>> NARRATOR: Tonight-- 
It was a landmark ruling, 
thousands of New Yorkers with
severe mental illness had 
a right to live on their own.
>> There was a huge question
about whether people that had
been institutionalized can live
successfully in the community.
>> NARRATOR: And a right to
fail.
>> They just brought me there
and said, “ta daaa!”
This is your apartment.
>> NARRATOR: “Frontline” and
ProPublica examine the
challenges and the risks.
>> My brother was found totally
naked.
Was he taking his medication?
Was he not taking his
medication?
What was going on prior to that?
>> I mean these are not 24 hour
supervised settings nor were
they intended to be.
>> NARRATOR: Tonight on
“Frontline”--
>> The question is when
do you take away somebody's
liberty?
>> NARRATOR: "Right to Fail”.
♪ ♪
>> NARRATOR: This is a story
that is set in New York City,
miles away from the tall
buildings and high-rent
neighborhoods of Manhattan and
Brooklyn.
It's about people with serious
mental illness and who decides
where they live.
Here on the outskirts of the
city, the state has long housed
poor, psychiatrically disabled
people in places infamous for
bad care.
They're called adult homes.
♪ ♪
>> In the adult home, there were
people who were not getting the
proper care, drugs and alcohol.
It was bedbug-infested.
There was prostitution.
>> There is this sense of being
divorced from the world.
It's a separate reality and a
separate way of dealing with
people.
>> I don't want to be in
somebody else's building, living
a life that somebody else tells
me to live.
I want my life.
My life.
>> NARRATOR: In 2014, a federal
court order gave some of those
residents the chance to move
out, to live independently in
apartments, integrated into the
community.
It affected thousands of people.
ProPublica reporter Joaquin
Sapien spent more than a year
looking into how the ruling was
playing out and examining the
raging debate behind it all,
about giving people with severe
mental illness the right to live
independently and succeed on
their own terms.
But also the right to fail.
>> Up until the mid-1950s, early
'60s, you had these huge state
hospitals that would hold
sometimes a thousand people or
more.
They were really warehouses.
Lots of reports chronicled
atrocities in state mental
hospitals, and there was outcry.
So the goal of
deinstitutionalization was to
get these hospitals closed and
to get people into the
community.
>> In New York state, the adult
homes would be the solution.
But the adult homes were
profit-driven residential
facilities that were called upon
to become small psychiatric
hospitals, but with none of the
services, none of the expertise,
none of the training that a
psychiatric hospital has.
In 2002, I wrote a three-part
series examining the whole
system of adult homes in the
city and state.
What I discovered was quite
eye-opening: people dying and
their corpse not being
discovered for days;
prostitution; drug abuse;
physical abuse of residents.
People would have all sorts of
psychiatric breakdowns.
They would get suicidal.
There was a complete lack of any
system that was taking care of
these people's needs.
But the state regulators were
not penalizing the homes.
And I realized, well, they don't
want to close these places
because they don't know what to
do with these people.
You know, they are truly some of
the most voiceless people in
society.
And, as a result, the state, the
government just wants to push
them aside.
♪ ♪
There was really no effort to
integrate them into the
community.
So, ultimately, it was kind of
a catastrophic failure of
transferring the vision into
practice.
>> NARRATOR: Following Cliff
Levy's investigation, advocates
sued New York state in federal
court, claiming it had
segregated those with serious
mental illness-- their civil
rights had been violated.
The legal battle lasted 11
years.
Plaintiff attorneys brought in
dozens of adult home residents,
as well as experts.
>> I was brought in to testify
to this case because there was a
huge question about whether
people that had been
institutionalized can live
successfully in the community.
And the judge heard loud and
clear that people can live
independently; that their
psychiatric disability does not
define their existence.
And they should have the same
choices as the rest of us.
>> NARRATOR: The 2014 court
order applied to a class of
about 4,000 adult home
residents, allowing them the
choice to live independently and
receive in-home care.
The state would place them into
an existing program called
supported housing, overseen by
the Office of Mental Health.
>> Supported housing was a
particular model for people who
are quite high-functioning.
It's meant for people who can
manage their medications, do
some cooking, and pretty much
take care of themselves.
>> NARRATOR: A plaintiff in the
lawsuit, Ilona Spiegel, was one
of the first people to be given
an apartment as part of the
court order.
She had lived in adult homes for
15 years before moving into
supported housing.
>> I was scared.
I was scared.
>> SAPIEN: Why were you scared?
>> Um, I didn't know any
different.
Change is scary.
And this was a major change.
I didn't know what it was like
anymore to go into a supermarket
or cook.
But as time and the neighborhood
became more and more friendly
and familial...
It became easier and easier.
I felt like a human being for
the first time in so many years.
>> NARRATOR: Like many residents
in the court class, Ilona can
live independently without major
problems.
But there were concerns that the
supported housing system
couldn't handle people who
needed more extensive care.
