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California Jail’s Psychotropic Medication Policy Leads to Lawsuit, Settlement

Cost cutting is a staple of most prison and jail systems. However, a mid-2007 decision by California’s Fresno County Jail (FCJ) to restrict psychotropic drugs for prisoners turned out to be a short-sighted exercise that resulted in human suffering and financial costs far exceeding any savings.

FCJ was accredited in 1998 and 2000 for meeting constitutional standards of medical treatment by the Institute for Medical Quality, an organization that examines healthcare in California prisons and jails. Citing budgetary issues, FCJ did not seek the voluntary accreditation after 2002.

Oversight of FCJ’s psychiatric services was within the jurisdiction of the Fresno County Behavioral Health Department, but faced with a $16 million budget deficit at the end of 2005, that task was handed off to the Department of Health.

The county’s health department was better equipped to administer flu shots, inspect restaurants, and operate clinics for sexually transmitted diseases and tuberculosis. Dr. Edward Moreno, the county’s health officer, warned county supervisors that “There would be instances when some inmates would not be seen at all.”

Faced with his own budget shortfalls, Moreno obtained approval to make his statement self-fulfilling. To save $768,231, the Board of Supervisors approved the elimination of FCJ’s 11:00pm to 7:30am nursing shift. Guards took over medical and mental health screening of arrestees during that period.

“I had the impression it wasn’t as thorough,” said retired jail guard Joanne Cox. “It was more checklist-oriented, and they didn’t seem to research it any more than that. If you weren’t exhibiting some kind of a problem, they would say ‘He’s fine,’ until it became a crisis call.”

Shortly after eliminating the nursing shift, health officials started looking for more ways to cut costs. Psychotropic medication expenses were next on the list. In 2006-07, FCJ spent $974,372 on such drugs. After a review of the jail’s formulary, or list of approved medications, FCJ changed from brand-name drugs to generics wherever possible. It also cut Seroquel, used to treat schizophrenia, and Wellbutrin, an anti-depressant, from the formulary, except in isolated cases.

The financial savings were dramatic. Over the next five years the cost of psychotropic drugs at FCJ dropped by 89%; in 2011-12, the jail spent only $99,302 on such medications.FCJ officials contended that the formulary change was about more than just cost cutting; it was also to address drug abuse by prisoners. George “Bud” Laird, a psychologist in the county’s correctional health division, and Pratap Narayan, FCJ’s full-time psychiatrist, presented a paper at a March 2009 meeting of the California Department of Corrections and Rehabilitation’s Council on Mentally Ill Offenders. Their paper, “Formulary Controls: Abuse of Psychotropic and Dispensary Costs in the Incarceration Environment,” argued that prisoners were faking mental illnesses to obtain Seroquel and Wellbutrin.

According to Laird, prisoners called Seroquel “baby heroin” and crushed or snorted Wellbutrin to obtain a rush similar to speed. Cost reduction, he said, was not a motivator in the changes to the FCJ’s formulary. “I was not pressured to cut costs at the jail,” he claimed.

However, a former county supervisor recognized the real reason behind the medication changes at FCJ. “When the county does anything like that, it’s always about saving money,” said Susan Anderson, who served three terms on the Board of Supervisors before retiring in 2012.

Withholding necessary drugs, including psychotropic medications, is bad practice. “You can’t be so simplistic as to say, ‘If you’re already on it, you can’t stay on it,’” said Rusty Selix, executive director of Mental Health America of California. “There are definitely people who need those drugs. For some, they’re the only drugs that will work.”

While the new medication policy at FCJ resulted in dramatic cost savings, it also caused appalling human suffering and loss of life. Prior to entering FCJ in 2012, Travis Fendley was taking four drugs: the antipsychotic medication Latuda, the anti-anxiety medication Clonazepam, and two antidepressants, Prozac and Frazodone.

Fendley, whose mental health diagnosis included schizophrenia which caused him to hear voices, was given only Prozac by FCJ medical staff. The lack of medications and treatment resulted in his mental illness spinning out of control.

Upon his release from FCJ on December 17, 2012, even Fendley, 23, knew he had problems. “Things aren’t going to turn out well,” he told his aunt, Becky Alford, who picked him up from the jail. He told family members “the demons in his head” were ordering him to hurt himself and his loved ones. While at FCJ, he had tried to slash his throat during a suicide attempt.

