Woman’s suicide after repeated 911 calls reveals gaps in one city's pioneering crisis response system

Editor’s note: This story contains descriptions of suicide. If you or someone you know is struggling or in crisis, help is available. Call or text 988 or chat at 988lifeline.org.

At first, the police officer stepping into Pamela Antoni’s empty one-bedroom apartment observed nothing out of the ordinary. The air was cool and smelled fresh. Clothes hung in the shower and a packed bag sat on the floor by the bed. 

But Officer Jonathon Fetherolf, an officer in training in Bend, Oregon, also noted the shattered toilet tank lid in the bathroom and the shards of broken beer bottles littering the floor around the couch and coffee table. Walking out the back door, his eyes followed a trickle of white-brown liquid that ran from an empty pint glass across the balcony to the opposite corner. 

Antoni’s body was still there, hanging from the railing. She was 49 years old.

Two stories below, a group of residents who had found their neighbor dead 15 minutes earlier was gathered on the street. Paramedics had blocked traffic with cones and vehicles. Just an hour of daylight filled the sky: It was 6:30 a.m. on June 4.

This was far from the first time Bend police had responded to Antoni’s apartment in the Eddy, a complex billed on its website as “The perfect home in the perfect neighborhood.” But the packed bag, spilled drink and smashed glass didn’t shed much light on how the tragedy unfolded—because the most glaring clues that Antoni had been teetering on the precipice of suicide were not inside her apartment. 

They were in the nine 911 calls she had made over the last six months asking for help with paranoid fears and, once, threatening explicitly to kill herself. They were in the reports from friends and neighbors who received alarming text messages and menacing letters, and who had heard screaming and glass breaking late at night. They were in the door knocks, voicemails and texts from police and the county’s crisis response team, staffed with trained mental health clinicians, who combined had contacted her at least four times before. 

But when Antoni turned them away, they left her alone. Her neighbors, who witnessed her decline in real time, had gone from apprehensive to outraged.

“Every day, I was like ‘What’s going to happen?’” said Ellen Yater, who said she still struggles with the memory of seeing Antoni. “No one did anything to help her.”

Bend, a growing, increasingly progressive city known for beer, bike trails and some of the best weather in Oregon, is also seen as a leader in crisis resources for mental illness. Behavioral health authorities and advocates applaud Deschutes County for investing in innovative strategies to serve people experiencing mental health crises. Oregon’s triad goal at the heart of its crisis behavioral health strategy—“Someone to call, someone to respond, and somewhere to go”—is considered fully realized in that part of the state.

Yet Antoni’s death shines a light on the weak points that persist even within a cutting-edge crisis response system. Her story highlights the ways that isolated people and those who are reluctant to engage with services remain vulnerable. Because increased funding and more sophisticated training have not eliminated a profound quandary that first responders face: At what point is it right to force someone who might harm themselves to receive help? 

In Antoni’s case, the failure to prevent her death is partially bound up in how Oregon’s laws limit crisis workers and police officers’ ability to do that. But it is also the consequence of what some called missed opportunities by first responders to dig deeper into her struggles in order to stabilize her. Antoni’s battles with paranoia and suicidal ideation were evident as she called, then hung up on 911 dispatchers, told crisis workers she didn’t trust them and kept her door closed when police officers knocked. But when she called for help on the last night of her life, no one followed up with her.

“It’s so frustrating,” said Xavier Amador, a clinical psychologist and faculty researcher at Columbia University for nearly two decades. “I hear these stories and I gotta tell you, more than frustrating, it’s tragic. She didn’t need to die.”

The Neighbors

Many of the residents talking with police on the street that morning or waking to frantic texts had their own miniature histories to offer about Antoni.

One woman said she heard cabinets slamming and Antoni yelling from her own apartment. A man down the hall from Antoni had called police just a few nights earlier to report screaming and glass being thrown into the street from her apartment. Another woman had received an unsettling letter in which Antoni wrote that the apartment complex, called the Eddy, was “a lawsuit ready to blow up.”

“Everyone had seen her mental decline,” one couple told police.

Several neighbors questioned: Why wasn’t more done to protect Antoni—and them?

Brandon Arsenault, who would chat with Antoni from his adjacent balcony, was one of few who tried to check on her directly. When he asked if she was doing all right, he said, she flashed a big smile and told him she was fine. He told her to text if she needed anything. She never did.

