A deadly encounter

On a rainy Sunday in January 1999, Kendra Webdale left her Manhattan home and descended the stairs to a New York City subway.  Newspapers would later report that as she waited for the train, a man approached and asked her for the time.  His name was Andrew Goldstein.

Passenger John Norwood was on the subway platform, too.

John Norwood, witness: He just looked very, very average. 

Goldstein may not have appeared threatening, but as dateline discovered, he had a long history of violence. Over a two year period, he’d attacked 13 people.  All were strangers, most were women. Kendra would never know this and only later would those who knew Andrew, like his housemate Zach Vega, put together all the clues.

Zach Vega, Andrew Goldstein’s housemate: Four or five days before this happened, he was a little strange.

He remembers Andrew pacing all night long, through the streets and even cemeteries of their Queens neighborhood, listening to Pink Floyd, blanking out in the middle of a sentence, and asking to eat his neighbors’ leftover food.

Vega:  Every time he walked out of the door, I worried he was the loneliest thing I ever saw. And I spent a lot of time with him because of that.

Goldstein was 29, unemployed, and, but for the disability check that paid his rent, virtually penniless.

Looking back, it’s hard to believe he ended up this way.

He was an exceptional student—so bright that he attended the Bronx High School of Science—one of the city’s most elite public schools.

But during his freshman year of college, the brain that had earned him so much praise began to falter—before long disorientation gave way to full blown delusion. He told doctors that his neck had disappeared and that strange storms were affecting his body making him shrink.

In the summer of 1989, Andrew pushed his mother into a wall and wound up in a psychiatric hospital.

The official diagnosis: schizophrenia—an incurable brain disease that can cause hallucinations, paranoia, and, in rare untreated cases, bizarre, and even violent behavior.

A diagnosis of schizophrenia is devastating.  But Andrew Goldstein lived in New York—a state with a proud history of caring for its mentally ill.  Still, as a Dateline investigation discovered, Andrew Goldstein did not get the help he needed.  Instead, he embarked on a journey through poorly coordinated services and revolving door care—one that would, in the end, lead to a subway platform, and Kendra Webdale.

To find out where the safety net failed, and why, Dateline got access to confidential files which document Goldstein’s ten year odyssey through the mental health care system.  For several days we combed through some 3500 pages of hospital notes—transcribing records which reveal what those in the system knew about Goldstein, when they knew it, and what they did—or didn’t—do for him..

Michael Winerip, New York Times reporter: I was shocked when I saw the records. I was shocked that it was there in such detail.

New York Times reporter Michael Winerip who covered the mental health care system for 15 years—and wrote extensively on this case—also got a look at Andrew’s confidential psychiatric file.

Winerip: At one point or another Andrew Goldstein got almost every kind of treatment that we have in our mental health system. But that care was never coordinated, it was sporadic. He was at crucial points denied all kinds of treatment that he needed.

Notes from Andrew’s first hospital stay say he pleaded for help—a plea he’d make over and over through the years:  “I want to live” he told doctors—“and lead a normal life.” 

They tried to subdue his delusions with the drug Haldol - a common treatment for schizophrenia.  They found he “improved” and “prognosis can be good if patient will take his medication.” 

But, like so many schizophrenics,  Goldstein resisted the drugs.

Larry Termo, ex-housemate of Goldstein’s: I did see him getting gradually worse.

Larry Termo shared an apartment with Goldstein in 1992.  He says Andrew   complained about Haldol’s sometimes debilitating side effects.

Termo: He had spasms where he had twisted almost totally into a pretzel. He didn’t think he was going to make it home.

So Goldstein went off his medicine—and his condition deteriorated. In December of 1992, he committed himself to Creedmoor—a big state psychiatric hospital in Queens.

Hospital notes portray a man so paranoid and delusional that he barricaded himself in a nurses station because he believed the staff was “poisoning him with cyanide” and that someone was after him with a gun.

Goldstein lashed out—attacking two social workers and a nurse.

Faced with an “extremely dangerous and potentially violent” patient, Creedmoor held on to Goldstein.  But only for a while.  In the last 30 years, there has been a nationwide effort to get the mentally ill out of big psychiatric hospitals, and into community facilities.

So although the records show Andrew did well at Creedmoor, after eight  months, he had to go.  Creedmoor moved him to its own group home, right here on the hospital grounds—a place where he’d have somewhat more freedom, but still get constant supervision and care.  Once again he did well. But once again—it wouldn’t last.

