Before Carlton McPherson was accused of fatally shoving a stranger in front of a subway train last week, he was placed by New York City into specialized homeless shelters meant to help people with severe mental illness.

But at one shelter, in Brooklyn, he became erratic and attacked a security guard. At another, he jumped on tables and would cycle between anger and ecstasy. At a third, his fellow residents said it was clear his psychological issues were not being addressed.

“That man needed help,” said Roe Dewayne, who stayed with Mr. McPherson at a mental health shelter in the Bronx. “If they were monitoring him like they were supposed to, this wouldn’t be going on.”

As New York has struggled to provide services for homeless mentally ill people across the city, its mental health shelters were supposed to help fill a crucial need, with on-call psychiatrists and social workers on staff to ensure that the thousands of people like Mr. McPherson were connected to treatment, and did not harm themselves or someone else.

The reality has been different, a New York Times examination of the shelters has found. Based on city records and interviews with shelter workers, residents and their family members, the review showed that mental health services have been offered only sporadically across the 38 specialized facilities, which were operated by city contractors at a cost of about $260 million a year. Episodes of violence, disorder and preventable harm, meanwhile, have become commonplace.

Fifty people died in the mental health shelters during a recent four-year period, records show. About half of those deaths occurred after suspected drug overdoses, when staff members found the bodies of men and women slumped on bathroom floors, next to empty pill bottles or in bed with foam coming out of their mouths. Eight people staying in the shelters killed themselves.

More than 1,400 fights broke out during the same span, with more than half of those resulting in “serious injury.” At a shelter in Queens, a woman threatened her roommate with a Swiss Army knife before hurling a nail-studded two-by-four at a facility glass front door, records show. Another woman at the shelter tried to suffocate her roommate with a plastic bag.

The mental health shelters were also the scene of more than 40 fires — half of which appeared to have been set deliberately. On at least 344 occasions, the facilities lost heat, water or power for four hours or longer, The Times found.

Although the first mental health shelters opened decades ago, the city has dramatically expanded their reach in recent years, steadily adding funding and creating beds for about 5,500 people.

A spokeswoman for the Department of Homeless Services, which oversees the city’s shelters, said the agency is required to provide shelter to all those who need it. She said it does its best to connect people to mental health services but added that it is primarily focused on providing emergency housing, not psychiatric care.

“Ensuring the health and safety of our clients is a top priority,” said the spokeswoman, Neha Sharma.

She said that the psychiatric services at the shelters are strictly voluntary, and that the agency cannot force people in the shelters to attend appointments or take medication. But the city has worked to improve safety at the shelters by training staff on how to reverse overdoses, prevent suicide and link the neediest clients to more intensive psychiatric services.

The city homeless shelter system is just one part of a broader safety net that has often given way in recent years while straining to meet a soaring need. Hospitals across New York have often discharged people in the midst of mental health crises while they were still unstable. Specialized treatment teams, which cater to some of the most volatile and difficult to treat patients, have long waiting lists, and they rely on underpaid, undertrained and overwhelmed workers who have sometimes failed to respond to signs that a person was unraveling.

The shelters have often become a place of last resort for thousands of profoundly ill people. Still, their failures help explain how people like Mr. McPherson can become dangerously unstable despite being flagged for extra care.

In operating the shelters, the city too often “kicks the proverbial can down the road,” said Mary Brosnahan, who spent 30 years leading the Coalition for the Homeless, a New York advocacy and service organization.

“It’s all about just trying to not have these catastrophic incidents,” Ms. Brosnahan said. “They are investing our tax dollars in a model that you just know is not going to give people what they need at the end of that day, and we all pay the price for that.”

On Monday evening, Mr. McPherson was on a subway platform in Manhattan at East 125th Street and Lexington Avenue when he approached another man and shoved him in front of an oncoming train, the police said.

The man, Jason Volz, 54, was crushed to death. Mr. McPherson, 24, was charged with murder.

Afterward, Mayor Eric Adams announced that the city would soon begin hiring clinicians to deploy teams of mental health workers in the subway system in an effort to keep riders safe. Mr. Adams has made addressing the city’s mental health crisis a priority since the second week of his administration, when a mentally ill homeless man shoved Michelle Go, a financial consultant, in front of a subway train in Times Square, killing her.

“People need the help that they deserve, and we are focused on doing that with the entire team that we have in place,” Mr. Adams said on Thursday. “It plays on the psyche of New Yorkers when someone is pushed to the tracks or someone shoots a gun in the subway system.”

Mr. McPherson had long struggled with mental illness, said his mother, Octavia Scouras. She tried her best to help him, but once he became an adult, she said, “no one was willing to continue to invest in him.” He spiraled out of control.

He moved in with his grandmother in the Bronx for a time, but a neighbor described seeing him sleeping in a hallway closet in the building after his grandmother began refusing to let him into her apartment. He became homeless and was sent to a mental health shelter in a rundown brick building in the Bedford-Stuyvesant neighborhood in Brooklyn in 2023, according to court records and interviews with shelter staff members.

