SC men­tal health pa­tients endure night­mare trans­ports

The Charlotte Observer (Sunday) - - Front Page - BY CARLI BROSSEAU AND ALEX LANG [email protected]­sob­server.com [email protected]­sun­news.com

It was sup­posed to be a rou­tine jour­ney in­land from the coast.

A sher­iff’s van turned onto a ru­ral high­way.

Two women, ac­cused of no crimes, were locked in a cage in the back.

The van headed north on S.C. 9 into Ni­chols, a tiny town an hour from Myr­tle Beach where wa­ter left be­hind by Hur­ri­cane Florence lapped at the road’s edge. Far­ther along, it deep­ened to cover the as­phalt.

On a washed-out sec­tion of road­way, the van plunged into flood­wa­ter. Deputies as­signed to the women’s care sur­vived by climb­ing onto the roof. Trapped in­side, the women drowned.

Like thou­sands of peo­ple in South Carolina each year, Wendy Newton and Nikki Green had been or­dered into psy­chi­atric care. It was left to law en­force­ment to drive them to health­care fa­cil­i­ties for treat­ment.

An in­ves­ti­ga­tion into the prac­tice by The News & Observer and The Sun News found that such pa­tients com­monly endure hours-long trips in hand­cuffs or cramped metal cages, even when they’ve shown no signs of

vi­o­lence.

In­ter­views with law en­force­ment of­fi­cials, med­i­cal pro­fes­sion­als, pa­tients and dis­abil­ity rights ad­vo­cates por­tray a makeshift sys­tem of care that dis­ori­ents and de­means the state’s res­i­dents when they are most in need of help.

En­snared in this largely in­vis­i­ble setup are vet­er­ans, se­niors, first re­spon­ders and a large num­ber of chil­dren.

Nearly a quar­ter of men­tal health trans­ports last year in Horry County, where deputies picked up Newton and Green, in­volved some­one un­der 18, a re­view of trip logs found. The youngest child was 8.

Al­most one in three Horry County trips took longer than two hours. Dozens of Charleston County trips last year stretched to 10 hours and be­yond.

At shift change, deputies some­times hand off pa­tients at gift shops or gas sta­tions.

Just about ev­ery­one aware of the sys­tem agrees it can be trau­ma­tiz­ing. Ad­vo­cates long have con­demned of­fi­cer trans­ports, say­ing they dis­cour­age peo­ple from seek­ing fu­ture care.

“They shouldn’t be shack­led with chains and locked in a cage,” said Sen. Mar­lon E. Kimp­son, a Charleston Demo­crat who pro­posed changes af­ter Newton and Green died in Septem­ber. “These peo­ple are on our streets, these are fam­ily mem­bers or rel­a­tives, and one day it might be us.”

Some states have be­gun re­ly­ing less on law en­force­ment and re­straints.

But in South Carolina, the high-pro­file deaths and calls to ac­tion that fol­lowed were not enough to stir law­mak­ers to de­vote money to re­form.

The bill Kimp­son in­tro­duced this win­ter passed out of the Se­nate only af­ter it was stripped of a pro­vi­sion that en­cour­aged use of un­marked sedans. It then stalled in a House com­mit­tee on which Wil­liam H. Bai­ley, an Horry County Repub­li­can with a back­ground in pub­lic safety, serves.

Linda Green, Nikki’s mother, was out­raged by law­mak­ers’ tepid re­ac­tion.

“They still want to use the van?” she asked, in­cred­u­lous.

She couldn’t be­lieve a per­son in need of care would be sub­jected, by de­fault, to such harsh treat­ment.

“It’s an ill­ness,” Green said. “It’s a dis­ease. It’s not a crime.”

‘LIKELY TO CAUSE HARM’

By the time Newton and Green met in the sher­iff’s van, each had dealt with symp­toms of schizophre­nia for decades. Nei­ther was vi­o­lent, their fam­i­lies said.

The morn­ing of Sept. 18, Green went to Wac­ca­maw Cen­ter for Men­tal Health ex­pect­ing a rou­tine coun­sel­ing ap­point­ment. Her 19-year-old daugh­ter, Rose, had driven her from their home in Myr­tle Beach to the clinic in Conway, and the two planned to go out to eat after­ward.

