GILBERT, Ariz. — It’s a complex that spans a few blocks, right on the edge of downtown Phoenix. Most people probably wouldn’t recognize it if they were driving or walking by. From the street, you can see stone and brick buildings and layers of barbed wire encasing parts of the facility. Sometimes, you can catch glimpses of people in bright orange sweatsuits walking laps around the yard or doing pushups.
This looks and probably sounds like a prison, but this is different.
It’s the Arizona State Hospital, or ASH as some people call it. It is a complex place where people can be placed for mental health treatment. It doesn’t take in just anybody. There’s a facility for sexually violent people. Then there’s the civil hospital where adults can be court-ordered for treatment if they’re deemed dangerous to themselves or others. There’s also a forensic hospital for certain people who have been involved in the criminal justice system. These people could be awaiting trial, or they could be sentenced to the state hospital for treatment after committing a violent crime, like Christopher Lambeth.
RELATED: Locked Inside: How an Arizona law allowed a man who killed his grandparents to not go to jail
In Locked Inside episode 2: Guilty Except Insane, the 12 News I-Team uncovered that Christopher Lambeth was sentenced 25 to life at the state hospital for treatment, where he was placed under the jurisdiction of the Psychiatric Security Review Board, after he killed his grandparents.
Psychiatric Security Review Board
The Psychiatric Security Review Board, or PSRB, monitors all people who have been deemed guilty except insane. It’s the Board’s decision to determine whether those people stay locked inside the state hospital or whether they’re well enough to be released into the community.
If someone has completed serving their sentence, the Board decides if that person needs more services when they’re let out of the hospital.
The Board typically meets once a month to discuss and make decisions on various cases. There aren’t many visitors at these meetings. Mostly, it’s just attorneys representing people deemed guilty except insane or hospital staff members that can weigh in on a case. And in the age of COVID-19, some of these people just join the Board’s video call instead. It’s not common for members of the public to just drop in.
The stated goal of this law is for people who are deemed guilty except insane to get the help they need at the state hospital and get to a point of stable remission so they can potentially go back into the community.
The Board is tasked with balancing the goal of treating people until they’re in remission, and keeping the public safe from individuals convicted of violent crimes.
Only three states in the nation use psychiatric security review boards: Oregon, Connecticut and Arizona. In Arizona, it manages a very small part of the criminal justice system.
The latest available data from 2020 shows there are 113 people deemed guilty except insane under the PSRB’s jurisdiction. To put that in context, there are more than 33,000 people incarcerated in Arizona prisons at the time of this publication, meaning the 113 convicted people under the Board’s watch represent a very small fraction of people convicted of crimes.
Most patients deemed guilty except insane go before the Board every two years for a status update, where the Board determines if that person should receive privileges on the hospital grounds or eventually be released back into the community. Board meetings are usually when these check-ins happen unless the Board needs to intervene in a case for some other reason.
Until recently, the Board had five members. Three of them were mental health professionals, one worked in probation and parole and the other was a community member. Each board member is appointed by the Governor of Arizona. The Board doesn’t have any oversight, so whatever these five people decide goes.
The people that are guilty except insane are convicted killers or other violent offenders with serious mental health concerns, who at one point posed such a threat to the community that they had to be sentenced to treatment.
The decision to let these people live in the community again should be taken seriously.
“I was shocked to hear that he was let out of the state mental hospital from covering the double murder of his grandparents,” said Sheryl Kornman, the former Tucson Citizen reporter who weighed in on Locked Inside episode 2.
Kornman is talking about Christopher Lambeth who was sentenced to 25 to life at the state hospital for killing his grandparents. Instead, after nine years in the state hospital, he got out, and started living in the community again. Records indicate he’d been living in a group home for a few years before he was arrested and accused of killing Steven Howells at Tilda Manor in April 2021.
“In talking to the friends of the grandparents and the deputies who handled the case, this is a guy that probably needed to be hospitalized for the rest of his life,” Kornman recalled. “Because of his mental illness, he couldn't be trusted to take his own medication. He needed to be supervised 24/7.”
