(3-4-16) A physically healthy 24 year-old man is put in jail for taking $5 worth of snack food from a convenience store. Jailers know that he has a serious mental illness. Yet for 101 days, he never leaves his cell. He never showers. He often is covered with his own feces and urine is found on the floor of his isolation cell. His weight drops NOT 34 pounds, as has been previously reported, but 46 pounds, from 190 pounds to 144 pounds. An autopsy shows he suffered a heart attack brought on by him starving himself to death.
Yet, Lt. Col. Eugene Taylor III, assistant superintendent of Hampton Roads Regional Jail in Portsmouth, said last week that the jail had conducted a thorough investigation and found no evidence of any wrongdoing or mishandling of this prisoner’s case by his staff.
“To us, it’s an unbelievable tragedy, but it was not a circumstance where it could have been prevented by the Hampton Roads Regional Jail,” Taylor was quoted as saying by reporter Sarah Kleiner in a story published Friday by the Richmond Times-Dispatch.
Taylor said the jail would not make its internal investigation — that cleared itself — public, but he defended the jail’s treatment of Jamycheal Mitchell, whose body was found dead in his cell last August. Taylor told Kleiner that Mitchell was offered a shower every third day but never accepted it. He had a chance to spend an hour five days a week in the gym, playing basketball, running or interacting with other inmates but he opted to stay alone in the cell.
Taylor also revealed that Mitchell was held in a cell that was monitored by an officer every half hour and that medical personnel in the jail were required to check on him daily. In any given day, Mitchell was supposed to have been observed 49 times by correctional officers or nurses.
49 times.
But Taylor said no red flags were raised and no one on his staff realized that Mitchell was starving himself because food trays that were passed into the cell each day were returned empty. Taylor also questioned if Mitchell actually “starved to death” in jail.
“We have no indication that he lost so much weight that his heart stopped,” Taylor said. The jailer did not explain why he disagreed with a state medical examiner’s autopsy that found Mitchell died of “probable cardiac arrhythmia accompanying wasting syndrome of unknown etiology.” Wasting syndrome is when a person loses more than 10 percent of their weight in a short period from not eating. Taylor, who does not have a medical degree, said he didn’t believe that ruling.
At the risk of appearing cruel, I’d like to ask Taylor if he would have been satisfied with the explanation that he gave to the Richmond paper if Mitchell would have been his child. If his son had been held in a jail cell 101 days without ever taking a shower or coming out to exercise and had lost 46 pounds would he believe that his son’s death in jail “was not a circumstance where it could have been prevented”?
Now here is another sobering thought.
No one in the jail was disciplined. No one was fired. There were no reprimands put into anyone’s file and no policies have been changed. Meanwhile, Taylor remains in charge of 244 other inmates who have diagnosed mental illnesses.
If Taylor really believes that his employees aren’t culpable and there is no need for the jail to change any of its practices, then why will he not release the results of his internal investigation that cleared everyone?
Of course, correctional officers were not the only individuals responsible for the well-being of Mitchell. The jail hired a for profit company called NAPHCARE, based in Alabama, to provide medical care to inmates. It would be its nurses who should have been aware of Mitchell’s weight loss. That company has not commented on Mitchell’s death.
The only investigation that has been made public was completed by the state Department of Behavioral Health and Developmental Services. To refresh your memory, on March 11, I posted a blog asking why the DBHDS and the Office of the State Inspector General had not made public the results of their investigations seven months after Mitchell’s death.
A week later, the DBHDS released a copy of its investigation. It revealed that a DBHDS employee at Eastern State Hospital had put a court order informing the hospital that Mitchell needed to a bed there into a locked desk drawer and not found it until five days after his death. The DBHDS report also disclosed that a DBHDS employee, who was specifically hired to monitor inmates waiting in the jail for a hospital bed, had gone to the jail to check on Mitchell on the same day that he was in court. After waiting 45 minutes, she left and never bothered to check on him. She never saw him during his entire 101 day incarceration.
Reporter Kleiner has been relentless in pursuing the Mitchell story. She reported that there were 115 empty beds in Virginia state hospitals while Mitchell was languishing in jail.
Mira Signer, the executive director of the National Alliance on Mental Illness in Virginia, has been ruffling feathers too. Along with G. Douglas Bevelacqua, the former state inspector general for mental health, and the NAACP, Signer delivered a letter to Virginia Governor Terry McAuliffe demanding that the state Office of Inspector General make its investigation of the Mitchell case public.
Reacting to that letter, the governor called Mitchell’s death “sad beyond comprehension” but he said that he would not interfere with the IG investigation because that agency is supposed to be an independent watchdog.
NAMI’s Signer continued to push, writing a powerful letter to the Richmond paper Friday while reporter Kleiner interviewed Lt. Taylor after the jail rebuffed her efforts to obtain a copy of its internal investigation.
The state OSIG — inspector general — announced that it is working as quickly as it could to complete its probe. That statement came at about the same time a rumor began circulating through mental health circles that the IG’s office actually had completed its investigation months ago without ever bothering to send an investigator to Portsmouth and only now was scrambling to take a deeper look because of recent news stories.
Whether or not that rumor is true or mean-spirited gossip is difficult to confirm but it shows that some advocates in Virginia are suspicious of how the OSIG conducts its probes. That suspicion is based on former IG G. Douglas Bevelacqua’s highly publicized decision to resign rather than water down a report that he wrote about the tragedy that involved state Sen. Creigh Deeds and his son, Gus. At the time, Bevelacqua claimed his boss was pressuring him to soft peddle his criticism of state officials.
Governor McAuliffe assured listeners of a radio program last week that his administration was determined to fully investigate Mitchell’s death.
I’m glad that NAMI’s Mira Signer and Richmond Reporter Sarah Kleiner will be watching to make certain that actually happens.
Here’s a copy of Mira Signer’s letter to the Richmond paper:
Editor, Times-Dispatch:
As a mother, a social worker and the executive director of the National Alliance on Mental Illness of Virginia, I read with horror and disbelief Sarah’s Kleiner’s news article “Clerical errors preceded death of Va. man jailed for stealing junk food.” I can imagine few things worse than learning your 24-year-old with a history of mental illness has been arrested and incarcerated and that due to sheer negligence and a failing system, he died in jail instead of being discharged to receive treatment in a hospital.
That’s what happened to Jamycheal Mitchell, a young man with a history of mental illness. The event should cause outrage among the public and state lawmakers. It has been seven months and the investigation into his death still isn’t complete. Why isn’t there more urgency on figuring out what went wrong and holding officials accountable? Is it because more and more Virginians are being treated in jails so society accepts this as the norm? We shouldn’t.
Officials will say that Virginia’s complex system and overworked employees are part of the long-standing problems that led to the death of this young man. We know that the mental health care system has problems, including being underfunded and complicated to navigate. But that shouldn’t be an excuse for what happened.
There are people whose job it is to ensure that someone like Mitchell doesn’t fall through the cracks. Those at the highest levels of government should hold all of the departments and agencies accountable. They should accept responsibility and do whatever it takes to make sure a horrible death like Mitchell’s never happens again.
Strategies like jail diversion, transitional and supportive housing, case management and re-entry services work. I am grateful that the General Assembly has allocated more funding but that money must be coupled with competent, responsible and accountable leadership.
Mira Signer,
Executive Director,National Alliance on Mental Illness of Virginia.Richmond.
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