In charge of the entire effort
were the same government
agencies in the state capital
that had been sued over the
adult homes.
>> I explained that people from
institutional settings, moving
into more independent housing,
will need a lot of support.
I was very concerned that, at
the expense and misery of the
people leaving the adult home,
that this kind of model would
just lead to really poor
outcomes.
♪ ♪
>> SAPIEN: There had been
stories already on the bad
state psychiatric hospitals and
bad adult homes.
No one's really explored what
it looks like when people leave.
>> NARRATOR: By the fifth year
of the program, 770 people had
moved from adult homes of the
about 4,000 who were eligible.
They'd been given the right to
choose where and how to live,
and promised enough support.
But ProPublica and "Frontline"
found more than two dozen cases
where people were struggling or
outright failing to adjust.
Cases that exposed the risks at
the heart of the program, from
identifying the right people to
providing enough care.
>> SAPIEN: How long were you in
your own apartment?
>> Maybe three months, I'm not
sure.
>> SAPIEN: How did it go when
you moved back?
>> I cried.
I don't want to struggle no
more.
>> NARRATOR: Once an apartment
is available, the move is
immediate.
There is no gradual transition.
>> I mean, basically, they said
that I was going to get a
roommate, but I'm supposed to
know what this person is like
from a five-minute meeting.
>> NARRATOR: For some, the new
freedom was too much.
They wound up on the street or
back in adult homes.
>> People feel that when they
leave, they get the apartment
and they say, "I'm cured, I have
an apartment."
God knows what they're going to
do.
>> NARRATOR: Some had become
dangerous to themselves.
For Abraham Clemente, who has
schizophrenia, things went well
at first.
And then he started to refuse
care.
>> SAPIEN: So, Abraham, how's, 
how long have you
been here for?
>> I don't know.
>> SAPIEN: You don't know?
>> For eternity.
>> SAPIEN: For eternity?
>> I've seen people move in,
people move out.
>> SAPIEN: It looks like you
might have an infection of some
kind on your finger there.
>> Oh, because I hit myself with
a surgical hammer.
And I banged it and it swelled
up.
And then it started bleeding pus
and everything.
>> SAPIEN: When was that?
>> A couple of months back.
>> SAPIEN: It's been like that
for a couple of months?
>> (coughs): Yeah.
It's going to take a long time
to heal because I'm a diabetic.
>> SAPIEN: What's that?
>> That's dog (bleep).
A dog walked in here and took a
(bleep) there.
>> SAPIEN: Do you feel like you
need somebody to help you?
>> No.
They interfere.
I do it myself.
>> I live in this building, but
I'm scared.
He put a chicken in the oven and
he totally forgot about the
chicken.
And it was a lot of smoke.
I live on the third floor, you
know?
I'm lucky I got a fire escape.
He need a lot of help.
He really do.
>> NARRATOR: Under the supported
housing system, Abraham was
allowed to live this way, even
to refuse care.
>> In order for somebody to have
agency, dignity, integrity, they
have to be able to make a
choice.
Even if those choices are bad
choices.
>> SAPIEN: It does seem like
we're at a point now where we're
letting people who hallucinate,
hear voices, are very delusional
make their own decisions on
where they should live.
>> We are doing that.
Absolutely.
I tend to take the position of,
more freedom is better than less
freedom, but there are cases
where you have to wonder.
Like, you know, what are we
doing?
>> NARRATOR: Abraham Clemente
was one of the most challenging
cases, because he was refusing
care.
But we found other stories
that raised concerns about the
program, even when care was
being accpeted.
One case is particular kept
coming up, a man who had been
institutionalized most of his
adult life.
He was 52 when he got his chance
to live independently for the
first time.
His name was Nestor Bunch.
Caregivers said his experience
reflected some of the biggest
shortcomings of the
court-ordered program.
(car door slams)
Joaquin was given an address for
Nestor in Queens, an apartment
above a fast food restaurant.
Nestor was no longer living
there; another participant in
the supported housing program
had taken his place.
>> SAPIEN: Do you know of a guy,
Nestor Bunch?
He used to live here, right?
>> Yeah.
>> SAPIEN: You don't have any
idea when he moved out, do you?
>> No.
>> SAPIEN: Yeah.
>> NARRATOR: There was another
address where Nestor once lived,
his old roommate was 
still there.
>> Living with him, I
found out the guy needed help.
He didn't last here that long.
>> SAPIEN: Right.
>> Not even a month.
>> SAPIEN: Not even a month?
>> Not even a month here.
I don't know where they put him
at right now.
He might be in Jamaica
psychiatric.
Or in jail psychiatric.
Who knows where's this guy at?
>> SAPIEN: I'm working on a
story about supported housing.
His name was Nestor Bunch.
I know he lived here because
he's received mail there.
Okay, thanks.
