Photo via justicenotjails.org
Before breakfast on Saturday, November 8, 2014, at the Century Regional Detention Facility--or CRDF as the women's jail in the Los Angeles County system is most commonly known--an inmate named Unique Moore started coughing and complained that she couldn't breathe. Moore, a 37-year-old African American woman, had a history of diabetes, asthma, and severe mental illness.
When Moore was arrested three weeks earlier for a violation of the terms of her probation, she reportedly informed jail officials at intake that she had a long history of asthma, and that if she had an episode in which she had difficulty breathing, it could be fatal without the proper first aid.
She would need her inhaler.
Once inside the jail, Moore was prescribed various medications for her mental condition, including the antipsychotic Seroquel that, in 2011, the FDA found posed dangers of sudden cardiac death. But it was the threat of an asthma attack that worried her.
According to a new civil lawsuit filed by her parents, Elaine Bridges and Jimmie Lee Moore, Unique Moore's fears of an asthma attack came to pass around 6 a.m. on that Saturday last November. As she sat up and struggled to get her breath on the lower bunk of her cell, she called with difficulty to her cellmate, or "cellie," who was then still on the top bunk. Gasping, Moore asked the woman to shout to the guard that she needed an inhaler.
LA County jail policy doesn't allow inmates to keep inhalers permanently in their cells for fear that the hard plastic devices, designed to deliver medication to an asthma sufferer's lungs, might be repurposed as weapons.
Moore's cellmate told her version of the morning's traumatic events to attorney Portasha Moore, now co-counsel in the civil lawsuit. She said that Unique Moore next complained of feeling hot and asked her cellmate to fan her as they waited for the inhaler to be fetched. (Attorney Portasha Moore is not related to Unique Moore.)
Seeing her companion's distress, the cellmate immediately pressed an emergency call button located inside each cell to summon help, and began to shout for a deputy. When no help turned up, the cellmate's shouts were joined by nearby female inmates in unit 3400, a 30-cell section of the 2,300-woman jail located in suburban Lynwood. Reportedly, minutes went by and still no deputies arrived. Thee was more shouting, and more minutes without deputies. Eventually Moore collapsed to the floor of the cell, unconscious. The cellie said she screamed out again and again.
Eventually a deputy turned up. But, by then, Moore couldn't be aroused.
Kendra Cox, an inmate who was housed in the next jail module, unit 3300, told me in an interview, that the slow response on the part of jail deputies was not at all unusual. "A lot of times when we wanted toilet paper or sanitary napkins, they ignored us," said Cox. In the pod where Kendra bunked, the sounds from the next unit were muffled. Still, she said, on this particular morning, the inmates' cries for help were loud and alarming enough to wake Cox and those around her.
For what she estimated was close to 20 minutes, Kendra said, she stood near the door at her cell, looking out the window, and wondering where the guards were.
"They probably thought it was insignificant," she said, referring what she characterized as the agonizingly slow response to Moore's emergency. Just women wanting something. "They were men," she said.
According to Cox, the guards for Unique's pod weren't even present when the calling first began. Instead, she said, they were chatting with colleagues in the adjoining section - Cox's pod -before their shift began. All the while, according to Cox, the inmates in Moore's unit kept shouting and pounding on their thick metal doors.
Eventually, the guards did respond. But, by the time they showed up, according to her cellmate and others, Unique was on the cell floor unconscious. Deputies would later claim in reports that she was still completely conscious, that it was only when they returned to her cell again after getting the inhaler from the jail's medical clinic, that she had gone into cardiac arrest.
What is not in dispute is that paramedics were called for Unique Moore at around 6:30 a.m. The paramedics arrived and found Moore on the floor of her cell in full cardiac arrest at 6:38 a.m. She was given additional CPR (taking over from jail staff), plus four doses of Epinephrine and intubated, meaning a flexible plastic tube was inserted down her a windpipe to maintain an open airway, so she could receive oxygen. Then she was transported via ambulance from the jail to St. Francis Medical Center, where she arrived at 7:17 a.m, and was given further treatment. Unique Moore was declared dead at 7:41 a.m.
During the day on Saturday, word spread quickly via the highly active jailhouse grapevine about the fate of the woman nicknamed "Chocolate."
The Los Angeles County Sheriff's Department officials, however, declined for close to a year to acknowledge that a death had occurred at all. Then, when this reporter presented department officials with the coroner's report on Unique Moore, LASD spokespeople finally conceded that, yes, Moore had died. But Homicide Bureau Detective Lt. David Dolson disputed the claim that there was any neglect, mishandling, or any other kind of institutional failures in the Los Angeles County Sheriffs Department response to Moore's lethal emergency.
"The Homicide Bureau's investigation did not reveal any apparent delay in providing the inhaler,'" Dolson said in a written statement.