Winerip: They just had to free up the bed.

Edie Magnus, Dateline correspondent: Why couldn’t he stay there if he did well there?

Winerip: Because there are so few of those supervised beds in the community.

Magnus: But they knew Andrew Goldstein wasn’t any better, right?

Winerip: That’s right…

In fact, the records show Creedmoor knew that Andrew  “did not take medication” when he went home on weekends and that he had “failed several interviews” to live in apartments with less supervision. Nevertheless, after one year in the group home, Goldstein had to go.

Winerip: They pushed him toward something that in New York State is called an “adult home,” which has no supervision at all.

Magnus: So he’s too sick for moderate supervision, so they put him in a home with almost no supervision?

Winerip: Exactly.

By 1996, the year Kendra Webdale began her New York City adventure, Andrew Goldstein was living completely on his own—in a basement apartment in queens.  No counselors or social workers checked up on him.

And in December of 1996, the terrible cycle began. Andrew stopped taking his medicine and he became violent— assaulting a customer in a supermarket—ending up in a hospital psychiatric ward. 

In the next year and a half, Andrew Goldstein wound up in emergency rooms ten more times,  delusional,  and asking for help. He told doctors that the earth was running out of oxygen or that he saw people shrinking and then growing, or that he was the Italian composer Ottorino Respighi.

Sometimes he walked in on his own to the hospital—other times he was brought there by police. He’d attacked a doctor at a clinic, punched a patient in hospital, assaulted customers at a fast food restaurant and a bookstore.  All of the victims were women—in fact notes from one hospital said Andrew was, “concerned about his impulses to hurt women.”

Winerip: He’s constantly attacking strangers. The records actually say that—that he’s lashing out for no reason to people he doesn’t know. 

Repeatedly, doctors noted that Goldstein had stopped taking his medicine.  Repeatedly they noted that he was a danger to himself and others. Repeatedly our investigation found that he asked to live in a group home or psychiatric hospital—someplace he would be watched.

But each time, the hospitals discharged Goldstein after a few days or weeks at most.

Why did the hospitals keep sending such a sick and dangerous man out the door? Our investigation found that sometimes, hospital social workers sometimes tried to find long term care for Goldstein in community—but there were waiting lists—there was no place to put him.

So they sent Goldstein back on the streets with a short supply of medicine and a referral for outpatient therapy.  By law, that’s all they were required to do.

Magnus: Someone who is clearly a danger to others can still be pushed out into the community?

Winerip: Yes.

Magnus: With everybody knowing just how dangerous he is?

Winerip: And well the excuse is, at the time he was discharged he was medically stable.

Magnus: What does that mean? 

Winerip: He was shot full of medication.

And just months before he would meet Kendra Webdale on that subway platform, another attack — this one landed him in Brookdale Hospital.  And, even inside, he was nearly impossible to control.

On the second day of his stay records say he “attacked a nurse and a doctor.” 

Three days later, another note: “patient suddenly lunged from his seat... attacked me, hitting me in the face with both hands.”...

Two weeks after that, it happened again: Goldstein “punched [a woman] in the face, hitting her square between the eyes.”

Winerip: It wasn’t like he was pushing people and the state and the mental health system didn’t know. He was pushing and hurting and attacking psychiatrists and nurses. They knew he was a ticking time bomb.

Again, Goldstein asked to be sent back to Creedmoor.  And it looked promising. But there was a catch—

Winerip: This time Creedmoor says, okay, in principle we will take him. He’s dangerous he’s seriously mentally ill. But we don’t have any room right now. We have a waiting list. We’ll call you when we have room.

That call wouldn’t come soon enough.  After six weeks, Andrew requested to be discharged.  Brookdale could have fought in court to keep him, but it didn’t.  So when the transfer to Creedmoor  came through, he was gone—out living on his own.

Brookdale had gotten him to make what would seem a preposterous promise—that he would, “hit furniture, not a human being, if he feels he can’t return to the ER in time to speak to his therapist.”

Winerip: They send him out into the streets and it starts all over again.

There’s something else you should know about Andrew Goldstein’s stay at Brookdale: He was brought there because he’d attacked a woman on a subway. In just five months, he would be standing on another subway platform, next to Kendra Webdale.

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