Editor’s note: This story is on the topic of suicide and mental health. If you or someone you know is struggling with suicidal ideations or a mental health crisis, the National Suicide Prevention Lifeline can offer resources and support at 1.800.273.Talk (8255)
PORTLAND, Ore. (KOIN) — A wrongful death lawsuit has been filed against the Clackamas County Jail after a man with schizophrenia died while in-custody last July.
The suicide death of Jermelle Madison Jr. sparked several Oregon City protests, after his family raised questions on how the jail processes people with mental illness.
The critique comes as health officials with Disability Rights Oregon have said prisons and jails have inadvertently become the largest mental health institutions in the state.
Madison was found unresponsive after hanging himself in his cell at approximately 2:15 p.m. on June 28, according to a Clackamas County DA’s report obtained by KOIN 6 News.
This was eight days after he was arrested for missing a court date for previous charges.
After being resuscitated by jail staff, Madison was placed on life support and died less than a week later at Kaiser Permanente Sunnyside Medical Center on July 3.
An August investigation by the Clackamas County Major Crimes Team unit concluded Madison’s in-custody death was a result of his suicide attempt and not criminal homicide.
Though, a subsequent report by the DA’s office found that the Clackamas County Jail did not place the young man on suicide watch, despite having documented proof of Madison’s recent suicidal ideations and schizophrenia diagnosis.
For Lynette Madison, the news of her grandson’s death came as a complete shock, since she said the Clackamas County Jail not only knew about Madison’s deteriorating mental health, but their staff are the ones who helped get him diagnosed in the first place.
“If he goes to jail the first time and they look at him and they see how bad his mental state is, then put him on meds, and take him to the State Hospital to get him diagnosed, how can they take him back and say ‘we didn’t know?’” Lynette Madison, told KOIN 6 News.
According to his family, Madison was experiencing an ongoing mental health crisis after his father died of cancer just three months after Madison’s first incarceration at Clackamas County jail back in Dec. 2020, for charges of unlawful use of a weapon, menacing, fourth-degree assault, and resisting arrest.
Court documents show that Madison’s mental state resulted in him being found “unfit to aid in his own trial,” diagnosed with schizophrenia, and consequently released from jail into the Central City Concern LEAD program, which aims to provide treatment and recovery for those experiencing homelessness, mental health, and substance abuse related issues.
KOIN 6 News reached out to CCSO for a statement on Madison’s death and received the following response from a spokesperson: “The County received a tort claim notice from the Madison family indicating their intent to sue. As a result, the Sheriff’s Office has been advised by County Counsel not to comment on the matter.”
KOIN 6 News also reached out to the Oregon Sheriff’s Association to get a law enforcement perspective on handling mentally ill inmates, but the agency did not immediately respond.
Lynette Madison said prior to his deteriorating mental health, her grandson (whom she called Mel-Mel) was a hard working, optimistic young man who rarely got into trouble and enjoyed gardening and making music.
“He was a giving, kind, caring person, and then he developed schizophrenia,” Lynette recalled. “He didn’t ask for this disease. It just developed. He didn’t understand what was going on in his mind. But he also didn’t have outside help.”
Milwaukie police took Madison into custody on June 20 on an outstanding warrant for failing to appear in court for his December arrest.
Records obtained by KOIN 6 News included seven police-owned cell phone videos of Madison’s June arrest, in which he declares he is going to kill himself more than 10 times, threatens officers, attempts to harm himself, and references his mental health issues.
His family told KOIN 6 News they believed Madison would be placed on suicide watch until he could be transferred to a hospital for specialized care, since the jail had Madison’s documented history of mental illness and he was found unable to aid and assist in his trial just this past year. But Madison was dead 13 days after his booking.
“I thought he was in the mental health ward getting the help he needed and being watched,” Lynette explained. “Now my grandson’s not here, and I do blame Clackamas County Jail because they knew. And all they had to do is have him on suicide watch and he would be here today.”
It is unclear why Madison was not placed on suicide watch, though the DA’s report states Madison “denied that he had any suicide ideations” during his inmate screening interview.
But an arresting officer with the Milwaukie PD wrote on the jail’s intake assessment form that Madison “stated multiple times on June 20th that he wanted to die.”
In the two hours of video footage obtained and reviewed by KOIN 6 News from the DA’s office, Madison stated that he intended to end his life more than five times during his arrest. The video footage also showed Madison trying to harm himself and officers as he said that returning to jail would ruin his mental health.
“Clackamas County Jail needs to admit the fact that they screwed up … for them to put him in general population instead of suicide watch was their fault,” Lynette told KOIN 6 News, referring to her grandson’s mental health. “They are accountable. He would be here today if it wasn’t for Clackamas County Jail screwing up.”
In the months to follow, Madison’s in-custody death would become the catalyst for several large protests and ‘Justice for Jermelle’ rallies throughout Oregon City.
Family and demonstrators questioned the jail protocol and why Madison was placed in the general population, calling on the county to release information of events leading up to Madison’s death.
Lynette told KOIN 6 News she hopes grandson’s story helps bring about awareness for a much larger issue saying, “I don’t want anybody else to have to go through the pain our family is suffering because the help isn’t out there. We need to get some programs to help these people. There’s too many young people dying for no reason, just because there’s no help.”
