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No place to be sick: When jail cell becomes a death chamber

Olympia makes no effort to regulate Washington’s jails, the state’s psychiatric hospitals of last resort

By Levi Pulkkinen,

Jimi Johnson, bottom, was 27 when he killed himself at Mason County Jail on April 23, 2013. Two years later, on Sept. 16, 2015, Brandon Dahl did the same. Dahl's noose and cell at that Shelton jail are pictured above. 

Jimi Johnson had been bouncing between the emergency room and jail for months before he was booked for the final time.

At 27, Johnson’s schizophrenia was feeding him hallucinations that only grew worse inside his Shelton jail cell. He downplayed them in a last letter to his grandmother – the voices, he wrote from solitary, were “not that BAD!!” Then, on April 23, 2013, he strangled himself with a bedsheet looped over his Mason County Jail bunk.

Two years later, it happened again.

Like Johnson, 31-year-old Brandon Dahl found himself locked up alone after a string of strange, minor crimes. Having been badly beaten during a purported “attitude adjustment” delivered by other inmates, Dahl tried suicide on Sept. 15, 2015.

He didn’t manage it that night. But, left alone with a sheet and uncontrolled mental illness, he tried again the next night and succeeded.

“The bottom line is that we were left without the tools necessary to care for mentally ill inmates,” one former jail worker said in a sworn statement. “Everyone knew it, nobody did anything about it, and at least two inmates died as a result.”

“Their families thought, ‘At least there, they’ll be watched. At least there, they’ll be taken care of,’” said Ryan Dreveskracht, an attorney representing Dahl’s father and Johnson’s grandmother. “The jailers should’ve been trained on how to recognize and know how to deal with mentally ill people. There should be policies in place that keep them safe. …

“Everyone is at risk when you have these sort of roughshod operations like these jails.”

And yet there is absolutely nothing in Washington state law that would change them.

No oversight, no standards

Washington, like the rest of the United States, moved away from large psychiatric institutions in the 1970s and 1980s. The change was motivated in part by disgust at the hospitals, seen as hopeless, overly restrictive and abusive places.

Instead, by accident and negligence, the nation’s mentally ill were sent to jail.

Jails are meant to temporarily house criminal defendants waiting for trial or serving short sentences. They are designed for waiting, transition and confinement. They are not built for healing.

No one denies that reality. No one seems to like the situation either. Whether anyone will change it, though, remains an open question.

Olympia does not set standards for Washington's jails. Each is profoundly local, managed by an elected sheriff and funded by county taxes.

State prisons officials note that they are the state’s largest mental healthcare provider. King County’s jails may be the state’s second biggest de facto mental institution. Most of Washington’s county jails are the only secure facilities in their jurisdictions where a person in crisis can easily be held against their will.

Smaller jails have not adapted to the new reality. A recent Public Citizen/Treatment Advocacy Center survey showed that just 11 percent of jails with fewer than 50 inmates have added civilian staff to care for seriously mentally ill inmates. Only one third of America’s jails offer individual psychiatric counseling.

Most of Washington’s 57 county and city jails don’t have full-time medical staff, said Ned Newlin, a former corrections chief for Kitsap County now with the Washington Association of Sheriffs and Police Chiefs. Very few have psychiatric services.

“It’s not that sheriffs and chiefs that run jails don’t want to provide those services,” Newlin said. “A lot of times, those services don’t exist in the community.”

Every Washington county outside the Olympia-to-Everett urban belt is experiencing a critical shortage of mental health workers. Not counting Indian Health Services doctors, there were only two psychiatrists practicing in rural Washington in 2014.

In March, a team of Gonzaga University law students, led by Disability Rights Washington researchers, did a snap survey of all of Washington’s jails.

They found most facilities weren’t built or staffed to care for people with mental illnesses. Jail staff often placed severely mentally ill inmates in solitary cells. There was no consistency in practices, policy or oversight.

“We just didn’t know what was happening,” said Kayley Bebber, an attorney with Disability Rights Washington’s jail project, Amplifying Voices of Inmates with Disabilities. “No one else is keeping track right now.”

‘The last priority’

Inmates who could use inpatient psychiatric treatment rarely receive it, Newlin said. Hospital space is at a premium in Washington – some advocates estimate the state needs five times the number of psychiatric beds currently on offer – and the highest priority is given to people in the community.

“The last priority are the people who are in jails,” he said. “That’s the way it goes with the civil commitment process.”

