andolph Maddix, a schizophrenic who lived at a
private home for the mentally ill in Brooklyn, was often left alone
to suffer seizures, his body crumpling to the floor of his squalid
room. The home, Seaport Manor, is responsible for 325 starkly ill
people, yet many of its workers could barely qualify for fast-food
jobs. So it was no surprise that Mr. Maddix, 51, was dead for more
than 12 hours before an aide finally checked on him. His back,
curled and stiff with rigor mortis, had to be broken to fit him into
a body bag.
At Anna Erika, a similar adult home in Staten Island entrusted by
the state to care for the mentally ill, three other residents had
previously jumped to their deaths when a distraught Lisa Valante,
37, sought help. But it was after 5 p.m. and, as usual, the
residents, some so sick they cannot tie their shoes, were expected
to fend for themselves. No one stopped Ms. Valante, then, from
flinging herself out a seventh-floor window.
Sometimes at these homes, the greatest threat can be the person
who sleeps in the next bed. Despite a history of violent behavior,
Erik Chapman was accepted at Park Manor in Brooklyn. After four
years of roaming the place with a knife, Mr. Chapman stabbed his
roommate, Gregory Ridges, more than 20 times. At last, Mr. Chapman
was sent to a secure psychiatric facility. Mr. Ridges was sent to
Cypress Hills Cemetery at the age of 35.
Every day, New Yorkers come face to face with the mentally ill
who have ended up on the streets since the state began closing its
disgraced psychiatric wards more than a generation ago. Mr. Maddix,
Ms. Valante and Mr. Ridges were among thousands more who ended up in
dozens of privately run and state-regulated adult homes in New York
A yearlong reporting effort by The New York Times, drawing upon
more than 5,000 pages of annual state inspection reports, 200
interviews with workers, residents and family members, and three
dozen visits to the homes show that many of them have devolved into
places of misery and neglect, just like the psychiatric institutions
But if The Times's investigation found that the state's own files
over the years have chronicled a stunning array of disorder and
abuse at many of the homes, it discovered that the state has not
kept track of what could be the greatest indicator of how broken the
homes are: how many residents are dying, under what circumstances
and at what ages.
The Times's investigation has produced the first full accounting
of deaths of adult home residents. At 26 of the largest and most
troubled homes in the city, which collectively shelter some 5,000
mentally ill people, The Times documented 946 deaths from 1995
through 2001. Of those, 326 were of people under 60, including 126
in their 20's, 30's and 40's.
At two of the largest homes, Leben Home in Queens and Seaport
Manor in Brooklyn, roughly a quarter of the 145 residents who died
were under 50. The Times's analysis of the deaths used Social
Security, state, court and coroner's records, as well as psychiatric
and medical files.
The analysis shows that some residents died roasting in their
rooms during heat waves. Others threw themselves from rooftops,
making up some of at least 14 suicides in that seven-year period.
Still more, lacking the most basic care, succumbed to routinely
treatable ailments, from burst appendixes to seizures.
Some of the hundreds of deaths undoubtedly stemmed from natural
causes and were unavoidable. Studies have found that the mentally
ill typically have shorter life expectancies than the general
population, because they have difficulty caring for themselves and
are more prone to health problems. The average age of death in the
overall survey was 63.
There are few extensive studies on death rates of the mentally
ill in facilities like adult homes. But Dr. E. Fuller Torrey, a
psychiatrist who is a nationally recognized expert on mental illness
and mortality, called The Times's analysis disturbing.
"It would certainly suggest a fair number of deaths that were
premature," said Dr. Torrey, who is executive director of the
Stanley Medical Research Institute in Bethesda, Md., and is familiar
with the adult home system in New York City. "There is no question
that if these people were getting better care and more skilled care,
they would be living longer. And this poor care leading to death is
going to cut right across the age population. It also means that
people who are 70 are dying prematurely."
In the end, whether the residents were in their 20's or 70's, it
is impossible to know just how many of their deaths could have been
prevented. The only other accounting of the dead seems to be on Hart
Island in the East River, where scores of adult home residents are
buried in the mass graves of potter's field.
Officials at the State Department of Health, which regulates the
homes, acknowledge that they have never enforced a 1994 law that
requires the homes to report all deaths to the state. Asked for
records of any investigations into deaths at the homes, the
department produced files on only 3 of the nearly 1,000 deaths.
None of the suicides were among the three. Even the fatal
stabbing of Mr. Ridges at Park Manor went unexamined by the
department. The city medical examiner's office said it had not
received a single inquiry in recent memory from state inspectors
regarding an autopsy of an adult home resident.
Neither Gov. George E. Pataki nor his health commissioner, Dr.
Antonia C. Novello, would comment on The Times's investigation.
Their aides said a deputy health commissioner would speak for the
Presented with The Times's findings, the deputy health
commissioner, Robert R. Hinckley, said the department would examine
"ways to better investigate those deaths that are reported to
To that end, Mr. Hinckley said the state would issue a regulation
alerting the homes that it would strictly enforce the 1994 law on
"We want facilities to follow the law, and we are redoubling our
efforts to get them to report all deaths," he said.
As of Friday, seven weeks after Mr. Hinckley's promise, the
department had still not issued the