Kornman wrote multiple reports on Christopher Lambeth and the aftermath of his grandparents’ deaths. She had no idea he’d been arrested and charged with murder again or that he’d even been released from the Arizona State Hospital until 12 News reached out to her last summer.
“It doesn't sound like they've dug very deep,” Kornman said, referring to the state’s Psychiatric Security Review Board. “And it also sounds like they ignored the brutality of the murder of his own grandparents, who had been taking care of him almost full time for a couple of years before he killed them. So, I think there was a lack of not understanding of how sick he was, but I think the state board dropped the ball.”
'He takes care of himself completely.'
Christopher Lambeth’s 25 to life sentence to the Arizona State Hospital meant that the PSRB had to approve his every move for the rest of his life, unless he petitioned against that after 25 years.
He was first sentenced to treatment in 2007 and had his first hearing in front of the PSRB in 2009. At that point, the Board ruled he wasn’t well enough for any privileges at the hospital.
By 2010, meeting minutes show that that changed. At that point, Lambeth was granted more freedoms on hospital grounds and could eventually get passes to go off hospital grounds for things like a family visit or a doctor’s appointment.
It stayed this way until the end of 2016 when meeting minutes show Christopher Lambeth was approved to live in the community, meaning he no longer had to live at the state hospital, even though he was still under the PSRB’s watch. His release required 24/7 supervision at a residential facility and required he stick to all of his medications and an outpatient treatment plan.
Christopher Lambeth's conditional release letter:
It seemed that first he was released to the Tucson area and at some point later he was moved to Tilda Manor, although the minutes don’t say exactly when he moved into the Gilbert group home.
In September 2017 he went before the Board again, about nine months after he’d been approved to live in the community.
In audio recorded from that meeting, the Chair of the Board explained why Lambeth was there. Lambeth’s treatment team was asking for less supervision, based on all the success he’d been having in his 24/7 setting. Christopher Lambeth’s sister declined to talk with 12 News about her brother, but she did speak out at that September 2017 PSRB hearing on her brother’s behalf.
She told the Board that “his progress has just been phenomenal,” and that “he takes care of himself completely.”
The audio from the meeting detailed that Christopher Lambeth had a job at an Amazon warehouse in Phoenix and that he played ice hockey on a rec team at a rink in Tempe. His attorney told the Board that he could go to a baseball game with Christopher Lambeth or eat lunch with him.
One Board member asked if there were any concerns for his overnight behavior if he were to be in a place with less supervision. His treatment team told the Board they had no concerns that Lambeth would act out with less supervision and ultimately the Board approved him to move to a flex-care facility that would have 15-16 hours of supervision each day.
The changes didn’t stop there. In September 2018, just one year later, he was back before the Board again. At that point, he hadn’t moved out of Tilda Manor because there weren’t any beds available at any of the facilities in the area offering less supervision.
Still, his team was asking for independent living. That meant Lambeth would live on his own but should have had services available to him to continue his treatment.
Audio from that September 2018 meeting indicates all but one Board member approved this move. The Board member who opposed was the Board’s Chair, Dr. James Clark. He explained that he’d feel more comfortable if Lambeth moved to a home with less supervision first before living independently. But the Board majority ruled, and Christopher Lambeth was approved to live on his own.
“I don’t know what was going on with that guy,” said attorney Nora Greer, referring to Christopher Lambeth’s fast-tracked approval for independent living.
Greer is a defense attorney who, over the years, said she’s represented dozens of people at the state hospital deemed guilty except insane. She said she filled in one time for Christopher Lambeth’s attorney during a status hearing, but otherwise never represented him. She is familiar with his case and knows how the PSRB operates based on her own clients’ experiences.
“I don't know how he got out,” she explained. “I'm kind of surprised.”
Moving from a place with 24-hour supervision to a place with none could be a challenge for anyone required to go to meetings, appointments and stay compliant with medications.
