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Death Exposes Inadequate Mental Health Care in Oregon Prisons

On April 29, 2002, the tormented life of 45-year-old Oregon prisoner William Owens came to a tragic end in the Disciplinary Segregation Unit (DSU) of the Snake River Correctional Institution (SRCI). His death exposed numerous problems with the treatment afforded mentally ill prisoners in Oregon Department of Corrections (ODOC) facilities, according to a September, 2003, investigative report of the Oregon Advocacy Center (OAC), a federally authorized and funded law office established under the Protection and Advocacy for Mentally Ill Individuals Act of 1986 (42 U.S.C. §§ 10801-10851).

Throughout most of his life, Owens was haunted by debilitating mental illness, stemming from severe childhood abuse including such horrors as being tortured with electricity, bullwhipped, hit with a 2 x 4, witnessing a sister's rape and separation from his parents, all before the age of ten. Owens began using methamphetamine, heroin and crack cocaine intravenously and drinking alcohol as a teenager. He dropped out of school in the 10th grade and was later determined to be in the borderline range of intellectual functioning and as having low-average intelligence and possibly brain damage.

In 1987, Owens was charged with the attempted murder of his grandmother and his brother. He had a good relationship with these family members and described "his criminal behavior as the result of `bad drugs' (amphetamines). He evidently believed that some evil intruder inhabited his grandmother's body and that he had to free [her] by killing the evil intruder. His brother intervened to protect [her]."

While in jail awaiting trial, Owens attempted suicide by cutting his right wrist on glass while suffering paranoid delusions and hearing voices. He was determined to be mentally unfit to proceed to trial and was committed to the Oregon State Hospital (OSH) for six months.

In 1988, Owens was eventually brought to trial, convicted of attempted murder and sentenced to 20 years in prison. He was initially sent to the Oregon State Penitentiary (OSP) but was transferred to OSH on four separate occasions due to his mental problems.

Owens was paroled in 1992 but he was returned to prison in 1994 for using alcohol and methamphetamines on parole. He then spent more time at OSP and OSH before ultimately ending up at SRCI. "Throughout his incarceration, [] Owens had recurring psychosis wherein he believed that his family was being tortured, was being killed or was dead. He experienced visual and auditory hallucinations along with paranoid delusional thinking. Mr. Owens heard screaming and crying that he believed to be from family members. . . While psychotic, he sometimes refused meals, medications and showers."

"When actively psychotic, Mr. Owens became convinced that there was a conspiracy/plot against his family and loved ones. He was considered to have exceedingly dangerous paranoid delusions. He believed that staff or other inmates were part of a conspiracy or plot against his family. He heard the television, inmates and staff talking about plans to harm or torture his family. He became angry and anxious. He confronted and accused other inmates of harming his family."

During his incarceration, Owens took unusually high does of anti-psychotic medications such as Haldol. He was admitted to the prison psychiatric ward at least thirteen times, spending nearly a year there upon his last admission. "He also spent over eighteen months on transfer to [OSH] for treatment of delusional, paranoid thinking, potential for violence against others, potential for self-directed violence, social isolation and other mental health symptom management." As early as 1991, he was diagnosed with chronic schizophrenia.

Throughout his confinement, Owens had several incidents of self-harm and attempted suicide. In 1994, "he attempted to hang himself with coveralls and sheets while in [DSU] . . . and was found lying face down in his cell with smears of blood on the wall and floor near his head three months prior to his death."

Owens was described as obese during his incarceration. At the time of his death he was 5' 8" tall but weighed 270 pounds. "His breathing was noisy and he needed to expend much effort even for small movements."

As a result of his mental illness, Owens was confined in DSU on several occasions. On February 18, 2002, Owens was sent to DSU for an altercation with his cellmate while hearing voices. He was sanctioned to serve 145 days in DSU. He served 70 days of that sanction before his death.

In the days and hours preceding his death, Owens exhibited several significant signs of his deteriorating mental state which were ignored by prison staff. "On the day before his death, Mr. Owens was found at 7:33 p.m., punching his cell window with his fist such that his knuckles were bloodied. He refused medical attention. He reportedly kicked his cell door throughout that evening. SRCI staff did not immediately remove him from [DSU] and thoroughly assess his mental health status."

