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| Hospitalization order for black man who died in cell never processed, report says | Hospitalization order for black man who died in cell never processed, report says |
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| A young black man who spent more than three months in a Virginia jail for stealing $5 worth of snacks died in his cell after a judge’s order for his hospitalization was placed in a drawer by medical officials – and forgotten. | A young black man who spent more than three months in a Virginia jail for stealing $5 worth of snacks died in his cell after a judge’s order for his hospitalization was placed in a drawer by medical officials – and forgotten. |
| Related: Young black man jailed since April for alleged $5 theft found dead in cell | Related: Young black man jailed since April for alleged $5 theft found dead in cell |
| Jamycheal Mitchell never even made it on to the waiting list for a hospital bed and a requested mental health evaluation was not carried out, it emerged on Monday, as an official report on his death identified serious failures by public authorities. | Jamycheal Mitchell never even made it on to the waiting list for a hospital bed and a requested mental health evaluation was not carried out, it emerged on Monday, as an official report on his death identified serious failures by public authorities. |
| According to the report, an unnamed staff member at Eastern State hospital was “astonished and distraught” to find the court order requesting treatment for Mitchell sitting in a file inside a desk drawer, five days after the 24-year-old’s death in August last year. | |
| Up to a dozen similar orders for other prisoners needing treatment were also found unprocessed in the drawer. | Up to a dozen similar orders for other prisoners needing treatment were also found unprocessed in the drawer. |
| The Guardian revealed last summer that Mitchell was found dead in his cell at Hampton Roads regional jail almost four months after being arrested for stealing a bottle of Mountain Dew, a Snickers bar and a Zebra Cake from a 7-Eleven store in Portsmouth. | The Guardian revealed last summer that Mitchell was found dead in his cell at Hampton Roads regional jail almost four months after being arrested for stealing a bottle of Mountain Dew, a Snickers bar and a Zebra Cake from a 7-Eleven store in Portsmouth. |
| Mitchell was suffering from mental health problems and relatives said he appeared to have starved. A medical examiner found Mitchell died due to a probable irregular heartbeat and a “wasting syndrome”. | Mitchell was suffering from mental health problems and relatives said he appeared to have starved. A medical examiner found Mitchell died due to a probable irregular heartbeat and a “wasting syndrome”. |
| The report released on Monday said jail officials were still trying to work out exactly what happened to Mitchell. Other inmates had told them his “food trays were empty” after meals and that he would even ask other prisoners for food. | The report released on Monday said jail officials were still trying to work out exactly what happened to Mitchell. Other inmates had told them his “food trays were empty” after meals and that he would even ask other prisoners for food. |
| Complaints were made claiming that jailers punished Mitchell by not feeding him or spraying him with water, but “nothing was found to substantiate these allegations”, the report said. | Complaints were made claiming that jailers punished Mitchell by not feeding him or spraying him with water, but “nothing was found to substantiate these allegations”, the report said. |
| State medical records said Mitchell had been “psychotic” since being detained and had refused to take medication. | State medical records said Mitchell had been “psychotic” since being detained and had refused to take medication. |
| The story of Mitchell’s death was followed closely by regional and national media as an emblem for lethal failings in cooperation between criminal justice and public health systems in Virginia. It also prompted action by state legislators in an attempt to tackle such problems. | The story of Mitchell’s death was followed closely by regional and national media as an emblem for lethal failings in cooperation between criminal justice and public health systems in Virginia. It also prompted action by state legislators in an attempt to tackle such problems. |
| On Monday, the state’s department of behavioral health and developmental services published a report on an inquiry into Mitchell’s death by its office of internal audit. The report was heavily redacted to protect the identities of all public officials who participated in Mitchell’s case, leaving the account difficult to follow and making it difficult to hold specific people accountable. | On Monday, the state’s department of behavioral health and developmental services published a report on an inquiry into Mitchell’s death by its office of internal audit. The report was heavily redacted to protect the identities of all public officials who participated in Mitchell’s case, leaving the account difficult to follow and making it difficult to hold specific people accountable. |
| The report confirmed the Guardian’s original disclosures, starting with the fact that on 21 May, Judge Morton Whitlow – whose name was also redacted – ruled that Mitchell was not competent to stand trial and ordered that he be transferred to Eastern State hospital, a state-run mental health facility in Williamsburg. | The report confirmed the Guardian’s original disclosures, starting with the fact that on 21 May, Judge Morton Whitlow – whose name was also redacted – ruled that Mitchell was not competent to stand trial and ordered that he be transferred to Eastern State hospital, a state-run mental health facility in Williamsburg. |
