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The Untold Stories of Jail Deaths in Washington, Columbia Legal Services, 2019

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GONE BUT NOT FORGOTTEN
The Untold Stories of Jail Deaths
in Washington

May 2019

Columbia Legal Services advocates for laws that advance social, economic,
and racial equity for people living in poverty. www.columbialegal.org

For more information about this report, please contact:
Nick Straley
101 Yesler Way, Suite 300
Seattle, WA 98104
(206) 464-1122 Ext. 144
nick.straley@columbialegal.org
Or visit:
https://columbialegal.org/policy_reforms/gone-but-not-forgotten/

www.columbialegal.org
/ColumbiaLegalServices

@columbialegal

/columbialegal

Dedication
This report is dedicated to the men and women who have died in Washington’s jails and
the family and friends who continue to grieve for them.
It contains graphic descriptions of terrible suffering and death. It includes statistics and
numbers that chronicle those deaths in arithmetical terms. We have struggled with how to
present this information in an informative and compelling way that also properly respects
the real men and women who died while in custody. They were too often people whom
society had ignored and thrown away, people fighting addiction, homelessness, mental
illness, ill health, and poverty.
Yet each was also a husband, wife, father, mother, son, daughter, brother, sister, aunt
or uncle, who ended up behind bars. Each of their lives was unique and special, but
collectively their deaths demonstrate serious flaws in our carceral system: A punitive and
inequitable model that holds people who have not been convicted of any crime simply
because they cannot afford bail; a model that condemns people fighting mental illness
and cognitive disabilities to serve days, weeks, or months for behaviors associated with
their disabilities; a model compounded by chronically inadequate health care both in the
community and in jails; a model that only provides housing to people when they finally end
up behind bars; and a model deeply infected with systemic racism and classism. We hope
that we honor the people whose lives were lost by shining a light on the institutions and
systems that led to their deaths.

Acknowledgements
The authors would like to acknowledge the tremendous efforts of so many people who
assisted in researching, writing and publishing this report. They include Emina Dacic,
Pamela Lyons, Maddie Flood, and Alexa Sinclair, who spent countless hours reviewing
records and chronicling the terrible facts that those records memorialize. Alex Bergstrom
assisted with research and drafting of the report, particularly sections related to suicides
in jail. His help was essential. Staff at Columbia Legal Services, Maureen Janega, Maria
Quintero, Odile Valenzuela, Julia Bladin, and Charlie McAteer all played vital roles in making
sure that the report was grounded in fact, well written, and visually compelling. Adriana
Hernandez particularly went above and beyond the call of duty by accommodating last
minute changes and transforming half-baked ideas into readable text and persuasive
charts. Other Columbia Legal Services staff, including Nick Allen, Kim Gunning, Hillary
Madsen, Janet Chung, and Merf Ehman reviewed drafts, provided invaluable edits, and
encouragement. Rachael Seevers and Disability Rights Washington provided pictures and
access to other essential materials. Any errors are the authors’ alone.

Table of Contents
EXECUTIVE SUMMARY ........................................................................................................................1
LACK OF TRANSPARENCY LIMITS AVAILABLE INFORMATION ON JAIL DEATHS AND
KEEPS MAJOR PROBLEMS HIDDEN FROM VIEW........................................................................4
INFORMATION ABOUT WASHINGTON’S JAILS AND THE PEOPLE LOCKED UP INSIDE
THEM .........................................................................................................................................................5
	
Demographics of the people locked up in Washington’s jails.....................................................5
	
Demographics of people who died in Washington’s jails.............................................................6
SUICIDE ....................................................................................................................................................8
	
General Risk Factors.......................................................................................................................9
	
Individual Risk Factors..................................................................................................................10
OVERDOSE AND WITHDRAWAL ......................................................................................................13
	Overdose........................................................................................................................................13
	Withdrawal.....................................................................................................................................15
	
Other Serious Medical Conditions Left Untreated.......................................................................17
USE OF FORCE AND NEGLECT .......................................................................................................18
RECOMMENDATIONS .........................................................................................................................21
Reduce the number of people living with mental illness or substance use disorders in jails..22
Increase oversight and transparency of what happens inside jails............................................22
Every jail must have an adequate and timely medical, mental health, and substance use
intake process..........................................................................................................................22
Every jail must have overdose and withdrawal protocols and provide medications when
appropriate...............................................................................................................................23
Jails must change how they care for people who have expressed suicidal thoughts or may be
actively suicidal........................................................................................................................23
Staff must be trained to manage people in crises, utilize effective de-escalation techniques,
and use force only when absolutely necessary......................................................................24
Each jail must have enough staff to ensure that all people receive appropriate supervision
and care....................................................................................................................................25
Every jail should be required to engage in a full serious incident administrative review and
provide that report to appropriate third parties.....................................................................26
CONCLUSION .......................................................................................................................................26

Executive Summary
Only 22 years-old, Lindsay Kronberger,
a four-sport athlete while in high school,
battled drug addiction and ended up in
jail, booked into the Snohomish County
jail on January 3, 2014.1 Upon booking,
she admitted to having recently taken
heroin and that she was feeling the
early stages of withdrawal. Over the
next several days, Lindsay suffered
terribly from severe nausea, vomiting
and diarrhea.
Weighing only 95 pounds at booking
and appearing “emaciated,” Lindsay
proceeded to lose another eight pounds
Source: https://www.seattlepi.com/local/crime/article/Claim-Jailers-mocked-dyingyoung-woman-during-9121704.php
while locked up. Medical professionals
in the jail noted that her blood pressure
fluctuated dramatically during the nine days she spent there. Desperate because of the severity of
her symptoms, she begged to be taken to the hospital, but reports indicate that the jail’s staff did
not feel it was necessary and so she remained in the Snohomish County jail. At one point, Lindsay
was so weak that she was not able to walk even a few feet from her cell. A federal judge would later
note that “more intensive therapies could have been initiated to improve her hydration and reverse
the deadly spiral of vomiting and diarrhea that resulted in severe dehydration and electrolyte
imbalance.”2 Nine days after being booked into jail, Lindsay was found face down in her cell’s toilet dead from dehydration-triggered cardiac arrest.
Lindsay’s untimely death is unfortunately not an isolated incident. Every day many people suffering
like her are booked into jails throughout Washington. Some, like Lindsay, die there. Many of
these deaths are entirely avoidable, caused in part by society’s failure to properly care for the
many people with mental illness, traumatic brain injuries, cognitive disabilities, and substance
use disorders who end up behind bars. Faced with the chronic failure of federal, state, and local
governments to properly fund essential services, jails struggle to maintain order and treat all people
humanely, respectfully, and safely.
On any given night, roughly 12,500 men and women sleep behind the walls of county and local jails
in Washington. Most of them have not been convicted of a crime and are there simply because they
cannot afford the bail that a court has set.3 Those who have been convicted are generally serving
short sentences for low-level crimes or minor probation violations. The majority are indigent, and
many battle substance use disorders and symptoms of severe mental illness, traumatic brain
injuries or cognitive disabilities.4 Others come to jail suffering from complicated, chronic, and poorly
managed medical conditions, such as diabetes, coronary heart disease, high blood pressure, and
asthma. People locked up in jails are our friends and family members. Over half of all adults in the
United States have an immediate family member who has been incarcerated.5
Gone But Not Forgotten

1

Unfortunately, society has abdicated its responsibility to provide humane, cost-effective, communitybased housing and treatment services for people with serious medical, mental, and behavioral
health needs. Instead we spend millions of dollars a year warehousing people in our jails institutions ill-equipped to provide appropriate and adequate care.6 Far too many die behind bars as
a result.

Jails operate without public transparency or outside
supervision. As a result, policy makers and the public are
largely unaware of the true costs of incarceration.
Jail deaths are merely the most egregious examples of the systemic failures that injure thousands
of people locked up in Washington every year. The misdirection of resources to Washington’s
jails and away from other more effective and humane, community-based alternatives has caused
unnecessary suffering and death. In this report we review deaths in Washington jails in the hope of
spurring reform to ensure that no person needlessly dies behind bars.
Locking people up in jail is not cheap. Washington counties and localities spend hundreds of
millions of dollars a year holding people in
jail. King County will spend over $320 million
Each year Spokane County spends
in the next two years to operate its jails.7
$43,000 per detainee. By contrast,
Spokane County spends over $43,000 per
8
detainee per year in its jails. By comparison,
the Spokane Public Schools spends
Spokane Public Schools spends under
under $11,700 per student.
$12,000 per student each year.9
Moreover, the allocation of millions of dollars to jails is not effective, as medical and mental health
care remain seriously deficient in many jails.10 As Disability Rights Washington has noted: “while
mental health treatment may prevent inmate deterioration and enhance protection from self-harm
and suicidal or homicidal ideation, jails are ill-equipped to respond appropriately to the needs of
individuals with mental illness seeking mental treatment.”11
This report takes a deep look at available information regarding deaths that occurred in Washington
jails between January 2005 and June 2016.12 On average, 17 people died every year while locked
up during this period. Though a small percentage of the total population, these events highlight
larger issues within the jail system, as many other people suffer severe non-deadly harms as a
result of our carceral system.
Our analysis of the available data on jail deaths reveals the following:
• Most jail deaths occur within the first days following booking.
• Drugs or alcohol played a significant role in many of the deaths, and these deaths are by and
large avoidable.
• Few jails appear to have effective policies and practices in place to avoid deaths caused by
overdose or withdrawal from drugs or alcohol.

Gone But Not Forgotten

2

•	 Suicide, particularly suicide by hanging, makes up a large percentage of deaths, and current
practices in many jails may be increasing the likelihood of suicide.
•	 Use of force or neglect by jail officers played a contributing role in a significant number of
deaths.
People will continue to needlessly die in jails until adequate resources are put into cheaper,
community-based programs and treatment. A few relatively inexpensive reforms can reduce or
eliminate deaths in Washington’s jails. These reforms include:
1.	 Reducing the number of people living with mental illness, cognitive disabilities, or substance
use disorders in jails by increasing diversion programs, eliminating the use of cash bail, and
improving community-based treatment and housing options.
2.	 Increasing oversight and transparency by establishing reporting requirements and
introducing statewide standards and monitoring of jails.
3.	 Implementing an adequate and timely medical, mental health, and substance use intake
process in every jail that includes a thorough health examination of each person detained for
more than a few days.
4.	 Using evidence-based overdose and withdrawal protocols in every jail that include
appropriate medications and other vital medical, mental health, and substance use disorder
interventions.
5.	 Instituting comprehensive suicide prevention policies and practices that treat all people with
dignity and eliminate isolation as a method of responding to people who threaten suicide.
6.	 Training all staff on how to manage people in crisis, utilize effective de-escalation
techniques, and only use force when absolutely necessary.
7.	 Providing sufficient financial resources to ensure that all jails employ enough staff to properly
supervise and care for every person locked behind bars.
8.	 Requiring that every jail perform a comprehensive and detailed, serious incident
administrative review and prepare a written report which is shared with the Washington
State Department of Health or another appropriate agency and the public.
Implementing these relatively few reforms will dramatically reduce the number of people injured,
disabled, or killed in our jails.

