When systems fail the seriously mentally ill—and everyone else

The Jonathan Grall case exposes a dereliction of duty by the Portland Police Bureau

First of a two-part look at the failures of the Portland Police Bureau and Oregon’s mental health system in the Jonathan Grall murder case.

Like many Portlanders, I was shocked and saddened by the murder of the Reiners by their son, Nick Reiner, who suffered from schizophrenia. Reading about that case alerted me to “The Best Minds” by Jonathan Rosen, which tells the story of Michael Laudor—a Yale Law School graduate once profiled by The New York Times as a triumph over mental illness. Several years later, Laudor murdered his pregnant girlfriend, believing she was a threatening windup doll.

More recently, Maxine Bernstein’s reporting in The Oregonian https://www.oregonlive.com/crime/2025/12/two-families-devastated-by-portland-police-mistake-now-somebodys-dead.html detailed the case of Jonathan Grall, a man with schizophrenia who killed an innocent pedestrian, Jonathan Bennett, in downtown Portland.

Grall wasn’t famous and didn’t graduate from Yale, and Bennett didn’t make movies in Hollywood, but the underlying story was the same: untreated schizophrenia, worsened by substance abuse, combined with systemic failures, led to the death of an innocent person.

These cases are not aberrations. They are warnings.

This piece examines how the Grall case exposes failures within the Portland Police Bureau—and why simply adding officers, while necessary, will not be sufficient unless those failures are addressed. A subsequent piece will examine the even deeper failures of Oregon’s mental health system.

Let me be clear at the outset: I worked with the Portland Police Bureau for many years and have great respect for most of the men and women who serve this city. I also have great confidence in Chief Bob Day’s leadership at a difficult moment. I support the effort by police union president Aaron Schmautz and businessman Jeff Swickard to invest unexpended Portland Clean Energy Fund dollars to increase police staffing.https://www.wweek.com/news/2025/11/12/murmurs-initiative-seeks-to-reroute-climate-tax-to-cops/ Portland clearly needs more officers.

But that alone will not fix what went wrong in the Grall case.

First, a few realities about serious mental illness must be acknowledged. As Rosen documents, we do not fully understand what causes illnesses like schizophrenia. We know they often emerge in adolescence, are frequently aggravated by substance abuse and can sometimes—though imperfectly—be managed by medication. We also know that a defining feature of these illnesses is often the belief that one is not mentally ill and does not need treatment. The claim that people stop taking medication solely because of side effects is only a partial truth.

Jonathan Grall embodied this complexity—and our systems failed to respond.

On Nov. 17, 2022, Grall stabbed a fellow tenant, Anitza Garcia Urquiza, in his apartment building because, in a delusional state, he believed she was threatening him. The victim suffered a bleeding facial wound just below her eye. Grall fled the scene. The victim, shaken, did not immediately report the assault.

Grall did.

When police responded to his call, they found no victim or witnesses or other evidence of a stabbing and understandably concluded the incident was a product of his delusional thinking. The officer documented the call and closed the matter. But the assault was real—a Measure 11 offense. Had it been investigated and prosecuted, Grall would almost certainly have been in custody in a secure mental health setting. The murder that occurred two and a half months later would never have happened. At this point, it was no one’s fault that it wasn’t.

However, there was a second chance for that to occur because, three days later, the victim walked into Central Precinct and reported the stabbing. The officer who took her statement collected evidence, documented the crime and connected it to her fellow officer’s earlier report. But she did nothing more. No arrest. No referral for prosecution. Despite follow-up calls by the victim, the case went nowhere.

Only after Grall committed murder did a prosecutor notice the earlier assault and ask police to locate Garcia Urquiza. A detective was assigned to find her and spent months trying to do so. From the report he wrote, other than going to her last known address and talking to the apartment manager, it is unclear what methods he used, but he could not find her. An Oregonian reporter did—using social media. I found her in minutes using Google. Garcia Urquiza only learned of the murder and the outcome of the case from that reporter. As of last week, she has still never heard from law enforcement.

Insufficient explanation

A police spokesperson attributed these failures in part to computer coding issues that have since been corrected. He said that training now emphasizes that patrol officers can email detectives directly. That explanation is insufficient. Every report in this case was reviewed by a supervisor. No real corrective action appears to have been taken. One of the officers involved has since been promoted. It appears the other has never had the obvious failings of his search for the assault victim even brought to his attention. The supervisors appear to have not been identified.

Acknowledging “room for improvement” as the police spokesman did is not enough. Accountability and corrective action matter—especially when the consequences of failure are fatal. Training for all officers on the lessons for the case should be held and specific written procedures adopted to prevent the errors from occurring again. Corrective work action should have been taken with both officers involved and the supervisors who reviewed their reports.

Last week, the bureau released a 2025 Year-End Review video highlighting many genuine and commendable achievements by officers. It presented the real and outstanding acts of officers and other employees of the bureau. Unfortunately, there is no mention of Jonathan Grall, Anitza Garcia Urquiza, Jonathan Bennett or steps that have been taken to ensure the failures in their case do not happen again.

Portlanders should reject simplistic, reflexive attacks on police. But we should also reject complacency. We can—and must—both fund and respect the police while demanding basic administrative competence, effective supervision and accountability when significant failures result.

Next: We confront the even more troubling failures of Oregon’s mental health system—and the false hope that recent statutory changes will fix what is broken.