Photo via justicenotjails.org
Before breakfast on November 8, 2014 in the women's jail in Los Angeles County, a popular inmate named Unique Moore started coughing and complained that she couldn't breathe. A 37-year-old African-American, she had a history of diabetes, asthma and severe mental illness. She told her jailers when she was locked up for her final time, according to a recent lawsuit filed against LA County, "She had a long history of asthma and that if she had an episode where she could not breathe, that it could be fatal without the proper first aid." But on that morning, Moore struggled to get her breath on the lower bunk and asked her cellmate, or "cellie," in the top bunk to call the guard for an inhaler; LA County jail policy doesn't allow inhalers permanently in the cells for fear they could be used as weapons or dispensers for illegal drugs. What's more, Unique complained of feeling hot and asked her cell-mate to fan her as they waited for the inhaler to be brought to her, as her cellie told Portasha Moore, the family' co-counsel who filed the lawsuit along with veteran litigator John Sweeney. After pressing the emergency button located inside each cell to summon help, the cellmate and Moore herself, joined by other inmates, "implored and eventually begged Defendant [Deputies 1-10] to bring a breathing device," the lawsuit says.
Inside the cell in "pod" 3400 -- a 30-cell section of the 2,300-woman jail in suburban Lynwood -- the minutes ticked by without a response. About ten minutes into the ordeal, Moore fell down unconscious. The cellie screamed out. But Moore couldn't be aroused.
It was Unique Moore's last stop on the endless route of drug use, jail and mental health crises she had traveled. She was just another of the county's roughly 500,000 people with serious mental illness, half of whom receive no treatment at all in the course of a year, according to officials with the county's Department of Mental Health (DMH). They too often die far too young -- from violent attacks, medical neglect, dangerous overmedication or suicide -- while thousands of them are routed into the LA County jail system each year, perhaps the largest single facility holding mentally ill people in the country. There are as many as 4,000 of them behind bars at any one time, Los Angeles County Sheriff Jim McDonnell has said, or over 20 percent of the jail population of about 17,000. (Serious mental illnesses are generally defined as schizophrenia, severe bipolar disorder and major, disabling depression.)
On that morning, the guards, mostly men at this time of day, took their time in responding to Unique Moore. "A lot of times when we wanted toilet paper or sanitary napkins, they ignored us," recalls Kendra Cox, who was jailed in the adjoining pod, 3300. "They probably thought it was insignificant," she says, citing the apathetic response to the efforts to aid Unique. "They were men."
But the guards for Unique's pod weren't even present. They were schmoozing with colleagues in the adjoining section -- Kendra's pod --before their work day. Kendra alleges that initially they didn't answer the incessant ringing alarm from Unique's cell. Kendra learned about the delayed emergency response another way: The inmates near Unique shouted and pounded on their thick metal doors with the small observation windows in the adjoining pod. In the other pod where Kendra bunked, the sounds were muffled. Yet the inmates' cries for help were loud enough to wake Kendra and inmates nearby.
But the shouting and pounding did not stir the guards. For close to a half hour, Kendra says, she stood near the door at her cell, looking out the window, and wondering where the guards were. Eventually, the guards responded. When they showed up, Unique was on the cell floor unconscious, and, the deputies later claimed in reports, still breathing. After the jail's medical staff arrived at her cell, she had gone into cardiac arrest before they could administer CPR, deputies claimed. Then they summoned the county's Fire Department paramedics.
After she was carted away from the jail in an ambulance, word spread through the jailhouse grapevine about the woman nicknamed "Chocolate." Shortly before 8 a.m., at St. Francis Medical Center, Unique Moore was declared dead.
The wrongful death and civil rights lawsuit filed on her behalf charges, "Defendant[Deputies 1-10], in spite of hearing loud wails and pleading for help, paid no attention to said petitions for help and let Decedent MOORE die." The lawsuit also names, in addition to the county government, the sheriff's department and 50 unnamed deputy sheriffs and other officials. (At the time of the lawsuit's filing in November 2015, the family's attorneys didn't have the full legal names and job titles of all the deputies and officials involved, so they're called "DOES," as in the anonymous name "John DOE," but they planned to submit those names later when obtained.) If his legal team's preliminary findings are confirmed through the discovery process now underway, attorney John Sweeney observes, "They clearly failed her. She clearly had a bad asthmatic condition and she was put in a cell with nothing to remedy her attack."
He adds, "It is literally horrible that she died on the floor after her cell-mate pushed the emergency button and they didn't come in a timely manner."
The Los Angeles County Sheriff's Department refused for close to a year to acknowledge publicly that a death had occurred at all and officials still strongly deny that there was any medical neglect. Then, after presented with the coroner's report on Unique Moore last fall by this reporter, LASD staff finally conceded that the death occurred. But Homicide Bureau Detective Lt. David Dolson, citing a Homicide Bureau investigation required in all inmate deaths, disputed the claim that there were any failures in the response to Moore's emergency: "The Homicide Bureau's investigation did not reveal any 'apparent delay in providing the inhaler,'" he said in a written statement, quoting my question about the allegations of neglect. A spokesperson for the sheriff's department says it can't comment further on the lawsuit's allegations while the litigation is pending.
