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The Santa Clara County Morgue at the medical examiner's office. Lisa Pickoff-White/KQED
The Santa Clara County Morgue at the medical examiner's office. (Lisa Pickoff-White/KQED)

Two Deaths In One Jail In One Month: How Are We Treating Mentally Ill Inmates?

Two Deaths In One Jail In One Month: How Are We Treating Mentally Ill Inmates?

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The final three weeks of Walter Roches' life last September were, like much of his previous decade, violent and chaotic, complicated by mental illness and repeated encounters with law enforcement.

Roches, 32, had completed a state prison sentence for domestic violence. Afterward, he was placed in the Evans Lane Wellness and Recovery Center, a San Jose facility that, among other things, treats mentally ill parolees.

On Sept. 5, over Labor Day weekend, Roches was arrested and charged with battery after a "physical and sexual altercation" at Evans Lane. He was sent to the Santa Clara Valley Medical Center, where he reportedly assaulted two staff members, according to arrest records.

Roches spent the next two weeks in the jail's general population, where he reportedly refused to take a drug prescribed to treat him for psychotic behavior. Jail staff initially noted him to be "clean and exhibiting good speech." But he rapidly deteriorated, and on Sept. 16 was described as "poorly groomed and disheveled," according to the coroner's report on his death.

Three days after that observation, Roches was released. He wasn't on the street for long, though. Milpitas police arrested him the next day for assault and battery, and public drunkenness.

Back at Santa Clara County Jail, staff found Roches had deteriorated further. After noting his refusal to talk, shower or cooperate with other requests -- later reports described Roches as "catatonic" -- the staff decided to move him to the jail's psychiatric ward. The officers commanded him to come out of his cell, but he didn’t respond.


Because of his psychosis, Roches may not have understood the commands or been able to respond, said Dr. Michelle Jorden, an assistant medical examiner in Santa Clara County.

So the officers tried pepper spray. Roches did not respond. Next, they threw a canister of tear gas through the food slot in the cell door. No response. Then using an FN303 “less lethal” firearm, the officers shot three times through the food slot, hitting Roches with plastic projectiles. He still didn’t respond. Finally, the officers opened the door.

Roches remained mute and did not struggle during the cell extraction or when the officers escorted him out, Jorden said. As part of her investigation she saw a video of the incident, which is not publicly available.

Roches died in the jail a week later. While conducting an autopsy, Jorden found Roches had suffered head trauma and had dozens of bruises on his torso and arms, ranging in size from less than an inch to a 12-by-7.5-inch bruise on his abdomen.

But Jorden said Roches did not die from those injuries. He died from an “untreated mental illness” and sepsis from an untreated urinary tract infection, according to her report. Roches had been diagnosed with bipolar disorder and schizophrenia in the past. Jorden said he became acutely manic while at the jail, which raised his heart rate and blood pressure.

Assistant Medical Examiner Dr. Michelle Jorden conducted Roches autopsy. She says he died from untreated mental illness, complicated by sepsis.
Assistant Medical Examiner Dr. Michelle Jorden conducted an autopsy on Roches. She says he died from untreated mental illness, complicated by sepsis. (Lisa Pickoff-White/KQED)

“Over time the body can take so much," she said, "and then you can enter into an exhaustive stage and exhibit circulatory collapse.” Being subject to force would have “heightened and accelerated” the process.

The FBI is now investigating the deaths of Roches, another mentally ill inmate and additional complaints about Santa Clara jails.

At the time of Roches' death, Santa Clara County had the equivalent of one and a half psychiatrists for between about 3,500 and 4,000 inmates. Judges, lawyers, correctional officers and advocates agree that it could take weeks or months for an inmate to see a psychiatrist.

Kelly Knapp, an attorney with the Prison Law Office, filed a class action lawsuit in November against Santa Clara County for inhumane conditions.

“There are some serious questions about whether [Roches] was capable of refusing care or whether he should have been involuntarily medicated,” Knapp said.

Roches' death occurred just a month after another mentally ill man died in the same jail following what investigators say was a brutal beating at the hands of three guards. That case led to murder charges and unprecedented scrutiny of how the jail handles mentally ill inmates.