Rose waited in the car un­til she got a text from her mother say­ing the doc­tor was hav­ing her com­mit­ted. Hours later, she watched her mom get into the van.

The same morn­ing, Newton trav­eled from Ta­bor City, N.C., where her mother lived, to an emer­gency room in Loris. In the days since Hur­ri­cane Florence pushed ashore near her home in Shal­lotte, N.C., Newton had run low on medication, and she was ex­pe­ri­enc­ing fright­en­ing hal­lu­ci­na­tions.

Her fam­ily ar­ranged for a sher­iff’s deputy to take Newton to the hos­pi­tal, along with her 27-year-old daugh­ter, Abi­gail, for sup­port.

When Abi­gail left the hos­pi­tal around noon, her mother was med­i­cated and asleep.

South Carolina physi­cians can force some­one into psy­chi­atric treat­ment if they con­clude the per­son has a men­tal ill­ness and, as a re­sult, is “likely to cause harm” to them­selves or oth­ers if not im­me­di­ately hos­pi­tal­ized.

Self harm is de­fined broadly. The law says it can come “through ne­glect, in­abil­ity to care for him­self, or per­sonal in­jury, or oth­er­wise.”

A doc­tor’s sig­na­ture au­tho­rizes the emer­gency hos­pi­tal ad­mis­sion. Re­view from a judge comes later.

The cer­tifi­cate the doc­tor signs or­ders law en­force­ment to pick the pa­tient up, usu­ally from an emer­gency room, and de­liver the pa­tient to a fa­cil­ity with spe­cial­ized in­pa­tient care.

But the pa­per­work makes clear that there’s an ex­cep­tion: A friend or fam­ily mem­ber may trans­port the pa­tient if they’re will­ing to as­sume the re­spon­si­bil­ity and the cost. They may also hire an am­bu­lance.

In prac­tice, that rarely hap­pens, ex­perts say, largely due to con­cerns about li­a­bil­ity. Hos­pi­tals will usu­ally ask the lo­cal sher­iff’s of­fice to pick up the pa­tient.

The Green and Newton fam­i­lies said there’s no ques­tion they would have ac­cepted re­spon­si­bil­ity for the drive, if only they had been given the op­tion.

‘OVER­WHELM­ING BUR­DEN’

The ex­ec­u­tive di­rec­tor of the South Carolina Sher­iffs’ As­so­ci­a­tion has asked leg­is­la­tors for dra­matic re­form that would take a med­i­cal is­sue out of the hands of law en­force­ment.

At a Fe­bru­ary Se­nate sub­com­mit­tee meet­ing, Jar­rod Bruder de­scribed men­tal health trans­ports as “an over­whelm­ing bur­den.” Deputies statewide did be­tween 12,000 and 15,000 trans­ports last year, he es­ti­mates, based on a sur­vey that 26 of 43 sher­iff’s of­fices an­swered.

The bill Kimp­son in­tro­duced would have had each agency cre­ate a “ther­a­peu­tic trans­port unit” re­quir­ing of­fi­cers to re­ceive train­ing on how to deal with peo­ple in men­tal health cri­sis, and as of­ten as pos­si­ble, drive an un­marked car.

Bruder said short staffing and scant fund­ing at ru­ral agen­cies makes the re­forms im­pos­si­ble.

His­tor­i­cally, sher­iff’s deputies have done most of the men­tal health trans­ports be­cause of their close re­la­tion­ship to the courts, but the law man­dates trans­ports by “a state or lo­cal law en­force­ment of­fi­cer.” State agen­cies and some lo­cal po­lice de­part­ments refuse the job, Bruder told law­mak­ers.

READ: ‘We were run­ning out of time’: Tes­ti­mony re­veals how 2 women drowned in sher­iff’s van

South Carolina of­fi­cers were for­mally given the task in 1974, amid a trans­for­ma­tion of the men­tal health­care sys­tem aimed at pro­vid­ing care for pa­tients in their home com­mu­ni­ties rather than state hos­pi­tals. De­in­sti­tu­tion­al­iza­tion was sup­posed to mean less con­fine­ment for peo­ple with psy­chi­atric dis­abil­i­ties, long sub­jected to bars and cages.