An investigation for the Witness LA criminal justice news site, co-published in The Huffington Post, has found that the lawsuit adds to continuing questions about conditions at the women's jail and the LASD's commitment to transparency and reform. All this follows years of scandals focused mostly on the men's jails, a wave of criminal prosecutions of LASD officials and the civil settlements with the ACLU and the Justice Department in 2014 and 2015 that have imposed sweeping court-monitored changes on the sheriff's department management of the jail system.
The ground-breaking settlements have especially targeted the jail's approach to mentally ill inmates and broader patterns of brutality, abuse and neglect, but their focus has largely been on the men's jails.
The women's jail, officially known as the Century Regional Detention Facility (CRDF) in Lynwood, hasn't gotten sustained legal, advocacy group or media attention until this past August. That's when the reform group, Dignity and Power Now (DPN), working with students researchers from UCLA Law School's International Human Rights Clinic, issued a shocking, detailed report, Breaking the Silence, about a broad pattern of abuse and neglect especially damaging to women of color with mental illnesses. But these findings were downplayed or ignored by virtually all major Los Angeles English-language media outlets. (Prior to the report, perhaps the only major public attention the women's jail received was by a cartoonist portraying her 2014 incarceration in the LA Weekly.)
The DPN report highlighted seven individual victims of maltreatment at the women's jail. They witnessed or experienced such abuses as pregnant women being shackled and inmates forced to lie in their own waste and menstrual blood for days in their cells without access to sanitary products; their names were changed in the report to protect their privacy -- and, presumably, to protect them from guard retaliation if they are jailed again.
Perhaps the most striking was the account of "Nina," who told the UCLA investigators why she hurled herself off a second-story balcony in September 2014: "I wanted to see a doctor and I couldn't. That's why I jumped." In an April 2015 interview, she recounted that before being arrested, the 47-year-old Nina had been diagnosed with bipolar disorder, schizophrenia and depression. She claimed that for two weeks deputies denied her access to any health professionals or medications, while keeping her confined to her cell for all but 30 minutes a day. The report said, "She asked to see a psychiatrist or clinician every day, and in response the deputies responsible for her care systematically ridiculed and denied her requests;" they verbally abused her sometimes because of her race and sometimes because of her mental illness, according to the investigation. The researchers reported what happened next:
"Unable to take any more abuse, Nina saw what she considered a way out of her misery when a medic came to her cell to check her blood pressure. She managed to escape her cell, and hoping finally to silence the voices in her head, she jumped from a second story balcony at CRDF.
"Nina survived the fall, but the medical neglect and abuse that drove her to it continued. Deputies transferred her to St. Francis Medical Center in Lynwood, a public hospital a short drive away from CRDF, where she was placed on suicide watch. She was kept there for another two weeks, handcuffed to her bed. Although medical professionals treated her foot [injury], blood pressure, and bipolar disorder, Nina was forcibly confined to her bed. Staff forced her to relieve herself in a bedpan in front of a male guard, despite her repeated protests. [Emphasis added.] Staff also forced her to lie in her own filth--a nurse washed her only once in two weeks. Weakened, humiliated, and depressed, Nina lost the will to eat for almost a week.
"After her hospital stay, deputies handcuffed Nina to a gurney and transferred her to Twin Towers Correctional Facility [which has a small section for women]. No doctors consulted with her at Twin Towers," the report claimed. It said officials just fed her a pain-killer and the anti-anxiety drug Klonopin to quiet her, and she continued to face ridicule and verbal abuse over her race and mental state. Even though she had a severe foot injury because of the suicide jump, she periodically was denied access to a wheelchair that she needed to move -- forcing her, she says, to sometimes crawl on her hands and knees across the filthy floor to get to the toilet and to miss a few court dates. She was confined at Twin Towers for over seven more months.
"Today, Nina walks with a severe limp and requires comprehensive physical and mental therapy," the report concluded about her case. " Her hope now is to begin to repair the deep physical and psychological wounds that her incarceration inflicted on her."
The Department of Mental Health is supposed to track and implement the mental health care provided inmates with such serious mental illnesses, while the sheriff's department has been in charge of medical care. Yet apparently neither did their job correctly -- if at all -- in this and other cases, according to the DPN report and the 2014 Department of Justice inquiry. (Neither DMH or LASD were willing to comment specifically on the serious allegations of neglect throughout the Dignity and Power Now report.)
Nina's story was hardly unique, our investigation and the independent report by Dignity and Power Now found. The DPN study concluded that LASD and county DMH officials "forced women suffering from mental health conditions such as bipolar disorder, schizophrenia and depression to suffer--sometimes for months--without access to necessary medication. These [LASD] deputies verbally abused these women and rarely permitted them to leave their cells. These officials forced these women to lie in their own filth for days, and denied them access to adequate reproductive hygiene products such as tampons or pads, leaving these women to bleed on themselves. Women interviewed for this report recounted how deputies shackled pregnant women, and punished women with mental health conditions by placing them in solitary confinement.... By medically neglecting and abusing women of color, deputies and other personnel increased these women's risk of suicide." The report also outlined how the alleged maltreatment violated civil rights laws, along with California and international human rights statutes and standards.
