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Hall died of "environmental hyperthermia."

Mentally ill suffer deadly neglect
With a promise of community care, psychiatric wards were unlocked 30 years ago. Today, the sickest patients live in squalor.
By MEG KISSINGER
mkissinger@journalsentinel.com
Posted: Mar. 18, 2006
First of three parts

Tony Hall roasted to death in the stifling heat of an unregulated rooming house.

Street thugs murdered David Rutledge.

John Collins died after falling from his wheelchair, down the stairs of the unlicensed, mouse-infested group home where his Milwaukee County caseworker placed him. For months after Collins' death, someone kept using his food stamps.

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Thirty years ago, a Milwaukee County lawsuit sparked a nationwide revolution in mental health care. Patients living in locked psychiatric hospital wards were released to live in freedom with the aid of new drug treatments.

An investigation by the Journal Sentinel has found that hundreds of today's sickest patients suffer in the city's most broken-down neighborhoods. Some are dying; others are preyed upon by opportunists and neglected by the people responsible for their care. They are not able to fend for themselves, and no one else is taking responsibility for them, despite being paid more than $10 million a year in tax dollars to do so.

In the first comprehensive accounting of Milwaukee's severely ill mental patients, the newspaper found:

• Hundreds are living in illegal group homes and rooming houses - many of them filthy and dangerous, some deadly - which have sprung up as stealth mental hospitals to replace county wards.

• City building inspectors have failed to identify and close down these illegal homes. And they have never reported illegal group homes to the state licensing agency.

• County caseworkers, responsible for their clients' well-being, regularly send them to these houses and apartments, despite knowing how filthy and dangerous the buildings are. This is a direct violation of a federal court agreement.

• State group home inspectors generally don't investigate homes unless they are licensed. As a result, unlicensed, illegal group homes escape scrutiny.

• The federal government adds to the problem by allowing landlords to receive all of a tenant's disability check directly, despite the obvious opportunity for exploitation.

• Bureaucrats point their fingers at each other, claiming someone else is responsible.

• The problem is especially pronounced in Milwaukee County, where most of the state's mentally ill people live.

"It is a hidden and shameful thing that goes on here in Milwaukee," said Tom Hlavacek, who served as chairman of the Milwaukee Mental Health Task Force until last year.

Just how bad are these places?

Ask Willie Teague how two of his buddies died.

On Aug. 7, 2000, city building inspectors got a complaint from some psychiatric caseworkers that Gene Gokhman, a Mequon businessman, was running an illegal group home in his apartment building at 4276 N. 27th St. The caller said eight men, all mentally ill, were living there, signing over their Social Security checks to Gokhman. Inspectors visited eight days later but said they weren't able to verify that the building was a group home.

Case managers for the county complained again, months later, this time about broken toilets and the lack of heat in the building. City inspectors went back out in January 2001 and found merit to the complaint, but again did not cite the building as an illegal group home or fine Gokhman.

On July 22, 2001, Teague awoke in choking heat and found his roommate, Tony Hall, 34, sprawled out on the couch, dead from heat stroke. Hall was on anti-psychotic medication, which inhibited his ability to regulate body temperature. The home lacked enough ventilation ; Hall died of "environmental hyperthermia."

Teague ran as fast as he could to a pay phone down the block to let police know. They carted away Hall's body before the rats that roamed the rooms at night could get to it. Hall's core body temperature was 100 degrees at the time of his autopsy, which was performed more than five hours after he was found dead.

Police found a notice, near the back door, requiring that the building be boarded and the tenants be vacated. It was signed by the city and dated 10 days earlier.

Scott Ivanowski, Hall's psychiatric case manager, told police that he had been to Hall's apartment many times and was aware of the conditions. His former co-workers said he was so upset about Hall's death that he quit his job and moved away.

Teague took his friend's death hard, too. He went into a spiral after Hall died, crying often and saying he wanted to be with his mother, Lilly, who had died years earlier. He became combative and eventually ended up in jail for battery. Teague still talks about how much he misses Hall.

"He was a real good guy," Teague said. "He was my friend."

Gokhman said he had no idea when he bought the building in 2000 that people with severe mental illness lived there. He admitted that his employee used to feed the men their meals from one common area, in violation of city code. The men had no refrigerators or stoves in their living areas.

"The guy who sold it to me didn't say nothing about it. I didn't know it was a group home until later," said Gokhman. He said he didn't get a license because he didn't know he needed one.

Gokhman said he ran errands for the men.

"I helped these guys a lot," said Gokhman, who confirmed that he had the men sign over their disability checks to him.

Gokhman sold the building in May to a company based in Las Vegas for $305,000, more than twice what he had paid for it five years earlier.

Gokhman didn't remember details about Hall's death.