But in the 1970s a ma­jor shift in gov­ern­ment fund­ing away from health and wel­fare ser­vices and into the crim­i­nal jus­tice sys­tem was ac­cel­er­at­ing, said Anne Par­sons, his­tory pro­fes­sor at UNC Greens­boro and au­thor of “From Asy­lum to Prison.”

Im­pris­on­ment be­came the de­fault re­sponse to all kinds of so­cial dis­or­der, Par­sons said, and peo­ple with men­tal ill­ness got caught in the net.

South Carolina law en­force­ment lead­ers have protested their pre­scribed trans­port du­ties for decades.

In 1996, the po­lice chief of Ridge Spring told the at­tor­ney gen­eral he wor­ried that trans­port­ing men­tal health pa­tients in hand­cuffs vi­o­lated pa­tients’ civil rights and made his agency vul­ner­a­ble to get­ting sued.

The at­tor­ney gen­eral’s of­fice com­mended Chief Richard Palmer for his con­cerns, not­ing that other de­part­ments had also raised the is­sue, but said un­less the Gen­eral Assem­bly changed the law, Palmer’s of­fi­cers had to do the trans­ports.

Rich­land County turned to the at­tor­ney gen­eral to clar­ify the law fol­low­ing a 2016 amend­ment al­low­ing trans­ports by emer­gency med­i­cal tech­ni­cians. The sher­iff ar­gued that men­tal health pa­tients should now travel by am­bu­lance, but the state came down on the county man­ager’s side: Un­less there was a spe­cial ar­range­ment, deputies still had the job.

A LONG ROAD TO HELP

The sher­iff’s van car­ry­ing Green and Newton sank in ru­ral Mar­ion County, just west of the Horry County line.

The van had picked up Green in Conway, stopped at the jail for a shift change, then went on to get Newton in Loris, some 40 miles to the north.

Green’s desti­na­tion was in Dar­ling­ton, about 65 miles to the west. Then deputies planned to take Newton to Lan­caster, some 80 miles far­ther.

Sher­iff’s of­fice records show that a jour­ney with more than one pa­tient and more than one desti­na­tion is not un­usual. Horry County deputies made al­most 50 multi-part trips last year.

Roughly a third of the county’s men­tal health trans­ports were longer than 100 miles.

When a doc­tor deems some­one in need of emer­gency in­pa­tient psy­chi­atric care, sev­eral fac­tors de­ter­mine where the per­son ends up for treat­ment, among them age, other med­i­cal con­di­tions and type of in­sur­ance.

In emer­gency rooms and com­mu­nity men­tal health cen­ters, case work­ers are tasked with find­ing an open bed. Hos­pi­tals that pro­vide psy­chi­atric care have ad­mis­sions co­or­di­na­tors to field calls from the case work­ers.

The goal is to get a pa­tient to the hos­pi­tal they pre­fer or one they have used be­fore, ideally a hos­pi­tal near their home.

But that can be dif­fi­cult, es­pe­cially if a pa­tient is unin­sured or, like Newton and Green, in­sured through Med­i­caid.

Due to fed­eral reg­u­la­tions dat­ing to the 1960s, Med­i­caid re­cip­i­ents who are not part of a man­aged care or­ga­ni­za­tion can only get in­pa­tient psy­chi­atric care in a com­mu­nity hos­pi­tal or state fa­cil­ity.

About a quar­ter of South Carolina’s in­pa­tient psy­chi­atric beds are in free­stand­ing, pri­vate psy­chi­atric fa­cil­i­ties and thereby off lim­its. In Horry County, that share is 78 per­cent.

CRI­SIS WITH­OUT CARE­TAK­ERS

South Carolina is among the hard­est places in the coun­try to get psy­chi­atric care.

A re­cent rank­ing by Men­tal Health Amer­ica, a non­profit that pro­motes early in­ter­ven­tion to ward off cri­sis sit­u­a­tions, found only Texas and Mis­sis­sippi are worse.

Ex­perts agree there are not enough men­tal health pro­fes­sion­als, es­pe­cially in ru­ral ar­eas, where hos­pi­tals have been clos­ing. Com­pound­ing the dif­fi­culty, men­tal health providers are more likely than other med­i­cal providers to de­cline in­sur­ance.