What is especially notable is that the report cited incidents as late as the fall of 2014, such as Nina's suicide attempt and her apparently abusive care at Twin Towers. All this occurred after LASD and DMH officials disputed a June 2014 DOJ letter to the county saying the jail system's handling of mentally ill inmates was an unconstitutional violation of their rights. These agency leaders, on the other hand, claimed they were making great progress, challenged the Justice Department's harsh findings and opposed the court oversight that was ultimately imposed in August 2015 on the jail system as part of a sweeping settlement.
"We are disappointed that today's [DOJ] report fails to fully recognize the additional progress made over the last year and a half to improve mental health services," the Sheriff's Department and the Department of Mental Health said in a joint statement in June 2014. "The report also mischaracterizes and significantly understates the incredible efforts made to improve our suicide prevention practices."
Three months later, Nina tried to jump to her death because no doctor would see her. By early November, Unique Moore, heavily sedated with psychotropic drugs and apparently denied her inhaler, suffered cardiac arrest in the jail.
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This account of Unique Moore's death and the alleged maltreatment of other mentally ill inmates in the women's jail that has led them to such desperate measures as smearing feces on themselves is based on a wide range of documents and interview sources. These include interviews with former inmates, attorneys who have sued the sheriff's department, former LA County Department of Mental Health jail staffers, LASD officials and a review of the coroner's report and legal filings about Moore, along with federal, county, ACLU and advocacy group investigations.
Soon after Unique Moore's death, the Los Angeles County Sheriff's Department (LASD) began offering a version of events sharply at odds with inmate eyewitnesses and some sections of the subsequent coroner's report. As the LASD officials told their tale, Moore was quickly provided an inhaler but collapsed anyway before they could revive her, due to her poor health from years of drug abuse. But the initial autopsy report written shortly after her death by the deputy medical examiner, concluded, "From the anatomic findings and pertinent history I ascribe the death to "Asthma (Clinical History)." The report cited "other conditions contributing but not related to the immediate cause of death: diabetes mellitus, hypertension, bipolar disease, schizophrenia, drug use (history)." (Emphasis added.)
A few months later, after receiving further input from LASD Homicide Bureau detectives and reviewing the homicide bureau's report, the deputy medical examiner Dr. Vladimir Levicky concluded his final March 2015 autopsy report with a different emphasis, "The cause of death of death in this case is asthma. The mode of death is accident due to the history of drug use." (Emphasis added.) There were no illegal drugs in her system, but because the coroner believed the LASD's story that Moore was quickly provided an inhaler, he concluded that it was an unavoidable accident worsened by her history of drug abuse.
In their interviews with the coroner's office, according to its case file on Moore, LASD officials painted a rosy picture of the high quality of medical care Moore received. As the coroner's report claimed in its report the day after the death, Moore "was routinely seen by medical staff at the jail. Every time the decedent needed her inhaler, medical staff would check her blood sugar level. On Sunday, the decedent told her cell mate she needed her inhaler. The cell mate called a deputy, and the deputy arrived at the decedent's cell. The cellmate told the deputy that the decedent needed the inhaler."
Shortly after her death, LASD homicide detective Jeff Cochran gave a benign version of the subsequent tragic events that day to the coroner. According to the detective's account, after the deputy learned about the asthma emergency, he then sped his way to the medical staff, retrieved the inhaler for Moore and returned to find that Unique had fallen to the floor, semi-conscious and breathing with difficulty. "As soon as the decedent was pulled out of her cell, the decedent went into cardiac arrest," Cochran told the coroner.
This version was best summarized in a November 2015 email to me written by his colleague, Lt. Dolson, roughly a year after Moore's death: "Inmate Moore died at the hospital after experiencing difficulty breathing in her cell. Prior to her death, Moore's cellmate activated the emergency call button in their cell. A deputy responded and was told by the cellmate that Moore needed her inhaler. Nursing staff was notified, and the deputy returned to Moore's cell. She was now unresponsive, but breathing. Medical staff responded and monitored Moore. Paramedics were summoned. Moore was transported to the hospital where she died."
Before then, for close to a year after Moore's death, the Los Angeles County Sherriff's Department declined to comment on the incident or even concede that Unique had died. "There are no records to provide in response to your request," the jail's custody division first wrote to me in July 2015, a position that didn't change until I followed up with the coroner's report and more questions last fall.
The silence and apparent evasions could reflect the LASD's legacy of controversial and, all too often, illegal practices. These include the sheriff department's long history of refusal to provide full information on shooting fatalities in the streets and inmate discipline; its proven cover-ups of jailhouse brutality; and the recent obstruction of justice convictions of deputies. All that was capped by the retired Los Angeles County Sheriff, Lee Baca, pleading guilty in February to lying to federal investigators during their probe of corruption and brutality in the jail system -- after years of denying any role in the scandals. His former second-in-command, Undersheriff Paul Tanaka, is slated to stand trial in March on similar charges of obstructing a federal investigation into corruption and deputy violence in the jails. Hidden from the glaring public spotlight shined on the men's jails, however, the women's jail has seemingly remained infected by the sheriff's department longstanding culture of neglect and cruelty.
"It's not safe for our clients there," observes Kristina Ronnquist, a former DMH social work intern-turned-whistleblower after she left -- or for clinicians who report abuse. "I was very clearly told not to speak out, that it would harm me professionally, given the unsafe environment of going against the sheriff's department," she says.