>> NARRATOR: Joaquin found a
healthcare worker who'd kept
case files that might help
locate Nestor.
But the documents had been
thrown out just before he
arrived and had to be retrieved
from a dumpster.
>> Oh, man, this is like
Christmas.
>> SAPIEN: Let's see.
We need to find the top part of
this sheet because,
unfortunately, it ends at
Buchanan and we don't have the
top part, which would have...
>> SAPIEN: Nestor Bunch.
>> Ah!
Where's Nestor Bunch?
>> NARRATOR: Joaquin had been
looking for Nestor for about a
month when he found a source who
said he knew where he was.
It was a large building in
Brooklyn, used to temporarily
house hundreds of people with
mental illness, supervised
around the clock.
It was the opposite of 
independent living.
>> SAPIEN: I asked the first
person I saw, "Hey, do you know
Nestor Bunch?"
And he said, "Yeah, that's me."
Nestor, thanks for meeting with
us.
I know it's not every day you
have someone coming by.
>> Oh, no, my pleasure.
Thanks for the attention.
>> SAPIEN: As I was explaining
to you out in front that I'm a
journalist.
>> You know what's a good move?
Besides being a corrections
officer?
A spy and a detective and a
detective and a spy.
Say defense lawyer.
That's four syllables, right?
>> SAPIEN: Right.
>> That takes care of that, that
takes care of that, that takes
care of that, that takes care of
that.
>> SAPIEN: What did they
diagnose you with?
>> Uh, drug-induced
schizophrenia.
>> SAPIEN: Drug-induced
schizophrenia?
>> Yeah.
>> SAPIEN: You used to take a
lot of drugs?
>> Yeah, yeah.
>> SAPIEN: Oh, yeah?
Um, I know you've got a unique
story.
It's important to the subject
I'm writing about, which has to
do with people moving out of
adult homes...
>> Right.
>> SAPIEN: ...and into their own
apartments.
Which I understand was your
experience, right?
>> Uh, somewhat.
I think I was living in that
Queens Adult Center, that place
there.
But it didn't work out.
>> SAPIEN: Do you know how long
you were at the Queens Adult
Care Center?
>> Um, about a month.
>> SAPIEN: About a month?
>> Yeah.
>> SAPIEN: He could not piece
together time.
You know, he thought that he was
at the Queens Adult Care Center
for weeks.
He was actually there for six
years.
Do you feel like you were
ready to be on your own?
>> Yeah.
You know, what happened is, they
just brought me there and said,
"Ta-da!
This is your apartment."
Everything was set.
They were making sure I eat.
They were making sure I had hot
water, but they couldn't do it.
So that's where they moved me to
another place, yeah.
>> SAPIEN: Was it above a
chicken takeout place?
Golden Krust?
>> Exactly.
And my roommate, he was naked
and funky and listening to music
and stuff.
>> SAPIEN: And that first
roommate, what was his name?
>> I'm not sure.
Jiffy passed away on me.
And I couldn't make heads or
tails of it.
>> SAPIEN: Right.
>> NARRATOR: It was difficult to
know what had happened to
Nestor in supported housing: he
experiences hallucinations,
hears voices, and has long gaps
in his memory.
>> SAPIEN: So we had to go out
and basically find witnesses to
his life who could testify in a
sense and tell us what exactly
had happened to him.
We were in Nestor's bedroom
one afternoon and we found a
Christmas card, and the return
address was for Nora Weinerth.
Nora has known Nestor since his
late 20s.
>> Look at these beautiful
flowers.
>> Yeah.
>> I inherited Nestor.
He is the son of a dear friend
of mine.
I loved him from the time I
first met him.
I just loved him.
What other songs do you like?
>> Oh, a lot of them.
♪ Like a bridge over troubled
waters ♪
>> ♪ Over troubled waters ♪
>> ♪ I will lay me down ♪
>> NARRATOR: Nora said Nestor
had lived in a big psychiatric
hospital before he moved into an
adult home, then supported
housing.
>> He was his mother's only
child, and she reared him very,
very devotedly and very
lovingly.
He was a healthy child until
about 14 and 15.
Then he began to show some
signs, talking to himself, he
was hearing voices.
That's a very frightening
experience, because a person you
know and love and have so much
hope for has lost everything,
the future.
And Elda became a very active
advocate, which was her way of
managing the deep, deep agony of
losing her only child to mental
illness.
This is Elda.
She claimed to be 5'2".
Actually she was 4'6".
She got a lot of joy from her
activism.
>> SAPIEN: Wow.
This fact that she had been a
advocate of, you know, some
renown, known by President
Clinton and others, came to our
attention through Nestor.
I didn't believe it.
But here's the evidence.
Couldn't have been more clear
that it really did happen.
>> Yes.
>> SAPIEN: She signs almost
every letter "Single mother of
a wonderful son with
schizophrenia."
