Search Results for: virginia inspector general

(4-25-16) Leadership. How do you define it?

I was asked to speak last week at the National Stepping Up Summit in our nation’s capital and when I glanced out from the podium, I spotted a table where a delegation from Fairfax County, Virginia, was seated. Among them was Sheriff Stacey A. Kincaid, Deputy County Executive David M. Rohrer, Community Service Board (mental health provider) Director Tisha Deeghan and Gary Ambrose and Laura Yager, who are in heading up our county’s Diversion First initiative.  (1.)

As in so many communities, Fairfax officials made jail diversion a priority after a tragedy — the 2015 death of Natasha McKenna, a 37 year-old African American woman with schizophrenia who died after being repeated stunned with a taser while shackled inside the jail. I was one of the loudest critics about how county officials handled that senseless death.

But let’s compare the McKenna case to what is unfolding now in Virginia’s Hampton Roads area where Jamycheal Mitchell, a 24 year-old African American inmate with mental illness died in jail from a heart attack brought on by him starving himself while waiting to be sent to a state hospital.

After McKenna’s death, Sheriff Kincaid banned the use of tasers inside the jail. She stopped locking mentally ill inmates into solitary confinement unless necessary for their own safety. She began training deputies in crisis intervention team training and created special housing units for mentally ill women and men. She also led a delegation to Bexar County, Texas, to learn about its jail diversion program and when she returned, she became a leader in pushing for Diversion First, which Board of Supervisor Chair Sharon Bulova has made a top priority. Today, individuals such as McKenna are taken to a crisis center for evaluation rather than directly to jail or an emergency room.

What has happened since Jamycheal Mitchell’s death last August in Portsmouth?

Eight days after his feces smeared body was found in a cell, Lt. Col. Eugene Taylor III, assistant superintendent of Hampton Roads Regional Jail, announced that the jail had conducted a thorough investigation and found no evidence of any wrongdoing or mishandling by jail employees. Despite repeated requests, jail officials have refused to make their internal investigation public. The local police department chose not to investigate Mitchell’s death.

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(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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(3-22-16) An Eastern State Hospital employee was “astonished and distraught” when she opened a desk drawer last August and discovered that a Virginia judge had ordered Jamycheal Mitchell to be sent from a Portsmouth jail to the mental hospital to be evaluated.

The judge’s order had been issued more than three months earlier but had been overlooked in that desk drawer until she discovered it — five days after Mitchell had died of a heart attack caused by starvation while in jail.

That disclosure is one of several troubling admissions revealed yesterday when the Virginia Department of Behavioral Health and Developmental Services  finally released an edited version of the investigation that it conducted into the August 19, 2015 death of Mitchell, a 24 year-old, African American inmate with a serious mental illness who’d been charged with petty larceny and trespassing after stealing $5 worth of snacks from a convenience store.

Last week, I posted a blog that questioned why three Virginia agencies responsible for investigating the Mitchell tragedy hadn’t made public their investigations. The DBHDS released copies of its 29-page report, minus the identities of the employees who investigators questioned, without comment based on separate Freedom of Information requests filed by Sarah Kleiner, an investigative reporter at Richmond Times Dispatch, and by me.

When called by reporters for comment, I said that I was “furious and outraged” by the report. “Jamycheal Mitchell was lost in plain sight because of incompetency and indifference. This kid died because no one in that jail and no state mental health official did anything to help him. Shame on them. Imagine if he was your son. Now there will be lots of finger-pointing and lawyering up, but no real changes. That’s been our sad history in Virginia. This is because officials will blame the victim, as they did in the Natasha McKenna case, and legislators will not put any more money into mental health services.”

What did the internal investigation reveal?

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Why haven’t two state agencies investigating the death of Jamycheal Mitchell, a 24 year-old Virginia man diagnosed with bipolar disorder who was found dead in his jail cell August 19, 2015, released the results of their investigations?

Mitchell was arrested on April 22, 2015 for trespassing and stealing a Mountain Dew soft drink, a Snickers Bar, and a Zebra Cake from a 7-Eleven on George Washington Highway in Portsmouth. A judge ruled that he was incompetent to stand trial and ordered him to be transferred to Eastern State Hospital in Williamsburg to be made competent for trial. Instead, he died in the Hampton Roads Regional Jail 90 days after that order was sent. Inmates who saw him there told reporters that he spent his last days alone in the cell with feces smeared on the walls and urine on the floor.

Nine days after his body was discovered, jail officials issued a statement saying that they had found no evidence of wrongdoing by their correction officials. In December, the state medical examiner’s office released an autopsy report that concluded Mitchell died of “probable cardiac arrhythmia accompanying wasting syndrome of unknown etiology. ” Wasting syndrome is defined as a profound loss of weight, greater than 10 percent of a person’s original body weight.

Let’s review those statements. A healthy but psychotic young man is arrested for stealing $5 worth of food and jailed. During the four months that he is in custody he loses so much weight that his heart gives out. But no on in the jail who was responsible for watching him did anything wrong. Once again in Virginia, the public is told that if anyone is at fault, it is the mentally ill prisoner himself.

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