DOJ report exposes failures of jail reform measures

REUTERS/Joshua Lott

(Reuters) - Andrew Holland died in San Luis Obispo County Jail in 2017, after being shackled to a chair for 46 hours, naked except for a helmet and blanket, writhing in his own filth as guards watched through the cell door.

The 36-year-old struggled with schizophrenia and was facing charges including battery and resisting arrest. A court had ordered his transfer to the county psychiatric facility after finding him incompetent to stand trial, but the hospital was unable to accept him. Holland was held in isolation for 16 months even before the “restraint chair.”

Officials for the central California county admitted the death was avoidable, paid out a $5 million settlement to Holland’s family, and pledged to enact changes to “ensure something like this does not happen again.” The sheriff’s office has since stopped using its restraint chairs and created housing units with specialized staff for people with mental illnesses. Most notably, San Luis Obispo County in 2019 hired Wellpath LLC to take over mental health services at its jail.

But there are still avoidable deaths in San Luis Obispo County Jail, and people are still suffering abuse, even after officials started implementing their reforms, according to an investigation and an Aug. 31 report by the Department of Justice.

The jail houses about 540 prisoners at any given time, and nearly 11,000 arrestees cycle through annually. Roughly 39% of the population is taking some form of psychotropic medication, the DOJ said. Sixteen prisoners died in jail custody between January 2012 and June 2020, the DOJ said.

The report concluded that prisoners are abused and sometimes die because of unconstitutional practices, including excessive force, denial of healthcare, over-reliance on isolation of prisoners and refusal to accommodate disabilities.

Wellpath and its staff "appear not to take seriously" prisoner’s medical concerns, the DOJ said. It noted that the company’s health services administrator used a “popular meme” from the television show Downton Abbey to mock prisoner concerns as “whining” during a presentation made to jail leadership. (A company representative told me this individual is no longer employed by Wellpath.)

The DOJ’s report, while focused on the operations at San Luis Obispo Jail, shows that many of the reforms supported by law enforcement and policymakers to address the ever-expanding problems of mass incarceration and lack of mental health-care in the U.S. are inadequate, particularly in light of the historical trend toward privatizing jails.

It demonstrates the need for much more far-reaching reform, and especially the need to shift certain social problems – like traffic violations, non-payment of civil fines and mental illness – outside the purview of law enforcement.

County Sheriff Ian Parkinson’s offices didn’t respond to my requests for comment about the DOJ's report.

Rita Neal, county counsel, Wellpath, and Parkinson’s office have all said that DOJ identified old problems.

“Most of the deficiencies noted in the report have been resolved,” Neal told me.

Kip Hallman, president of Wellpath told me, "We and the Sheriff’s Office are appropriately proud of the care we provide to the patients we both serve." He said that Wellpath initiated work at the jail "several months into the DOJ investigation."

The agency's report relates to a transitional period in the first six months of Wellpath's tenure, and "virtually all issues identified" have "been resolved" since then, Hallman said.

But the DOJ's report, which mentions some reforms, also threatens a lawsuit against the county if officials don't address continuing deficiencies within 49 days after receipt.

Thom Mrozek, spokesperson for the U.S. Attorney's Office for the Central District of California, told me the "report speaks for itself." (Mrozek also told the San Luis Obispo Tribune on Sunday that the problems DOJ identified are current problems.)

I asked California defense attorney Paula Canny, who represented Holland's family, about county officials' responses that most of the problems have been fixed.

"That's not true, and I know because people suffering and being mistreated in that jail call me multiple times a week," Canny said.

The DOJ report, to my mind, tells a story of official indifference.

Wellpath is the largest jail healthcare business in the U.S. It was formed when a private equity group acquired Correct Care Solutions in 2018, and combined it with a smaller competitor, Correctional Medical Group Companies.

County officials contracted with the company despite that its predecessor has a well-documented history of the same sort of problems that led to Holland’s death and has been sued numerous times for deaths and injuries, according to a review of Westlaw’s databases. A June 2019 investigation by CNN reported that Correct Care Solutions – now Wellpath – had "been sued for more than 70 deaths" over the previous five years.

In October 2020, Reuters conducted the most definitive examination to date of the multi-billion dollar correctional healthcare industry. It found that jails with private healthcare had 17 deaths per 10,000 inmates, compared with 13 in publicly-run units. Wellpath-serviced facilities had a death rate of about 16 per 10,000.

Problems at the jail persisted after Wellpath was brought on, according to the report. Among them: Medical practitioners, including a doctor and dentist, were mistaken about who their direct supervisor was, DOJ said. The medical director wasn’t aware that his position included management duties for the unit, and believed he only had to provide patient care.

The DOJ found the jail doesn’t track critical incidents, discipline or deaths in any systematic way, and jail officials had missed an apparent suicide attempt when they produced a list – until the agency “repeatedly pointed out” the omission.

Sometimes, officials didn’t bother trying to determine how or why someone died, the DOJ said. And, there was “no mechanism for the county to remedy deficiencies in Wellpath’s care” under its contract with the company, the DOJ said.

This is all after Holland's highly publicized death that county officials admitted was preventable and after implementing reforms described by its administrative office as sweeping changes.

And now, despite the dismal findings released just last week, county officials are insisting they have already addressed the problems the DOJ is threatening to sue them for.

The reforms the county claims to have made and its response (or lack of) to the findings of a DOJ investigation, indicate to me a disinterest in making effective changes, even as mostly poor, and mostly Black and brown Americans are dying unnecessarily in jails, often for minor violations.

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Hassan Kanu writes about access to justice, race, and equality under law. Kanu, who was born in Sierra Leone and grew up in Silver Spring, Maryland, worked in public interest law after graduating from Duke University School of Law. After that, he spent five years reporting on mostly employment law. He lives in Washington, D.C. Reach Kanu at