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BOISE — Ruben Diaz didn’t know the man raking leaves on a cloudy, early November morning in Boise.

Nevertheless, Diaz approached the stranger, asked for directions, then began stabbing him in the face, hands and neck, police say. The gashes were so deep that the 74-year-old’s facial nerve was severed, affecting his ability to move the right side of his face, according to a GoFundMe page created by his son.

Diaz admitted to police that he had purchased a knife the morning of the attack “for the sole purpose of trying to kill someone,” prosecutors say.

Diaz, 36, has been charged with attempted murder. A judge on Wednesday determined his current mental state makes him unfit to stand trial.

In the years leading up to the stabbing, a pattern for Diaz’s behavior had already emerged.

Diaz, who was diagnosed with schizophrenia and autism sometime before 2008, would stop taking his medication and threaten people with violence or attack them, according to court records. He told a state parole commission that, when unmedicated, he could lapse into delusions that other people were aliens.

The state released him in July to an unsecured group home, with orders to take his meds, and it and relied on its staff and Diaz’s health care providers to make sure he was taking his medication.

That may not have happened.

“Due to health-privacy concerns, it would be inappropriate for me to discuss matters pertaining to any offender’s medication regimen,” IDOC spokesman Jeff Ray said when asked if Diaz was taking prescribed medication.

The parole commission executive director says Diaz’s story illuminates the “holes in the system.”

The state knew Diaz was dangerous when unmedicated. He knew it, too. He wanted to stay healthy, and his early release from prison required it — as do countless other parole contracts. But the system in place to make sure he was getting the treatment he needed may have failed, in a state where access to mental health care is among the worst in the nation. And the secure housing that state officials believe may have helped doesn’t exist in Idaho.

“The person off his meds is a very dangerous person,” his mother told the Idaho Pardons and Parole Commission in a hearing. “But on his meds, he is a good, kind person.”

‘Public safety is a concern’

Ruben Diaz didn’t know the man who was taking a walk on a spring afternoon in 2006 in Idaho Falls, either. But Diaz came up behind the man and began stabbing him with a kitchen knife.

That was the first time Diaz was charged with a violent crime: almost 13 years ago. He hadn’t been taking his medications because he “thought they had some bad effects” on him, he later told the parole commission.

The second time, in September 2007, he attacked his roommate with a three-and-a-half-foot sword and cut off the man’s fingers. Diaz had forgotten to take his meds, he said.

“He was drugged and thought they were aliens,” parole hearing records state. “He wasn’t on his mental health medications like he was supposed to be at the time.”

His parole hearing records catalog more incidents:

  • May 2008: “The offender said he was off his meds,” the hearing record says. “He guesses he was delusional, because he started thinking people were aliens.”
  • July 2013: “Subject was threatening to hit another [inmate].”
  • August 2013: “Subject threatened to chop off another [inmate’s] head.”

And there were others.

When he was properly medicated, he felt good, Diaz told the commission in January 2010. On his meds, he didn’t hear voices or hallucinate and wasn’t afraid people were evil aliens, he said.

“The commission noted that subject is mentally ill and that he is very dangerous when he does not take his meds and advised his mother that he needs to remain compliant on his medications,” hearing records from 2010 state.

“Public safety is a concern,” the commission determined after another hearing, five years later.

Diaz told the parole commission in 2010 that he wanted to live in a “group home” if he was paroled because he believed that would keep him on his medication. The commissioners agreed.

One of many with mental illness

Research shows that people with mental illness are more often victims of violence than perpetrators of it.

However, some people with untreated mental illness can lose touch with reality and become violent — they believe they’re defending themselves from a threat or they believe God or another entity is telling them to fight, among other reasons.

Diaz’s case is an extreme example of that.

But his parole hearing records also show one thing that happens to many people with a chronic mental illness: They stop taking their medication.

The reasons vary. Some people experience unpleasant side effects to the medications, they think they’re cured, they can’t afford the drugs or they simply forget to take them. That’s one reason why some people get drugs for schizophrenia administered through a long-acting shot. It is unclear from the records whether Diaz was given or offered such injections while he was on parole.

“He suffers from an inability to communicate appropriately, an inability to handle financial transactions, and suffers a lack of reasoning skills,” according to a 2008 petition from his mother to be his court-ordered guardian and conservator.

One commissioner told Diaz that staying on his meds would “probably be his biggest issue” and that he would “probably be okay if he does that.”

His mother said during a hearing that she thought he needed to go to a hospital.

Diaz’s parents told the state parole commission that they believed their son should return to society, but that he needed treatment. His father told the commission how Diaz loved animals. They wondered if he might volunteer or work at a veterinary hospital someday.

Efforts by the Idaho Statesman to contact Diaz’s family via phone and email have been unsuccessful. A message left Dec. 5 for Diaz’s mother’s former attorney was not returned.

Calls made to the victim’s son by the Statesman were also not returned.

Who makes sure parolees take meds?