A spokesperson for the sheriff's department would not comment further on the lawsuit's allegations while the litigation is pending.
"They failed her," said the Moore family's co-attorney, John Sweeney, "She clearly had a bad asthmatic condition and she died on the floor after her cell-mate pushed the emergency button and [deputies] didn't come in a timely manner."
TWO CORONER REPORTS
The initial autopsy report written shortly after Moore's death by a deputy medical examiner concluded, "From the anatomic findings and pertinent history I ascribe the death to Asthma (Clinical History)." The report also cited "other conditions contributing but not related to the immediate cause of death: diabetes mellitus, hypertension, bipolar disease, schizophrenia, drug use (history)."
A few months later, however, after receiving further input from LASD Homicide Bureau detectives and reviewing the homicide bureau's report, deputy medical examiner Dr. Vladimir Levicky concluded his final March 2015 autopsy report with a different emphasis.
"The cause of death of death in this case is asthma," he wrote. "The mode of death is accident due to the history of drug use." Never mind that there were no illegal drugs whatsoever in her system according to the toxicology report. No cocaine, barbiturates, opiates, MDMA, methamphetamines, codeine, morphine, marijuana, hydrocodone, nor anything related.
In their interviews given to coroner's office, according to its case file on Moore, LASD officials painted a rosy picture of the high quality of medical care Moore received. As the coroner's report stated, Moore "was routinely seen by medical staff at the jail. Every time the decedent needed her inhaler, medical staff would check her blood sugar level. On Sunday, the decedent told her cell mate she needed her inhaler. The cellmate called a deputy, and the deputy arrived at the decedent's cell. The cellmate told the deputy that the decedent needed the inhaler."
Shortly after her death, LASD homicide detective Jeff Cochran gave the coroner a version of events that differs markedly from eyewitness accounts of the day of Moore's death. According to Cochran's narrative, after one of the jail deputy learned about the asthma emergency, he then sped to the medical staff, retrieved the inhaler for Moore and returned to find that she had fallen to the floor, semi-conscious and breathing with difficulty. "As soon as the decedent was pulled out of her cell, the decedent went into cardiac arrest," Cochran told the coroner.
This version was expanded upon in a November 2015 email to me written by Cochran's colleague, Lt. Dolson, roughly a year after Moore's death: "Inmate Moore died at the hospital after experiencing difficulty breathing in her cell. Prior to her death, Moore's cellmate activated the emergency call button in their cell. A deputy responded and was told by the cellmate that Moore needed her inhaler. Nursing staff was notified, and the deputy returned to Moore's cell. She was now unresponsive, but breathing. Medical staff responded and monitored Moore. Paramedics were summoned. Moore was transported to the hospital where she died."
AN ALL TOO ORDINARY STORY
Unique Moore had much in the common with the thousands of mentally ill who, despite growing efforts at diversion away from incarceration and into community diversion programs, still cycle in and out of LA County's jail system. When she was arrested for a probation violation in October 2014, she was in the heart of LA's Skid Row district seemingly looking for drugs when she was supposed to be completing a series of required drug rehabilitation classes.
Moore had a long history of drug addiction, which appeared to be an effort at self-medication for the mental problems that had dogged her since she was seven years old. As she got older, her initial symptoms bloomed into a serious mood disorder, worsened by the hallucinations caused by schizophrenia, according to what her father told his attorneys. As her mental health worsened, Moore's self medication moved from marijuana to harder drugs, including PCP, cocaine and meth.
During her mid-teens, Moore served the first of her stints in the county's juvenile detention facilities, which were soon replaced by adult lock-up time, on drug charges.
Around 95 percent of the approximately 4000 mentally ill inmates who reside in in LA County's jail system on any given day, like Unique Moore, have substance-abuse disorders and are often so unmoored from their families and communities that more than 80 percent are homeless or lack stable housing when released, as the new Los Angeles County Sheriff, Jim McDonnell, noted in testimony in February 2015 before the President's Task Force on 21st Century Policing. "Jails were not built as treatment centers or with long-term treatment in mind," McDonnell said.
WAS ATTENTION PAID?
When Unique Moore returned to CRDF for the final time in the fall of 2014, the Los Angeles Sheriff's Department was still reeling from the effects of one scandal after the other involving general departmental corruption, brutality in the LASD-run jails, and mistreatment of the jail system's mentally ill inmates, specifically. More than 20 department members had been federally indicted, many of them for charges involving brutality in the county's jail facilities.
Two years before, in September 2012, the specially appointed Citizens Commission for Jail Violence had issued its scathing report describing a "troubling culture" among jail deputies with "a disturbing mindset that promotes a lack of respect for inmates, an aggressive view that force is best used early and often to control the inmate population." This was, wrote the commissioners, the result of "a failure of leadership" by the sheriff, Lee Baca, whereas his undersheriff, Paul Tanaka, not only failed "to identify and correct problems in the jails, he exacerbated them."