Marc Moreno could’ve used a hospital bed instead of a jail cell. That, Bebber said, was why the Pasco teen’s family took him to a crisis services center.

The Kennewick center, aware that the 18-year-old had outstanding warrants, called the police and had Moreno arrested on March 3, Bebber said. Moreno died of dehydration eight days later as Benton County Jail workers carefully noted his decline.

“Everything that could have gone wrong did go wrong,” Bebber said.

“Why,” she asked rhetorically, “are we sending people to jail when they’re in the middle of a mental health crisis?”

Moreno’s family is preparing to sue Benton County over the young man’s death. His supporters produced a video tribute to him after the county released a humiliating video showing Moreno’s booking.

In-custody mental health care generally comes down to medication management. But jails struggle to ensure that inmates are able to receive medication when they’re transitioning into or out of jail.

“Care coordination is a big challenge for jails,” Newlin said.

“Most people don’t come into jail with their medications,” he said. “The reason they come across the criminal justice system is that they’ve stopped taking their medications and committed some crime.”

Of course, a difficult job can still be done right. Or wrong.

‘Absolutely no training’

Lori Dodge, a former Mason County Jail worker, said no one there knew the rules for handling mentally ill inmates. Dodge, in a statement to the court, said she and her colleagues received “absolutely no training” on the official policies.

Instead, jail staff followed unofficial practices set out by managers there, Dodge said. Inmates known to present a suicide risk were left alone and unsupervised.

Lawyers for Mason County contend jail staff didn’t know Johnson posed a suicide risk, and that practices at the jail were legally sufficient. They’ve denied responsibility for Dahl’s death as well.

By Dodge’s account, the jail was chronically understaffed. Overburdened jailers could not complete all their duties or respond to “kites” – written requests for assistance from inmates. The kites were passed from one shift to the next without action. Most ended up in the trash.

Suicide prevention measures were not implemented. The danger had been known since at least 1999, when another young man strangled himself at the jail, Dodge said.

“It was only a matter of time until someone died again,” she said.

Following Johnson's suicide, Mason County Sheriff’s Office brass sought funding for crisis intervention training that would help jail staff better serve mentally ill inmates. They didn’t get it.

“And we were just denied mental health funds for our (crisis intervention) training,” Sheriff Casey Salisbury said in a memo uncovered by attorneys for Dahl and Johnson. “We’re so progressive! Let’s wait and see how many people’s lives are damaged before we do something proactive.

“I just don’t know what people are thinking,” wrote Salisbury, who was the county’s undersheriff when he wrote the 2014 memo.

Nationally, just 2 percent of a corrections officer’s training relates to mental health services. They are taught to operate a jail, not a psychiatric hospital, which probably made sense in an era when they weren’t being asked to do so.

Locked alone with a terrifying mind 

Jimi Johnson spent the last months of his life in crisis.

He tried to end it at least three times, and was hospitalized with suicidal ideation and schizophrenia four times, including a forced 10-day stay. By the time he broke down in October 2012, he was sleeping just an hour or two a night.

His grandmother, Peggy Johnson, took him to Olympia’s Providence St. Peter Hospital on Oct. 9 of that year, after he told her he was hearing voices urging him to kill himself. He asked staff at the hospital if someone could read “the microchip in his head.”

“I think I’m going to be here for a long time,” Johnson told staff.

That, too, was a delusion.

Johnson was discharged the next day without a plan for his care, according to medical records filed with the court. He was told to make an appointment with a counselor.

Johnson bounced in and out of the hospital’s emergency room for a few days. Peggy wanted him committed somewhere that could keep him safe until his psychosis could be managed; he wanted a brain scan to find the chip he believed to be in his head.

“I’m not crazy,” Johnson told a counselor at the hospital. “It is not mental health. There are microchips behind my ear and in my stomach. Quit playing stupid with me, you know what’s going on.”

Johnson was sent home with his grandmother.

The cycle repeated again a few weeks later. Psychotic and suicidal, Johnson’s father had found him standing on a chair with a noose looped around his neck. Johnson refused to provide blood and urine samples necessary to have him voluntarily admitted to inpatient treatment. He told hospital staff he was only there to have the microchips examined.

After six months of psychosis, Johnson was involuntarily committed on Oct. 25, 2012. Johnson was diagnosed with schizophrenia and released after a 10-day stay. He had planned to move into a Shelton motel and receive outpatient care through the Squaxin Island Tribe’s medical office.