>> That was an important thing
to say, because, to show that
people who have mental illness
through no fault of their own,
like Nestor, are not discards--
they're loved.
>> SAPIEN: This is really
interesting, because it has to
do with supported housing.
She's expressing support for the
inclusion of $423 million in
supportive housing funds in
1993, which means that 23 years
later, her son was living in a
supported housing apartment,
which is something that she had
advocated for.
>> Yes.
>> SAPIEN: But he doesn't have
the success that she would have
hoped for.
How do you think she would feel
about what happened with her
son?
>> I don't have the words to
describe how upset she would be.
>> NARRATOR: Nestor was moved
into his first apartment in July
2015.
It was a small walk-up studio
out by JFK Airport.
He was alone and unsupervised
for the first time in his life.
>> Nestor called me up and told
me he was going to be moved to
an apartment in a private house.
>> SAPIEN: And so what was your
feeling about that?
I mean, were you...
>> I was very worried about
things that can go wrong.
Is someone going to help him
straighten things out?
He needs a lot of help.
He does.
>> NARRATOR: Nestor was being
cared for by two non-profit
agencies, one called Federation
of Organizations coordinated
medical care.
They declined to be interviewed.
The other, ICL, was in charge of
housing and provided weekly
visits.
ICL's C.E.O., David Woodlock,
agreed to review Nestor's
records.
>> Nestor very much wanted to
live on his own.
And that was really clear.
Whether or not he appreciated
what that was going to be like
for him or not, you know, I
think we all went into that
trying to do our best, including
Nestor.
>> NARRATOR: Nestor gave us
permission to access thousands
of pages of his medical records,
from at least eight separate
care providers.
Among them was the assessment
used to determine if a resident
is too dangerous to themselves
or others to live independently.
His assessment noted he
wanted to stop his medication.
It also said that he was hearing
voices and believed that he
could heal others
telepathically.
Based on the court settlement,
none of this was disqualifying.
>> My job when I first met
Nestor was helping him pack his
medication every week.
Because the idea was that he
needed to be comfortable with
doing it himself independently.
>> NARRATOR: Shaquan Young was
one of Nestor's care
coordinators and one of the only
people who directly worked with
Nestor who would go on camera.
>> SAPIEN: So what was your gut
sense of how he was going to do
on his own?
>> It seemed to me like he was
on his way to independence.
You know, um...
>> SAPIEN: And when did that
start to change?
>> When he started going to the
hospital on his own because of
his own suicidal ideations.
>> NARRATOR: In Nestor's medical
records, we found that his
first experience with
independent living had
lasted five months.
Then he was admitted to a
psychiatric ward.
After months of reporting,
his story was coming into
focus.
>> SAPIEN: Um, Nestor, you'd
asked how we got interested in
your story, right?
>> (chuckles): Yeah.
>> SAPIEN: Yeah.
That's probably a good place to
start, actually.
I went to the Queens Adult Care
Center.
You remember that place?
>> Yeah.
>> SAPIEN: Where you lived in
Elmhurst?
>> Yeah, yeah.
Who told you about me?
>> SAPIEN: Well, a bunch of
people, actually.
>> How are they doing over
there?
They don't deserve to be there.
I hope they get homes and stuff.
Beautiful happy homes and stuff.
>> SAPIEN: Yeah.
So do you remember when you
first moved out of the adult
home?
>> Yeah.
What happened is, I went to an
apartment for me.
I had no heat.
No hot water.
>> SAPIEN: Did it feel like you
were left alone?
>> I had no company, actually.
So that's why I decompensated.
>> SAPIEN: I have some records
that show that you wanted to
hurt yourself when you were in
that first apartment.
>> Oh, my God, yeah.
>> SAPIEN: And you went to
Elmhurst Hospital to get help.
>> Yeah, hmm.
>> SAPIEN: Why do you think you
would have said things like,
"Oh, I'm gonna poke my eyes,"
or, "I'm gonna cut my wrists"?
Do you think you felt
overwhelmed?
>> Look at my eyes for a second.
>> SAPIEN (chuckles): Nestor.
That was pretty wild.
>> So, I look at that and I said
if I tried poke my eyes out,
these things'd say, "No!"
It seems to say, "Don't poke
your eyes... No!"
And, yeah, that's one answer,
indubitably, if you know what I,
what I mean.
>> NARRATOR: Nestor's records
show a lack of coordinated care.
Multiple agencies hadn't been
able to get his subsidy checks
to him.
He didn't have money to spend on
food and couldn't pay his rent.
The apartment was a mess--
"Dirt/grime in the bathroom.
The smell of urine."
He felt hopeless.
Ultimately, the agencies decided
that Nestor needed somebody
else, a roommate.
That roommate would be Bernard
Walker.
♪ ♪
>> Bernard and I were four years
apart.
Growing up, he was just like any
other brother.
We always had our good times and
our bad times.
He was always a peaceful, quiet
person.
