by Gary A. Harki, The Virginian-Pilot

Bradley Thomas had bipolar disorder and was in a severe depressive episode when he was arrested for a misdemeanor in Oregon. He had spit on his landlord’s face and threatened her husband with a sword.

While in jail, Thomas refused meals and medication. His condition quickly worsened. Soon he was flooding his cell with toilet water and smearing feces on the walls.

He was ordered to a state mental hospital but no beds were available. Thomas, like so many others with mental illness in jail, died in his cell.

The Virginian-Pilot tracked the cases of 404 people with mental illness who have died in America’s jails since 2010. The total number is likely much larger, but it’s untraceable – what little information the federal government keeps on jail deaths does not accurately track the mental health of prisoners.

These deaths are symptomatic of a bigger problem – how the country’s criminal justice system treats some of its most vulnerable citizens, those with a mental illness.

Some of the people who died were diagnosed with schizophrenia. Others with bipolar disorder. Or depression. All had mental illness. And all died – many under horrific circumstances – after being taken to jail.

There was Charlton Cash Chrisman, who had a history of mental illness and drug abuse. He was shot with pepper balls while coming out of his cell. He was then shackled and a spit hood was put over his face. He died a short time later.

The Pilot’s database was created using court records, Google searches, newspaper websites, state records and a variety of existing databases.

This is the first database to track such deaths across the nation, but it likely contains only a fraction of the true total. The federal government tallies more than 900 jail deaths a year. But it does not keep track of mental illness diagnoses. Only a few states do so, and then sporadically.

Yet jails are the default treatment center for many with mental illness in America. And they are woefully ill-equipped for the job.

What the country is left with is a system in which many with mental illness get little or no treatment. There is no way to know how many of the 404 prisoners would have lived had they not been arrested.

But law enforcement officials and mental illness experts across the country do know this much: The system is broken.

Investigation Tracks Hundreds of Deaths

Jerome Murdough, a homeless veteran diagnosed with schizophrenia and bipolar disorder, baked to death in a jail cell at Rikers Island in New York after being arrested for trespassing.

David O’Quin was arrested for disturbing the peace in Louisiana. His father pleaded in vain to jail officials for him to be given his medications for severe mental disorders. Less than two weeks later, O’Quin died from a bacterial infection after his own excrement got into cuts that he received from being beaten and put in a restraint chair. 

Jennifer Towle was suffering from depression so severe she started eating a nail clipper, milk cartons and other objects while jailed in New Jersey. After she died, an autopsy found about three liters of such material in her stomach.

People with mental illnesses in jails around the country are routinely dying in horrific ways and under preventable circumstances, a Virginian-Pilot investigation has found.

The country’s 3,000-plus jails are the default treatment center for many. There is often nowhere else to take them.

The Pilot and students from Marquette University in Milwaukee tracked 404 deaths since 2010 in what experts say is the most comprehensive effort to examine what happens to people with mental illness in jails throughout the country. The findings were compiled using state data, news reports, existing databases and court filings.

The total number of deaths for the period is likely significantly higher than what could be documented through available records.

The same grim patterns emerge again and again:

• At least 41 percent of those who died were in isolation or recently had been. Solitary confinement has long been known to exacerbate the symptoms of mental illnesses. 

• 44 percent of the deaths were by suicide, which can often be prevented with close monitoring.

• In 70 cases, prisoners were shocked with a Taser or stun gun, pepper-sprayed or restrained – often in some combination – before dying.

• In at least 11 percent of the cases, family or friends warned the jail that their loved one had a mental illness. In at least six of those, they tried to bring the correct medications to the jail. Without medications and proper treatment, someone with a disease like schizophrenia can rapidly decline. It’s not uncommon for such prisoners to wind up in isolation, naked and smearing feces around their cell.

For years, sheriffs, mental health advocates, families and prosecutors have sounded the alarm about the number of people with illnesses such as bipolar disorder, schizophrenia and severe depression who are sent to jail, often for minor crimes. Unlike prisons, which house those convicted of and sentenced for a crime, jails must take in anyone arrested – including those in the throes of a mental health crisis.

