By Cynthia Hubert and Phillip Reese

Six months after he was discharged to a Greyhound bus and shipped out of Las Vegas, one former patient of Nevada's primary hospital for mentally ill people stabbed a man to death in Iowa.

Another former patient, responding to voices in his head, set off explosions in a grocery store and a doughnut shop in Tennessee just a month after Rawson-Neal Psychiatric Hospital in Las Vegas gave him a one-way ticket to Knoxville in July 2012.

Nevada bused yet another Rawson-Neal patient, a convicted child molester, to San Diego in 2011, even as he faced criminal charges in Las Vegas for failing to register as a sex offender. He also failed to register in San Diego, where he disappeared into the streets and soon became the target of a citywide manhunt.

Yet another former Rawson-Neal patient was found dead, his body floating in the American River near a homeless camp, seven months after he received a Greyhound ticket to Sacramento courtesy of the state of Nevada.

Even as Nevada's embattled state mental hospital works to revamp operations, the fallout from its aggressive busing policies continues to resonate from California to Florida. A Sacramento Bee investigation into the fates of hundreds of mentally ill men and women whom the Nevada hospital shipped out of Las Vegas via Greyhound bus in recent years has found that crime and tragedy often followed.

The Bee recently obtained Greyhound bus receipts listing the names of more than 1,000 people who, after arriving at Rawson-Neal, were issued one-way tickets to cities across the country over the past three years. More than 325 of them boarded buses to California.

A check of passenger names against criminal databases found dozens of apparent matches across the state and nation for arrests involving murder, attempted murder, assault, sex crimes, drug crimes, theft, vagrancy, vandalism and other violations in the counties to which they were shipped in the months after they arrived. Many of the crimes involved repeated offenses for minor violations often associated with homelessness.

The names of bus passengers on the list did not include dates of birth or other unique identifiers, which can help establish specific identities. Many of the names were uncommon, indicating a high probability the matches were accurate. But additional information was required to confirm that an individual passenger was the same person later arrested for a crime in the destination city. All of the former Rawson-Neal patients named in this story reflect cases in which identities could be confirmed through interviews with the individuals, their families or, in one case, media reports.

The analysis also found more than 50 matches between names of mental patients bused out of Nevada and suspects facing criminal charges in Las Vegas. In most cases, proceedings in those cases stopped cold and judges issued bench warrants for arrests of these suspects soon after the patients were bused. Without dates of birth, the matches could not be confirmed by name alone. But interviews with patients or their families confirmed that in at least some of those cases, the hospital effectively helped suspects skip town.

In recent months, Nevada Gov. Brian Sandoval has ordered reviews of the state's mental health care system and additional funding for services. But his administration also has defended Rawson-Neal's busing practices as safe and humane. On Friday, in response to The Bee's latest findings, Sandoval said he is "appalled."

"An investigation is underway, and those responsible will be held accountable," Sandoval said through his spokeswoman, Mary-Sarah Kinner. "This type of conduct is indefensible."

Kinner said Sandoval is assembling a panel of legislators, law enforcement officials and mental health experts to investigate "mental health services throughout the state," including those provided by Rawson-Neal.

It has been nine months since The Bee first reported Rawson-Neal's unusual busing program, which sent about 1,500 mental patients to cities across the lower 48 states between July 2008 and April of this year. Patients typically were dispatched by taxi to a Las Vegas Greyhound station and put on buses, alone and sometimes heavily medicated, for journeys that in many cases spanned multiple states and several days.

Nevada health authorities revised the protocols in April, saying they no longer would bus patients across state lines without chaperones. But state officials have generally defended the decades-old program, contending the vast majority of patients were bused to their "home communities" and only after Rawson-Neal staff had contacted family at the destination and made arrangements for treatment and care.

Former patients and their families have told a different story, asserting that the hospital made no such arrangements, and in some cases shipped former patients off to cities where they had tenuous ties, or none at all. Many of those interviewed ended up on the streets, at public hospitals or in shelters, which essentially shifted the burden of their care from Nevada to their destination cities.

In some cases, the program came at broader public expense: The hospital exported not only mentally ill people and the costs of their care, but criminal conduct as well.