He was never, you know, going
crazy and yelling.
But sometimes he would just be
rocking like that, so then I
know that, okay, Bernard is in
his little zone at that point,
you know?
>> The housing program and ICL
felt like Nestor would be better
suited to live with a roommate.
The idea was that, okay, if you
have a roommate that's higher-
functioning, you would probably
follow that person's lead, your
roommate's lead.
Nestor Bunch definitely seemed
to be in more of a need than
Bernard.
>> My biggest concern about
Bernard having his own place
was, did they properly train him
to be sufficient in that
environment?
>> SAPIEN: How about the idea of
him helping somebody else with
all that stuff?
>> I would say no.
I would say no.
It's scary just thinking about
it.
I'm wrenching my hands, like, he
has to care for someone else in
addition to himself?
No, no.
>> NARRATOR: Bernard was living
in the apartment above the fast
food restaurant in Queens.
He had been alone for two
months and feeling isolated
before Nestor arrived.
But their pairing was short-
lived, only 16 days.
>> Bernard, he was nice.
He would say hi to me.
He would say hi to the kids.
So it's very sad.
But at that time, we already
started saying, "There's
something wrong with him."
♪ ♪
He would come out, knock on the
door in underwears, trying to
sell you the grocery, ask you
for change all day long.
And he was becoming worse.
And like two days before, he
kept banging harder and harder,
doing it more and more.
That day, he came early in
the morning and he was knocking
on the door in underwears.
And I told him, "Can you please
stop coming to my door?"
Like, "I got kids.
I got my daughters here."
It was in January, and it was
the big storm.
And it was real cold.
We decided we're going to go
get some snacks.
And when we came out, he was in
the bottom stairs dead, naked.
Which means he was wandering
around naked.
Nestor was there living with him
and I knocked.
"Can you please go check?"
And he went down and he said,
"Oh, it's Bernard.
He's dead."
And I called the cops.
>> SAPIEN: I think it would be
pretty painful.
>> Yeah.
>> SAPIEN: So we'll approach it
delicately.
>> Mm-hmm.
>> SAPIEN: All right.
You ready for this?
>> NARRATOR: Bernard's brother
Michael is a former New York
City police officer.
He helped get the medical
examiner's report on Bernard's
death.
Until now, he hadn't looked at
it.
>> SAPIEN: So that's the
building.
>> Mm-hmm.
>> SAPIEN: Oh, man.
Look at all that snow outside.
>> Yeah.
>> SAPIEN: You sure you want to
see all this?
>> I'm good.
My brother was found totally
naked.
Was he taking his medication?
Was he not taking his
medication?
Um, what was going on prior to
that?
>> NARRATOR: Bernard's medical
records show that within a month
of moving in, he was struggling.
>> SAPIEN: We know from
neighbors that he's outside
practicing karate in the cold in
his underwear in the days before
his death.
He's on a battery of medication
that includes antipsychotics and
other drugs for his physical
health.
And he's inconsistent about
taking that medication.
I mean, he's clearly not doing
well in the days before he died.
This progress note is from
January 22.
His ICL case worker shows up to
check out his apartment, sees
that he's not there, and
leaves.
>> NARRATOR: Later that day, a
caseworker from the other
nonprofit saw him for 15 minutes
to check that he had his
medicine.
Two days later, Bernard was
dead.
>> SAPIEN: So one of the things
that Nestor mentions is that
Bernard was walking around naked
a lot in the days prior to his
death.
Would that be cause for concern
or further investigation for
ICL?
>> Sure, to the extent that
those are symptoms of his not
managing stress well or those
kinds of things or some
potential decompensation.
Sure, that would tend to trigger
either additional services, a
different kind of check,
touching base with the
psychiatrist or the therapist,
depending on how serious it was
judged to be.
>> SAPIEN: So, this is a guy
who's got schizoaffective
disorder, had just moved into
the community, paired with
somebody who arguably is less
functional than he is, and he's
found naked and dead on a
freezing cold day.
What does ICL do?
>> Do our best to understand
what happened, which I don't
think... and, again, I have not
reviewed his records, so I can't
speak to any of the specifics
of his care.
What I do understand is, as you
mentioned, that he was... an
attempt to visit him was two
days prior to that and, as I
understand, no particular reason
for alarm at that point.
>> SAPIEN: But he wasn't there.
>> Right.
People live on their own.
I mean, that's, you know, I'm
sure people would have come back
to visit him a few days later,
which is sort of the cycle of
things.
I mean, these are not 24-hour
supervised settings, nor were
they intended to be.
>> NARRATOR: But in cases like
Bernard's, it was that lack of
supervision that had critics
worried in the first place.
And all along, a federal court
monitor had been warning of a
systemic lack of coordination
among the agencies implementing
the program.
>> It's a bureaucracy.
So there's no one single point
of responsibility that you could
point to.