“We are arresting people who have no idea what the laws are or the rules are because they’re off their medications,” said Nashville Sheriff Daron Hall, a vice president of the National Sheriffs’ Association. “You’d never arrest someone for a heart attack, but you’re comfortable arresting someone who is diagnosed mentally ill. No other country in the world is doing it this way.”

In addition to causing pain and suffering for people with mental illness, the practice is costing municipalities millions.

At least 53 percent of the deaths examined have resulted in a lawsuit. Combined, the cases have cost municipalities at least $145 million. The true cost is much higher – in many cases, lawsuits are still pending and in others the settlement amount is secret. The figures also do not take into account lawyers’ fees.

Examining how people with mental illness die in jail is key to understanding how the criminal justice system treats them in the United States, said Elizabeth Sinclair, director of research and public affairs for the Treatment Advocacy Center, a mental health advocacy group based in Arlington.

Sinclair said she sees The Pilot’s research as a step toward making sure the system’s failure is brought to the public’s attention.

“The lack of data collection, the lack of accountability is such a systematic, widespread issue, and the fact is that this is the only database that has this information available to people – it points to the fact that if the data doesn’t exist, then they can’t be held accountable to what’s happening,” she said. “I think people expect the data to be collected by the criminal justice system, but the reality is, it’s not systematically collected at any level.

“I see this as a starting point for reform, for finding out why this is happening and what we need to do to fix it.”

A Tragic Pattern

Marc Moreno’s death in the Benton County Jail in Washington state fits a pattern found time and again: A mental health crisis leads to an arrest, which leads to poor treatment of the illness, which leads to death.

Jessica Moreno was very close to her brother, the baby of the family. They would go out with friends together during the summer, often swimming or playing soccer. He was humble, a good kid, she said.

In March 2016, the 18-year-old was having a crisis and his family was afraid he would hurt himself. Moreno was diagnosed with schizophrenia and bipolar disorder, which causes alternating periods of elation and depression.

The Morenos had dealt with such situations before. A history of mental illness runs in the family.

Marc’s father took him from treatment center to treatment center, looking for a bed so his son could get help.

Mental health treatment can be hard to come by in the United States. Most facilities are small and expensive. Finding a bed can be daunting, if not impossible. That often leaves family members to make sure loved ones with severe mental illness take their medications and stay out of trouble.

Few people with mental illness who end up in jail are career criminals, said John Snook, executive director of the Treatment Advocacy Center. “Really what you are looking at is a clear failure of the mental health system,” he said. “Very often these people ... are booked for the lack of a treatment bed.” Eventually the Moreno family took Marc to the Benton Franklin Crisis Response Unit in Kennewick, where someone called the police.

“He was not oriented to time and place, he couldn’t answer basic questions,” said Edwin Budge, the lawyer for the Moreno family. “It was pretty obvious he was experiencing a mental health crisis.”

But rather than let him get help, police decided to arrest him on March 3, 2016 on misdemeanor charges of driving on a suspended license and failing to transfer the title to a vehicle within 45 days. Eight days later he was dead.

“I’m talking to angels,” the 18-year-old told the doctor evaluating him at the jail.

After his condition was assessed, Marc was put in a small cell by himself with no toilet or sink.

“There was a grate on the floor, but it wasn’t sufficient for defecation,” Budge said. He had no access to water in the cell, no bed, no mattress, no bench.”

Just four walls, the floor and the constant illumination of the overhead lights.

Being locked up in isolation can exacerbate mental illnesses, causing symptoms to worsen as outside stimulus is reduced to a meal tray shoved through a cell door.

Jail officials often claim they have no other choice: They need to protect the prisoner from the general population and vice versa.

Jessica Moreno said that her father tried to warn the jail that his son needed treatment, but that the staff did not listen.

In 63 percent of the cases tracked by The Pilot, family members claimed that the jails had not properly taken care of their loved one.

Day by day, Marc’s condition deteriorated.

