The waitlist for mental health help in Texas jails is a mess, with fatal consequences

In less than a year in Bexar County jail, 61-year-old Fernando Macias lost over 100 pounds then died after refusing medication and kidney dialysis. Naquan Carter, a 23-year-old with developmental disabilities, died face down in a Travis County jail cell after losing a third of his body weight. 

The common link between Macias, Carter and at least 10 other individuals KXAN discovered who had died in Texas jails in the past six years: they were all mentally ill and had been found incompetent to stand trial. They all sat in jail on a waitlist unable to quickly transfer to state hospitals that have been filled to capacity for years.

Conditions in local jails, particularly for people suffering from mental illness, can be horrific. Alone in their cells, these individuals can fall deep into unchecked psychosis. In the worst cases, they completely lose connection with reality, reject their own lifesaving medications and refuse to eat food. Then they die. 

Our latest investigation, undertaken with the assistance of a grant from the University of Southern California’s Annenberg Center for Health Journalism, dug into the consequences of the waitlist and shortfalls in the state’s collection of information about people on the waitlist. Without adequate data, experts told KXAN the state would continue struggling to improve the situation.

We discovered the Texas Health and Human Services Commission (HHSC) does not know how many people on its waitlist are unable to afford an attorney or experienced homelessness before being booked into jail. We also found the race and ethnicity data the state receives from law enforcement and the courts are not uniformly collected and are likely inaccurate, which could skew counts of Latino and white populations. Without reliable race and ethnicity data, it may not be possible to find inequities in the system, experts told KXAN. That means we may not know if people of color are being held longer in jail or experiencing worse mental health outcomes than white people.

Exactly how many people have died in Texas jails awaiting a state hospital bed isn’t clear either. Our investigation learned HHSC, which is the only agency we found with access to the complete state hospital waitlist, doesn’t track those deaths. We analyzed four of the state’s largest counties, but Texas has 250 more counties and many more potential deaths have been left uncounted.

We first dug into problems with the state hospital system’s waitlist in 2020 in our investigation “Locked in Limbo,” which examined HHSC’s struggle to handle the influx of people in need of mental competency restoration. In late 2019, there were roughly 1,000 people waiting for a state hospital bed. Two years later, that number nearly doubled to more than 1,900.

Our investigation found there are other important pieces of data the state doesn’t track that could help officials understand the root causes and solutions for fixing this problem.

How we did it

The biggest obstacle to digging into Texas’ state hospital waitlist is that the list is secret. Due to federal and state privacy laws, the names of people on the list aren’t available, at least not from state officials and not in the form of a comprehensive list.

To better understand what’s been happening to people waiting for state hospital beds, we had to take a backdoor route — through the courts. We found district clerks’ offices could, in some cases, export data showing cases in which a judge ordered a person found incompetent to be sent to the state hospital.

We got datasets from four of the state’s largest counties showing every person charged with a felony and found incompetent to stand trial. To find waitlist deaths, we merged those spreadsheets of incompetent people with the state’s custodial death database, which is the nonprofit Texas Justice Initiative makes available for download. When we found matches, we pulled court records, called attorneys and family members associated with the cases and researched media reports. 

Questioning the state’s data collection

What we also found were scattershot approaches to recording race and ethnicity information by district clerks, local law enforcement and jails. District clerk offices said they don’t independently collect race or ethnicity. The details are provided by law enforcement, which could be potentially reporting those details inaccurately. As we looked through Dallas County, for example, we found no court records that identified individuals as Hispanic, yet dozens of individuals found incompetent in that county had common Hispanic first and last names.

We found further inconsistencies between sheriff’s offices. In Travis County, a spokesperson for the sheriff’s office said when a person is booked, they use the exact race and ethnicity recorded by the arresting officer. The choices there are “Alaska Native/American Indian, Asian/Pacific Islander, Black, Hispanic/Latino or White.” But the Bexar County Sheriff’s Office, for instance, has different set of option in its computer booking system for recording race, including “Asian, Black, Chinese, Indian, Japanese, Latin, Other, Unknown, White.”

Considering the differences in recording race and ethnicity between county law enforcement and courts, it is not clear how reliable HHSC’s waitlist data can be.

Analyzing the socioeconomic status of individuals on the waitlist was also tough, but we knew from interviews that income and housing have a correlation with whether people achieve long-term mental health improvement. Since the state didn’t have a county-by-county breakdown of that information, we created a dataset ourselves. To do that, we identified and counted individuals who could not afford an attorney and were appointed one by the court. We individually searched more than 2,230 cases in Harris, Bexar and Dallas Counties to find which incompetent individuals were appointed an attorney. Travis County provided all necessary data, and we were able to merge it without having to search individual cases for additional details.

We found the percentage of people experiencing homelessness on the waitlist in Harris and Travis counties by using defendant addresses listed in district clerk data. People experiencing homelessness were labeled as “homeless” or “transient” or used a homeless shelter for their address. The district clerks in Bexar and Dallas counties did not provide address information, so we couldn’t calculate homeless statistics for those counties.

KXAN will continue following these trends and shortfalls, and how state leaders address them or don’t. Officials said they would display race and ethnicity data for the first time at a quarterly advisory meeting in late January. We plan to cover that and continue reporting on the state’s waitlist and its impacts.

David Barer and Josh Hinkle’s reporting on shortfalls in the state’s oversight of its mental hospital waitlist was undertaken as a USC Annenberg Center for Health Journalism 2021 National Fellow, and they were grantees of its Dennis Hunt Fund for Health Journalism.