The practice of locking up people who are chronically sick, mentally ill or drug addicted in under-resourced city, county and regional jails in Washington is resulting in inmate deaths and a failure to “treat all people humanely, respectfully, and safely,” according to a new report by the statewide nonprofit law firm Columbia Legal Services.
The 31-page report, “Gone But Not Forgotten: The Untold Stories of Jail Deaths in Washington,” identifies 210 inmates -- ages 18 to 82 -- who died between 2005 and 2016 in 54 jails across the state.
“They were too often people whom society had ignored and thrown away, people fighting addiction, homelessness, mental illness, ill health, and poverty,” the report said.
Suicide was the leading cause of death followed by illness. Nearly 20% of deaths among female inmates were the result of drug or alcohol withdrawal. The vast majority of deaths happened within 14 days of someone being admitted to jail.
They included 24-year-old Lindsay Kronberger who was found “face down in her cell’s toilet” in the Snohomish County Jail in January 2014. Kronberger, a former high school athlete who became addicted to heroin, died from “dehydration-triggered cardiac arrest,” according to the report. During the nine days leading up to her death, Kronberger exhibited signs of heroin withdrawal, including vomiting and diarrhea. She lost eight pounds and could barely walk because she was so weak.
“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,” the report said.
The report reinforces the findings of an investigation earlier this year by Oregon Public Broadcasting, KUOW and the Northwest News Network that identified 306 deaths in Washington and Oregon county jails between 2008 and 2018.
In that investigation, “Booked and Buried: Northwest Jails’ Mounting Death Toll,” the news outlets found that at least 70% of the inmates who died had not yet been convicted. Nearly half the deaths were from suicide and people of color were disproportionately represented in jail deaths.
The Columbia Legal Services report, which draws remarkably similar conclusions about who’s dying in jail, lays blame not just on jails, but on a lack of diversion options for people with serious medical and behavioral health needs.
“We have locked up too many people for the wrong reasons,” said Nick Straley, an attorney with Columbia Legal Service’s “Institutions Project” and the lead author of the report. “We have utilized jails now as the primary mental health facilities in our state and we have criminalized substance use disorders.”
The report recommends systemic fixes to address jail deaths, including:
- Increasing diversion programs
- Eliminating the use of cash bail
- Ending the practice of isolating suicidal inmates
- Requiring thorough health reviews and exams of all inmates
- Implementing overdose and drug withdrawal protocols and medicine assisted treatment
- Adopting statewide jail standards and oversight. Increasing funding to ensure jails are adequately staffed
- Training jail staff in de-escalation and crisis intervention techniques to minimize use of force
- Requiring jails to review and report all serious incidents and deaths
“Implementing these relatively few reforms will dramatically reduce the number of people injured, disabled, or killed in our jails,” the report said.
According to Columbia Legal Services, Washington is one of 17 states without state oversight of local jails. In addition, Washington jails often refuse to release information, even after the death of an inmate, citing an exception in the state’s Public Disclosure Act that restricts the release of “records of a person confined to a jail.”
“Absent legislative changes to mandate some level of oversight, jails will continue to operate without transparency or real accountability,” the report said.
Jails with disproportionately high rates of deaths included Clark, Cowlitz, Okanogan, Spokane and Whatcom counties, according to the report.
In some cases, the report found, Washington jails were employing suicide prevention practices that put inmates at more risk, not less. These included placing suicidal inmates on “suicide watch” in isolation cells and not giving them adequate supervision.
Sometimes the isolation cells, the report said, lacked running water and the inmate was forced to use a “grated hole in the floor” to go to the bathroom.
Often, suicidal inmates are stripped of their belongings and put in a suicide smock or even shackled, according to the report.
“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,” said the report.
While men make up the majority of suicides, the report found that women have a higher risk for suicide behind bars.
Women were also much more likely to die from a drug or alcohol related death in jail. That was a factor in more than half the deaths of female inmates and in 38% of all inmate deaths.
In some cases, inmates overdosed from drugs or alcohol while in custody. The report recommends that all jails have a “ready supply” of Naloxone, a drug that can reverse the effects of an opioid overdose.
In other cases, inmates died from drug withdrawal. The Columbia Legal Services report highlights six deaths where withdrawal symptoms allegedly weren’t properly treated.
The report calls on jails to implement medication-assisted treatment for inmates withdrawing from heroin and opioids.
“Failure to treat opioid use disorder during incarceration has serious consequences, including an extremely high risk of death of overdose death,” the report said.
Another issue the report highlights are inmates who die from a serious medical conditions -- like sepsis, pneumonia and staph infections -- that jailers misdiagnosed as drug withdrawal related. The report identified 62 deaths that could be tied to deficient medical or mental health care in a jail.
“Health care needs to be provided in a much more comprehensive and appropriate way in many county jails,” Straley said.
In other cases, the report said, inmates died because jail staff didn’t ensure they got enough food and water.
The report also found that 16 Washington inmates died after jailers used force, including Tasers, restraints or “physical takedowns.”
The report recommends better training and supervision of staff with an emphasis on de-escalation, crisis intervention and cultural competency. Columbia Legal Services is also calling for new laws to restrict the use of restraint chairs, Tasers and pepper spray in jail.
Washington lawmakers this year funded several initiatives designed to reduce jail populations. They include more mental health and substance abuse services, additional crisis triage beds and new jail diversion programs.