Gone But Not Forgotten

3

Lack of Transparency Limits Available Information on Jail
Deaths and Keeps Major Problems Hidden from View
Washington is one of 17 states that lack any
type of state oversight of jail operations or
conditions.13 Though jails house thousands
of people every year and have become the
primary health care provider for many
Washingtonians, local governments have no
obligation to provide information to any state
agency or the public regarding conditions
within their jails. Information that jails
voluntarily provide to the federal government
and the Washington Association of Sheriffs
and Police Chiefs (WASPC) is extremely narrow
in scope and divulges very little about what
is actually happening behind jail walls.14
The information in this report comes from a
review of documents we received from jails
regarding any person who died while in custody
between January 1, 2005, and June 15, 2016.
We received thousands of pages of documents
from 54 jails based on our Public Records Act
requests to each of the 59 county, local, and
joint-jurisdictional jails in Washington. While
many jails provided significant documentation,
several jails provided nothing or very little
documentation. We supplemented the review
of jail-provided documents with WASPC and
federally published data, media reports, and
other publicly available information to gain
as complete a picture of each death as
possible. However, in a number of cases we
had difficulty determining the facts because
of limited disclosures and severely redacted
documents.
State law protects jails from having to
disclose dangerous conditions or serious
events to state government or the public.
RCW 70.48.100 contains a broad exemption
from Washington’s otherwise expansive
Public Records Act. This provision generally
bans disclosure of “records of a person
Gone But Not Forgotten

confined in a jail” to all parties but law
enforcement.15
As we discovered during the investigation for
this report, jails interpret the bounds of this
exemption differently. A number refused to
provide any information at all - not even the
names of people who died in their custody.
Others provided basic information regarding
the death itself, but withheld information
regarding contributing factors that may have
played a role in the death.
Illustration 1, below, is an example of the
heavily redacted documents that counties
and cities typically provided in response to our
Public Records Act requests.
Undoubtedly, it is important to protect the
confidentiality of some jail records. However,
a legitimate need to maintain the privacy of
detainees should not allow jails to keep bad
practices and unfortunate events hidden from
view. Absent legislative changes to mandate
some level of oversight and reporting, jails will
continue to operate without transparency or
real accountability.16
Illustration 1

Photo Credit: Alex Bergstrom

4

Information about Washington’s Jails and the People
Locked Up Inside Them
There are 59 county, local, and jointjurisdictional jails in Washington. Combined,
these jails are designed to hold 14,819
people.17 The number of people locked up in
each jail differs dramatically, from a reported
average of seven people per night in the Oak
Harbor city jail to almost 2,000 people per
night in the two King County jails. The top five
largest jails in Washington house roughly half
of all people detained in the state, while the
44 smallest jails hold less than a quarter of all
people.
The cost to incarcerate people also varies by
jurisdiction, from a low average daily bed rate
of $31 per night per detainee in Adams County
to more than $100 per night in a number of
larger jails.20 In 2017, Snohomish County spent
almost $92,000 a day to keep people locked
up every night inside its jail.21

In total, Washington jails
are designed to hold
almost 15,000 people.
Between 12,000 and 12,500
people sleep in jail on an
average night, meaning
that Washington has at
least 2,500 more jail beds
than it currently needs.18
Nonetheless, some jails are
significantly overcrowded,
including Clark, Spokane, and
Whatcom County jails.19

Demographics of the people locked up in Washington’s jails.
The gender, racial, and ethnic
breakdown of people held in
jail between 2007 to 2015
is set out in Figure 1. Men
made up more than 85% of
the jail population during
that period.22 People of color
are also disproportionately
represented in Washington’s
jails. Black Washingtonians
are just over 4% of the state
population, but represent
16% of people incarcerated
in our jails. Similarly, Native
Americans make up less than
2% of the state population, but
4.5% of people in jail.

Gone But Not Forgotten

Figure 1: People in Washington’s jails

5

The average jail stay is 16 days, but most
people booked into jails stay for only a few
days - 40% for fewer than 24 hours. However,
many people remain in jail for months or even
years.24
People entering into jail tend to have more
significant behavioral health needs than the
general public.25 One study indicates that as
many as 60% of people entering Washington
jails may have either a substance use disorder
or a mental health need, and over 40% have
co-occurring disorder indicators.26 These local
numbers are similar to national averages.27

Demographics of people who
died in Washington’s jails.
We reviewed records of 210 people who
died while in the custody of Washington
jails between January 1, 2005, and June
15, 2016.34 The gender and racial or ethnic
breakdown of the people who died is set out in
Figure 2.

Figure 2: People who died in
Washington’s jails

In addition, many people arrive with other
complicated and poorly managed medical
needs. People detained in jails are nearly
two times more likely than the general public
to experience high blood pressure, asthma,
or diabetes.28 Nationally, over half of jail
detainees report having experienced a
chronic medical or mental health condition at
some point in their lives, and three-quarters
were experiencing that condition upon
admission to jail.29 The incidence of chronic
conditions is greater among women than
men.30 Not surprisingly, the older the person,
the more likely she will suffer from a chronic
medical condition.31 Moreover, the rates of
chronic medical conditions among people
in jail are increasing at a dramatic clip.32
Available data indicate that local conditions
reflect these national trends.33
Roughly two thirds of people sitting in
Washington jails are awaiting trial, none of
whom have been found guilty of the crime with
which they have been charged. Most languish
there because they cannot afford the cash bail
that courts routinely require. The remaining
one-third of people in jail are serving lowlevel, mostly misdemeanor sentences of less
than a year or are being held for short stays
for violations of Department of Corrections
community custody conditions.

Gone But Not Forgotten

6

The ages of people who died ranged
from the youngest, who was 18, to an
82-year-old man. The average age of
people who died was 40.
Most deaths occurred within days
of booking. Over 72% of all deaths
occurred within 14 days, and most
occurred within the first seven days.36
The numbers are particularly stark for
women. 82% of all women who died
did so within 14 days of booking, with
73% dying in the first seven days. See
Figure 3.

Figure 3: Length of stay before deaths
Died within 14 days of admission

All deaths

Men

Women

The vast majority of early deaths involved alcohol,
drugs, or suicide. Substance use-related deaths
and suicides made up 85% of the deaths that
occurred within the first 72 hours of admission.37
Figure 4 identifies the number and percentage of
deaths that involved drugs or alcohol within the
first week and after eight days.

Died within 7 days of admission
72%
61%
64%
58%
82%
73%

Figure 4: Deaths related to
drugs or alcohol by time period

Charge or conviction38
47% of the men who died were charged or
convicted of a violent offense, including domestic
violence, while 62% of women were charged or
serving a sentence for a property, driving, or drug
crime or were serving time on an outstanding
warrant or DOC violation.

Figure 5: Type of charge

Gone But Not Forgotten

7

Cause of death

Figure 6: Cause of death

Percentage
Percentage Percentage
Suicide is the
Women
of
women
Men
of men
of total
leading cause of
deaths
deaths
deaths
death among both
Accident
0
0%
3
2%
1%
women and men
in Washington
Withdrawal
8
18%
5
3%
6%
jails, causing over
Cardiac event
6
13%
12
7%
9%
42% of all deaths
Homicide
0
0%
2
1%
1%
and over 45% of
deaths of men. A
Illness
10
22%
40
24%
24%
disproportionately
Overdose
2
4%
9
5%
5%
greater number of
Suicide
15
33%
74
45%
42%
women - almost
Unknown
4
9%
14
8%
9%
20% - died as result
Use of force
0
0%
6
4%
3%
of withdrawal from
TOTALS
45
100%
165
100%
100%
drugs or alcohol.
Eleven men died as
a result of homicide,
County jail between January 2005 and June
accident, or use of force. Moreover, uses of
2016. Other jails that have experienced
force may have played a role in at least ten
disproportionately greater rates of death
other deaths. No women died as a result of
include the Cowlitz County, Okanogan County,
one of these three categories.
Whatcom County, and Spokane County jails.
A number of these jails also appear to house
Information about individual jails
many more people than their facilities are
designed to detain, indicating significant
Larger jails experienced a higher rate of death
overcrowding. Specific information for deaths
than smaller jails. While some jails had no
by jail is included in the Appendix at the end of
deaths during the period reviewed, a number
this report.
of jails had multiple deaths.39 For example,
22 people died, 16 by suicide, in the Clark

Suicide
Suicide is a leading cause of death in jails
both nationally and in Washington. Recent
high-profile incidents, including the deaths
of Sandra Bland and Aaron Hernandez, have
raised public awareness of the issue around
the country, and at an important time. After
falling steadily for two decades, suicide rates
in jails have been rising nationally since
2009.40 Yet despite the risk and the increased
Gone But Not Forgotten

incidence of suicide in jails, nationally,
only 20% of jails have written policies that
encompass all the important components of
suicide prevention.41 A jail that fails to take
active, appropriate, evidence-based steps
to prevent suicides is operating illegally and
faces significant risk of liability.42 Factors that
make jails a particularly high-risk environment
include the large proportion of inmates who
8

have mental illness, the high rate of enforced
withdrawal from alcohol and drugs, and the
traumatic effect that criminal conviction and
incarceration have on an inmate’s personal
life.43
Experts generally agree on the factors in a
jail setting that increase the risk of death
by suicide and on the contents of a “gold
standard,” comprehensive, suicide prevention
program.

A comprehensive
prevention policy must
consider who is at risk,
when they are at risk, and
how that risk manifests into
self-harm.

General Risk Factors
There are a collection of general and individual
risk factors for suicide that converge uniquely
in jail settings. Unfortunately, many Washington
jails utilize suicide prevention practices or have
design flaws that increase the likelihood of
suicide and place people at risk. Inadequate
staffing, protocols that provide for isolating
potentially suicidal detainees and cells or
other physical structures that enable hanging
are particularly dangerous. Over 80% of jail
suicides in Washington occurred as a result of
hanging, many occurring in single occupancy
cells or in other spaces where detainees
were alone, like showers.44 A few examples
demonstrate how too few staff, isolation, and
jail design are contributing factors in many
suicides.

