To Janet Woodson’s alarm, her grown son was unraveling again, a year after he had been diagnosed with schizophrenia. Maurice Louis, 29, was drinking heavily and not taking his meds.

On a Monday night, Oct. 28, she persuaded him to accompany her to Mercy Fitzgerald hospital in Darby Borough, three miles from their West Philadelphia home. But there, according to hospital records obtained by The Inquirer, Louis said he was mentally sound, had no suicidal urges, and didn’t want to talk to a psychiatrist.

The hospital sent him and Woodson on their way. The next day, Louis bought a shotgun and killed his 51-year-old mother, her husband, and his two half-brothers, police say. Officers say they found him inside the home naked and holding a bottle of vodka. Messages in the family’s blood were on the walls. He is now facing four murder charges.

Some experts say the tragedy was unavoidable — and perhaps a reflection of state laws that limit the ability of parents to commit troubled children without their consent. Still, internal hospital documents and interviews with experts raise questions about how the hospital responded to the mother’s bid for help.

“The system failed my family,” said Valerie Pini, Woodson’s sister, following a Thursday night vigil outside Woodson’s house. “If they had done their job appropriately, I believe my sister, my brother in law, and my nephews would still be here today."

The hospital, while saying it could not discuss a specific incident, said “every patient” is evaluated upon arrival. But records say staff at the hospital’s crisis center spoke with Louis only briefly, and the on-call psychiatrist did not evaluate him before saying, “He can go.”

Louis’ short visit to the facility also shone new light on the troubled history of Mercy Catholic Medical Center’s crisis center on the Mercy Fitzgerald Campus. State officials revealed Friday that the center flunked its fifth consecutive inspection in August, prompting the hospital to abandon a protracted appeal and announce plans to close it in early 2020.

After the Oct. 29 tragedy, the hospital accelerated its schedule. It closed the crisis center, which provided immediate and short-term psychological care, a day after a team from the state Department of Human Services visited, seeking information about how it had handled the visit by the mother and son.

Bernadine Mills, lifelong friend of Janet Woodson, embraces Woodson's sister, Kia Smith, during a Thursday vigil for the family who died in the quadruple homicide.
ELIZABETH ROBERTSON / Staff Photographer
Bernadine Mills, lifelong friend of Janet Woodson, embraces Woodson's sister, Kia Smith, during a Thursday vigil for the family who died in the quadruple homicide.

The deaths stirred anew a long-running debate among mental-health experts about whether Pennsylvania should join other states in relaxing strict rules dictating the commitment of mentally troubled people. State law generally limits involuntary commitment to when a person is a “clear and present danger” to themselves or others.

D.J. Jaffe, executive director of the Mental Heath Policy Organization, a New York City-based research and advocacy group, said mass shootings involving seriously mentally ill people “follow the same patterns.”

“All these cases involve adults," Jaffe said. “They are known to the mental-health system. And they are allowed to go untreated. In this case, we had a heroic mother who tried to do the right thing. Here’s a mother who did everything to get help and was turned away.”

Janet Woodson (fourth from left) and her family had returned to West Philadelphia from a trip to Walt Disney World on Oct. 13. Two weeks later, the unthinkable happened: Woodson's son Maurice Louis allegedly shot and killed Woodson; her sons Sy-eed Woodson (second from left) and Leslie Woodson-Holmes (second from right); and Leslie Holmes, her husband (far right).
Courtesy Kia Smith
Janet Woodson (fourth from left) and her family had returned to West Philadelphia from a trip to Walt Disney World on Oct. 13. Two weeks later, the unthinkable happened: Woodson's son Maurice Louis allegedly shot and killed Woodson; her sons Sy-eed Woodson (second from left) and Leslie Woodson-Holmes (second from right); and Leslie Holmes, her husband (far right).

‘There is no documentation of his arrival or evaluation’

After earning a degree in Japanese studies from Towson University in Maryland, Louis began behaving strangely and using drugs. In June 2018, his family had him voluntarily committed to a crisis response center in West Philadelphia operated by Mercy Catholic Medical Center. He stayed eight days and left with a diagnosis of schizophrenia.

On Oct. 28, Woodson and her son chose not to return to the West Philadelphia crisis center, a half-mile from their home in the Cedar Park neighborhood, driving instead more than three miles to the center on Lansdowne Avenue in Delaware County.

Maurice Louis, 29, is charged with four counts of murder in the shooting deaths of his mother, stepfather, and two brothers.
Philadelphia Police Department
Maurice Louis, 29, is charged with four counts of murder in the shooting deaths of his mother, stepfather, and two brothers.

At 10:18 p.m., they entered the large brick facility through the emergency department.

Louis “denied any mental health issues and denied suicidal thoughts or intent,” Roger McBride, the hospital’s director of behavior health, wrote to executives in an email obtained by The Inquirer. McBride declined further comment Friday.

In a statement Friday, hospital spokesperson Ann D’Antonio would only talk in general terms about policy. She said emergency patients “exhibiting behavioral health symptoms receive a mental health evaluation in the ED.” When discharged from emergency, she said, they are sometimes referred to the crisis center.

After their stop in the emergency room, Woodson and Louis were escorted by a technician through hospital corridors to the crisis center, a four-room wing typically staffed with only one intake worker, one nurse, and a psychiatrist on call.