“There's always a risk,” Greer said. “You can relapse and either, you know, hurt yourself or somebody else. The other thing too is if you're not ready, you can't do what you need to do to be successful.”
Each year the PSRB puts out an annual report showing how many people are under its watch, what crimes they committed and how many people were released that year.
It does not detail things like how many murderers are out on release.
The 12 News I-Team analyzed more than two-thousand pages of PSRB files, focusing on nearly 75 cases of people who were released to the community. Within the past five years, we identified at least 13 murderers out on release to the community before their sentences were up, all while they were still supposed to be under the Board’s watch.
The PSRB 2020 annual report:
That data included Christopher Lambeth’s case. It’s possible there could be more murderers out that the Board is still monitoring, but the Board wouldn’t break down that information for 12 News.
“A lot of them are going to get out of the hospital anyway,” Greer explained. “And they should get started on doing stuff that helps them do better when they're in with the rest of us as opposed to being on a locked ward and bang, you're out the next day. And what's going to happen to you? You don't want to see that with these people.”
Just like the PSRB has the power to release people to the community early, it can also take it back. If a person violates the terms of their release, the Board can bring that person back to the state hospital.
12 News asked the Board how often this happens, but it didn’t provide an answer. Instead, the I-Team tried to analyze the data we got in a records request.
Most of the murderers we identified hadn’t killed again.
However, some of the people on release returned to the state hospital for things like not taking their medicine, using illegal drugs or having contraband in a group home. Some of the minutes don’t say why a person was ordered back to the state hospital.
In some cases, others went on to commit another violent crime after their time at the state hospital was up. So, they were no longer under the Board’s watch, but it makes one wonder whether their treatment at the state hospital was really effective.
12 News covered a sad example six years ago.
'She did not deserve to have this happen to her.'
On July 25, 2015, Phoenix Police responded to a brutal crime scene. A woman had been decapitated and her pet dogs were severely injured.
That woman was Trina Heisch. The only suspect was her husband, Kenneth Wakefield. They took him into custody after he gouged out his left eye and self-amputated his arm. He was taken to the hospital before he was taken to jail.
In an interview with Trina’s mother and daughter in 2015, they told 12 News there were warning signs.
The couple had only been there together for 3 months, according to neighbors, who said they often heard yelling and fighting. Police said they responded to the home 5 times before this deadly call and said Wakefield also had a history with drugs. But that morning nothing stopped him from killing Trina.
“There was something really severely wrong with him,” Trina’s mother told 12 News in the days after the murder. “She was going to leave him. She didn’t have time for that.”
Trina Heisch and Kenneth Wakefield met at the Arizona State Hospital.
Both had tried to kill a family member and both were found guilty except insane and both were under the watch of the PSRB, according to the Board’s records.
Trina got out first in 2010 after finishing her sentence at the state hospital. Wakefield’s sentence was up at the end of 2014, but he got at least two chances to go out and live in the community on conditional release before that.
Both times, the PSRB revoked his privilege and brought him back into the state hospital, according to minute entries. The public records don’t say what happened, just that he violated his release orders.
The last time he lost this privilege seemed to be just a few weeks before his sentence ended. He was getting out whether he still needed mental health treatment or not.
“I was never afraid of him,” Trina’s mother said in that 2015 interview. “Except this last time he got out of the hospital. And it wasn’t him. It was totally strange because he wasn’t the same.”
When Wakefield was released, PSRB records show the board wanted him to continue getting treatment, including ongoing supervision. The PSRB asked the Maricopa County Attorney’s Office to start that process, but that didn’t happen and it’s not clear why.
“I questioned whether or not he was released with the right supports and what he needed to be successful,” attorney Nora Greer said.
Greer said she actually represented Trina Heisch while she was sentenced to the state hospital. Greer remembered Trina was artistic and could do really nice water colors.
“And certainly she did not deserve to have this happen to her,” Greer said. “I felt really bad. You feel sad about this, about this stuff happening. It should not happen. But it does.”