Even, even in the monitor's
report, there's state Office of
Mental Health, there's the
Department of Health.
It's, like, which commissioner
is going to actually... you
know, where does the buck stop?
Where's that desk that says "the
buck stops here" on the adult
home case?
That's what I'd like to know.
>> NARRATOR: No one from the New
York Office of Mental Health
would go on camera.
In an email, they said the vast
majority of former adult-home
residents have thrived in their
new homes, and the move has
given them hope and opportunity.
They acknowledged that a small
percentage did not succeed in
supported housing.
"Frontline" and ProPublica asked
about those cases for months.
Finally, they said 39 residents
returned to adult homes and 33
had died.
They wouldn't provide any other
details.
(phone dialing out)
>> Detective Gallagher.
>> Hey, how you doing, Detective
Gallagher?
This is retired officer P.O.
Walker.
How're you doing?
>> Good, how are you?
>> Good, good.
I have you on speakerphone.
I'm in just a room with one of
my friends.
He's a reporter.
We're trying to get information
on what happened with my
brother.
>> I mean, there really wasn't
much to it.
He passed away due to
hypertensive cardiovascular
disease.
Looks like he had a heart
attack.
>> Yeah, I went to the M.E.'s
office and I got their full
extensive report on that.
>> SAPIEN: What was your
instinct to find him in that
kind of condition, I mean, given
that he was naked?
>> Well, at first, it was odd
and then after speaking to
Nestor, Nestor said that he was
running around the house naked
all the time.
You know, we had asked Nestor if
he knew if Benny was taking his
medicine, but he couldn't say
for sure.
>> SAPIEN: Given that he was
mentally ill and the condition
that he was found, is there any
type of procedure or requirement
for a follow-up to figure out,
you know, if he was taking care
of his medication or if he was
being properly taken care of?
>> It wasn't followed up on per
se.
>> NARRATOR: Michael Walker kept
wondering what more could have
been done to prevent his
brother's death.
♪ ♪
>> I was caring for Nestor's
mother at the time.
And I got a call from the police
saying, "Don't worry, Nestor is
alive, but his roommate is
dead."
Nestor said he was fine.
But it's a very shocking,
traumatizing experience.
I wanted to know his condition
as a result of this experience.
And then, only a few days later,
his mom died.
>> SAPIEN: Were you two very
close?
>> Who, me and my mom?
Yeah.
>> SAPIEN: Did you say goodbye
to her?
>> No, if I said goodbye, I
would have been destroyed.
My mom was just, like, kind of
unconscious, you know?
And she just fell asleep, I
guess, you know?
And after that, well, Nora came
up to me and said, "Regito, your
mom died."
And I said, "Oh, my God, what
happened?"
And she said, "She died of
cancer and pneumonia."
It was the most powerful blow I
ever felt in my life, you know?
(sighs)
♪ ♪
>> It was awful, just tragic.
His mom passed away, his
roommate had passed away.
And even though we didn't see
any emotion, we didn't see him
processing his grief,
we didn't see him grieving, but
you knew.
Like, it was showing through his
actions, you know?
It was showing through that--
not eating, not taking his
medication.
I asked Nestor, was everything
all right?
His speech was very fast, but
I couldn't comprehend it.
His words were very slurred.
That was a clear indicator that
he wasn't doing well.
So I called 911.
E.M.S. came.
They very delicately, very
gingerly, they brought Nestor
downstairs.
And they brought him to Long
Island Jewish Hospital.
(sirens wailing)
>> NARRATOR: Nestor was put in a
psychiatric ward for several
weeks, then was moved again.
>> SAPIEN: According to this
document, the care coordinator
"was not even told that they
were considering moving him."
She's the person that's
responsible for making sure that
Nestor has the services in place
to live safely in the community.
This document shows she doesn't
even know where he is.
>> NARRATOR: He was in another
Queens neighborhood. 
In a small brick rowhouse.
This new roommate had been
diagnosed with paranoid
schizophrenia and had a history
of severe alcohol abuse.
Almost four months after he
moved in, Nestor was found badly
injured with broken ribs and
kidney damage.
His medical records say he'd
likely been beaten.
>> SAPIEN: So, Nestor, we're
just trying to piece together
what may have happened to you
after you were in the hospital
after your mother died.
Do you remember when you moved
in with the guy that you told me
about?
>> Yeah, what about him?
>> SAPIEN: And you went to the
hospital while you were living
with him.
>> Right.
>> SAPIEN: You got hurt.
>> Got hurt?
>> SAPIEN: Do you remember any
of that?
>> I just wound up in the
hospital, and I say, "Gee, I'm
here in Wonderland," you know?
>> Somebody called to say that
he was in the hospital.
The doctor hypothesized that he
had been beaten up by someone.
His ribs were broken.
The doctor said it looked like
he had been on the ground and
was kicked badly enough for his
kidneys to have stopped
functioning.