The Death of Michael Tyree

That other inmate, 31-year-old Michael Tyree, was sentenced to five days in jail for violating probation on a minor drug charge in August. Judge Stephen Manley presides over Santa Clara County’s mental health court and sentenced Tyree, who struggled with bipolar disorder and addiction. Manley said he wanted to send Tyree to a treatment center, but there were no beds available at the time.

The coroner’s report shows that Tyree died of blunt force trauma, including severe internal bleeding. During a preliminary hearing, Dr. Joseph O’Hara of the county Medical Examiner-Coroner’s Office testified that the most brutal of Tyree’s injuries were equivalent to being hit with a truck. O’Hara testified that Tyree could not have caused his own fatal injuries, which the deputies' defense attorneys argued.

A photo of Michael Tyree several years before his death.
A photo of Michael Tyree several years before his death. (Courtesy the Tyree family)

During the hearing, Tyree's sister Elizabeth Ott reacted to seeing photographs of her brother lying naked on the cell floor and covered with feces, vomit and bruises.

“It was really horrible," she said through tears outside the courthouse. "I don’t know what would possess somebody to do such a horrible thing to anybody. He was a person, he was valued, he was loved."

When asked about Tyree’s death, Santa Clara Sheriff Laurie Smith responded, “You’re asking me how it could have happened? It was a crime. It’s being prosecuted. We did a thorough investigation, we made arrests within a week. It’s a horrible crime.”

An independent commission was created to investigate the jail. Attorneys for that body recently interviewed nearly a thousand inmates, dozens of jail staff and one inmate’s family. In their report, attorneys said numerous inmates complained that correctional officers beat mentally ill inmates to set an example for other prisoners about what behavior they will and won’t tolerate. Those prisoners are targeted, fellow inmates say, because guards do not think mentally ill inmates will report the abuse. Some guards continue to abuse mentally ill offenders, according to the report.

Smith says her department is investigating.

“We’re getting additional grievances," she said. "We’re getting additional allegations. We’ve added staff to our internal affairs unit, to our detective unit, and we’re committed to following up everything.”

Correctional officers said at commission meetings that mentally ill inmates housed in general population dormitories often suffer violence at the hands of fellow prisoners.

Sean Allen, a correctional officer suing the sheriff’s office for workplace discrimination, is concerned that mentally ill inmates are routinely housed with the general population. He says mentally ill inmates will “kick the doors sometimes -- in some cases all night -- disrupting a dorm of 60 to 90 people. So when you open the doors you’ll find violence because these people will attack this person.”

Allen says that when correctional officers try to move mentally ill inmates to the jail’s psychiatric unit, they’re often told there’s no room.

“We’ll write these mental health referrals, multiple on one particular person, and mental health will go, ‘Eh, we don’t have the space upstairs,'” Allen said.

Judge Manley is also concerned about the psychiatric ward's capacity.

“The waiting list to place people in treatment outside of the jail is roughly the same now as it was six months ago," he said. "It’s anywhere from 90 to 150 people that I’ve ordered released into custody, from custody into treatment, who are not released because there is no treatment."

The FBI and two independent commissions are investigating the operations of Santa Clara County's Main Jail.
The FBI and two independent commissions are investigating the operations of Santa Clara County's Main Jail. (Lisa Pickoff-White/KQED)

Currently, the psychiatric ward can serve 139 inmates. In February, the Santa Clara County Board of Supervisors voted to double the number of beds for mentally ill inmates in a planned new jail facility.

The independent commission, including Manley, called on Saturday for the Board of Supervisors to take immediate steps to change the jail leadership.

“The Blue Ribbon Commission has learned that the myriad problems in the operation of the jails are not recent, but have been ongoing for some time. The problems range from, but are not limited to, mismanagement of the Inmate Welfare Fund, a broken grievance/complaint process, a flawed classification system, a broken medical and mental health system for inmates, a problematic custody input report process, a fear of retaliation by both correctional officers and inmates, a stunning lack of transparency in the jail operations and the murder of Michael Tyree. The Board of Supervisors should acknowledge that the operation of the jails under the current leadership has been a failure for the inmates, for the correctional officers and for the Taxpayers,” the commissioners wrote in a report.

