2015-2016 Santa Clara County Civil Grand Jury Report Addressing Mental Illness in Santa Clara County Jails

Conclusions 16

• CL1 Page 19
  Custody Bureau policies and procedures are out of date.
• CL2 Page 19
  Interim changes to existing Custody Bureau policies and procedures are not explicitly tied to the policies and procedures they affect.
• CL3 Page 20
  Current staffing levels necessitate that correctional deputies typically work alone in a housing unit. This makes it extremely difficult, if not impossible, for the correctional deputies to fulfill their duties and responsibilities.
• CL4 Page 20
  Supervision of correctional deputies on the housing floors is inadequate. There are not enough sergeants to provide sufficient coaching, support, and remediation where needed. Watch commanders are not on site at all times.
• CL5 Page 20
  The number of mental health clinicians is insufficient to adequately address the needs of mentally ill inmates in the jails.
• CL6 Page 21
  There is a need for improvement at all management levels of Custody Health Services.
• CL7 Page 21
  Custody Health Services is unable to facilitate a “warm handoff” of mentally ill inmates to community providers upon release from jail.
• CL8 Page 21
  Implementation of multi-disciplinary teams approved by the Board of Supervisors has been poorly executed, and the proposed benefits have not been realized.
• CL9 Page 21
  There is significant opportunity to enhance the quality and training methods of Custody Academy courses that deal with mentally ill inmates.
• CL10 Page 22
  While the Custody Bureau has expanded its curriculum to include Crisis Intervention Team training, some of that training is not relevant to the custody environment.
• CL11 Page 22
  There is no content specific to dealing with mentally ill inmates in the Probationary On-the-Job Training manual.
• CL12 Page 18
  The unfortunate truth about the County jails is that they have become jail/prison hybrids and warehouses for the mentally ill. As the state initiatives that led to these changes took place, the County Board of Supervisors, the Sheriff’s Office Custody Bureau/Department of Correction, and the Santa Clara Valley Health & Hospital System were dealing with dwindling budgets. They have had difficulty expanding services to meet the needs of the increasing mentally ill population in the jails. The Board, Custody Bureau, CHS, and BHS are now in reactive mode. Changes are being made, but the Grand Jury was unable to identify overall plans or priorities. Consultants hired by the County may make some valid recommendations for improvement; however, successful implementation of any changes will require priority setting, comprehensive planning, funding, good
• CL13 Page 19
  communication, and accountability. Sustained commitment and collaboration are essential among the Board of Supervisors, the Sheriff, and the Director of Santa Clara Valley Health & Hospital System. The Grand Jury observed that the vast majority of Custody Bureau, Custody Health Services, and Behavioral Health Services personnel are sincere and professional. They are doing their best to perform a difficult job during this very challenging time. The lack of supervision and observation by superiors could have contributed to the situation that resulted in Michael Tyree’s death. The difficult nature of the job, long hours, insufficient staffing levels, and limited training of Custody Bureau personnel in dealing with mentally ill inmates may have contributed as well. The Grand Jury found some key issues that should be addressed in the areas of training, use of force, and treatment for mentally ill inmates. Findings and Recommendations Finding 1 Custody Bureau policies and procedures are out of date. Recommendation 1 The Office of the Sheriff should assign personnel whose sole responsibility is to update and maintain all Custody Bureau policies and procedures with priority given to the Medical and Health Care Services chapter and the Security and Control chapter. Finding 2 Interim changes to existing Custody Bureau policies and procedures are not explicitly tied to the policies and procedures they affect. Recommendation 2 The Office of the Sheriff should use a document control method to ensure any interim changes to existing policies and procedures are explicitly tied to the policies and procedures they affect.
• CL14 Page 20
  Finding 3 Current staffing levels necessitate that correctional deputies typically work alone in a housing unit. This makes it extremely difficult, if not impossible, for the correctional deputies to fulfill their duties and responsibilities. Recommendation 3 The Office of the Sheriff should increase staffing levels so that at least two correctional deputies are assigned to each housing unit on all shifts to manage the workload, reduce stress, increase security and safety, and allow correctional deputies more flexibility in dealing with the behavior and needs of all inmates, including those with mental health issues. Finding 4 Supervision of correctional deputies on the housing floors is inadequate. There are not enough sergeants to provide sufficient coaching, support, and remediation where needed. Watch commanders are not on site at all times. Recommendation 4a The Office of the Sheriff should increase the number of sergeants on each shift to one sergeant per housing floor in Main Jail and comparable supervision levels at the Elmwood facilities. Recommendation 4b The Office of the Sheriff should have a watch commander (lieutenant or above) at both Main Jail and Elmwood at all times. Finding 5 The number of mental health clinicians is insufficient to adequately address the needs of mentally ill inmates in the jails. Recommendation 5 The Santa Clara Valley Health & Hospital System should increase clinician staffing levels in the jails to improve the level of support counseling, therapy, and advocacy for mentally ill inmates.
• CL15 Page 21
  Finding 6 There is a need for improvement at all management levels of Custody Health Services. Recommendation 6 The Santa Clara County Board of Supervisors should commission a thorough independent audit of the Custody Health Services organization to ensure best management practices are identified and employed. Finding 7 Custody Health Services is unable to facilitate a “warm handoff” of mentally ill inmates to community providers upon release from jail. Recommendation 7 Custody Health Services should develop a process to ensure discharge planning begins upon incarceration and leads to a “warm handoff” to community support services at time of release. Finding 8 Implementation of multi-disciplinary teams approved by the Board of Supervisors has been poorly executed, and the proposed benefits have not been realized. Recommendation 8 The Board of Supervisors should appoint a project manager to oversee the implementation of the multi-disciplinary teams to ensure their anticipated benefits are fully realized. Finding 9 There is significant opportunity to enhance the quality and training methods of Custody Academy courses that deal with mentally ill inmates. Recommendation 9a The Office of the Sheriff should increase the use of scripted scenarios and role- playing in Custody Academy courses on mental health to develop and practice de- escalation and critical thinking skills.
• CL16 Page 22
  Recommendation 9b The Office of the Sheriff should have mental health classes at the Custody Academy audited for effectiveness annually by subject matter experts and teaching professionals. Finding 10 While the Custody Bureau has expanded its curriculum to include Crisis Intervention Team training, some of that training is not relevant to the custody environment. Recommendation 10 The Office of the Sheriff should develop or select a custody-centric Crisis Intervention Team training program for the Custody Bureau by December 31, 2016, for immediate implementation. Finding 11 There is no content specific to dealing with mentally ill inmates in the Probationary On-the-Job Training manual. Recommendation 11 The Office of the Sheriff should add content on dealing with mentally ill inmates to the Probationary On-the-Job Training manual. Evaluation criteria should include interaction with mentally ill inmates and those with developmental disabilities, de- escalation techniques, and appropriate use of force.

No Responses Found 2

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