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When Jail Becomes A Death Sentence

This undated photo shows Rochelle Nishimoto recounting the death of her son, Jason, with her other son, Adrian.
Lisa Pickoff-White / KQED
This undated photo shows Rochelle Nishimoto recounting the death of her son, Jason, with her other son, Adrian.

In life, San Diego County residents Heron Moriarty and Jason Nishimoto never crossed paths.

In death, they became brothers of a sort. Both took their own lives after suffering acute episodes of mental illness. Both died before ever making a court appearance. Relatives said both men shared one more common bond: that jail officials didn’t respond to repeated warnings that the men were desperately ill and in danger of suicide.

When Jail Becomes A Death Sentence
When Jail Becomes A Death Sentence GUEST:Julie Small, reporter, KQED

I am Maureen Cavanaugh. It is Monday, August 22. Our top story, one third of California inmates suffer from muscle disorders. Most talk of California lacked the staff and facilities to properly treat them. Last year, 38 people killed themselves while in custody across the state and sadly, San Diego County has the highest suicide rate of all major rail systems in California. Julie small has the story. On a Sunday patio in her home in a quiet neighborhood, Michelle Moriarty visibly shakes as she recounts the death of her husband. He was 43 and never showed signs of mental illness at all until his last five weeks of life. They owned a couple of electrical shops. Michelle took care of their children -- three children. They melt at a singles group in their church. She describes her husband as generous, warm and always smiling. In April, he changed. He started acting strangely and talking in circles and not making sense. They took him to the hospital. Doctors cannot find anything physically wrong with him they sent him to a psychiatric hospital visit they diagnosed him with bipolar. He was manic with psychosis. Over the next few weeks his condition worsened. He refused to take medications and called himself a prophet. Michelle moved with her children to a temporary home. She was trying to get him sit back to the psychiatric hospital. But before that can happen, they arrested him for assault. He threw a rock through the front window of his brothers home. He was laying in the street when they pulled up. He jumped in front of cars. He told them that he would close his eyes when he was driving. They still took him to jail rather than the hospital. They took him to the best that the tension sensor. He was placed in a cell where he stayed alone 23 hours a day. The jail staff told Michelle he would be protected from other inmate, but she worried. During an incident, he told the police officer he wanted to kill himself. For 6 days I was calling continuously. I was talking to the nurse and I was telling them I was scared for his like the whole time. And they told me not to worry. That he was in good hands. She says a nurse told her that they would try to get him in to see a psychiatrist. Six days after his arrest, jail staff said -- down temp with the T-shirt pulled tight around his neck and another shirt stuffed in his mouth. Efforts to resuscitate him failed. The next morning she could not find her husband's name in a list of inmates. And when I called them and asked why his name is not on the list they said they would have to call me back. They called me back and told me what happened. The county coroner said that he is been created himself and ruled his death a suicide. He was one of 26 inmates who committed suicide between 2010-2016. An analysis of death record shows half of those had attempted suicide before. We're told that deputies and their families told authorities that they wanted to. Jail staff were shown new training videos like this one. Hi my name is Dr. Alfred Shasha what. I'm here to speak about the inmate safety program. Our suicide prevention program that was designed specifically for San Diego County jails. In the video they look what -- at what suicide factors look for. At risk inmates are supposed to be held in special cells per These are self defined where an inmate will not be able to jump, to harm themselves or to be able to hang themselves. The investigation on the data shows that jail staff at the Vista detention center did not place them in such a cell. Aboard that investigates complaints is looking into Moriarty's death. We tried to talk to County officials about jail suicides but they all declined. A spokeswoman for the sheriff said that they were too busy to participate in our report. We were not allowed to tour the detention center. As for Michelle Moriarty, she plans to sue San Diego County future says her husband should not have died in jail. He loved life. And he loved his family. And we had -- he would have never chosen this end. I want people to rumor his life and not how he died. Tomorrow I will have more on the group of why a civil writes group is suing San Diego for ignoring inmates. This is a huge systemic problem. They say this problem has persisted for years. I am Julie small in San Diego. I spoke with one of the reporters, Julie small. Welcome to the program. Thank you. We heard that the shares office may not have followed changes they made to their own policies to prevent suicides. Can you tell us more about some of those policies ? One of the main things that the policies do, they set a list of things to look for that would put someone at the highest risk of suicide. Like whether if they have up history of previous suicide attempts, or if they tell an officer or someone in the jail or a family member that they are suicidal. That should trigger an automatic higher level of scrutiny. To put them in observation in a cell where they cannot hurt themselves. It is supposed to trigger a review by psychiatric staff you If those policies have been follow, two experts say they would cut down on jail suicides ? Yes. They deal with the known risk factors. Mental illness is a risk factor. That is in the protocol, do they have a history of mental illness ? If they have committed of violent crime ? They are more at risk. We know that when inmates are most likely to kill themselves are with in 24 hours or the first 4 days. We have all of this information that can be utilized. But the observation has to be followed by treatment. And that is something that jails are having a hard time doing. What are the conditions inside the jail for inmates with mental illness ? Most of what we found out was for attorneys -- to attorneys of inmates. The sheriff would not speak to us. Based on that, we know that it takes nearly one week for someone to see a psychiatrist if they come into the jail. That they may be off of their medications that hold time. -- Whole time. And they are likely to be isolated 23 hours a day in a cell by themselves. That is not punishment, but mentally ill inmates tend to be at risk from violence from other inmates. They end up in these cells by themselves. Experts say that isolation and idleness are two of the worst conditions for people with mental illness. You mention that she wanted to talk to the sheriff's department. At that they did not respond, or that they did not welcome you into the jail. We asked them for a reaction to the future, and there was sponsored reads in part, we are in the protracted process of examining our policies and procedures. Our efforts to improve medical care and confinement have resulted in fewer suicides as far to date. This is an ongoing effort monitored closely by shares more. My question to you is, do you see in the that is the case ? That their efforts has resulted in fewer suicides to date ? They had a dip in this suicides in 2013. But it has gone back up. It may be that the overall number is down, but the trajectory is on the rise. Part of the problem, in prisons across the state, there is a state law that keeps many inmates serving sentences in jails instead of hospitals. Were and are jails not properly prepared for the influx of mentally ill inmates ? The realignment powerful free -- policy shifted the responsibility which resulted in reduced crowding in the prisons. They got money to handle the new population, but that does not mean you have the officers, the training and expertise. They of had to ratchet up what they were doing. In your report, to help improve the treatment of mentally ill inmates, you found that LA County jails have agreed to federal oversight. But in the year that we are talking about, LA only had one jail inmate suicide, and San Diego had six. Why no DOJ oversight in San Diego County jails ? I'm not sure why they have not taken it on. It may be in the works. Legal advocates who have been involved in the LA jails have put a spotlight on what happened there. And they sued the jail system. The disability five California and the prison law office, which has brought a lot of the class action lawsuits for insufficient medical care in the jails, they toward San Diego jails last year and they're talking with officials now. What would you be focusing on in part two of the series ? We will talk about the attorneys that are representing these families and why families are turning to the court. They seem to death as part of a long pattern of the failure of the sheriff's department to adequately provide medical care for inmates. And also a history of an adequate training and inadequate supervision. We'll be looking at some of those larger systemic issues. I have been speaking with Julie small. Thank you so much. Thank you.

