Alameda County's Santa Rita Jail holds roughly 2000 detainees on any given day and is one of the largest jails in the country. Credit: Pete Rosos

Alameda County has violated the civil rights of people with mental illnesses by failing to provide adequate care and allowing them to spiral into crises, ending up “warehoused” in the county jail, where other egregious violations of their rights have been reported, the U.S. Department of Justice’s Civil Rights Division announced Thursday.

The Justice Department’s 45-page report amounts to a sweeping indictment of the way that mental health resources are provided in Alameda County. The DOJ’s investigators emphasized that Santa Rita Jail, the massive complex in Dublin, has become the county’s de facto largest provider of mental health services due to the fact that the county has not invested in community services that could prevent people from needing to be taken into custody. Many mentally ill people also are treated at the county’s psychiatric hospital, John George Psychiatric Pavilion in San Leandro, but the facility is often overcrowded and fails to provide adequate discharge plans to prevent people from cycling back into the hospital or the jail. 

The Alameda County Counsel, the county’s attorney, did not respond to a request for comment about the DOJ’s findings. 

The Department of Justice will seek a settlement to address the violations, but if one isn’t reached, the federal government could sue the county to force it to improve its provision of mental health care services and to eliminate unconstitutional conditions in the jail. 

The Justice Department’s report was based on a four-year investigation. DOJ investigators found that conditions in the jail violate the Eighth and Fourteenth Amendments to the U.S. Constitution, which prohibit cruel and unusual punishment and grant people equal protection under the law. The jail was also found to have violated the Americans with Disabilities Act, which was passed in 1990 to prohibit discrimination against people with disabilities, including mental illnesses and developmental disabilities, and ensure them the same protections others are afforded. 

The inadequate mental health services described by the DOJ include the situation in the jail where detainees are unable to talk to mental health staff for more than 15 minutes a day, and the use of isolation for those suffering from mental health issues, a practice that can worsen a person’s mental state. 

These conditions in the jail have contributed to deaths and injuries of detainees. From 2015 to 2019, at least 14 people killed themselves in the jail, a rate twice the national average. Two others have died by suicide in the last two months.

“Our investigation uncovered evidence of violations that, taken together, result in a system where people with mental health disabilities in Alameda County find themselves unnecessarily cycling in and out of psychiatric institutions and jails because they lack access to proven services that would allow them to recover and participate in community life,” Pamela Karlan of the Civil Rights Division said in a statement.

Alameda County Sheriff Gregory Ahern, who runs the jail, said in an interview that as soon as the report was issued he had assigned staff to review it. “The county will have to decide on the next steps and how we’re going to proceed and we’ll do our best to come to a resolution that works out for all parties involved,” he told The Oaklandside.

The county’s mental health care system is also the subject of two class action lawsuits which focus on allegations similar to those the Department of Justice examined. 

Ahern argued that the county has been making progress improving jail conditions and mental health care services in response to one of the lawsuits, which was filed in 2018.

More people suffer from mental health crises in Alameda County than anywhere else in California. It has the highest rate of involuntary psychiatric holds in the state, 195.7 per 10,000, nearly twice that of the next highest county, according to the state Department of Health Care Services.

A system of inadequate care that leads to injury and death for some detainees

The Department of Justice investigation pointed to the 2019 case of 20-year-old Christian Madrigal as an example of how the lack of community services inappropriately led someone suffering a mental health crisis into the criminal justice system, where negligence by a sheriff’s lieutenant and a breakdown in the chain of command led to his death.

Madrigal’s parents called 911 in the hopes of having him hospitalized for a psychological breakdown, but he was arrested by Fremont police officers who believed he was on drugs. Police placed him in a full-body restraint and took him to Santa Rita Jail. Department of Justice investigators pointed out that this could have been avoided if there had been a crisis intervention team available. The county has these types of teams, but they haven’t operated in Fremont consistently and aren’t staffed to the level where they can respond to all mental health calls.

Madrigal was still in restraints when he was taken to the Santa Rita Jail. After he squirmed when deputies tried to remove it, the deputies said that they were concerned they would have to use force on Madrigal. Lt. Craig Cedergren ordered them to chain Madrigal to a cell door through a cuffing port using leg irons. When the deputies returned to check on him, he had slipped his handcuffs to the front of his body and the chain was loose. One deputy tried to alert supervisors that this was a dangerous position for the young man to be in, but jail officials apparently didn’t take the warning seriously and left Madrigal chained to the door.

Some of the deputies also joked about Madrigal’s consuming mushrooms, though there is no evidence that he did that day. Lt. Justin McComas, who was also present, joked about putting Madrigal on a train to San Francisco or sending him to the “funny farm.”

