Michayla Brilz arrived at the Missoula County Detention Center on a busy Tuesday night, April 26, 2011. It wasn't the 27-year-old's first time in jail. Over the previous two years, she'd been charged for, among other things, resisting arrest and driving under the influence. Now, she was booked for allegedly paying a babysitter with sleeping pills and anti-anxiety medication, and violating the terms of her previous release.
Detention Center Supervisor Luke Johnson was working the booking desk alone when Brilz arrived around 10 p.m., so he asked Officer Debra Ann Reiner to place Brilz in a holding cell until he had a chance to admit her into the facility. Reiner put Brilz in Holding Cell C and told her it would be just a few minutes before someone retrieved her.
Thirty-five minutes later, Reiner returned to find Brilz seated and unconscious on the holding cell floor with a payphone cord wrapped around her neck. She did not regain consciousness. Paramedics transported Brilz to St. Patrick Hospital, where she was pronounced dead at 11:10 p.m.
Last month, nearly three years after Brilz's death, her family entered formal negotiations with Missoula County to settle allegations of jailer negligence.
During interviews prior to the confidential settlement talks, family attorney Milt Datsopoulos alleged that guards failed to follow commonly accepted guidelines when handling Brilz. The detention center didn't screen her for mental illness prior to placing her in the cell alone with the means to harm herself. She had been in the facility before, and Datsopoulos believes staff knew or should have known that she was unstable. Why didn't they keep a closer watch?
"They violated national standards and criteria as it relates to protecting the rights and ensuring the reasonable safety of people who are incarcerated," Datsopoulos says.
The Brilz family isn't alone in alleging negligence at the Missoula County Detention Center. The family of 31-year-old Heather Wasson filed a lawsuit against the county in 2011, two years after Wasson died alone in a jail cell from a seizure caused by acute alcohol withdrawals.
In fact, within the past five years, four inmates have died from unnatural causes at the facility. In 2010, Jay Brian Johnson hung himself with jail-issue socks. In 2013, Danny Wayne Johnston tied towels together to hang and asphyxiate himself.
Datsopoulos took the Brilz case because he wants jailers to be held accountable and do a better job preventing suicides. Since founding his Missoula law practice 45 years ago, Datsopoulos has represented a steady stream of defendants like Brilz, people who are mentally ill and addicted. It troubles him that rather than receiving intensive treatment, they are locked up and largely forgotten. "It's a shameful thing," Datsopoulos says.
Armed with constitutional principles that require jailers to ensure a minimum standard of safety, Datsopoulos wants to change the system. When making his case, he acknowledges the conversation surrounding how to help people like Brilz and Wasson is at times challenging and uncomfortable. But he believes that discomfort helps fuel a tendency to dismiss their suicides as inconsequential. In light of the sprawling human and financial costs associated with inmate deaths, Datsopoulos says it's incumbent upon lawmakers to overhaul the system. And, in his experience, Datsopoulos says the only way to force policymakers to fix something is to hit them where it hurts: the wallet.
"Otherwise, there's a story or two on it," he says. "The person in charge gets up and denies almost everything. And people say, 'Well, what the hell? This was somebody that obviously was a throwaway person, or they wouldn't be in jail. Let's don't worry about it. We've got other things to worry about.' What disturbs me is that these people aren't afforded serious consideration by the legal system, unless what occurred is pushed, and people are forced to look at the reality of what occurred, why it occurred, but more importantly, how easily it could have been avoided."
In spring 2011, Michayla Brilz felt the world was closing in. There was never enough money. Her moods turned erratic. She angered easily and clashed with the people around her. Even seemingly mundane tasks became increasingly difficult.
Court records indicate that Brilz had been diagnosed with bipolar disorder and was taking Zoloft. She was especially anxious about her children. Two years earlier, she and her ex-husband painstakingly carved out custody arrangements. She'd get their two kids, then ages 7 and 4, on Mother's Day, her birthday and two nights a week. He would have them the rest of the time.