But Arsenault could hear the screaming in her apartment from his bedroom and eventually reported it to the property manager. By mid-April, the company was working to evict Antoni over another neighbor’s complaint, though Arsenault didn’t know that.

For most of the two years, Arsenault said, Antoni was “the ideal neighbor.”

“I’ve lived all over the country, and Pam was quiet, very sweet and outgoing,” he said. 

Some who knew Antoni in Bend described her as “a light.” Others said she frightened them. A few said she was “quirky.” She worked a variety of part-time jobs and side hustles, including at a local organic grocery and an athletic apparel store. She mixed wild patterns in her clothing and always wore bold lipstick.

Kori Iverson, a friend and former coworker at the apparel store, said Antoni would sometimes call her at work, asking Iverson to pick up a takeout meal and walk it to the Deschutes River nearby. There, Antoni would be perched on her stand-up paddleboard, listening to a concert at the amphitheater on the opposite bank. 

“She had no problem just kind of being different than the societal norm,” Iverson said. “And I admired that about her.”

She and Antoni had briefly discussed mental health, she said, including trading information on different types of medication. Antoni never disclosed a diagnosis.

Antoni didn’t always mesh within her own family—she was the eighth of nine children, the baby until her youngest brother was born a decade after her. Raised Pamela Lisa Kuschnick, her childhood in Gervais, a farm town of less than 3,000 people just outside Salem, included helping out on the family farm. Her family remembers her riding the summer parade circuit around bucolic Willamette Valley towns with Shorty, a Shetland pony she had seen advertised in the newspaper at 5 years old and convinced her father to buy.

Antoni was athletic, playing volleyball in college at Clackamas Community College, Missouri Valley College and Western Oregon University. In her 30s, she completed two Ironman competitions. She was married in 1997 at 22, then divorced seven years later. She had no children. While her siblings stayed close to Gervais as they grew up and started their own families, Antoni lived in and around Portland for several years and later moved to Bend, where she embraced its wealth of outdoor recreational opportunities.

Family members trace the start of Antoni’s mental health struggles back about a decade. Greg Kuschnick, Pam’s oldest brother, recited the fears that his sister began to fixate on: The military was spying on her. An old boyfriend was controlling her mind. A cartel was threatening her family.

From a document he found while cleaning out his sister’s apartment after her death, Kuschnick learned that she had been diagnosed as recently as February with bipolar disorder with psychotic features and paranoid ideation. For many years, though, he said he and the rest of the family tried mostly to look past Antoni’s claims. They didn’t know how to respond to them or her accusations that they were colluding with the powers conspiring against her. When they pushed back, she shut down, he said.

She grew apart from the family, though Kuschnick and a few of the siblings stayed in touch.

Sometimes, he and his sister talked about everyday things. Kuschnick is a creature of habit, and Antoni would text on Sundays asking if he was washing his car like usual. He tried to nudge her toward a healthy routine, too. Some mornings, he sent his sister a picture of his neatly arranged bed, along with a playful question: 

“Did you make your bed this morning?”

And sometimes, he found himself just trying to help the best he knew how.

“Even the last conversations I had with her, at the end of May, we were texting, I said, ‘Pack up all your stuff, move back here so you’re closer to family and reconnect with everybody and try to put your head on straight,’” Kuschnick said. “She would never follow up on it.”

Meanwhile, Arsenault and others began to notice a shift in Antoni’s behavior around the beginning of 2024. She lost her job at the apparel store and was keeping odd hours. Neighbors told the landlord about the letters and said that Antoni was following them in the hallways.

In February, unbeknownst to her neighbors, Antoni went to the emergency room at St. Charles Medical Center in Bend. A police report from a few months later noted that she was there “for having suicidal ideations.”

She had also begun telling her brother Greg that she wanted to die. He didn’t know how to help. Antoni was resistant to his suggestions, he said, and he didn’t think her threats to harm herself were enough to force her to receive treatment involuntarily. He felt stuck, struggling to respond.

“I would tell her, ‘There’s so much to live for, life is too short,’” he said. “But she said, ‘I’m being tormented by these people controlling my mind.’”

The Remedy

In 2005, about a decade before Antoni moved to Bend, Terry Schroeder arrived to help grow Deschutes County’s 24/7 mobile crisis response team.

