The Washington PostDemocracy Dies in Darkness

My son died in a mental health facility. If we keep protecting dangerous hospitals, he won’t be the last.

Questionable patient deaths keep getting swept under the rug.

Mia St. John receives a hug from her son, Julian. (Bryan Randall)

On Nov. 23, I received the call no parent wants to get – my only son was dead. My beautiful, 24-year-old boy was gone. It is a nightmare I have yet to wake up from; one I will never wake up from.

I could barely hear the words from the other end of the line; my cries were drowning them out. I was driving when I received the call, and had to pull over to call my son’s father. Then I had to drive home to deliver the news to my daughter, Paris. How I made it home without getting in a wreck is a mystery to me.

Two-and-a-half months prior, my ex-husband, Kristoff St. John, and I had placed our son, Julian, at Telecare’s La Casa Mental Health Rehabilitation Center in Long Beach, Calif. on a 72-hour involuntary psychiatric hold. Julian had been diagnosed with paranoid schizophrenia when he was 17 and had become suicidal while off his medication and on a powerful substance – meth. The staff upgraded him to a 14-day hold, and then lengthened it again for an indefinite period, to give him adequate time to get off of meth.

Like many parents of children with mental health issues, our goal was to find help for our son who suffers from a horrific illness for which there is no cure. We knew that, with proper medication and therapy, Julian had a chance of living a comfortable life. So we sought help from Los Angeles County’s Department of Mental Health, which referred us to Telecare’s facility. The county says it pays Telecare $17 million per year to contract 190 beds at La Casa. We had hoped that the facility would help him withdraw from meth and get back on his meds, and that within the year, Julian would come home – alive.

But we made a fatal mistake placing our son in the care of La Casa, one of many mental health facilities in this country that contracts with state and local governments. Like many before him, Julian didn’t make it out alive.

La Casa staff told us that our son, because of his suicidal behavior, would be checked every 15 minutes. Yet, a little more than six weeks after he arrived, Julian escaped from the facility by climbing the fence. When I asked management and several of the employees of La Casa how my son, who was supposed to be checked on regularly, could escape, they responded, seemingly unconcerned, “it happens.”

Julian was missing for several hours before police, whom La Casa had notified, found him at a bus stop. But in the days after he returned to the facility, Julian managed to smoke in the bathroom and even consume alcohol, all on the watch of La Casa’s staff.

Then, five days after he escaped, Julian attempted suicide using a plastic bag. His roommate discovered him and alerted the staff. I was terrified to leave Julian at La Casa, but staffers vehemently assured me that plastic bags would be banned from the section of the facility where he lived, and Julian would never be left alone. But after about two weeks, he was taken off 24-hour watch and put back on 15-minute precautionary watch. Three days later, my son was found face down in the bathroom with a plastic bag over his head – the same plastic bags that were supposedly removed.

[Editor’s note: Contacted by The Post about these allegations, legal representatives of La Casa denied negligence and wrongdoing in Julian St. John’s death.]

Unfortunately, Julian’s story isn’t unique. La Casa employees, who went on strike in 2013 because of the dangerous conditions, said patients regularly escape from the facility. More than two patients per month fled La Casa in 2012, according to the Press-Telegram. In 2013, 20-year-old Christian Torres broke through a locked gate at La Casa and police found him hours later in a nearby industrial area. Torres died soon after in police custody.

La Casa employees blame these problems on low staffing, inadequate training, and a culture that values profit over safety, according to the Press-Telegram. There are similar complaints at the nearby College Hospital, where there have been multiple sexual assaults and suspicious patient deaths in recent years, according to the employee union. That hospital had to pay $1.6 million in a legal settlement with the city of Los Angeles for dumping 150 mentally ill patients on the city’s notorious Skid Row over two years.