Brilz's drug and alcohol use jeopardized her relationship with her son and daughter entirely. In January 2010, she was found guilty of obstructing a police officer and resisting arrest. Eleven months later, Brilz pleaded guilty to possession of drug paraphernalia. Brilz was on misdemeanor probation for driving under the influence in March 2011 when Missoula County prosecutors alleged that she paid a babysitter with drugs.
On April 26, 2011, when law enforcement came to take Brilz into custody for violating the terms of her probation, she refused to answer the door. University of Montana Public Safety Officer Casey Gunter testified during the Brilz inquest that after the woman finally let him into her apartment in the Lewis and Clark student housing complex, she asked them if they had children. She also asked, Gunter said, why they "weren't out arresting larger criminals than herself."
Detention center guards testified that once Brilz arrived to the jail, she was calm and coherent. She asked for her eyeglasses and talked about working to get her kids back. Officer Reiner, the guard who placed Brilz in the holding cell, encouraged Brilz to stay positive.
"I gave her a little hope and said, 'Well, that gives you something to look forward to when you get out. You'll see the judge tomorrow, and you'll be fine,'" Reiner testified.
Brilz's autopsy found nicotine, caffeine and sertraline, Zoloft's active ingredient, in her body. Her blood-alcohol content was .20, almost two-and-a-half times the legal limit.
Each of the guards who testified during the inquest said Brilz gave no indication that she intended to kill herself.
In July 2011, a six-member jury that convened for the coroner's inquest unanimously found the county innocent of criminal negligence. That result didn't surprise Datsopoulos. Prior to entering settlement negotiations with the county, he said inquests are typically one-sided affairs, with only prosecuting attorneys—the ones who work for the county—engaging in witness questioning.
"Most coroner's inquests result in the facility being absolved and there's some inherent conflicts there, because it isn't really a fair inquiry," he says. "It's only a one-sided inquiry. There's no real cross examination. Nobody can bring in witnesses that really impeach the people they bring in, or disagree with them. But usually, if the coroner's inquest comes out and says, 'Well, we didn't see anything illegal or improper with the handling of this inmate,' that ends it."
The veteran trial lawyer notes further that inquests weigh criminal liability. There's a significantly lower threshold of proof required to show civil negligence, which Datsopoulos would have to prove if the Brilz case went to court.
Complaints similar to the Brilz family's are often settled out of court. During an 18-month period in 2004 and 2005, for example, four Ravalli County Detention Center inmates killed themselves. According to Ravalli County Sheriff Chris Hoffman, three of those deaths resulted in litigation. All three lawsuits were settled out of court for undisclosed amounts of money.
Hoffman says the series of deaths prompted the jail to overhaul policies governing physical and mental health care. Ravalli County now contracts with an outside company, Spectrum Medical, to provide on-site health care. It also increased training and hired a mental health provider, who is now on call for emergencies.
"It changed the way we did business on so many levels," Hoffman says.
Immediately after being booked into the Fergus County Jail on Jan. 3, 2011, Carl Odell Stacy told guards he intended to commit suicide. Despite the threats and the fact that Stacy attempted suicide while incarcerated at the same facility five years prior, he was left unattended for 46 minutes. During that time, he hung himself with a sheet.
The attorney representing Stacy's family, Torger Oaas, noted during a 2012 trial to debate Fergus County's responsibility that jailers were fully aware of Stacy's suicide risk. "Carl was mentally ill and they knew that," Oaas said, as the Associated Press reported. "Carl had ADHD and depression. It was all over their paperwork."
The jury found Fergus County negligent and awarded Stacy's family $149,000.
Similar precedents dot the legal landscape. Last year, a federal jury awarded the family of a 27-year-old Missouri woman who committed suicide while incarcerated $2.85 million after finding guards exhibited "complete indifference to or conscious disregard" for her health and safety. Despite knowing she was suicidal, jailers failed to remove a string from her hooded sweatshirt. The woman used that string to hang herself.
