A Jail Increased Extreme Isolation to Stop Suicides. More People Killed Themselves.
By: Jason Pohl, The Sacramento Bee, and Ryan Gabrielson, ProPublica
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BAKERSFIELD, Calif. — Shackled at the wrists and ankles, Christine Taylor followed a red line on the basement floor directing her to the elevator at Kern County’s central jail. She heard groans and cries from among the hundred people locked above, a wail echoing through the shaft.
It was minutes before daybreak on a Monday morning in May 2017 as the elevator lifted her toward the voices. Jail staff had assigned Taylor to something called “suicide watch,” a block of single cells where she’d be alone 24 hours a day. The sound of other people would soon become a luxury.
What a stupid mistake, Taylor fumed.
Earlier, she had argued with jail staff during her booking at the downtown jail. Have you ever attempted suicide, a deputy asked. Taylor glared back, her hands trembling. She had never been in serious trouble with law enforcement, and she considered her arrest that night a gross misunderstanding.
“Do you think I’m going to try to kill myself with my shirt?” Taylor responded, flippantly. “Maybe.”
Her answer got her a glimpse of how the jail handles people it perceives as suicide risks.
Within minutes, deputies moved Taylor into a changing room on the third floor and had her strip naked. They handed her just two items: paper-thin clothes that come apart under pressure and a blue yoga mat.
Exhausted and scared, she followed orders, walked down a hall and stepped into a bathroom-sized isolation cell. The door slammed behind her. The floors felt colder inside, and a mold smell came up from the toilet-sink fixture. A bed was mounted to the brick wall. Hazy fluorescent lights reflected off the ash-white paint. And, as Taylor soon learned, jail staff never turned them off.
To shield herself, she crawled under the bed and put the yoga mat over her torso like a blanket.
She pressed her eyelids shut but couldn’t block the glare or the rush of tears.
“Cruel and Unusual” Punishment; No Limits
Each year, the Kern County Sheriff’s Office sends hundreds of people into this kind of suicide watch isolation. Inmates awaiting trial spend weeks and sometimes months in solitary, according to state and county records. When those cells fill up, deputies place people into “overflow” areas, rooms with nothing more than four rubberized walls and a grate in the floor for bodily fluids. They receive no mental health treatment, only a yoga mat to rest on.
Kern County sheriff’s officials say they turned to isolation rooms to help prevent deaths after a spate of jail suicides that started in 2011.
This wasn’t what state lawmakers envisioned when they undertook a sweeping criminal justice overhaul nearly a decade ago to alleviate what the U.S. Supreme Court deemed the “cruel and unusual” conditions for people in overcrowded state prisons. Those prisoners, the court found, would languish for months, even years, in “telephone-booth-sized cages” without treatment, resulting in “needless suffering and death.”
California’s reforms, dubbed “realignment,” diverted thousands of offenders to county jails so, among other things, the corrections system could see to basic health needs and meet minimum constitutional requirements. That shift also transferred billions of dollars to local sheriffs to better run jails.
Some, like Kern County Sheriff Donny Youngblood, have rejected warnings from the state to improve the outdated and often brutal forms of isolation that helped trigger the state’s prison crisis.
The state can’t do much about it, a McClatchy and ProPublica investigation found. The California Board of State and Community Corrections, which is supposed to maintain minimum jail standards and inspect local facilities, has no legal authority to force local lockups to meet those standards or ensure inmates are physically safe and mentally sound.
Last year, for instance, a state board inspector called out the Kern County Sheriff’s Office for 27 violations, a majority of them for using yoga mats instead of mattresses in suicide watch cells. But his letter read more like an invitation than a warning. “If you choose to address the noncompliant issues,” he wrote, “please provide your corrective plan to the BSCC for documentation in your inspection file.”
The sheriff’s office disregarded the findings and bought more than 100 additional mats this year, agency records show.
“It’s completely unethical, and counter to clinical evidence for what people need,” Homer Venters, the former chief medical officer of New York City jails, said of Kern County’s suicide watch. “For any human, that represents punishment and humiliation.”
Isolation practices save lives, Kern County officials argue. But records show the strategy didn’t work; inmates continued to kill themselves.
In one case, an inmate hanged himself in a suicide watch cell, after grabbing an extension cord that guards left within reach. Since 2011, 11 others have taken their lives in other parts of the jail. During the past four years, Kern County had the highest suicide rate of the state’s 10 largest jail systems, with 5.61 deaths per 100,000 bookings, close to twice the statewide rate, an analysis by ProPublica and McClatchy found. Overall, inmate suicides declined slightly in California county jails over that period.