Gone But Not Forgotten

“[I]solation escalates
a sense of alienation
and further removes the
individual from proper staff
supervision. Whenever
possible, suicidal inmates
should be housed in the
general population unit,
mental health unit, or
medical infirmary, and
should be located close to
facility staff.” 45
• A.G.A. died as a result of suicide in
the Chelan County jail after being
isolated for “mental health problems”
and violence toward jail staff. There
were many indications that A.G.A. was
at risk of suicide, including a history
of attempts and concerns expressed
by his wife. Unfortunately, instead of
being monitored in a medical setting,
A.G.A. was housed alone with two hours
between wellness checks. He was found
hanging in his cell and pronounced
dead soon thereafter at a local hospital.
• After being booked into the Yakima
County jail, S.K. was moved to solitary
confinement for “anti-social behavior.”
She was placed in isolation even though
her medical records indicate that she
had previously attempted suicide
and struggled with mental health
issues. S.K. repeatedly activated the
emergency button in her cell during
the night and early morning before
her death, imploring jail officers to let
her out of solitary confinement. Later
that morning, another inmate found
her hanging from a sheet in her cell.
Paramedics rushed her to the hospital,
but she died there a few days later. S.K.
9

had been scheduled to see a mental
health care provider the next day.
• C.S. died in the Franklin County jail from
hanging. He had attempted suicide
during his last admission at the jail,
resulting in a days-long hospital stay.
His booking intake indicated that he
had a history of suicidality and might
be currently suicidal. However, this
information was not conveyed to the
jail’s mental health staff. C.S. was
placed in isolation without constant
observation and took his own life a few
days later.
As a matter of
general practice,
many jails place
people who
describe suicidal
thoughts or
threaten selfharm in solitary
confinement,
usually without
constant, direct
observation
by staff. This
type of “suicide
watch” is often
Photo Credit: Hamilton Medical
humiliating and
Products
dehumanizing.
People are generally stripped of all of their
clothes and placed naked in a “suicide
smock,” a tear-resistant bag with slots for arms
and the head. They are often held in “dry”
cells, concrete or padded cells without running
water or other fixtures, the only toilet a grated
hole in the floor. Some may be shackled for
hours in a restraint chair or other device that
severely limits body movements.
Not only can these practices increase the
dangers that someone may take his own life,
they also may deter potentially suicidal people
from making their intentions known. A number
Gone But Not Forgotten

of people who
died from
suicide did
so without
expressing
their thoughts
because
of terrible,
dehumanizing
experiences
they had
suffered
during a prior
placement
in isolation
as part of a
“suicide watch.”
• B.O. was booked into Clark County jail
and was placed on suicide watch at
one point. His solitary confinement
continued after being released from
suicide watch. Other detainees
apparently informed jail staff that B.O.
was not stable. However, no mental
health staff was available to evaluate
him at the time. B.O. was found hanging
from a bed sheet tied to the crossbars
of the window frame in his cell the next
day. Officers found a suicide note he
had written that said in part that he did
not want to be forced into a suicide vest
again.

Individual Risk Factors
Individual risk factors such as age, length of
stay, type of charge, and co-occurring mental
health disorders also show strong correlation
with the incidence of suicide. In absolute
terms, most suicides in jails are committed by
men. However, women are at greater risk of
suicide than men relative to their numbers in
jails.46 There is very little research on suicide
rates among transgender and gender nonconforming people in jails. Though it is likely
10

that they also face an increased risk of selfharm because of the unique hardships they
face while incarcerated.47
At additional risk are the very young or very old;
people who have a history of suicide attempts;
are intoxicated at the time of incarceration;
have an ongoing substance use disorder;
have experienced recent personal trauma; are
experiencing one or more mental illnesses; or
are facing sex offense charges.48 These factors
were present in a number of the deaths by
suicide that we reviewed.

Figure 7: Deaths by suicide by
length of stay

• B.C. was arrested after he drunkenly
assaulted a bus driver. He resisted
arrest and was clearly severely
intoxicated during his arrest and
subsequent booking into the Thurston
County jail. Because of his condition he
was placed alone in a cell and a nurse
was called to evaluate him. The nurse
decided that he was healthy enough to
remain alone. Later that day, he dove
head-first from the top bunk of his cell,
killing himself.
Generally speaking, suicide attempts are most
likely at certain points during a detention.
Most suicides take place within the first
days of incarceration. Over half of suicides
in Washington jails occurred in the first week
of incarceration. However, suicides occur at
any stage. 17% occurred after the person had
spent more than three months behind bars.
Specific events can also increase the chances
of suicide. Negative outcomes in a person’s
case (conviction or other bad news) and
withdrawal from drugs or alcohol make suicide
more likely. Other triggering events such as
bad news from family on the outside, conflicts
with cellmates, or ongoing substance abuse
also increase the chances that someone may
engage in self-harm.49

Gone But Not Forgotten

“[H]igh risk periods
include immediately upon
admission, following new
legal problems (e.g.,
new charges, additional
sentences…), after the
receipt of bad news
regarding self or family…,
after suffering humiliation
(e.g., sexual assault) or
rejection[.]” 50

11

Figure 8: Charge faced by people who died from suicide
Violent
DV
Property
Drugs
Driving
Warrants
Other

Women

Men

Total

4
3
0
0
1
3
1

26
8
10
4
3
4
1

30
11
10
4
4
7
2

Most of these risk factors were apparent in the
population of people who died as a result of
suicide in Washington’s jails. Substance use
issues, including active withdrawal or a recent
history of substance use disorders, appear
to have contributed to many of the suicides.
Moreover, at least 19 of the decedents
had previous suicide attempts. Most of the
men who died were awaiting trial for violent
offenses, including domestic violence. Six men
facing a sex offense charge died as a result of
suicide. In every case but one, the underlying
charge involved sexual conduct with a child.
Women who died of suicide were more likely to
be charged with a violent crime than women
facing criminal charges generally.
Importantly, many people who took their own
lives made their intentions clear to other
people within a few days of their deaths.
Records indicate that at least 22 people
expressed suicidal intentions to someone,
including jail staff, other detainees, or family
members before their final suicide attempt.
Others had been actively suicidal during their
current admission, including at least 13 who
had been on suicide watch at some point
prior to the attempt that ended in their death.
Records indicate the jail had notice of some
sort that the person was likely suicidal in at
least 30 instances.
•	 R.M.G. died as a result of suicide
in the Skagit County jail, at age 59
Gone But Not Forgotten

Percentage
of women
33%
25%
0%
0%
8%
25%
8%

Percentage
of men
46%
14%
18%
7%
5%
7%
2%

Percentage
total
45%
16%
15%
6%
6%
10%
3%

following a recent 20-26 year sentence
for multiple counts of child rape.
After expressing suicidal thoughts to
his lawyer and jail staff, he refused
food, water, and diabetes medication
for days. He died from complications
related to his unmanaged diabetes,
apparently without the jail taking active
steps to intervene and provide him with
necessary medical care.
•	 D.M. was booked into Clark County
jail on March 29, 2015. He had a
history of mental illness, including
hospitalizations and previous suicide
attempts. The jail’s mental health
intake indicated he had mental health
needs. Prior to his death, D.M.’s fiancée
called the jail to discuss his need for
psychotropic medications. A mental
health care provider met with D.M.,
who denied being suicidal or needing
medication. However, D.M. spoke with
his father on the telephone the day that
he died. His father reported that D.M.
had not been doing well emotionally
when they last spoke. D.M. was in
solitary confinement when he hung
himself on March 30.
Among the records we compiled were stories
of people misidentified, misplaced, and
mishandled even when properly identified.
The use of isolation cells, inattention to
12

the presentation of risky behavior, lack
of communication and monitoring, and
dangerous fixtures inside of cells all stand out
as common threads through much of our data.

Although each case includes its own unique
circumstances, as discussed below, there are
comprehensive policies and practices that if
implemented will save lives in the future.

Overdose and Withdrawal
It’s estimated that more than 47,000 people
in Washington regularly use opioids (heroin or
prescription pain medications) and over half of
them will be incarcerated in a Washington jail
at some point in 2019.51 Nationally, overdose
from drugs, particularly opioids, has become
the leading cause of death for Americans
under 50.52 A recent report stressed the need
for Washington jails to implement effective
and appropriate treatment protocols to avoid
needless overdoses or deaths caused by
unmanaged withdrawal.53

“Failure to treat opioid
use disorder during
incarceration has serious
consequences, including an
extremely high risk of death
of overdose death after
release, [death or injury]
from opioid withdrawal
during incarceration,
high rates of crime and
recidivism, and social and
medical consequences
of untreated opioid use
disorder after release.” 54

Drugs or alcohol played some part in at least
38% of all of the jail deaths, the percentage
being significantly higher for women than men.
Gone But Not Forgotten

Drugs or alcohol were likely at least a
contributing factor in 54% of the deaths of
women.55 Irrespective of gender, most deaths
that occurred within the first few days following
booking were related to drugs or alcohol. As
set out in Figure 4, 60% of the deaths within
the first week of admission involved drugs or
alcohol. The vast majority of deaths involving
drugs or alcohol occurred within the first seven
days after booking.
Drug- or alcohol-related deaths included
overdoses and alcohol poisonings, deaths
caused in part by poorly managed withdrawal,
and deaths caused by other serious medical
conditions whose symptoms jail staff
mistakenly attributed to withdrawal. These
deaths highlight what can occur without
proper management and supervision of people
suffering from substance use disorders or
withdrawal from those substances.

