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Lawsuit: Jailers let mentally disabled man starve to death

After Mitchell tried to flush his clothing down the toilet, guards took his clothes, mattress, sheet and
blankets, leaving him to sleep on a "metal sheet," according to the lawsuit.
When Mitchell was fed, Dillon said, he ate voraciously, often using the same hands he used to smear
his feces on the window.
The office slammed NaphCare for failing to respond to Mitchell's weight loss, his refusal to eat and
his inability to care for himself, in addition to failing to treat his psychosis.
A state Department of Behavioral Health and Development Services investigation found at least 10
other similar orders in the same behavioral health official's drawer, the lawsuit states.
Post-mortem outcry
The Portsmouth Department of Behavioral Healthcare Services said Mitchell was a candidate for a
jail diversion program, but he wouldn't accept services. The same day, the city jail documented again
that the "inmate continues to be psychotic," according to the suit.
Even after the cleaning, the chief medical examiner's office noted the cell's "foul odor."
The prisoners said they also witnessed guards spraying a water bottle in Mitchell's face, kicking him,
handcuffing him and leaving him naked in the hallway, abusing him outside the range of prison
surveillance cameras, taunting him by leaving food outside his cell, and punching and twisting his
arm as he reached through the chuck hole for food.
By the time Mitchell died in August -- officially, of a heart condition "accompanying wasting
syndrome of unknown etiology" -- jail staff had allegedly denied him many meals, cut off the water to
his cell and left him naked with no bedding or shoes as he smeared feces on the window of his urinecovered cell, the lawsuit states, citing numerous inmates who served time with Mitchell.
When a guard tried to clean Mitchell's cell, it earned the howl of his fellow inmates, who accused the
guard of "tampering with a crime scene," the lawsuit states.
Fellow inmates, too, were shocked, not only by Mitchell's appearance, but also by his behavior and
the jailors' treatment of their counterpart, the lawsuit says.
On August 16, Mitchell told Dillon he was sick. Dillon told guards, "but they ignored Dillon's
concerns," the lawsuit states.
On June 11, according to the lawsuit, Mitchell asked a health care provider, whom he thought was
the U.S. president, to touch his eye and give him a kiss, prompting a report that the "patient appears
to remain psychotic."
Later, Mitchell wouldn't get out of bed, wouldn't take his dinner tray and didn't respond when
Vaughan called to him, the lawsuit states.
Mitchell lost about 40 pounds during his time in jail, documents say. A medical examiner said he was

"nearly cachectic," meaning his weight loss could not be reversed via nutrition.

Not only were there no backlogs, according to the report, but between May 21, when the judge
issued the order, and August 19, "there was only one day when all beds were full."
Days before death
Vaughan two days later saw Mitchell slumped over the sink in his cell, his legs sticking out.
"I watched a physically healthy young man grow into a physically broken old man in a matter of
months," Gray wrote.
A statement from an attorney for Birmingham, Alabama-based NaphCare, which no longer provides
health care at the jail, called Mitchell's death a tragedy and said NaphCare's employees "took
appropriate steps" to have him transferred to a state mental health facility.
CNN's Joshua Berlinger and Tony Marco contributed to this report.
The order was reportedly sent May 27, but the lawsuit says there is no proof it was mailed, and an
investigation conducted by the Virginia Department of Behavioral Health & Developmental Services
showed no record of the hospital receiving it.
Inmate Dominique Vaughan backed Dillon's account that the guards withheld food from Mitchell and
would sometimes deny him water, according to the lawsuit. Mitchell was sometimes so famished,
he'd request extra food, which was denied, Vaughan alleged.
In his cell with the Plexiglass window, Mitchell would whistle, make noises and talk to other inmates
through the gap between the doorjamb and door.
The judge issued a competency restoration order, which required Mitchell be transferred to Eastern
State Hospital, a mental health facility in Williamsburg, roughly 50 miles north of Norfolk.
Though jail officials said Mitchell refused the drugs, "those statements suggest an informed and
conscious decision, which Mitchell was incapable of making," the lawsuit says, adding that guards
would encourage nurses to ignore him because he was "crazy."