On March 5, he was no longer answering questions. On March 6, a doctor noted that he’d slept less than 30 minutes in the previous two days.

By March 7, the fifth day of his confinement, he was smearing feces on the walls and rolling on the floor naked. Staff made no effort to get him mental health treatment or remove him from isolation.

Staff noted on March 10 that Marc had not had food or water for several days. He had also not been able to appear for a scheduled arraignment in front of a judge.

On March 11, having not had anything to eat or drink for at least six days, Moreno died in a cell. He was covered in his own waste.

“One of the things I wonder is – what was the plan?” said Budge, who represented Moreno’s family in a lawsuit that resulted in a $1.2 million settlement. “Who was in charge? Was there any design for taking care of this young man for the long term or was it due to the lack of any place to put him that that was where he was going to be?”

Marc Moreno’s death has left a hole in his family’s heart. Jessica Moreno says her father blames himself for what happened. The grief and guilt in such cases can’t be quantified.

“We were thinking we were doing the right thing, which was to try to get him help,” she said. “And in a way we feel, oh, that’s what caused him to die.... What ended up was him locked up somewhere and left to die.”

At the county level, there seems to be a lack of concern about preventing these types of deaths, Budge said. His law firm has represented families in similar lawsuits for more than two decades.

There is always an insurance company, always a payout and never any change.

“It’s the type of thing that people think, ‘Oh maybe this happens in North Korea. Maybe this happens in Iran.’ But it happens right here,” Budge said. “You can identify failures on multiple levels, but the long and short of it is that someone needed help. Instead they were stuck in a jail cell and left to rot.” 

Jails: The Last Resort

How America’s jails came to warehouse people with mental illness is no secret.
Deinstitutionalization, the release of patients from large institutions, began when Thorazine started being widely used in the 1950s. The medication was the first effective antipsychotic drug, calming and sedating people with schizophrenia and other serious mental illnesses.

By then, the horrific conditions inside America’s mental hospitals were well-known.

“It is only after one is in trouble that one realizes how little sympathy and kindness there are in the world,” Nellie Bly wrote in Ten Days in a Madhouse, her 1887 book on Blackwell’s Island Asylum in New York, America’s first municipal mental hospital.

The process of deinstitutionalization sped up rapidly in 1965, when Congress created Medicaid. The new health program excluded payments to large “institutions for mental diseases.” That forced the shutdown of mental hospitals across the country and was designed to create smaller facilities within communities.

In 1955, state mental institutions had about 558,000 beds. There were 337 mental hospital beds per 100,000 people in the United States, according to a 2016 study by the Treatment Advocacy Center. 

Far too few smaller community facilities opened to make up the difference. Today, there are roughly 12 beds per 100,000 people.

“It is not at all a coincidence that the only illness discriminated from Medicaid funding is mental illness and that there are so many mentally ill in jails,” said Snook, the Treatment Advocacy Center director.

Medicaid will only pay for stays in mental health hospitals that have no more than 16 beds. But facilities that small often can’t survive, Snook said. “They are not big enough to have economies of scale. So what happens is beds disappear, and you have only what the state will pay for.”

That leaves people with mental illness few places to go for help. Even obtaining, and staying on, much-needed medications can be difficult. The drugs can have severe side effects and may need to be changed over time.

Weak, fragmented mental health-care systems across the country have so many gaps that people routinely fall through the cracks, even with family guidance.
“They are looking for anyone to help, and they come up with so few resources. The mental health system has nothing to offer, social support systems have nothing to offer,” said Laura Usher, a mental health advocate and the former senior manager for criminal justice and advocacy at the National Alliance on Mental Illness. “They are seen by others as people to be afraid of rather than as friends and neighbors.”

When families can’t find beds or other services, they often have nowhere else to turn but the police. And in many parts of the country, police have just one option readily available: jail.
Since the start of deinstitutionalization, jail populations have increased exponentially. In 1950, American jails held about 86,500 people. By 1983 there were more than 223,500 prisoners. In 2016, the last year for which data is available, the Bureau of Justice Statistics counted more than 740,700, slightly down from the peak of 785,500 in 2008.

