SHERMAN -- A worried call from his daughter's boyfriend sent Paul Boren rushing to her apartment on the morning of March 27, 2004. He drove the eight blocks to her apartment, peering into his neighbors' yards, searching for Andre Thomas, Laura Boren's estranged husband.
He drove past the brightly colored slides, swings and bouncy plastic animals in Fairview Park across the street from the apartment where Ms. Boren, 20, and her two children lived. He pulled into a parking spot below and immediately saw that her door was broken. As his heart raced, Mr. Boren, a white-haired giant of a man, bounded up the stairwell, calling out for his daughter.
He found her on the white carpet, smeared with blood, a gaping hole in her chest. Beside her left leg, a one-dollar bill was folded lengthwise, the radiating eye of the pyramid facing up. Mr. Boren knew she was gone.
In a panic, he rushed past the stuffed animals, dolls and plastic toys strewn along the hallway to the bedroom shared by his two grandchildren. The body of 13-month-old Leyha Hughes lay on the floor next to a blood-spattered doll nearly as big as she was.
Andre Boren, 4, lay on his back in his white children's bed just above Leyha. He looked as if he could have been sleeping -- a moment away from revealing the toothy grin that typically spread from one of his round cheeks to the other -- except for the massive chest wound that matched the ones his father, Andre Thomas (the boy was also known as Andre Jr.), had inflicted on his mother and his half-sister as he tried to remove their hearts.
"You just can't believe that it's real," said Sherry Boren, Laura Boren's mother. "You're hoping that it's not, that it's a dream or something, that you're going to wake up at any minute."
Mr. Thomas, who confessed to the murders of his wife, their son and her daughter by another man, was convicted in 2005 and sentenced to death at age 21. While awaiting trial in 2004, he gouged out one of his eyes, and in 2008 on death row, he removed the other and ate it.
At least twice in the three weeks before the crime, Mr. Thomas had sought mental health treatment, babbling illogically and threatening to commit suicide. On two occasions, staff members at the medical facilities were so worried that his psychosis made him a threat to himself or others that they sought emergency detention warrants for him.
Despite talk of suicide and bizarre biblical delusions, he was not detained for treatment. Mr. Thomas later told the police that he was convinced that Ms. Boren was the wicked Jezebel from the Bible, that his own son was the Antichrist and that Leyha was involved in an evil conspiracy with them.
He was on a mission from God, he said, to free their hearts of demons.
Hospitals do not have legal authority to detain people who voluntarily enter their facilities in search of mental health care but then decide to leave. It is one of many holes in the state's nearly 30-year-old mental health code that advocates, police officers and judges say lawmakers need to fix. In a report last year, Texas Appleseed, a nonprofit advocacy organization, called on lawmakers to replace the existing code with one that reflects contemporary mental health needs.
"It was last fully revised in 1985, and clearly the mental health system has changed drastically since then," said Susan Stone, a lawyer and psychiatrist who led the two-year Texas Appleseed project to study and recommend reforms to the code. Lawmakers have said that although the code may need to be revamped, it will not happen in this year's legislative session. Such an undertaking requires legislative studies that have not been conducted. But advocates are urging legislators to make a few critical changes that they say could prevent tragedies, including giving hospitals the right to detain someone who is having a mental health crisis.
From the time Mr. Thomas was 10, he had told friends he heard demons in his head instructing him to do bad things. The cacophony drove him to attempt suicide repeatedly as an adolescent, according to court records. He drank and abused drugs to try to quiet the noise.
By the time he was 16, he was a father with a long history of arrests. At 18, he was married to his son's mother. A few months after their wedding, the two separated. Mr. Thomas struggled to hold a job, and the older he got, friends and family members say, the more pronounced his mental illness became.
By March 5, 2004, it was too much. A friend took Mr. Thomas to a local mental health clinic, where he told staff members that he wanted to die and that he could not stand the sound of his own voice. He said that if someone there did not shoot him, he would do it himself, court records show. Frantic and delusional, he said, "If I can't talk to someone now, I will throw myself in front of a bus."