>> SAPIEN: There's supposed to
be this whole network of
professionals involved in his
life.
>> To keep track of him, yes.
>> SAPIEN: Were they able to
answer any of those questions
for you?
>> Nobody said anything.
Nobody really seemed interested
in that.
I don't know, but it was a very
thorough, systematic beating, it
seemed.
>> SAPIEN: So I just want to
make sure that I understand.
Nestor is an extremely
vulnerable person.
Doctors think there may have
been an assault.
>> Mm-hmm.
>> SAPIEN: And there's no
effort to find out if there was.
>> Again, I would just say
Nestor, as I understand it,
never reported to us, anyway,
that he had been assaulted.
There were any number of reasons
for the symptoms that he was
experiencing.
If he had collapsed on the
street and fallen against a
step-- I'm speculating
completely now-- could have
potentially hurt his ribs.
But in the absence of some
reason to think it was
necessarily an assault,
everything else is speculation.
>> SAPIEN: But given what we
know about Nestor, right, I
mean, he was unconscious.
>> Mm-hmm.
>> SAPIEN: He's schizophrenic.
Just because he said he couldn't
remember what happened doesn't
necessarily mean nothing
happened.
>> It doesn't mean it didn't
happen.
It doesn't mean it did, either.
I mean, something certainly
happened.
>> NARRATOR: Nestor spent five
days in the I.C.U. and more than
three months in the hospital and
rehab.
Then the agencies overseeing his
care returned him to independent
living.
>> I felt like Nestor definitely
required some intensive
assistance long before he was
assaulted.
I used to mention this a lot
with Nestor's therapist at New
York Psychotherapy.
Nestor's therapist was very,
very, very vocal about Nestor.
>> SAPIEN: The therapist
expresses her disagreement with
Nestor's discharge back to the
community, stating that she
believes that this was an unsafe
discharge for Nestor.
Let me ask you this, what does
it take to move somebody into a
higher level of care?
>> It requires the entire team
to agree.
So, the Department of Health,
the Office of Mental Health, and
the clinical team members have
to agree that a person has to go
back to a higher level of care
before they'll do it.
There's some risk involved
sometimes.
But there's risk involved for
anybody if you're going to move
forward in your life.
(knocking on door)
>> SAPIEN: Hey, Abraham.
Are you home?
>> NARRATOR: It was one of the
hottest days of the summer.
>> SAPIEN: Abraham, you home?
(knocking on door)
>> NARRATOR: Abraham Clemente
wasn't answering his door.
A caseworker who happened to be
in the building called 911.
(siren wailing, approaching)
>> Abraham?
This place is a mess.
(toy whirring)
(man speaking on police radio)
>> Good morning, officer.
>> How you doing, Mr.
Clemente?
>> I'm doing all right.
>> You feel dehydrated?
>> No, no, no.
>> No, you feel fine?
>> No, I'm fine.
I'm fine.
>> Okay.
I still want E.M.S. to come
check you out, okay?
We're just a little concerned
for you.
>> Whatever you want, officer.
You know, I'm here all alone, I
don't want to abandon this
place.
I want to live like a human
being.
>> SAPIEN: Yeah.
>> Be human, you know, like
being in the jungle.
(device beeping)
>> Hey, Abraham.
>> Mm-hmm?
>> Do you feel dizzy or short of
breath or anything like that?
Any pain anywhere?
>> No, no pain.
>> I remember, I've seen you
before.
I remember you.
You know what month it is?
>> Um, uh, no.
>> Your sugar's a little high.
It's 209.
Squeeze in on your hand.
>> We're going to the hospital?
>> Yeah, we're going to have to
go to the hospital to get
checked out, okay?
>> All right.
>> A lot of people feel like,
who are we to say you are not
well enough, you shouldn't be
living on your own?
Who are we to infringe on
somebody's freedom?
Other people say, well, that's
just a copout.
Are you giving me my right to
fail?
Or are you letting me cling to
my right to be free to such an
extent that it's going to be the
death of me?
>> NARRATOR: It took another two
months and one psychiatric
hospital admission before
Abraham's caregivers determined
he could not live on his own.
He ended up back at an adult
home.
>> I don't want to go back on my
own.
I can't live like that again.
Nobody to talk to.
Nobody to check on me.
I felt lonely.
Worthless.
Unwanted.
Unloved.
I don't want to live like that
again.
I'm going to fail.
I don't want to fail.
(car horn honking)
>> SAPIEN: Hey, man.
>> How are you?
>> NARRATOR: When Joaquin last
saw Michael Walker, he'd
promised to keep looking into
what led to the death of his
brother Bernard during the
winter storm in 2016.
>> SAPIEN: It's been a long
haul.
There's a few things in here
that I wanted to show you.
One of the things we did learn
is that there was an
investigation into your
brother's death.
>> Conducted by?
>> SAPIEN: It's not clear if
it's by the Department of Health
or the Office of Mental Health.