Overdose
Many people are arrested under the influence
of drugs or alcohol and brought directly to jail.
As a result, death or injury from overdose or
alcohol toxicity is a significant danger within
the first few hours after booking.
• Following his arrest on drug charges,
D.D. was taken to the hospital by
the arresting officer prior to booking
because of concern that he had
ingested heroin. He was cleared at
the hospital and booked into the King
13

County jail. Though being monitored
in a holding cell, because of concern
about his high blood sugar, he died as
a result of acute combined heroin and
cocaine intoxication.
• T.S. was arrested for DUI and booked
into the SCORE jail in Des Moines.
During the booking process, jail officers
observed him slumping forward in his
chair with his eyes rolling back in his
head. He was incontinent, had difficulty
answering questions, and appeared
to lose consciousness at points during
the process. At one point, he required
medical attention after suffering a
seizure. He was placed in a cell and
found unresponsive a few hours later
on a mattress soaked with urine. Notes
indicate that his death was caused by
possible withdrawal from alcohol or
benzodiazepines.
While most prevalent within the first hours
after booking, overdoses can also occur later in
a person’s incarceration, either through drugs
smuggled into the facility or from jail-provided
medications that are stored over time and then
taken in high doses.
• V.T., a man with serious mental
illness, was booked into Clark County
jail. During intake he made suicidal
statements and was put on suicide
watch. After a series of volatile and
unpredictable outbursts, V.T. was sent
to Western State Hospital for three
months for observation and treatment.
A week after his return to Clark County
Jail, V.T. died of an overdose of the
psychotropic medication, fluoxetine,
also known as Prozac. Investigators
believe that he stored his medications
for a period of time and then took a
massive amount that ended his life.
Deaths and injuries from overdose are largely
Gone But Not Forgotten

Photo Credit: Adapt Pharma

preventable. Simple medical interventions can
mean the difference between life and death for
someone experiencing an overdose. Naloxone
and other similar medications immediately
block the sedative effects of opioids and bring
someone experiencing an overdose back from
the brink of death.
These medications are easily administered,
even in a non-clinical setting. NARCAN, a form
of naloxone, can be given via a nasal spray,
without the need for needles or any other
significant medical procedure. There is no
reason why every jail in the state should not
have a ready supply of Naloxone and officers
trained to administer it when necessary.
Eliminating overdoses from opioids in
Washington jails is readily attainable, provided
jails do their part.
Treatments for severe alcohol poisoning
involve more invasive medical procedures that
are routinely done in emergency rooms across
the country. With proper training, correctional
officers can learn to identify when a person is
in need of more intensive medical attention
as a result of possible alcohol toxicity. Timely
action is absolutely essential to avoid an
otherwise entirely needless death. People
will continue to die of overdoses inside jail
walls if jails remain unprepared and their staff
untrained.
14

Withdrawal
A person with an active substance use disorder
will likely suffer withdrawal symptoms upon
being booked into jail. A range of awful and
debilitating symptoms accompany withdrawal
from opioids, including severe muscle aches,
agitation, sweats, hypertension, fever, nausea,
vomiting, diarrhea, abdominal cramps,
depression, anxiety, severe drug cravings,
and suicidal thoughts.56 Symptoms can begin
within a few hours of last use and continue for
a week or more, depending on the substance
and the severity of use.57 These symptoms can
kill people if not properly treated.
The withdrawal process for someone coming
down from alcohol can also be very dangerous
or even fatal. Similar to opioid withdrawal,
alcohol withdrawal can cause anxiety, muscle
aches, nausea, vomiting, high blood pressure,
or insomnia. If not properly managed,
alcohol withdrawal can also bring on serious
hallucinations, and in severe cases, seizures,
heart arrhythmias, and death.

“Contrary to commonly held
notions, withdrawal is often
not only uncomfortable or
painful, but also may be
harmful to health and even
fatal.” 58

The National Commission on Correctional
Health Care (NCCHC) makes clear that
“severe withdrawal symptoms must never be
managed outside of a hospital. Deaths from
acute intoxication or severe withdrawal have
occurred in correctional institutions.”59 Cases
in Washington demonstrate the dangers of
poorly managed withdrawal inside of jails.

Gone But Not Forgotten

• S.D. was booked into Cowlitz County jail
on August 3, 2013. The next day she
sought medical attention for withdrawal
from heroin and methamphetamines.
She was placed on a withdrawal
protocol and her symptoms, including
severe “stomach problems,” continued
for the next several days. At times, she
was unresponsive when contacted
by staff. On August 10, a nurse
found S.D. slurring her words, and
she had difficulty finding her pulse.
S.D. went into cardiac arrest and lost
consciousness. She was rushed to the
hospital, but died shortly after arrival.
• B.B. was taken to the hospital and
cleared by staff there before being
booked into the King County jail. The
next day he was found unresponsive
in his cell. Emergency measures were
unsuccessful and B.B. died. Other
detainees told investigators that B.B.
had been seriously ill from vomiting
and diarrhea and repeatedly sought
the attention of jail staff by ringing
the emergency bell for assistance,
without success. The coroner’s report
found that he died as a result of
dehydration from vomiting and diarrhea
as a consequence of withdrawal from
opioids.
Suffering withdrawal in jail can be incredibly
dehumanizing, debilitating, and in some
circumstances, fatal. During our work with
people incarcerated in jails across the state we
have heard numerous stories of people in the
midst of severe opioid or alcohol withdrawal
being left alone, unsupervised in solitary
confinement; condemned to agonizing cramps,
nausea and pain while sleeping in their
own filth and vomit. Others have described
sharing a tiny cell with someone in the grip of
withdrawal, heaving into a shared toilet and
moaning throughout night.60

15

• G.G. was booked into Okanogan
County jail on October 18, 2014, for
the delivery of controlled substances
including heroin, methamphetamine,
mushrooms, and oxycodone. Upon
booking, G.G was severely nauseous
and vomiting because of withdrawal.
Though provided medications for
nausea, he had on-going bouts of
vomiting and refused to eat or drink
because of his symptoms. On October
21, G.G. begged to be taken to the
hospital because of his severe, ongoing
withdrawal symptoms. Jail staff refused
his request, and later that day, he was
found dead in his cell.
• K.J.M. was booked into King County jail
on September 15, 2007 after her arrest
for selling narcotics. During booking,
K.J.M. apparently passed out and fell
to the floor, injuring her head in the
process. She was taken to Harborview
Medical Center for evaluation. After
being treated for her head injury, K.J.M.
was transported back to the jail where
she began exhibiting signs of “dope
sickness.” For the next several hours
she suffered frequent vomiting and
bouts of loose stool, but reportedly

refused medical attention. K.J.M.
placed her mattress pad on the floor
of her cell to be closer to the toilet. The
next morning K.J.M. was unresponsive.
Resuscitative efforts failed and she
died. King County implemented
new protocols for monitoring people
experiencing withdrawal after her
death.
• D.G. died in custody in Pierce County
jail due to severe alcohol withdrawal
only a few days after being booked into
jail. He had been experiencing extreme
withdrawal symptoms, smelled toxic,
and had not been eating prior to his
death. Jail staff expressed concerns to
nursing staff, but since he was able to
hold down some water, no other efforts
were made to help him. He died alone
in his cell.
• M.M., an 18-year-old man battling bipolar disorder and schizophrenia, was
booked into the Benton County jail after
becoming agitated at a Richland mental
health facility. Reports indicate that jail
staff provided him with water and food,
but did not monitor whether he was
actually eating or drinking. M.M. was
found dead in his cell eleven
days after he arrived. The
coroner ruled that he died as a
result of an irregular heartbeat
and dehydration related to use
of synthetic marijuana.
The need for humane
medical care for people
experiencing withdrawal
in jails is particularly
important because people
admitted to jail are forced
to go through withdrawal
regardless of whether they
are psychologically and
emotionally prepared to do

Gone But Not Forgotten

16

so. Unlike people who seek treatment in the
community, withdrawal behind bars occurs
without the true consent of the person
affected, thereby increasing the chances of
depression, anxiety, and immediate relapse
upon release from jail.
Medications and proper medical care can
greatly reduce the terrible effects of withdrawal
and eliminate the chances that someone may
die as a result of unmanaged withdrawal.
Medications like methadone, buprenorphine,
and naltrexone minimize the suffering that
withdrawal causes and help people avoid
relapse.61 Other medications can assist
with withdrawal from alcohol and other
drugs. Experts therefore stress the need
for appropriate medication management of
people suffering withdrawal in jail.62 All jails
should have medications readily available for
people who are struggling with substance use
disorders.63

A recent report on withdrawal
services in Washington jails
recommends that jails
“[c]losely monitor patients at
risk for opioid withdrawal using
a validated instrument, and
treat withdrawal symptoms
with buprenorphine, or
methadone, if available.” 64

A jail that fails to provide these essential
medical services is operating in violation of
its constitutional and other legal obligations.65
Unfortunately, a recent study found that
most Washington jails have no protocol for
monitoring withdrawal, and fewer than half of
the jails surveyed provided any medications to
people suffering withdrawal.66
Gone But Not Forgotten

Other Serious Medical
Conditions Left Untreated
Withdrawal symptoms can also mask, multiply,
or replicate symptoms caused by other medical
conditions that if left untreated can also prove
disabling or even fatal. Sepsis, pneumonia and
staph infections, including MRSA infections,
are regularly found in people who have been
living unsheltered or recently using intravenous
drugs. Unless medical professionals are
knowledgeable and careful, symptoms of
these illnesses can be easily mistaken for
symptoms of withdrawal, or withdrawal can
mask symptoms of these other potentially lifethreatening conditions. Jail staff in a number
of cases failed to properly diagnose and
treat serious medical conditions because it
appears they attributed reported symptoms to
withdrawal.
• L.L. died from a severe lung infection
after a stay in the Snohomish County
jail. Reports indicate that she had
sought treatment for severe breathing
problems for a number of days, had
a high temperature, elevated heart
rate, and low oxygen saturation.
Nonetheless, medical staff did not
provide her with antibiotics or order
a chest x-ray. They did, however, note
that they believed that she was “drug
seeking.” She died when her chest
filled with fluid, collapsing her lungs
and suffocating her. Snohomish County
agreed to pay L.L.’s estate $1.5 million
in damages as a result of its negligence
in her death.
• L.I. was booked into the King County jail
on disorderly conduct and drug charges.
Two days later, he complained of severe
abdominal pain, reporting that it felt
like his “liver exploded.” He required
a wheelchair to get from his cell to
the infirmary because of the pain.
Medical staff in the infirmary noted in
17

his records that he was coming down
from heroin and alcohol. He asked to
be taken to the hospital because of his
pain, but instead medical staff placed
him in the medical unit in the jail for
observation. He was found unconscious
and unresponsive the next morning. An
autopsy showed that he died of acute
peritonitis (burst appendix). His life
could have been saved had he received
appropriate treatment promptly upon
reporting his symptoms.
People like Lindsay Kronberger have died from

inadequately managed withdrawal, others from
overdoses, and still others, because medical
professionals mistook symptoms and failed to
properly treat other serious medical conditions.
These deaths demonstrate that medical
professionals operating in jails must provide
medications and other appropriate therapies
to mitigate the symptoms of withdrawal, and
also carefully evaluate the patient in order
to determine whether some other serious
condition may also be involved. Jails must take
active steps to avoid any additional needless
deaths from overdose, withdrawal, or other
serious medical conditions.