At the crisis center, Louis “did not want to be seen" and “stated nicely, ‘I don’t want to talk to anybody. I just want to go,’" said one nurse, according to the internal records.

“It’s his right not to be seen, as a voluntary patient," the nurse added.

Mercy Fitzgerald Hospital's Crisis Intervention Center in Darby.
STEVEN M. FALK / Staff Photographer
Mercy Fitzgerald Hospital's Crisis Intervention Center in Darby.

The crisis center did not fully record his visit to the facility.

“There is no documentation of his arrival or evaluation" in the crisis center, director McBride wrote in the email to executives.

The records establish that psychiatrist Waqar Rizvi was in the center when Louis arrived, but a nurse responded "no” when asked if Rizvi had seen Louis, and added, “He did not evaluate him.” Rizvi could not be reached for comment.

The records do say that a nurse pulled Louis’ chart from the ER for Rizvi, who then said Louis could leave.

At the same time, the intake worker who registers patients into the center stepped away to assist police with a patient bleeding from a head wound, the records show. By the time she finished treating that patient, Louis was gone. Rizvi had approved his release without Louis being formally registered, the records say.

Woodson could have sought to have her son involuntarily committed. But state law requires that the subjects of such orders pose a threat. Moreover, she would have had to find a psychiatrist to affirm her request.

Less than 24 hours later, police say, Louis killed Woodson; her husband, Leslie Holmes, 56; and her 7- and 18-year-old sons, Leslie Jr. and Sy-eed.

Louis is being held without bail. His lawyer, W. Fred Harrison Jr., could not be reached for comment.

On Friday, Jack Rozel, a psychiatrist who directs the crisis intervention network in Pittsburgh, said that generally, people who do not want to be committed pose difficult issues for crisis centers.

“If they are there voluntarily, there’s nothing you can do,” said Rozel, president of the American Association for Emergency Psychiatry.

Nor must every walk-in be seen by a psychiatrist, Rozel said, even “someone with schizophrenia.”

Janet Woodson, left, with her sisters Kia Smith (middle) and Valerie Pini.
Courtesy of Kia Smith
Janet Woodson, left, with her sisters Kia Smith (middle) and Valerie Pini.

A center marred by failures

The center failed four consecutive inspections between 2016 and 2017, with regulators repeatedly citing the facility for mishandling case records, inaccurately documenting patient care, and not providing crisis counseling.

As a result, the Department of Human Services did not renew the center’s license in June 2018. The hospital filed an appeal the next month. That kept the center open for 17 more months.

State officials conducted a surprise inspection on Aug. 5 and “found continued noncompliance as well as failure to comply with previous Plans of Correction,” said a DHS spokesperson. The center planned to close in early 2020.

On Monday, one week after Woodson and Louis visited the hospital, DHS officials went to Mercy Fitzgerald again — and concluded that the center was still not meeting state guidelines. The hospital closed it at 5 p.m. Tuesday.

“Regrettably ... we continue to fall short of necessary requirements to operate the center and our high standard of care,” hospital president Chris Cullom wrote in a staff memo obtained by The Inquirer. “As a result, we have voluntarily relinquished our license...."

Sue Walthers, executive director of the Mental Health Association in Pennsylvania, questioned why the state had permitted the center to remain open despite so many failed inspections.

“I’m not clear why they were allowed to operate,” she said. “That’s frustrating.”

To critics, the deaths reflect problems in Pennsylvania law regarding mental health. They say the law places too much emphasis on someone having to be a “clear and present danger” to themselves or others to receive inpatient care.

“Laws should prevent danger and not require it,” said Jaffe.

John Snook, executive director of the Treatment Advocacy Center, an Arlington, Va., nonprofit that works for effective treatment of people with serious mental illnesses, said some people can mislead health professionals. “Oftentimes, someone who’s sick can hold it together for someone who is a treatment professional" during a brief screening, he said.

Philadelphia Police Chaplain Floyd Steadly, 18th District Victim Assistance Officer Sharone Johnson, and relatives and friends stand during a vigil for the West Philadelphia family killed in a quadruple shooting.
ELIZABETH ROBERTSON / Staff Photographer
Philadelphia Police Chaplain Floyd Steadly, 18th District Victim Assistance Officer Sharone Johnson, and relatives and friends stand during a vigil for the West Philadelphia family killed in a quadruple shooting.

For Woodson’s relatives, grief has only deepened since the shootings.

A week after the gunfire, Woodson’s uncle opened her purse, left behind in the family house. In it he found an admission slip from Mercy Fitzgerald. This was the first they knew that she had sought help there.

Homicide detectives apparently did not discover the note in her purse or learn of the hospital visit. The Police Department declined comment.

After the family’s vigil Thursday, Bernadine Mills, Woodson’s godsister and neighbor, recalled asking her, after seeing Louis’ increasingly strange behavior, if she was going to get her son admitted again.

“Poo,” Woodson replied, using Mills’ pet name, “I’m working on it. I’m working on it.”

Bernadine Mills, 67, sits on her porch outside of her home on the 5000 block of Walton Avenue, where a family was killed in a quadruple shooting.
HEATHER KHALIFA / Staff Photographer
Bernadine Mills, 67, sits on her porch outside of her home on the 5000 block of Walton Avenue, where a family was killed in a quadruple shooting.