The bureau estimates that 44 percent of jail prisoners have been told by a mental health professional that they have a mental disorder. More than a quarter of the jail population – roughly 186,000 people – are believed to be in serious psychological distress.

Deinstitutionalization never really happened, said Hall, the Nashville sheriff; the burden of care simply shifted.

 “I tell everybody we just reinstitutionalize these people in a different building,” he said. Jails are dealing with a population that has needs beyond what the criminal justice system is able to address.

“It really makes no sense.”

Hall remembered sitting in a National Sheriffs’ Association board meeting about three years ago watching a presentation on a survey that sheriffs had taken to determine their most pressing issue. Someone had created a word cloud out of the answers. The biggest phrase by far was “mental health.”

“From Laramie, Wyoming, to Florida to Vermont and in every Southern state and everywhere else, the number one issue facing sheriffs was mental health,” Hall said. “It gets the attention of most people in what I call the elected offices in law enforcement.”

A Crisis Without Data

Still, little in the way of concrete information is being collected about the conditions people with mental illness endure in jail. Across the country, mental health diagnoses are seldom reported by jails, which can hold someone anywhere from a few days to years. In many cases, jails never get a definitive diagnosis.

The Pilot’s investigation includes every death in which there was an indication of mental illness before the person was arrested. But the 404 deaths counted in the database are likely a fraction of the true number and only hint at conditions for the larger population of people with mental illness in jail.

Through a voluntary questionnaire, the federal government counts more than 900 jail deaths a year in the U.S. but gives few indications of how many of those prisoners were mentally ill. The responses count 522 people who died behind bars after spending a night in a mental health facility while in jail custody between 2009 and 2013, the only years for which data is available.

The Justice Department will not release their names and does not include in its survey any questions to determine whether they had a mental illness before their arrest.
In most cases, inquiries to state agencies yielded little information. Only eight states could provide any indication of how many people with mental illness died in their jails.

For example, about a dozen of the 36 deaths that occurred in a Utah jail, prison or detention facility in 2013 and 2014 were of people with a mental health problem. Officials did not break down the statistics further.

In Virginia, the state Office of the Chief Medical Examiner examined National Violent Death Reporting System data at The Pilot’s request to determine whether information about such deaths could be found there. It provided a report indicating that between 2003 and 2015 about 31 percent of the 709 deaths in custody – which includes deaths in prisons, in police custody and in foster care, among other circumstances – were of people with mental health problems.

Only Texas provided concrete data recording when someone with a mental illness died in an in-state jail. Officials there say their collection methods have gotten more accurate in recent years. Still, the numbers are not perfect.

Texas provided a list of 55 deaths of people with mental illness in state jails. The Pilot’s investigation had already uncovered 36 deaths in the state, but only six of them overlapped with the Texas data.

Usher called it a “travesty” that months of research went into finding out how people with mental illness die in jails and that the picture is still so incomplete.
“I don’t think anyone has investigated this as thoughtfully and thoroughly,” she said of The Pilot’s database. “And I think it shows how far we have to go in treating people with mental health conditions with humanity and dignity. It’s also outrageous that this sort of information, this sort of data is not available publicly. Our jails and our criminal justice system should be held accountable.”

In October 2019, the Bureau of Justice Assistance will start collecting more accurate data on deaths in police and jail custody. The collection, which has been long delayed, was prompted by the 2013 Death in Custody Reporting Act, sponsored by U.S. Rep. Bobby Scott, D-Newport News.

The bureau also will have the ability to withhold some funding from jails and police agencies that do not submit their data, likely making it a far more accurate count of such deaths.

Jails will be asked to submit basic demographic information, as well as the date, time and location of death, the law enforcement agency involved and a brief description of the circumstances.

The bureau will not, a Justice Department spokeswoman said, collect any specific information on whether the person involved was mentally ill.