The Idaho Commission of Pardons and Parole is responsible for setting the parameters around an offender’s release from prison. The parole officer, who is employed by the Idaho Department of Correction, is responsible for enforcing those parameters. Parole officers handle each case differently, based on the risks and needs of the newly released offender.

The commission granted Diaz parole in January 2017. Diaz “showed no delusions, ideations, etc., and is stable at this time,” according to hearing records.

But while he was waiting to be released, he was written up for destroying another inmate’s property in August 2017, again delaying his release from prison.

He again went before the parole commission in April 2018 and was granted release. He left the prison in July and moved into the Hancock House — becoming one of 620 parolees in Idaho who, between September 2017 and September 2018, had an order to take prescribed medication.

In that time, the commission made 2,158 rulings on parolees — about 28 percent of those decisions included mandating that medications be taken.

The mandates are not just to protect the public. When untreated, a person with mental illness is more likely to be victimized.

“This role of treatment adherence is strongly supported by [a 2002 North Carolina study] that found individuals with severe mental illness participating in court-ordered outpatient treatment — and thereby taking medication as prescribed — were victimized half as often as those who were not on assisted outpatient treatment,” says the Treatment Advocacy Center.

Did Diaz fall through the cracks?

But in Idaho, no single person is tasked with checking on medication compliance for Idaho’s parolees.

Instead, it’s part of everyone’s job to keep track of a parolee’s mental health. There’s the parole officer, employed by IDOC. There’s often a caseworker, and a doctor or nurse practitioner who prescribes their medications. There may be a psychosocial rehabilitation worker, employed by a private social-service agency.

And if they live in a group home, there’s the facility staff.

“Folks did a lot of things right,” said Steve Allen, senior policy advisor at the Council of State Governments Justice Center. Allen is an expert in behavioral health care for people in the criminal justice system.

What went right: Diaz had insight about his condition and was willing to take medication, the criminal justice officials put in place measures for him to take it, and there were people assigned to help and monitor him.

But as to what went wrong in Diaz’s case, Allen said, he would look for missed warning signs. “What about the ... treatment team, what was their role in this?” he said. “How frequently were they meeting with the person? How carefully were they observing them?”

The workers at the state-licensed facilities aren’t required to have medical training, Idaho Department of Health and Welfare spokeswoman Niki Forbing-Orr said. Facilities such as the Hancock House are only required to have a registered nurse visit once every 90 days. Staff at the assisted living facility cannot prescribe medications, but distribute and “observe” residents taking them.

The owner of Hancock House said his employees are trained to work with people who have mental illnesses and with parolees. He said staff watch the residents take their medications, and people can be kicked out for not taking them.

“It’s relatively rare that people will ‘cheek’ them or throw them up,” said Chris Moore, who owns Hancock House and a few other assisted living homes. “But they do have a right to refuse their meds. Everyone does. It’s not jail. We are not the jail. We’re held to residents rights pretty strictly by the state, making sure we’re not imprisoning anyone or creating an environment where they’re being treated like they are in jail.”

In 2014, the facility was written up for not watching each patient take their medications, according to inspection records.

Moore said the company holds regular in-services to refresh employees’ training on medications.

“It’s easy to get casual when you don’t have any issues. And my [residents] usually don’t have issues,” he said.

Why not test?

The Idaho Department of Correction’s parole officers routinely order parolees be tested for illicit drugs or alcohol. But it does not routinely test to make sure they’re taking prescribed medication, or enough of it.

“Why would they if there’s not a problem?” Moore said.

David Birch, chief of probation and parole for IDOC, said his staff can’t require a parolee to do medication-compliance testing “if it’s not specifically called out in a court order or in their parole contract.”

Sandy Jones, executive director for the Pardons and Parole Commission, said testing for prescribed medication would be up to a medical provider. It’s not the parole officer’s job, she said.

Jones and Birch didn’t specify what would bar medication testing but allow drug and alcohol testing to be a condition of parole.

“If you’re taking medication that needs monitoring, based on your blood levels, your provider is going to do that,” Jones said. “All the PO is going to know is are you taking them or not, based on what the provider tells them.”

Birch said parole officers can look at prescription bottles and count how many pills remain, or query the Idaho Board of Pharmacy to check on whether they’re getting refills.

Diaz’s parole officer “was making collateral contacts with the case manager, as well as the staff at the house where he was living, to verify he was taking the prescribed medications,” according to Jeff Ray, IDOC spokesman. “Any testing conducted by IDOC would have been focused on illegal substances and not prescribed medications.”

A blood test at a local hospital to check that a person has an effective level of antipsychotics in their system costs anywhere from $10 to $125, before insurance. Such blood tests can be used in other ways, like in clinical studies where researchers need to check whether people are taking their medication.

Other states might perform blood tests to check on medication compliance, in some cases.

Florida and Pennsylvania, where someone can be found not guilty for reason of insanity, can include the tests as a condition of an acquitted person’s release.

But Allen noted some reasons why blood testing may not be done. “Any time you are sticking a needle in someone, it’s pretty intrusive, and there’s a lot of rights issues attached to that,” he said.