Schroeder had close to 20 years of experience working in crisis mental health treatment already. He spent 13 years in Flathead County, Montana, setting up the state’s first mobile crisis team, was the clinical supervisor in Spokane for a couple of years before that and worked as a crisis clinician in Seattle.

Schroeder helped secure county and state funding for Bend’s crisis response team, plus buy-in from local law enforcement. Eventually, the team was staffed with a consistent roster of trained therapists who could respond to mental health-related calls around the clock. It was one of only a handful in Oregon for 11 years before the state Legislature embraced the model fully.

“The primary purpose of any of these mobile crisis teams is protecting individuals that they come into contact with and the community,” he said. “That’s their primary purpose: to provide whatever tools they’re given to protect that individual in the least restrictive manner possible.”

A 2021 state law now requires all communities to have mental health crisis responders available around the clock. They are expected to handle mental health calls without law enforcement anytime that it’s safe for them to do so. The law provided initial funding to help counties set up the teams, along with call centers in Oregon for 988, the number for the suicide prevention hotline Lines for Life. In 2023, lawmakers dedicated another $118 million over two years to further expand mobile crisis response.

Oregon is one of at least 38 states that are shifting mental health crisis response away from law enforcement for a few reasons. High-profile police responses that ended in arrests, injuries and deaths are one driver. So are lawsuits, including a complaint that Disability Rights Oregon filed in April against Washington County, which argues that failure to provide therapeutic mental health services violates the Americans with Disabilities Act. The federal Department of Justice has made a similar argument in several other cities, including in Louisville, Kentucky, where investigators found that police were responding to nonviolent mental health calls and frequently using excessive force.

“Police are neither trained nor appropriate responders for someone who has broken their leg and calls 911—and the same holds for someone having a mental health emergency,” said Jake Cornett, executive director and CEO of Disability Rights Oregon in a news release about its lawsuit. 

Today, nearly two decades after he came to Bend, Schroeder is a compliance specialist with the Oregon Health Authority. Part of his job includes training the mobile crisis units across the state on applicable regulations and protocols to ensure they do their job consistently and in line with the law.

Each mobile crisis team must track and report certain outcomes to the state, such as how long it takes them to respond to calls and the number of people they come in contact with each year.

Deschutes County was one of the first to implement the requirements of the 2021 law. County authorities also created a walk-in crisis stabilization center in 2020. There, people can find a safe place to de-escalate and if needed, connect with a case manager who can help them with resources for housing, food and other necessities. 

“They are an excellent model,” said Christa Jones, behavioral health strategic projects director for the Oregon Health Authority.

Tracking the impact of these crisis resources—how many deaths were avoided because people received help—can be difficult, Schroeder said. However, in Deschutes County, the behavioral health division has reported the number of people who told stabilization center staff that their time there had helped dissuade them from attempting suicide: 108 people, as of June 2023.

But advocates said crisis workers could help more people if Oregon had enough mental and behavioral health resources available in the community.

A 2022 report by the state’s Alcohol and Drug Policy Commission, which works to improve prevention and treatment services for substance use disorders, showed Oregon had 35,000 fewer behavioral health care workers than it needs. Six counties have no psychologists; of those, two also have no counselors or therapists. The state has one of the highest prevalences of adults who have seriously considered suicide, and one of the lowest rates of adults with substance use disorders who have been able to access treatment, according to a 2024 report by Mental Health America, a mental health advocacy nonprofit.

Crisis mental health work can only be so effective without that broader support, said Meghan Moyer, public policy director for Disability Rights Oregon. People’s inability to access mental health care increases their likelihood of reaching a crisis point, putting greater stress on those resources. A community-based behavioral health system through which people can voluntarily access intensive care is “very limited or not at all existent, depending on what part of the state you’re in,” Moyer said.

Crisis clinicians must also navigate their limited authority to force interventions on people who don’t want them. In most cases, if a closed door, a hung-up phone or ignored text ends the interaction, clinicians have to weigh whether they have a reason under the law to push further. 

So stories like Antoni’s are not rare, said Chris Bouneff, executive director of Oregon’s National Alliance on Mental Illness. 