Use of Force and Neglect
A number of deaths have been caused in part
or in whole by uses of force committed by jail
officers or by outright neglect of the people
under their care. A use of force appears to
have played a factor in at least 16 deaths
reviewed. Most of these deaths occurred
following the use of Tasers, restraints, or direct
physical takedowns of detainees.67 Often they
also involved the interplay of excessive alcohol
or drug use, mental illness, and poor medical
or mental health treatment. A few examples
demonstrate how a number of variables
including uses of force can come together
with tragic consequences.

officers attempted to place him in an
isolation cell, but he began to resist
again. An officer shot him again with a
Taser. Finally, four officers wrestled him
into a cell and left him on his stomach
with his hands cuffed behind his
back. An officer estimated that about
a minute later she saw B.W. take two
deep breaths and then stop breathing.
Officers flipped him onto his back,
pulled him out of the cell and began

• B.W. died while being booked into the
Snohomish County Jail for shoplifting
beer and cigarettes. B.W., a man with
a long history of alcoholism, drug
dependency, and mental illness,
became combative during the booking
process, whereupon jail officers
wrestled him to the ground and
shocked him with a Taser. He began
struggling to breathe and turned blue.
When he appeared to recover, jail
Gone But Not Forgotten

18

resuscitation efforts, which proved
unsuccessful. B.W. died on the floor of
the jail. It later came out that a local
mental health provider had warned that
B.W. was in the midst of a “psychiatric
episode.” However, this information was
not conveyed to police or jail staff prior
to his death.
•	 C.P. was a 33-year-old man with
diabetes who died in Spokane County
jail on February 24, 2013. Earlier that
morning he had called 911 claiming
he was paranoid, diabetic, and high
on methamphetamine. Police officers
arrived and discovered C.P. had a
warrant for his arrest due to unpaid
child support. Instead of taking him to
the hospital, he was arrested. While in
a holding cell, C.P. began swaying and
grasping his head in his hands. He was
asked to sit down in the cell, but he
did not comply. Jail staff placed him in
a headlock, shocked him twice with a
Taser, and strapped him into a restraint
chair. He lost consciousness, stopped
breathing, and died in the hallway of the
Spokane County jail. An autopsy ruled
his death a homicide, with the cause
of death being a methamphetamine
overdose “with restraint stress.” His
blood sugar was over 2000 when he
died, a blood sugar level sufficient
to cause hallucinations, abnormal
behavior, coma, or death.
•	 T.S. entered the Asotin County jail in
November 2005 on assault charges.
His family called and informed jail
staff at least twice that he had
bipolar disorder and that he had been
hospitalized recently. Jail officers
used force on T.S., including Tasers
and a restraint chair, on at least three
occasions before the episode that
resulted in his death. On November
25, 2005, staff found him screaming
Gone But Not Forgotten

incomprehensibly and beating his head
against the walls of his cell. Officers
shot him with a Taser in an effort to
subdue him. When he continued to
resist, an officer repeatedly hit T.S. with
a baton. Other officers then Tased him
three or four more times before they
were able to handcuff him. They then
put T.S. in a restraint chair, where he
lost consciousness and subsequently
died. An autopsy determined that he
died of arrhythmia following multiple
blunt force injuries and the use
of Tasers. His death was ruled an
“accident.” Media reports indicate that
a lack of adequate staffing may have
contributed to T.S.’s death.
•	 M.A. was asphyxiated by jail staff
during a use of force incident at the
Clark County jail. M.A. who had been
diagnosed with bi-polar disorder was
awaiting transport to Western State
Hospital for a mental competency
evaluation at the time of his death. By
his third day in jail, he reported being
suicidal and was placed in a suicide
smock in a solitary cell on suicide
watch. Witnesses reported that M.A.
banged his head almost constantly
against his cell walls, the door and a
metal grate in the floor used as a toilet.
Jail officers placed him in a restraint
chair several times before his death. He
died during a struggle with the guards
who were once again trying to force
him into the restraint chair. He was
Tased, and when guards couldn’t get
him into the chair, they pinned him on
the floor where he suffocated. His death
was ruled a “homicide by mechanical
asphyxia.”
Other deaths demonstrate how jail staff can
neglect the needs of detainees by denying
them essential medical care or failing to
adequately monitor their food and water
19

intake. A number of cases demonstrated
problems with access to necessary medical
care. In fact, in 62 of cases there was some
indication that the jail’s medical or mental
health care was deficient. Health carerelated inadequacies ranged from failing to
conduct a thorough medical intake, failures
of communication between staff members,
and poor medical decisions or inappropriate
treatments. In other instances, staff simply
ignored the needs of detainees and failed to
ensure that they received proper food, water
or medical attention. Again, mental illness or
substance use disorders were factors in many
of these cases.
• D.B. informed an officer that he was
suffering from back pain while being
booked into the Cowlitz County jail on
January 13, 2014. Two days later he
again complained to medical staff of
shortness of breath, achy bones, and a
sharp pain in his back and was unable
to move or lift his arms. On January 16,
D.B. reported that he had a chest injury,
depression, and anxiety. The clinician
dismissed his complaints, recording
that they were just manipulative
behaviors and that D.B. was “okay.”
Later that day, jail staff placed him in a
Gone But Not Forgotten

restraint chair in his cell in response
to a threat of self- harm. When
medical staff arrived, they found
him unresponsive and with blood on
his face. He responded to ammonia
after two attempts. On January 18,
D.B. again complained to medical
staff that he had chest pain and
difficulty breathing when sitting up.
He said his chest felt like “pins and
needles.” Later that night, he was
found coughing up blood, sweating
profusely and complaining of severe
chest pain. The next morning jail
staff found him screaming in his cell
because of the pain he felt while
inhaling. A clinician noted that he
had blood in the back of his throat,
but nonetheless recommended that
staff just continue to monitor him. He
was found dead in his cell early in the
morning on January 20. The medical
examiner determined that he died
from bilateral pneumonia and a staph
infection, which likely led to sepsis.
• A.N. had been jailed in the Walla
Walla County jail for over a week when
she died from septic shock. She had
complained of chest pain and seen a
jail nurse on a couple of occasions. Her
autopsy showed an extreme infection
in her chest that had “marbled her”
chest muscle wall and eaten a quarter
size hole in her sternum. Her lungs also
showed signs of severe infection.
• K.F., a young man suffering from severe
bipolar disorder, was booked into
Island County jail. Family members
contacted the jail to inform them about
his significant mental health needs. He
refused food or water for many days
due to his severely disturbed condition.
Nonetheless, jail officials took no action
to intervene, even though they were
aware of his condition and his refusal to
20

eat or drink. K.F. died alone in his cell
from dehydration and malnutrition a
number of days after admission. Later,
a jail officer admitted to falsifying safety
check logs in an attempt to hide the
horrendous treatment he had received.
K.F.’s death has received much
attention in the media and resulted in
important reforms at the Island County
jail.
•	 J.M. was incarcerated at Kittitas County
jail in August 2012 to serve a 270-day
sentence for a DUI. He became ill in
early February 2013 and on February 8,
was seen by a nurse who noted he was
feeling sick, could barely talk, had a
dry cough, and little appetite. Though it
appears a doctor prescribed antibiotics,
the medications were either never
ordered or not given to him. Early in the
morning a few days later, J.M. pressed
the emergency button and explained
through the intercom that he was
having trouble breathing. Jail officers
dismissed his concerns as an anxiety
attack. He continued struggling for
breath and again asked to be taken to
the hospital. Staff refused his request.
He continued to beg for assistance

throughout the morning before his
oxygen levels were finally checked. He
was immediately sent to the hospital
where he died later that evening. Other
detainees who were later interviewed
reported that staff repeatedly ignored
his requests for assistance, telling
him that he would have to wait until
Monday to see the doctor. Investigators
acknowledged that “all of the inmates
who were interviewed expressed
concern about [J.M.]’s condition and
what they referred to as a lack of
concern by jail staff for his care and
well-being.”
Abuse and neglect are unfortunate realities
inside too many jails. Underpaid, overworked,
and undertrained staff react in inappropriate
ways or fail to properly monitor the people
under their care. While better supervision and
training are essential, more importantly, jails
must reduce the number of people held within
their walls and employ enough properly trained
staff to ensure that all people who remain
incarcerated are properly monitored and
treated humanely. If governments continue to
refuse to spend what is necessary to effectively
treat these populations, more people will
inevitably die.

Recommendations
The medical and mental health needs of people living with these challenges can be much better
served outside of jail walls. However, the criminalization of certain behaviors, the routine use of
pre-trial incarceration, and the reduction in supports for community-based, mental health, chemical
dependency, and medical services has placed the responsibility for care upon jail administrators
and their staff. Unfortunately, jails are ill-equipped to meet the need, thereby injuring both the
people locked up there and the professionals tasked with keeping them safe and secure.68 Though
it is likely inevitable that some people will die in jail, there are a number of steps that can be taken
to limit the number of deaths and reduce or eliminate preventable deaths.

Gone But Not Forgotten

21

Reduce the number of people living with mental illness or
substance use disorders in jails.
Community-based treatment and supports are much more effective, inexpensive, and humane than
are jails in treating people with mental illness or substance use disorders. With the expansion of
Medicaid under the Affordable Care Act, many people are now newly eligible for medical, mental
health, and substance use treatment. However, Medicaid is not available to people who are
currently incarcerated. People must be kept in the community in order to receive the benefits of
these significant federally provided health care dollars. In addition to being cost-effective, keeping
people in their communities and out of jail is also the option most likely to result in positive health
outcomes.69 By dramatically increasing the use of pre-arrest and pre-trial diversion programs,
eradicating the use of cash bail, and providing community-based alternatives to incarceration,
counties and localities will reduce the number of people inside their jails, improve the outcomes
that they achieve and save money.

Increase oversight and transparency of what happens inside jails.
As detailed above, there currently exists no centralized oversight of Washington jails, and jails have
no obligation to report information to any state agency after a major event such as a death, suicide
attempt, or other serious injury. Laws should be changed to require reporting after serious incidents
to a state agency, like the Department of Health, that is empowered to take action to review the
incident and address any shortcomings. Mandated reporting following serious events will ensure
accountability and provide a mechanism whereby proper reforms can be identified and initiated.
Public disclosure laws should be amended to require jails to provide more information to the
public regarding deaths and other serious events. Names and other identifying information can be
redacted from relevant records to protect the privacy of the people involved.

Every jail must have an adequate and timely medical, mental health,
and substance use intake process.
Most jails have some form of
intake process to gather some
amount of medical, mental
health, and substance use
information from detainees.
However, often the information
gathered is insufficient to
actually identify and understand
the person’s current needs.
These intakes are generally
taken by jail staff without proper
health care expertise or training.
Important information is missed
or ignored. Inadequate intake
Gone But Not Forgotten

22

procedures and neglected care contributed to a number of the deaths that we investigated.
Thorough intake questionnaires filled out by trained staff and timely communication and follow
up with health care staff are absolutely essential initial steps in increasing safety. Each inmate
should then have a much more detailed medical, mental health, and substance use examination
by a qualified health care professional within a few days of entry into jail.70 The failure to identify
medical conditions in a timely manner or provide appropriate mental health or withdrawal treatment
contributed to a number of the deaths. Early evaluation and treatment would likely have changed
the outcome in some of these cases.

