UPDATE: On Tuesday, a new report was released about Mitchell’s death from the Office of the State Inspector General.
They say there are problems with the process and if it is not fixed, this situation could happen again.
“The current process of transferring inmates from HRRJ to ESH has multiple, significant risk points. In the absence of written and agreed upon protocols with responsible parties, timelines, and monitoring systems in place, the root causes of the significant event in HRRJ remain at risk for recurrence,” documents say.
This report also acknowledges that changes have been made to the administration office at ESH but that more things need to be fixed when it comes to the jail transfer waiting list. They say this was just one of the root problems that led to Mitchell’s death.
- DBHDS should develop regional protocol relevant to the management of individuals in HRRJ with mental illness.
- ESH should revise the process for the development, management, and oversight of the Jail Transfer Waiting List.
- The recommendations of DBHDS’s Transformation Team for the Justice Involved were substantive and needs to be developed immediately.
- DBHDS’s investigations of critical events should be conducted independently by professionals trained and experienced in conducting healthcare root cause analyses and who have experience working in the behavioral health system(s) in question.
- HRRJ should revise the process for overseeing the quality and outcomes of any contract agency that provides medical and mental health care in their jail.
Portsmouth, Va. – A mentally ill Jamycheal Mitchell died inside of a Portsmouth jail cell, while the judge’s order that would have sent him to a state mental health facility had been sitting in a file drawer for weeks. NewsChannel 3 has learned the woman responsible for the mishap retired from Eastern State Hospital after the mistake was uncovered.
Mitchell was arrested in April 2015 for stealing $5 in food from a Portsmouth convenience store. Portsmouth Judge MW Whitlow twice ordered Mitchell to Eastern State Hospital for treatment. A state investigation reveals the second order on July 31, 2015 made it to ESH admission coordinator Gail Hart, but she never placed Mitchell on the waiting list. Her colleagues described her as “astonished and distraught” when she found Mitchell’s order five days after her death. The state report also said Hart was “overwhelmed due to the increased number of admissions and the loss of staff in the admissions department.”
Maria Reppas, communications director for the Department of Behavioral Health and Developmental Services, sent NewsChannel 3 an e-mail outlining the changes and goals within the department since Mitchell’s death in August 2015:
“Since September 2015, the following steps have been taken by DBHDS to address the forensic waiting list:
- In 2015, DBHDS hired a full-time employee at Eastern State Hospital to triage individuals on the waiting list and assist transition to and from jail.
- Since fall 2015, the Eastern State Hospital Facility Director and staff review the waiting list on a weekly basis.
- In December 2015, the Extraordinary Barriers to Discharge List (EBL) was changed to include individuals on the list who are clinically ready for discharge for more than 14 days instead of 30 days.
- In fall 2015, DBHDS established a goal that all individuals ordered to a DBHDS facility for competency restoration be admitted within one week of receipt of the order. “
She added “In addition, the General Assembly adopted legislation (SB342/HB645) during the 2016 session that requires the clerk of court to provide a copy of a forensic evaluation order to the appointed evaluator or hospital and an acknowledgement of receipt from the evaluator or hospital. The General Assembly also appropriated additional funding for permanent supportive housing that will assist individuals on the EBL.”
A second investigation from the Inspector General’s office is pending. Mitchell’s family has not yet filed a lawsuit.