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Tragedy highlights system's flaws

August 1, 2006
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Andrew Goldstein, the man who pushed Kendra Webdale to her death in 1999, seems destined to be known as the “man who refused treatment” and triggered “Kendra's Law” (See the June issue, p. 32). Far from refusing treatment, Goldstein tried in vain to get treatment. New York State's investigation of the case confirms this fact in a report published at

The fact that Goldstein had been shoehorned into the role of “treatment refuser” was swept away by publicity geared to pass Kendra's Law. As the truth emerged, Goldstein's psychiatric history became evident—an appalling account of mistakes and missed opportunities by the psychiatric facilities he turned to, often voluntarily, for help. Perhaps the most tragic aspect of Webdale's death is how nearly it never happened. What if North General Hospital had not discharged Goldstein too soon? What if they had discharged him to a supervised residence and escorted him there? What if he had been given a month's supply of medication, rather than a one-week supply? What if they had assigned a mental health worker to accompany him to clinic appointments? What if the pleas for supervision from both Goldstein and his mother had been heeded by providers? Just a few basic supportive services could have saved Webdale's life.

Cases like Goldstein's are not uncommon, as a sample of homicides from the Treatment Advocacy Center's “Preventable Tragedies” database ( shows. We looked at the 66 data entries for July-December 2004 and found that 1 in 8 homicides followed an assailant's premature hospital discharge or refused entry. Although Goldstein has been made the poster boy for involuntary outpatient commitment, he is more fittingly a symbol of the gaps in an uncoordinated, underfunded mental health system.

Jean Arnold, Cofounder and Chair, National Stigma Clearinghouse, New York, New York