About six weeks later, after doctors were unable to conduct a mental status exam because Mitchell
was so aggressive, the jail discontinued his medication because he refused to take it, the lawsuit
states.
No cause was determined. Mitchell now weighed 145 pounds.
"Throughout the past few months, the Department of Behavioral Health and Developmental Services
has recognized and taken a number of steps to reduce the forensic wait list," she said in an email to
CNN. "Serving individuals with mental illness, who are involved in the criminal justice system, is a
multifaceted process, and we will continue to work with other state and local entities to ensure that
this population's needs are effectively served."
Mitchell "LACKED," the doctor wrote in capital letters for emphasis, "the capacity to assist counsel
in preparing a defense."
At the time of his arrest, the 6-foot-1 Mitchell weighed 180 pounds. He had just turned 24 two days
before.
She said the department is taking steps to shorten wait times for those being transferred for mental
health treatment, including hiring an employee to triage those on the wait list.
Repeated diagnoses
Transfer to Hampton Roads
"Day after day, he stood cold and naked at the doorway to his cell. He did not have any shoes to
insulate his feet from the frigid cement floor," the lawsuit says, adding that Mitchell told another
inmate he stood there for the warmth from an overhead light.

After his arrest, Mitchell was sent for a medical screening at Portsmouth City Jail, which determined
Mitchell's "thought process does not make sense." On April 24, he was said to have "delusions," the
lawsuit states.
Mitchell was found in his cell not breathing and without a pulse August 19. He weighed 144 pounds.
The lawsuit further says that between April and September, the waiting list for state mental health
beds never topped 45, while the number of beds never sunk below 176.
Before Mitchell went to jail, a Portsmouth Department of Behavioral Healthcare Services employee
would take Mitchell to a clinic every two weeks for an injection of psychotropic drugs.
Doctors diagnosed him with edema, hypoalbuminemia, which is low levels of a blood protein possibly
resulting from malnutrition, and elevated transaminase, a possible indicator of liver damage.
In jail, Mitchell received "virtually no psychotropic medication," and a month before his death all his
medication was discontinued, the lawsuit alleges.

A doctor conducted a May 20 psychological


evaluation, in which he documented that Mitchell
had "psychotic and grandiose ideas," according to
the lawsuit. He was unable to coherently discuss his
case, and during a break in the evaluation the
doctor heard Mitchell "singing and yelling
incomprehensibly."
Former inmate Reginald Morst recalled being
ordered to clean Mitchell's cell. He almost vomited
upon entering.
On May 11, Mitchell was transferred to the Hampton Roads Regional Jail in Portsmouth. His file
noted he needed medical treatment, including psychotropic medications, and advised he should be
monitored as a suicide precaution.
Maria Reppas, spokeswoman for the Virginia Department of Behavioral Health and Developmental
Services, told CNN that her department would not comment on Mitchell's specific case beyond the
reports that have already been released publicly.
Defendants mum
On April 29, he was labeled "very psychotic -- delusional" and those charged with screening him said
he "rambles from subject to subject" and asked where tech icon Bill Gates and Steve Jobs were. A
judge the next day ordered a psychological evaluation, the lawsuit states.
Inmates said they pleaded with guards to help Mitchell during his stay, but their pleas were ignored
or disregarded, according to the lawsuit.
"Get help. I can't move," Mitchell told Vaughan, but when Vaughan tried to get help, the guards
ignored him, according to the lawsuit.
Mitchell had a history of mental illness. He was diagnosed as mildly intellectually disabled in fourth
grade, and the next year as bipolar schizophrenic. Well behind his classmates in his studies, he
dropped out of school in the 10th grade, according to the lawsuit.
Jeff Rosen, an attorney representing the jail, could not be reached for comment.
Dillon never saw Mitchell wearing clothes, he said, describing his fellow inmate during his finals
days as "all skin and bones. He looked sick."

He was also "forced to the ground, dragged, sprayed with mace, stood upon," and Mitchell could be
heard weeping in his cell after the abuse, the lawsuit says.
Despite a state behavioral health official saying backlogs were responsible for the court order that
Mitchell be moved to a hospital being found in a desk drawer, a report last month by the Office of
the State Inspector General determined otherwise.

