PHOENIX — Adam Cooley had a job he loved.
He didn’t want fame and fortune, he wanted to be happy. And being a bouncer made him happy.
Cooley worked security at the Great Alaskan Bush Company strip club on Grand Avenue.
“He wasn't the guy that threw people to the ground," Cooley's sister Janine Rodriguez said. "He was never that. He was just this calm person and it just...he was just in the wrong place at the wrong time.”
It was Dec. 26, 2010. Cooley had just switched to cover the door at the strip club.
A man named Gavin MacFarlane was inside the club before he went to the parking lot, got a gun from his car, and started shooting.
MacFarlane shot four people, killing two...including Adam Cooley.
“I don't really like to think about that, because he was so quiet," Rodriguez said. "And the chaos surrounding his death really hurts my heart because he didn't live his life in chaos.”
MacFarlane later told police that he wanted to see if he had what it took to kill people. He had no other reason.
Court documents show MacFarlane had a history of mental illness. At some point during his court case, he pleaded Guilty Except Insane (GEI).
He did not go to jail.
“I remember when the prosecutor was trying to explain that he was going to be GEI," Rodriguez said. "And that's when I broke down."
Instead of prison, MacFarlane was sentenced to 25 years to life in the Arizona State Hospital. Adam’s family thought that was where he would stay forever.
Until they learned that "life" doesn't always mean life and there’s a way some people convicted of violent crimes could get out early.
"On April 12, 2021...18 days ago, we learned something is broken with conditional release," Rodriguez told the people in control of MacFarlane's future.
Christopher Lambeth
On April 12, 2021, Christopher Lambeth was arrested at a group home in Gilbert. Police said he had beaten a man to death.
They found Lambeth inside the group home where he had been living, apparently washing off the victim’s blood in the shower.
It wasn’t the first time Lambeth had been arrested for murder. He killed his grandparents in Tucson in 2005. His lawyer said he was hallucinating, going through a psychotic break, and was schizophrenic.
He also pleaded Guilty Except Insane and was given 25 to life in the state hospital.
So how could he be in a group home only 14 years later?
The PSRB
The Psychiatric Security Review Board (PSRB) is the board that voted to let Lambeth out.
The PSRB has the final word on what happens to people found Guilty Except Insane in the state hospital. They listen to recommendations from the state hospital and determine if a patient is well enough to get released.
Arizona is one of only three states that has a PSRB along with Oregon and Connecticut. The five board members are appointed.
Currently, three are mental health professionals, one is a lawyer and one works in parole and probation. Their decisions are final and they’re independent of any other state agency.
Meaning, they have no oversight.
None," said attorney Holly Gieszl. "They produce an annual report and it’s a report that gives statistics on the annual cases, [a] breakdown of the gender…but it’s very much a nitty-gritty number about their cases.”
Those numbers show the PSRB supervises 113 people. According to the most recent annual report, 97 of them are in the Arizona State Hospital. 32 are on some sort of conditional release, meaning anything from short field trips outside the hospital to living on their own.
Of those 113 people, 54 were convicted of murder, like Lambeth.
Gieszl remembers Lambeth's case. She said it stuck out.
“It caught my eye immediately," she said. "Because there was no risk assessment, no report from a psychiatrist, no report from a psychologist, it was pretty rote."
But Lambeth’s isn’t the only case that showed problems.
Other Cases
Kenneth Wakefield stabbed his mother in the neck, chest and throat.
It was March 2003. Wakefield was charged with attempted second-degree murder. He was found Guilty Except Insane and sentenced to 10 and a half years in the Arizona State Hospital.
In 2014, Wakefield’s doctors told the PSRB he was ready to be released and that he was no longer mentally ill.
Wakefield also met his wife, Karen Hersh, in the state hospital. She was also released by the PSRB.
Two months after releasing Wakefield, the board changed its mind and told the county attorney’s office to start the civil commitment process. They did, but he wasn’t committed.
Not before he stabbed and decapitated his wife and two dogs. He also cut off his own arm and gouged out one of his own eyes.
Wakefield is now serving 29 years in prison.