“I wish I could tell you you’re telling me a story I haven’t been told a million times before,” he said. “This is going on all over the state of Oregon, and in fact, it’s going on in many other states as well.”

The Calls

After her emergency room visit in February, Antoni called 911 on April 11. She was suicidal again. 

She told dispatchers “that she did not have a gun but ‘could figure it out,’” according to a police report written two months later, after her death.

A single sentence in the report summarizes the response to her call: “Attempts to contact her from (the Deschutes County Crisis Response Team) and officers were unsuccessful, and no action was taken.”

Bend police, Deschutes County Behavioral Health and 911 dispatch all declined to answer questions about their contacts with Antoni, saying her interactions with behavioral health workers are confidential under privacy laws and she was never accused of a crime. Logs from the 11 calls made by and about Antoni and the police report provide basic details on the responses from police and crisis workers.

The next month, Antoni called 911 four times and hung up without saying anything. When an officer knocked on her door on May 19, she yelled from inside for them to go away, according to a police report.

By that time, Antoni had stayed about a month beyond her eviction date. The property management company received a court order stating that a sheriff’s deputy would escort Antoni off the premises if she wasn’t out by June 6. She was running out of time.

When Antoni called again on May 29, she asked the dispatcher to send someone to check on her brother, saying the cartel and “Mongols”—referring to the California-based motorcycle club, according to her brother—were threatening her family and coming into her apartment when she wasn’t there.

“They take my phone. I can’t get ahold of people,” she said. “It’s ugly. They are stalking the shit out of me and killing me pretty much.”

The dispatcher who took Antoni’s call again notified the county crisis response team. Clinicians attempted to contact Antoni via text message, according to the police report, but she declined to speak with them because she suspected they, too, were Mongols.

Xavier Amador, a longtime faculty researcher at Columbia University, is the founder of the LEAP Institute. The organization trains people to work with people who experience anosognosia, which experts define as a “lack of awareness” that they are experiencing signs of mental illness.

Inconsistent as Antoni’s behaviors might seem, they’re not uncommon for someone with psychotic illness, said Amador, the Columbia University researcher who is an expert in psychotic disorders. Amador said he has encountered many people who are willing to ask for help addressing the threats they believe they are facing, but shut down when those threats are dismissed as delusions.

“They’re saying what any of us would say if we didn’t understand we needed help: ‘Everything is fine. Please go away,’” Amador said. 

Amador’s research focuses on anosognosia, a symptom that occurs in half of cases of psychotic disorders, according to the Diagnostic and Statistical Manual of Mental Disorders-5. It is often defined as “lack of insight” by a person that they have mental illness or are experiencing delusions. To try to treat people with this symptom more effectively, Amador pioneered the LEAP method, which stands for Listen Empathize Agree and Partner. Deschutes County crisis workers are trained in similar techniques, according to the division director.

“If you can start to engage the person again—asking questions, being curious, having the person feel they can reveal what’s happening to them and what they’re thinking without there being negative consequences—you’re more likely to hear the truth of what’s going on,” Amador said.

In Antoni’s case, it’s unclear if crisis workers followed up with her at any point after the 911 calls were closed. Patient privacy laws would shield that information if it exists. 

But records do show that May 29 was the last time that 911 dispatchers looped in the crisis team. The calls continued, but Antoni would only deal with police from that point on.

Swift Decisions

Of the 25,000 calls per month to Deschutes County 911, about 200 to 300 are typically mental health related, said Chris Perry, operations manager for the agency. 

Dispatchers have been trained to sort out whether a call should go to police or the crisis team. Protocol says they should alert the crisis team when a caller is having a mental health crisis, but if there’s any threat of violence or damage to property, they should route the call to police. The lines are not always that clear, however.

“None of these calls fits into a perfect box,” Perry said. “It is challenging to sort out what’s actually happening versus the guidelines.”

Some 911 call centers embed a mental health clinician to help them determine the correct response to mental health calls. Perry said the county has decided against that for now.

Once they’re in contact with someone in crisis, health care workers and police have their own complex choices to navigate, depending on what type of services the person needs and wants to receive. If someone is suicidal, however, both are granted the ability under Oregon law to intervene even if the person doesn’t want it. 

