State of Texas: Leaders consider ‘consequences’ of not tracking state hospital waitlist data

Investigative Summary:

For two years, KXAN investigators have explored a growing backlog of people in Texas jails who need mental competency restoration. While an advisory committee has largely focused on finding state hospital beds for that group, our team took a closer look at the backgrounds of individuals on the waitlist to determine trends experts say could help drive down numbers. Our research found data on this topic is often hidden or unreliable – a discovery sparking promise for change from state leaders. The resulting “Mental Competency Consequences” project is supported by the USC Annenberg Center for Health Journalism.

AUSTIN (KXAN) — In Texas, people charged with crimes and found mentally incompetent to stand trial most often obtain restoration treatment at a state hospital before returning to jail and being able to actively participate in their defense. In recent years, there have been efforts to increase other competency restoration alternatives – like jail-based or outpatient methods – but for some people, those options are not always available.

“A long waiting list is not a good thing,” Joint Committee on Access and Forensic Services Chair Stephen Glazier told KXAN in October when the state’s mental competency waitlist hit a new record, soaring beyond 1,830 people. “There are all kinds of negative consequences that come from that. It’s important, I think, to reinforce everybody’s motivation to work as hard as we can to fix this problem.”

Working to identify trends on the waitlist, KXAN investigators discovered deaths are just one of several crucial data points going untracked by the JCAFS, an advisory panel that makes recommendations to Texas Health and Human Services Commission and state lawmakers, in part, to help drive down the waitlist numbers.

During his conversation with KXAN, Glazier said he would make it a priority for the committee to address how it could track the housing status of people on the waitlist and other details related to homelessness. HHSC later told KXAN it had recently started collecting data on those individuals’ race and ethnicity and would be providing those details to the committee by January 2022.

Mental health advocates like Lynda Frost, formerly of the Hogg Foundation for Mental Health, acknowledge the committee, established in 2015, has improved its data initiatives in recent years. That work has largely focused on statewide aggregate overviews with a recently formed data analysis subcommittee and updates from the state’s forensic director. But Frost agrees more information could help the state better deliver services to individuals on the waitlist and possibly reduce their wait times.

“We know that people are not treated equally across our criminal justice system,” she said. “We want to know how that plays out. And, if we don’t have that data, it’s harder to figure out what we can do to ensure that our justice systems are truly just.”

Until the committee begins tracking those additional details statewide, it is only possible to understand the scope of such problems through data analysis by county. Because the identities on the state’s waitlist are hidden for privacy reasons, KXAN took a backdoor approach, obtaining district clerks’ lists of felony defendants found incompetent to stand trial, then examining specific cases to learn more about their backgrounds. But county jails and courts in Texas do not have a uniform data collection system, and we discovered some of what they do collect is likely inaccurate and not always required to be passed along to HHSC.

‘Fundamental obligation’

Names like Naquan Carter and Fernando Macias were two of at least 12 mentally incompetent, incarcerated individuals KXAN discovered died in Texas’ most populated counties since early 2015. Because the state does not track that number, we had to cross-reference custodial deaths – which sheriffs’ offices are required to submit to the attorney general’s office – with district clerks’ lists of people found mentally incompetent to stand trial – county by county. The total we compiled, so far, is just from Travis, Harris, Bexar, Dallas and Tarrant Counties. Reviewing Texas’ other 249 counties would require more time and resources but could likely reveal additional deaths.

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KXANs Josh Hinkle speaks with Walter Macias, whose brother died in the custody of the Bexar County Sheriffs Office in 2018 awaiting mental competency restoration treatment. (KXAN Photo/David Barer)

KXAN shared its tally with the JCAFS chair, who stopped short of saying the committee would begin tracking deaths. Yet Glazier called what we uncovered one of the “consequences of the waitlist” that could “create some momentum to get public policy change.” When later pressed on whether it would begin tracking deaths, HHSC’s spokesperson said it is still not part of agency plans.

“There’s no more fundamental obligation that jails have than to keep the people inside them safe and alive,” said Michele Deitch, a distinguished senior lecturer who focuses on criminal justice policy issues and deaths in custody at the University of Texas LBJ School of Public Affairs. “And, if we’re not tracking what’s happening to the people in there, we don’t know what’s going on inside those jails.”

‘Downward economic spiral’

Learning HHSC does not track deaths led KXAN to dig deeper into other data mental health advocates say could help spark change – if leaders had an evidence-based grasp of the problems facing people on the waitlist. Along with race and ethnicity, poverty and indigency challenges were most frequently mentioned when it came to the intersection of mental health and the criminal justice system.

“If I’m not independently wealthy, I may have trouble keeping a job and may have trouble making my rent,” Frost explained. “Serious unaddressed mental health challenges can lead someone in a downward economic spiral… that certainly could be a trigger to make it worse.”

KXAN wanted to know how those aspects factored into the mental competency backlog. But, because the state keeps identities on its waitlist secret and does not track socioeconomic backgrounds, we had to analyze district clerk data in specific counties to better understand financial challenges – specifically people who were incompetent to stand trial and could not afford to hire a lawyer. Almost every case, including Macias’ and Carter’s, met that criteria.

Determining whether people had experienced homelessness is more difficult. HHSC admits – since those on the waitlist are not in the agency’s care yet – it receives “limited information on them.” Court documents are sent to the state hospital once restoration services are available, but they “do not necessarily include details on various socioeconomic factors, such as homelessness or indigence.” People finally admitted to state hospitals do receive “complete and accurate” assessments of their demographic profiles – but hundreds of others still waiting in jail do not.

“We’ve seen how the waitlist can explode very quickly,” Glazier said. “Where did all these new people come from? I think the committee would really like to… see if we can get some hard numbers to track. Where are we having the biggest problems? How highly correlated is homelessness to some of the outcomes that we’re trying to avoid?”