State of­fi­cials must ex­pand ser­vices de­signed to pre­vent hos­pi­tal­iza­tion as part of a re­cent le­gal set­tle­ment. Plans in­clude ex­pand­ing telepsy­chi­a­try and open­ing cri­sis sta­bi­liza­tion units across the state. They’re also try­ing to in­crease the num­ber of in­pa­tient psy­chi­atric beds at com­mu­nity hos­pi­tals by of­fer­ing to pay for them in ad­vance.

But the bud­get is bleak. South Carolina made some of the coun­try’s most dras­tic cuts to men­tal health fund­ing dur­ing the Re­ces­sion — chop­ping 39 per­cent be­tween 2008 and 2012, ac­cord­ing to a re­port by a statewide task force. And al­lo­ca­tions have been slow to re­bound.

The con­se­quences can be seen in emer­gency rooms. More and more peo­ple have been show­ing up in cri­sis, ex­perts say, and doc­tors con­sider forced psy­chi­atric care, some­times re­ferred to as in­vol­un­tary commitment, to be a pri­mary tool.

Tim Smoak, vice pres­i­dent of pa­tient ser­vices for McLeod Health, said small hos­pi­tals in the com­pany’s net­work get be­tween 30 and 60 psy­chi­atric vis­its a month on av­er­age and its re­gional hos­pi­tal in Florence gets about 300, draw­ing from the sur­round­ing ru­ral area.

Roughly 50 per­cent of those psy­chi­atric vis­its end in forced in­pa­tient treat­ment, Smoak said.

He thinks the num­bers are ris­ing “be­cause of con­cerns with lit­i­ga­tion and be­cause of the lack of re­sources for out­pa­tient providers.”

And there’s an­other con­tribut­ing fac­tor — trans­porta­tion.

“Some­body in ru­ral South Carolina that goes to an emer­gency room be­cause they’re depressed or they’re drunk or whatever and they don’t have a way,” Smoak said,

“they’re go­ing to get com­mit­ted so that then they can get a ride.”

STRIPPED OF DIG­NITY

What a South Carolina fire­fighter re­mem­bers about the process is hu­mil­i­a­tion. Walking by peo­ple he knew in the hos­pi­tal wear­ing hand­cuffs and a belly chain. Ask­ing an of­fi­cer not to hand­cuff him in front of his par­ents. See­ing his mom’s hand pressed against the win­dow of the squad car.

The News & Observer and The Sun News are not iden­ti­fy­ing him be­cause he fears his co-work­ers wouldn’t trust him if they knew about his forced psy­chi­atric treat­ment.

He traces the cri­sis that landed him in the hos­pi­tal back to his job.

The trau­matic calls stacked up. The ones in­volv­ing chil­dren par­tic­u­larly both­ered him. But he didn’t talk about it.

“There’s an area in my mind I call Pan­dora’s Box,” he said. “You just pack it all away and say it’s okay, it’s okay, it’s okay.”

He said he saw a spe­cial­ist in ther­apy for first re­spon­ders, but his in­sur­ance cut him off.

He sent a long emo­tional text to some friends that they in­ter­preted as sui­ci­dal, and they ap­pealed to a pro­bate judge to have him in­vol­un­tar­ily com­mit­ted. He ar­rived home from work to find a squad car parked in front of his house.

“I felt I lost my rights, not just a hu­man be­ing, but as a ci­ti­zen,” he said. “And I felt my dig­nity was stripped away.”

The hos­pi­tal where he was taken for an eval­u­a­tion did not give his fam­ily the op­tion to drive him to the in­pa­tient fa­cil­ity where he was re­quired to get treat­ment. So he rode an­other two hours in hand­cuffs.

RE­FORM STALLED

Kimp­son and his col­leagues on a spe­cial cor­rec­tions com­mit­tee this win­ter put for­ward a rel­a­tively mod­est pro­posal.

S. 303 would have given of­fi­cers more time to make trans­ports when con­di­tions are haz­ardous and made the law more ex­plicit about when a pa­tient can be trans­ported by a friend or fam­ily mem­ber.

The bill said trans­port­ing of­fi­cers should be part of a spe­cial­ized unit and must re­ceive “cri­sis in­ter­ven­tion train­ing.”

Since Jan­uary 2018, of­fi­cers have been re­quired to com­plete two hours of men­tal health train­ing dur­ing a three­year cy­cle as part of main­tain­ing their state cer­ti­fi­ca­tion.

