PORTLAND, Ore. — Inadequate medical and mental health care, among other factors, contributed to the deaths of ten inmates at eight local jail facilities throughout Oregon over the course of 2020, according to an investigative report by Disability Rights Oregon released on Monday.
The report looked at ten deaths between the beginning of January and the end of October, 2020, in Clatsop, Deschutes, Jackson, Klamath, Marion, and Polk counties, as well as the Springfield Municipal Jail and the NORCOR detention center in The Dalles.
"As the jail population plummeted last year in response to the threat of COVID-19, the number of deaths in Oregon jails rose," DRO said in a statement. "Jails are shielded from public scrutiny like few other places in society. DRO’s investigation documents the systemic failures — by both hospitals and jails — that led to this tragic loss of human life, and makes clear that many, if not most, of deaths that occurred in Oregon jails were preventable."
According to the DRO report, nine out of the ten inmates who died had a disability. Five had documented mental health conditions, and six of them died by suicide. Eight had documented substance use disorder, and six of those were in custody on drug-related charges. At least four were homeless, or had a history of housing insecurity.
The ten deaths examined were unrelated to COVID-19, and did not include deaths in the state prison system.
The organization concluded that the deaths resulted from a combination of restraint practices that are banned in clinical settings, inadequate assessment of medical conditions, an inability of the jails to provide necessary treatment, and a failure to take adequate measures to prevent suicide — in addition to a lack of meaningful transparency or oversight, and a revolving door of detainees with a lack of community treatment options.
Though including them in the report, DRO did not explicitly cite details from the cases that occurred in Jackson and Klamath counties. The Jackson County Jail reported the death of 46-year-old Carl Sullivant in February of 2020 after he died following an apparent medical emergency. 22-year-old Randall Holmes, the suspect in a 2019 drive-by shooting, reportedly died in the Klamath County Jail in April.
"While this report does not tell the entire story of each person’s death, each individual case is its own tragedy and speaks to the urgent need for action," DRO said. "Use of force, inadequate medical and mental healthcare, insufficient screening, and failure to follow safety protocols contributed to the deaths analyzed in this report. Criminalization of mental health conditions, lack of substantive healthcare standards, and lack of jail oversight were systemic issues uncovered through this investigation."
The report examined two cases in particular. Alex Jimenez, an Army veteran, struggled with mental illness and addiction. According to DRO, officers approached Jimenez in Warrenton, Clatsop County, for jaywalking. He was tased and forcibly taken into custody when he did not respond to commands. He was taken to a local hospital for an assessment prior to booking.
"A doctor’s medical assessment consisted of looking at Alex as he sat in the back of a police car yelling and moving around," DRO said. "The hospital did not measure Alex’s vitals, examine the area where he was tased, or assess his mental health needs. Based on a cursory observation, the doctor cleared him for jail, saying 'I guess you’re ready to go to jail.'"
Outside of the Clatsop County Jail, Jimenez struggled with officers as they tried to steer him toward the facility. He was forced to the ground and held down to the pavement with "as many as six people holding him down" until he stopped moving and one of the officers found that he wasn't breathing.
While Jimenez was briefly revived at the hospital, he died later that day. The medical examiner's report concluded that his death was caused by methamphetamine toxicity, with "recent application of conductive electrical devices" and fatty liver cited as contributing factors.
The DRO report also cited the case of 26-year-old Jennifer McLaren, a woman with a history of drug possession charges, who died from a severe case of undiagnosed pneumonia at a jail in The Dalles. Though McLaren complained of rib pain and her cellmate asked to be moved because "she seemed sick," she was not taken to a hospital for eight days — instead, she was moved to a booking cell for closer observation.
"The day before her death, Jennifer became very dehydrated. This concerned medical staff, so they ordered her to drink a gallon of juice but did not attempt to have her hospitalized," the report said.
Emergency medical staff were not called until just before McLaren fell unconscious, and she died at the jail before she could receive treatment. The medical examiner listed her cause of death as pneumonia in both lungs, with blood-borne bacteria that had spread throughout her body.
The majority of the ten deaths investigated by DRO were caused by suicide, but the organization found that none of the individuals had been placed on suicide watch, even where there were indications of elevated risk.
"All of those who committed suicide died by hanging: Each person was left unsupervised in cells with unmitigated ligature risks," DRO said. "Unlike hospital licensing which requires eliminating all furnishings or fixtures that a patient could use to hang themselves, there is no oversight or licensing body in Oregon that proactively requires jails to address ligature risks."
Though Oregon law requires hourly welfare checks in correctional facilities, the investigation found that — in at least two of the cases — jail staff failed to conduct adequate checks, resulting in the inmates laying "dead for hours" before being discovered.
In cases where deaths were caused by medical emergencies, the report also placed some of the responsibility on hospitals, which had cleared the inmates for booking.
"Over the course of this investigation, Oregon sheriffs and jail commanders reported that local hospitals regularly clear patients for jail transport, regardless of the severity of their medical or mental health condition," DRO said. "In two cases reviewed for this report, hospital staff quickly released the individuals with conditions that ultimately contributed to their death."
DRO did say that jail commanders and sheriffs from the investigated facilities provided them with "extensive records in a forthcoming and timely manner." Oregon does not have a centralized source for data on jail deaths, the organization said.
A DRO investigation into the death of a Medford man at the Oregon State Penitentiary resulted in his family suing the state for wrongful death. The state Department of Corrections agreed to a record $2.75 million settlement in October.