| Court officials mailed and faxed the judge’s competency restoration order (CRO) to the hospital on 27 May, they told investigators. A cover sheet was found to support this. Hospital officials, however, claimed they never received this order. Investigators said they could not find records to definitively prove it was sent. Mitchell was taken to the hospital emergency room on 30 July, according to the report, but refused treatment and would not answer questions.Judge Whitlow issued another CRO for Mitchell at a court hearing on 31 July, and court officials faxed this to the hospital that day. The fax was received and Mitchell should have been added to the hospital’s list of 34 people waiting for a bed. | Court officials mailed and faxed the judge’s competency restoration order (CRO) to the hospital on 27 May, they told investigators. A cover sheet was found to support this. Hospital officials, however, claimed they never received this order. Investigators said they could not find records to definitively prove it was sent. Mitchell was taken to the hospital emergency room on 30 July, according to the report, but refused treatment and would not answer questions.Judge Whitlow issued another CRO for Mitchell at a court hearing on 31 July, and court officials faxed this to the hospital that day. The fax was received and Mitchell should have been added to the hospital’s list of 34 people waiting for a bed. |
| He was never added to this list and his CRO – along with 10 to 12 for other prisoners – was filed away in a drawer. According to Monday’s report, hospital “management did not learn about the existence of the fax until 24 August 2015, five days after Mr Mitchell’s death”. | He was never added to this list and his CRO – along with 10 to 12 for other prisoners – was filed away in a drawer. According to Monday’s report, hospital “management did not learn about the existence of the fax until 24 August 2015, five days after Mr Mitchell’s death”. |
| Asked to explain how this could have happened, the unnamed hospital official said she was “overwhelmed due to the increased number of admissions and the loss of staff in the admissions department”, investigators found. | Asked to explain how this could have happened, the unnamed hospital official said she was “overwhelmed due to the increased number of admissions and the loss of staff in the admissions department”, investigators found. |
| The backlog of orders was not cleared until two weeks after Mitchell’s death, when prisoners’ names were added to the waiting list for beds. One official told investigators “they’re doing the best they can”, according to the report. One unidentified hospital official involved has since retired.The report said that on the morning of 31 July, a jail official separately called state mental health authorities to find out if Mitchell could be committed to hospital involuntarily. | The backlog of orders was not cleared until two weeks after Mitchell’s death, when prisoners’ names were added to the waiting list for beds. One official told investigators “they’re doing the best they can”, according to the report. One unidentified hospital official involved has since retired.The report said that on the morning of 31 July, a jail official separately called state mental health authorities to find out if Mitchell could be committed to hospital involuntarily. |
| A state official attempted to visit Mitchell to assess his mental health that same morning but was told Mitchell was unavailable because he was in court. At that court hearing, the judge was to make his second order to have Mitchell hospitalized, which would later be put in the hospital drawer. The state mental health official told investigators she waited for 40 minutes at the jail and then left, leaving a message telling jail staff to call her. She did not hear back from them, she said, adding that typically if the jail “doesn’t call back, she feels that the situation has been resolved”. | A state official attempted to visit Mitchell to assess his mental health that same morning but was told Mitchell was unavailable because he was in court. At that court hearing, the judge was to make his second order to have Mitchell hospitalized, which would later be put in the hospital drawer. The state mental health official told investigators she waited for 40 minutes at the jail and then left, leaving a message telling jail staff to call her. She did not hear back from them, she said, adding that typically if the jail “doesn’t call back, she feels that the situation has been resolved”. |
| This state official “admitted that documentation should have been added” to Mitchell’s state files, and that she should have called the jail herself to follow up on the case, according to investigators.Monday’s report recommended that hospital managers educate all hospital staff on handling mail to ensure that court orders are received “without delay” and logged to ensure they are not lost. It also said that state mental health authorities must overhaul their system for receiving and processing court orders. | This state official “admitted that documentation should have been added” to Mitchell’s state files, and that she should have called the jail herself to follow up on the case, according to investigators.Monday’s report recommended that hospital managers educate all hospital staff on handling mail to ensure that court orders are received “without delay” and logged to ensure they are not lost. It also said that state mental health authorities must overhaul their system for receiving and processing court orders. |
| Mitchell’s death remains under inquiry by police and other state authorities.Earlier this month, the Virginia house and senate passed a bill intended as a response to Mitchell’s death. The new law, which is awaiting approval by Governor Terry McAuliffe, says court clerks must alert hospital staff about hospitalization orders by no later than the day after they are made. Hospital staff must also acknowledge receipt of these orders using a new official form. | Mitchell’s death remains under inquiry by police and other state authorities.Earlier this month, the Virginia house and senate passed a bill intended as a response to Mitchell’s death. The new law, which is awaiting approval by Governor Terry McAuliffe, says court clerks must alert hospital staff about hospitalization orders by no later than the day after they are made. Hospital staff must also acknowledge receipt of these orders using a new official form. |