The massacres in Newtown, Connecticut, Aurora, Colorado and Tucson have thrust the issue of mental illness into the national spotlight.
Everybody agrees the goal is to identify and treat mentally ill individuals to prevent such tragedies.
But when our courts determine incarceration or commitment is required, the criminally insane and severely mentally ill are confined to the
Arizona State Hospital (ASH).
The facility is supposed to protect the patients as well as the public.
A COMPOUND IN THE HEART OF THE CITY
It sits on 90 acres at 24th and Van Buren streets.
The hospital is surrounded by high walls, some with razor wire and security cameras.
Arizona State Hospital CEO Cory Nelson admits, "Being right here in the middle of Phoenix does create its own set of challenges."
Nelson said, "We have some individuals here on campus who have committed some very serious crimes and we can't take that for granted.
But we also have people here simply because they have a mental illness, so we're trying to do the same thing that Banner, Mayo and
MIHS (Maricopa Integrated Health System) are trying to do—we're trying to help them through their illness until they can recover and lead a quality life."
But the ABC15 Investigators spoke with more than a dozen insiders—current and former staff.
They say there are gaping holes in security and recent changes have made it worse.
One of those insiders told us, "They got rid of a lot of the security force. We worry for the public at that point."
A TRAGEDY RAISES ALARM
Monika Vinquist recalls the day in August 2011, when a police officer came to her home in Lake Havasu.
The mother of five says, "He came to tell me sad news. It was my worst nightmare come true."
The policeman told her an escaped mental patient murdered her daughter, April Mott.
"It's a black cloud that no one deserves," Vinquist said.
In May 2011, Jesus Murrieta, a patient at the hospital, pulled a badge off an employee's neck, got past security, out the door and into the night.
Murrieta had been admitted to the Arizona State Hospital suffering from symptoms of mental illness.
Three months after his escape, Murrieta was arrested for the murder of 32-year-old April Mott.
Mott had been brutally beaten, her body covered in bruises and her throat slit.
Murrieta pled guilty and was sentenced to 22 years in prison.
"The good thing is that I did get to say goodbye and there was closure," said Vinquist, Mott's mother.
PREVENTING FUTURE TRAGEDIES
Cory Nelson was hired to run the hospital in July 2011.
"We've added some more cameras and fencing and every time we identify an area that is a potential risk—we try to remediate that risk immediately."
Nelson points out the hospital took steps to improve security.
But he says with 230 patients; including some who are criminally insane, challenges remain.
"It's a place where anything can happen on any given day," Nelson said.
The ABC15 Investigators dug through thousands of public records, police logs, incident reports and federal inspection documents.
We found 16 escapes in the past three years.
Three of those escapes involved criminally insane patients.
SEE OUR INTERACTIVE GRAPHIC BELOW.
One criminally insane escapee was on the loose for 24 hours after he disappeared while on a field trip at Castles & Coasters where patients were escorted to play miniature golf.
Just last year, another criminally insane patient was caught at a crowded fast food restaurant across the street from the hospital.
A hospital insider told ABC15, "He could have taken somebody hostage. He could have done all sorts of horrific things."
"Any time somebody walks away from this facility, that's a problem. We take those very, very seriously," said Nelson.
But what many insiders told us they find so surprising is that after April Mott's murder, the actual number of security guards at the hospital was cut.
In fact, it was cut by more than half.
The number of security guards went from 110 to 50—that's 60 security guards eliminated after Mott's murder.
When we asked Nelson if he felt that having fewer security guards raises the risk of more escapes he told us, "Absolutely not."
He pointed out the facility is a hospital, not a prison.
And the goal is treatment for the mentally ill, not incarceration.
"What you get when you have a large security department like that is you actually end up with a false sense of security," Nelson said.
"We have worked on filling those 60 positions with staff members who are actually working with the patients."
But our investigation found that has not happened.
Records show there are actually fewer direct care staff now than there were before security was cut.
In Fiscal Year 2012 the hospital had 416 staff members providing direct care to patients.
Today, they have 409.
An insider, whose identity we are protecting for fear of retaliation, told ABC15, "With the lack of security now, I think the level of AWOLS and escapes are going to rise."
The ABC15 Investigators spoke with a number of mental health experts including a former high ranking administrator at the hospital.
They told us a balance is necessary between the number of staff who provide treatment, and enough guards to provide security.
Nelson says the ultimate goal is, "to make sure that we balance the treatment of individuals with the safety of individuals and the safety of the public."
Documents show there have been three escapes since the security changes began.
Insiders say they are frustrated and concerned.
"Everything that was promised, like putting extra techs on the floor, having the nurses more involved, you know, beefing up the campus support (security)—none of that has happened."
Nelson said while the changes he's made have not alleviated the problem, he does not believe they have increased the problem either.
The experts say Nelson's task is not an easy one and it is too soon to tell if his new approach is going to succeed.
Insiders expressed doubts.
They told us they feel the changes have "failed miserably" to enhance security and safety.
When asked whether they were pursuing a lawsuit, Monika Vinquist said, "If I take their money, then how are they going to help the next kid?"