Efforts by Alford to calm Fendley failed, and he jumped out of her car and began walking towards his 78-year-old grandmother’s house. Once there, he begged Alford to allow him to stay. She let him spend the night in the garage and left.

The next morning, Fendley twice answered the phone to say his grandmother was sleeping. Alford arrived to find she had been strangled to death; according to a police detective, Fendley confessed to killing her. He pleaded not guilty by reason of insanity.

Since 2007, FCJ has sent nearly 400 prisoners to state mental hospitals, the highest per capita rate of all California counties except Kern. The average hospital stay of six months costs about $108,000. FCJ sent 75 people to three California state mental hospitals in 2011-12, which cost taxpayers about $8.1 million.

The justice system experiences additional costs and backlogs as cases are put on the backburner while defendants receive treatment. Some cases result in several trips to a hospital because the prisoner’s medication is discontinued upon their return to FCJ, and they decompensate.

“You need to get them proper care right off the bat,” said Fresno psychiatrist Howard Terrell. “Get them healthy, so you don’t need to go off to [a state mental hospital]. It relieves huge amounts of pain and suffering, costs to the jail, crowding in the jail, and streamlines the legal system. Doing the right thing makes sense medically, ethically, and financially.”

Defense attorney Scott Kinney experienced the lack of adequate treatment at FCJ firsthand after his 2008 arrest for domestic violence. He had taken lithium for 15 years to treat his manic depression and bipolar disorder. For nine months at the jail, he did not receive medication.

“They wait for you to fall apart before they take care of your medical condition, but by then you think they’re Martians and it’s too late. The jail doesn’t want to recognize that people will deteriorate, but when they do they’ll become a bigger problem,” said Kinney. “My behavior must have been bizarre.”

FCJ was sued in 2011 by the Prison Law Office, an Oakland-based organization that files lawsuits against prisons and jails over unconstitutional conditions. “We singled out Fresno County because of the stories we were hearing about their refusal to prescribe medications,” said Prison Law Office staff attorney Kelly Knapp.

Following a series of allegations of medical malpractice, the former chief of psychiatric services at FCJ, Dr. Narayan, had his medical license suspended and was ordered to enroll in a clinical training program. Narayan worked at FCJ for five years before accepting a position at Avenal State Prison in February 2013; he was placed on probation by the Medical Board of California. [See: PLN, March 2016, p.50].

Still to come are more lawsuits stemming from FCJ’s medication policies. One suit alleged the jail was responsible for the February 2012 murder of Tracy Dewayne Phillips, 47, by his mentally ill cellmate, Jose “Jesse” Guadalupe Cuevas, 27. In April 2016, Cuevas was found guilty after a jury determined he was sane at the time he stabbed Phillips to death with a pencil. Fresno psychologist Harold Seymour said he expects more litigation.

“The jail just had a mess on their hands because nobody was getting the treatment that was clearly indicated,” he said. “It’s going to cost so much more than what the county saved on a short-term basis.”

The Prison Law Office settled its federal class-action lawsuit in May 2015, requiring Fresno County to hire 127 new jail guards and pay $900,000 in attorney fees. While prisoners did not receive any money from the settlement, the county agreed to implement a Remedial Plan to address shortcomings in FCJ’s medical and mental health care at a cost of approximately $4 million during the first year alone. The county is also on the hook for $40,000 in annual monitoring costs to ensure compliance with the settlement terms.

Specifically, the settlement requires the jail to ensure that prisoners with chronic conditions receive the medications they need; that pregnant prisoners receive prenatal and postpartum care; that suicidal prisoners receive risk assessments; that mentally ill prisoners in solitary receive out-of-cell recreation time for at least seven hours a week; and that disabled prisoners are placed in appropriate housing based on their disabilities. See: Hall v. Mims, U.S.D.C. (E.D. Cal.), Case No. 1:11-cv-02047-LJO-BAM.

“I truly think that what we’ve done here will create a better environment for both inmates and correctional officers and this is a situation where people of Fresno County should be happy with the results,” said attorney Michael Woods, who represented the county.

Unfortunately, it took years of mentally ill prisoners suffering without their psychotropic medication to reach that point. The final settlement agreement was approved by the district court in November 2015, and three experts were appointed to “advise the Court on the adequacy of implementation of the Remedial Plan.”

The prisoner class members were represented by the Prison Law Office, Disability Rights California and the law firm of Cooley LLP.


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Related legal case

Hall v. Mims