Still, a new leaf was supposed to have been turned with the swearing in of a reform-minded sheriff, Jim McDonnell in December 2014, the first non-LASD member sheriff in a century, who vowed a new era of accountability and transparency. He has publicly released more records on police shootings and expressed a strong commitment to improving services for mentally ill inmates while supporting reducing their inordinate incarceration.
Yet, in the department's response to the Moore case and other problems at the women's jail, echoes of a scandal-ridden past apparently remain. "There's a disconnect between what goes on inside the jail and what the leadership is saying," observes Mark-Anthony Johnson, the director of health and wellness for Dignity and Power Now. After all, in recent years federal prosecutors have hit the sheriff's department with over 20 federal criminal indictments for assault, obstruction of justice and corruption; at least eight guards or administrators have been sentenced to prison for as long as 41 months; and, all told, there have been over a dozen former LASD officials convicted in the ongoing investigation.
Mentally ill inmates are vulnerable across the country but especially so in LA County. They have been attacked at higher rates than other inmates, according to the sheriff department's own "use of force" data and the May 2015 report on dangerous conditions throughout the US by Human Rights Watch: "Callous And Cruel."
The Los Angeles County Sheriff's Department, critics say, has also dragged its collective feet on reform until forced to take action by court orders in 2014 and 2015. But if the response to the 2014 Moore and "Nina" incidents are any indication of deeply rooted patterns in the jail system, it's not at all clear how well they're responding now. It's worth recalling that jail officials didn't start trying to root out the system-wide violence and neglect in earnest until after 18 deputies were first indicted in December 2013; the then-sheriff, Lee Baca, retired under pressure early; and the Board of Supervisors ordered the department to reform. In December 2014, the sheriff's department was forced to settle the class-action lawsuit with the ACLU by agreeing to thorough court monitoring, although enforcement only applied to the men's jails. Public awareness of the scandal and the FBI investigation were initially spurred in large part by a series of reports and lawsuits by the ACLU of Southern California, and the investigative work of The Los Angeles Times and Witness LA.
There was a crescendo of heavily publicized legal and criminal actions throughout 2014. The then-pending ACLU brutality lawsuit and the Justice Department investigation into maltreatment of mentally ill prisoners were augmented by the convictions in July 2014 of six deputies for obstructing justice in a federal probe into violence and corruption at the jails, later followed by imposing prison terms as long as 41 months on them in September 2014. "Blind obedience to a corrupt culture has serious consequences," United States District Judge Percy Anderson declared, before ordering all the defendants to prison.
Yet all those legal actions, indictments and prison terms didn't seem to change the culture or practices of deputies in the women's jail by the time Unique Moore died in November 2014 and Nina tried to kill herself in September 2014.
On top of that, some LA County Jail health professionals -- from both LASD and the Department of Mental Health (DMH) -- have exhibited many of the same scornful and indifferent attitudes towards mentally ill and other inmates that have marked the sheriff's deputies. Those sorts of actions -- from laughing at the mentally ill to ignoring inmates in physical agony -- and the callous views of many clinicians have been countenanced or simply ignored by Department of Mental Health leaders, according to my interviews with former DMH workers, the Department of Justice findings and the recent DPN report. This hard-hearted mindset helped make it possible for the deputy-driven violence against inmates, including the mentally ill, to continue unabated for so long. These sorts of harsh assessments have been made for years in critical reports and lawsuits by the ACLU and the Department of Justice, among other organizations, supplemented by court rulings, stretching back as far as the late 1970s -- although they looked primarily at the notorious men's jails.
Problems continued despite the mounting legal and media pressure on the sheriff's department in recent years. As a former Department of Mental Health jail clinician, who asked to remain anonymous, points out, "The deputies and the sheriff's department are in charge," setting the tone and approach to mental health care by the hundreds of DMH staff members in the jail system, which is in fact dominated by this same sheriff's department and its staff. That may help explain why too many mental health workers at the Los Angeles County Jail have allegedly lost their moral compass and departed from the Hippocratic Oath: "First, Do No Harm." Even so, few, if any, DMH staff members have been held publicly accountable or faced sanctions for the broad patterns of alleged abuse and neglect uncovered by independent investigations into conditions at the women's jail.
The mental health department's public affairs director, Kathleen Piché, and other DMH officials declined to directly address any of the specific allegations about conditions at the women's jail and the allegedly scornful DMH staff attitudes towards mentally ill inmates. But the department indirectly acknowledged past problems in this statement issued by Piche:"Based upon investigations by the US Department of Justice and its subsequent report, the Los Angeles County Department of Mental Health is fully involved in working with the Department of Justice and other agencies in addressing the findings and improving the quality of mental health services in the Los Angeles County jails."
The leadership of the Department of Mental Health has changed since the worst of the abuses in the jail system were made public. The DMH director, Dr. Marvin Southard, retired in November 2015, and the top DMH clinical officials in the men's and women's jails either left the department or were reassigned. Yet it's not clear if the allegedly poisonous culture of health professionals in the jails has changed along with the re-arranging of leaders at the top.
As a non-violent addict with severe mental illness, someone like Unique Moore should not have ended up in jail in the first place. Of the roughly 4,000 seriously mentally ill inmates in the men's and women's jails, most have lacked reliable access to community-based services and treatment facilities, let alone high-quality care. As reported by the Virginia-based Treatment Advocacy Center, ten times as many seriously mentally ill prisoners are in the nation's jails and state prisons -- mostly for non-violent offenses -- than in state mental hospitals. In Los Angeles County, a perfect storm of neglect, an absence of accountability and the sheriff department's shielding of wrongdoers have led to the well-chronicled, decades-long nightmare that brutalized mentally ill and other inmates.