In early 2014, after being elected to four terms, Sheriff Lee Baca had abruptly resigned under a cloud, But, by the fall of the year when Unique Moore had her asthma attack, former undersheriff Paul Tanaka, who had been so harshly criticized in the jail commission report, was in a runoff election to become the new sheriff. The Department of Justice was threatening to slap the department with a federal consent decree over its treatment of the mentally ill inmates in its jails, an action the county Department of Mental Health (DMH) and then Sheriff John Scott protested as unnecessary because of the purported "incredible efforts" and "progress" in caring for those inmates.
Earlier, the Southern California ACLU had filed a massive class action suit alleging horrific abuse in the jails, that would eventually result in a landmark settlement mandating a new system of outside monitors to oversee jail reform. A few years prior, the ACLU had issued a devastating report on Mental Health inside the jails.
Yet, for all the focus on brutality and neglect inside the nation's largest jail system, most of the attention was directed toward the men's jails. CRDF hasn't gotten sustained legal, advocacy group or media attention until this past August when the reform group, Dignity and Power Now (DPN), working with student researchers from UCLA Law School's International Human Rights Clinic, issued a highly detailed report called Breaking the Silence, alleging a broad pattern of abuse and neglect that was especially damaging to women of color with mental illnesses.
The report was centered on the accounts of seven women who had been incarcerated at CRDF, and who were interviewed in detail by the UCLA researchers about their experiences. The most harrowing was the story of "Nina," a forty-seven-year-old African-American woman diagnosed with bipolar disorder, schizophrenia and depression. After two weeks at CRDF, where she was reportedly denied access to appropriate medical professionals, and to the needed medication to "quiet the voices" in her head, Nina attempted suicide by jumping off of a second-story balcony.
Unique Moore had a complex medical history, according to the coroner's report, jail medical records and the pending lawsuit. She had congestive heart failure, diabetes, asthma, anemia, chronic obstructive pulmonary disease and neuropathy, all clearly disclosed to the jail's medical staff when she was arrested for violating her probation less than a month before she died.
Because of her condition, and the medication she was taking, she needed careful monitoring and prompt attention in case of breathing or cardiac emergencies. But as far as Kendra Cox and other former inmates could tell, few, if any, of the mentally ill inmates who mixed in with the general population got regular medical exams or care. These assertions received support from the harsh assessment by Department of Justice in its June 2014 report about the quality of care given mentally ill inmates, the UCLA/Dignity and Power Now report, and the views of some current and former LA County Department of Mental Health clinicians expressed in exclusive interviews.
"It's not safe for our clients there," said Kristina Ronnquist, a former Department of Mental Health social work intern who worked in the women's jail in 2013 and 2014. It was also not a good climate for employees who report abuse, she said. "I was very clearly told not to speak out, that it would harm me professionally, given the unsafe environment of going against the sheriff's department."
Ronnquist testified to what she'd seen in front of the Jail Commission in 2012, and told the LA County Board of Supervisors about her experiences in CRDF in May 2014.
"One of my teenage clients just recently made a very serious attempt at suicide," she said, "and one day later was taunted by a sheriff's deputy, who slammed her fingers in the door after she refused to move them, causing serious injury."
According to Ronnquist, other mental health clinicians wanted to speak out about abuse they'd observed "but they're too scared to say anything," she said.
Ronnquist's accounts were echoed by former CRDF inmates like Kendra Cox. "They treated us horribly like we were second-class citizens," Cox said of the custody staff, noting that no inmates dared to report the guards on the early-morning shift for their alleged delayed response to Unique Moore. "We didn't tell them what really happened," Cox said after her release from jail. Inmates were much too worried about retaliation, she said.
Other former inmates told similar stories. "Ain't nobody tell the truth in jail," said Tina Middlebrooks, 50, who was released in February 2015 after a three-year stint for drug dealing. "When you're in jail, it wasn't cool for you if the guards thought you were snitching. They tore up your cell and threw all your [personal] stuff out."
Middlebrooks was staying in a section of the jail that was not at all near to Moore's, but said she learned about the tragedy on the same day that Unique Moore died. "I really tripped out on her death," she told me later.
Middlebrooks had gotten to know Moore several years earlier when they were both in state prison on drug charges. She said found Moore's death particularly disturbing because she was grappling with her own mental illness -- schizophrenia -- while being housed in the general population and taking her prescribed Seroquel, just like Unique Moore.
"She was a beautiful person both inside and out," Middlebrooks said of Moore. "She was funny and outgoing. I was devastated."
This article is co-published in the criminal justice news site, Witness LA.