The state’s board has no authority to investigate deaths in local lockups. The agency answers to the Legislature, which has not held a single hearing about jail inspections or the dozens of gruesome deaths in facilities across the state in the past eight years.
Texas and New Jersey, meanwhile, have boards that regularly examine such deaths.
“California is flying blind without a state regulatory agency that has meaningful enforcement authority. It’s time to correct this institutional failure,” said Ross Mirkarimi, the former San Francisco sheriff who is now a jail consultant. “It is a perfect opportunity for the governor to arc from the era of realignment into a new period of reform for California jails.”
Sen. Nancy Skinner, D-Berkeley, chairs the California Senate Public Safety Committee. She voted in support of realignment in 2011, when she was in the Assembly. Skinner said “there’s a lot of frustration” about how passive the state board has been in overseeing county jails.
“The sheriffs do have the authority here, and they could do the right thing,” Skinner said in an interview. “We as the state definitely have to improve our oversight.”
Gov. Gavin Newsom’s office, in a written statement, said Kern County’s jail practices are unacceptable, and local officials should reform their policies.
“County jails should not hold people in their custody in isolation indefinitely, no matter what the situation is,” the governor’s statement reads. “This is troubling, and it is this Administration’s hope that the findings in the reports issued by the Board of State and Community Corrections will catalyze change and reforms at the local level, where authority to make those changes ultimately resides.”
Many local jails across the country use variations of suicide watch to remove hazards and increase monitoring of vulnerable inmates. But Kern County uses isolation far more aggressively, and often exclusively, to prevent suicide deaths. “In my career, this is how suicide watch is done,” said Chief Deputy Tyson Davis, the jails’ top administrator. “They go into a cell by themselves with as few points to hurt themselves on as possible.”
That runs counter to best practices advocated by mental health experts, who are increasingly critical of isolating and stripping people considering suicide. A growing body of research shows the practice can harm a person’s mental health and actually increase their suicide risk once they are released from watch.
Youngblood, the sheriff, declined multiple interview requests, and his office declined to discuss specific cases, including Taylor’s.
After McClatchy and ProPublica asked questions about Kern County’s isolation practices and its use of yoga mats, the sheriff’s office replaced the mats with blankets that are resistant to rips. And Davis said in September that he is working to add mental health specialists to inmate screening, which deputies alone have long conducted. The new clinical positions are not funded yet.
Bill Walker, Kern County’s behavioral health director, is in charge of mental health care in the jails. When asked in August if isolation without clinical treatment is harmful, Walker replied, “I would be the first to agree with you.” However, he continued, Kern County’s suicide watch is better than the indifference institutions inflicted decades ago on the people they detained.
“We used to bury people in the state hospitals in unmarked graves,” Walker said. “The humanity of safety is to keep them alive.”
This account is based on interviews with Kern County’s top jail administrators and deputies, county behavioral health directors, former inmates and families of the deceased. The sheriff’s office took reporters on tours of its jail facilities and to see the suicide watch cells. McClatchy and ProPublica also reviewed and analyzed state inspection documents, autopsy reports, court filings, jail purchasing records and state data on in-custody deaths.
An Uptick in Suicides, Then Yoga Mats
In 2011, Lorena Diaz tried to end her life by jumping off a highway bridge. She survived, and a county mental health clinic released her, apparently no more stable than before.
Desperate, her mother called Diaz’s parole agent to ask for help, to find a place where her daughter would be safe. The agent alerted local police, who promptly arrested and booked Diaz into the downtown Bakersfield jail, according to sheriff’s office records. But within two days of her arrival, staff found the 29-year-old mother hanging from a bed sheet tied to a wall vent.
The death was the first in a string of suicides over the next year: A 42-year-old man charged with crashing into a sheriff’s patrol car cut his wrist with a razor and bled out while his cellmates slept. A 20-year-old murder defendant who told deputies he heard voices hanged himself in an isolation cell.
In response to the suicides, Youngblood and his jail staff began sending far more people to suicide watch cells, records show. The practice continues to this day.
“The tripwire to get on suicide watch is fairly light,” said Lt. Ian Silva, who oversees many of the jails’ day-to-day operations. “We don’t want to take any chances.”