'I hope he's dead'

Consider Mark Hesselgrave's case.

Convicted in 1993 for strangling his wife at their home near Phoenix, Hesselgrave spent about 20 years in prison before making his way to Las Vegas earlier this year. Depressed and unable to find work, he tried to kill himself by stepping in front of a cab, he said in an interview.

That episode got him admitted to Rawson-Neal in Las Vegas Jan. 31 of this year. Hospital records from his stay show Rawson-Neal kept him about two days before putting him on a Greyhound bus back to Phoenix.

The records note that staff members did not contact anyone in Phoenix about his discharge "as the patient did not consent" for them to do so. Hesselgrave said the hospital never asked him about arrangements for treatment or housing. "They didn't even ask me for a phone number. Nobody knew I was going to Arizona," he said.

Rawson-Neal was aware Hesselgrave had been released from prison just three months before on a second-degree murder conviction, the records show. The patient "feels depressed most of the time," the records note, but "endorses no homicidal thoughts. No evidence of psychosis, although he does report occasional feelings of paranoia, especially during times when he takes drugs."

On Feb. 2, two days after he was admitted, Rawson-Neal deemed Hesselgrave fit for bus travel, the records state, and discharged him with a bus ticket, psychiatric medications for the ride and a recommendation to seek out Narcotics Anonymous meetings in Phoenix.

After a bus ride that he described as "crazy," Hesselgrave said he arrived at the Phoenix terminal with no one waiting for him. Without money or a place to live, he said, he ended up walking about 20 miles to a friend's house in the suburbs.

From Arizona, Hesselgrave migrated to North Dakota to pursue a job in the oil fields. He quickly found work. Things were going pretty well, he said, until May 12, when he stabbed his roommate repeatedly. Eddie Bergeson survived, but suffered stab wounds in his face, stomach and back, according to a police affidavit.

"I hope he's dead, I think he's dead, I'm glad he's dead," Hesselgrave said as he stood over Bergeson, according to the affidavit.

Hesselgrave remains jailed in North Dakota, awaiting trial on charges of attempted murder. Police say he planned the attack;

Hesselgrave contends they were drinking and got in a fight. He said he wonders whether things would have turned out differently had he received more treatment after his release from prison.

Rawson-Neal "didn't try to treat me or nothing," he said. "They could have kept me for 21 days. They could have ... got my depression in check."

A free ride

Joseph Ceretti is another former Rawson-Neal patient now facing a lengthy prison sentence.

Unlike Hesselgrave, Ceretti had lived on and off in Las Vegas for years, splitting time between Nevada and Des Moines, Iowa, where he had family. He had a criminal history in both places, and had been arrested repeatedly for crimes related to drugs and assault.

"I was a violent guy," he said in an interview from Polk County jail in Iowa.

Ceretti said he had been to Rawson-Neal multiple times over the years, often after feeling suicidal. He has been diagnosed, he said, with schizoaffective disorder, depression and anxiety.

"They warehoused you," he said. "They haven't done nothing for me."

On May 21, 2012, he landed at Rawson-Neal after another breakdown.

Ceretti's medical records state that he told staff he was depressed, anxious and suicidal. "He is a known patient at this hospital with several previous admissions and most recent about six weeks ago," the records state.

The intake records also show the hospital was aware he had a lengthy criminal record, including a history of assaults. Ceretti said he knew from other patients that the hospital would hand out bus tickets without asking too many questions. He said he told them about having family in Des Moines. "I wanted a free ride," he said.

The medical records note that Ceretti had requested a bus ticket "back home," and that during two days of care, he showed "No aggression or Manic outbursts. ... " He was discharged May 23, 2012, with a bus ticket to Des Moines, psychiatric meds and a recommendation to continue getting mental health treatment in Iowa. The medical records say that Ceretti's mother, Diane Mazzie, had agreed to pick him up when he got to Des Moines.

But Mazzie said she had no notice he was coming. "I never got a phone call," she said in an interview.

She said she was staying at a friend's house when her son arrived, and was unable to offer him a place to stay. "I was on the streets," Ceretti said. "I slept outside for a week."