"Their beloved Jamycheal, despite his struggles with mental illness, had been a vibrant young man
who loved music and always made people laugh. In his place was a withered figure the family could
hardly recognize," the lawsuit says.
The lawsuit claims that NaphCare and corrections officers could have intervened on many occasions,
either by informing the court that the hospital hadn't yet admitted Mitchell, or by advising the judge
of his deterioration, his refusal to take medicine and "the danger to him absent court-ordered
treatment."
His aunt said she didn't even recognize Mitchell when she saw his body. She asked if officials were
sure they had the right person, she told WTKR.
"If he would've gone to Eastern State (mental health facility), we wouldn't be going through what
we're going through now," she told the station.
On numerous occasions during his incarceration, Mitchell was denied his medications, the lawsuit
alleges. Sometimes he refused them outright; other times he became aggressive, cursing and at
least once spitting on a nurse and corrections officer. In a handful of instances, jail staff noted that
he would dip his finger in the crushed drugs and pretend to put them in his nose as if he was using
cocaine, the lawsuit states.
Adams is demanding a jury trial and at least $60 million in a lawsuit that alleges willful and wanton
negligence and five counts of civil rights deprivation.
Trip to hospital
"As long as he doesn't die on my watch," one inmate recalled being told.
"As the individual was thought to lack capacity to assist an attorney in his own defense, expectations
that the individual would have the ability to seek out medical treatment independently while acutely
symptomatic seem unreasonable and likely to fail," the report said.
Former inmate Justin Dillon has told media outlets, including The Washington Post and CNN affiliate
WAVY, that the guards wouldn't feed Mitchell because he refused to return the trays from his
previous meal through the "chuck hole" in the cell door.
Inmate Steven Gray said in a letter to Mitchell's family that Mitchell was sometimes denied food "for
days at a time."
"When you opened his slot, you smelled this horrific smell. It was like walking in the forest after
something had died," Morst said, according to the lawsuit. "Everyone in the jail knew of (Mitchell).
He was always in his cell screaming."
Mitchell's family, including Adams, his aunt, were shocked by his gaunt appearance. Adams
estimated that she called more than 40 times to express her concerns. Jail staff, the lawsuit states,
told Adams and Mitchell's mother that they weren't on the visitor's list, and therefore were unable to
see him.
The 112-page lawsuit filed last week outlines the litany of allegations against 39 defendants,
including the Hampton Roads Regional Jail, the state Department of Behavioral Health &
Developmental Services and the private prison health care firm, NaphCare.

The two-person confinement reeked of feces and urine, and "indicative of the depth of his mental
illness, and/or out of an effort by him to simply be noticed and helped, Mitchell smeared feces on the
Plexiglass window to his cell," the lawsuit says.
The next month, the jail would again report problems with Mitchell, and again it invoked the words,
psychotic and delusional. A May 2015 report said Mitchell was disoriented, speaking loudly and
having hallucinations.
He was given a consultation with a gastrointestinal doctor, but in the almost three weeks between
the hospital visit and Mitchell's death, he had no followup visits, according to the lawsuit.
"The investigative reports of his death suggest gaps and failures within the state's mental health
system prevented Mr. Mitchell from receiving the inpatient care he needed," it said. "The allegations
of indifference and neglect against NaphCare's providers are false and unfounded. NaphCare will
vigorously defend these false allegations."
Mitchell continued to be uncooperative when he was taken to Bon Secours Maryview Medical Center
in Portsmouth on July 30 to have the swelling in his feet and legs -- which one fellow inmate
described as "elephant like" -- examined.
At the time, he falsely claimed his father owned the store, and the treats were his, the lawsuit states.
He was held on a theft charge, as well as a count of trespassing because he had previously been
banned from the store.
He weighed 178 pounds.
Wasting syndrome and cachectic are terms most often used with sufferers of chronic disease such as
cancer and AIDS.
Jail spokesman Lt. Col Eugene Taylor said, "We really can't speak about the Jamycheal Mitchell case
at all," citing advice from counsel.
The story of Mitchell's demise begins April 22, 2015, when the Portsmouth man was arrested for
stealing a 2-liter bottle of Mountain Dew, a Snickers and a Little Debbie Zebra Cake from a 7-Eleven.
"Inmate continues to present as acutely psychotic -- deputies report that he goes for hours just
yelling," the report said, according to the lawsuit.