The U.S. Justice Department continues its criminal probe into violence, corruption and obstruction of justice at the LA County Jail -- even after finalizing in August the court-ordered consent decree to force reform of the "persistent failure" of the jail system's abysmal mental health care and medical neglect.
This federal oversight would come too late for Unique Moore. Kendra and other inmates often saw Unique, short-haired and ballooning to more than 200 pounds in part due to her meds, wandering around the open area outside the cells in a medication-induced stupor. Unique, it's worth remembering, was an inmate with a history of serious mental illness, including bipolar disorder and schizophrenia. Yet she was still kept with the general jail population. She was also given a potentially fatal cocktail of drugs, including the antipsychotic Seroquel that the FDA in 2011 found posed dangers of sudden cardiac death. Unique had a complex medical history, according to the coroner's report, jail medical records and the pending lawsuit. She had congestive heart failure, diabetes, asthma, anemia, chronic obstructive pulmonary disease and neuropathy, all clearly disclosed to the jail's medical staff when she was arrested for violating her probation less than a month before she died.
Unique needed careful monitoring and prompt attention in case of breathing or cardiac emergencies. But as far as Kendra and other former inmates could tell, few, if any, of the mentally ill inmates who mixed in with the general population got medical exams or regular care. Kendra's assertion received support from the harsh assessment the Department of Justice rendered in June 2014 about the quality of care given mentally ill inmates, the DPN report and the views of some current and former LA County Department of Mental Health clinicians in exclusive interviews. "There was no oversight and an indifference to bad clinical care" for both medical and psychological conditions, one DMH therapist says.
But according to the LASD's official version, Moore had received plentiful, regular health care. The medical examiner found no illegal drugs in her system, just prescribed medications including Seroquel, the antidepressants Elavil and Pamelor, along with Benadryl. As noted earlier, the final version of the autopsy report attributed the cause of death to the asthma attack and the mode of death to an accident caused by her history of drug abuse, basically echoing the views of the LASD's Homicide Bureau as far as the autopsy results permitted.
Unique had been in jail less than a month, caught in the heart of the Skid Row district seemingly looking for drugs when she was supposed to be taking a drug rehabilitation class. Police arrested her for violating her probation. She had a long history of drug addiction and stretches in prison and jail. As a teenager, she smoked weed, while her school work and attendance plummeted at about the same time as the mental problems that had dogged her since she was seven years old flourished into a full-blown mood disorder, all worsened by the hallucinations of schizophrenia. That's what her father, still too distraught to be interviewed by the media, told the co-counsel in the family's lawsuit, Portasha Moore. Then Unique moved on to harder drugs, including PCP, cocaine and meth, that further unhinged her shaky grip on sanity.
Looking back, it's clear the public mental-health and drug treatment clinics in Los Angeles's ghetto areas were of little use even when she was able to get treatment. (Comparable flaws afflict most mental health and drug clinics throughout the country, largely because they fail to use proven treatments, according to the National Center on Addiction and Substance Abuse at Columbia University and data from the federal Substance Abuse and Mental Health Services Agency.) By her mid-teens, she was getting in trouble with the law already and served the first of her stints in juvenile detention facilities. In addition, "The state failed her," Unique's father, Jimmie Lee Moore, believes, in part because the drug treatment programs she attended during her prison stays -- the longest for 18 months -- were undercut by the widespread availability of illegal drugs in prison.
This shoddy care has a cost. After they end up in the LA County jail, 95 percent of mentally ill inmates have substance-abuse disorders and are so unmoored from their families and communities that more than 80 percent are homeless or lack stable housing when released, as the new Los Angeles County Sheriff, Jim McDonnell, noted in testimony in February 2015 before the President's Task Force on 21st Century Policing. "Jails were not built as treatment centers or with long-term treatment in mind," McDonnell said. But that's little excuse for the apparent widespread patterns of neglect and abuse that continue in the women's jail after the men's jails have gotten so much law enforcement, media and legal attention.
When Unique Moore returned to the LA County women's jail in the fall of 2014 for the final time, it was probably one of the worst places in the country for a person with her problems to be incarcerated. In fact, DMH workers and former inmates report that female inmates' medical and psychiatric problems are often ignored for weeks. In extreme cases, female inmates pull out their own rotting teeth, according to Ronnquist, a former social worker intern in the women's jail in 2013 and 2014. Just as disturbing for some inmates, Ronnquist notes, "On the second floor [for the most seriously mentally ill], they're decompensating because of the environment. They're rubbing feces over themselves and rubbing it on the windows. And many of them are non-violent." She adds, "I had no idea any of this was going on. I was shocked and horrified."
Sheriff's deputies and detectives launched a seemingly superficial inquiry into Unique Moore's death. Although they did so within hours of her demise, the investigating officers were from the same department that allegedly threatened, terrorized and intimidated the inmates under their watch. "They treated us horribly like we were second-class citizens," Kendra Cox says of the custody staff, noting that no inmates dared to call out the guards on the early-morning shift for their alleged delayed response to Unique Moore. "We didn't tell them what really happened," Cox says now.