Scott, who also sponsored the 2013 bill’s predecessor more than two decades earlier, believes the Justice Department should collect data on mental illness, even if it is just in the brief description.

“At least start collecting it. Then people can start doing some research,” he said. “The first step is to get the data. You can review the data and find out what’s happening. And if it’s suicides, you can look and find out how they committed suicide.”

Without data, Scott said, you don’t know what the problems are. And if you don’t know what the problems are, you can’t fix them.

“You know, it seems like a little thing,” he said.

One Jail at a Crossroads

Tucked behind a gas station off Interstate 264 in Portsmouth, the Hampton Roads Regional Jail looks like a series of oversized gray Lego bricks nestled among the trees.

The scene outside, with its ponds, geese and flagpole, is almost serene.

Inside is another matter. Every day, the staff confronts the mental health issues facing all jails, and then some.

The facility has become the physical and mental health-care jail for Norfolk, Portsmouth, Chesapeake, Hampton and Newport News – five of Virginia’s largest municipalities.
The regional jail houses about 1,100 prisoners a day. Unlike most jails nationally, which are run by a sheriff, it is managed by a board of local city managers, sheriffs and city council members.

A dumping ground for prisoners with all kinds of sickness, it is the largest mental health care center in Virginia.

That has led to tragedy.

In April 2015, Jamycheal Mitchell stole a soda and snack cake from a 7-Eleven and ended up in the regional jail. Mitchell, who was bipolar and schizophrenic, thought that the store was owned by his father and that he could take what he wanted.

A judge ordered him twice to a state mental hospital so his competency could be restored and he could stand trial. Court clerks claim the first order was lost in the mail on its way to the hospital. The second was tucked into a desk drawer and forgotten.

Once, jailers tried to send him to the hospital through an emergency order, but he was in court when someone from the local mental health agency arrived and the person never came back.

Through the spring and summer, Mitchell’s condition worsened. He was given no clothes, only a suicide smock that resembles something between a blanket and a mattress pad. He complained that his cell was constantly cold. In a moment of lucidity, he told a fellow prisoner that he stood by the small window in his cell door all the time because he felt some heat there from the overhead light.

Family members said they begged the jail for help for Mitchell but got nowhere. Mitchell clogged his toilet, which caused it to overflow, leading jailers to shut off his water. Prisoners in isolation often flood their cells. Doing so is one of the few ways they can influence their environment.

Mitchell’s feet swelled from constant pacing.

On August 19, 2015, three months after he was first ordered to a mental hospital, Mitchell died alone in his cell with feces on the walls and urine on the floor. The official cause of death was “wasting disease.”

He is one of 71 prisoners with schizophrenia or bipolar disease counted by The Pilot’s database to have died alone in a cell since 2010.

A Justice Department investigation and a lawsuit are still pending in the case. [Ed. Note: the lawsuit settled in January 2019; it will be reported in PLN].

Since Mitchell’s death, the jail has also received a grant of nearly a million dollars to help with staffing for mental health care workers. New management has worked hard to prevent more deaths in the jail and to care for people with mental illness housed there.

“I think it’s fair to say with the leadership having left, with the Department of Justice investigating, with the number of lawsuits, there was definitely a crisis. The community did not trust the jail,” said Linda Bryant, who spent more than a year as the facility’s assistant superintendent following Mitchell’s death.

The staff there now – most of whom are longtime employees – do care about doing a good job, Bryant said. They realize their work is more about responding to and preventing crises than about meting out punishment.

But they routinely find themselves in impossible situations.

A social worker at the jail had to press charges against a severely mentally ill prisoner who masturbated whenever he saw her.

A prisoner who took a bedsheet and climbed atop a basketball backboard had to be talked out of killing himself.

A man taking medications for depression so severe that he was nearly catatonic had to be watched carefully once the drugs started working. Now that he had more energy he could move around, which meant he might try to kill himself.

Each morning, high-level staff members – jail and mental health professionals – start by studying a whiteboard of their sickest prisoners. Their goal is to make it to the next day with everyone alive.