"I was out of town. But I heard it was real hot that week," he said.

ILLEGAL HOMES ABOUND
Building inspectors frequently come across squalid conditions

Ronald Roberts, Milwaukee's building inspection supervisor, said inspectors know of "dozens and dozens" of illegal homes for people with mental illness - "so many that we can't begin to count them all." Roberts said he and his co-workers have seen and fielded complaints about places with no running water, no heat, rats, roaches, broken smoke detectors and faulty wiring, places where tenants are kept in basements and attics, beaten by their landlords or made to sleep on filthy floors. Building inspectors have found people begging on the streets for food because they don't get enough from landlords who take their disability checks, leaving them with next to nothing, Roberts said.

Mental health advocates said they, too, have fielded reports of physical abuse.

Ed Hofman, a city building inspector for 30 years until his retirement last year, said he regularly came across people with severe mental illness who were living in squalor.

"Not everyone was meant to live independently," he said.

As county services for people with chronic mental illness have diminished over the years, entrepreneurs have moved in to fill the gap, Roberts said. That has meant a proliferation of illegally operated homes for people with mental illness.

Roberts said there are dozens of operators like Gokhman who run illegal homes, claiming not to know they are doing so. Some of these operators have little or no experience in mental health care, offering services that they are not trained or licensed to perform.

Jimmy McClendon and his wife, Iola, run two unlicensed group homes on N. 27th St. for people with mental illness who also abuse drugs and alcohol. The two have been repeatedly cited by the city for operating illegal group homes, but they remain open and getting taxpayer money as they appeal to the city for a special use permit. The permit would allow them to run their apartment buildings as transitional living facilities, places that offer more services than rooming houses but requiring less oversight than state-licensed group homes.

The county regularly refers people with mental illness to the McClendon homes. On a recent day when a newspaper reporter and photographer stopped by, the medicine cabinet was unlocked and an exterminator was setting traps for mice. When the building manager, a former drug addict, called Jimmy McClendon to let him know that the reporter and photographer were there, he ordered the cabinet locked. Anyone dispensing medication needs a license to do so, and the McClendons do not have a license.

"We get folks from the streets, men who sleep in the woods, that no one else will take," Jimmy McClendon said. "I'm talking about human lives. This is a faith-based operation. I made a pledge with God to help my brothers and sisters. We are changing lives here."

Many illegal rooming houses and apartment buildings go unchecked, Roberts said, because no one reports them and they "miss our radar." Unlike many other cities, Milwaukee does not regularly inspect apartments. Inspectors check common areas, but not individual units. Rooming houses are inspected annually, but, unless inspectors see more than three unrelated people in the house, they do not write up the infraction.

"We might show up and find one or two people living there, and then, if you go back at night, there are five or six," Roberts said.

Roberts' boss, Martin Collins, commissioner of the City of Milwaukee Department of Neighborhood Services, compares the situation to prostitution, in which both the victim and perpetrator have an incentive to conceal the crime. He blames county case managers who see their clients living in these places and fail to take action.

"They are the eyes and ears and voice for these people," Collins said. "If they don't tell us about these conditions, we don't know about them."

County officials admit arranging for patients to live in these houses and apartments. They say they do so because they have no choice - no one else will rent to mentally ill people - and because any place is better than no place at all.

Jim Hill, administrator of Milwaukee County's Behavioral Health Division, who oversees the psychiatric caseworkers, called the living conditions for many of Milwaukee's sickest patients "heartbreaking" but said his case managers often have no choice.

"We're not in the housing business," he said. "We're in the mental health treatment business. Did you ask the city building inspectors why they don't go in and close these places down? Honestly, we can't do it all."

A review by the newspaper of more than 8,250 city building inspection complaints over the past 12 years found more than 200 reports of possible illegal homes and overcrowded conditions. They close down roughly two homes a year, said Todd Weiler, spokesman for the city's Department of Neighborhood Services. None was referred to the county or the state for prosecution.

State administrators, charged with licensing group homes, called the Journal Sentinel's findings "astonishing" and "disheartening" but added that they don't have the resources to look for illegal group homes. Like the city, they only respond to complaints, officials said. Last year, the state cited three illegal group homes in Milwaukee County, none involving tenants with chronic mental illness. The year before, there were no verified cases of illegal group homes in the county.

State administrators said they have no reports on file of the city complaining about illegal group homes, including the building where Hall died.

"We don't know what we don't know," said Sinikka Santala, administrator of the state Division of Disability and Elder Services. "We wish the loved ones of people living in such places would report it."

All too often, there are no loved ones.

At Lois Wimmer's house at 2717 W. Vliet St., Bessie Johnson lay on the floor on a bare mattress soaked in her urine.

