cochran says, CIT officers bring a level of understanding to their policing that makes a critical difference.

“Because they’ve volunteered and because their training has helped them to see things from the perspective of the someone on the other end of the situation, they’ve got an empathy that changes the whole situation,” Cochran says.

The results of implementing the CIT program in Memphis were dramatic. In the three years before CIT was instituted, mental-health-related calls led to injuries 35 times out of 100,000. In the three years after CIT was in place, that rate dropped to seven injuries in 100,000 calls.

The CIT model was a hit. Over the past 25 years, versions of the program have been adopted by police departments around the world and in almost every state in the nation, from small-town departments to big-city forces including those in Seattle, Portland, Los Angeles, Houston, and Chicago. It has won plaudits from Amnesty International, the National Alliance on Mental Illness, the U.S. Justice Department, and the International Association of Chiefs of Police. The Council of State Governments has been advocating for the adoption of CIT-like programs across the country.

One consistent exception to the spread of the CIT model has been the New York Police Department. Mental-health advocates have repeatedly pressed the NYPD to consider adopting a similar model, but the NYPD hasn’t been interested. The NYPD didn’t respond to requests for comment for this story, but mental-health advocates say they’re often told by NYPD leadership that the CIT model wouldn’t work here.

“They say New York is too big,” says Jennifer Parish, director of criminal-justice advocacy at the Urban Justice Center’s Mental Health Project. “They say the force is so large that training the proportion of officers necessary to make CIT work would be too unwieldy.”

Instead, the NYPD points to its Emergency Services Unit, an elite division of the force that receives extra training on interacting with people in psychiatric distress.

The problem with relying on the ESUs, mental-health advocates say, is twofold. “The ESU is used for lots of different things, from terrorist attacks to missing persons to people in psychiatric distress,” Parish says. “Skills that might make someone effective for the ESU might not be the same skills that would serve well on an EDP call.”

More fundamentally, as specialized units, ESU teams are rarely the first police at an EDP call. That means the officers on the scene in the critical first five minutes of contact with a person in emotional distress often haven’t received any specialized training at all beyond what they got at the academy.

To the NYPD’s credit, it recently overhauled that training, tapping mental-health advocate Fred Levine to help rewrite Chapter 23 of the recruit’s guide in the mid 2000s. Levine, who’s a believer in the policing principles of the Memphis Model, incorporated many of its basic tactical guidelines in his rewrite. He cautioned against sudden actions, threats, and rushing the situation.

“Officers should take great care to assure that they do not restrain or confine EDP’s in ways that may hurt—or even kill—them,” the police student’s guide reads. “Never confine EDP’s—or anybody else—in facedown, prone positions for longer than it takes to handcuff them.”

But while some of the training materials have been updated, advocates say changing the textbook isn’t enough. NYPD recruits only get 18 hours of training on mental-health issues. Follow-up in-service tactical-refresher trainings offered to veteran police are also relatively short and are often tacked onto the end of a shift.

Even the best training in the world won’t help if officers don’t feel they have the time to talk through a situation with someone in psychiatric crisis.

“It takes oversight,” Parish says. “A commander in a precinct who expects every call to be responded to very quickly and then get back out on the street, that doesn’t give officers much time for empathy.”

After a spate of Daily News stories and pressure from the City Council turned up the pressure on the NYPD to re-examine its mental-health policies in 2008, it revived the Link Committee, a group of mental-health professionals and advocates who had been consulting with the police on policy issues before a lack of departmental interest led the committee to founder for years.

Parish and Levine attended the first meetings of the revived committee with optimism but were soon frustrated by the messages they were getting from the department.

“They wanted to limit the scope of the conversation to reviewing the training,” Parish says. “Anything beyond that, they weren’t really interested.”

Ultimately, the Link Committee stopped meeting, without releasing any reports or recommendations, leaving members pessimistic about the prospects for change.

“At this point, I think getting change may require a new mayor and a new police commissioner who may be more open to listening,” Parish says.

Experts on law enforcement and mental health agree that it’s unfair to put all the blame on police when an encounter with a mentally ill person goes wrong. “This is an issue that goes all the way through our society,” says Cochran of the Memphis police. “Everyone has a stake in how we treat each other, it takes all of our involvement to change those relationships, and when something goes wrong like that, it reflects something being wrong all across the board. This isn’t just about fixing the training. Getting it right requires dedication and cooperation and conversation from the whole community.”

But by refusing to take part in the kind of wider discussion that could bring reforms, Levine says, the NYPD is becoming an obstacle to broader civic solutions.

“The NYPD shouldn’t bear sole responsibility for every single tragedy as if they had the magic to prevent it,” he says. “But their failure to aggressively participate—within their department, across agency lines, and outside the city where expertise clearly exists—that’s something I’ll always blame them for until they change. And I’ll blame them for the next tragedy because of that failure.”

It’s a sentiment shared by the Francis family. Since Shereese died, they say, many people have told them stories of similar—if less fatal—episodes in which the police mishandled a person in emotional distress.

“That’s why it’s necessary for this to be out there,” George Francis says. “So that they put a new system in place to prevent this from happening to other people. They will be more careful when they know that they will be brought to account.”

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