Justice

The Death Of Victoria Gray: How Texas Jails Are Failing Their Most Vulnerable Captives

CREDIT: Family photo

If a reporter asks John Gray to do an in-person interview, he insists that the backdrop is the same: The Brazoria County Jail, in Angleton, Texas, just south of Houston. It’s a dismal looking building — off-white and weather-worn — but Gray chooses this particular location because he says the story isn’t about him. It’s about his daughter Victoria, whom he believes the jail failed from start to finish.

Just over a year ago, Victoria was found hanging from a bookshelf inside her jail cell. She had been placed there in isolation, and a jailer conducting routine checks happened upon her around 10:30 p.m. — nearly 30 minutes after she was last visited. The 18-year-old brunette, who was diagnosed with bipolar disorder and schizophrenia when she was 13 years old, had already tried to kill herself in the Brazoria jail just a few months earlier, John said, and all the warning signs were there.

“If they couldn’t save Victoria, they can’t save anybody,” he told ThinkProgress. “They treated her like she was a common criminal.”

An investigation into Victoria’s death by the Texas Commission on Jail Standards, an oversight agency that inspects all of the state’s 240-plus jails annually, concluded that in the 12 hours before Victoria’s death, jailers failed to check on her every 30 minutes, as state law requires for suicidal inmates, nearly a dozen times. Moreover, although Victoria was screened and determined to be suicidal at the time she entered the Brazoria County Jail, a judge was not notified within 72 hours that an inmate suspected of having mental illness had been admitted to the jail, as is also required by law. And, because the incident took place over Labor Day weekend, the jail did not have anyone from a mental health center on call. In short, John declared, “this is a case of Brazoria County not caring at all.”

Victoria’s death made a few local headlines, but it didn’t receive widespread media attention. Less than a year later, though, a reported suicide out of another Texas jail did. In July, Sandra Bland, a 28-year-old black woman, was taken into police custody after a state trooper pulled her over for failing to signal a lane change. Three days after her arrest, Bland was found dead in her cell in Texas’ Waller County jail. An autopsy concluded that Bland’s death was a suicide by hanging — which those who were close to her said was “unfathomable” — but intake screening forms released by the Waller County Sheriff’s Office indicated that Bland had previously attempted suicide and that she was feeling “very depressed” on the day of her arrest.

A week after Bland’s death, the Waller County Jail was issued a notice of non-compliance from the Texas Commission, which inspected the jail and found that officers were not checking on inmates as frequently as they should be, and that not all jail staff had undergone an annual suicide prevention training required by their own suicide prevention plan. It wasn’t the first time the jail had been been cited for non-compliance. In 2012, after a 29-year-old man killed himself, the jail was cited for the same reason: It didn’t conduct its mandatory hourly checks on inmates.

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Bland’s death revealed a pressing problem. In Texas prisons and jails, suicide is the second-leading cause of death. Since 2010, 135 people have killed themselves in Texas county jails, according to the Texas Commission. Like Victoria, the majority of them died by hanging. Many used objects that were readily available to them, like telephone cords, sheets, trash bags, blankets, and mattress covers.

It is difficult to say just how many of those people suffered from mental illness. But documents obtained by ThinkProgress paint a picture of a fragmented system that allows many of its most vulnerable citizens to fall through the cracks; where mental health screenings in jail don’t trigger the cautions they should, and where many of the jails in which inmates kill themselves are cited for non-compliance. What’s more, over the past several years, many Texas jails have failed to meet the standard, mandated procedures for screening and monitoring inmates with mental illness.

According to Texas Commission jail inspection reports obtained by ThinkProgress, at least 62 jails were cited between 2010 and 2015 for failing to properly use their required suicide prevention and mental health screening forms, and for failing to visually observe inmates, including suicidal ones, in the intervals that the Commission requires. Remarkably, more than 40 percent of the 134 inmates who killed themselves over the past five years did so at one of the facilities cited for non-compliance in those areas. Moreover, many inmates who took their lives expressed mental health histories, suicide attempts, and suicidal ideations in the jail intake screening forms we obtained, which are embedded below.