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When Jail Becomes A Death Sentence Part 2
When Jail Becomes A Death Sentence Part 2

The Moriarty and Heron cases are just two among more than two dozen San Diego County jail suicides between 2010 and 2015, a string of deaths that significantly exceeds the number seen in other counties. Statewide in 2015, one in four inmates who died in county jails took their own lives. But in San Diego County, half of deaths were from inmates taking their own lives. The deaths have prompted a series of lawsuits against the county and its Sheriff’s Department, which runs the jails, and has raised questions about whether the county is doing enough to stop seriously mentally ill inmates from harming themselves.

The San Diego County suicides also shed light on a national problem: the increasing number of mentally ill people landing in jails.

In California, the problem is compounded by what amounts to a massive statewide experiment: the transfer of thousands of inmates, some of them suffering from serious psychiatric disorders, from state prisons to county jails. Many of the local lockups have been unprepared to deal with the arrival of often seriously afflicted prisoners. At the same time, state hospitals that might treat prisoners are overcrowded, leaving mentally ill inmates languishing in jails with inadequate treatment facilities.

Heron Moriarty did not have long to understand the ins and outs of living with mental illness. Until this past spring, his family knew him as an energetic and religious family man.

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An electrical contractor, Moriarty often awoke at 2 in the morning to keep up with business. He and his wife, Michelle, met in a church singles group in the late 1990s and had three children. The family was actively involved in their evangelical Christian church, where Moriarty mentored others.

Then, in April, things changed.

