By Royal Calkins
Monterey County officials have agreed to a $2.5 million settlement in the latest in a series of jail death lawsuits, this one involving a schizophrenic inmate who died from consuming a huge amount of water after having received almost no psychiatric care for months on end.
Rafael Ramirez Lara was 57 when he essentially drowned in his own vomit after compulsively drinking an excessive amount of water. That resulted in acute water intoxication, which caused a fatal electrolyte imbalance, an autopsy by the Monterey County Coroner’s Office concluded.
- RELATED: Jail death claims since 2013
According to the federal civil rights lawsuit filed in Oakland, the jail staff and Wellpath, the private company that provides mental health services to the jail, ignored an assortment of dangerous and erratic behavior by Lara and shrugged off repeated requests by his family to provide psychiatric treatment.
On the day of Lara’s death in December 2019, a rookie deputy twice walked past Lara’s cell that was draining water into the hallway but he did nothing even though others had reported hearing repeated flushing of the cell toilet and hours of persistent coughing. According to the lawsuit, the deputy failed to actually check on Lara until 40 minutes later when he found him face down on the cell floor in a pool of fluid and blood. He was declared dead shortly later at Natividad Medical Center.
Cost of the settlement will be split between the county and Wellpath. The percentages have not been made public.
The Lara family’s attorney is Lori Rifkin, a former U.S. Department of Justice civil rights lawyer. This is the fifth successful federal lawsuit she has filed over preventable deaths at the Monterey County Jail, which since 2015 has been under federal judicial order to dramatically improve the general care and health care provided to inmates.
Defendants in the Lara case include the county, Sheriff Steve Bernal, former jail chief James Bass, acting Undersheriff John Thornburg, sheriff’s Cmdr. Ray Tongol, Wellpath, several Wellpath executives, and the company’s regional director, registered nurse Christina Kaupp.
Wellpath, based in Nashville, Tenn., is the nation’s largest provider of medical care to jail and prison inmates. Kaupp apparently remains a Wellpath employee but was recently moved out of the county pending investigation into allegations she stole pain medications from her employer and passed them to sheriff’s Cmdr. Dustin Hedberg, who is on leave while facing possible termination.
Sheriff’s Capt. Joe Moses, who is in charge of the jail, was not a defendant but his deposition was taken. Moses is currently a candidate for sheriff and has promised to improve jail conditions, especially mental health care, but he has said little about how he would actually bring about change. Court papers show that Moses participated in Sheriff’s Office inquiries that concluded the sheriff’s staff had treated Lara appropriately and had followed all pertinent procedures.
In the lawsuit, Rifkin emphasizes that a federal court found seven years ago that Monterey County was “deliberately indifferent” to the medical and mental health needs of the inmates. That resulted in a settlement agreement in the case of Hernandez v. County of Monterey, in which the county accepted federal oversight and promised significant improvements. That has not occurred, Rifkin alleges. However, Sheriff Bernal and other sheriff’s officials have routinely cited the requirements of the Hernandez ruling as an excuse for overall understaffing and slow response times. In other words, that the Hernandez agreement consumes an inordinate amount of resources. Even when the requirements of Hernandez are being ignored, as Rifkin contends.
The lawsuit alleges that despite lofty verbiage, county officials have largely ignored the Hernandez settlement as well as criticisms of jail practices by the Monterey County grand jury and previous studies documenting inadequate care and ignorance of stated policy.
“There is no indication,” Rifkin wrote in the lawsuit, “ … that provision of health care in the jail now meets even minimum standards of care, or that the deficiencies specifically identified in (the Hernandez class action litigation) have been adequately addressed.”
Lara’s family, two daughters and a son, say they pressed the lawsuit because the death made no sense. Daughter Patty said she was first told that her father might have died of a heart attack.
The siblings said they last saw him the last time he was arrested. They said he had been acting irrationally and was paranoid, expressing unfounded fear that his family was in danger.
“His sense of reality was definitely distorted,” said son Ralph. At first, he said, the family was somewhat relieved because he had been unhoused and had not been receiving any treatment. They said they hoped that being in jail would keep him safe while he received the help he needed.
“They said there are people who will help him,” said Patty, “and I said OK, we’re going to trust them.”
County officials have not provided clear explanations of why substandard conditions are tolerated in the jail but it clearly comes down to training, money, staffing and attitude. It isn’t known whether the county has ever calculated the cost of continued litigation versus the cost of providing proper care. If it has, inmate health seems to have been given slight weight in the equation, based on the evidence in the Lara case and others.