"I'm feeling fine today, honey. How are you?" said Johnson, with a sweet smile that suggested that she was oblivious to the human waste stuck to the vinyl floor or the stench of used toilet paper in a pile near where she slept.

There was no heat in the hallways, despite the winter temperatures outside. Upstairs, in the kitchen, a plate full of undercooked, discolored eggs sat on the table. It's what passed that day as breakfast for the four tenants, all profoundly mentally ill and former patients at Milwaukee County's psychiatric hospital. Fruit flies buzzed around a bowl of mushy fruit salad. The freshness dates for the cereal in the pantry had expired more than a year earlier. Sitting in the office, drinking coffee and eating doughnuts, Wimmer said she got much of the food that she served to her tenants for free from a storefront church minister.

"Pretty good deal, eh?" said Wimmer, who charges $550 a month for room and board.

Wimmer used to run 15 rooming houses for as many as 75 people, all with chronic mental illness. She has sold all but the Vliet St. place. Over the 16 years that she has been in business, six of her tenants have died, including two in one day - one from a heart attack and one from heat exhaustion. One woman was dead in her room for three days before anyone noticed, Wimmer said.

"They get mad at me, but what am I supposed to do?" said Wimmer, who recently spent three days as a patient at Milwaukee County's public psychiatric hospital in the same ward with some of her former tenants. "It's not my job to baby-sit these people."

CITED AS ILLEGAL SIX TIMES
Rats, sewage, loose plaster - and yet, still open for business

City building inspection records show that Wimmer has been cited six times over the past three years for running an illegal group home at the Vliet St. building. Inspectors found other violations, too: plaster falling from the walls; rats gnawing at the foundation; broken smoke alarms; overcrowding; open sewage; no doors on the bedrooms; and a host of electrical and plumbing violations.

At one point last summer, six people lived in Wimmer's building, including a woman with schizophrenia who slept in the living room on a grease-stained couch with broken legs, and another woman with schizophrenia who shared a room with Johnson, complaining all the while about the stench. Wimmer has been issued citations and fined more than $3,000. There is a warrant for her arrest over unpaid taxes.

Still, her house remains open for business, and county social workers routinely send patients there after they are released from the psychiatric hospital. Only those who the county determines are dangerous to themselves or others are held, and usually that is only for a few days. Nurses and psychiatric case managers contracted by the county stop at Wimmer's house each day - weekends included - to check on their clients.

Debra Rhodes, 50, one foot bare despite the cold, sat on a broken chair, the back black with dirt, and watched the buzz of activity at the coin laundry across the street from Wimmer's house. Rhodes' toenails were so long they scraped the floor. Her lipstick smeared and sweater torn, she considered what she would do with the $2 that her caseworker just dropped off, along with her daily allowance of a pack of cigarettes.

"I'm thinking I'll go get something to drink," she said.

Rhodes, who has been evicted twice in the past year, will prostitute herself for a can of soda, one of her caseworkers said. That's why the agency, Health Care for the Homeless, gives her a pack of cigarettes each day.

Thirty years ago, people like Teague and Hall and Johnson and Rhodes would have lived behind locked doors in one of the county's psychiatric hospitals. But public policy shifted as medications improved. With the ability to contain psychotic behavior, it was no longer deemed necessary to lock up people to keep them safe. It was decided that it would be more humane - and less expensive - to let them live on their own, free to come and go as they please, and to deliver mental health care in clinics scattered around the community.

Milwaukee led the way.

'A HUGE DISCONNECT'
Change begins without enough thought to consequences

A 1976 U.S. Supreme Court decision involving Alberta Lessard, a West Allis schoolteacher who had been hospitalized against her will, changed civil rights for people with mental illness across the country.

Before the Lessard case, Wisconsin - like most other states at the time - had a loose standard for commitment, requiring only that a person be "a proper subject for custody and treatment." Opportunities for abuse by unhappy spouses or disgruntled family members abounded. Federal judges in the Lessard case ruled that the government had to prove a person was an imminent danger to himself or herself or to others, in an adversarial court proceeding much like a criminal trial. The person who was being considered for commitment was entitled to legal representation, and the state would have to make its case in a particular time frame and with definite standards of what constituted dangerousness. The Lessard case became the new benchmark in mental health law. People all over the country who had lived their entire adult lives in locked hospital wards essentially were set free.

The number of long-term psychiatric beds at Milwaukee County's facilities dropped from about 4,000 at that time to roughly 100 today.

But when social engineers pushed the idea of closing mental hospitals and delivering health care in the community, they overlooked a critical element: Where would these people live? Who would take care of those who could not take care of themselves?

"It was simply assumed that there would be housing for these folks," said Hlavacek, the former Mental Health Task Force chairman. "It was a huge disconnect."