Moore believes Diaz was given his meds, but he argues that medication alone isn’t a solution and can become ineffective or less effective for a variety of reasons.

Living at Hancock House

Diaz was released and moved in July to a four-bedroom 1970s ranch house in a Southeast Boise neighborhood. Hancock House is one of several state-licensed assisted living facilities owned by Moore’s CTM Assisted Living, whose specialty is helping people with mental illness to live on their own.

Here’s what Hancock House is not: a halfway house, a sober house, a nursing home or a medical facility.

The home’s assistant manager told the Statesman shortly after the stabbing that nine people were living at Hancock House. There were no major problems with Diaz, who the manager said was quiet and got along with the other residents.

“Everyone here is in a state of shock,” the assistant manager told the Statesman last month. “It was completely out of character from everything we’ve seen.”

Moore, the home’s owner, said this is the first incident of its kind in the 22 years he’s been in the assisted-living business. He could think of only two other violent incidents when residents fought with each other.

Jones said when the state parole commission uses the term “assisted living,” it’s not necessarily the definition the Idaho Department of Health and Welfare uses for licensed facilities. It means the commission wanted “a residential program that can assist him with his medication management needs, and provide additional oversight,” Jones said.

The IDOC case manager made arrangements from there.

A review of 911 calls made from Hancock House found two troubling incidents during the four months Diaz lived there.

Someone called to report that a patient, who wasn’t Diaz, had knives in his room, and she wanted “police to know in case he used them in a crime,” according to dispatch logs from the Ada County Sheriff’s Office. Another call made from Hancock House in September reported an unidentified patient had left the facility with an “altered mental status” and they needed help searching the area.

An ideal solution? It doesn’t exist in Idaho

Jones said a structured mental health facility would be preferred to the options currently available for offenders like Diaz. But she doesn’t know of any facilities like that here.

“He’s defined the holes in the system” for housing people with serious mental illnesses and violent histories, she said.

Sometimes long, indeterminate sentences become life sentences for inmates who can’t be placed in the community, she said. The state cannot force an assisted living facility to take a parolee, making it a challenge to find a place for them to live. It’s even harder to find housing for those with a history of violence or sex offenses, she said.

“Everybody can’t go to the state hospital,” she said.

When choosing whether to release someone with a serious mental health problem and violent tendencies, the commission also must consider how the parolee will pay for their medications.

“The worry is, once the meds run out, where will they get them and how will they pay for them?” Jones said. “If I have to choose between putting food on the table and buying my meds, that’s a tough call. ... Do they want to hold someone in prison because they can’t afford the meds? That’s not right, either. So, it’s a difficult, tricky situation.”

Birch said the Idaho Legislature in the 2017 session gave the Idaho Department of Health and Welfare a budget for just that purpose. It took a while to implement, he said, but now parolees can get their prescriptions from one of dozens of clinics around the state. Locally, they’d go to Terry Reilly Health Services.

IDOC spokesman Jeff Ray said the department does have a “serious incident review“ underway to learn more about what happened with Diaz, something it does whenever a parolee is accused of a parole major violation. The review is meant to answer several questions, including whether IDOC could have done anything to prevent the attack, or whether the department might be able to prevent future incidents like it.

Awaiting trial

Diaz has been in custody at the Ada County Jail with bond set at $1 million. His next court appearance was set for January, but a judge on Wednesday ordered him to undergo psychiatric treatment. His mental state at this point makes him unfit for trial, the judge said.

Diaz “lacks capacity to make informed decisions about treatment” and “presents a substantial risk of physical harm to other persons,” District Judge Jonathan Medema said.

Moore said the violence not only shocked the public. It also scared the people who lived with Diaz at Hancock House.

And it could have a ripple effect on future parolees. It’s making Moore rethink being one of few places in Boise where parolees with severe mental illness can live.

“We’re going to have to reassess how we take people from the prison after this incident,” he told the Statesman.

That’s not something he ever wanted to consider, because people with mental illness already face challenges, he said.

“Mental illness is just like every other disease. We don’t shun people with cancer or Parkinson’s,” he said. “We treat poorly people who are struggling with a very difficult illness.”

It doesn’t help that mental health care in Idaho is so hard to get, even for people like Diaz who have a team assigned to them. Just getting patients to their appointments is a struggle when they can’t count on Medicaid transportation services, Moore said.

With more resources, he said, “things like the Ruben incident wouldn’t happen — not because of meds, but because he would have better therapy and support and someone to reach out to and talk to instead of lashing out.”

When those who knew Diaz heard about what happened that morning in November, it was hard to believe, Moore said.

Diaz would have walked about six blocks from Hancock House to the 74-year-old man’s yard last month. When police arrived, they found Diaz still attacking the man, they said. Two officers took him down with stun guns because he wouldn’t put down the knife, they said.

“He’d been a model person ... easygoing and friendly and nice ... but something happened,” he said.

“If we could have prevented it, we would have, obviously.”

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