For example, the Montgomery County Jail, which has had six suicides since 2010, was cited in 2013 for failing to conduct face-to-face observation of all inmates at least once an hour, as required by law. In the Hansford County Jail, a 28-year-old woman killed herself on July 19, 2012; a week later, the jail was cited for by the Commission for failing to complete its mandatory face-to-face observation of inmates on suicide watch at least once every 15 minutes.

These already troublesome revelations are compounded by the mass incarceration of people with mentall illness in America. In 2012, there were ten times more people with mental illness in U.S. prisons and jails than in state hospitals. In Texas, people with serious mental illness are almost eight times more likely to wind up in a state jail or prison than in a hospital. In fact, the conditions inside Texas jails can be so bad for inmates that Diana Claitor, the executive director of the Texas Jail Project, an inmate advocacy organization, said she’s “surprised there’s not more suicides” in jail. “I really am. Because of the treatment and the neglect,” she explained. “A lot of people don’t realize how much damage can be done to individuals in the county jails. Whether they’re physically and mentally ill, or whether they’re just like me.”

Screening forms for Suicide and Medical and Mental Impairments by erica hellerstein

The Shock Of Confinement

The problem extends well beyond Texas. Nationally, suicides continue to be a leading cause of inmate death. In 2013, more than one-third of all inmate deaths were suicides, a rate which has been steadily increasing over the past several years. From 2009 to 2013, the jail suicide rate increased by 23 percent, and shot up 14 percent between 2012 and 2013.

Although inmate suicides remain a persistent problem throughout the correctional system, the suicide rate is around three times higher in jails than it is in prisons. Some experts attribute this to a phenomena they call the “shock of confinement”: For some people, jail is the first serious encounter with the legal system they have ever had, and the experience can be profoundly traumatizing. Not only are inmates isolated from family and friends, they might not know how severe their sentences will be.

When they go to prison, “all those unknowns and question marks are gone,” explained Lindsay Hayes, an expert in jail suicides and the project director at the National Center on Institutions and Alternatives. “Because you survived that process. Now you’re in prison, you know where you’re going and how long you’re going to serve.”

In Texas, like the rest of the country, suicide accounts for almost a third of all jail deaths. That Bland and Gray took their lives not long after they were admitted to jail is not out of step with the data. Nearly one-fifth of suicides happened within the first day inmates were admitted, and more than 40 percent happened within the first week, according to a 2013 study on Texas jail suicides.

Although inmate suicide rates have been rising over the past few years, they had been steadily decreasing since the 1980s. In 1983, suicides accounted for 55 percent of all U.S. jail deaths; by 2007, they dropped to 26 percent. Why? According to Hayes, the decline can be attributed at least partially to increased awareness about jail suicides: “These lower suicides continue to demonstrate that jail suicides are preventable,” he told ThinkProgress.

However, inmates with serious mental illness are more likely than other inmates to kill themselves: According to a 2002 study by the Sentencing Project, “more than 95 percent of those who commit suicide in correctional facilities have a treatable psychiatric illness.”

But locking people with mental illness behind bars instead of connecting them with needed health services isn’t just wrong, advocates say, it’s also expensive. Up-to-date national numbers are hard to come by, but a 2003 report by the National Alliance on Mental Illness (NAMI) estimated that prisoners with mental illness cost the country nearly $9 billion annually. And in Texas, inmates with mental illness cost between $30,000 and $50,000 annually as of 2003, while other prisoners cost around $22,000.

Now, advocates warn, these factors have combined to create a situation that is unsustainable both financially and morally. Paton Blough, a mental health advocate with bipolar disorder who was incarcerated, recalled “disturbing memories” while he was in jail. “The way they handled people that were psychotic — it gets really, really bad. I’ve seen people lying almost lifeless in their cells.”

Blough said there are leaders “just crying for solutions” in his state. “Who is going to say that a prison or jail is a good place for mental health recovery?” he wondered. “Nobody’s able to walk into these places and recognize these human rights violations that are going on today. I’ve seen it… To ignore this problem is only getting more expensive and [it’s] a waste of human lives.”

What Should Have Happened To Victoria Gray?

Victoria Gray’s father adamantly believes that his daughter’s case is an extreme example of everything a jail shouldn’t do when confronted with an inmate who has mental illness and poses a suicide risk.