“He started acting strangely, and talking in circles and not making any sense,” Michelle Moriarty said. The family took him to an emergency room and then to a psychiatric hospital where he was diagnosed as bipolar and manic with psychosis.

Heron and Michelle Moriarty pose with their three children in a photo taken before his death.
Moriarty family
Heron and Michelle Moriarty pose with their three children in a photo taken before his death.

He got worse. He refused medications because he believed his illness was a gift from God. He called himself a prophet and said the Lord had commanded him to sacrifice his children. He said he was willing to do it.

Michelle Moriarty said she took the kids and moved out. Shortly afterward, on May 25, 2016, Heron Moriarty was arrested after throwing a rock through the front window of his brother’s home and smashing his truck into several cars.

“When they arrested him, I was relieved,” Michelle Moriarty said. “I thought, ‘He’s going to get the help he needs.’”

Heron Moriarty was jailed in the Vista Detention Facility in northern San Diego County. His wife said she called, faxed and emailed jail staff several times a day to tell them about her husband’s illness and medications. She spoke to a chaplain, she faxed a report from a Psychiatric Emergency Response Team officer who had arrested Heron three weeks earlier and sent him to a hospital for treatment. All told, Michelle Moriarty said she called the Sheriff’s Department 28 times in six days.

“I was telling them I was scared for his life the whole time. And they told me not to worry, that he was in good hands,” Michelle Moriarty said.

Despite the warnings, Heron Moriarty was neither placed on suicide watch nor seen by a psychiatrist. On the sixth day he was there, May 31, jail staff found him dead in his cell, with a T-shirt pulled tight around his neck and another shirt stuffed in his mouth.

“My husband shouldn’t have had two shirts to be able to do that to himself,” Michelle Moriarty said. “You know, he should have had paper clothes or no clothes or something after me warning them day after day.”

For more than two decades, Jason Nishimoto and his family managed his schizophrenia. He worked as a welder refitting plumbing pipes on Navy ships. He loved to write short stories and poems.

But last year, Nishimoto started experiencing side effects from his psychiatric medications, leaving him depressed and prompting several suicide attempts.

Then on Sept. 24, Nishimoto tried to kill himself by taking a full bottle of an anti-seizure drug. The overdose made him manic. Jason’s brother Adrian took his car keys away and called 911.

Jason responded by grabbing a garden shovel and threatening Adrian, who tackled him.

This undated photo shows Jason Nishimoto,left, posing with family and friends on a beach.
Nishimoto family
This undated photo shows Jason Nishimoto,left, posing with family and friends on a beach.

“He was like the drunkest man you’ve ever seen,” Adrian Nishimoto said. “So his attempts were not in any way going to hurt me. I was egging him on, to get him to do that so he would stay here. … I just wanted to keep him in this area until the police showed up.”

The next morning, a psychiatric nurse at Vista Detention Facility called Jason’s mother, Rochelle Nishimoto, to ask about his current medications because he was too incoherent to answer her questions. It was the first time the family realized that Jason had been jailed and not hospitalized.

The last thing the psychiatric nurse said was, “Don’t worry, mom, we’ll take care of him,” Rochelle said.

On his fourth night in jail, the evening before he was scheduled to see a psychiatrist, Jason Nishimoto hanged himself with a bedsheet.

“They blatantly ignored their own policies,” Rochelle Nishimoto said. “I’m a registered nurse. Any time that we would have a patient or resident that was suicidal, I know what 15-minute watches are, suicidal precautions. Any nursing home, any hospital that does not follow those — they would be hit with the biggest fine. People would be fired. It would not be tolerated. Period.”

Earlier this month, Rochelle Nishimoto sued the the county and Sheriff’s Department for Jason’s death in federal court for wrongful death and violation of civil rights. She said it’s the only way to prevent more deaths.

“It would be much easier — less emotional — for me to let it go. But then this stubborn streak comes up and says, ‘How dare they neglect my son? How dare they?’” she said, pounding her kitchen table.

The Citizens’ Law Enforcement Review Board, an independent board, is still investigating Jason Nishimoto’s and Heron Moriarty’s deaths.

One of the striking aspects of the suicides of Jason Nishimoto and Heron Moriarty is that they occurred after the high number of deaths in San Diego County’s jails had received widespread public attention. They also followed the jails’ adoption of new procedures designed to identify at-risk inmates and stop them from killing themselves.

County officials, including the medical examiner’s officer, the Citizens’ Law Enforcement Review Board and county Board of Supervisors declined to be interviewed for this story, referring us to the Sheriff’s Department.