Every jail must have overdose and withdrawal protocols and
provide medications when appropriate.
As detailed above, overdose and poorly managed withdrawal kill people. However, even when
withdrawal does not lead to death, it causes unnecessary torment and trauma to people
experiencing it. With proper identification and timely treatment, most, if not all deaths and suffering
can be avoided.
The NCCHC has promulgated standards for withdrawal management that should be provided in
every jail.71 Essential practices include:
•	 Proper training for staff to identify people suffering withdrawal symptoms.
•	 Protocols that meet current, evidence based, treatment guidelines.
•	 Intake procedures that ensure that people under the influence of drugs or alcohol are
identified immediately upon booking and properly supervised.
•	 Withdrawal management that is done under the supervision of qualified health care
professionals who utilize recognized validated assessments to judge the severity of
withdrawal symptoms.72
•	 Policies mandating the medication management of detainees suffering from withdrawal.
Every jail in Washington must adopt appropriate withdrawal protocols in order to ensure the
humane treatment of all people under their care. Staff training and the ready availability of
medications like Narcan and Suboxone, which temper the worst aspects of withdrawal and save
lives, are essential elements.

Jails must change how they care for people who have expressed
suicidal thoughts or may be actively suicidal.
As with overdoses and deaths from withdrawal, jails can take active steps to significantly reduce
the number of suicides inside their facilities. Isolation is not an appropriate management tool for
someone who is suicidal. It exacerbates symptoms and increases the likelihood that a person
considering suicide will take action. Terrible prior experiences with isolation also deter people
who may be suicidal from reporting their condition to jail staff. Jails must ensure that people
experiencing acute suicidal feelings are constantly and directly monitored by jail staff. To the extent
that jails do not have the facilities or staffing to ensure such constant monitoring, detainees must
Gone But Not Forgotten

23

be transferred to outside facilities that can provide the
necessary level of care.
Comprehensive written policies are foundational to a
successful suicide prevention program. Jails should also
abandon certain common practices that actually increase
the likelihood of a suicide attempt, like isolation. Any
comprehensive suicide prevention program should include:

“[T]he antiquated
mindset that ‘inmate
suicides cannot be
prevented’ should
forever be put to rest.” 73

• Regular training for staff, regardless of tenure.
• Identification, referral, and evaluation protocols that properly assess the risk of self-harm
and include review of prior incarcerations to identify any history of self-harm. Jails should
revisit this risk assessment regularly throughout the person’s incarceration.74
• Jails not simply accepting a person’s word that he is not currently suicidal, particularly for a
detainee with a history of self-harm.75
• Avoidance of solitary confinement or other dehumanizing conditions.
• Appropriate, safe housing in “suicide-proof” cells.
• Constant, direct observation of any person who is actively suicidal.
• An assessment for suicide risk of every person placed in solitary confinement at the outset
of their placement and then regularly thereafter during their entire stay in solitary.
• Identification of likely stressors and communication between staff regarding upcoming
events that may cause someone to engage in self-harm.
• Development of suicide “profiles” to quickly identify who might be most at risk, and when.76
• Jail policies and practices which do not deter a detainee, family, friends or other detainees
from reporting suicidal thoughts or actions.
• Avenues of communication that detainees and people on the outside can use to report
threats of self-harm.
• Ongoing observation and treatment plans for people identified as vulnerable to suicide.
• Access to emergency response services.
• Administrative review of any suicide attempts to identify opportunities for improvement.

Staff must be trained to manage people in crisis, utilize effective
de-escalation techniques, and use force only when absolutely
necessary.
Newly passed Initiative 940 requires that all law enforcement officers in Washington complete
approved violence de-escalation training and training on how to work with people with mental
illness. The new law also requires such training on a regular, annual basis thereafter.77 By contrast,
current regulations governing mandatory training for jail officers do not include such requirements.78
However, jail staff, like law enforcement, should be trained in “de-escalation… and interpersonal
communication training, including tactical methods to use time, distance, cover, and concealment,
to avoid escalating situations that lead to violence.”79 Other relevant requirements include training
regarding “implicit and explicit bias, cultural competency, and the historical intersection between
race and [the criminal justice system]”; “[s]kills including de-escalation techniques to effectively,
safely, and respectfully interact with people with disabilities and/or behavioral health issues”; and
Gone But Not Forgotten

24

“[a]lternatives to the use of physical or deadly force.”80 State law should be changed to require
similar training for all jail staff.
Laws should also be enacted to limit the use of restraint chairs, Tasers, pepper spray, and other
weapons deployed within jails. They should be utilized only in appropriate situations involving
imminent threat of bodily injury, only after all other non-violent means have failed and then only to
the extent necessary to eliminate the immediate danger. The steps that jails must take to ensure
the health and safety of the person against whom force was used should also be set out in statute.
Finally, each jail should be required to create and maintain records related to any use of force and
make them available to an appropriate third party for review on a regular basis.

Each jail must have enough staff to ensure that all people receive
appropriate supervision and care.
Inadequate staffing is a perennial problem facing jails short on resources. Shortages of security,
medical, and mental health staff lead to myriad problems, including the neglect of detainees, too
frequent use of solitary confinement, and poor medical and mental health care. A number of the
deaths studied indicated that had more staff been available to provide appropriate supervision for
people who were threatening
self-harm, deaths would have
been avoided. Other deaths we
reviewed demonstrate a lack
of appropriate attention from
medical or mental health care
professionals, either because
they were not actually present
in the jail at relevant periods or
because they were inattentive
because of the sheer number of
other demands on their time.
Both the inability to provide
full medical, mental health or
substance abuse evaluations
for all admitted detainees
within a few days and a jail’s
failure to provide medically
appropriate supervision of people suffering from withdrawal are the product of too many detainees
and too few resources. Jails could provide the appropriate level of care set out in national standards
promulgated by organizations like the NCCHC.81 However, policy makers and the public have
required them to house too many people and yet neglected to provide them the resources sufficient
to do so. To the extent that society has forced jails to meet the needs of people combatting mental
illness, traumatic brain injuries, or substance abuse, we must give them the resources necessary to
provide that care in an adequate, safe, humane, and respectful manner. To continue to do less is to
ensure that more people will needlessly die behind bars.

Gone But Not Forgotten

25

Every jail should be required to engage in a full serious incident
administrative review and provide that report to appropriate third
parties.
The NCCHC standards require that “[a]ll deaths are reviewed to determine the appropriateness of
clinical care; to ascertain whether changes to policies, procedures, or practices are warranted; and
to identify issues that require further study.”82 These reviews should include three components:
an administrative review, a clinical mortality review, and a psychological autopsy that examines the
individual’s life “with an emphasis on factors that led up to and may have contributed to the
individual’s death.”83 The review’s result should be summarized in a written report that lays out
the cause of death, any precipitating factors, and recommendations regarding changes to policy,
training, physical structures, medical and mental health services, or other operational practices.84
Best practice is to do a review after every serious incident, even incidents that do not result in
death.
Many jails appear to engage in some level of review following deaths. However, a number either do
nothing, or their reviews are insufficient to identify causes and changes in policy and practice that
may be required. Such reviews should be mandated following every serious incident and relevant
information made available to appropriate state agencies and the public generally.85

Conclusion
This report details deaths that occurred within Washington jails from January 2005 through June
2016. However, people continue to die in Washington’s jails. Eight people have died in the Spokane
County Jail alone since June 2016 from a variety of different causes.86 In Snohomish County,
another man died as a result of a use of force while in the custody of the jail, and a young woman
died from meningitis after suffering terribly for days while locked away there.87 None of these ten
deaths are included in those discussed in this report, but they indicate that serious problems
continue.
Without sufficient community-based services and alternative housing options, jails have become the
primary medical, mental health, and substance use treatment providers for thousands of people in
Washington. The lack of other adequate treatment and housing options means that people fighting
mental health and substance use disorders cycle in and out of jails. These realities stress the
systems and the people who live and work within them. People die as a result.
However, as detailed in this report, there are many actions that can be taken to reduce the number
of deaths inside Washington’s jails. Reducing the jail population, increasing the availability of
community-based treatment and housing, requiring greater transparency, and giving jails the
resources they need in order to properly care for our friends and family members, are absolutely
essential steps that should be taken. Anything less will condemn other men and women to needless
injury and death behind bars.
Gone But Not Forgotten

26

Endnotes
1.	 We have identified Ms. Lindsay Kronberger by
name in this report because her story has been
covered extensively in the media. See e.g., Levi
Pulkkinen, Claim: Jailers Mocked Dying Young
Woman During Her Last Hours, Seattle P.I. (August
3, 2016), http://www.seattlepi.com/local/crime/
article/Claim-Jailers-mocked-dy-ing-young-womanduring-9121704.php; Scott North, Lawsuit Contends
Staff Ignored Inmate’s Peril Before She Died,
Everett Herald (August 4, 2016), https://www.
heraldnet.com/news/lawsuit-against-snohomishcounty-focus-es-on-inmates-death/. Most of the
other cases we discuss in this report did not receive
similar public attention. In all other cases, we refer
to people who died solely by their initials in the
interest of preserving their identities.
2.	 Gohranson v. Snohomish Cty., 2018 WL 2411756,
at *6 (W.D. Wash. May 29, 2018).
3.	 “Roughly two-thirds of people sitting in Washington
jails are awaiting trial; none of whom have been
found guilty of the criminal charge with which they
have been accused. Most languish there because
they cannot afford the cash bail that courts routinely
require.” ACLU, No Money, No Freedom: The Need
For Bail Reform, 7 (September 2016), https://www.
aclu-wa.org/bail.
4.	 National statistics indicate that 60% of people in
jails actively exhibit mental health symptoms and
30% of people in jails have a cognitive disability
of some type. See Disability Rights Washington,
County Jails, Statewide Problems: A Look at How
Our Friends, Family and Neighbors With Disabilities
Are Treated in Washington’s Jails, 16 (April 2016),
https://www.disabilityrightswa.org/wp-content/
uploads/2016/04/CountyJailsStatewideProblems_
April2016.pdf.
5.	 See FWD.us, Every Second: The Impact of the
Incarceration Crisis on America’s Families, 10
(December 2018), https://everysecond.fwd.us/
downloads/EverySecond.fwd.us.pdf.
6.	 One study indicates that as many as 76% of people
living with severe mental illness who are locked up
in jails receive acute psychiatric in-patient treatment
solely while in jail and not in community-based,
mental health facilities. See H. Richard Lamb et
al., Treatment Prospects for Persons With Severe
Mental Illness in an Urban County Jail, 58 Psychiatr
Serv. 782, 784-86 (June 2007), https://www.ncbi.
nlm.nih.gov/pubmed/17535937.
7.	 King County Executive’s Office, 2019-2020 King
County Proposed Biennial Budget, 409, https://
kingcounty.gov/depts/executive/performancestrategy-budget/budget/2019-2020-ProposedGone But Not Forgotten