The number of people dying in jails for mental illness-related issues is staggering, according to KC Lewis, Managing Attorney of Disability Rights Oregon’s Mental Health Rights Project. He told KOIN 6 News that as tragic as Jermelle’s death is, the outcome is fairly common.
“We did a report last year where we took a look at all 10 of the deaths that occurred across Oregon’s jails and we found, of those 10, nine of those people were suffering from a disability of some sort and a large number living with mental illness,” said Lewis.
The full report can be viewed here.
An Oregon Health Authority spokesperson with Behavioral Health Services told KOIN 6 News, “The number of patients under Aid and Assist orders continues to increase and we are hopeful more beds will soon be open in the community to house those who need hospital level of care while they receive the care they need to aid and assist in their own defense.”
Aid and Assist orders are applicable to those who have been found unfit to assist their defense at trial due to a mental illness, among other criteria.
KOIN 6 News obtained reports from Oregon State Hospital regarding the number of people in custody within each county waiting for state hospital admission for mental health treatment.
The data revealed mental illness in jails is on the rise.
According to the data, in July of 2021, 24 people were waitlisted to be evaluated under aid and assist orders, with the longest wait period being 11 days. In October 2021, 28 people in jail awaited treatment but the average wait time spiked with one person waiting 38 days.
OHA data showed the number of people like Madison, placed under Aid and Assist Orders, increased each month. In June 2021, OSH had an average daily population (ADP) of Aid & Assist Patients of nearly 360. By October, that number rose to 372.
In December 2021, the daily average number of Aid and Assist Patients at OSH had risen above 400. Recent OHA data showed that in December 2021, the number of people waiting in jail for treatment had risen to 31, with the longest wait time listed at 18 days.
Lewis said the report showed hospital capacity and waitlist issues often prolonged the time a person with mental illness must go without proper treatment and until they can be admitted they remain in jail.
Lewis suggested for many people living with mental illness the process of going through the criminal justice system and being housed in a jail can rapidly deteriorate a person’s mental health and lead to increased criminal behavior, creating a cycle.
“Often, even if you’re not injured or otherwise harmed while in jail, you can still see people’s mental illness getting significantly worse,” Lewis explained. “To the point that they get pulled further into the system through the aid and assist process, or end up with more charges stacked up because they continue to get worse and have more disability related behaviors.”
According to Lewis, the overcriminalization of mental illness has become the primary reason people suffering from mental and behavioral health disorders continue to be funneled into the criminal justice system.
He told KOIN 6 News a lack of proper funding for community resources such as housing, counseling, and medical support has inadvertently made jails the only alternative.
“When you call 911 when you see someone in crisis, the police are generally the ones who show up,” Lewis explained. “We have currently built a mental health system where jails, which were never intended to function as mental healthcare providers, are now housing a large number of our people with mental illness.”
Lewis went on to say “if you talk to the jail commanders they’ll tell you the same thing, ‘this is not what we are built for, this is not what we have the training to do, and it’s not what we want to be doing,’ but unfortunately they’re the stop of last resort.”
Madison’s story is just one example of what Lewis called a broken system. He warned there are potentially deadly repercussions if those experiencing a mental health crisis are denied proper care.
“There are people who die in jail because they don’t get that care. Whether from suicide or having other unmet health needs,” Lewis said. “Jails are not a treatment facility and people don’t get what they need there, and sometimes that can have the most tragic results possible.”
The DRO’s investigative report “Grave Consequences: How the Criminalization of Disability Leads to Deaths in Jail,” found suicide was the leading cause of death in Oregon jails and most people who died in-custody had a disability.
The report claimed jails failed to identify and prevent suicide, stating, “Six of the ten individuals who died in Oregon jails in the first ten months of 2020 died by suicide.”
The records revealed a lack of safe jail conditions or procedures to mitigate the risk. None of the individuals were on suicide watch, though in some cases there were indications that the person was at risk, including a recent hospitalization for attempted suicide.”
Disability Rights Oregon’s Mental Health Rights Project put together a committee to advocate for uniform healthcare standards across jails, including suicide watch protocols.
Lewis told KOIN 6 News the next step is to ensure oversight for those standards because no centralized place where mental illness-related incidents and deaths are reported currently exists.
“The most important thing and what we are concentrating most of our energy on is that we just need to put fewer people with mental illness into jails,” Lewis said. “Putting more resources into community treatment and keeping people from going to jail in the first place is the only way to be sure we’re keeping them safe. This system is not designed for people with mental illness and it’s really straining at the seams when we try to force it to do this thing that it’s not supposed to do. And we know there are such better ways to treat these people.”
Lynette Madison told KOIN 6 News she hopes that change comes soon so people like Jermelle are able to get the help they need, instead of feeling helpless in the system.
The family told KOIN 6 News they have hired an attorney and are in the early stages of filing a wrongful death claim against the Clackamas County Jail.
“My grandson should not be gone. He needed help and the system failed him,” Lynette stated. “I hope that Mel-Mel’s story can raise awareness and maybe help save somebody else’s life. I mean, we all know someone with mental health issues — just look around. I just pray to God that we can get some help for these people, before another person has to die.”
If you or someone you know is struggling with suicidal ideations or a mental health crisis, the National Suicide Prevention Lifeline can offer resources and support at 1.800.273.Talk (8255)