Isaac Bonelli was arrested in 2002 for shooting at a cop in Tucson. He also pled Guilty Except Insane and got 15 years in the state hospital. But after 11 years, the PSRB voted to let Bonelli out "unconditionally".
Three months later, Bonelli was arrested after crashing his car with two loaded guns. He was suspected of stealing more guns from a Wal-Mart and driving to a border patrol station in Casa Grande, claiming to be sent on orders from the Department of Homeland Security.
He was arrested again and sentenced to three years in prison.
It wasn’t until after he was released from prison that the PSRB ordered him back to the hospital. A few months later, the board voted to let him go for good.
'Our Worst Nightmare'
Cooley's niece, Emily Miles, saw Lambeth’s arrest on the news.
“It was absolutely our worst nightmare," Miles said. "I read that and I went, 'Oh my gosh, this is what we're dealing with.'”
Just a few weeks after Lambeth’s arrest – the hospital applied to give Gavin MacFarlane some freedoms too. It would be the first in a long line of steps that could eventually end with MacFarlane living unsupervised and released from the state hospital, under the terms of "conditional release".
MacFarlane would be supervised on small outings from the hospital and fitted with an ankle monitor.
It’s the first step toward eventual release into the community, as long as the hospital staff says MacFarlane is not a danger and his mental illness is in "stable remission."
Adam Cooley’s family was furious.
“We were under the impression, or even if it's not behind bars it was completely behind the walls of ash," Cooley's niece Lindsey said during the PSRB meeting.
“He's dangerous," Rodriguez said during the same meeting. "Does this facility need more blood on their hands?"
During the PSRB hearing, the county attorney’s office accused the Arizona State Hospital of copying and pasting reports to try and release patients.
“Look at the report that was written in August of 2020 and you review the report that was written in April of 2021," prosecutor Juli Warzynski said. "There's very little difference. The first section is exactly the same. The second section is exactly the same. The third section is exactly the same. The fourth section is exactly the same."
According to meeting minutes, the hospital had put MacFarlane up for release just six months earlier. At that time, the board found he was not well enough to be let out.
But they were back before the board, making virtually the same case.
“How is it possible that an individual that committed his offense at the end of 2010, spent 10 years without any improvement...well, with the limited improvements that he had," Warzynski continued, "and then now all of a sudden, is miraculously all better? That is not believable.”
Oversight
The closest the PSRB gets to oversight is the state auditor general. And the board has been audited before, in 2018.
"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," Chair James P. Clark said during a state congressional hearing in 2019.
But the auditor general found the board was making decisions with “inconsistent data”. It also found the board didn’t get detailed mental health reports, which made it hard for the board to make “timely and consistent decisions.”
The board said it fixed all those problems.
“They seemed not to appreciate that a group of five people were going to make mistakes if they didn’t tighten up the way they were running the organization," Gieszl said. "Most of us would say, oh my gosh, give me that list we’re going to fix that tomorrow. The PSRB seemed to be insulted.”
Gieszl said when patients are approved or denied, there’s no reason given, at least not in writing. She said that means she can’t tell her clients what they need to work on.
“They’re intentionally opaque," she said.
MacFarlane's hearing
MacFarlane’s lawyer disputed the criticisms of the hospital’s plan. She said the parts of MacFarlane’s report that were identified were things that never change from meeting to meeting anyway.
But after the family testimony and the criticism from the county attorney's office, the board voted to deny giving MacFarlane any release conditions...for now.
The board took another unusual step, telling the state hospital not to bring MacFarlane back to them for another year.
“We need to make changes," Rodriguez said. "This happened, it can happen again because I know somebody who killed two people. This needs to change.”
The PSRB's sunset
And it will change.
A bill passed in June of 2021 dissolves, or "sunsets", the PSRB in 2023.
When it does, courts will make decisions about which patients are let out and under what conditions.
That will change the process for Adam Cooley’s family. But it doesn’t necessarily change the fact that he could still be let out eventually.
The case they thought was over, isn’t really over. the case will continue to come up, bringing with it memories of Adam Cooley, and the pain of losing him.
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