Rifkin, the lawyer, said in an interview that the problem in Monterey County is that the sheriff’s administration simply doesn’t care about the health and welfare of its inmates. To fix the problem, she said, “I would ask for a clean house in the administration. They need a complete culture change from top to bottom.”
“They need new leadership,” she continued. “The captains, the commanders, they all need to be changed.”
She said she would urge the county to stop using for-profit medical care contractors such as Wellpath and start using the county government’s existing health care system to serve the jail. The county employs a complete slate of physicians, nurses and other medical professionals at Natividad, just blocks from the jail.
“I personally have no desire to bring any more lawsuits in Monterey because it’s so disheartening to think that nobody cares, that this is just happening over and over again,” the lawyer said.
Rifkin, who first sued the Sheriff’s Office in 2013, said there was a considerably better attitude at the start of the decade when Scott Miller was sheriff.
“He tried to do some things, but it’s very clear that he faced bitter resistance from the leadership of the jail.” After one term, Miller was replaced by Bernal.
About Wellpath, Rifkin said, “It’s not a secret that they provide terrible care.”
Wellpath has been on a rapid growth path in recent years to become the largest provider of inmate medical care in U.S. jails and prisons despite lawsuit after lawsuit alleging instances of inadequate care, especially for mentally ill or suicidal inmates. It contracts with most California counties.
For three decades, Monterey County contracted with another controversial medical provider, California Forensic Medical Group, whose founder, psychiatrist Taylor Fithian, was a regular and generous contributor to the campaigns of Monterey County sheriffs and supervisors. Three years ago, Fithian’s company was absorbed by Wellpath and became part of an ambitious expansion that has put the company into significant debt. Fithian is a principal in Wellpath and remains involved in care decisions locally.
Since shortly before Lara’s death, Wellpath has been owned by H.I.G. Capital, a private hedge fund that is not required to disclose most of its financial information. Often, despite concerns about the company’s performance, it is the only bidder when counties accept proposals for jail health care services. Sometimes, its contract spells out a fixed amount the company is to be paid for each inmate and the company is required to cover the actual cost of services, creating a disincentive to provide care beyond the routine. (Voices submitted a public records act request for a copy of Monterey County’s contract with Wellpath but it has not been provided.)
The chronology of Lara’s decline and death follows a path increasingly familiar in jails across the country.
The details below come mostly from the lawsuit and related paperwork.
Lara was a Spanish speaker, a farmworker with a rudimentary understanding of English. Most of his survivors live in Gonzales. He was arrested initially for a carjacking that amounted to more of a misunderstanding and was jailed a total of three times between April 2018 and his death in December 2019.
In all, he was incarcerated for eight months in 2018 and 2019. The jail staff knew him well but provided him with no psychiatric care.
In June 2018, Lara repeatedly hit his head against his cell wall and broke his right hand by punching a window. He was taken to Natividad Medical Center where he told the staff that he had been hearing voices telling him his family was in danger. His behavior was officially noted as “bizarre” and he was prescribed Haldol, an anti-psychotic medication.
His condition improved until he was returned to the jail and his Haldol prescription ran out. Under jail protocols, he should have been seen by a psychiatrist but was not. Under the Hernandez settlement, his prescription likely should have been continued.
Unmedicated, Lara told deputies that he planned to grab a deputy’s gun in order to shoot himself. He said he was again hearing voices and was put on suicide watch for one day. He then remained unmedicated for two weeks until being released from jail.
He was arrested again a year later. He had been sleeping in a park because he didn’t feel safe at home. He called police twice to say he feared his ex-wife and children were in danger. His relatives reported that he was paranoid or otherwise ill.
He showed up at the family home on Aug. 31, 2019.
“His clothes were dirty and torn,” the complaint says. “He surveyed the entire home one room at a time in a panic and asked his family repeatedly if they were okay.”
The family tried to calm him down and clean him up but he refused. They prepared a meal and filled a backpack with fresh clothes but he left without either.
The family called Gonzales police to have him placed on a three-day psychiatric hold but he was arrested first and returned to the county jail.
The lawsuit alleges that the jail staff conducted an intake health screening but in English, violating the Hernandez settlement. And despite his well-documented history of schizophrenia, delusions, suicidal thoughts and Haldol treatment, the jail staff did not refer him to mental health specialists. He told the staff that he had a history of alcohol abuse and had drank that day, but he was not referred to detoxification treatment as jail regulations required.