“Everybody failed her,” the 42-year-old computer programmer insisted. “From the probation officer to the jailers to the people who put her in solitary confinement to the people who didn’t give her her medicine to the people that didn’t check on her. There wasn’t one part that was done right.”

In Texas, jailers are required to run inmates’ vital information — name, date of birth, Social Security number, and driver’s license — through a query system called the CCQ (Continuity of Care Query) when they arrive. That system cross-references inmates’ information with the Departments of Public Safety and State Health Services to check if they have previously received mental health services within the public system. Additionally, jailers are also required to fill out a screening form for suicide and medical and mental impairments. This form, which can vary from jail to jail but ultimately has to be approved by the Commission, asks inmates questions about their mental health history and previous suicide attempts (you can see examples of that form in the screening forms embedded above).

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When Victoria arrived at the Brazoria County Jail, she was screened and determined to be suicidal, according to a report from the Texas Commission, but a judge was not notified that someone with mental illness had been admitted to the jail until after her death. Jail officials ought to have known about Victoria, though. In March 2013 she was sent to the Brazoria County Jail for the first time. The next year, in early 2014, she was sent to jail again, this time for setting her father’s house ablaze “because the walls told her to,” Gray told ThinkProgress.

It was during that jail visit that Victoria first tried to hang herself, but she was cut down and sent to Austin State Hospital for treatment, according to her father. Months later, she landed in the Brazoria County Jail, again. That’s when she eventually did take her life. ThinkProgress asked the Brazoria County District Attorney’s Office if the jail was aware of Victoria’s previous suicide attempt when she was screened upon her arrival to Brazoria in August 2014 but did not hear back.

Failures by Texas jails to follow through with their mandated procedures are not uncommon. As noted earlier, a ThinkProgress review of inspection reports from 2010 to 2015 found that at least 62 jails were cited by the Commission for being non-compliant with intake screening standards and visual observation requirements.

Moreover, a recent survey by the Texas Public Policy Foundation found that just 77 percent of jails reported using standard screening forms to identify inmates with mental illness, only 41 percent ran inmates’ names through the CCQ database, and less than 35 percent are notifying a magistrate or judge of the inmates’ mental health problems. In Texas’ Bosque County, for example, 75 percent of files they reviewed showed no evidence that inmates’ names had been through the CCQ to determine if they had accessed public mental health services.

While there are no federal laws on the matter, there are national best practices and standards on suicide prevention and screening procedures for jails and prisons. According to the standards from the National Commission on Correctional Health Care, the American Bar Association, and the American Correctional Association, the screening should be performed by a health care professional or by specially trained correctional staff. But these are guidelines and suggestions, and state jails are not obligated to follow them. The Texas Commission’s standards, for example, don’t require a health care professional to complete the screening forms.

And if the jail happens to fill out the proper screening form and the inmate admits to a history of mental illness, then what happens? Currently, the Commission does not have requirements on how jails should respond if an inmate answers ‘yes’ to any of the questions on the intake form about his or her mental health. It does have a recommendation of notification guide, but, as Katharine Ligon, a policy analyst Texas’ Center for Public Policy Priorities, explained, “it’s not mandated. It’s a should, not a have to.”

She continued, “what you see is that even if they checked yes, the onus is on the jailer to follow their protocol to ensure that the magistrate judge is contacted and the mental health professional is contacted… That’s where we are concerned. We have these processes in place, but they’re not really being done.”

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Information about the circumstances of Victoria’s death is limited. The Brazoria County Jail sent multiple public records requests from ThinkProgress to the Texas Attorney General, citing pending litigation, and did not respond to follow-up inquiries.

Still, the details that have been made available raise several questions. According to an investigation by the Commission, Victoria was determined to be suicidal when she entered the Brazoria County Jail. However, she was not put on suicide watch, according to jail documents provided by the Commission. Those same documents state that Victoria was placed in a separation cell though they don’t specify why.