Wakefield was charged with second-degree murder and animal cruelty for killing his wife Trina and hurting their two dogs. He wailed during his first court appearance, where he stood in front of a judge with an eye patch and bandaging where he cut off his arm. Listening in, one can’t help but think about his mental health history.
This time he was sentenced to nearly 30 years in prison, not the state hospital. Right now, he’s still serving that sentence. His rap sheet shows he’s been in trouble while in prison with recent infractions for fighting and aggravated assault on a staff member.
'That’s their worst nightmare.'
It’s worth noting that some people don’t have problems when they’re back in the community. After reviewing dozens of cases, the I-Team found that a lot of people try sticking with their treatment plans, showing it’s possible to remain in stable remission.
Sometimes there are tears of joy when people deemed guilty except insane were approved for another level of freedom. Family members sit in on Board meetings and show their support. Attorney Nora Greer’s seen success, too.
She recalled one Pima County client in particular whose Board term ended last year. She said he’s been staying sober, living with his family and running his own business.
“I've worked with clients who've done really well,” Greer said. “You know, they did everything the Board asked them to do, but there aren't a whole lot of those people.”
These changes can also go wrong, which is why each Board decision matters so much.
“Human behavior itself sometimes is not that predictable,” Greer said. “Sometimes people do behave in surprising ways.”
The Board can’t predict the future. But were members doing everything they could to at least come close?
Because the Board was created by a state law, the closest thing it has to oversight is the state legislature, which could change the law and therefore impact the Board.
“I think the Board members do good work, make reasoned decisions, and are very careful to make sure the public is kept safe and protected,” said the Board’s Chairman, Dr. James Clark, in a November 2019 state Senate hearing.
The state Senate was trying to determine what to do with the Board after a state audit in 2018 found the Board was making decisions with inconsistent data, like mental health reports lacking “sufficient details.”
Because of this, the audit claimed it was hard for the Board to make timely and consistent decisions.
The PSRB 2018 state audit:
The Auditor General laid out suggestions on what the Board could fix like creating a set of rules, policies and procedures to follow, and requesting help to publish hearing and decision orders to reduce errors.
The Board claimed it did fix the problems and the state Senate approved the Board to run for another 8 years.
The PSRB declined to talk with 12 News about the Christopher Lambeth case or any follow-up questions.
“What's happened is that they let somebody out, he wasn't properly supervised, and he went out and (allegedly) committed a homicide,” Greer surmised. “You know, to them, that's their worst nightmare.”
A reminder that Christopher Lambeth is facing a murder charge in the death of Steven Howells. He pleaded not guilty to the group home killing and is awaiting trial.
Life doesn’t always mean life
It’s not just people deemed guilty except insane who have to face the PSRB.
Janine Rodriguez has seen firsthand how the Board operates—and it’s not because she wants to. Back in 2010, she said spent the holidays with her family, including her 34-year-old brother Adam Cooley. It was a cheerful time, like the holidays should be. Until her brother went to work the night of December 26th.
Cooley worked security at a strip club in Phoenix.He just switched to man the front door that night when police say a guy inside the club walked outside, beelined to his car, pulled out a gun and started shooting. The shooter hit four people, killing two, including Adam Cooley.
“I don't really like to think about that because he was so quiet and the chaos surrounding his death really hurts my heart because he didn't live his life in chaos,” Rodriguez said.
Ever after all these years, it’s hard for Rodriguez to think back to that day. To think about the way her brother’s life was taken and the person who pulled the trigger.
Phoenix Police discovered the shooter was a man named Gavin McFarlane. He had a history of mental illness and reportedly wanted to see if he had what it took to kill people.
The I-Team's investigation into the PSRB and Adam Cooley's murder:
McFarlane pleaded Guilty Except Insane. And like everyone else who takes that plea, McFarlane didn’t go to prison. Instead, he was sentenced to life at Arizona’s state hospital. But life doesn’t always mean life.
Just a few weeks after Christopher Lambeth was arrested and charged with murder at the group home, Gavin McFarlane’s treatment team requested he get passes to go into the community. He’d have to be supervised if he left, but it’s the first step of many before the Board can approve a full release.