Both of the sher­iff’s deputies in­volved in the deaths of Green and Newton had some men­tal health train­ing. In 2013, the year af­ter Joshua Bishop was hired, he took a two-hour “Dis­or­der Man­age­ment” class and a 15-minute class on “Trans­port­ing In­ca­pac­i­tated/Dis­abled In­mates.” Records show that in the sub­se­quent two years, Bishop took seven hours of classes on men­tal health top­ics. And in Au­gust 2018, he earned Bs in “Men­tal Health in Jails” and “Sui­cide Pre­ven­tion.”

Stephen Flood, a 10year vet­eran of the Horry County Sher­iff’s Of­fice, has a sim­i­lar train­ing record, re­ceiv­ing most of his men­tal health train­ing in 2013 and 2014. Records show his last men­tal health hours date to Novem­ber 2015.

Both deputies had sat­is­fac­tory per­for­mance re­views up un­til Oc­to­ber, when Horry County fired them, cit­ing “Giv­ing neg­li­gent or sub­stan­dard care to any pa­tient” as one of the rea­sons. They have also been in­dicted. Each faces in­vol­un­tary man­slaugh­ter charges; as the driver, Flood was charged with reck­less homi­cide.

The South Carolina chap­ter of the Na­tional Al­liance on Men­tal Ill­ness, or NAMI, teaches the 40-hour course nec­es­sary for cer­ti­fi­ca­tion as a CIT of­fi­cer, but it also of­fers two- and four-hour cour­ses, Ex­ec­u­tive Di­rec­tor Bill Lindsey said.

If law­mak­ers ex­pected trans­port of­fi­cers to take the 40-hour course, Lindsey said, it would cost $125,000 to $175,000, not in­clud­ing the ex­pense to the Depart­ment of Men­tal Health, which pro­vides some in­struc­tion, and lo­cal agen­cies, which pay of­fi­cers’ salaries while they at­tend the train­ing and have to cover those of­fi­cers’ shifts. Cour­ses cost about $ 750 per of­fi­cer for NAMI.

The over­all ev­i­dence about how well cri­sis in­ter­ven­tion train­ing works is in­con­clu­sive. It’s par­tic­u­larly un­clear whether of­fi­cers are learn­ing to be­have in ways that are less trau­matic to peo­ple be­ing forced into psy­chi­atric treat­ment, Di­nah Miller and An­nette Han­son wrote in their 2016 book “Com­mit­ted.”

Lindsey would like to see ex­pan­sion of a Charleston pro­gram that em­beds men­tal health providers with law en­force­ment of­fi­cers to other parts of the state, but law­mak­ers have de­clined to fund it.

In an in­ter­view in March, Kimp­son lamented his col­leagues’ re­luc­tance to put se­ri­ous money into men­tal health.

“The whole men­tal health is­sue,” he said, “we talk about it when there’s a shoot­ing, we talk about in the con­text of homelessne­ss, but we don’t do a

god­damn thing to ad­dress it.”

TRANS­PORT OF LAST RE­SORT

Very briefly this win­ter, a more am­bi­tious re­form idea glim­mered with pos­si­bil­ity.

Se­na­tors were in­ter­ested in cre­at­ing a re­gional trans­porta­tion ser­vice un­der the Depart­ment of Men­tal Health.

Ac­counts vary on ex­actly why the idea was buried, but ev­ery­one blames cost.

Ex­penses are cur­rently distribute­d across lo­cal gov­ern­ments and a few hos­pi­tals that of­fer their own trans­port ser­vices. If trans­ports were con­sol­i­dated un­der one state agency, the price tag would be vis­i­ble as a line item in the state bud­get.

At law­mak­ers’ re­quest, the Depart­ment of Men­tal Health started to com­pile an es­ti­mate for ex­pand­ing its se­cu­rity divi­sion. A draft doc­u­ment shows salaries for of­fi­cers of var­i­ous ranks; $ 7,600 per of­fi­cer for uni­forms, guns and re­straints; and $1.5 mil­lion for a dis­patch sys­tem. For other items, in place of a dol­lar fig­ure, there was a red ques­tion mark.