The sheriff’s office also added a new feature to its suicide protocol. In March 2012, the agency purchased 25 blue yoga mats, finance records show, and ordered 109 more in July of that year. The mats are a half-inch of foam designed to cushion people doing floor exercises.
They became the only thing Kern County’s suicidal inmates got to sleep on, besides the cement floor or metal bunk. They were also a signal that isolation was no longer a fleeting experience. People began spending longer periods of time on suicide watch.
In state prisons, at-risk inmates receive mattresses. Silva said the sheriff’s office chose to give yoga mats instead to ensure inmates cannot impede deputies from entering cells. “Our big concern with full mattresses is barricading,” Silva said.
Because people with suicidal thoughts often spend their time searching for methods to end their lives, jail experts say suicide watch cells should not contain anything a person can use to asphyxiate or cut themselves.
Kern County deputies violated that rule in August 2013, after deputies booked Luis Campos on a stack of domestic violence charges. Campos had tried to kill himself before, so deputies put him in the watch cell closest to their desk.
The aging facility’s air-conditioning system regularly faltered in the summer, internal investigation records show. So deputies rigged up a portable fan with an extension cord and duct tape to blow air at their watch station as the afternoon heat topped 90 degrees.
They found Campos dead during morning rounds two days later, dangling from the cell bars, an extension cord noosed around his neck.
Until last year, the sheriff’s office had only 11 specialized suicide watch cells across its three jail facilities, and they were always full. So deputies began using what are called safety cells as suicide watch overflow.
Safety cells are closet-sized rooms with nothing but four walls and a grate in the floor. No bed. No water fountain or toilet. They’re temporary storage boxes for people who’ve lost control.
California jail standards say safety cells should only hold inmates who are damaging the building or showing an active intent to hurt themselves or others. Medical staff members are required to evaluate each inmate within 12 hours, and a jail administrator needs to reapprove holding them in the safety cell every 24 hours thereafter.
By early 2015, Kern County’s jail deputies were sending nearly three dozen people a week to suicide watch, a 29% increase from a year earlier. Some were removed from watch in hours. Others stayed for days.
Still, elsewhere in the jails, the suicides continued. That January, a 31-year-old man hanged himself. He’d first tried to kill himself days earlier, a nearby inmate later told detectives. The following September, a 25-year-old man with a history of depression died the same way in a group cell after telling his parents he would kill himself if they did not bail him out.
Deputies said they were unaware that either posed a suicide risk, according to autopsy records.
Meanwhile, state inspectors from the corrections board made their routine tours of Kern County’s jails and reviewed their internal records every two years. By the time an inspector arrived in June 2016, 10 inmates had taken their lives in 5 1/2 years. The inspector did not mention the deaths in the reports. And in evaluating safety cells, one of the reports simply noted “documentation for the use of those cells were good.”
Two more men hanged themselves in January and February 2017, as deputies sent upward of 36 inmates a week to isolation cells.
Christine Taylor was soon among those on suicide watch.
“When Am I Going to Get Out?”
Keys banging on the door woke her that first morning.
“Taylor!” the deputy making the morning rounds shouted. She crawled from underneath the cell bed, where she had been hiding from the lights, and moved toward the metal door. She looked out the smudged plexiglass window. It was like peering through a porthole on a space shuttle, she said.
The person on the other side wouldn’t open the door. Kern County jail staff almost never do during these routine cell checks and brief behavioral health evaluations. So Taylor crouched on her knees and spoke to the specialist through the food-tray slot in the door. She said she was not suicidal. She was only on suicide watch, she pleaded, because she hadn’t cooperated with deputies during intake.
“When am I going to get out?” Taylor asked as the staffer walked away.
“Well,” she heard, “we’ll see.”
Police had arrested her on suspicion of elder abuse. Her father, who suffers from Alzheimer’s disease, claimed that she attacked him during a middle-of-the-night disagreement. But Taylor, then 47, had video showing the opposite; in fact, officers had responded to similar calls at their home before, for offenses imagined or badly misunderstood. This time, deputies refused to watch the tape.
Now Taylor was alone, a dozen yards from the deputy desk. She tried to sleep. It was the only thing to do — inmates on suicide watch in Kern County don’t get books to read or recreation time to interact with other inmates because even that could be too dangerous, sheriff’s officials said.
So she covered her eyes from the light with her clothes and rolled up her yoga mat to use as a pillow. About four hours crawled by after she entered the jail when staff returned to the door and said they were moving her.
