These were not inevitable.

An hour in the emergency room, five hours to a death

Rhamell Burke, 32, was held in Bellevue Hospital's psychiatric emergency room for approximately one hour and then discharged. About five hours later, Ross Falzone, a 76-year-old retired educator, was fatally injured in Chelsea. Mayor Zohran Mamdani directed NYC Health + Hospitals to determine what steps should have been taken to prevent it and to review the hospital's psychiatric evaluation and discharge protocols, and asked the state Health Department to examine similar cases at Bellevue for systemic gaps.

NAMI-NYC asked publicly how crisis evaluations are conducted, whether discharge decisions are made with sufficient time and clinical rigor, whether anyone consults PSYCKES before releasing a patient, and what follow-up exists after someone leaves a psychiatric emergency setting.

Ordered under constant monitoring, and left alone

An investigation by the New York Attorney General into Westchester Medical Center, MidHudson Regional Hospital, and HealthAlliance Hospital found that a patient whom psychiatrists had ordered kept under constant monitoring was left unsupervised, that the required precautions were not taken, that the patient left the hospital without being discharged, and that the patient died shortly afterward. The same investigation found patients with active suicidal ideation discharged without stabilization, and agitated children medicated without adequate attempts at de-escalation.

The settlement requires the hospital system to restore and maintain inpatient psychiatric beds, implement enhanced suicide risk screening, write individualized discharge plans with follow-up coordination, document every use of restraint and medication with clinical justification, and report compliance to the Attorney General every six months.

Jordan Neely was on the city's list of people who needed help most

Jordan Neely, 30, died after being restrained in a chokehold on an F train. He had severe schizophrenia, and he had been placed on New York City's "Top 50" list — an internal register of the homeless New Yorkers with mental illness judged most urgently in need of intervention. Being identified by the city as one of the fifty people most in need of help was not enough to get him housed and treated before he died.

He is on this page because the same failure produces both kinds of outcome. The system that could not reach him is the system that does not reach the families who write to us.

Twenty years after a diagnosis, no continuous care

Michelle Alyssa Go, 40, was pushed in front of an oncoming R train at the Times Square–42nd Street station and killed. Martial Simon, 61, a former taxi driver, had been diagnosed with schizophrenia in 2002 and had spent the two decades since cycling between hospitals, shelters, the streets, and the criminal legal system. He was found unfit to stand trial in April 2022 and committed to a secure psychiatric facility; he was later found fit to proceed in 2024.

Twenty years of documented severe mental illness produced no sustained treatment relationship. That is the failure, and it took place entirely inside systems that knew who he was.

Nearly 100 cases, one decade, the same gaps

A New York Times investigation identified close to 100 cases over ten years in which a person had contact with social services before committing an act of violence. It documented private hospitals cutting psychiatric beds because they are unprofitable; public emergency rooms absorbing close to 50,000 psychiatric patients a year; outreach workers understaffed and stretched thin; and more than a billion dollars spent on mental health shelters whose frontline staff lacked the tools even to identify that a resident had a psychiatric condition. Among the cases was a woman discharged from a psychiatric unit days before pushing a toddler during a psychotic episode.