Since the U.S. Supreme Court in 1976 began spelling out the minimum standards to guide detainee health care, courts have increasingly found that jailers must protect detainees from others and themselves. Ignoring that mandate constitutes a violation of prohibitions against cruel and unusual punishment.
While such standards better ensure prisoners receive humane treatment, jailers can be hard-pressed to satisfy them.
"Counties just don't have adequate funding and resources to provide constitutional levels of care in a lot of situations," says Montana ACLU staff attorney Anna Conley.
Problems meeting those standards are exacerbated by the fact that an increasing number of mentally ill and addicted offenders are flooding jails. According to the National Center for Substance Abuse at Columbia University, one-third of all people detained in local and state detention centers in 2006 had a mental illness. That same report found that of the 2.3 million inmates incarcerated in 2006, 1.5 million, or 65 percent, were addicts.
While the treatment needs of detainees become more complex, the volume of people being housed in jails has increased exponentially. Between 1930 and 1970, incarceration rates in the United States hovered at roughly 100 detainees per 100,000. That number is now 716 per 100,000.
Experts say it's not a coincidence that prison rates started to skyrocket just as lawmakers set to work disassembling the nation's mental health infrastructure. According to the National Association of State Mental Health Program Directors, state funding for psychiatric services in 2006, adjusted for inflation and population growth, amounted to less than 12 percent of the total spent in 1955. In 1955, there was one psychiatric bed available for every 300 Americans. Today, that number is one for every 3,000.
"There's no treatment," says Missoula social worker Catherine O'Day, who oversees a mental health care program at the Missoula County Detention Center. "There's nowhere for them to go."
Meanwhile, while treatment services decrease, prison costs skyrocket. The Missoula County Detention Center's 2014 budget is $11.8 million, a 59-percent increase from 2004.
In May 2009, 31-year-old Heather Wasson seemed more nervous than usual. She didn't like going to the Department of Correction's Missoula Office of Probations and Parole for her regular check-ins, the result of a 2004 conviction on forgery and criminal possession of dangerous drugs charges.
Her probation officer, Kim Lahiff, testified that Wasson normally shook when meeting with her at the office. But that day she seemed even shakier.
Lahiff suspected that something was wrong and so she screened Wasson for illegal drugs. Wasson's 2004 conviction stemmed from methamphetamine use. After finding no contraband in Wasson's system, Lahiff sent her home.
Two days after Wasson failed to show up for her June 16 check-in with Lahiff, the Missoula Police arrested her for violating the terms of her release. On the way to the detention center, Wasson hit her head on the Plexiglas cage in the back of the patrol car while screaming and kicking in protest.
When she was booked into the jail, Wasson told guards that for a week and a half she'd been drinking vodka and wine and in the past had experienced alcohol withdrawal symptoms. She was also taking Xanax and the antidepressant Effexor. She said she was "kind of" thinking about killing herself and that she had hit her head the previous night. She added that she didn't want to miss her son's birthday later that week.
"She just kept saying that she wanted to get out of there, that she didn't belong there," detention officer Tonia Turner told law enforcement days later.
Roughly 40 hours after Wasson was booked into the Missoula County Detention Center, she died from cardiac arrest resulting from acute alcohol withdrawals.
In May 2011, Wasson's family filed a lawsuit alleging that Missoula County and detention center contractor Spectrum Medical Services were negligent because they failed to adequately treat Wasson.
"The defendants, and each of them, were negligent in, among other things, failing to make cell checks of Heather, and to provide adequately for her safety," states the complaint filed in Missoula Fourth Judicial District Court. "They knew or had reason to know that she was at risk for severe alcohol/drug withdrawal."
Wasson was left unattended for roughly 90 minutes before jailers discovered her. American Correctional Association guidelines direct guards to check on high- and medium-security inmates personally every 30 minutes. The association, which accredits 1,500 institutions nationally and has more than 20,000 members, advises more stringent oversight of mentally ill inmates.