Budget/2019-2020-ProposedBudgetBook.aspx.
8.	 Spokane City, Budget Presentation (October
16, 2018), https://www.spokanecounty.org/
DocumentCenter/View/23128/2019-Public-SafetyJustice-Presentation.
9.	 https://www.publicschoolreview.com/washington/
spokane/5308250-school-district.
10.	 See generally Disability Rights Washington, Lost
and Forgotten: Conditions of Confinement While
Waiting for Competency Evaluation and Restoration
(January 2013), https://www.disabilityrightswa.org/
wp-content/uploads/2017/12/LostandForgotten_
January2013.pdf.
11.	 Id. at 7.
12.	 The authors reviewed all available records for all
deaths that occurred in jails between January 1,
2005 and June 15, 2016.
13.	 Keri-Anne Jetzer, Jail Bookings in Washington State,
Washington State Statistical Analysis Center, 1 (June
2016), https://www.ofm.wa.gov/sites/default/files/
public/legacy/researchbriefs/2016/brief078.pdf.
14.	 The Bureau of Justice Statistics, a division of
the federal Department of Justice, does annual
surveys of jails across the country. Those surveys
ask jails to provide information about average daily
populations, the demographics of jail population,
and very limited information regarding any jail death
that has occurred in the prior year. This information
includes the person’s gender and very basic
information about the cause of death. Jails need
not provide any additional explanation or supporting
documentation. WASPC asks jails in Washington
to provide demographic information about the
people detained, but does not request information
regarding jail deaths or other serious events. And
the data jails provide is often faulty or incomplete.
“[T]here is little standardization related to the input
or coding of the [WASPC] data being entered by jail
staff.” Id. at 1.
15.	 RCW 70.48.100(2)
16.	 The threat of litigation is not sufficient to compel all
jails to implement necessary reforms. Washington
law significantly limits financial recoveries in
wrongful death cases, particularly those involving
people who have limited economic prospects or
no dependents. See, e.g., Otani ex rel. Shigaki
v. Broudy, 151 Wn.2d 750, 760 (2004) (loss of
enjoyment of life damages not recoverable as part
of wrongful death claim).
17.	 WASPC, 2015 Washington State Jail Statistics –
County, Regional, City and Tribal, https://www.
waspc.org/crime-statistics-reports.
18.	 Id. Compare the aggregate average daily
27

populations for all jails with the design capacities for
all jails.
19.	 See WASPC, 2017 Washington State Jail Statistics
– County, Regional, City and Tribal, https://www.
waspc.org/crime-statistics-reports).
20.	 Id.
21.	 Id. Compare Average Daily Population for
Snohomish County with its Average Daily Bed Rate.
22.	 This report identifies gender in a binary fashion,
“men” and “women.” The authors could not find
information regarding people who are transgender,
intersex or otherwise gender non-conforming in jails
in Washington from any source. The information
provided by jails did not include any gender markers
other than traditional binary indicators. The authors
hope that more precise records and analysis can be
conducted in the future in order to understand the
impacts that jail life has upon all people.
23.	 See U.S. Census Bureau, Statistics for Washington,
https://www.census.gov/quickfacts/wa. The
information regarding demographics of the jail
population from 2005 to 2015 comes from
aggregating data from WASPC, Washington State
Jail Statistics – County, Regional, City and Tribal,
https://www.waspc.org/crime-statistics-reports.
24.	 Jetzer Report, supra note 13, at 3.
25.	 A recent study of people in Washington indicates
that 58% of people who both receive Medicaid and
had at least one stay in jail have significant mental
health treatment needs, compared to only 42% of
all people who receive Medicaid. In addition, six in
ten people entering jail had substance use disorder
treatment needs and four in ten had co-occurring
disorder indicators. See DSHS Research and Data
Analysis Division, Behavioral Health Needs of Jail
Inmates in Washington State, 1 (January 2016),
https://www.dshs.wa.gov/sites/default/files/SESA/
rda/documents/research-11-226a.pdf.
26.	 Id.
27.	 See Doris J. James & Lauren E. Glaze, BJS Special
Report: Mental Health Problems of Prison and Jail
Inmates, 1 (September 2006), https://www.bjs.gov/
content/pub/pdf/mhppji.pdf.
28.	 Id. at 3.
29.	 Id. at 10.
30.	 Roughly two-thirds of women detained in jails
reported having had a chronic medical condition,
while just under half of men in jail reported the
same. Id. at 5.
31.	 Id.
32.	 For example, rates of high blood pressure among
detainees increased by nearly 50%, and rates of
diabetes doubled between 2004 and 2012. Id. at
6-7.
33.	 See generally DSHS Behavioral Health Needs
Study, supra note 24; and Disability Rights
Washington reports, supra notes 4 & 10.
Gone But Not Forgotten

34.	 We have had difficulty determining the actual
number of deaths with precision given the limited
information available in many cases. For example,
the Bureau of Justice Statistics has reported data
on jail deaths only through 2014. The authors
attempted to be as precise as possible, but
acknowledge that the actual number of deaths
may be slightly greater or slightly fewer than 210.
Counted deaths include deaths that occurred in
a hospital following an event that occurred within
a jail. They do not include deaths that occurred
while a person was living in the community on work
release, furlough, probation, or electronic home
monitoring.
35.	 Our review indicates that jail deaths did not
disproportionately impact any particular racial or
ethnic group, with one exception: Native people died
in jail at a higher rate than the population of Native
people in jails. However, the small sample set of
Native people who died makes it difficult to draw
any conclusion with significant certainty.
36.	 These percentages are based solely upon
those deaths for which a length of stay could be
calculated. It was not possible to calculate how
long the person had been incarcerated before her
death in 48 circumstances because of incomplete
available information.
37.	 Drug or alcohol-related deaths included those in
which the person was under the influence at the
time of her death, suffering from withdrawal or
likely suffering withdrawal at the time of her death.
Alcohol or drugs was involved in 67% of deaths
within the first 72 hours, while ten suicides that
appear unrelated to drugs or alcohol occurred
during that same period.
38.	 The Jetzer Report includes data regarding
the charging offenses that people booked into
Washington jails face. However, the categories
included in that report are not the same as
identified here. Jetzer reports that 30% of detainees
face gross misdemeanor charges, 21% other types
of charges, including violent felonies, 10% other
misdemeanors, 13% for violations of community
custody or warrants for failure to appear. Jezter
Report, supra note 13, at 3.
39.	 During the period studied, 24 jails reported no
deaths, nine reported one death, 17 reported
between two and ten deaths and seven reported
more than ten deaths. The 33 jails that reported no
deaths or only one death are generally very small
local or county jails that collectively house only 12%
of the total statewide jail population. See Appendix.
40.	 National Institute of Corrections presentation,
Basics and Beyond: Suicide Prevention in Jails, slide
6, https://s3.amazonaws.com/static.nicic.gov/
Library/026251.pdf.
41.	 Linda Peckel, Preventing Suicide in Prison Inmates,
28

Psychiatry Advisor (December 2017), https://www.
psychiatryadvisor.com/home/topics/suicide-andself-harm/preventing-suicide-in-prison-inmates.
42.	 See De Vincenzi v. City of Chico, 592 F. App’x 632,
634 (9th Cir. 2015) (“the officers’ duty to provide
medical care, including suicide prevention, [is]
clearly established”) (citation omitted); Clouthier v.
County of Contra Costa, 591 F.3d 1232, 1244-45
(9th Cir. 2010) (failure to follow appropriate suicide
prevention practices can violate constitutional
obligations).
43.	 J. Richard Goss et al., Characteristics of Suicide
Attempts in a Large Urban Jail System With an
Established Suicide Prevention Program, 53
Psychiatric Services 574, 574 (May 2002), https://
ps.psychiatryonline.org/doi/pdf/10.1176/appi.
ps.53.5.574.
44.	 Our review indicated that at least 40% of all
suicides happened while in solitary confinement.
However, the number is likely far greater, because
limitations in the records did not allow us to
determine the location of each suicide or whether it
occurred during a period of isolation.
45.	 Lindsay M. Hayes, National Study of Jail
Suicide – 20 Years Later, 50 (April 2010),
https://s3.amazonaws.com/static.nicic.gov/
Library/024308.pdf.
46.	 See Peckel article, supra note 41.
47.	 Transgender people who are incarcerated are at
very high risk of sexual assault and other forms of
violence. In addition, many jails place transgender
people in solitary “protective custody”. See National
Center on Transgender Equality, LGBTQ People
Behind Bars: A Guide to Understanding the Issues
Facing Trans- gender Prisoners and Their Legal
Rights, 13-14 (October 2018), https://transequality.
org/transpeoplebehindbars. Being a victim of
sexual assault and being placed in isolation are
two significant risk factors for suicidal thoughts and
actions.
48.	 See National Institute of Corrections presentation,
supra note 40, at slides 13-14.
49.	 Suicide Prevention Resource Center, What
Corrections Professionals Can Do to Prevent
Suicide, 2 - 3 (October 2017), https://ubhc.rutgers.
edu/tlc/docs/suicideAwareness/SPR/SPRC%20
Corrections%20Professionals.pdf.
50.	 National Commission on Correctional Health Care
(NCCHC), Standards for Health Services in Jails,
Standard J-G-05 Suicide Prevention Program, 119
(2014).
51.	 Lucinda Grande & Marc Stern, Providing Medication
to Treat Opioid Use Disorder in Washington State
Jails, 5 (July 3, 2018), https://www.waspc.org/
assets/docs/opioid%20treatment%20in%20jail%20
-%20final%20pdf.pdf.
52.	 Center for Health & Justice at TASC, Safe
Gone But Not Forgotten