A month after he arrived, Ceretti was arrested for trespassing. Two months later, he was arrested on suspicion of domestic abuse causing serious injury, and later pleaded guilty to that charge.

In November 2012, while still homeless, Ceretti stabbed an old friend, Eric Naylor, killing him. Police describe the attack as a drug encounter gone bad. Ceretti called it self-defense. He pleaded guilty to voluntary manslaughter and was sentenced to 45 years in prison.

"I would just like to say to the family I'm really sorry," he said at his sentencing hearing.

Ceretti later tried to take back his plea, saying he had failed to disclose he was on psychotropic medications when he agreed to the deal. He was charged with perjury, and pleaded guilty. He remains in an Iowa prison.

Homeless in Vegas

The Nevada hospital issued a bus ticket to another patient, Justin David Brinsky, even as he was still under court supervision for battery and disorderly conduct convictions in Las Vegas. Brinsky was bused to Sacramento in June 2012, and now sits in the Sacramento County Main Jail, awaiting trial on two charges of attempted robbery.

Brinsky said in a jailhouse interview that he has been diagnosed with bipolar disorder and disabling "manic" episodes and depression. He said he became homeless in Vegas after traveling there to live with a family friend, and was arrested for stealing food from a supermarket. First he went to jail, he said, then to Rawson-Neal.

Brinsky could not recall how long he stayed at the hospital, but said that at some point, he was offered a bus ticket to Sacramento, where he has relatives. "They asked me where I wanted to get sent, and I was fine with it," he said. "There are some good people there. It's not a bad hospital."

In the months since he arrived in Sacramento, he has been arrested for a variety of serious crimes, including accusations of fighting with a police officer and trying to break into the home of a young mother in the middle of the night while under the influence of methamphetamines. At the county jail, he has spent weeks in isolation for attempting to assault both inmates and officers, according to court records.

When a reporter, separated from Brinsky by a Plexiglas barrier, asked for further information about his experience, Brinsky dropped to his knees and clasped his hands as if in prayer.

Then he waved goodbye.

A body in the river

Martin Roller may have simply given up on life after the Las Vegas hospital bused him back to Sacramento in July 2010, said his former wife, Patricia.

When he returned to the capital city, where he and Patricia once lived together, the couple were estranged, she said. She had minimal contact with him. Seven months after his bus trip, he was dead.

Roller was a drug abuser, may have had bipolar disorder and had attempted suicide at least once while he was living in Las Vegas, his former wife said. She found out about his hospitalization and subsequent bus trip only after he returned to Sacramento, she said.

In the months after he arrived in Sacramento, Roller was arrested for alleged battery on a police officer and resisting arrest.

On Feb. 9, 2011, Roller's body was discovered in the American River near a transient camp. A coroner's report said he likely drowned and that no evidence of drugs was discovered in his system. Because of his history, the report did not rule out the possibility that he took his own life.

"He may have tried to kill himself," his former wife said. "I guess we will never know."

A manhunt in San Diego

Trouble also followed Christopher Dustrude, a Montana native who records indicate was bused from Las Vegas to San Diego in 2011. In 2004, Dustrude was convicted of sexually assaulting two family members, then 7 and 9, in Montana. In 2010, he was rearrested for failing to notify Montana authorities he had moved. He also had been convicted twice for violating protective orders, court records show.

While awaiting sentencing on those charges, Dustrude headed to Las Vegas, where police arrested him in January 2011 for failing to register as a sex offender. That criminal case was still outstanding when, for reasons that are not clear, he wound up at Rawson-Neal. Patient busing receipts show the hospital bought a Christopher Dustrude a seat on a Greyhound bus bound for San Diego on Jan. 26.

Within days, a federal magistrate issued a warrant for his arrest, and the U.S. Marshals Service initiated a manhunt in San Diego. Law enforcement authorities said in media reports at the time that Dustrude would sometimes pretend to be mentally disabled or suicidal to gain entry to hospitals and shelters, where he would then volunteer to work with children.