But as my interviews with former inmates revealed, the Homicide Bureau detectives apparently failed either to elicit honest interviews with Moore's neighboring inmates or didn't contact inmates on her pod after they were released. Amid an environment of intimidated inmates at the women's jail, the Homicide Bureau passed along to the coroner the allegedly sanitized version of events told by the deputies who were on duty in the pod area when Unique Moore died.
All those claims, though, may unravel in the face of the recent lawsuit with multiple eyewitnesses to the reportedly deadly delay that cost Unique Moore her life. If the deputies' version of events falls apart, that could potentially add to the millions of dollars the Los Angeles County Sheriff's Department has already paid out for legal settlements following neglect, fatal shootings or abuse by law enforcement officers. Indeed, total legal costs jumped 50 percent to nearly $120 million in 2015 compared to 2014.
Despite all these mounting legal claims and criminal prosecutions against sheriff's deputies, at the women's jail, inmates still fear retaliation. "Ain't nobody tell the truth in jail," said Tina Middlebrooks, 50, who was released in February 2015 after a three-year stint for drug dealing. "When you're in jail, it wasn't cool for you if the guards thought you were snitching. They tore up your cell and threw all your [personal] stuff out." She was staying in another section of the jail but learned later about the tragedy on the same day that Unique Moore died. "I was devastated," she says. "I really tripped out on her death." It was especially worrisome because Tina was grappling with her own mental illness -- schizophrenia -- while being housed amid the general population and taking her prescribed Seroquel, just like Unique Moore. She met Moore several years ago in state prison while they were there on drug-related charges. "She was a beautiful person both inside and out," she recalled. "She was funny and outgoing."
But Moore's death -- previously unreported by any local media outlet until this Witness LA investigation -- was ignored, along with the wrongful death lawsuit filed last fall. In a similar way, the abuse, violence and neglect that allegedly continues at the women's jail to an unknown degree has received scant newspaper ink or broadcast coverage.
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The lion's share of media and legal scrutiny goes to the men's jails, and it has been well-deserved.
Amid all these high-profile jail scandals, however, the Department of Mental Health's role in contributing to the jail's well-documented dangerous culture has received little attention. Mental health officials defend the quality of care and have seemingly ignored for years widespread brutality at the county jail that victimizes mentally ill prisoners most of all. Yet when I spoke to jail psychologist Sarah Hough early in 2014, she told me, "In the 15 years I've been here, I've never been informed of brutality," she said, from either mental health staff or any inmates. (One stunned Justice Department official scoffed: "That's ludicrous on its face.") She was then the clinical director of all jail mental health programs for the county's Department of Mental Health and later became the head of mental health programs at the women's jail before taking another post in the department. (For personnel privacy reasons, the department says it won't disclose when Hough served at the women's jail or left her position there. )
The Pollyannaish views then prevalent among Department of Mental Health leaders contrasted with ACLU reports, DOJ findings and the successful class-action lawsuit over widespread deputy violence that the county government settled in December 2014. Following that settlement, in the words of Margaret Winter, director of the National Prison Project, and Peter Eliasberg, the legal director of the ACLU of Southern California, "The reign of terror ends at LA County Jails." Yet Eliaserg remained cautious about the prospects for change in the jail system: "It's better now, but it still needs a significant amount of work," he told The Los Angeles Times.
Change may take a while. In 2014, the Los Angeles County Sheriff's Department reported an 11 percent uptick in deputy "use of force" incidents against inmates in the jail system through September of that year. That generalized figure, though, masked even more troubling data: a 36 percent rise in the women's jail in Lynwood and a 40 percent jump at the North County Correctional Facility in Castaic compared to the same period in 2013, when the department had claimed that reforms began. (Updated and accurate use of force data in the jails for 2015 has been promised by Sheriff McDonnell for release later in 2016.) And, as a reminder, the 2014 figures represented only the officially reported uses of violence before the legal settlements scrutiny were finalized -- not the secret beatings that were still being done out of the range of cameras and omitted from paperwork in 2015, according to Patrisse Cullors, the founder of Dignity and Power Now.
The importance of any continuing violence in the jails is that it reflects a broader reality that affects women inmates: change comes slowly to an organization that has fought and resisted reform for decades. Even after seven deputies were indicted in 2014 -- and sentenced to prison -- for threatening and hiding from the FBI an informant documenting deputy violence, another male FBI informant was brutally beaten early in 2015, Cullors says. His undercover role was apparently unknown to the deputies and Cullors has alerted government investigators to the attacks. "Cameras can't see everything," she says. Further reforms are expected if the LA County Jails under the new sheriff fully complies with the ACLU and Department of Justice settlements. Until relatively recently, the ACLU received about 4,500 complaints a year from inmates.
Fortunately, the public pressure and investigations have contributed to a two-thirds decline in brutality complaints to the ACLU since the end of 2012; those complaints are also less likely to involve broken bones and deputies piling on with savage head strikes. Yet significant problems continue: At least 1,000-violence related complaints are made to the organization each year.