This problem exists beyond California. About 1,800 people commit suicide while hospitalized in the United States each year. In 2012, poor medical care led to the deaths of at least four patients at Milwaukee County’s Mental Health Complex, which inspectors had cited nine times in eight years for putting patients in immediate danger, according to the Journal Sentinel. Three patient deaths in 18 months involved staff failures at Arbour Health System, which operates mental health clinics in Massachusetts, according to the Boston Globe. And in Florida, a 2011 investigation found that three patients in the privately run South Florida State Hospital died in cases that may have involved overmedication and neglect. In one of those cases, the patient was found dead in a scalding bath after staff failed to perform a required 15-minute check on him, according to the Sun Sentinel.

La Casa employees recorded that they had checked on Julian every 15 minutes, as mandated. But surveillance cameras show otherwise. The video revealed that, once Julian entered his room that afternoon and shut the door behind him, no one else entered except his roommate. A staffer found him 45 minutes later. The sickening insult is that La Casa’s records show the staff was performing the mandatory checks on Julian dutifully until 3:15 p.m. My son was already dead and taken out of the facility by approximately 1:30 p.m.

La Casa also says that staffers attempted to save Julian’s life, but according to 911 tapes and the Long Beach Police Department, no one from the facility called for emergency assistance until 17 minutes after he was found. And his toxicology reports showed no sign of the vital anti-psychotic medication my son was supposed to be taking.

Had Julian been medicated and monitored by La Casa, as we and the county paid the facility to do, my son would surely be alive today.

[I take care of schizophrenics and sex predators. I’m completely unqualified.]

We never would have sent Julian to La Casa had we known about the facility’s track record of safety problems and patient escapes. But Los Angeles County doesn’t publicly report patient deaths and other failures at the health care facilities where it sends sick residents. The public didn’t know about the problems at La Casa until employees went on strike and revealed them.

The same lack of transparency exists at mental health agencies nationwide. In a 2009 report, the National Alliance on Mental Illness criticized the limited data available on mental health services, saying it lags far behind data collection in other health care disciplines: “Across the country, there is an extremely limited capacity to provide even the most rudimentary information on mental health services.”

Neglect and falsifying records is unfathomable and deplorable, but unfortunately, it is not uncommon in our nation’s mental health facilities. As long as the scope of this misconduct and its fatal outcomes are hidden from the public, there will be little incentive to fix them. Local and state governments that pay millions to each of these facilities to shelter, protect, and treat their patients, our loved ones, must provide better oversight. Patients and their families should be made aware of each facility’s safety record, and the worst offenders – facilities that wrack up numerous complaints and lawsuits – should be shut down.

Julian was a gifted artist, writer, and musician. His art had been displayed in several galleries, including self-portraits of a beautiful, but tormented, soul. We have transformed his art studio, Stone Art, into a center for those who, like him, express themselves through art, because words aren’t sufficient. His art lives on to inspire children and young adults that suffer from addiction and mental illness. We accept anyone and everyone, from the homeless, the mentally ill to the “addict that still suffers.” I knew this is what Julian would have wanted.

Julian was insightful and compassionate, and always in awe of the world’s beauty. He desperately wanted to live. Unfortunately, my son’s dreams will never materialize. His paintbrushes will never touch another canvas. We’ll never have long talks about life, love and the universe again. I’ll never hug or kiss my little boy again. La Casa did not just take the life of my son, it took my life as well. It’s been eight months since my son’s death and the future ahead feels so long that time has come to a stop. Trying to move forward feels so daunting.

Our son wasn’t the first victim of inadequate mental health care, but it is our mission to make sure he is the last. In May, Kristoff and I, working with our attorney, Mark Geragos, filed a wrongful death law suit against La Casa and its parent company, Telecare. Our mission is to shine a bright light on the nation’s broken mental health care institutions. This will be one case mental health hospitals won’t be able to settle out of court, hidden from public view. I asked my sister, “Why my son?” She responded, “Because this is one case they will not be able to sweep under the rug, and his death will save the lives of many.”

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