Justice Dept. Slams Virginia Jail. “Deliberate Indifference” Led To Numerous Deaths But No One Punished

Starved To Death In Jail

(12-20-18) The U.S. Department of Justice has said there is reasonable evidence to conclude that officials at the Hampton Roads Regional Jail in Virginia are violating the constitutional rights of prisoners with mental illnesses. The report refers to  “deliberate indifference to prisoners’ constitutional rights to adequate medical care” and a “deliberate indifference to prisoner health and safety.”

In a 43-page investigative report released late last night, the Justice Department’s Civil Rights Division and the U.S. Attorney’s Office for the Eastern District of Virginia disclosed information about deaths at the jail not previously widely known.

Perhaps the saddest findings are frequent references to the “indifference” jail officials and medical workers showed toward mentally ill prisoners. It noted the jail “does not take prisoner grievances about lack of access to medical care seriously, resulting in significant harm to prisoners, even death.”

The federal government launched its investigation of the Portsmouth regional jail at the request of the National Alliance on Mental Illness, Mental Health America, the NAACP, the ACLU, and the Bazelon Center for Mental Health Law after widespread publicity swirling around the death of Jamycheal Mitchell and Virginia state officials’ bungling of state investigations.

Mitchell, a 24 year-old African American with a diagnosed mental illness, was found dead in his cell four months after he was arrested for allegedly stealing $5.05 in candy and a soda from a convenience store. Mitchell died from a heart attack that a Virginia medical examiner said was caused by “wasting away” syndrome (starvation.) He had lost 40 pounds during the 100 days he was jailed in solitary confinement awaiting transfer to a state mental hospital. In a civil suit filed by his family, attorneys claimed correctional officers denied Mitchell food as punishment, kicked, beat, and pepper sprayed him.

The Justice Department noted that jail officials failed to improve medical services even after Mitchell’s highly publicized death. A second inmate died a year later after his repeated pleas for medical help were ignored.

Although the Justice Department concluded there is reasonable evidence to suggest the jail was and continues to violate prisoners’ 8th and 14th Constitutional rights and the Americans with Disability Act, no official was cited for discipline and no criminal charges apparently will be filed against any individuals.

The Hampton Road Jail holds more prisoners with mental illnesses in Virginia than most jails. The report cited 25% as compared to 9.55 percent in other jails. It also had the second highest number of military veterans, of which, 47% had a mental illness.

The report disclosed other deaths inside the jail that had not been publicized, including these examples:

Death One: He asked for help “before its [sic] too late.”

BB was admitted into the jail on June 7, 2016, for a probation violation relating to a prior conviction for shoplifting. This was his third time in the jail. He had previously spent 404 days there in 2012 on assault and shoplifting charges, and 26 days in 2014 for a probation violation.

When he was admitted to the Jail in June 2016, he had a mass on his neck. Beginning on July 10 and continuing over the course of the next month, BB complained of heartburn and wrote several medical grievances. In one complaint, he wrote that the medication he was receiving was not relieving his abdominal pain and requested to see a doctor. He received a written response, nine days later, stating that he would be seen by a provider. He was not. On July 30, he wrote that he had not been able to keep down food for two weeks and had lost 14 pounds since the last time he was weighed.

On August 1, he wrote that he needed to see a medical provider “ASAP” because he was having a lot of problems with his bladder movement and bowels and, the next day, complained that he had not used the bathroom in two weeks and had not been eating for days. He asked for help “before its [sic] too late.”

The head nurse responded in writing to this complaint by stating that BB had been seen at the hospital and had two scans done on his neck; however, she ignored his complaints about his stomach.

On August 4, he wrote that he had blacked out two times in less than 24 hours and could not eat or hold down water. However, medical personnel did not respond, instead noting that he had been seen walking around on the top tier of the housing unit and then lying on the walkway. The nurse stated that “no seizure activity was present,” nor any “signs or symptoms of concern.” BB died of a perforated ulcer several days later. The autopsy revealed that he had a pint of blood in his stomach at the time of his death. He had lost 35 pounds from the time he was admitted to the Jail in June to the time he died in early August, weighing 132 pounds at the time of his death.

Death Two: “Help Me Please!” Repeatedly asked for Help

DD, a 69-year-old prisoner, died in March 2016 of severe acute pancreatitis, which was caused by gallstones and coronary artery disease. He was incarcerated for a probation violation.  

He repeatedly sought emergency care for his abdominal pain and his chest pain, but there is no documented evidence that he received any medical assistance in the days prior to his death.

In the two days before his death, DD wrote several sick call slips. A correctional officer returned one request because DD used profanity and there is no evidence in his medical chart that this request was received by medical staff or that they responded to his complaint. Two hours before his death, he had another prisoner submit a sick call request on his behalf. DD was given a form by a correctional officer, to whom DD complained that he had chest pain and had not had a bowel movement in five days.