At 9:15 a.m. the next morning, DSU staff told Owens they were going to let him out for a shower. "He reportedly glared at the officers, put on his shower shoes and walked to the cell door. When he reportedly continued to glare at staff, a staff person asked him if he was going to cause any trouble during the escort. Mr. Owens nodded his head, signifying yes. Staff then informed him that he was being refused a shower because he affirmed he planned to cause a problem to staff." "At 11:00 a.m., when lunch was being served, he was asked if he was going to eat and he shook his head in a manner that was taken to mean, `No.'

"At 1:10 p.m., (more than seventeen hours after Mr. Owens was found punching his cell window, approximately four hours after he had been denied a shower, and more than two hours after he refused to eat) two escort officers arrived at his cell with the intent to move him to close supervision status. Mr. Owens was found in his cell lying face down on the floor with his hands beneath him. Blood smears were observed on the wall and floor of his cell." His glasses were broken and lying near his head. Although Owens was breathing and some movement was noted, he did not respond to orders to show his hands.

An extraction team was organized to subdue Owens and remove him from the cell. A guard and "nurse attempted to get a response from Mr. Owens by calling out his name and knocking on the cell door. He was not immediately responsive but then he stood up. Blood was observed on his face and forehead. What appeared to be a broken pen was observed in his right hand. He began to stab himself in the right side of his neck with the pen."

A guard ordered him to stop stabbing himself, drop the weapon and back up to be restrained. When he did not comply, Owens was sprayed with "Freeze Plus P" pepper spray for approximately four seconds. He then stopped stabbing himself and sat on his bunk.

Owens "again began stabbing himself in the right side of his neck. . . He appeared to be out of touch reality. The response team leader sprayed Mr. Owens with a second dose of pepper spray for approximately four seconds. He stopped stabbing himself . . . briefly, but then recommenced. At this point, Mr. Owens was sprayed with pepper spray for a third time for approximately two seconds."

The pepper spray was so potent that a nurse who was not in or near the cell had to be relieved due to second-hand inhalation of pepper spray and a guard was affected by the spray and had to step outside to breathe more freely.

"Throughout this incident guards shouted commands at him such as `stop resisting.' The guards did not specify how Mr. Owens was resisting. There were essentially no attempts to engage him in any dialogue. Mr. Owens seemed `out of it,' his movements were slow and unsteady and he seemed disoriented and frenzied. He never spoke nor acknowledged staff directives."

Guards determined that Owens was "resisting" and he "was put into a wrist restraint mechanism attached to the wall and guards were holding him on either side." A guard ordered him, in "a sharp, mean tone to face the fall. His face appeared bloody at this time. His forehead was forcefully shoved against the cinder block wall for no apparent reason."

Five guards then took Owens to the ground, and ordered him "to settle down, to stop resisting, to cool down, to think, and to follow staff directives. . . . While on the ground, he began spitting up blood."

"Owens was face down (i.e., in a prone position) on the floor with his hands handcuffed behind his back with several officers kneeling around him. At this time, [someone] stated that Mr. Owens was not breathing." He was subsequently moved onto his side and removed from the wall restraint prior to being moved to the center of the room and positioned on his back.

"During the revival efforts, there were many security and medical staff present, but no one appeared to be in charge of the situation. No one instructed staff to immediately begin CPR. There appeared to be hesitancy to begin CPR, which began only after discussion and locating of a mask." Staff was not able to revive Owens and he was pronounced dead at the scene.

"From the moment Mr. Owens was found not to be breathing: Approximately two minutes passed before staff, with a nurse present, removed Mr. Owens from the wrist restraints that bound his hands behind his back; over four minutes passed before CPR was commenced: the first `rescue breath' was given after over four minutes of delay and the first chest compression was administered after an additional one-half minute delay; over four minutes passed before an ambulance was contacted; nearly twenty minutes passed before an ambulance arrived." Additionally, "as Mr. Owens lie dying, SRCI staff members engaged in" unrelated banter, "unrelated conversation, laughter, a kiss from a nurse to an officer, a staff person who asked for a round of applause and ensuing laughter."

The Medical Examiner stated the cause of death as "Restraint Syndrome with preterminal positional asphyxia." The Oregon State Police "report determined that Mr. Owens' death was an accident, with the cause being Restraint Syndrome." The matter was referred to the Malheur County District Attorney's Office, but the case was not prosecuted because the "[d]eath was not caused by a criminal act."

