The Woman Who Died in the Waiting Room

In January 2007, Green began acting erratically. She would eat very little, pace the floors all night long and fall silent for days. She would appear, disheveled and out of sorts, at the doorstep of this friend or that one, in the middle of the day or late at night, asking for a place to sit quietly. And she had taken to running around the apartment over the church, where she lived with two other women, gathering dresses, plates and other items into large trash bags and putting them out onto the street. Her roommates would call Pastor Johnson, and Johnson and her husband would come over and carry everything back upstairs. "Her best clothes, her roommates' valuables, would all be out there," Johnson says. "Sometimes she would not remember doing it; other times she would remember but have no explanation."

So began a slow deterioration marked by repeat visits to Kings County's G Building. Each time it was the same: her roommates would grow uneasy with some outburst or strange incident and call 911. The hospital would admit her and keep her for a few days. When they discharged her, Pastor Johnson would come to bring her home. It remains unclear what type of treatment she received during these stays. An autopsy released on Friday determined that untreated blood clots had exacerbated a chronic paranoid schizophrenia. "Were she examined, she could have been given an anticoagulant and instructed to walk around," says attorney Sanford Rubenstein, who is representing Green's family in their lawsuit. "If that were done, she might still be alive today."

But over the past year, as Green's behavior grew more erratic, Johnson was less concerned with Green's diagnosis than with keeping her under control. After one hospitalization, she stayed with Johnson's sister Babs while Johnson prevailed upon Green's roommates over the church to take her back in. "They were nervous, and Sister Green didn't want anyone else in the parish to know she was sick because she was embarrassed," says Johnson. "So we couldn't really ask the others to help." When it was time to leave Babs's and return to the church apartment, Green disappeared. "It took us two hours before my husband found her hiding in the back of a small coat closet," Johnson recalls, laughing warmly. "She just flashed us this huge grin, like a little child who'd been caught taking too many cookies."

On another occasion, Johnson went to visit Green at the hospital, but Green refused to see her. "I stood there smiling and she walked right up to me, looked, turned around and walked away like she didn't recognize me," says Johnson. "A few hours later she called me at home and asked why I had not come to see her. 'Everybody have visitors and me have none,' she said. So I went back, and she was all hugs and smiles."

The surveillance tape that captured Green's last visit to Kings County was obtained by the NYCLU as part of a routine evidence request for its ongoing lawsuit. The first thing attorney Beth Haroules noticed as she watched the footage was how shiny the floors were. Haroules had been working for more than a year on the lawsuit against the hospital, and until now, progress had been glacial. Even with a Department of Justice investigation spurred by the NYCLU's findings, the defendants had only recently managed to paint the walls and clean the floors. "Those floors used to be disgusting," Haroules says. "Not that their being clean has made any difference here."

Haroules has been around long enough to watch her own efforts at solving the psychiatric-care crisis come full circle.She joined the NYCLU in the late 1980s, just as new laws that the organization had pushed for were forcing the state to create separate emergency rooms for psychiatric patients. But if those specially designated facilities spare psychiatric patients from the trauma of a typical emergency room, critics say that they also replace that trauma with a callous approach to care. Haroules doesn't regret the establishment of these facilities, known as Comprehensive Psychiatric Emergency Programs, or CPEPs, but says much more is needed to protect psychiatric patients. "This was supposed to be a whole new way of doing business, but we're right back where we started from," she says. "Only it's worse because now, the most vulnerable population is also the most isolated, and that has led to poorer quality in terms of staff, infrastructure and financial resources."