Although she was placed in isolation, it doesn’t appear that Victoria was put in a suicide-resistant cell for high-risk inmates. “It sounds like they identified her as low-risk if they were following their own policy and that’s inconceivable to me when she had a previous serious suicide attempt in jail,” Michele Deitch, a senior lecturer at the University of Texas who has spent decades working on prison and jail issues, said. If Victoria had been identified as high-risk, according to Brazoria County’s own suicide prevention plan, she would have been placed in a cell with padded walls and without clothing, bedding, or anything she could use to hurt herself.

Instead, on September 2, at around 10:30 pm, Victoria was found hanging from a bookshelf on the right side of her cell, with a white noose fastened around her neck. She had constructed it out of a mattress cover.

The Criminalization Of Mental Illness

Type “mental illness,” “jails,” and “health care providers” into Google and a number of headlines will pop up: “When did prisons become acceptable mental healthcare facilities?,” “Jails are America’s largest mental healthcare providers,” “Inside a mental hospital called jail.”

These days, it’s regularly said that prisons and jails have become the nation’s de-facto mental health providers. That this has become an untenable situation for the criminal justice system shouldn’t come as a surprise; obviously, jails and prisons are not mental health treatment centers, nor were they ever intended to be.

So, how did we get here? The narratives that triggered this downward spiral took form in the 1960s, when the overcrowded and dehumanizing conditions in state-run psychiatric hospitals were brought to public attention. Exposes and books chronicling the horrifying conditions inside of psychiatric hospitals, including Ken Kesey’s classic, One Flew Over The Cuckoo’s Nest, helped influence public opinion about the need for reform within the mental health system.

Meanwhile, as that movement was gaining momentum, new drugs discovered in the 1950s were becoming incorporated into treatment for people with mental illness, an option that wasn’t previously available to patients in psychiatric hospitals. These elements combined to set the stage for deinstitutionalization, a process that removed patients with mental illness from state psychiatric hospitals and then shut many of those places down. The practice gained the support of a broad coalition, including fiscal conservatives who saw an opportunity to save funds by closing state hospitals, as well as civil rights proponents advocating for more humane treatment of people with mental illness.

Deinstitutionalization soon found an ally in President John F. Kennedy. In 1963, he signed the Community Mental Health Act, which provided federal funding for the construction of community-based mental health treatment facilities. The legislation was intended to protect the civil liberties of people living with mental illness and to treat them in the least restrictive settings, ultimately transitioning them into community mental health centers. In the end, though, the program was never adequately funded, and many people who were released into the community didn’t get the services they needed.

“There was this big push to close all of the state psychiatric hospitals,” Laura Usher, a program manager of the crisis intervention team at the National Alliance on Mental Illness, explained. “The vision was that we would have this national network of community mental health centers… But what happened is only about half of those centers were created. And they were never fully funded.”

Instead, many people who were released back into the community but remained in need of mental health services started appearing in prisons and jails, or, as the nonprofit Treatment Advocacy Center (TAC) called them, “the new asylums.”

In 1972, Marc Abramson, a California-based psychiatrist, issued a sobering warning. As California, a leader of deinstitutionalization under Ronald Reagan’s governorship, continued clearing out its state psychiatric hospitals, he noticed that there seemed to be an increase in the number of people with mental illness in the San Mateo County Jail. Abramson, who called the phenomenon the “criminalization of mentally disordered behavior,” understood the potentially calamitous impacts of the changes he was observing.

“If the mental health system is forced to release mentally disordered persons into the community prematurely, there will be an increase in pressure for use of the criminal justice system to reinstitutionalize them,” he cautioned. “Those who castigate institutional psychiatry for its present and past deficiencies may be quite ignorant of what occurs when mentally disordered patients are forced into the criminal justice system.”

President John F. Kennedy Signs the Community Mental Health Act

President John F. Kennedy Signs the Community Mental Health Act

CREDIT: Abbie Rowe/White House Photographs/John F. Kennedy Presidential Library and Museum

These early warnings proved to be prescient. Deinstitutionalization accelerated nationally in the 1980s under President Reagan. In 1981, the Mental Health Systems Act, which sought to expand mental health services and was signed into law by President Jimmy Carter, was repealed. The Alcohol, Drug Abuse and Mental Health (ADMS) Block Grant was enacted in its place, which converted funding into state block grants and slashed federal mental health spending by 25 percent. As of 1998, a Department of Justice report found that 16 percent of state prison and local jail inmates “reported either a mental condition or an overnight stay in a mental hospital.”