Clinicians told Mr. Thomas to go to the emergency room, and at their request a judge issued an emergency detention order. But Mr. Thomas did not make it to the emergency room that day, and no one sought him out.
About three weeks later, less than two days before the murders, Mr. Thomas -- high on cough medicine and alcohol -- stabbed himself in the chest with a knife. Early the next day, he walked into the emergency room at the Texoma Medical Center and told a nurse he had cut himself trying to "cross over into heaven." The nurse made a written note that Mr. Thomas was psychotic.
While Dr. William Bowen examined him, Mr. Thomas rambled on about the text on the dollar bill and a new world order. After X-rays determined that the stab wound was not serious, Dr. Bowen applied for an emergency detention order to keep Mr. Thomas hospitalized. By the time he returned to the room, Mr. Thomas had walked out of the hospital unnoticed.
After the murders, the Boren family sued Texoma Medical Center, arguing that the hospital was negligent in allowing Mr. Thomas to leave when doctors knew that he was psychotic.
"When you walk into a hospital or an E.R. and you tell someone that you feel like you're going to do harm to yourself or someone else, I mean, I think it's negligent for them to just leave him by himself like that," Sherry Boren said.
The hospital, in legal filings, argued that doctors could not have foreseen the horrific crime that Mr. Thomas would commit. The court agreed with the hospital and rejected the lawsuit, ruling that the hospital had no legal authority to hold Mr. Thomas.
Guy Herman, a Travis County probate judge who was on the Texas Appleseed steering committee that developed recommendations to overhaul the mental health code, said that because current law did not allow hospitals to detain people, their only recourse was to do so illegally or to let patients go and hope that the police would catch them before something bad happened.
"We would prefer to have a system set up so that a hospital can legally hold a person," Mr. Herman said.
The Appleseed report's recommendations include eliminating provisions in the code that call for law enforcement to obtain a warrant to detain someone in a mental health crisis and adding explicit laws that allow officers to confiscate firearms from people who become dangerous as a result of their mental condition.
Another recommendation calls for the adoption of a uniform one-page intake form for law enforcement officers to complete when they take someone in crisis to a mental hospital. Currently, forms across the state vary; some are many pages long and take hours to complete.
Tragedies like the murders Mr. Thomas committed are the reason Representative José Menéndez, Democrat of San Antonio, filed House Bill 245. The measure would allow hospitals to detain mentally ill and dangerous patients for up to 24 hours.
"I'm putting it in the hands of E.M.S. or emergency room professionals to make the call to say this person is a danger to himself or others," Mr. Menéndez said.
Lt. Michael Lee of the Houston Police Department said giving that authority to medical staff members would help officers, who would not need to respond to an already volatile situation.
"Some situations we've seen have turned very negative very quickly when the person sees a police officer enter the hospital," Lieutenant Lee said.
Hospital officials say they face a Catch-22 under current law: if they detain a mentally ill person against his or her will, they face liability because they have no legal authority to do so. If they allow the person to leave and something tragic happens, they risk a lawsuit like the one the Boren family filed.
"Physicians are trained to determine whether patients meet the criteria for an emergency detention," Stacy Wilson, associate general counsel for the Texas Hospital Association, wrote in an e-mail. "A law that permits physicians to initiate an emergency detention would ease the burden on law enforcement and would help protect patients, their treating physicians and facilities, as well as the community."
After Mr. Thomas left the emergency room on March 26, 2004, Dr. Bowen alerted the local police that the young man might be dangerous and gave them his description. But Dr. Bowen called the police department in Denison, where the hospital was situated; Mr. Thomas had walked to his home in Sherman, about 10 miles away.
Less than 24 hours later, Mr. Thomas packed three knives in his pants pocket and grabbed a roll of duct tape. He took one knife for each of his victims, worried that God would not want him to cross-contaminate their blood.
A short while later, he charged up the stairs to Ms. Boren's apartment and smashed down the door, beginning his bloody rampage.
This article originally appeared in The New York Times.