Following Owens' death, the ODOC conducted an internal investigation and completed a Critical Incident Review (CIR). "The CIR raised concerns regarding compliance with DOC rules regarding use of force. Among several other concerns, the CIR found "that there was not a correctional objective for using pepper spray on Mr. Owens, who was unresponsive." The CIR also cited concerns regarding the delays in revival efforts and a lack of professionalism of the staff that were present.

The OAC found: (1) inadequate mental health treatment and care at SRCI, stating that Owens "was . . . sanctioned to disciplinary segregation for behaviors that appear to be a direct result of his mental illness. Punishing psychotic behavior with segregation is inhumane, unjust, and ineffective[;]" (2) failure to avoid using a prone restraint/containment technique in a psychiatric/medical emergency circumstance, stating "[t]he use of prone restraint is dangerous and should be avoided particularly when a person is exhibiting psychotic or delirious behavior[;]" and (3) inadequate care and monitoring during the use of chemical and physical restraints. Additionally, the OAC recommended: (1) improving mental health treatment and care for residents at DOC facilities by (a) providing mental health treatment rather than punishment for behavior that is symptomatic of serious mental illness, (b) providing comprehensive training of all DOC staff in identifying symptoms of emotional and mental disorders, (c) the adoption of more stringent and specific policies restricting the use of disciplinary segregation for persons with serious mental illness requiring at a minimum thorough evaluation of contraindications to disciplinary segregation, due process procedures, (iii) evaluation of the relationship between a prisoner's behavior and mental illness, (iv) consideration of all alternatives to disciplinary segregation, (v) a cap of fifteen days of disciplinary segregation, and (vi) provision of appropriate mental health treatment to prisoners in disciplinary segregation; (2) avoiding prone restraint/prone containment of prisoners; and (3) improving seclusion and restraint care and monitoring practices.

Finally, the OAC noted that "[a]pproximately fifteen SRCI employees filed grievances through their Union Representative," raising concerns about (1) their exposure to blood borne pathogens (BBP); (2) the denial of an opportunity to clean-up after their exposure to BBP; and (3) the failure to have been offered the option to take administrative leave following the death of Mr. Owens. Yet, nobody was moved to file a complaint about the way Owens was treated which resulted in his death. Ultimately, the OAC concluded "Mr. Owens' death may have been avoided if clinical considerations had been paramount in planning his transport."

ODOC spokesperson Perrin Damon said the ODOC is taking the OAC's recommendations seriously. Yet, responded to the report by stating: guards followed proper procedures; Owens faked being unconscious before jumping up from the floor and repeatedly stabbing himself in the neck with the pen; and he refused to follow verbal orders and put up a struggle. "This pattern presented a particular danger to the staff," the department said. ODOC officials also suggested that staff were slow to help Owens because they weren't sure if he was feigning unconsciousness, and staff had trouble finding a mask to begin mouth-to-mouth resuscitation.

On April 27, 2004, Owens' family filed suit in federal court against the state, 10 guards and the former SRCI Superintendent Robert Lampert, alleging cruel and unusual punishment and seeking unspecified economic, non-economic, and punitive damages.

Don Loving, spokesman for Oregon Council 75 of the American Federation of State, County and Municipal Employees took issue with the "tone" of the newspaper article concerning the suit filed by Owens' family, stating "To say that Billy Owens, an inmate with a long history of mental illness, `died at the hands of correctional officers' paints a very tainted truth. . . . Billy Owens' death was a tragedy that likely could have been avoided. But don't blame the officers involved. It sounds like a cliché, but blame `the system.' It needs to change."

It should be noted that the Ninth Circuit court of Appeals approved the Oregon DOC's use of restraints in LeMaire v. Maass, 2 F.3d 851 (9th Cir. 1993), amended 12 F.3d 1444 (9th Cir. 1993) and it has been an ongoing problem ever since. As the OAC noted "[t]here is increasing evidence that the use of prone restraint can be lethal." The OAC report may be reviewed at

Finally, unrelated to this incident, Superintendent Lampert was removed from his position as Superintendent of SRCI, demoted to Assistant Superintendent and transferred to OSP for sexual harassment. Subsequently, he was hired as Director of the Wyoming Department of Corrections.

Sources: Report of A Review of the Mental Health Treatment, Restraint, and Death of William James Owens in the Oregon Correctional System, Oregon Advocacy Center, (September 2003); The Oregonian.

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