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While ignoring decades of violence, Department of Mental Health officials I interviewed also failed to acknowledge major problems with their care. They say they provide high-quality, regular services. For instance, the department's then-director, Dr. Marvin Southard, said the mental health staff in the scandal-plagued Twin Towers men's jail delivers exemplary care. "The Department of Justice is happy with the level of service we provide mentally ill people in the jail, given the limitations of the facility," he said in an interview shortly before Department of Justice in June 2014 released a stinging report to the contrary covering all the jails in the system; these included suicide prevention failures in the women's jail. The letter of findings denounced mental health care in the jail as an "unconstitutional" violation of inmate rights. Although the 36-page letter acknowledged improvements in services, the Justice Department took steps to impose court oversight of the jail, which was finally set in motion with the DOJ settlement in August 2015.
What critics see as the clueless views of Southard and other former DMH officials haven't been forcefully disavowed by new leadership at the department. "The treatment of mentally ill men and women in the jail is a disaster, and the fact that Dr. Southard wasn't honest about it is frightening," Patrisse Cullors says. The department's new leadership hasn't publicly identified or acknowledged any specific, significant failures in the quality of mental health care in the jail, either, so it's not clear to reformers how much real progress can be expected, although court monitoring offers them some hope.
Meanwhile, the LASD deputies' scorn towards mentally ill inmates has not been disguised, and still shows relatively few signs of changing: routinely, deputies refer to mentally ill inmates as "dings." In 2014, even after Department of Mental Health and sheriff's department officials sought to stave off federal court oversight of jail mental health care, deputies in the women's jail still responded to a delusionary, untreated woman standing on a table talking to herself by laughing and hooting at her, Tina Middlebrooks recalls. "They're letting people act out really crazy," she says. In the world of the LA County jail, the mentally ill at least are good for laughs from deputies and clinical staffers, former DMH counselors and inmates say.
The shortage of decent care is apparently still evident in the women's jail in Lynwood because of the lack until recently of any outside monitoring, which is still being put in place following the complex August 2015 settlement with DOJ. County officials estimate that of the roughly 2,300 inmates, one-quarter of them have a serious mental illness. Still, only 330 health beds are set aside for them. Abuse and neglect have been common, according to Ronnquist, the former social worker intern who now volunteers with Dignity and Power Now. "DMH clinicians know that abuse is going on by the sheriff's department, but they're too scared to say anything," she said.
In addition, untrained deputies have reportedly assaulted mentally ill inmates and even some patients who've attempted suicide for unruly conduct or slight infractions. As Ronnquist told the Board of Supervisors in May 2014, "One of my teenage clients just recently made a very serious attempt at suicide and one day later was taunted by a sheriff's deputy, who slammed her fingers in the door after she refused to move them, causing serious injury."
Ronnquist was interviewed as part of an LASD inquiry in the spring of 2014 into the deputy's conduct, but the department didn't substantiate her allegations. But with the new heat on the department, her public testimony held out the hope of a fresh examination of the case. Ultimately, nobody did anything about the allegations. Officials still insisted they couldn't confirm them after months of failing to answer Ronnquist's follow-up inquiries. Before ending the investigation in 2015, an LASD spokesperson said in a written statement to this reporter, "The Sheriff's Department in conjunction with the Office of Inspector General, is reviewing the circumstances surrounding the concerns expressed by Ms. Kristina Ronnquist. We remain committed to the appropriate treatment of all inmates, including the mentally ill."
Many who have witnessed conditions there disagree with the sheriff department's claims. "If the deputies were having a bad day, and an inmate flinched, they felt justified beating them up," says another former Department of Mental Health jail worker. Two deputies warned this staffer after they brutally kicked a woman inmate's head: "You didn't see anything, right?" they told her. A former inmate without a history of mental illness, who wishes to remain anonymous, stayed in jail there in 2012 and remains wracked with anxiety and depression. She saw a 60-year-old disabled woman beaten up after accidentally bumping a deputy with her chair during a meal. "They felt disrespected," she recalls. "She didn't do nothing to them, but they jumped and punched her." (The sheriff's department hasn't responded to requests for comment on these allegations in the absence of further identifying details, but denied that the jail system has had a pattern of deputy violence, despite all the legal settlements involving court monitoring of the department. )
Just as troubling, says Ronnquist, "The culture of the DMH clinicians is so toxic that they sit around in their office all day and make fun of the women with delusions." As a result, the inmates see therapists as little as once every six to eight weeks, psychiatrists as infrequently as twice a year. In fact, Ronnquist was told by a supervisor, "Our job is to babysit them and make sure they don't die."
But that minimal goal often wasn't met. Three suicides in six months in late 2012 and early 2013 in the women's jail didn't change or improve the training of department or jail staffers, she and other critics say. Ronnquist did what she could, complaining to supervisors about neglectful care. Southard replied later that her complaints were "over-dramatic," and that county agencies' internal inquiries, including by DMH, failed to substantiate her allegations. But the rigor of the purported DMH review was questionable: No one from the agency called to interview her.
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From 2012 to mid-2014, the number of "preventable" suicides in the jail system rose sharply, to 15. As a result, the Justice Department buttressed its 12-year-old monitoring of the jail's "deplorable," "vermin-infested" conditions that raised the risk of suicide. Figures for 2014 showed that the number of suicides dropped from 10 in 2013 to five. (Final results for 2015 and early 2016 haven't been made public yet.) One reason for the decline in 2014: The sheriff's department finally realized that putting suicidal and depressed patients in solitary cells was a bad idea. The wide-ranging August 2015 settlement with the Department of Justice included a requirement for revamping training in suicide prevention and monitoring mentally ill inmates more closely.
