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Fatal stabbing of a 3-year-old raises questions about Ohio's mental health safety net

A hospital bed is seen inside MetroHealth's main campus emergency department in October 2023.
Ryan Loew
Ideastream Public Media
A hospital bed inside MetroHealth's main campus emergency department in October 2023.

About three months before Bionca Ellis was arrested and charged with randomly stabbing a mother and her 3-year-old child in a Giant Eagle parking lot in North Olmsted, killing the child, Cleveland police were called to the women’s shelter in Downtown Cleveland.

On that day in February, Ellis confessed to a murder in California, according to the police report.

“The staff at the shelter state that Bionca registered at the shelter a few days ago and has laid in bed for approximately 3 days until she got up today,” the responding officer wrote in a report. “When she awoke, she demanded the staff call 911 so she can confess to a murder.”

Officers found no evidence tying Ellis to a murder in Bakersfield, California, though, according to the police report, she did have arrest warrants there. Then she told officers that if she wasn’t taken to jail, she would murder someone at the shelter. And that she wanted to eat human flesh.

Officers brought Ellis to MetroHealth, Cuyahoga County’s safety net hospital, where the report states she became irate, fought with staff and had to be sedated.

About three months later, Ellis would be charged in connection with the boy's death outside the North Olmstead supermarket. The circumstances preceding the killing have raised questions about whether Ellis had “fallen through the cracks” of the mental health system.

How does the system treat people in crisis who could be a danger to themselves or others?

The responding officer “pink slipped” Ellis.

“Pink slip” is a shorthand term for the process of involuntarily hospitalizing someone in a mental health crisis because they are a “substantial risk of physical harm” to themselves or others.

It is called “pink slip” because the application forms for “emergency admission” used to be pink.

It’s not clear how long Ellis stayed at the hospital. Details about her medical treatment are confidential. The doctors and other experts interviewed for this story did not treat her, but they did discuss generally how the system works.

Police and medical providers say they face serious ethical and legal considerations when deciding whether to hospitalize people against their will who may pose a risk to others.

Health care providers should use the process of involuntary hospitalization cautiously and the vast majority of people with mental health diagnoses should never be "pink slipped,” according Ben Schwan, a Case Western Reserve University bioethics professor.

“It would be unreasonable to lock that person away forever or for the rest of their lives for the mere reason that they might be off of their meds and start doing these types of things again,” Schwan said.

According to state law, a doctor must do a mental health assessment within 24 hours of a patient's arrival at the hospital. And then, if needed, the hospital files for a court order for involuntary hospitalization within 72 hours.

But the high bar that the medical community uses for involuntary hospitalization has led to some frustration among Cleveland police.

In a 2020 survey on crisis intervention, several officers said pink slips have little effect and hospitals don’t listen to officers.

“It’s not a practical reality,” wrote one anonymous officer. “At any given time there are 100’s maybe 1000’s of people in this city who could be pink-slipped. And what can be done to help them anyway? Take them to the hospital where they are strapped down, forcibly medicated, released, and repeat?”

Other officers also wrote they bring the same people over and over to hospitals, and they are released within hours.

“I read that survey and it broke my heart because officers should never feel as though their input is invalidated,” said Katie Jenkins, executive director of the National Alliance on Mental Illness’ Cleveland office.

Jenkins has worked at Northcoast Behavioral Healthcare, the state psychiatric hospital for the Cleveland area, and said the police report on Bionca Ellis’ encounter with officers in February reads more like someone who is delusional, not psychotic.

Whatever happened while Ellis was at MetroHealth, Jenkins said it’s very unlikely Ellis was just sent back out after a few hours.

“People aren't just being bounced on the street after four hours, which I know that perception happens,” Jenkins said. “But there is a lot of work that happens while that person's in the emergency department if they're not going inpatient.”

How do doctors decide?

The mental health system has never been built up enough to have cracks for someone like Ellis to fall through, said Jenkins. What exists, she said, is already fragmented — police officers, hospitals and social workers each just get about 40 minutes with a patient.

“And so they get that snapshot. And then that snapshot that a police officer may have can be completely different from the snapshot that the hospital has,” Jenkins said. “It really just depends on who that individual is interacting with.”

Sometimes the mental health assessment that doctors do at the hospital is very different from what officers observe on the street, said Dr. Leslie Koblentz, the chief clinical officer with the Alcohol, Drug Addiction and Mental Health Services Board of Cuyahoga County, the board that oversees public spending on addiction and mental health services.

"People can calm down,” Koblentz said. “Maybe you realize they haven't been able to get to an appointment that day for a sick child, or they had to do this and they don't know how to do it, or they have to get to that.”

The hospital, just like a family member or anyone else, could file an affidavit arguing for involuntary hospitalization with Cuyahoga County Probate Court.

“We don’t do something because someone demands to us we do it, if they don’t meet the criteria,” said Magistrate John Spiccia, who oversees the court’s psychiatric docket. “You’re affecting someone’s life in a very negative way when you make someone go to the hospital and they don’t want to go.”

Spiccia has been the magistrate in charge of the docket that considers requests for involuntary hospitalization for the past seven years.

There are strict time limits for hearings for people being held at a hospital — within five days. The person being held is represented by an attorney. The doctor requesting hospitalization also testifies.

“You can look at it as a mini trial,” Spiccia said. “I think it's a little bit unfair to say... that people slip through the cracks because we send people to the hospital all the time. And when they're discharged from the hospital, they're given follow up. And you can only do so much to get people to help themselves.”

The order for involuntary hospitalization from the court only lasts for 90 days but, according to Spiccia, people rarely stay for more than a week or two.

“There’s a distinct lack of psychiatric hospital beds in the county,” said Spiccia.

Why psychiatric hospital beds are in such short supply

If MetroHealth doctors had decided back in February that Ellis couldn’t be released back onto the streets, it may have been challenging to find a spot for her in a state psychiatric hospital.

A recent report from the think tank Policy Matters Ohio found that between 2019 and 2023, involuntary commitments at the state’s six psychiatric hospitals dropped by two-thirds.

That’s in part because more than 90% of the beds at those hospitals were taken by people sent by a judge for a psychiatric evaluation before trial, not for treatment before entering the criminal justice system, the report says.

The report’s author, Kathryn Poe, spent six months researching the topic and is still unclear on where people in Ohio go for involuntary hospitalization after they’ve been “pink-slipped.”

“What happens to folks? Do they get released? Are they stuck in an emergency room?” Poe said. “I've heard variations of all of these situations throughout covering this issue. But it just really seems like the question of where people are going, we genuinely don't know.”

Ideastream Public Media reached out to alcohol, drug addiction and mental health boards in several counties to ask for how many emergency admissions cases they’ve handled during the past several years and any information they have on the outcomes of these cases. None of the boards provided that information.

Poe said the state could begin addressing this issue by investing more in behavioral health crisis centers throughout Ohio and by getting more of these services covered by Medicaid.

Editor’s Note: 988 offers 24/7 judgment-free support for mental health, substance use, and more. Text, call, or chat 988.

The American Psychological Association says that violence is relatively uncommon among those with serious mental illness, but that when it does happen it’s often also intertwined with other issues like substance use and adverse childhood experiences.

Matthew Richmond is a reporter/producer focused on criminal justice issues at Ideastream Public Media.