Jamycheal Mitchell’s death in a Virginia jail cell still hasn’t been explained.
It should be a national scandal.

by Dahlia Lithwick, Slate

On August 19, 2015, 24-year-old Jamycheal Mitchell was found dead in his cell at the Hampton Roads Regional Jail in Virginia. New revelations in May 2016 about how state officials acted in the aftermath of his death and a $60 million lawsuit filed by his family have shown that the state’s treatment of Mitchell – in life and in death – was somehow even more horrific than previously detailed. Multiple official investigations later – and with the videotape of his last days in prison conveniently erased forever – the official line appears to be that “the system” was to blame. So, there’s apparently nothing to see here folks. Until the next time.

Mitchell, who according to his family suffered from schizophrenia and bipolar disorder for most of his life, had been arrested four months prior to his death for stealing a Mountain Dew, a Snickers bar and a Zebra Cake from a 7-Eleven. Mitchell was denied bond, he was awaiting trial and a judge had twice ordered him moved to a state mental health hospital, but no beds were available.

So Jamycheal Mitchell spent 101 days in jail while he waited for that transfer, evidently starving himself to death over the weeks and months he remained there. A jail officer found Mitchell lying dead in his bunk on that Wednesday in August, his feces smeared all over the walls and his urine on the floor of his cell. When he arrived at the Hampton Roads Regional Jail in May, Mitchell weighed 182 pounds. He weighed 144 pounds during a post-death examination.

Mitchell’s story is both horrifying and somehow unremarkable. It exposes this country’s grotesque tendency to warehouse the severely mentally ill in jails – 10 times more of them are in jails and prisons than are in state psychiatric hospitals. But it also proves the horrendous abuse and neglect these people will suffer there. Mitchell had a long history of mental illness and had waived his right to counsel even though he was deemed “manic and psychotic” by a forensic psychologist. His bail was inexplicably set at $3,000 for stealing less than $5 worth of junk food. Despite years of scandals and exposés, the shortage of beds in mental health hospitals in Virginia still hasn’t been redressed. When I wrote about the case in September, various investigations were being launched, but their results are either secret, partial, inconclusive or arm-waving and vague. Mitchell’s story upsettingly never became the national scandal that it should be.

In the year since Mitchell was arrested, two separate reports by state agencies have blamed a series of “systematic failures” for Mitchell’s continued detention when he should have been in a mental health facility for treatment. These reports hardly begin to address the institutional abuses that have been alleged in a $60 million lawsuit filed by Mitchell’s family on May 12, 2016 in district court.

The 112-page lawsuit names 31 defendants – ranging from state mental health officials, jail administrators and guards to court staff and health care workers. Prisoners who witnessed Mitchell’s deterioration over his 101 days in jail allege in the lawsuit that he was dragged naked out of his cell and put on display like a “circus animal.” Several prisoners alleged that guards didn’t give him meal trays for days at a time or deliberately put his trays out of his reach to punish him. The suit claims that correctional officers turned off the water in Mitchell’s cell and that he was routinely allowed to smear his feces on the walls without a cleanup. Prisoners reported beatings, abuse and hearing Mitchell crying in his cell.

One of the defendants named in the suit is Gail Hart, who worked in the admissions department of Eastern State Hospital. When the May 2015 judicial order for Mitchell to be transferred to the hospital came across her desk, Hart stuffed it into a drawer, according to the Department of Behavioral Health and Developmental Services’ investigation. The paperwork only turned up after he died.

That’s not all. In April 2016, the Richmond Times-Dispatch reported that video images captured outside Mitchell’s cell in the days and hours leading up to his death had been automatically erased, according to jail protocol. The jailhouse system automatically tapes over footage 18 days after it is recorded, but Mitchell’s family lawyer had requested that it be preserved. And even if it had not been requested, how can it possibly be appropriate for officials to erase footage of a prisoner who has died because of alleged abuse and neglect? Lt. Col. Eugene Taylor III, an assistant superintendent at the jail, told the Times-Dispatch that the video was not preserved “because it did not show any type of criminality or negligence.” Good to know.

Lawyers for Mitchell’s family argue that without the video there is no way of knowing whether he was being checked on every 30 minutes by guards and once a day by medical personnel – as protocol required – and how often Mitchell was actually offered food, or whether those trays came back empty. That a mentally ill man could starve to death in a jail and nobody thought to preserve the video of his treatment in his last days is unimaginable. Except of course it happened.

Mitchell’s family has also made a formal request to the Department of Justice’s Civil Rights Division to open an investigation. As mentioned, the current official reports fall flat in their attempts to exonerate jail workers and others for potential institutional faults.

As the Times-Dispatch explains: “The jail conducted an internal investigation that it says cleared its employees of wrongdoing, but it has refused to release the report to the public. The Virginia Department of Behavioral Health and Developmental Services and the Office of the State Inspector General conducted separate inquiries, but neither dealt with anything that took place inside the jail or revealed what led to Mitchell’s death.”

The Behavioral Health report, released in late March 2016, detailed the failures across the system, including the lost transfer order and an assessment for involuntary hospitalization that never occurred. Lost messages, scarce resources, overwhelmed and underpaid staff are all noted. The report does not explain why nothing was done about Mitchell’s deteriorating health while in jail. The report released by the inspector general, meanwhile, noted that there were “multiple, significant risk points” and that NaphCare, the company that was contracted by the jail to do medical and mental health care services, provided “incomplete and inconsistent” records. This report also did not delve into the care Mitchell received while in the jail.

G. Douglas Bevelacqua, a former state inspector general who has investigated the state of mental health services in Virginia, condemned both reports: “Regrettably, after reading [the reports], I cannot answer the basic question of how did corrections staff and mental health workers allow Mitchell to waste away in plain sight for 3½ months.”

The problem – we keep hearing – is “systemic.” But the system remains largely unchanged and any potential institutional flaws have clearly not been properly examined. Indeed, responses to the reports suggest that nobody knows who has the authority to even effectuate the changes that are suggested.

The medical examiner’s office in Norfolk has said Mitchell died because of a heart defect and “wasting syndrome,” or extreme weight loss. The editorial pages seem to have captured what all of the “investigators” have missed: A man with severe mental illness died in our care in our prison system and nobody is responsible and nobody cares.

Every time someone with a mental illness expires in jail, we are reminded of how sprawling and intractable the problems with our mental health and criminal justice systems have become. Meaningful reforms are not impossible – the Commonwealth of Virginia has known for years that there is a serious problem here – but secret reports, deleted videotape and pass-the-buck investigations change nothing. We now know about Jamycheal Mitchell – a poor, mentally ill black man lost in the paper bureaucracy of our prison system – not because he was mentally ill, or poor, or lost in that bureaucracy like so many others. We now know about him simply because he is dead.

Whether or not the alleged institutional abuses are ultimately proven, the reality is this: A severely ill young man wasted away, smeared in his own feces, under the watchful eyes of multiple health care workers, corrections staff and other prisoners. His death will force no accountability and will bring about no change. The illness from which Jamycheal Mitchell suffered could have been better managed through medication, proper treatment and simple respect. The illness that allows the rest of us to jail great masses of dangerously sick people and mistreat them until they die? It is increasingly seeming to be untreatable and incurable.

This article was originally published by Slate on May 13, 2016. It is reprinted with the editor’s permission, with minor edits.