For a moment, Taylor felt a rush of excitement. She thought about all the things this might mean: a pillow, a toothbrush, a shower, maybe even a cellmate, someone to talk to.
Deputies instead led her around the corner to another suicide watch cell, next to a deputy’s desk. The furnishings were the same: bed, toilet and yoga mat. But the move shortened the distance the deputies had to walk as they signed off on the required twice-every-30-minutes checks. And she could see staff and inmates walking out of the elevators past the window. There were people around, Taylor thought, people to hear about how she’d been wronged.
“Innocent until proven guilty!” she screamed, calling out to other inmates to join her protest. No one did. “I didn’t get my phone call! I didn’t get my phone call!” Taylor chanted.
Her confusion had given way to resentment. There was nothing the jailers could do to her that would be worse than being in that cell, she thought, so Taylor vowed to make everybody in earshot hear her outrage. She’d become part of the collective wail that greeted her just hours earlier.
Jail staff ignored her.
Taylor tried another tactic: She ripped a piece of material from her paper-thin shirt and fashioned it into a small nooselike loop. She said she dangled it in the porthole window. (Jail staff wrote that she put it around her neck, sheriff’s office records show.) Deputies stormed the cell and restrained her, Taylor said, and records show staff replaced the clothes with a hunter green, tear-resistant suicide smock.
The following day, around noon on Tuesday, jail records show deputies transferred her to a punishment cell, known as administrative segregation.
“If They’re Committed, It’s Hard to Stop Them”
Kern County’s behavioral health department doesn’t provide treatment to inmates on suicide watch, aside from dispensing medication for previously diagnosed conditions, said Walker, the department’s director. Last year, the county agency doubled its jail staff, which now employs about 40 caregivers.
Counties usually have a written agreement with the behavioral health provider working in the jails. The contract — among the most foundational parts of jail-medical operations — dictates what the provider will do, as well as the consequences for failing to deliver services. But in Kern County, the jail has had no such agreement for “several years,” Walker said. That means there’s no written accountability for when things go wrong. County officials maintain a contract isn’t necessary.
The behavioral health department does not reliably track how many people have attempted suicide in the cells, why people were placed in isolation or how long they stayed, he said. It also does not keep data on inmates sent to outside hospitals because of mental illness.
After every death of a mentally ill inmate, behavioral health and jail staff meet to review the case and determine if there are ways to prevent similar fatalities in the future. However, officials have not examined the jails’ suicide deaths as a whole at any point since 2011, Silva and Walker confirmed.
During an interview in August, the county’s top behavioral health officials demurred when asked why Kern County’s jail suicide deaths had increased dramatically.
“I don’t think I have an answer I could give you at the moment,” Walker said. Deputies don’t send all suicidal inmates to behavioral health staff. Greg Gonzales, head of correctional care, said suicide prevention cannot keep all inmates safe. “If they’re committed, it’s hard to stop them,” he said.
At the sheriff’s office, Silva partly attributed the increased deaths to “bad luck.”
The behavioral health department provides inmates the best care it can afford, Gonzales said.
Over the past two decades, researchers have examined suicides in local jails, where death rates are often higher than among the general public and in prisons. They’ve consistently opposed the use of isolation, saying it increases the likelihood that inmates will attempt to hurt themselves. A guide from the World Health Organization states, “Prisoners at risk should not be left alone, but observation and companionship should be provided.”
The key to keeping people safe in local jails is paying attention, said Sheriff Tom Dart from Cook County, Illinois, whose Chicago-area jails are increasingly a model for humane practices. Dart said he eliminated isolation as punishment when his department’s data showed the practice actually led to more rule violations and security problems.
“If you value something as a society, you study it,” Dart said. “You analyze it. You spend money on the data. If you don’t care about something, you don’t study it.”
A 2014 statistical analysis of New York City’s jail inmates found serious mental illness and solitary confinement were the strongest factors in suicide attempts.
Lindsay Hayes, a national expert on correctional suicide prevention, said jails use isolation with good intentions. “I truly believe that correctional officials and mental health and medical officials and leadership are not intentionally trying to punish people, to create tortuous types of environments,” Hayes said. “They’re just being extremely careful and, in many ways, over-protective and over-reactive.”
A “Lonely Cell” and Endless Daylight
Taylor felt worlds away from another human being. In the punishment cell, around the corner from suicide watch, no one walked by. She couldn’t hear voices or the clatter of activity. Distance muted everything.
