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Extracted from Consolidated Report

This investigation was originally published as part of a larger consolidated report containing multiple investigations. View the consolidated PDF for the complete document.

Mendocino County Grand Jury • 1998-1999

Investigation of a Suicide at the Mendocino County Adult Detention Facility

4 pages
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Findings 7 findings

F1 Page 86
According to a September 1, 1996, psychiatric evaluation, supplemented by information from the mother of the decedent, he was, in general, in good physical health, but had a history of mental instability beginning at an early age, involving various diagnoses: major depression, dysthymia, oppositional defiant disorder, narcissistic personality traits, and post traumatic stress disorder. He had been hospitalized several times based on incidents of assaultive behavior, suicidal gestures, fighting with peers or adults and “creating mayhem and breaking into cottages and vandalizing campus property” (September 1, 1996 evaluation).
F2 Page 86
The evaluation also indicated that the decedent had a long history of drug use; at the age of nine he was using marijuana. He also admitted to use of LSD and psychedelic mushrooms, but, at one time, denied using cocaine, methamphetamine, inhalants or narcotics, although in a December 30, 1996, comment, he admitted to “long use” of “speed,” or methamphetamine. His major drug problem was with alcohol, involving frequent use, sometimes resulting in blackouts. Though his symptoms indicated alcoholism, he had taken part in no treatment programs for that condition.
F3 Page 86
Prior to turning 18, the decedent spent time in Juvenile Hall on a number of occasions for such activities as petty theft, shoplifting, vandalism, fighting and marijuana possession. He spent his eighteenth birthday, October 17, 1996, in that facility and transferred the following day to the Jail. His jail medical record includes entries from his stay in Juvenile Hall.
F4 Page 86
At the time he entered the Jail, he was taking psychiatric medication (Depakote) and on October 22, 1996, he saw the contract psychiatrist who said he should continue with it. Released on October 28, 1996, he was back the following month and saw the psychiatrist on November 13, 1996; the doctor repeated the Depakote recommendation. Released on November 16, 1996, he was back again in December. On booking for that period of incarceration, December 22, 1996, he had answered “yes” to the question “mental/emotional upset,” and “yes” to the question, “Do you want to talk to a mental health [sic] or a psychiatrist?” with a notation, “Bi-Polar.” On December 30, 1996, eight days after submitting a request, he saw the psychiatric technician, who recommended restarting the Depakote, which he had apparently discontinued. He saw the psychiatrist the next day and declined to begin again with the Depakote. However, he did agree to “anti- depressants,” as witnessed by the psychiatrist. The record indicates that on January 19, 1997, he had refused his last six doses of Prozac. He was released on February 26, 1997.
F5 Page 87
In May, 1997, he was in the Sonoma County Jail, transferring to the Mendocino County Jail on June 9, 1997. Upon booking at that time, he denied any mental health involvement or any desire to see a mental health worker. On June 13, 1997, he submitted a sick call slip, noting, “I would like to speak with mental health. ASAP.” That slip was picked up the following day. The psychiatric technician saw him five days later, on June 18, 1997. At that time, he said he wanted to get back on the medication, which he had stopped taking because “I didn’t think I needed them.” On June 20, 1997, he again asked, “I would like to see mental health.” His request was picked up on June 22, 1997 and the psychiatric technician saw him four days later, on June 26, 1997. He was released on July 28, 1997.
F6 Page 87
As illustrated above, there were many points at which the decedent's history and behavior indicated his unstable mental condition. Jail personnel should have been aware of the decedent's need for help.
F7 Page 88
The Medical Contractor psychiatric technician went to work early on the morning of January 23, 1998, to see the decedent and was informed that he had committed suicide

Recommendations 2