But the person must be at imminent risk of harming themselves to qualify for either involuntary holds or civil commitments, meaning they have the intent and the means to do so. Critics of Oregon’s civil commitment laws say its vagueness on “harm to self or others” has contributed to people not getting the help they need. As recently as 2021, a bill that would have allowed civil commitment criteria to include a person’s history of suicidal ideation and attempts and expanded the timeline in which they may harm themselves or others, garnered passionate testimony from both supporters and opponents. It died in the state appropriations committee.

Multiple people have to agree that involuntary hospitalization is needed to protect someone’s life in order for it to happen. Crisis clinicians have the legal authority to initiate a hold, but often need a law enforcement officer to transport the person to a hospital for evaluation. Once a person is at the emergency room, two practitioners need to sign off to admit the person on a hold. Unless the patient presents a clear risk of harm to others, the law requires their consent for medication to be administered.

In Oregon, a civil commitment investigator must see the person staying on a hold within five business days and recommend either that they be released or seen in a hearing for a civil commitment. Civil commitments can last up to a year in extreme circumstances, but most are much shorter. They can take place in a facility or involve required participation in treatments in the community. 

The decision of whether or not to compel an unwilling person to receive treatment is almost always fraught, multiple clinicians said. Patients can be traumatized by being held against their will, and aren’t necessarily stabilized in the longer term.

Because of frequent shortages of available hospital beds, people sometimes spend the entirety of their hold in the emergency room, hardly a therapeutic environment. While the hold is ongoing, anything the person says or does can be scrutinized in the civil commitment investigation, which can discourage people from being open about their suicidal thoughts.

“Once you’re on a hold, everything changes,” said Moyer, Disability Rights Oregon’s legislative director. “It becomes potentially not in your best interest to be open, to be engaged or to talk about your prior mental health experiences.”

But it’s worthwhile to prevent someone who is imminently suicidal from harming themselves, even temporarily, Amador said. That matters because, although tied to underlying mental health issues and other factors, many suicides are impulsive. That’s why red flag laws to delay gun purchases and locks for firearms are suicide prevention strategies. While involuntary care presents risks, he said, it can at least keep the person alive.

“Disability rights advocates and I both agree that the way involuntary treatment is currently utilized is typically ineffective, but you don’t throw the baby out with the bathwater,” Amador said. “Let’s make involuntary treatment more effective, and that means attention to continuity of care, attention to what happens when the person leaves the hospital and to have it be informed by the science.”

Outside of Antoni’s visit to the emergency room, her family is not aware of any time she received treatment, voluntarily or not. But her diagnosis with a psychotic disorder was a risk factor for suicide, research shows. So too was her lack of employment and looming loss of housing. Beyond that, she was isolated.

After learning how many times Antoni had called first responders leading up to her death, her neighbors were stunned that it wasn’t enough to trigger interventions against her will.

“How many times does a person have to call saying they’re suicidal to say, ‘OK, we need to get your ass’?” asked Francesca Lunardi, another of Antoni’s neighbors. “‘We’re coming to pick you up, whether you like it or not, and you’re going to get assessed.’”

The Unraveling

Early May 31, residents at the Eddy apartment complex awoke to the sound of glass smashing against the pavement of Southwest Bradbury Avenue in Bend. It was just past 12:30 a.m.

Pamela Antoni exhibited signs of paranoia for about a decade before her death by suicide in June 2024, according to her family. She repeatedly called 911 in the months leading up to her death, but when crisis workers and police contacted her, she declined to speak with them.

A neighbor told a 911 dispatcher he heard screaming from Antoni’s apartment, where it appeared someone was throwing glass bottles off the balcony. The dispatcher who took the call notified police because of the property damage. 

An officer who arrived within five minutes knocked on Antoni’s door and wrote in the call log that she did not answer. 

The call was closed.

Just 10 hours later, another 911 dispatcher took a report from Iverson, Antoni’s former coworker, about a text she had received at 12:45 a.m. The message was one word: “die.”

Iverson called after learning that another former coworker also received alarming texts, saying things like “bloodbath” and “blood on your hands.” Iverson also tried to check on Antoni herself.

“The next morning, I messaged her: ‘Pam, are you okay? Talk to me,’” Iverson said. “I just never received anything.”