A Growing Statewide Problem

California’s jails were built to hold inmates for relatively short sentences -- usually just a few months. But a change in state law five years ago, known as realignment, shifted more felons to local jails and out of the overcrowded state prisons. In May 2011, the average daily population of jails was 69,406; in May 2015, it was 73,301. Since realignment, the state has provided more than $2.2 billion to counties to help build new correctional facilities, hire staff or create programming.

But one of the biggest changes that local law enforcement is grappling with is holding offenders for long periods of time.

“I’m not just dealing with somebody for 90 days. I’m dealing with somebody for possibly two years,” says Ventura County Sheriff Geoff Dean, who chairs a state committee to revise jail regulations.

That’s had an impact on mentally ill inmates. Dean says that there’s a big difference between holding someone who is mentally ill for several months and holding that person for several years.

“You look at more of a long-term treatment program, maybe a different application of medication that might help them, and then what kind of long-term programming to provide,” Dean said.

No one knows how many of the roughly 73,300 people in California's jails on a daily basis are suffering from mental illness or how many of them are receiving treatment.

The Board of State and Community Corrections oversees county jails from the statewide level. It collects data using a voluntary survey, including information on mental health cases and psychotropic medications. However, the agency’s staff say that some counties have interpreted what constitutes a mental health case differently.

In 2010 an average of 247 county jail inmates received mental health care on a daily basis statewide, compared with 343 in 2014. During the same time period, 166 inmates received psychotropic medications on a daily basis in 2010, compared with 238 in 2014.


However, the information has gaps.

Out of almost five full years of data from the voluntary BSCC survey, counties did not report how many inmates they treated for mental illness almost one quarter of the time, and also did not report on how many inmates received psychotropic medications 16 percent of the time.

More inmates are also dying in jails.

In 2014, 153 inmates died in custody of county jails, compared to 120 in 2010, according to state Department of Justice data.

Statistics suggest that inmates commit suicide at a higher rate in jails. In 2014, 38 inmates committed suicide while in custody of county jails, accounting for nearly 25 percent of deaths, compared to the 23 inmates who committed suicide while in custody of state prisons, accounting for 7 percent of deaths. There are seven deaths that occurred in 2014 in state jails the cause of which are still being investigated.


Special Assistant Attorney General Justin Erlich oversees the state Department of Justice open data project. He says mental illness could be a contributing factor in the increase of in-custody deaths.

“We’ve got a lot of work to do around the mental health and physical health of inmates in county jails,” he said. “When you know something is happening, but you don’t know the extent of the problem, it can inhibit progress.”

On Wednesday, a committee will discuss some of the first proposed changes to Title 15, the state law that sets minimum standards for jails, since realignment. Sheriff Dean of Ventura County chairs the committee.

One proposal is to mandate training for all correctional staff who screen incoming inmates for mental illness. This would be part of an eight-hour training session that would include reviewing minimum jail standards and operations within the first six months of employment.

Manley says that training all correctional staff is imperative.

“I don’t know anywhere in California they are receiving the appropriate training, and that has to change,” Manley said. “The culture has to change to understand that mentally ill offenders are very difficult to work with. They are not easy to work with and they take a lot of time, a lot of patience, and they take some compassion. And these are all things that can be taught and can be learned. But you have to be willing to do it.”

The committee also proposed expanding efforts to prevent suicide. However, no changes have been proposed to restrict the use of force.

Advocates for mentally ill inmates want the Board of State and Community Corrections to make far more dramatic changes in how the jails are run.

"The BSCC is rejecting or failing to implement substantive changes that would ensure people with mental illness receive adequate mental health care and are not at risk of harm from suicide, solitary confinement, lengthy use of restraints and disciplinary actions for behaviors they cannot control,” says Knapp of the Prison Law Office.

Judge Manley says that making jails safer for mentally ill inmates is not enough.

“Jails are for punishment. After punishment you have to look at rehabilitation and treatment,” he said. “When mentally ill offenders have served their punishment time and there is no treatment for them, they simply recycle back through the jail. So we are not doing anything to promote public safety and we are not doing anything to improve the mental health of those individuals who are incarcerated.”

Don Clyde, Alex Cwalinski, Amy Mostafa, Peter Jon Shuler and Nicole West of KQED News contributed to this report.

This article was produced as a project for the California Data Fellowship, a program of the Center for Health Journalism at the USC Annenberg School for Communication and Journalism.

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