By 2005, more than half of all jail and prison inmates had a mental health problem. The recession dealt another blow: Between 2009 and 2012, states cut more than $4 billion from their mental health budgets, making it the largest combined reduction in funding since deinstitutionalization.

Forty years after Abramson’s prophecy, the number of people with mental illness forced into jails and prisons across the U.S. is nothing short of harrowing. According to a recent report by the Treatment Advocacy Center, there are ten times as many people in prisons and jails with serious mental illness than in state psychiatric hospitals. In at least 44 states, there are more people behind bars with serious mental illnesses than in the largest state psychiatric hospital. Moreover, they are more likely to be sexually assaulted, beaten, abused, and placed in solitary confinement.

“Emptying America’s mental hospitals without ensuring that the discharged patients received appropriate treatment in the community has been an egregious mistake. For the approximately half of discharged patients who have ended up homeless or in jails and prisons, it has been a personal tragedy,” the Treatment Advocacy Center asserted in an earlier report. “Although deinstitutionalization was well intentioned, the failure to provide for the treatment needs of the patients has turned this policy into one of the greatest social disasters of the 20th century.”

Those conditions have helped to create a system that’s often crisis driven, where people who may have previously been admitted to state psychiatric hospitals now only receive care when they’re in the middle of an immediate mental health crisis. Meanwhile, the care that they do end up receiving tends to be short-term — like a hospital emergency room, or in many cases, jail.

Paton Blough, the mental health advocate with bipolar disorder, was arrested six times over the course of three years — often because people would call the police on him during times of psychosis. “I had episode after episode,” he recalled. “I did all of the extreme things you read about a bipolar person doing.”

Although Blough didn’t have a criminal record before his arrests, he ended up receiving two felony convictions while he was incarcerated — one for spitting on a jail officer and another for threatening a sheriff. “I felt like there were several instances when I was not taken care of,” he said. “I lost everything.”

Unfortunately, Blough’s story is not uncommon: Half of all previously incarcerated people with mental illness are rearrested and returned to prisons. “Once you get in the system, it’s very difficult for you to get out,” he said. “People have to understand that we don’t lock people up for cancer or diabetes, but we do for the medical condition of mental illness… It’s a big massive problem of epidemic proportions that we’re dealing with in the most incarcerated nation in the world.”

Screening form of an inmate who killed himself in a Texas jail.

Screening form of an inmate who killed himself in a Texas jail.

The Challenge Of Oversight

The mere fact that Texas has the Jail Commission puts it ahead of many of its neighbors. According to a 2010 state survey by Deitch, just 28 states have independent oversight bodies with mandatory inspection duties.

That number has declined over the past several decades. When Hayes began his work in the 1980s, he said that there were close to 40 states with jail inspection programs. “There has been a dramatic decrease for a number of reasons,” he explained. “One is financial — when the downsizing of state government occurs, one of the first hit are correctional agencies. The second is that they’re not well-liked by sheriffs because a state agency is coming on-site every year and telling them what they’re doing wrong. And a lot of sheriffs just don’t like that. So they petition their legislatures to do away with them.”

Indeed, Texas’ position compared to states without jail inspection programs is something that many experts will readily point out. “I think it’s fabulous that we have the Jail Standards Commission and more states ought to have something like that,” Deitch said. “The Jail Standards Commission is an oversight body. It’s not a management body. It’s the sheriff that’s responsible for his or her own jail. There are definitely ways that we can strengthen the Jail Standards Commission as an oversight body and we should.” But, she added, referencing the Sandra Bland case, “it’s not their fault that this happened.”

And even in Texas, with a commission, experts agree that the agency’s scope is limited due to a lack of resources. The Commission has an annual budget of less than one million dollars and just four full-time inspectors for more than 240 jails in the state. Ana Yáñez-Correa, the executive director of the Texas Criminal Justice Coalition, said that her organization’s efforts have been focused primarily on making sure the Commission stays put. “It’s really important to have them,” she said. “The challenge the Commission faces is that they don’t have enough money… It’s challenging for them to do what we would like for them to be able to do on a one million dollar budget.”