The conditions in the LA County jail highlight a nationwide crisis for mentally ill people being abused and neglected in the nation's jails and prisons. Some counties, such as Miami-Dade in Florida, arrange alternative services for mentally ill offenders who commit non-violent crimes. Their programs have helped slash recidivism rates for even felony offers to as little as six percent. By contrast, 95 percent of repeat offenders with mental illness in the Los Angeles County sheriff's department commit crimes again.
Yet despite all the complaints and allegations, Dr. Marvin Southard told me, the department he headed has "devised a strategy to try to systematically tap into the idealism that draws people to this work."
That noble spirit isn't apparent in the jails. "After 25-plus years of breaking bones, the culture hasn't been transformed," says Patrisse Cullors, the founder of DPN and its offshoot, the Coalition to End Sheriff Violence in L.A. Jails. Former inmates and reformers simply don't share DMH officials' generally rosy views of the jail's current mental health care and the $2 billion proposal for building new men's and women's jails initially approved by the Board of Supervisors, and now back on track. The critics attack what they say is a culture of neglect and violence at the jail, including Twin Towers and at Lynwood's women's jail, and don't see it being changed by building expensive new buildings at the expense of diversion programs for non-violent offenders. As Mark-Anthony Johnson of DPN points out, "The concept of providing mental health care inside a jail is an oxymoron: the idea that you can provide quality care in a jail is very problematic."
To underscore these dangers and the limits of court monitoring, he points to the scandalous rise in suicides at the California Institution for Women -- four in 18 months as of August 2015 -- eight times the national rate for female inmates. The same facility was hailed by a federal court monitor, Matthew Lopes and other officials as providing high-quality care for women inmates, just as court monitors will oversee reforms on maltreatment of Los Angeles inmates. Johnson also offers this reminder: the notorious Twin Towers that houses most of the jail's mentally ill inmates was originally hyped in the 1990s as a state-of-the-art facility that would offer a compassionate approach to mentally ill inmates provided by well-trained clinicians and deputies.
That's the sort of promise being claimed again for a new mental health facility to replace the "dungeon-like" Men's Central jail and for the modern women's facility that has been planned to be built on the site of the Mira Loma Detention Center previously used for illegal immigrants. The staffers in these new facilities would supposedly be improved by the new DOJ-ordered training of deputies.
Yet Johnson points out, "Culture overrides training." For now, there's little sign that DMH's new leadership has moved to change that culture -- as opposed to following a new checklist of guidelines imposed by the Justice Department -- that permitted questionable practices and attitudes by DMH to flourish in the jails for years.
So when I visited DMH officials in 2014, they were for some reason still boasting about their quality jail care, including their discharge planning. They were unfazed by the allegations of needless suicides and the reckless post-discharge dumping of mentally ill inmates, as chronicled in a wrongful death lawsuit settled in 2015 for $1.6 million on behalf of a suicidal 23-year-old inmate discharged without being transferred to a treatment facility as planned; the inmate was re-arrested and then hung himself in a solitary cell in September 2013. Yet before this wrongful death settlement and the 2015 agreement with the Department of Justice ordering reforms in handling mentally ill prisoners, DMH officials didn't publicly acknowledge any problems in their approach to helping these inmates when released -- and still haven't done so. "Everyone's offered after-care and we make sure their needs are met, whether it's for medication management follow-up or housing," Hough claimed.
As it turned out, in June 2015 the members of the Board of Supervisors put an end to the DMH leaders' misguided pride and their role in managing jail mental health care through what amounts to a no-confidence vote. They moved to strip both the Department of Mental Health and the Los Angeles County Sheriff's Department medical division of the authority to run the poorly coordinated medical and mental health care in the Los Angeles County jail system. Instead, they set up a new consolidated office under the county's Department of Health, a separate agency, with a Correctional Health Director scheduled to assume full authority later in 2016.
That still wouldn't guarantee that the culture of violence and neglect harming mentally ill inmates would disappear overnight. But to the ACLU's Peter Eliasberg it was an important step, as he noted in a letter to the board supporting the reform: "There are numerous reasons why these changes make sense including a) the obvious unsuitability of a law enforcement agency for the provision of medical care and b) the well-documented and long-standing failures of DMH to provide appropriate care to inmate with mental illness."
Yet by removing responsibility from the department to run jail mental health care, it might also free up DMH to devote more of its resources, staff and its $2 billion budget to offering services it is actually skilled at providing, but perhaps now could expand to more people. These included delivering outreach services to troubled people in crisis that actually helped many stay out of jail; and, for the most serious and chronic mentally ill people, offering intensive, supportive team treatments, such as at Long Beach's The Village, that improved their lives. But until services and care are transformed for mentally ill offenders still stuck in the jails, and alternative diversion programs became far more common than the jailing of non-violent offenders, all the department's other potential good works would likely be undone by the hell known as the Los Angeles County Jail.
Equally troubling, women inmates facing the same conditions as Unique Moore and "Nina" remain potentially at risk of losing their lives at the Lynwood jail -- despite all the high-minded, court-monitored reforms trumpeted recently in press releases and news accounts.
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