One of Lara’s daughters, Patty Ramirez, later called the jail to report his behavior and request a mental evaluation.
“Jail staff advised Ms. Ramirez to the effect of ‘Mr. Lara can seek help if he wants’,” the lawsuit alleges. She replied that he needed help immediately.
On Sept. 5, a jail therapist talked to Lara through the bars of his cell. Lara reportedly told the therapist he had no family and didn’t want to say any more. The same thing happened a week later.
“Despite Mr. Lara’s unusual behavior, the information from Mr. Lara’s family and the jail’s own records indicating that Mr. Lara had a history of schizophrenia, including auditory hallucinations, paranoia, delusions and self-harm, for which he required medication, jail staff still did not refer Mr. Lara for further mental health evaluations or even see him in a confidential setting. Rather, they left him without any further mental health contact, intervention or medication for the next 30 days,” the lawsuit says.
He was next seen by a social worker, who stood outside the cell, on Oct. 12, 2019. The social worker described him as paranoid and said he wouldn’t leave the cell. He was not referred to mental health services.
Two weeks later Lara got into an altercation with his cellmate who, he believed, had raped him in his sleep. With “blood all over his face and clothing,” he was taken to the jail infirmary and then to Natividad. Hospital records said he had a “significant past medical history of paranoid schizophrenia” for which he was not being treated.
Back in jail a day later, he received no therapy and the staff failed to perform a mandatory rape investigation.
On Oct. 25, 2019, a jail nurse reported that Lara was nonverbal, had a blank stare and was unable to follow directions. A deputy instructed him to leave the cell for a neurological assessment but Lara refused to move.
Jail records from two days later indicate that he would not eat or accept medical attention. The next day, a therapist spoke to him through a Spanish-speaking deputy. The therapist reported that Lara said everything was fine, that he was eating and taking medication, though he was not.
On Dec. 1, a therapist interviewed Lara in a private space outside the J-Pod cellblock. The therapist reported that Lara seemed to be confused, either because of psychosis, language barrier or an intellectual disability. Finally, 90 days after being jailed, he was referred to a Natividad psychiatrist, Dr. Paul Francisco, who reported only that Lara had refused to meet with him. Without any obvious effort to assess the inmate, Francisco simply reported that the Dec. 2 appointment had been “completed.”
According to the lawsuit, that was the last time the jail mental health staff attempted to make contact with Lara.
In the week before his death, he stopped leaving the cell for scheduled recreation periods. The morning before his death witnesses heard Lara repeatedly flushing his toilet and then they reported water flowing from the cell.
As part of his rounds, rookie jail deputy J. Tejada passed by Lara’s cell twice, spotted unexplained pools of water but failed to investigate. Instead, according to one witness, he “just looked at the water, stepped over it, then moved on.”
Forty minutes later after the second so-called welfare check,, Tejada found Lara face down and unresponsive on the wet floor. He summoned help. Other jail staffers performed chest compressions on Lara, to no effect.
As with all jail deaths, the Sheriff’s Office conducted various investigations. Tejada reportedly wasn’t questioned and the Internal Affairs investigation found no violations.
The autopsy determined that Lara had died of hyponatremia due to acute water intoxication stemming from psychogenic polydipsia due to schizophrenia. In other words, the schizophrenia caused him to compulsively drink water, which ultimately led to hyponatremia, a condition where a person’s sodium level becomes abnormally low and which can be fatal.
That was the conclusion of a pathologist working for the Monterey County Coroner’s Office, a division of the Monterey County Sheriff’s Office. According to Rifkin, the autopsy didn’t lead to any curiosity with the office.
The cause of death hardly squares with what Rifkin wrote in court papers regarding how “high-level county and Wellpath officials responsible for treatment of people incarcerated in the jail … personally ratified the actions of county and Wellpath employees with respect to Mr. Lara as within policy and procedure through their subsequent reviews of his death, including a mortality review, quality assurance review, MCSO detectives’ bureau investigation and MCSO internal affairs investigation.”
The lawsuit concludes, “Mr. Lara died as a result of defendants’ failures to adequately treat his known mental health condition to respond to his urgent need for medical intervention prior to his death.
“His death was foreseeable and preventable and resulted from defendants’ failures to meet their Constitutional obligations to treat him and protect him from harm.”
Have something to say about this story? Send us a letter or leave a comment below.