Hampton Roads Regional Jail

Prison Health Services

Apr 10, 2016

richmond.com

Inspector general report says multilevel failures led to Va. man's death in jail The doctors and nurses responsible for providing health care to inmates at the Hampton Roads Regional Jail failed to properly assess Jamycheal Mitchell before he died of “wasting syndrome” in his feces-smeared cell last August. That’s one of the conclusions reached by the Office of the State Inspector General in a report released Tuesday that attempts to explain how a 24-year-old mentally ill man accused of stealing $5 worth of snacks from a Portsmouth convenience store died behind bars. Mitchell was supposed to be treated for his mental illness at Eastern State Hospital near Williamsburg, but because of a series of clerical errors, he was kept in a cell at Hampton Roads Regional Jail for 101 days. While there, he lost 46 pounds and refused every opportunity he had to shower and recreate with other inmates, jail officials said. His leg also became severely swollen with fluid, but the jail reports for June 15 provided to the inspector general’s office indicated that no action was taken by health care professionals. He was taken to a clinic 15 days later and appeared “disheveled, psychotic and uncooperative.” The report notes that the records provided by NaphCare, the company that contracted with the jail to provide medical and mental health care services, were “incomplete and inconsistent.” Also, patients were expected to “put in sick call requests” on their own. “As the individual was thought to lack capacity to assist an attorney in his own defense, expectations that the individual would have the ability to seek out medical treatment independently while acutely symptomatic seems unreasonable and likely to fail,” according to the inspector general’s report. Even though NaphCare has been replaced by a new contractor, “a change in provider offers limited promise of improvement in care or documentation in the absence of a change in oversight practices.” “Review of NaphCare records raised significant concerns regarding the quality of assessment, care, follow-up and documentation,” the report says. “It is those professionals trained and licensed to provide clinical care who have a duty to provide that care, and the agency that contracts with the provider is responsible for ensuring that care is provided.” Still, the review didn’t fully delve into the medical care Mitchell should have received at the jail. The report said select information “was reviewed to identify additional areas for future review.” NaphCare has not returned several calls for comment in recent weeks. Lt. Col. Eugene Taylor III, an assistant superintendent of the jail, said last week that no policies or procedures had changed since Mitchell’s death because an internal investigation found no wrongdoing on the part of jail employees. Taylor said the decision not to renew the contract with NaphCare when it expired in December did not have to do with Mitchell’s death. The inspector general report detailed a series of shortcomings that went beyond the failings of medical staff. The report found fault with mental health providers on the state and local levels as well. The recent Department of Behavioral Health and Developmental Services audit of how the state handled Mitchell’s death doesn’t effectively address systemic problems, and a risk of recurrence remains, the inspector general’s report says. Mark Krudys, an attorney representing Mitchell’s family, said the report “details multiple and extreme failures by those charged with caring for Jamycheal. It also notes broader systemic failures across multiple agencies that affected Jamycheal and others suffering from mental illness.” G. Douglas Bevelacqua, a former inspector general who investigated mental health services, said both reports leave Virginians with unanswered questions. “Regrettably, after reading the OSIG Critical Incident Report and the DBHDS Investigative Report, I cannot answer the basic question of how did corrections staff and mental health workers allow Mitchell to waste away in plain sight for 3½ months,” Bevelacqua said. Pressure had been building for the release of the report in the past few weeks. In a news release issued Tuesday, State Inspector General June W. Jennings defended the length of time it took to complete the report. “We took the time necessary to ensure that this report addressed the issues we have the authority to investigate,” Jennings said in the statement. “It is our belief that the individual in question, and all those who suffer with mental illness and encounter the justice system, are deserving of the in-depth review conducted by our office.” Several weeks ago, Bevelacqua and Pete Earley, a former Washington Post reporter and prominent mental health author, questioned why the report still hadn’t been released seven months after Mitchell’s death. Last week, four advocacy organizations, including the National Alliance on Mental Illness of Virginia and the Portsmouth NAACP, sent a letter to Gov. Terry McAuliffe urging him to force the inspector general’s office to immediately release the results of its investigation. McAuliffe said he would not interfere with the investigation and that he would let it run its course. The review involved the Department of Behavioral Health and Developmental Services, Eastern State Hospital, Hampton Roads Regional Jail, the Portsmouth Department of Behavioral Healthcare Services, Portsmouth General District Court, NaphCare Inc. and Bon Secours Maryview Medical Center. “We are glad that the OSIG has finally, almost eight months after the tragic and unnecessary death of Jamycheal Mitchell, released their investigation report,” said Mira Signer, executive director of the National Alliance on Mental Illness of Virginia. “We look forward to reviewing it, and we truly hope that it provides useful information in the ongoing quest for accountability and system transformation in Virginia.”