The problem was - and is - that there is not enough safe, affordable housing for people whose income today is limited to the roughly $700 a month they get in Social Security or disability payments. That's $8,400 a year, or about 15% below the federal poverty guideline.

"That doesn't give you many options," said Jill Rodriguez, a case manager at the county's Southside Community Support Program. "I can't put my clients in Fox Point or Brookfield. It's pretty much the ghetto or nothing."

Many landlords in better neighborhoods refuse to rent to people with psychiatric problems or criminal convictions, as people with mental illness often have, because they are afraid that the person might become violent or destroy their property. About the only ones who will rent to people with severely psychotic behavior are slum landlords looking to get a steady government check, case managers say.

Therefore, people like Rhodes have three choices: places such as Wimmer's broken-down house; a homeless shelter, if there is room; or the streets.

The newspaper interviewed dozens of the 260 psychiatric case managers who work for the county or for agencies that contract with the county. Nearly all of them say that finding good housing is their biggest challenge. Many of the case managers say they are too frightened to visit some of their clients alone. Often, they go in pairs and before noon, when the threat of danger is lower.

"It's enough to make you sick to your stomach to see how some of these people live," said Sophia Dixon, a psychiatric case manager at Milwaukee Mental Health Services, an agency that contracts with the county.

One of her clients discovered a dead body in her backyard last summer and is now too frightened to let her 12-year-old daughter live with her.

"No one is looking out for these poor souls," Dixon said.

Hill, the county's behavioral health administrator, makes no apologies for the placements, only explanations.

"The plain fact is that there is a critical lack of safe, decent housing in Milwaukee," Hill said. "We have no choice sometimes but to put people in these places. Believe me, these are the kind of choices that keep me up at night and give our case managers gray hair."

Hill said the decision of where a person lives ultimately rests with the person, not the caseworker.

"It is their choice," he said. "Legally, we can't tell them where or where not to live."

Sandy Pasch, president emeritus of the National Alliance on Mental Illness of Greater Milwaukee, rejects that explanation.

"We're not honoring people's autonomy. We're not giving them good choices," Pasch said. "Autonomy is society's excuse for negligence."

Winnebago County psychiatrist Darold Treffert, a nationally renowned critic of mental health care, talks about patients in the post-Lessard era "dying with their rights on."

Yet Hlavacek said few want to return to the old days of care behind locked doors.

"We should be able to deliver good, meaningful mental health care in the community," he said.

'PERFECT' VICTIMS
People with mental illness can be invisible and alone

Some of the more unscrupulous landlords who rent to people with mental illness are lured by the promise of steady rent. Caseworkers for the county say they are solicited all the time by landlords looking to have mentally ill clients as tenants. Many landlords promise safe, clean, affordable housing and offer to help monitor their tenants' medications - even when they are not licensed to do so. At some agencies, caseworkers list the bad landlords on the bulletin boards.

"There are some real bad ones out there," Rodriguez said. "I don't care how desperate we are, I won't go to them."

Kathy Good, clinical coordinator for Project Access, an agency that contracts with Milwaukee County to provide community support programs for people with mental illness, said everyone shares in the blame.

No one wants to let people with mental illness live next door to them, Good said. In effect, she said, we all force them into horrible conditions by sending them out of the psychiatric wards without any good options of where to live.

"We call ourselves a good, Christian country? Give me a break," Good said.

In a way, people with mental illness are the perfect victims of this kind of abuse. They are more likely to slip from public view than perhaps any other kind of patient, case managers say. Often reclusive, paranoid and eccentric, many people with psychiatric disorders have severed their relationships with family members. Such isolation has proved deadly.

Barbara Burroughs, a 52-year-old woman with schizophrenia on psychotropic drugs that inhibited her body's ability to sweat, was dead for more than three days, locked in her room with the windows shut before the landlady smelled a horrible odor coming from her room. Burroughs, who was wearing sweatpants despite temperatures outside in the 90s, died of heat exhaustion, the same week that Teague found his buddy Hall dead on his couch.

Three years later, Teague would have to scramble again to find a pay phone to call police.

Teague was out for a walk when he found another friend, David Rutledge, 54, slumped on the sidewalk in front of the rooming house where they both lived, at N. 27th St. and W. Richardson Place. The corner is a favorite hangout of drug dealers and thieves. Rutledge, who, like Teague, had schizophrenia, was well-known for walking the neighborhood with Bible in hand, quoting from Scripture.

Rutledge had been beaten so badly that blood was pouring from his mouth and ears.

"Don't let me die, Willie," Rutledge said as Teague held his friend's head.

It didn't do any good.

Four days later, Rutledge was dead
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