Marshals finally tracked him down in early February at a San Diego psychiatric hospital. Authorities said they had gotten complaints from families in the area, who said Dustrude had made sexual advances toward them and their children.

An aunt, who described Dustrude as mentally disabled and childlike, said he since has disappeared onto the streets of Montana. Dorothea Butler said her nephew had no ties to San Diego, and that she had no idea why the hospital might have sent him there.

"He needs to be in an institution of some kind. But he just gets tossed around," she said.

"I can't understand why that hospital would send him to San Diego. They just put him on a bus and sent him on. They just wanted to get rid of him."

'A wing and a prayer'

Marc Berrier is among several former Rawson-Neal patients who went from being homeless in Las Vegas to homeless somewhere else after the hospital bused them out. Berrier, a native of Pennsylvania with an alcohol addiction, said he faked a mental illness to get off the streets of Vegas in the spring of 2012. "I told them I was suicidal," he said.

Once he landed at the Nevada state hospital, he received psychiatric medications and enjoyed "a nice break from the streets," he said. "I sat around and watched TV, mostly," he said.

A fellow patient told him that the hospital "will give you a bus ticket to anywhere you want to go," he said. Berrier looked at a map and decided "on a whim" to ask for a bus ticket to Seattle.

"They asked me to verify that I had relatives there, so I wrote down a fake phone number and said I had an uncle there," Berrier said. "They brought me a ticket to Seattle that night."

"I didn't know anything about Seattle," he said. "I left wearing shorts and a T-shirt, with four bottles of Ensure, on a wing and a prayer." He took Xanax with some young bus passengers near Portland, he recalled. "That's the last thing I remember about the trip." He said he woke up at Harborview Medical Center, a public hospital in King County.

Weeks later, King County officers arrested him for assault after he refused to cooperate when they asked him to refrain from drinking alcohol in a public park, records show.

Berrier now lives at a homeless mission in Seattle and is working to overcome his alcoholism and improve his life. "I've experienced a long, strange series of events to get here," he said.

Hospital staffers may unwittingly have helped him, he said, by busing him to Seattle, where the mission is helping him get back on track. But he wonders about other patients.

"I'm glad everything worked out for me," Berrier said. "But there were a lot of guys in there who weren't getting any help. I wonder what's happened to them."

'The client makes the choice'

Whether Rawson-Neal has any responsibility for what happens after patients leave their facility is a matter of debate. Psychiatric hospitals, including Rawson-Neal, are not required to check the criminal backgrounds of patients, and rarely conduct such checks, according to interviews with mental health experts.

Kathleen Piche, a spokeswoman for the Los Angeles County Department of Mental Health, said her agency might request a background check on a patient who caretakers are aware "has been involved in some kind of violence." But such cases are unusual, she said.

Agencies should not "assume that someone might have a criminal record because they are being treated for a mental illness," said David Wert, a spokesman for San Bernardino County. He said the county does not routinely conduct criminal background checks on mental patients.

But neither do most agencies routinely place mentally ill patients alone on public buses for long trips across the country, as Rawson-Neal did until recently.

"Certainly the hospital has a moral responsibility" to do everything possible to make sure that patients who board buses, as well as the passengers around them, are safe during their journeys, said DJ Jaffe, executive director of the Mental Illness Policy Organization. "And what about the impact on taxpayers in the states where these untreated patients are going? That is going to be considerable."

In recent months, Nevada health officials have explained the busing program by noting that Las Vegas is an international destination. They say many visitors and transplants who suffer mental breakdowns welcome the offer of free travel vouchers to return to a community where they have a stronger support system.

"The general purpose of the policy has always been to help people with transportation back to their home community, or community of choice, where they have family, employment and/or mental health support," Mary Woods, a spokeswoman for the Nevada Department of Health and Human Services, said in a written response.

"Transportation vouchers provided may or may not be used by a client," Woods said. "The client makes the choice to take the bus trip they requested."

Woods also noted that the state has launched multiple internal reviews and has revamped policies and procedures at Rawson-Neal since The Bee first reported on the busing policy.

"Those investigations resulted in termination of staff, strengthening of policies, and implementation of corrective action plans including increased scrutiny and oversight in our discharge practices, as well as the requirement for an accompanied chaperone," Woods said.