Sheriff’s spokeswoman Jan Caldwell ultimately responded to numerous requests for comment by telling us the department was “unable to participate.”

But public records requests and local reporting shed light on the Sheriff Department’s response to the deaths behind bars.

In San Diego, a registered nurse screens inmates for medical and mental health problems during booking. This determines whether an inmate will be placed in a psychiatric unit, a special cell for suicidal inmates, a single cell or in general population. Medication orders are placed, and medical or psychiatric visits scheduled.

Neither Heron Moriarty nor Jason Nishimoto was placed on suicide watch or given close examination when they were booked. Jail staff isolated both men, placing them in cells, alone, for up to 23 hours a day.

Terry Kupers, an East Bay psychiatrist and expert on the treatment of mentally ill patients in jails and prisons, said it’s common for mentally ill people to be segregated from the general population.

“The sheriff doesn’t mean it as a punitive measure. He’s just doing it to protect the inmate. But then you’re isolating someone with a serious mental illness, and that’s the worst thing for his treatment and his prognosis,” Kupers said.

The continuation of medication is also imperative. Jason Nishimoto did not receive any of his medications while in jail, Rochelle Nishimoto said. A psychiatric nurse told Rochelle that Jason’s medication was “too expensive.”

Jails determine what medications they will and won’t give inmates, but Kupers said the institutions’ medication lists are often inadequate for effective treatment.

“The newer medications are on patent, and they are more expensive. So the jails don’t tend to prescribe them, and it makes a lot of difference what medication you’re on,” Kupers said.

Being taken off some psychiatric medications suddenly is dangerous and can cause suicidal thoughts and medical problems.

Both Moriarty and Nishimoto also experienced another common problem during their brief stays at the Vista jail. The facility does not have an on-site psychiatrist. Instead, the county uses several psychiatrists who shuttle from jail to jail. This kind of delay to see a psychiatrist is very common in jails throughout California, and dangerous, Kupers said.

“So if someone comes in on a Saturday night and they’re very psychotic, and the psychiatrist comes in on Thursday, they will have no psychiatric attention between Saturday night and Thursday, and … they’re going to be very disturbed,” Kupers said.

In 2015, nearly one-third of the 4,980 or so inmates in San Diego County jails on any given day were receiving some form of mental health care.

Even when inmates receive therapy, it is far from what most people would think of as a normal session. Therapy in most county jails, including San Diego’s, is predominantly conducted through a food slot. San Diego has a policy that mental health professionals may only speak to patients through glass or bars. Cellmates, guards and others can easily listen in. Experts like Kupers said that this kind of therapy is common — and inadequate.

This undated photo shows Lydia Nunez holding a photo of her son, Ruben.
Lisa Pickoff-White / KQED
This undated photo shows Lydia Nunez holding a photo of her son, Ruben.

Lydia Nunez’s son Ruben — a 46-year-old, homeless schizophrenic — died in San Diego Central Jail almost exactly a year ago. She says the death tore a huge hole in her life.

“He always said he loved me,” she said. “There was a never a day where he wouldn’t stop saying that. So at this point, I miss him saying that to me.”

Ruben Nunez had suffered from severe mental illness his entire adult life, but the path that led to his death in the Central Jail began in March 2014, when he was arrested on felony assault charges for allegedly pitching a rock through a car window. His mental illness was so crippling that he was judged incompetent to stand trial and sent to Patton State Hospital in San Bernardino for treatment. He refused to take psychotropic drugs prescribed by doctors there, so he was medicated involuntarily.

Schizophrenia was far from Nunez’s only problem, doctors at Patton observed. They noted that he showed signs of psychogenic water intoxication, a complication of a psychiatric condition that made him want to drink massive volumes of water. Unchecked, the condition can be fatal.

Because Nunez was said to have been “drinking water in dangerous amounts,” doctors at Patton required him to be monitored closely to ensure he didn’t consume excessive amounts. Without that monitoring and other treatment, a Patton doctor wrote, Nunez’s water intake “could easily have killed him.”

That was Nunez’s state immediately before Patton State Hospital sent him to San Diego Central Jail last August to await a court hearing that would determine whether doctors could continue his involuntary medication.

Exactly what Central Jail staff knew about Nunez’s condition when he arrived on Aug. 8, 2015, isn’t clear. What is evident from medical examiner’s documents is that he was placed in a cell with a toilet and sink, meaning he had free access to water.