It is a daunting task, especially with chronic staff shortages.

In December 2017, Jonathan Ellis tied a sheet to the end of his bedpost and killed himself. Ronaldo Myers, the superintendent at the time, said there simply weren’t enough staff members keeping eyes on prisoners.

Myers asked the legislature for an additional $5 million for 31 permanent and 50 temporary positions.

In March 2018 the General Assembly rejected the funding increase. Myers left his job by the end of the month.

The new superintendent has not asked the five cities to increase funding to pay for the positions. The jail has hired people, reducing the number of unfilled jobs from 36 in January to nine in August 2018. Officials have also converted some support positions that had been staffed by sworn officers to civilian, freeing up more than a dozen officers to work directly with prisoners. 

In January 2018, Myers made the case in an interview that Mitchell’s death had raised awareness of the jail’s needs.

“The eyes are open. Now there are some dollars that need to be put behind everything to keep the system moving,” he said. “Because if the system gets stagnant, guess what we are going to do? We are going to fall back on the same old thing soon as everything quiets down.”

“They Did Kill Her”

Larryn Rayburn’s 2015 death in the Pontotoc County Justice Center in Oklahoma still haunts her mother, Terryl. The family’s suffering is part of the sad routine of such cases.

Like 124 others in the database, Larryn Rayburn had bipolar disorder. 

Like 43 others, her loved ones tried to warn the jail about her mental illness. 

And as in 254 other cases, there were allegations that the jail or medical provider did not properly treat her mental illness.

Rayburn was arrested and ordered to be held overnight in the jail for admitted marijuana use, according to a lawsuit by the family’s attorney. She was supposed to return to court the next morning, but the jail didn’t bring her back. 

Instead she, like at least 178 others placed in jail with mental illness, died by suicide. “Our view isn’t that she committed suicide,” said Terryl Rayburn. “Our view is that she was a victim of manslaughter. Nobody purposely set out to kill her, but due to their actions, they did kill her.”

Usher, who has worked with many people struggling with mental illness through the National Alliance on Mental Illness, said that families are usually trying to help and are desperate to find services.

“They are told they can’t get help until their loved one does something dangerous,” she said. “And clearly jail is not a safe place for people with mental illness, which your data clearly shows.”

What many people don’t realize, Usher said, is that mental health treatment works if people can get it.

“And even for people who are very ill and have very serious conditions, there is a lot of great recovery stories. Lots of people do really well if they get the right support,” she said. “It requires leadership and compassion and some resources.”

Hall, the Nashville sheriff, said that although the country’s sheriffs are a diverse group, the need to better address mental health care in jails is one issue that most, if not all, agree on.

Ultimately, money needs to be redirected from jails to treatment, he said, and people with mental illness charged with minor crimes need to be kept out of the criminal justice system altogether.

“I think you have to look people in the face, like myself and people in these positions, and say, ‘Look, you don’t need the money you have in your budget,’” Hall said.

“I think that’s how we got here,” he added. “It became sexier to call it public safety and hire police, buy police cars and jails and all that. And so you would need to remove that money out and put it in the hands of what I think is a health issue, not a criminal justice matter.”

Providing better mental health care is not cost-prohibitive, but it requires looking at big systems such as criminal justice and mental health care, and figuring out how to best spend tax dollars and treat people, Usher said.

“It requires that you look at and address the whole system rather than just one piece at a time,” she said. “You are spending a lot of money on jailing people, salaries for correctional officers, homeless services, ER beds – all that emergency and crisis care. So we are spending a lot of money there that we might be saving if we were providing counseling and case management. It’s a much better investment on the front end.”

Until that investment happens, mental illness will go on being criminalized.

And the deaths of prisoners with mental illness in America’s jails are bound to continue. 

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Marquette University students Alexandria Bursiek, Rebecca Carballo and Diana Dombrowski contributed to this report. This article was originally published by The Virginian-Pilot (www.pilotonline.com) on August 23, 2018; it is reprinted with permission, with minor edits. Copyright, The Virginian-Pilot 2018.

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