(4-6-16) A state agency in Virginia investigating the death of a 24 year-old prisoner with mental illness, whose feces covered body was discovered in his isolation cell August 19, 2015, reported yesterday that records kept by medical personnel who were responsible for watching him were “incomplete and inconsistent.”

But the long anticipated report does not assess blame on any individual. Rather it makes five recommendations about system changes that its authors claim could prevent future similar tragedies.

The 16-page report’s recommendations are bound to frustrate and disappoint the family of Jamycheal Mitchell who have asked for details that would explain what happened to Mitchell during the 101 days that he was languishing in jail waiting to be sent to Eastern State Hospital for a mental evaluation and competency restoration.

Mitchell died of “probable cardiac arrhythmia accompanying wasting syndrome of unknown etiology,” according to Donna Price, an administrator for the Medical Examiner’s Office in Norfolk. Wasting syndrome is defined as a profound loss of weight, greater than 10 percent of a person’s original body weight. Put simply, he had a heart attack caused by starvation.

The IG report stated that its investigators decided to not investigate who might have been responsible for Mitchell’s death. Nor did the IG investigate “every element of prior investigations.” (Jail officials already had conducted their own internal, confidential investigation and found themselves innocent of wrongdoing. State mental health officials released a report last month in which they acknowledged clerical errors were made.)

Instead, the IG said it focused on system errors rather than human ones. Just the same, the report contained several troubling revelations, most notably about the for-profit company NAPHCARE which was responsible for providing medical care to Mitchell in the jail but has since been replaced.Click to continue…

(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.

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(3-29-16) (This is the first of several personal stories which I plan to post periodically in memory of a loved one with mental illness. Lest they be forgotten.)

The Son I Wish You Knew

By Laura Pogliano

My son Zac was 16 when he had his first psychotic episode. Seven years later, he died of heart failure in his apartment. Of all the hellish components of my child’s life with schizophrenia, perhaps the most heart wrenching for me was that no doctors or caregivers ever knew my child before he became sick. They came to know him after he was drastically changed by illness, paranoia and the effects of medication.

Early on in his illness, when I begged doctors to save my child, I was speaking of his personhood, those intangibles that made Zac my son. His dry humor. His patience and compassion. His musical talents. His ‘old soul.’

When I first learned of his diagnosis, the specter of my son becoming a lifeless, chronic schizophrenic patient haunted me. Reconciling the loss of a child is incomprehensible; reconciling the loss of a child who is still living defies description. This unique kind of sorrow may be unintentionally compounded in mental illnesses by the very people who fight alongside you, knowing very little about the person they’re saving, or what he’s lost, despite endless conversations about how he compares to his baseline self.

At Zac’s wake, for the first time in seven years of his illness, I suddenly began remembering my own son. Looking through hundreds of photos for the wake, I kept seeing his broad smile and thinking, Wow! He was so handsome, and so happy. His life became so consumed with medical care, so overwhelmingly a sick life, I’d forgotten the son I knew. That’s the son I want to write about. That’s the son I wish you knew.

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(3-27-16) If you are a Christian, Easter is a sacred day of worship, remembrance and family so I will ask for your forgiveness for posting a blog on Easter. But I want to alert you to a news story in today’s Richmond Times Dispatch by Sarah Kleiner, who thankfully is continuing to probe the preventable death of Jamycheal Mitchell in Virginia.

Kleiner discovered there were 115 empty beds available in the state’s 1,500 bed system during the four months that Mitchell spent psychotic in jail waiting to be sent to Eastern State Hospital. He was one of 34 prisoners waiting for a bed at Eastern State Hospital in Williamsburg. Another fifty others were waiting for beds at other facilities, according to earlier reports.

All of those prisoners could have been assigned a bed but weren’t. Instead, they were left to languish in jails for an average of three months.

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(3-25-16) A letter by a distraught but courageous mother whose son has both autism and a mental illness was the most read article on my Facebook page and author’s website this week and, so far, the entire year. It was shared more than 180 times on Facebook and was seen by an estimated 100,000 readers.

Why did this mother’s letter resonate with so many readers? (If you missed it, you can read it here.) 

It’s because she is not alone in her suffering and her frustration about our broken mental health care system that is failing so many of our loved ones.

In addition to her letter, I posted blogs this week about the death of Jamycheal Mitchell, the 24 year-old African American with mental illness who literally wasted away in a jail cell waiting for a bed in a state hospital. Three prominent Virginia newspapers have published editorials about Mitchell’s preventible death, joining in the chorus of advocates demanding to be told how a prisoner was allowed to starve himself to death while under the watch of the for-profit, private NAPHCARE medical staff and state mental health officials.

The mother’s letter to me and Mitchell’s death are the latest examples of why we need significant reforms that have yet to come from Congress or state leaders.

Here are three snippets from emails sent to me by readers who were touched by the mother’s letters, followed by comments lifted from the editorials about Mitchell.

I feel her pain – literally. She spoke for so many of us who face the same things day after day. I know the agony of trying to make things better for a child (and now a grandchild) when they don’t understand why they even have to exist because they are in such pain.  Also the fear of the future and what it might bring.  I hope she has access to support – NAMI has been my lifesaver.  Just sharing with others and knowing that I am not alone is helpful.  I am sending love and prayers to her. –B.

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