Janine Rodriguez and her family stepped up, joining in on the PSRB meeting, expressing their concerns that this killer should not be released under any circumstance.
In audio from that meeting, an attorney with the county echoed the family’s concerns, accusing the state hospital of copying and pasting reports to try and release people.
The shooter’s team tried 6 months before this to get him privileges, but at that point the Board ruled he wasn’t well enough to get out. Yet, his team was making virtually the same case again.
“How is it possible that an individual that committed his offense at the end of 2010 spends 10 years without any improvement, well with limited improvement he had as of last September, and then now all of a sudden is miraculously all better?” the attorney for the county questioned during the meeting. “That is not believable.”
McFarlane’s attorney denied the accusations, saying the reports repeated themselves because things didn’t change meeting to meeting. But to Cooley’s family’s relief, the PSRB voted to deny McFarlane’s conditional release—at least for now.
RELATED: 'Something is Broken': The penal system for those convicted on the grounds of guilty but insane
His team can continue to push for privileges and his victim’s family will have to face this horrible case over and over again.
Christopher Lambeth’s case didn’t have the same kind of intervention.
Lambeth had reservations about living on his own
Christopher Lambeth’s last Board check-in was in August 2020, about 8 months before the group home killing.
Although Christopher Lambeth had been approved for independent living nearly 2 years before, he still hadn’t left the group home Tilda Manor. He was still under around-the-clock supervision and had been since he’d been released from the state hospital more than 3 years before this. His treatment team explained it had been tough to find a place for him to live.
In audio from that August 2020 hearing, one of Lambeth’s treatment team members said Lambeth wanted to stop taking one of his antipsychotic medications, something he’d been taking since at least 2015 when he was at the state hospital. His treatment team member said it was because of the side effects. She goes on to say that the nurse practitioner who prescribes Lambeth his medications was reluctant to take him off and asked the Board to help make a decision.
In Locked Inside episode 2 we revealed that Lambeth told detectives he wasn’t on his medication when he killed his grandparents. Changing his medications seems like it should be a serious conversation.
The Board’s Chair explained that it wasn’t their call to help make that decision because they’re not involved in his care. But another Board member recommended Lambeth not move to another level of care if there is a medication change made “to make sure that medication change does not come with compensation of his current mental status and the fact that he’s quite stable.”
At that point in the meeting, the Board questioned why they approved Lambeth for independent living. One of Lambeth’s treatment team members weighed in again, saying he had reservations about living on his own.
In the 14-minute hearing, no one seemed to ask Lambeth directly what he wanted to do. There was no discussion of any risk assessment. It’s possible there was a recent risk assessment in Lambeth’s confidential files, but 12 News can’t know for sure without the PSRB answering questions.
Attorney Nora Greer retired over the summer in 2021 and had to turn over all her PSRB cases to whoever else would be taking over her contract. When asked if she had faith in the state’s mental health care system, she didn’t hesitate with her answer.
“No,” Greer said. “Of course not. I don’t think it works really well. We don't put the resources where we need them.
“I don't want to say everybody in there is acting in bad faith because I do think there are people in there who care and really want this stuff to work better,” Greer added. “I think a lot of it is resources. We don't put resources towards what we want to do. So, of course, it's not going to work really well.”
And it’s not just the Board facing criticism.
You can catch that part of our investigation in the next chapter of Locked Inside: Sheltered wherever you listen to podcasts starting on May 3, 2022.
Anyone working with or representing Tilda Manor declined to talk with 12 News at this point in our story. Christopher Lambeth’s sister declined to talk with us for this series. Christopher Lambeth’s attorney at the time of this recording did not respond to our requests for comment. The PSRB declined to comment.
Locked Inside Podcast: Tilda Manor coverage
Locked Inside, a new 12-News I-Team and VAULT Studios podcast, follows the harrowing and heartbreaking story of Christopher Lambeth and those who crossed his path along the way.