In 2015 a mentally ill inmate in Santa Clara County’s main jail was found beaten to death in his cell.

Michael Tyree, 31, suffered from bipolar disorder and addiction. He was jailed for two weeks for a minor violation of his probation. The judge wanted to send him to a community facility for treatment, but no bed was available.

Tyree died on August 27. His body was covered with feces, vomit and bruises.

We wanted to know: Was Tyree’s death an anomaly, or evidence of systemic deficiencies that could lead to more deaths?

The county medical examiner said he died from massive internal bleeding from blunt force trauma. Dr. Joseph O’Hara later testified that the most brutal of Tyree’s injuries were equivalent to being hit with a truck.

Three jail deputies have been charged with his murder.

Tyree’s death raises serious questions about the safety and welfare of mentally ill offenders in jails. It comes at a time when jails throughout the nation are struggling with an increasing number of mentally ill people.

Santa Clara Isn’t Alone

In California, the problem is compounded by what amounts to a massive statewide experiment. A 2011 law enacted to comply with a U.S. Supreme Court order to reduce crowding in state prisons shifted responsibility for certain low-level felons to jails. Many local lockups were unprepared to deal with the arrival of often seriously afflicted prisoners. At the same time, state hospitals became overcrowded, leaving mentally ill inmates languishing for six months or more in jails with inadequate treatment facilities.

When we began our investigation attorneys for inmates had already filed class-action suits against Monterey, Santa Clara and Riverside counties describing gross lapses in health care for inmates. Disability Rights California was in negotiations to improve jail conditions in six counties, including San Diego. During our reporting the non-profit settled with Santa Barbara, Sacramento and Sonoma counties. The agency’s discovery of Sonoma County’s mishandling of involuntary medication became the focus of one of our stories.

Advocates and lawyers told us they were receiving complaints from inmates in more counties than they had the resources to investigate. They said most mentally ill inmates were not getting treated for their conditions. Those who were received the lowest levels of care: medication and infrequent cell-front visits with a psychiatrist or psychiatric nurse conducted through the food slot of the inmate’s cell door. Jail staff appeared poorly trained to cope with mentally ill inmates — sometimes resorting to excessive force.

The Series

In March, we reported on the deaths of Walter Roches and Michael Tyree. Several weeks after our story aired an independent task force convened after Tyree’s death presented 120 recommendations to the county board of supervisors. Their main recommendation: Remove jail operations from the sheriff. While the Supervisors unanimously accepted the recommendations they have not acted on all. The sheriff still shares oversight of county jails and an independent inspector general has not been appointed. Currently, the jail is also being sued by inmate-rights groups. Three deputies are also being tried for the death of Tyree.

Next, we examined Sonoma County jails after discovering that the county was spending more on psychotropic medications than other jurisdictions. During the process of our reporting Disability Rights California discovered that the county was improperly involuntarily medicating inmates. We were able to tour the jail and speak to jail staff about their policies before the change. The jail announced that they were changing their policy the week our story aired. Forum also hosted an episode with the sheriff’s department and Disability Rights California.

But in terms of human life lost one county stood out: San Diego.

There were more than two dozen San Diego County jail suicides between 2010 and 2015, a string of deaths that significantly exceeds the number seen in other counties. Statewide in 2015, one in four inmates who died in county jails took their own lives. But in San Diego County, half of deaths were from inmates taking their own lives. The deaths have prompted a series of lawsuits against the county and its Sheriff’s Department, which runs the jails, and has raised questions about whether the county is doing enough to stop seriously mentally ill inmates from harming themselves. Read the full story.

Outside outlets picked up on our reporting. NPR, PBS and the Marshall Project all shared the online story on Facebook and Twitter. Rough and Tumble and Politico also highlighted the stories in their newsletters.

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