"We take all allegations of improper treatment or discharge very seriously," she said, "and will further evaluate if additional policies, procedures and/or laws need to be revised or created." Woods said the hospital does not routinely do criminal background checks on patients, but will notify a law enforcement agency about a pending discharge if that agency has requested such information.

But Nevada state health officials have also acknowledged that they do not routinely follow up to see what happens to patients after they are bused to other cities or whether they arrived safely.

Busing patients out of town without properly treating their illness and arranging for future care is a prescription for disaster on many levels, said Dr. Jeffrey Geller, director of public sector psychiatry at the University of Massachusetts Medical School.

"Increased incidence of petty crime and serious crime," Geller said, listing the possible consequences to the communities that receive mental patients who are unmoored to family and services.

"New jail and hospital occupants. Burdens to general hospital emergency departments, courts, sanitation departments and mayor's office," he said. For the patients, "there is further estrangement from any natural supports that might exist, and an increasing sense in the individual with mental illness of being unwanted and unworthy."

Jaffe said he suspects Nevada's busing policy was motivated by finances, not treatment protocol. Between 2009 and 2012, as Rawson-Neal bused patients out of state at a steadily increasing rate, Nevada cut spending on mental health services by 28 percent to address state budget shortfalls.

"When they bus someone out of state, it's one less person that they need to care for," Jaffe said. "Any time the mental health system turns someone over to the criminal justice system, it's a victory for them" financially, Jaffe said.

Nevada officials, acknowledging that budget cuts have taken a toll, have targeted $30 million in additional funding for state mental health services, boosting outpatient programs aimed at treating mentally ill people in the community and steering them away from emergency rooms.

The state is remodeling a closed building on Rawson-Neal's campus that will serve as a satellite facility to Lake's Crossing in Reno, the state's only mental hospital for criminals. Rawson-Neal has been given additional state funding, and is poised to hire more staff.

In addition, the state has increased the number of beds available for inpatient care; established jail re-entry programs; and introduced home visiting programs for mentally ill patients, their families and the community.

"The Legislature and the governor have responded," said Clark County Public Defender Christy Craig, who has represented mentally ill people charged with crimes.

"The effects locally have been akin to an atomic bomb going off," she said of the national media attention over the busing policy. "We have been asking for some of these things for 20 years, and shining a light on the issue worked. It really worked."

Sheila Leslie, a former Nevada state senator who coordinates Washoe County's mental health and other specialty courts, remains skeptical. Leslie said the actions taken so far are not enough to repair a broken mental health system that has been ravaged by budget cuts during the past nine years.

"The whole situation has been a great wake-up call to state staff, legislators and the governor," she said. But, she added "clearly, it's not enough."

Nevada's support system for mentally ill people, including housing and outpatient treatment centers for those released from the state hospital, remains dangerously frayed, she said. As a result, Leslie said, Rawson-Neal continues to be a revolving door for patients unable to get meaningful help to turn around their lives.

"We're failing ourselves," said Leslie.

Nevada continues to grapple on several fronts with the consequences of its controversial busing policy. In July, following an investigation by the Joint Commission, Rawson-Neal lost its coveted accreditation. It remains under investigation by the U.S. Centers for Medicare and Medicaid Services, which has threatened to pull the hospital's Medicare funding.

In September, San Francisco City Attorney Dennis Herrera filed a lawsuit seeking class-action status against Nevada, accusing its leaders of essentially outsourcing mental patients to other states to avoid having to pay for their treatment and housing. The suit demands reimbursement for the public costs San Francisco and other California cities have incurred in caring for Rawson-Neal patients transported to their communities without arranging for services.

Sacramento attorney Mark Merin also has filed suit, accusing the hospital of violating the constitutional rights of indigent patients.

Herrera said Nevada must be held accountable for what happened to the patients under its care and the communities that received them. "In my opinion, they certainly are responsible morally for their failure to look after very vulnerable patients who they knew were unable to take care of themselves," Herrera said. "Then they tried to shift the financial burden to other jurisdictions. It's a terrible thing on two levels."

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