After a promising few weeks, Johnson tried to kill himself again on Dec. 30, stabbing himself in the arm with a steak knife while attempting to overdose. He ended up in Mason County Jail on warrants related to a prior sexual offense and allegations that he had failed to update his sex offender registration.

Johnson, refusing his medication, was housed in solitary confinement, “hooting and hollering” in his cell alone, another inmate reported. He was still hallucinating that April, writing in a letter to his grandmother that the drugs were helping.

Peggy Johnson was there in court on April 22, 2013. Johnson looked to her to be suicidal. She called the jail that day in a panic, begging jail staff to look after her grandson.

At 1 a.m. the next morning, a corrections officer found Johnson sitting next to his bunk. He had strangled himself by looping a noose, made from a torn sheet, over the bedframe.

'Obvious to any competent corrections official'

Despite a warning in jail policy papers that people experiencing psychosis are always to be considered a suicide risk Johnson had not been put on suicide watch. He’d been placed in a high-security area, jail staff later reported, because other inmates tend to abuse sexual offenders.

Eldon Vail, former head of Washington’s prison system, described the jail’s inaction in the wake of Johnson’s suicide as “deeply disturbing.”

“A death in a correctional facility is a very serious incident,” Vail said in an affidavit filed by Johnson’s attorneys, for whom he is a paid consultant.

Vail noted that the jail’s “suicide cells” were not adequate to that purpose. They lacked the large, fishbowl-like windows that enable jail staff to easily see the entire cell. In Mason County, the cells had solid steel doors and shutters.

Vail said that, during a March tour of the jail, a man could be heard “babbling incoherently” inside one of those cells. Jail staff had closed the shutters on the cell window.

“These problems are obvious to any competent corrections official exercising his or her good judgment,” the former Department of Corrections chief said in court papers.

Johnson’s death should have shaken the 150-inmate jail’s leaders into action, Dreveskracht said. But, the attorney continued, it didn’t change a thing.

And so it happened again.

‘Attitude adjustment’ ends in suicide

Brandon Dahl should’ve been a familiar face at Mason County Jail.

But when his father, Keith Dahl, called to ask after his son, the jail worker who was supposed to be caring for Brandon’s mental health didn’t know who he was. Keith was worried his son was going to kill himself.

Dahl had been jailed in October 2014 and then extradited to Utah the following January to resolve a warrant. When he was ready for release, Keith Dahl drove out to pick up him up.

Brandon Dahl was breaking down. He didn’t sleep for days, talked nonsense and was generally distraught.

Passing through Kittitas County, Dahl lost it. He attacked his father, punching him in the back of the head while ranting incoherently. He was arrested and taken to the Ellensburg jail.

Released again after a three-month jail stay, Dahl was enrolled in outpatient treatment. According to the lawsuit, Keith sought out a more intensive program but was told it was too full to accept his suicidal son.

His illness unmanaged, Dahl’s behavior worsened. He was arrested after stealing a case of beer and drinking it in front of the store. Released, he repeated the crime days later before punching his mother and stealing her car.

Dahl was arrested in the early hours of Sept. 13, 2015, and booked into Mason County Jail. He did not leave it alive.

Jail staff placed Dahl in solitary confinement, locked up alone 23 hours a day. Keith called the jail to warn staff that his son was suicidal.

According to his attorneys, Dahl was released to a larger unit for an “attitude adjustment” after angering a jail worker. He was beaten badly by three other inmates, then dumped in a solitary cell, unable to get up.

Dahl tried to hang himself shortly after the assault but couldn’t manage it. The bruises and abrasions still disfigured his face when he tried again the following day.

That night, Sept. 16, 2015, a jail worker passing Dahl’s cell spotted him strangled with a sheet tied to his bunk.

Dreveskracht described the autopsy that followed as having been shoddily done. Investigators determined that Dahl died of hanging and noted that his face was severely bruised; the attorney said medical examiners may have ignored or missed evidence that the earlier attack on Dahl contributed to his death.

Both men, Dreveskracht said, were basically tortured to death. Denied relief, they were tormented by their illnesses until they couldn’t stand it any longer.

Legislators pitching oversight; counties want money, too

Washington once had a robust set of statewide standards for jails. The Legislature created an oversight board in the 1970s meant to force modernization of the county jails.

But the state was also paying the counties’ way back then, assisting in the construction of new jails. That state funding disappeared and with it, in 1987, went uniform jail standards.