Madrigal became entangled in the chains and died of asphyxiation. Cedergren found him and started CPR. He rushed away after paramedics arrived and said, “He’s fucking dead. I fucked up.” The internal investigation recommended Cedergren’s termination and he resigned. The district attorney declined to prosecute Cedergren or other jail staff.

Madrigal’s parents have expressed remorse they ever called for help.

“The issues that we had there have been addressed and hopefully will never ever happen again, that’s a tragic event no doubt,” Ahern said. He added that since Madrigal’s death, the jail has improved training, added oversight, and encourages deputies to voice their concerns outside of the chain of command if they feel supervisors aren’t responding to a clearly dangerous situation. 

As for why Madrigal wasn’t seen by a mental health professional when he was booked into the jail, Ahern said he didn’t know, but none may have been available at the time.

The jail’s mental health services are minimal

Santa Rita Jail can hold up to 4,000 people, but over the years that the Civil Rights Division conducted its investigation it averaged about 2,400 people on any given day. According to the DOJ, jail staff estimate about 40% of the people in the jail need mental health treatment and the jail’s chief psychiatrist estimated that as high as 25% of the population has a serious mental illness. 

The jail has a mental health unit, but it is effectively solitary confinement, the civil rights investigation found. People placed in this unit are confined alone to their cells for the majority of the day, limited to less than three hours of time outside their cell. They receive little individualized treatment. In fact, mental health staff are only permitted into the unit for two hours a day to see people for treatment. Their time spent treating each inmate is limited to 10 to 15 minutes at a time, which they said was insufficient. 

Mental health care in the jail is generally limited to administering medicine, screening for suicide risk, and brief conversations. Even the conversations that they do have are in earshot of other inmates and guards, so people are often reluctant to disclose sensitive information.

Worse, some people with severe mental illness are housed in administrative segregation, an even more strict form of isolation where they are permitted only five hours outside their cells per week. When they are permitted to leave their cells, they are still alone and confined to indoor pod space and can’t go outdoors. Over the years, the sheriff’s office has objected to the use of the term solitary confinement because of its obvious negative connotations, but its administrative segregation practice is virtually the same thing.

A sign left by protesters in February outside John George Psychiatric Pavilion calling attention to the county’s funding for mental health services. Credit: Darwin BondGraham

During the last visit by DOJ investigators in 2019, there were 75 people in administrative segregation who had been there for more than 90 days.

Of the 14 people who killed themselves in the jail from 2014-2019, 11 had been held in some form of isolation. Half the cases of self-harm reviewed by investigators happened while the people were in isolation. Inmates placed on suicide watch are placed in intensive observation, where they can’t have socks, underwear, sheets or reading material. Because of that, people are discouraged from reporting if they’re feeling suicidal. 

The Justice Department also faulted the county for releasing people from the jail without providing services and adequate medication to stabilize them in the community and prevent them from returning to the jail. People leaving the jail “often receive little more than a sheet of paper that lists programs in the community,” the investigation found. 

Because of this, people who leave Santa Rita Jail often quickly end up in need of emergency psychiatric services. The investigation found that between 2012 and 2017, there were 4,200 instances of a person released from the jail who was seen at John George Psychiatric Pavilion within 30 days. Of the people receiving inpatient services during that time period, 53 percent had been in the jail.

The county’s emergency psychiatric hospital is overwhelmed with patients

An average of 1,111 people experiencing a mental health emergency enter John George Psychiatric Pavilion each month and remain there for up to 72 hours. The San Leandro hospital, which is operated by the county, provides care for people suffering nearly all of the acute psychiatric emergencies in the county. Nearly 240 people a month are admitted to inpatient services at the 80-bed public hospital, where they stay an average of 9 days. Some stay for months while they’re treated. Hundreds lasted for more than 30 days in a two-year period in 2017-2019. The hospital’s inpatient unit is used far more than other state and county psychiatric hospitals, according to the Department of Justice investigation. This intense utilization of the county’s emergency psychiatric hospital is due partly to the inadequacy of community-based mental health services that could treat people before they experience a crisis.

Investigators found that many people still occupying inpatient beds had been cleared for discharge but had nowhere to go. One year, 123 people stayed two weeks or more after they were cleared for discharge. There have long been reports of overcrowded conditions at John George, with patients cycling through as they are released without the means to live outside of the controlled setting. Many end up injuring themselves or others shortly after being released.

One unnamed woman mentioned in the DOJ investigation said she was taken to John George by police when she called to report domestic abuse. She spent two weeks there and said it was “the closest thing to Hell I’ve encountered.” When she was released, she had no treatment plan and received no medications, only a bus pass. 