Adan Munoz, the executive director of the Commission from 2006-2012, said the agency was spread so thin under his tenure that inspectors were forced to sleep three people to a room to stay within their budget whenever they were sent to a conference or training. “The Jail Commission is being stressed to do a lot of things for a lot of reasons but not given enough money to do it properly and correctly in my opinion,” he told ThinkProgress.

Munoz described some of the challenges the organization faces. With so many jails and just four inspectors, the Commission is only able to inspect every jail once a year, he said. That’s not often enough to identify and correct the numerous problems a jail could have. If a jail passes inspection, the Commission will generally leave it alone unless an issue is flagged or an incident like a jail death takes place. “When we leave that jail, they could go back to not doing regular hourly checks, they could go back to doing something that’s not within standards and we’ll never find out about it because we’re just not there,” Munoz added.

The Commission, which has been around for 40 years, is also required to inspect every jail in the state at least once a year and is granted the authority to issue notices of non-compliance to jails that do not pass the annual inspection. Although it does have the authority to shut down a jail if it is found non-compliant, that has only happened twice in the past 15 years.

Diana Claitor of the Texas Jail Project told ThinkProgress that when problems do come up, it’s mainly the fault of the individual jails rather than the Commission. If a jail has a sergeant, lieutenant, or administrator who doesn’t enforce the jail’s policy, then the jail inspector coming in just once might not do much. “I quote an ex-sheriff who will remain anonymous, who says a jail staff behaves and reflects the ideas and philosophies of the head honcho — and that’s the sheriff,” she said.

In one Texas jail, an inmate who killed himself on May 9, 2010, indicated that he was feeling suicidal in his screening form. A follow-up report obtained by ThinkProgress stated that he was put on suicide precautions after he expressed suicidal thoughts on May 1, but then refused to cooperate with a nurse or any medical personnel. He was then discharged from suicide precautions without having an assessment completed. “If he was not assessed by medical or mental health [officials] between May 1 and May 9, that certainly would be below the standard of care, and problematic,” the National Center on Institutions and Alternatives’ Hayes told ThinkProgress in an email.

Still In The Dark

In the landmark 1976 case Estelle v. Gamble, the Supreme Court ruled that prisons and jails are constitutionally required to provide adequate healthcare for prisoners. Thus, the failure of correctional facilities to provide inmates with crucial mental health services violates their constitutional rights. People who enter correctional facilities with severe mental illness should be screened and treated just as seriously as inmates who enter with tuberculosis, diabetes, or any other physical ailment. And yet, all too often mental illness is overlooked or misunderstood by jail officials who aren’t trained to recognize inmates’ symptoms.

The historical trajectory of this problem is revealing. In the 19th century, the public was shocked to learn that staggering numbers of people with mental illness were being warehoused in U.S. jails and prisons. As those revelations became widespread, a reformer named Dorothea Dix started a movement in the mid-1800s to improve conditions for prisoners with mental illness, which helped lead to the construction of state psychiatric hospitals.

More than a century later, deinstitutionalization helped pave the way for many of those hospitals to empty out. Some people with mental illness who were released managed to transition successfully into the community, but others did not fare so well, and the promised social service support was never funded. As a result, many of them have ended up where Veronica Gray found herself: Inside America’s jails and prisons.

Now, John Gray is left with little more than unanswered questions about what happened to his daughter in the days and hours leading up to her death in the Brazoria County Jail. And he likely isn’t the only one looking for answers about a suicide there. In 2012, a man in his early twenties hung himself with a mattress cover, and in 2009, a 48-year-old woman hung herself with a blanket just four hours after she was placed in a holding cell. Her screening form was not completed after she was admitted, a non-compliance report obtained by ThinkProgress shows.

John says he just wants to be able to stand in the cell his daughter died in — to know if she had a fighting chance. But the jail won’t let him, and so much of what happened on the evening of September 2, 2014 is still frustratingly unclear. For now, John remains in the dark. “I know nothing,” he said, his voice breaking. “I don’t understand.”

An earlier version of the piece stated that the Commission was formed after the prisoner rights lawsuit Ruiz v. Estelle, which is incorrect.