Around 2010, Newlin and other state jail leaders decided they would try to establish a jail review process that might be feasible for most Washington jails. Several national accreditations exist, but the expense and time involved dissuade most jurisdictions from pursuing them.

Newlin’s employer, the Washington Association of Sheriffs and Police Chiefs, rolled out an accreditation program in 2014. The South Correctional Entity – a regional Des Moines jail housing low-level suspects and offenders – was the first to receive the accreditation.

Working with Disability Rights Washington, SCORE was able to cut its use of solitary confinement by 60 percent. More than that, Executive Director Penny Bartley and her team changed the place’s culture.

SCORE added a full-time nurse to manage inmates’ medications and four therapists to provide counseling to inmates with mental illness. They improved screening practices so that staff at the 700-inmate jail know who in their care needs help, and moved those inmates into a wing oriented toward providing mental health care.

“Instead of warehousing them and waiting for them to leave, it’s in everyone’s best interest to invest in them while they’re here,” said Nancy Whitney, a veteran community health worker brought on as SCORE’s director of mental health services in July 2015.

“Jails are where mentally ill people show up now. … Old school is, throw them in a cell and wait them out,” Whitney said. “This is a major culture shift.”

Jim Kelly, SCORE’s deputy executive director, described the change as a “no-brainer.” About half of the jail’s inmates need mental health services. If they don’t receive them inside, they’re unlikely to get them anywhere.

Whitney said the work can be challenging, and there’s no sure fix. Some inmates continue to cycle in and out of SCORE without stabilizing. But the payoff, she said, is huge.

Picture an 18-year-old young man. He has landed in jail during his first psychotic break after, say, throwing his mother to the ground. At SCORE, if it all works correctly, he gets stabilized and connected with care.

“You get to send him to the hospital, and he comes back and looks like he’s joined a boy band,” Whitney said. “He’s back off to college and you never see him again.”

Bebber proposed a two-pronged approach – stop charging people with minor crimes tied to their illnesses, such as trespassing or unlawful bus conduct, and create a state oversight office to push jails toward better practices.

State Rep. Roger Goodman, D-Kirkland, put forward legislation that would create a task force to review conditions in the state’s jails. It didn’t get far but, as chair of the House Public Safety Committee, Goodman and co-sponsor Rep. Brad Klippert, R-Kennewick, may be able to move it forward in the coming session.

Without infusions of state money to Washington’s poorer, rural counties, though, it’s not clear how much change can be made. Municipal and law enforcement leaders cautioned that any reform from Olympia must be paid for with state money.

“We’ve always said that if the Legislature is going to consider mandating anything, then they’re going to have to provide 100 percent of the funding,” Newlin said.

‘He did not deserve to die’

Suicide is far and away the most common cause of in-custody deaths in American jails. Bureau of Justice Statistics numbers show 31 percent of all inmate deaths are attributed to suicide; heart disease, the No. 2 in-custody killer, accounts for 22 percent.

The year Johnson died, 327 in-jail deaths were attributed to suicide. And, while the number of Americans in jail has declined in recent years to 731,200 in 2013, the number of jail suicides has not.

Dahl and Johnson’s deaths drew the same heartbreaking refrain – they could have lived.

The young men’s suicides left their families shattered. Johnson’s death hit his grandmother the hardest.

They were best friends, Peggy and Jimi. Unstable as he was, Jimi was her rock.

“Now that Jimi is gone, Peggy is a shell of her former self,” Jimi’s aunt, Harriet Vasquez-Luna, said in court papers.

“Peggy still hurts. She cries every day,” said Jaralee Johnson, Jimi’s sister. “My family had hoped the trauma and scars caused by Jimi’s death would not be too deep and would start to fade with time. Unfortunately, this has not occurred.”

Jaralee remembers her troubled brother’s strengths. He was good at harvesting clams and oysters, and a fine fisherman. He could’ve provided for himself and been a productive member of the Skokomish tribal community.

The family saw jail as a safe place for Johnson, his sister said in court papers. He’d be watched there, they thought, and kept from killing himself.

“But Mason County did not keep Jimi safe. Far from it,” Jaralee said in a statement filed in February. “Mason County jailers were bullies, were hateful, and had no care for him because he was Native American and had mental health problems.

“They did not treat Jimi like he was human. But Jimi was human, and he had a family that loved him, and he did not deserve to die.”

Originally published on on December 14, 2016. Reprinted with permission. Read their special report here.

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