Patients Go Missing at San Antonio's State Psychiatric Hospital Every Week

On June 1, 1990, just one week after he checked out of a state psychiatric hospital, Gary Ligon murdered and dismembered his wife, leaving her torso in a field before attempting to burn her head in a washtub on the back porch of their home near Kerrville. 

It's unclear why Ligon's case lingered for some 16 years, but by 2007, prosecutors didn't contest the defense that Ligon, who according to court records had a long history of paranoid delusions and psychiatric treatment leading up to the grisly murder, was psychotic when he killed his wife. Declared not guilty by reason of insanity, a judge ordered Ligon into treatment at West Texas's Big Spring State Hospital, where he remained until 2013 when he was transferred to the San Antonio State Hospital on South New Braunfels Avenue. In the years before his transfer, one doctor called Ligon's progress in treatment "marginal" and offered this blunt assessment in a letter filed with the court overseeing his case: “Gary might be really scary and dangerous to others."

Other letters from Ligon's state hospital doctors filed in court show that even with prolonged treatment for schizoaffective and bipolar disorders, Ligon often refuses to take his meds, continues to suffer from "intractable paranoia and delusional thinking," and has a tendency to become aggressive with people he accuses of "blaspheming" him – likely the result of voices in his head. One 2013 assessment from his San Antonio doctors says that Ligon has “acted in the past to cut his wrists, stab himself in the abdomen, assault police, and go after female state hospital employees who reminded him of his deceased wife.” Ligon doesn't think he should be hospitalized, recently telling one doctor, "I've done nothing wrong. I've been exonerated." 

Which might be why, over the past 13 months, Ligon has escaped no less than three times, most recently when he walked off the south side campus this past Sunday morning. 

Ligon is one of dozens of San Antonio State Hospital patients who go missing every year, according to numbers provided by the Texas Department of State Health Services this week. Between September 2015 and this past August, the San Antonio State Hospital saw 91 so-called "unauthorized departures" – an average of almost two a week. The state says that, in general, patients who go missing are usually found "within a few hours to a few days."

According to data provided by DSHS, the problem appears to be worse in San Antonio than at other similarly-sized state hospitals. At the Rusk State Hospital, which sees anywhere between 7,500 and 10,000 patients at any given time, only 10 patients went missing this past year. Patients went missing at the Terrell State Hospital only five times last year. The only other state hospital with numbers like San Antonio’s was the North Texas State Hospital complex, which is in itself two facilities that treat roughly 17,000 patients at any given time. North Texas saw 135 of those patients go missing last year – DSHS spokeswoman Christine Mann says none were escapes from the Vernon campus, the complex’s maximum security facility.

It's not entirely clear why patients go missing in San Antonio more than at other state hospital facilities or why Ligon, who'd already walked off campus twice in the past year, was able to escape yet a third time this past weekend. Mann blamed the problem on "the large size" of San Antonio's state psychiatric facility – "It really is a sprawling campus," she told the Current. She said there have been security improvements at the facility in recent years, such as an additional interior fence built around the campus' so-called "forensic unit," where patients like Ligon are typically held. 

What's also not clear is how many of those lost patients, like Ligon, actually left the campus grounds or just went missing inside the facility. As Mann explained it, an "unauthorized departure," as the state defines it, could simply mean a patient who went missing for longer than an hour but was later found within the facility. DSHS doesn't differentiate between the two, she said, "because of how we report our numbers (to the feds)." She couldn't provide any further explanation. 

Mann said that state hospital staff won't physically restrain patients who try to walk off campus, but will try to talk them into staying. She says state hospital officials notify local law enforcement whenever there's an escape. As KSAT reports, however, officials didn't tell anyone living in the surrounding area about Ligon's escape. 

The Express-News reports that word of Ligon's escape from the San Antonio campus greatly upset not just the family of the woman he killed, but also the cop who investigated the murder. Ligon's wife's sister, Judy Clark, told the daily, “He said he would kill the rest of our family if he ever got out and had the chance. ...They told us in 2007 that he was going to a maximum security facility.” Kerr County Sheriff Rusty Hierholzer, who investigated the murder as a deputy with the department, sounded the alarm when he found out about Ligon's escape. 

Police say they found Ligon near the 8200 block of City Base Landing on Tuesday morning and returned him to the local state hospital. Mann with DSHS wouldn't comment on Ligon's escape specifically, but did say officials are looking into how to prevent future escapes. 

"Each incident is different," she told the Current. "We do look at these and try to make our facilities a little bit more secure... But with that said, our state mental hospitals – they’re mental hospitals, they’re not prisons. They’re patients, not inmates.”
Scroll to read more San Antonio News articles
Join the San Antonio Current Press Club

Local journalism is information. Information is power. And we believe everyone deserves access to accurate independent coverage of their community and state.
Help us keep this coverage going with a one-time donation or an ongoing membership pledge.


Join SA Current Newsletters

Subscribe now to get the latest news delivered right to your inbox.