At the shelter, Mr. McPherson often greeted staff members with a smile and small talk. But one day in October, he grew agitated in the cafeteria and hurled a drink at the kitchen workers. When a security guard tried to calm him, Mr. McPherson, who had recently suffered a leg injury, used a cane he was walking with to strike the guard several times in the face, bloodying his eye.

Mr. McPherson was arrested and charged with assault and menacing, but the guard, Stephen Olowogboye, said he declined to cooperate with prosecutors because he knew that Mr. McPherson was struggling with mental health issues. He thought the younger man needed support, not jail.

“He wasn’t in his right state of mind,” Mr. Olowogboye said. “I thought, what if that was my younger brother, what would I do? I felt pity for him.”

After the assault, Mr. McPherson was transferred from the Brooklyn shelter and eventually landed at a mental health shelter in the Bronx, according to interviews with residents and his family.

The shelter, housed in an imposing brick building on Jerome Avenue and operated by a nonprofit group called BronxWorks, has been the scene of violence and disorder in recent years, records and interviews show. At least nine residents of the shelter have died since 2018, and there were reports of more than 60 fights and 62 life-threatening injuries and hospitalizations.

One man staying at the shelter followed a staffer onto a nearby subway train and masturbated in the seat across from her, records show. In another instance, a man clutching a large kitchen knife walked into the lobby and tried to lure a shelter officer outside to fight.

“Being in places like here, they really don’t help out,” said Mr. Dewayne, 60, the Jerome Avenue resident who said he met Mr. McPherson there. “Everyone in this building is suffering and hurting.”

At the Jerome Avenue shelter, Mr. McPherson mostly kept to himself and did not act out, but it was clear he was struggling, according to two residents who remembered him. He confided in his mother that he was scared and did not know what to do, she said.

“That shelter was the last place a person like Carlton needed to be,” said Ms. Scouras, who said she had worked at the Jerome Avenue site years before her son was sent there — and had witnessed the rampant drug abuse and violence.

“It’s extremely dangerous and deadly,” she said. “You would be terrified to go to sleep, let alone use the restroom.”

Residents were crammed into communal dormitories — as many as 20 to a room — and often had little privacy, current and former employees said. By midmorning, they were expected to leave the building, with instructions to return at a set time each evening. Those who missed the curfew risked losing their bed for the night and were often transferred to another shelter.

The workers there tried their best to support the residents, but resources were limited, said Andrea Kepler, who joined BronxWorks in 2016 and briefly served as the program director at the Jerome Avenue shelter. Psychiatrists were on call to do telehealth appointments, she said, but often the residents needed more intensive care than the shelter could provide. She described frequently sending people in the throes of crisis to nearby hospitals only to see them be released hours later with few supports.

“It was heartbreaking to see people struggling,” Ms. Kepler said. “It was a very challenging environment.”

Scott Auwarter, the assistant executive director at BronxWorks, said the shelter was doing as best it could to service a population with complex needs.

“We get some of the toughest cases in the system,” he said, adding that staff had connected more than 100 residents to permanent supportive housing. “We try to go above and try to be as sensible as possible. But we are on the record as saying the system really needs lots of thought and change.”

Widespread problems

In many ways, the Jerome Avenue site was typical of mental health shelters across the city.

Every year, the city collects data on how many deaths, injuries, assaults and other so-called “priority 1” incidents occur inside its homeless shelters. The Times obtained and analyzed those records for mental health shelters from 2018 to 2021 and found that more than 7,400 serious incidents were reported during that time.

There were at least 604 accidents “leading to life-threatening injury” among shelter residents, the records show.

More than 40 rapes, attempted rapes or sexual assaults were reported to have occurred inside the shelters, along with 140 thefts and 283 instances of “criminal activity in or around the facility by residents that threatens the safety of the community as a whole.”

Behind the numbers were searing snapshots of individual suffering.

One man living in a Brooklyn shelter hanged himself with a bedsheet. Another leaped off the Brooklyn Bridge. A woman at a Bronx mental health shelter told staff she was hearing voices in the days before she jumped to her death in front of a subway train in 2020, records show.

At a mental health shelter along Ralph Avenue in Brooklyn in 2022, a man with bipolar disorder made a noose with a bedsheet and tried to hang himself from a toilet stall, declaring that he was “Jesus Christ, and I have to die for y’all.” When the shelter’s workers tried to help him, he ran out of the bathroom, threw a garbage bin at the workers and was eventually taken to a hospital.

At the same facility a few weeks later, a man smashed some windows, took up a piece of broken glass and threatened to use it to slit his throat.

In interviews, five people who have worked at the shelters said the city’s system was ill-equipped to handle the complex needs of the mentally ill. Rather than recognizing the violent outbursts as untreated symptoms of a psychiatric problem, and connecting these people to more intensive care and supportive housing, some officials take an easier path, the people said.

They simply move the sickest patients from one shelter to the next — further destabilizing those who need stability and increasing the likelihood of a breakdown.

Liset Cruz and Hurubie Meko contributed reporting. Susan C. Beachy contributed research.