"More frequent observation is required for those inmates who are mentally disordered or who demonstrate unusual or bizarre behavior. Suicidal inmates are under continuous observation," ACA guidelines state.
On June 19, a guard spoke with Wasson at 7:43 p.m. Roughly 12 minutes later, an unmonitored video surveillance camera in Wasson's cell recorded the woman having what appears to be a seizure. Her right arm stiffens and becomes rigid. The movement-activated camera then shuts off.
Doctor Walter Kemp of the Forensic Science Division determined the cause of death was an alcohol withdrawal seizure from chronic alcohol abuse. Detention Center nurse Judy Munsell testified during the Wasson inquest that her staff was providing Wasson with a half milligram of Xanax twice a day and that benzodiazepines, such as Xanax, are commonly used to ward off the potentially deadly effects of alcohol detoxification.
Munsell said Wasson didn't exhibit any obvious signs of withdrawals prior to her death. She was just like so many other inmates that nursing staff treats on a daily basis.
"A lot of people come into the jail and their intake forms are not different from this lady's. It's unfortunate, you know, that she died and I'm really sorry for that," Munsell said. "But there just wasn't anything on that sheet that was a big red flag. It just wasn't for us. We see dozens and dozens of people with similar information."
Missoula social worker Catherine O'Day says it's disheartening to watch detention center inmates get sober and begin planning ways to tackle their addictions, only to watch them fall apart when they leave.
"I see them losing hope," says O'Day, who, in addition to running a mental health program at the jail, teaches social work at the University of Montana.
Staying sober requires support, O'Day says. Offenders become pessimistic when they discover how little support exists for them. Columbia University found that in 2005, federal, state and local governments spent $74 billion on incarceration, court proceedings, probation and parole for substance-involved adult and juvenile offenders. That number dwarfs the $632 million spent on offender prevention and treatment.
Among the biggest problems, O'Day says, stems from the fact that Missoula has no alcohol detoxification facility. Detoxing can be deadly, as it was for Wasson. But the only place to go through a supervised withdrawal is at a hospital emergency room or in jail. And, as O'Day notes, "We're not a detox facility. ... Jail is not treatment."
As with lawsuits filed on behalf of suicidal inmates, addiction-related litigation is costly, too. In 2011, New York City agreed to pay $2 million to settle a lawsuit that alleged a postal worker died in jail because his severe alcohol withdrawal symptoms went untreated.
In Montana, meanwhile, the American Civil Liberties Union filed suit against Lake County jailers for refusing to provide Bethany Cajune medication prescribed to treat opiate addiction. The ACLU alleged Lake County's actions caused Cajune, who was pregnant and jailed for traffic violations, to go into severe withdrawal. Lake County denied wrongdoing, but settled the case out of court in 2011, agreeing in the future to provide medication maintenance therapy to addicted inmates.
Missoula County Sheriff Carl Ibsen declined to discuss the specifics of local detention center deaths, citing pending litigation. He did note that jailers are consistently working to better manage the rigors of their profession. As an example, he says staff took advantage of new suicide prevention curriculum rolled out two years ago at the Montana Law Enforcement Academy.
The statistics appear to show that increased education and awareness are helping. According to a 2010 report from the National Center on Institutions and Alternatives, the suicide rate in county jails decreased from 107 per 100,000 inmates in 1986 to 38 per 100,000 in 2006.
Despite the progress, Ibsen acknowledges that his officers aren't social workers and overseeing the complex needs of the nearly 400 inmates who live at the Missoula facility on any given day can be tough.
"It's a challenging thing, assessing them, making sure they're housed properly," Ibsen says.
In light of the challenges, Ibsen says he'd welcome more community services. "There should be better ways of dealing with them than putting them in jail," he says, "because jail I don't think is fixing them."
As for O'Day, she bristles when talking about allegations directed at Missoula County jailers. She says it's unfair for detention center staffers to accept blame for an issue that's rooted in policies and laws that extend far beyond their control.
"It's really a systemic failure," she says. "We can't change the world out there from in here."