A federal lawsuit filed in June 2016 on behalf of Lydia Nunez alleges that the jail’s failure to limit Nunez's water intake proved fatal.

Early the morning of Aug. 13, a guard found Nunez vomiting in his cell. A nurse visited shortly afterward to administer Nunez’s regular medications. Then Nunez was left alone. Less than an hour later, he was found unresponsive, covered in vomit and urine. Attempts to revive him failed, and Nunez was pronounced dead.

An autopsy found he died of complications of water intoxication. How much water would it have taken to kill him? The medical examiner’s report on the death remarked that “the quantity of water necessary for this condition is around 6 liters ingested in a short time.”

The Nunez lawsuit alleges that failures by both Patton State Hospital and Central Jail staff led to the death.

The complaint accuses Patton of failing to send the jail a specific alert about Nunez’s water disorder, a document that should have spelled out strict protocols for monitoring the condition.

The suit also alleges that jail staff ignored medical records showing that Nunez was at risk for water intoxication, then failed to act when he showed signs of being in severe distress.

The October 2015 medical examiner’s report on Nunez’s death notes that an investigator had obtained medical records through the San Diego Sheriff’s Department showing that the inmate “had a history of schizophrenia and hyponatremia, which required water restriction.“ (Hyponatremia is a potentially fatal condition marked by critically low sodium levels in the blood. The condition is most often caused by overconsumption of water.)

Ruben Nunez sings at a church in National City, 1990.
Nunez family
Ruben Nunez sings at a church in National City, 1990.

The lawsuit alleges that Nunez’s death is part of a long history characterized by the Sheriff Department’s “systemic failure” to provide adequate health care for inmates coupled with a wider failure by the county “to investigate incidents of medical neglect, staff misconduct and deaths in the jail.”

As with the Moriarty and Nishimoto deaths, the Sheriff’s Department declined to discuss the Nunez case.

For Lydia Nunez, though, the condition of her son as he died — on the floor of his cell, in jail clothing soaked with vomit and urine — speaks volumes.

“They just didn’t care about this person. This person that was just there, just lying there unconscious,” Lydia Nunez said. “I felt like they just ignored him.”

One of the many questions hanging over these deaths and others in the San Diego County jails is whether they’ve been adequately investigated.

That question emerged as a central factor in the case of Bernard Victorianne, a 28-year-old man who died in his county jail cell in September 2012.

Victorianne swallowed a baggie of methamphetamine as he was arrested for driving under the influence. A wrongful death lawsuit filed against the sheriff's department said Victorianne “was in distress for days, screaming and telling staff that his insides were ‘on fire.'”

CLERB’s inquiry into Victorianne’s death found that correctional and medical staff failed to take basic steps to respond to Victorianne’s situation or to investigate his death.

Julia Yoo, the attorney who sued on behalf of Victorianne’s family, said the county has agreed to settle the case for $2.3 million.

That’s just the latest in a series of expensive verdicts and settlements arising from inmate deaths. In 2014, a federal jury awarded $3 million to the parents of Daniel Sisson, a 21-year-old inmate who died in the Vista Detention Facility in 2011. Sisson was left untreated after he suffered an asthma attack while experiencing drug withdrawal.

The county also settled with the family of Tommy Tucker, a schizophrenic inmate who died at the Central Jail in 2009. Jail video shows that Tucker tried to get a cup of water back to his cell during a lockdown. It is unclear whether Tucker heard or understood the guards’ instructions to put the cup down. Jail guards rushed Tucker, using pepper spray, a chokehold and a spit sock to subdue him. Tucker died of asphyxiation during the hold.

CLERB did not investigate Tucker’s death. However, during trial it emerged that sheriff’s deputies reviewed the video together before writing reports about the death or being interviewed as part of the death investigation.

This winter, the review board suggested that the department stop allowing officers to review video footage before writing incident reports as part of their recommendations around body camera footage.

“In theory, what should happen is when there’s an unfortunate death there should be a serious investigation. And whatever can be found that led up to the death should be changed. That process is not very active in California,” psychiatrist Terry Kupers said.

There are currently about eight more wrongful death suits against San Diego County.

“It needs to stop right here, now,” Lydia Nunez said. “People are dying in the county jail and nobody’s doing anything about it.”

Copyright 2016 KQED.

Corrected: January 31, 2023 at 6:08 AM PST
This article was produced as a project for the California Data Fellowship, a program of the Center for Health Journalism at the USC Annenberg School for Communication and Journalism.