People are released from John George and come back again and again, the investigation found. During a two-year period from 2017 to 2019, almost 1,600 people were admitted to John George four or more times, and 11% of people discharged from the inpatient unit were readmitted within two weeks. And the rate of readmission appears to be increasing. 

Hospital staff told federal investigators that people are often discharged directly into a state of homelessness and that this often leads them to lose connection with community providers and transition staff. A mental health services expert working for the DOJ team reviewed a sample of discharge treatment plans and found none of them were adequate. 

The Justice Department concluded that with appropriate community-based services, many patients could have avoided returning to the hospital. 

A class action lawsuit brought by Disability Rights California last year makes similar allegations against the county for the conditions at John George. According to the lawsuit, the county holds people longer than clinically appropriate, fails to develop individual treatment and discharge plans, and fails to coordinate with other county services, so people are released without the means to receive continued treatment of support and end up right back in the hospital.

The county lacks services in the community

According to the Justice Department, what’s missing in Alameda County are crisis services available in the community. These should include residential programs that aren’t acute care facilities, and permanent supported housing for people who have mental health challenges.

One series of county programs is only funded for 850 people a month and in practice serves only 750 even though the county has estimated a need to serve 4,000-6,000 people. There is another program specifically for people with a history of significant criminal justice system involvement where the county has identified 290 eligible people, but only 17 were connected with the service when DOJ investigators reviewed the program. 

A key improvement would be to provide supported housing for people with mental health disabilities. Homeless people in the county account for a large proportion of those receiving mental health services: 10% of the people entering county programs for people with mental health disabilities were homeless, 2,700 people between 2018 and 2019. And 39% of homeless people in the county reported having a mental health condition. 

Since then, the number of homeless people, and the number needing mental health treatment, has grown. 

Has Alameda County improved its mental health services since the DOJ’s investigation began?

Halfway through the Department of Justice investigation in 2018, investigators shared their concerns with the county and jail leadership in hopes some improvements could be made immediately. A year later, the county had implemented some changes. 

“We appreciate the commitment to making these urgently needed changes,” the investigators wrote in their report released yesterday, “but remain concerned that there has been little actual progress to resolve the discrimination that is occurring in the County’s mental health system and the unconstitutional conditions and discrimination in the Santa Rita Jail.”

Most conditions they identified in 2017 were still deficient when they returned two years later, they said. 

Bolstering community-based services could save the county money, the investigators found. Providing acute psychiatric care and jailing people with mental health issues is more costly than providing community-based care prior to a crisis. The county spends an average of $120,000 a year on individuals who make up the top 3% of mental health patients it treats. This small number of people, who are frequently and repeatedly jailed or held at the hospital, account for 32% of all mental health care system costs. Providing community-based services could keep this population out of emergency care and reduce incarceration. 

Activists critical of the jail have long called for an audit of sheriff’s office spending and for more investment in community services. “This report makes clear what we’ve been saying for years: we need real investments in community care, not cages,” said Jose Bernal, an organizer with the Ella Baker Center for Human Rights, which leads the Decarcerate Alameda County campaign. “Alameda County is in desperate need of supportive housing, crisis response, and community based mental health treatment. Yet, county supervisors have continued to inexplicably funnel hundreds of millions of our tax-dollars into Santa Rita Jail and sheriff’s’ department salaries.”

But the county has yet to strengthen its community-based services. Faced with a class action lawsuit detailing allegations of inhumane mental health care in the jail, last year the county’s Board of Supervisors opted to increase funding to the jail, allocating $106 million more per year over the next three years to add sheriff’s deputies and mental health staff in Santa Rita.

Sheriff Ahern said that the county agreed he should receive that funding, of which $56 million would go to funding new sheriff’s deputies and the rest would go to mental health staff. However, he said he hasn’t started hiring yet and instead has been finding ways to quickly recruit. As far as the mental health staff, he said that is a different department’s responsibility.

“The people who are out in the community who violate the law who have mental health issues and they come to a point when they end up in custody, we try to identify them, identify their issues and get them the treatment they need and medications balanced out,” Ahern said Thursday.

He touted the programs that he’d brought to the jail as sheriff, saying he’d improved education and job training in programs that help reduce recidivism. But the Department of Justice investigation said that those programs are mostly unavailable to the people with mental health conditions, who are often held in isolation. 

The DOJ acknowledged that the sheriff had made a commitment to improve mental health care. But, they wrote in their report, “it is not clear what, if any, remedial measures have been put in place, whether they have been incorporated into the Jail’s policies and procedures, or whether any measures actually put in place will prove durable.”

Scott Morris is an independent journalist in Oakland covering policing, protest, and civil rights.