“It was the loneliest feeling I’ve ever had,” she said. “That feeling is what made me decide that I wanted to be good and go back to the cell behind the deputies.”
The “lonely cell,” as she called it, broke her in less than a day. She apologized. She told deputies she’d learned her lesson. More importantly, Taylor said, “I was just being quiet.”
Deputies moved her back to the suicide watch cell by the desk that Wednesday morning, two days after being booked into the facility, according to jail records.
She tried to measure the hour by watching how much sunlight streamed onto the jail hallway floor. Peering through the window, she learned to tell time by making mental notes about when one deputy’s shift ended and another person’s began.
She marked the hours with scraps of food and shreds of a paper plate, but it was all guesswork. The constant light triggered sleep deprivation and confusion. Taylor had lost track of just how long she’d been in Kern County’s jail.
Bedbugs, Yoga Mats and a Shrug
In California, this kind of isolation is entirely permissible.
To bolster oversight of county jails and distribute funds in the realignment era, state lawmakers created the corrections board. Every two years, it sends an inspector to each facility to make sure sheriffs and their officers are following the rules.
Steven Wicklander, an inspector for the state board, arrived at the Kern County jails in June 2018, a year after Taylor’s arrest. The central receiving jail was in the midst of a bedbug infestation. The sheriff’s staff was not regularly cleaning cell mattresses, Wicklander wrote in his notes. They handed out dirty beds and only washed them when the mattresses were “contaminated.”
Conditions weren’t much better in the newest jail, opened last year and built with $100 million in state funds to cope with an influx of inmates serving longer sentences in county facilities under realignment. Its expansive infirmary is primarily for suicide prevention, and its 14 isolation cells were constantly full.
Over three days, Wicklander toured the suicide watch halls at each jail facility. He saw maxed-out cells and deputies putting suicide watch inmates in safety cells for more than a week straight.
“The safety cell cannot be used as a substitution for treatment,” Wicklander wrote in his final report in August 2018.
There were violations at every stop. Kern County jails are so understaffed the sheriff’s office requires deputies to work overtime to cover the shifts, causing deputies to fall behind on safety and security checks. Suicide watch and safety cell practices, particularly the yoga mats, were against the rules.
Agency officials do not have authority to make county leaders change and generally see themselves as partners, not regulators, said Allison Ganter, deputy director overseeing the inspection team.
“We are not enforcement,” she said.
Youngblood and his staff waited eight months to respond to Wicklander’s report.
They wrote back this April and rejected the board’s findings that yoga mats violated the standards. The sheriff’s office spent $4,500 to buy 60 more mats the same month, finance records show.
Yoga mats, they wrote, provide people on suicide watch “the comfort of padding, albeit minimal, in an environment which is uncomfortable by design.”
A New Caregiver, and a Long Walk Home
As the week went on, Taylor tried to talk to anyone who walked by her cell. Once, a woman sat near her window, and they chatted briefly about being arrested and their legal cases. “She was telling me her story, which was almost like my story,” Taylor recalled.
She tried to get the staff talking. Taylor said she noticed a picture of a puppy on a deputy’s monitor and complimented the pet’s cuteness. The deputy scolded her and turned the screen away.
“The most exciting part of the day was when they would give me my food because there was actually somebody there,” Taylor said.
Saturday marked her sixth day in the jail. That morning, a different behavioral health specialist met with Taylor and decided that her suicide risk — however deputies calculated it initially — was gone. She moved to a space with the rest of the inmates in the jail’s general population ward, where she was thrilled to receive a toothbrush, soap, clothes and a mattress.
Deputies also gave her access to a phone for the first time since she’d been put on suicide watch early Monday morning. Taylor called her mom, who helped arrange for her to post the $35,000 bond. (Two weeks later, prosecutors dropped the charges. Taylor sued the county for wrongful detention, but the suit was dismissed.)
The sheriff’s office said it is not permitted to discuss her case under state law and would not answer reporters’ questions about her time in jail.
It can take hours to be formally released from custody, and oftentimes inmates are released in the middle of the night without reliable transportation. Late Sunday, the doors of the downtown Bakersfield jail swung open for Taylor. A 4-mile walk in the dark awaited her.
She had been in sweats when police arrested her and didn’t have a bra to wear for the trek home. Taylor asked if she could borrow one of the jail-issued ones.
“It’s bad luck to take anything home from here,” a deputy replied.
“Good advice,” she said.
