Report Raises Questions About Mass. Mental Health System

BOSTON — The Massachusetts mental health community gathers Tuesday for the second annual symposium on the safety of the state’s mental health workers — an event organized in response to the 2011 murder of counselor Stephanie Moulton by a client in the Revere group home where she worked.

That client, Deshawn James Chappell, is now serving a life sentence after he was convicted of Moulton’s murder in October.

A Massachusetts Department of Mental Health report on the murder obtained by WBUR raises troubling questions about the state’s mental health system. The report, which has not been publicly released, shows that Chappell had a long history of mental illness and violence and that Moulton told her supervisors that she was concerned about his behavior.

The report details the now-30-year-old Chappell’s downward spiral into psychosis. It says Chappell started to show symptoms of mental illness about 10 years ago. The report lists several instances where he was aggressive, violent, engaged in criminal behavior and used illegal drugs, but often failed to take his prescribed psychiatric medications.

“You have to understand this is a very sick individual,” explained Daniel Solomon, Chappell’s defense attorney. “A sick individual who led an absolutely normal life until his early 20s, which is typical for onset schizophrenia. The first manifestations was he was calling up his mother and saying, ‘Why are you talking to me in my head?’”

What stands out for Solomon in the report is that Chappell was placed in the Revere group home less than three weeks before Moulton’s murder. He was placed there after repeatedly refusing to taking his medications and assaulting a client in another state facility.

“The analogy is that they moved him from medium to minimum security,” Solomon said. “The negligence in that to me is pretty close to shocking.”

Solomon also says that staff at the group home, including Moulton, did not know about Chappell’s history. He argues the staff didn’t have the context to make decisions about how to handle his increasingly erratic behavior, including his refusal to wear clothes and follow rules, his sexual comments to Moulton.

Moulton, the report says, emailed her supervisor about Chappell’s behavior, but her supervisor was on maternity leave so that group home was overseen by an off-site program manager. The report also says the day before Moulton was killed, she took Chappell to a psychiatrist who prescribed more medication — which Solomon points to as a failure in the approach to treating mental illness.

“We live in a society where psychiatric or psychological care often devolves down to seeing a psychiatrist once a month for 20 minutes who adjusts your meds,” Solomon said. “Deshawn is responsible for whatever he is or is not responsible for, but he was failed by the system.”

Exactly what professionals should have done may be clearer now in hindsight, but mental health observers say there were some clear red flags in this case. Boston College associate professor Marylou Sudder, who once served as the the state’s mental health commissioner, says one thing in the report that stands out to her is Chappell’s history of not taking his prescribed medication. Sudder says he should have had a court guardian to ensure he was complying with this treatment.

“One of the, I think, absolute failures in this is — going back and looking at history — is that there should have been medication guardianship for this gentleman who had a history of noncompliance,” Sudder said.

The current state mental health commissioner, Marcia Fowler, would not comment directly on the report. But she said she agrees there should have been more supervision of Chappell and a greater effort to make sure staff members working with him knew about his history.

“What I can say is that if the information was not known it should have been known,” she said.

Fowler is quick to comment on the reforms implemented in the almost three years since Moulton’s murder. She points to legislative efforts to improve worker safety and screen for mental illness, better worker training and improved supervision. And Fowler says the state continues to more closely monitor North Suffolk Mental Health Association, the vendor that still operates the Revere group home where Moulton was murdered. But Fowler admits that the report raises some troubling questions.

“We need to do a better job supporting the direct care staff and that there’s appropriate clinical staff who have the training and skills that direct care workers don’t necessarily have so that they’re not left on their own to figure out how to deal with some very challenging people,” Fowler said.

Some of that training will be done at Tuesday’s Stephanie Moulton Symposium — an event which the state promises to hold every year to continue to strengthen safety following Moulton’s murder. But Moulton’s mother, Kim Flynn, says the information that was revealed during Chappell’s trial haunts her: her 25-year-old daughter, engaged to be married, earning $14 an hour and unknowingly left alone in a group home with a violent man who sexually assaulted and brutally murdered her.

Flynn believes the vendor, North Suffolk Mental Health Association, is just as guilty of her daughter’s murder as Chappell.

“Stephanie wasn’t aware of what was going on and the fact that there’s people that are supposed to be taking care of her and they all knew it and nobody did anything to help her,” Flynn said. “It’s just the hell and the horror that my daughter went through. It just wasn’t right. She was there to work and take care of people.”

Flynn is pursuing a civil lawsuit against North Suffolk, which has paid a $7,000 federal fine over Moulton’s murder. North Suffolk, which has about $14 million in state contracts to run mental health programs, did not respond to a request for comment on the report.