But they did say, and I have
that correspondence in here,
too, after many, many repeated
questions, they won't tell us
the results of the
investigation.
They said that it would be an
unwarranted invasion of your
brother's privacy to release
the investigation.
And these documents are exempt
from the Freedom of Information
law, anyway.
I asked, you know, "Does this
mean that the family is never
going to get the investigation?"
>> Mm-hmm.
>> SAPIEN: And they said, "Yeah,
that's right."
It takes us several months to
even get confirmation that there
was an investigation done,
period.
And here we are, almost a year
later, and we still don't
know...
>> And still... We have nothing.
>> SAPIEN: ...what the results
of that investigation were.
>> Yeah-- I can't understand why
the agency is not freely giving
the information.
>> SAPIEN: To you, at least.
>> As a family member, to me.
As a family member.
That would, that would just
clear the table of anything, you
know?
We have the M.E.'s report, we
have the police report, it's
there-- we can read it.
We'll break it down, no problem.
But now the agency itself
conducted their investigation.
How far did they go?
Or was it just a cursory
investigation?
♪ ♪
>> NARRATOR: Since the New York
court case, at least nine other
states are pursuing similar
independent living programs for
people with severe mental
illness, despite the risks.
In response to reporting by
ProPublica and "Frontline," the
federal judge overseeing the New
York court settlement has
ordered an investigation
into how caregivers report  
bad outcomes.
>> ...corrections officer?
Spy and a detective, and a
detective and a spy.
>> NARRATOR: Only two weeks
after being sent home from the
hospital in January 2017,
Nestor Bunch was found by
police freezing on a sidewalk,
alone.
He spent another four months in
a psychiatric hospital.
But after all he had been
through, Nestor still hoped to
live independently.
>> I'm not worried so much
about... well, I want to get an
apartment and at the same
time...
>> SAPIEN: Your own apartment.
>> Yeah.
>> Oh, this looks like it, okay.
(door clicks)
>> Oh, Reggie.
>> Hey, folks.
>> Hey, Reggie.
Reggie.
>> Hey, beautiful.
>> Hi, gorgeous.
>> Hello, love.
>> Oh, it's so nice to see you.
How are you doing?
>> Good.
>> Are you Jeanne?
>> Yes, I'm Jeanne.
>> Hi, Jeanne.
>> Jeanne, I'm Tom.
>> Nice to meet you.
>> NARRATOR: Three years after
Nestor'd left the adult home, he
had finally been placed in a
special apartment, with a higher
level of care, and with a new
roommate, Jeanne.
>> This is my room.
I have an air conditioner.
>> Yeah, it's nice.
>> Air conditioner in the back,
right?
My TV.
My cassette.
And my record player.
Got a nice soft bed.
Come on, let's check out the
rest of the apartment.
>> Nestor is getting the
supports now that he needs.
He's flourishing.
When I call him, he sounds
wonderful.
"Oh, hi, Nora.
Hi, Nora."
He is engaged.
And he expresses joy.
>> The one thing I do appreciate
about me being alone is, I do
make my own decisions, you know?
And there's something called the
Declaration of Independence, you
know what that is?
Well, it's an excellent example
of what a person can be by
themselves.
>> NARRATOR: In fact, Nestor had
technically failed out of
supported housing.
He now has an aide that spends
four hours a day with him seven
days a week.
>> So when was the last time you
heard voices, Nestor?
>> Um, the last time I heard
voices was, oh, about, um,
about two minutes ago.
>> Oh, yeah, what'd they say?
>> Like, a frog lost his arm.
>> Wow.
They haven't said anything mean
or tell you bad things?
>> No, just funny things that
they don't mean to say.
I think the medication's helping
me to not see things I
shouldn't, you know?
>> Mm-hmm, you haven't seen
anything, then?
>> No, not really.
But I want medication for my
hearing, you know?
>> Yeah, yeah.
>> NARRATOR: Yet all this extra
care is not meant to be
permanent.
If Nestor continues to do well,
it could trigger removal of the
support and a return to the
program he'd struggled in.
♪ ♪
>> The system can work.
We see it with Nestor now.
But I've seen the system fail
him very badly.
And if the system withdraws the
very elements that allow Nestor
to progress, then what happens?
I'm very concerned about that.
His survival is at stake.
>> We go food shopping, do the
laundry.
We do some cleaning and some
more cleaning.
I watch TV.
I listen to music, music TV.
I sleep.
I wake up.
I take a shower.
I get dressed.
I hang out.
Captioned by
Media Access Group at WGBH
access.wgbh.org
>> For more on this and other
"Frontline" programs, visit our 
website at pbs.org/frontline.
♪ ♪
To order "Frontline's"
"Right to Fail" on DVD
visit shop PBS,
or call 1-800-PLAY-PBS.
This program is also available
on Amazon Prime Video.
♪ ♪