DD wrote on the form, “Help me please!” He died hours later, before the grievance was received by the medical staff and after DD was denied access to emergency care.

Death Three: Not Seen By Psychiatrist: Put In Solitary

EE, a 53-year-old prisoner, was admitted to the Jail on March 31, 2016 and died ten days later. On admission, he was noted to be extremely psychotic, incoherent, and agitated, throwing feces. Medical staff recognized his psychosis, but were unable to transfer him to Eastern State Hospital because he first needed medical clearance. He was not seen by a psychiatrist to facilitate the clearance and refused his physical for three days after his admission.

On April 3, he was moved to restrictive housing because he was actively psychotic. Despite being psychotic, in his medical chart, it was noted that there were no contraindications to placement in restrictive housing. On April 5, a nurse wrote: “Patient seen in pod at officer request. Pt naked and kneeling on the floor. Pt. with RLQ (right lower quadrant of abdomen) bulge. Pressing against with his hand. Verbalizes intense pain. [Pod] officer to notify charge nurse.”

Fourteen hours later, a nurse wrote: “Pt seen on the pod. Per pod officer, pt. has thrown up and the vomit ‘looked and smelled like feces.’ Pt observed kneeling down on the floor with the lid to his blue bin in front of him which is covered with greenish clear bile. Pt will not verbally respond to questions. Will schedule visit with MD for evaluation.”

The nurse did not examine EE. She did not attempt to obtain vital signs. She did not call for emergency medical attention. The next day, EE remained in restrictive housing. He was not seen by the nurse or medical provider.

A chart note from the director of mental health services on April 7 reads: “Inmate (sic) went up to assess inmate to check on his mental history, and he was found unresponsive at the time. A code was called, and he later died from complications due to a duodenal ulcer. This was the first and only mental health visit EE received at the Jail. He did not receive any medical or psychiatric evaluation. According to our medical expert, EE’s death was preventable had he received adequate medical attention.

The Justice Department investigators reported that prisoners with mental illnesses were not screened when first admitted to the jail, that their medical records were not forwarded to the jail, that medications were not distributed as required, and that inmates with mental disorders were arbitrarily placed in solitary confinement without cause, simply because jail officials didn’t want to deal with their behavior even when they had not violated any rules. They referred to them as being “mentally deficient.”

Overuse of Solitary Confinement Making Illnesses Worse

In isolation cells, a prisoner is housed alone, typically for 22 or more hours per day during the week and even longer on weekends. The cells are 80 square feet and most have a metal sink and toilet, a metal desk and stool, and a metal bed frame with a mattress (although six cells do not have beds at all). Each cell has a horizontal window near the ceiling, roughly six inches tall and forty-five inches wide, which faces outside but is covered with an opaque film to allow light in but to prohibit prisoners from seeing outside. The cells have solid metal doors with narrow slots at waist level, wide enough for food trays to pass through, and small foggy, plexiglass windows facing into the housing unit’s common area.

During the first six months of 2017, a daily average of 70 prisoners with serious mental illness were held in restrictive housing. This accounts for 47% of prisoners held there. Of the 496 prisoners the Jail identified as having serious mental illness between July 2016 and July 2017, 67% had spent some time in restrictive housing, and 36% had spent more than a month consecutively in restrictive housing.

Sixty-three of those prisoners spent three consecutive months or more in restrictive housing

Prisoners with serious mental illness are not, for the most part, spending long periods of time in restrictive housing because of disciplinary infractions…The Jail places prisoners in restrictive housing for administrative reasons because the Jail is not providing adequate mental health treatment to address prisoners’ mental health needs while they are in general population. When these prisoners are unable to function in the general population because of their unmet mental health needs, the Jail sends them to restrictive housing on administrative status. We saw many examples of prisoners being transferred from general population to restrictive housing on administrative restriction, sometimes with a status of “administrative restriction – mental deficient” or “administrative restriction – unable to adapt.”

Similarly, a prisoner might serve a short stay in restrictive housing for disciplinary time but then be held in restrictive housing for longer periods of time in administrative restriction.

Jail officials were not the only ones who showed indifference to inmates in the jail.

After newspaper reporters in Richmond and Norfolk wrote repeated articles about Mitchell’s death, the state undertook its own “investigations.” The Virginia Senate was so disgusted by how sate Inspector General June Jennings oversaw her office’s probe that it voted overwhelmingly to oust her from that job – only to have then Gov. Terry McAuliffe reward her with another state position. She was not the only high ranking Virginia official whose actions raised eyebrows.

Until those responsible for violating these prisoners’ human rights and those in government, who were more interested in protecting the state than finding the truth, are specifically named and punished, history shows little will change.

Click here for Justice Department Findings.

About the author:

Pete Earley is the bestselling author of such books as The Hot House and Crazy. When he is not spending time with his family, he tours the globe advocating for mental health reform.

Learn more about Pete.