Earlier Coverage:

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  • PCMacGuy49

    Over three decades ago while at BU, I took an internship at the Center Club Boston and spent several semesters assisting in community relations. The Club helps people with psychiatric disabilities, and
    combines employment, housing and education services with social
    activities and wellness initiatives. “…there should have been medication guardianship for this gentleman(Chappell) who had a history of noncompliance.” This is key in caring for psychiatric clients. Recently I worked for a state agency providing support services for developmentally delayed adults. Both experiences exposed me to an underclass of deserving citizens. Hopefully the “2nd annual symposium on the safety of the state’s mental health workers” will bring about much needed change.

    • chris9465

      The state hospitals are just as much to blame………with the attempt to eliminate the use of restraints…….the anti social psychopaths know they can walk up punch a staff in the face put their hands up say am fine i want to go to my room and theres nothing we can do because the “regained control” then those same pts get discharged to your community……..no town should allow a mental health group home the people they put in those homes are violent, sex offenders and pedophiles………ive worked a long time in state hospitals and am yet to meet a pt id say ya i want him living on my street…….don’t believe the liberal BS these people are extremely dangerous

      • PCMacGuy49

        Oh, really? I was addressing the issue of “medication guardianship” and its vital importance in maintaining psychiatric patients at large in society. I’ve dealt with irrational, manipulative psychotic wack jobs and agree that they can be dangerous, but deinstitutionalization occurred a long time ago, and they are among us.
        Group homes are not half way houses. They offer a viable lifestyle
        alternative with structure, rather than false hope for a better life to
        come. Safety of the clients and staff is priority one, and proven therapeutic programs as well as consistent, documented administration of psych meds
        can’t be neglected. The alternative is chaos, and I for one have not
        thrown my hands up in despair. Politicizing this issue is a cop out.

  • pcl

    The state (and the US as a whole) continues to maintain a false divide between the “criminally responsible” and the “mentally ill”, even if those put in the latter category are equally violent. Is it really rational to say that someone who is not schizophrenic, but has been warped by a childhood filled with violence and abuse, is not “mentally ill”? I’d rather live in a society in which those with violent behavior are non-violently euthanized with no attempt to judge whether they “deserve it”. The one possible exception to this would be those who have only shown slight violent tendencies and can be treated with forced medication; but that should include a Norplant-like implanted device that doesn’t rely on the cooperation of the patient.

  • Susan Rose

    Closing of Greylock Pavilion

    Susan Rose, am living proof that the system works.

    were countless times that I wanted to end my life;

    I had multiple life-threatening
    suicide attempts.

    The hospital was only four minutes from my
    front door. A quick response from the emergency medical team saved my life and
    the grim prospect of being brain dead and in a coma.

    words “Thank you” are not enough to express my appreciation for the medical
    staff at the Greylock Pavilion in North Adams Massachusetts.

    only did they save my life, they saved the lives of my three children who
    suffered from Bipolar Disorder in their early twenties.

    of my sons was admitted at least 25 times.

    the services rendered by Greylock Pavilion my entire family would not have

    one and a half decades have passed and all my sons are doing well. One of my
    sons graduated from MCL with a bachelor’s degree in psychology.

    stayed in the Berkshires because of the mental health services that brought me
    from a crippling illness to a rich and full life as an artist and writer.

    I heard the news of the possible closing of Greylock Pavilion fear and panic
    shook my inner core. I haven’t been admitted in years but that doesn’t mean I’m
    immune to setback.

    know mental illness well. No matter how stable you are, this disorder is
    insidious and strikes like a viper, then can send you to your knees. I’m stable,
    but as you can see, always vigilant of the monster that dwell within.

    we become so desensitized to the needs of the mentally ill? We have dreams like
    everyone else.

    we going backward instead of forward?

    history repeat itself?

    patients be housed in institutions for the rest of our lives with moral
    monsters like Dr. Walter Freeman who, without anesthesia, forced lobotomies on countless
    patients by slamming an ice pick and hammer between their eyeballs to slice
    open their craniums?

    We cannot be housed like animals which brings
    me to this point. Fifteen years ago, in North Hampton, they let everyone out of
    the state hospital. These were human beings, lost on the streets, and no one
    spoke up. If someone opened the doors to a shelter for injured animals and
    forced them out to abruptly fend for themselves, they would face a prison
    sentence. What’s wrong with this picture?

    proposed day care center is not the answer. We need to look at this from all
    sides, including public safety. The mentally ill are not monsters. If untreated
    and there will be violence from, and more disturbingly, to them.

    can we handle potentially dangerous patients in our day care center in North
    Adams? There is not even a police officer on the premises.

    mentally ill here have no voice. But I regained mine, and I will speak on
    behalf of this population, which desperately needs more services… not less.


    Susan Rose

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