Withdrawal in Jail Settings: Preventing Deaths,
Reducing Risks to Counties and States, 1 (January
2018), http://www2.centerforhealthandjustice.
org/sites/www2.centerforhealthandjustice.org/
files/publications/Safe%20Withdrawal%20in%20
Jail_010918.pdf.
53.	 Grande Report, supra note 51, at 5.
54.	 Id.
55.	 See Appendix.
56.	 TASC Report, supra note 52, at 2.
57.	 While variable between people, major withdrawal
symptoms from opioids peak between 24–48 hours
after the last dose and subside after about a week.
https://www.drugabuse.gov/publications/researchreports/heroin/what-are-long-term-effects-heroinuse. Withdrawal from alcohol peaks with 48-72
hours and can last weeks. https://medlineplus.gov/
ency/article/000764.htm.
58.	 TASC Report, supra note 52, at 1.
59.	 NCCHC Jail Standards, supra note 50, Standard
J-G-07 Intoxification and Withdrawal, at 125.
60.	 The author of this report, Columbia Legal
Services’ Institutions Project, represents men and
women locked up in jails and prisons throughout
Washington. In that capacity, we have spoken
with hundreds of prisoners from all over the state
regarding the conditions they face. Many have
shared terrible stories of suffering from withdrawal
after being booked into jails.
61.	 Grande Report, supra note 51, at 5
62.	 Id.; TASC Report, supra note 52, at 2.
63.	 Grande Report, supra note 51, at 5.
64.	 Id. at 15.
65.	 See e,g, Pesce v. Coppinger, 355 F.Supp.3d 35,
45-48 (D. Mass. 2018) (correctional system’s
refusal to provide methadone treatment likely
violates ADA and 8th Amendment prohibition on
cruel and unusual punishment); Villareal v. County
of Monterey, 254 F.Supp.3d 1168, 1183 (N.D. Cal.
2017) (county sheriff can be held liable for jail’s
failure to properly care for woman in withdrawal).
66.	 Grande Report, supra note 51, at 7 and 13.
67.	 One detainee was killed by a correctional officer
who shot him during the course of an escape. Other
deaths occurred as a result of “excited delirium,”
with few other details provided. “Excited delirium”
is a condition that occurs suddenly, with symptoms
of bizarre and/or aggressive behavior, shouting,
paranoia, panic, violence toward others, unexpected
physical strength and hyperthermia. Often times
the use of stimulants, like methamphetamine or
cocaine, and the use of restraints or physical control
tactics by law enforcement or correctional officers
are correlated with the on-set of fatal episodes of
excited delirium. Asia Takeuchi, Terence L. Ahem,
Sean O. Henderson, Excited Delirium, West J.
Emerg. Med. (February 2011), https://www.ncbi.
29

nlm.nih.gov/pmc/articles/PMC3088378/. A death
by excited delirium likely involves a number of
different factors including “positional asphyxia,
hyperthermia, drug toxicity, and/or catecholamineinduced fatal arrhythmias.” Mohammad Otahbachi
et al., Excited Delirium, Restraints, and Unexpected
Death: A Review of Pathogenesis, Amer. J of
Forensic Med. and Pathology (June 2010).
68.	 “The physical and mental health needs of inmates
can place significant stress on COs, particularly
among treatment and medical staff.” Jaime Brower,
Correctional Officer Wellness and Safety Literature
Review, 5 (July 13), https://s3.amazonaws.com/
static.nicic.gov/Public/244831.pdf.
69.	 Community based interventions for people living
with mental illness leaving prisons and jails have
been shown to reduce recidivism, substance use,
suicidality, and psychiatric hospitalizations. See
generally E. Fuller Torrey et al., More Mentally Ill
Persons Are in Jails and Prisons Than Hospitals: A
Survey of the States, Mental Illness Policy Org. (May
2010), https://mentalillnesspolicy.org/ngri/jails-vshospitals.html.
70.	 The NCCHC recommends that every detainee
receive a full medical and mental health evaluation
within 14 days of admission. NCCHC Jail Health
Standards, supra note 50, Standard J-E-04 Initial
Health Assessment, at 76. However, waiting for 14
days to conduct such evaluations would have had
no impact on the vast majority of deaths, 73% of
which occurred within the first 14 days of admission.
71.	 NCCHC Jail Health Standards, supra note 50,
Standard J-G-07 Intoxication and Withdrawal, at
124-25.
72.	 Such validated assessments include the Clinical
Opiate Withdrawal Scale or the Objective Opiate
Withdrawal Scale and the Clinical Institute
Withdrawal Assessment of Alcohol Scale. See id.
73.	 Hayes Report, supra note 45, at xiii.
74.	 Each jail must integrate questions regarding suicide
risk into their initial intake questionnaires. The
Hayes Report sets out a list of questions that all
detainees should be asked. Id. at 48.
75.	 Jails should utilize other available sources of
information in order to make these determinations,
including records of prior incarcerations that
indicate a history of suicidal acts, information from
relatives or friends, prior statements the person has
made and records from community based health
providers. However, care must be taken to ensure
that jails do not make assumptions about suicidality
based on gender identity or other characteristics
that do not have any correlation to suicidal actions.
76.	 See RCW 43.101.450 & .452
77.	 See Department of Mental Health and Substance
Abuse, World Health Organization, Preventing
Suicide In Jails and Prisons, 14 (2007), https://
Gone But Not Forgotten

www.who.int/mental_health/prevention/suicide/
resource_jails_prisons.pdf. Such profiles must be
based solely upon actions that indicate a potential
likelihood for suicide and must be regularly updated
to reflect current evidence based thinking. Id. at 14.
Stereotypes based upon gender identity or other
characteristics which do not correlate to suicidality
should not be relied upon.
78.	 RCW 43.101.455(2)(a)
79.	 RCW 43.101.455(2)(b)-(f)
80.	 See WAC 139-10-230 Basic Corrections Officer
Academy Curriculum.
81.	 See NCCHC, Standards for Health Services in Jail
(2014); also NCCHC, Standards for Mental Health
Services in Correctional Facilities (2015).
82.	 NCCHC Jail Health Standards, supra note 50,
Standard J-A-10 Procedure in the Event of an
Inmate Death, at 22.
83.	 Id.
84.	 See Hayes Report, supra note 45, at 39. The
NCCHC standards require that all deaths are
reviewed within 30 days and that such reviews
include an administrative review, a clinical mortality
review and a psychological autopsy when suicide is
the cause. NCCHC Jail Health Standards, supra note
50, at 22.
85.	 Records from such serious incident reviews and
discussions during these reviews could be protected
from discovery during litigation. See for example,
RCW 70.41.200, which allows hospitals to refuse
to disclose certain documents created as part
of internal examinations of negative health care
outcomes.
86.	 Jonathan Glover, Spokane County Jail Records
Eighth Inmate Death in 14 Months, The Spokesman
Review (August 26, 2018), http://www.spokesman.
com/stories/2018/aug/26/spokane-county-jailrecords-eighth-inmate-death-in/.
87.	 Zachariah Bryan, New Documents Shed Light on
Fatal Struggle in County Jail, The Everett Herald
(October 18, 2018), https://www.heraldnet.com/
news/new-documents-shed-light-on-fatal-strugglein-county-jail/; Sidney Brownstone, She Was Jailed
for Shoplifting. A Month Later She Was Dead, KUOW
(February 7, 2019), https://www.kuow.org/stories/
their-daughter-died-after-being-booked-into-thesnohomish-county-jail-they-want-to-know-why.

30

Appendix

Adams
Asotin
Benton
Chelan
Clallam
Clark
Columbia
Cowlitz
Enumclaw
Ferry
Fife
Franklin
Garfield
Grant
Grays Harbor
Island
Jefferson
Kent
King
Kirkland
Kitsap
Kittitas
Klickitat
Lewis
Lincoln
Mason
Nisqually
Okanogan
Other city jails
Pacific
Pend Oreille
Pierce
San Juan
SCORE
Skagit
Skamania
Snohomish
Spokane
Stevens
Thurston
Wahkiakum
Walla Walla
Whatcom
Whitman
Yakima

Gone But Not Forgotten

Percentage Percentage
of Total Bed of Total Bed
Space
Usage
0.20%
0.24%
0.16%
0.57%
5.28%
4.95%
2.74%
2.49%
0.86%
1.01%
5.86%
6.52%
0.06%
0.05%
2.55%
2.33%
0.17%
0.17%
0.32%
0.23%
0.24%
0.20%
1.64%
1.69%
0.11%
0.06%
1.32%
1.57%
0.59%
1.33%
0.41%
0.47%
0.35%
0.35%
0.84%
1.04%
18.54%
17.73%
0.42%
0.30%
3.65%
3.42%
1.64%
0.78%
0.35%
0.40%
2.47%
1.59%
0.18%
0.21%
0.74%
1.12%
0.02%
0.02%
1.31%
1.53%
3.95%
4.45%
0.21%
0.35%
0.27%
0.20%
12.88%
9.89%
0.03%
0.02%
5.74%
5.15%
0.59%
1.82%
0.34%
0.24%
8.82%
8.60%
4.81%
7.84%
0.29%
0.37%
3.51%
3.78%
0.10%
0.09%
0.82%
0.62%
2.13%
3.18%
0.24%
0.32%
7.88%
6.90%

Total
Deaths
0
1
13
3
1
22
0
7
1
0
1
4
0
1
1
2
0
2
33
2
5
3
2
3
0
2
1
4
0
0
0
22
0
5
5
0
15
20
1
3
0
2
7
1
15

Total
Suicides
0
0
4
2
1
16
0
2
0
0
0
1
0
1
0
0
0
1
9
1
4
1
2
3
0
2
0
2
0
0
0
9
0
0
3
0
5
5
0
3
0
0
4
1
7

Percentage
of Total
Percentage
Deaths
of Suicides
0.00%
0.00%
0.48%
0.00%
6.19%
4.49%
1.43%
2.25%
0.48%
1.12%
10.48%
17.98%
0.00%
0.00%
3.33%
2.25%
0.48%
0.00%
0.00%
0.00%
0.48%
0.00%
1.90%
1.12%
0.00%
0.00%
0.48%
1.12%
0.48%
0.00%
0.95%
0.00%
0.00%
0.00%
0.95%
1.12%
15.71%
10.11%
0.95%
1.12%
2.38%
4.49%
1.43%
1.12%
0.95%
2.25%
1.43%
3.37%
0.00%
0.00%
0.95%
2.25%
0.48%
0.00%
1.90%
2.25%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
10.48%
10.11%
0.00%
0.00%
2.38%
0.00%
2.38%
3.37%
0.00%
0.00%
7.14%
5.62%
9.52%
5.62%
0.48%
0.00%
1.43%
3.37%
0.00%
0.00%
0.95%
0.00%
3.33%
4.49%
0.48%
1.12%
7.14%
7.87%

31

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Columbia Legal Services advocates for laws that advance social,
economic, and racial equity for people living in poverty.

www.columbialegal.org
/ColumbiaLegalServices

@columbialegal

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