How two reporters overcame big obstacles to report on plight of mentally ill in California’s jails

Published on
September 7, 2016

In 2015 a mentally ill inmate in Santa Clara County’s main jail was found beaten to death in his cell. 

Michael Tyree, 31, suffered from bipolar disorder and addiction. He was jailed for two weeks for a minor violation of his probation. The judge wanted to send him to a community facility for treatment, but no bed was available.

Tyree died on Aug. 27. His body was covered with feces, vomit and bruises.

The county medical examiner said he died from massive internal bleeding from blunt force trauma. Dr. Joseph O’Hara later testified that the most brutal of Tyree’s injuries were equivalent to being hit with a truck.

Three jail deputies have been charged with his murder.

Tyree’s death raises serious questions about the safety and welfare of mentally ill offenders in jails. It comes at a time when jails throughout the nation are struggling with an increasing number of mentally ill people.

In California, the problem is compounded by what amounts to a massive statewide experiment. A 2011 law enacted to comply with a U.S. Supreme Court order to reduce crowding in state prisons shifted responsibility for certain low-level felons to jails. Many local lockups were unprepared to deal with the arrival of often seriously afflicted prisoners. At the same time, state hospitals became overcrowded, leaving mentally ill inmates languishing for six months or more in jails with inadequate treatment facilities.

We wanted to know: Was Tyree’s death an anomaly, or evidence of systemic deficiencies that could lead to more deaths?

When we began our investigation, attorneys for inmates had already filed class-action suits against Monterey, Santa Clara and Riverside counties describing gross lapses in health care for inmates. Disability Rights California was in negotiations to improve jail conditions in six counties, including San Diego. During our reporting, the nonprofit settled with Santa Barbara, Sacramento and Sonoma counties. The agency’s discovery of Sonoma County’s mishandling of involuntary medication became the focus of one of our stories.

Advocates and lawyers told us they were receiving complaints from inmates in more counties than they had the resources to investigate. They said most mentally ill inmates were not getting treated for their conditions. Those who were received the lowest levels of care: medication and infrequent cell-front visits with a psychiatrist or psychiatric nurse conducted through the food slot of the inmate’s cell door. Jail staff appeared ill trained to cope with mentally ill inmates — sometimes resorting to excessive force.

We wanted data to help us quantify these problems. We found it in two sets of public records on inmate deaths:

  • Deaths-in-custody databases: The California Department of Justice tracks deaths in the jails.
  • County coroner reports: Coroners must determine cause of death for every inmate who dies in California.

In California, the State Attorney General’s Office requires jails to report inmate deaths within 10 days using form BCIA 713. These forms include the name of the deceased, where they died, how they died and when they died. Since there were forms, we knew there was an underlying database we could request.

We also made sure to request the original forms because several had a narrative area describing a death and investigation that was not included in the database.

The DOJ data allowed us to compare county suicide and death rates 2010-2015:

  • Jail deaths have increased 18 percent statewide.
  • San Diego County had the highest suicide rate of the largest jail systems in California.

The details in the DOJ database provided the key to unlocking coroner reports that include:

  • Investigative narrative on how the body was found
  • timeline of events leading up to the death
  • mental health history and diagnosis
  • prescriptions
  • interviews with friends and family
  • autopsy and toxicology reports

We reviewed coroner reports for all San Diego County jail deaths, from 2010 through 2016.

It was this individual review of reports that allowed us to determine that, in many cases, San Diego was not following its suicide prevention policies.

It also helped us determine how many of the inmates who died suffered from mental illness and substance abuse problems. We believe these statistics have not been reported before.

Obstacles to obtaining coroner reports

We encountered three main difficulties in obtaining the coroner reports: 1) cost; 2) pending investigations; and 3) different reporting methods.

Cost was one of our biggest obstacles. Every county has a different system for requesting autopsies, and a wide range of charges. We found that reports can easily cost more than $20 each in some counties and be free in others. For counties with large populations we found that the cost to request every available medical examiner’s report for people who died while in custody of a county jail was in the hundreds of dollars.

One tip for cost cutting is to get reports without signatures, sometimes called “unofficial.”

These are cheaper because you are just paying a copying fee. You can also request an electronic, or emailed, copy that can save you postage charges.

Documents are not available for people whose deaths are still being investigated. In San Diego, sometimes it can take about three months to produce a medical examiner report. But in Sonoma County we found that the medical examiner’s office was backlogged by years, making the non-existent reports unrequestable.

Finally, we found that medical examiner reports can vary drastically from county to county or even by examiner.

Finding general information

We also wanted statewide data on how many of the 70,000-plus inmates in county jail on any given day suffer from mental illness, how many of them are receiving treatment and what sort of treatment it is.

These seemed like straightforward questions. They’re not.

California’s 56 counties report some data to the Board of State and Community Corrections (BSCC), a state agency tasked with ensuring jails meet minimum standards, including information on mental health cases and psychotropic medications. Those data are included in monthly and quarterly surveys available online.

But counties are not technically required to participate in the surveys. So there are also big gaps in the reporting. Out of five full years of data from the 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.

Finding mentally ill inmates and their families

We learned that jails in California have no legal obligation to let you interview inmates on a tour, or even give you a tour. You can make the argument that free speech rights require they provide an alternate means for inmates to connect with you, such as through letters, telephone calls or visits.

Early on, we were also hoping to find inmates and their families through nonprofits and advocacy groups such as NAMI. However, we found that national organizations were often unresponsive. Some local organizations told us that speaking to us would endanger their funding or county support. One said that they were actively warned by jail officials against speaking to us.

When we could reach them, some families and individuals were afraid to talk on the record because of stigma around mental illness and incarceration.

So, we decided to try to reach out to inmates directly.

But jails do not make it easy to speak with inmates on the phone. Inmates cannot be called directly. Instead, they must call you. We worked with lawyers and advocates to send out postcards with our phone numbers to jail systems of interest. Postcards are easier to send to jails and prisons because they do not need to be opened to be screened.

Even after an inmate has your number, you need to have an active account with that jail’s phone service provider to accept the call. Every county has its own phone system setup. We found that there are three main companies in California county jails: Securus, GTL and ICSolutions. You must have a separate account for each phone number you want to use and maintain a minimum amount of money in the account. Currently, several counties are being sued for high jail phone rates. Phone calls from inmates will frequently appear from Texas or other area codes. We also found that, because the phone companies screen each call and record it, that many phone call recording apps do not work, such as Tape a Call Pro. In the end, we found that hooking up our cellphones to a recording kit and only recording the inmate was the best way to record the calls.

After speaking to several inmates, we wanted to broaden our search. So we turned to public records. In general, families of inmates who had died were much more likely to go on the record. Using the coroner reports, we could also find the decedent’s next of kin. Also, we started looking for settled or ongoing lawsuits. Many of the families who were suing said that they felt they had a moral obligation to speak out in hopes of preventing more deaths.

Read the stories in this series here.