The 911 dispatcher also routed this call to Bend police, though it’s not immediately clear why, given Antoni’s history of suicidal ideation and that her texts didn’t threaten violence toward anyone. The responding officer called Antoni’s cell and got her voicemail before reaching out to Deschutes County’s Stabilization Center to ask if Antoni had ever received care there. After a worker there said no, police closed the call, according to the notes.

The rest of the weekend was quiet. But Monday, June 3, Antoni decided she wanted to buy a gun. She went to two gun counters and paid for a firearm at each; she didn’t receive either, however, while her background check was pending. She went to a pizzeria and wrote about dying on a paper napkin. She was home by 7:35 p.m. 

At 10:30 and 11:30 p.m. Antoni made her final two 911 calls. Both times, she repeated her requests for a welfare check on her brother and even told the dispatcher she had called a week earlier for the same reason. She hung up both calls within five minutes.

Amador, who was briefed on the responses to Antoni’s calls, said these interactions should have raised more red flags for dispatchers.

“What a missed opportunity,” he said. “Rather than say, ‘We can’t do anything,’ there’s an opportunity there to pivot and say, ‘We’d like to learn more. We want to help you. We’re going to send someone out to talk to you.’”

Call notes show that on the final night of Antoni’s life, dispatchers, police and the county crisis team were all available to step in.

But the dispatcher who took the first call made no note about the county crisis team. The second dispatcher offered to put her in touch but wrote that Antoni declined to speak with them. Neither of the call’s notes mention of Antoni’s history of suicidal ideation or her contacts with police and the county. Both calls were set to a low, non-emergent priority.

A Bend police officer who was assigned Antoni’s 10:30 p.m. call cleared it without returning her call or knocking on her door. 

The Reckoning

On the morning of June 4, Yater, Antoni’s neighbors sent a warning to a group message with her neighbors: Don’t go outside.

Yater didn’t want anyone else to see what she saw. Antoni’s death was horrific, she said.

“I’ve had traumatic events in my life but haven’t seen something so traumatic that it will pop up into my head randomly,” she said. “The home I love is now tainted with this sad, horrific underlying tone.”

But it was not entirely surprising. Everything Yater had learned about Antoni throughout the last few months had put her on edge. 

“It was so clear she was not well,” she said.

She and three other residents said they thought police and the county had not done enough to investigate how dangerous their neighbor’s condition was. To them, Antoni’s paranoid and suicidal had sent clear signs that she needed help, even if she was reluctant to accept it.

Ginna Roth, a neighbor, said she was particularly haunted by how Antoni’s final phone calls were handled.

“That’s concerning to me that someone would call and clearly be saying things that are not in touch with reality and it would be marked as low priority, given her history,” Roth said. “We need some more training around mental health if that’s how we’re handling things.”

Roth is a licensed clinical social worker and has helped support family members dealing with psychosis. Antoni shouldn’t have been left alone as she was with her paranoia, she said.

“I just think that requires a more thorough assessment of someone’s risk, because you might be able to check those boxes like ‘They don’t have intent,’ or ‘I can’t really tell if they have clear intent,’ but well, they’re not thinking super clearly, either, and there’s probably impulsivity and paranoia,” she said.

Despite the investments Deschutes County and other communities have made to improve crisis response, not much is known about how much those changes reduce suicides. County health authorities say more than 100 people who have visited the stabilization center in the last four years were dissuaded from ending their life. But out in the community, it’s harder to track the difference that the crisis system is making in saving lives, Schroeder said.

The morning Antoni died, firefighters breached her closed apartment door—the barrier that had prevented police from reaching her multiple times before. Three officers assisted in the death investigation, along with the county medical examiner, district attorney’s office and behavioral health division. Officers combed through Antoni’s photos, notes to herself and call records. They called her family members to learn more about her history and frame of mind.

In the end, her death was marked “not suspicious.” A week later, Greg Kuschnick and his family came to collect her things, and, a month later, a new tenant moved in. 

Inside his sister’s apartment, Kuschnick puzzled over the broken glass and toilet lid. But other details he recognized from his only other visit to the apartment last November. There was the familiar artwork on the walls, including a picture of a running white horse that his sister loved. There was her pink Christmas tree, which he remembered Antoni putting up when she hosted the family for Christmas years ago.

And in the bedroom, his sister’s bed was neatly made.

This story was originally published by InvestigateWest (invw.org), an independent news nonprofit dedicated to investigative journalism in the Pacific Northwest.