The un­knowns were mas­sive, In­terim Di­rec­tor Mark Bink­ley said. No one knows the vol­ume of trans­ports across the state be­cause there’s no cen­tral data­base. Law en­force­ment records cap­ture only part of the pic­ture, and they don’t dis­tin­guish be­tween types of in­vol­un­tary com­mit­ments, which can take place un­der sev­eral statutes, not just the one Kimp­son and his col­leagues pro­posed to al­ter.

Be­fore launch­ing an over­haul, Bink­ley would like a com­mit­tee to gather data and study what other states have done.

● North Carolina, for ex­am­ple, is try­ing to en­cour­age al­ter­na­tives through con­tract­ing. A re­cent change in state law re­quires law en­force­ment and health­care providers to co­op­er­ate in draft­ing trans­porta­tion agree­ments, which can des­ig­nate pri­vate com­pa­nies or vol­un­teers to do all or part of the trans­ports in an area.

● In Wake County, the sher­iff has con­tracted with G4S, a pri­vate se­cu­rity mega cor­po­ra­tion, to trans­port pa­tients in Dodge Charg­ers bear­ing the com­pany’s name. The county has also al­lowed UNC po­lice of­fi­cers and an­other pri­vate se­cu­rity com­pany to do some trans­ports. Wake’s trans­porta­tion plan says the gen­der of the driver or at­ten­dant must match the pa­tient’s, un­less a fam­ily mem­ber or a NAMI vol­un­teer comes along on the ride, and driv­ers and at­ten­dants must re­ceive cri­sis in­ter­ven­tion train­ing. Still, the plan re­quires pa­tients to travel in a “car or van cage” or hand­cuffs with waist chains.

● Vir­ginia just an­nounced a $ 7 mil­lion, two-year con­tract with the com­pany. G4S will or­ga­nize ser­vices re­gion­ally and use un­marked cars with un­armed driv­ers wear­ing civil­ian clothes. Un­like in North Carolina, pas­sen­gers will not be restrained. Based on the find­ings of a pi­lot project, Vir­ginia of­fi­cials ex­pect the con­trac­tor to han­dle about half of the state’s 25,000 men­tal health trans­ports. Peo­ple deemed an ac­tive dan­ger to them­selves or oth­ers would still be trans­ported by law en­force­ment.

At least one South Carolina House mem­ber, Horry County rep­re­sen­ta­tive Bai­ley, is in­ter­ested in ex­plor­ing con­tract­ing with a med­i­cal com­pany. He plans to get to­gether with other mem­bers of an in­for­mal cau­cus of first re­spon­ders to come up with a rec­om­men­da­tion.

For now, Bink­ley is in fa­vor of lim­it­ing changes to tweaks. He said he’d heard about only a hand­ful of bad in­ci­dents over 33 years work­ing in the Depart­ment of Men­tal Health le­gal of­fice.

On March 20, the chair of the depart­ment’s board, Dr. Ali­son Evans, put the idea to law­mak­ers sim­ply: “It’s worked pretty well for a long time.”

Se­na­tors seemed in­clined to agree, push­ing off ques­tions about crim­i­nal­iz­ing and trau­ma­tiz­ing men­tal health pa­tients to a yet-to-be-ap­pointed study group.

Anna Maria Darwin, a lawyer with Pro­tec­tion & Ad­vo­cacy for Peo­ple with Dis­abil­i­ties Inc., finds the con­clu­sion that the sys­tem is work­ing ap­palling.

“The whole way that this is set up crim­i­nal­izes peo­ple with men­tal ill­ness,” she said. “They’re sup­posed to be on the way to treat­ment. They’re not sup­posed to be on the way to jail or prison, and that’s a sig­nif­i­cant dif­fer­ence.”

“If we don’t make changes now,” Darwin said, “we’re just ask­ing for this to re­peat, and is it go­ing to be a child next time? Whose rel­a­tive is it go­ing to be? When? How many peo­ple have to die?”

Pro­vided by the Depart­ment of Nat­u­ral Re­sources

The Horry County Sher­iff’s Of­fice van that was driven into flood­wa­ter Sept. 18 was towed out days later. Two pa­tients died in the van.

Pro­vided by the Depart­ment of Nat­u­ral Re­sources.

Res­cue teams stand on top of a Horry County Sher­iff’s Of­fice trans­port van af­ter it was swept into flood­wa­ters on Sept. 18. Two men­tal health pa­tients drowned in the van.

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