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An Eastern Washington teen went to a mental health clinic for help. Eight days later, he died in a jail cell

Seattle Times - 11/1/2020

Nov. 1--In March 2016, after an 18-year-old in Pasco started hearing voices, his family turned to a county-run mental health clinic for those in crisis as a last resort to get him treatment.

Marc Moreno had a long history of mental illness when he arrived at the Benton County Crisis Response Unit, according to records in a federal lawsuit.

A counselor there soon observed Moreno "was not oriented to time or place and was unable to understand basic questions," the lawsuit says. "He stated that he was talking to angels. At one point he began hitting himself in the face repeatedly."

But Moreno didn't get treated at the clinic. Instead, someone there called the police. Responding officers arrested him on misdemeanor warrants for driving with a suspended license and failing to transfer a vehicle title within 45 days.

Moreno was booked into the Benton County Jail on March 3. Eight days later, he was found dead on the floor of his cell. His official cause of death: cardiac arrhythmia and dehydration.

"Marc Moreno literally died of thirst," said Edwin Budge, whose Seattle law firm represented Moreno's family. "Something like that should never happen in an American jail."

In late September, Moreno's parents -- who filed a federal lawsuit over his death in 2018 -- quietly received an out-of-court settlement for $4.5 million from the jail's private health care contractors.

With Benton County previously settling for $1.2 million, the collective $5.7 million sum represents what Budge said is the largest publicly reported settlement for a jail inmate's death he's seen in Washington during 26 years of practice. The Our Lady of Lourdes Hospital and Lourdes Counseling Center, which oversaw mental health services at the jail, agreed to a separate undisclosed settlement in 2019.

Aside from the suit's allegations of the jail contractors' inhumane negligence, Moreno's case underscores a larger societal problem: that police, jail and other public officials, due to a lack of resources or a failure to recognize urgent needs, often resort to incarcerating those in crisis rather than treating them.

"It was certainly traumatic for the family to see that their loved one, who they'd taken to the mental health clinic for treatment, instead get put into jail," Budge said.

Searching for help

Representatives for Wellpath, the current name of the corporate inmate health care contractors Correct Care Solutions and Correctional Healthcare Companies named in the suit, did not respond to requests for comment last week.

Ryan Lukson, Benton County's assistant chief deputy prosecutor for civil cases, said Moreno's death directly led to reforms of jail policies and a change in inmate health care contractors. The county's crisis response clinic also has been transferred to private operators, he said.

"There were a lot of changes that were made as a result of the incident," Lukson said.

A spokesperson for the Kennewick Police Department, which wasn't named as a defendant, said officers faced an unusual situation when the Crisis Response Unit called for help in 2016.

The lawsuit states the clinic called police "to transport Marc to the hospital," but Kennewick Police Lt. Aaron Clem said police reports indicate officers were called "for a person who was being aggressive to staff members."

"Usually, if our officers encounter someone who's in crisis on the street, (the clinic is) who we'd be calling," Clem said. "But they were calling us."

When officers learned Moreno already had been discharged from an inpatient care hospital only a few days earlier, "they didn't have that many other options available," Clem said.

"From the officers' perspective, (they see) he's got warrants for his arrest," Clem said. "If we can't get him some place where he's safe and secure without hurting himself, then maybe we can get him some help at the jail, which has mental health professionals."

But, as the lawsuit lays out in graphic detail, Moreno spent his last days largely ignored -- left lying naked in his own feces on the floor of a cell as his crisis worsened.

Even so, the alleged neglect wasn't what tipped the legal case in favor of Moreno's family. In early June, a federal court entered a liability judgment against the jail contractors because they'd intentionally destroyed emails and other potentially damning records -- what a judge called a stunning "obstruction of the truth."

Left in a cell

Moreno struggled throughout his life with "mental illness characterized as bipolar or schizophrenic," Budge said. His father, Miguel, who immigrated from Mexico in 1974, and his siblings tried to help Moreno through his periodic bouts with his sickness.

"The illness ... in the family brought us closer together," Jessica Moreno, Marc's older sister, told the nonprofit Disability Rights Washington in a video about her brother's case. "But now, it just took us apart because now we're missing our main player."

In 2016, after Moreno's latest psychosis emerged, his family took him to the Lourdes hospital, but he was discharged after only a few days. An associated counseling center declined to admit Moreno, recommending his family take him to the crisis response clinic.

Later, after he was booked into jail, officers put Moreno into an isolation cell with "no bed, no toilet no sink and no access to drinking water," the suit states.

Over the next few days, a contracted social worker occasionally asked Moreno questions through the cell's door. The suit says she documented he was "unable to engage with her, that he was naked, rolling on the floor, talking to the wall, playing with his feces or engaging in other bizarre behavior."

But a jail nurse didn't check on Moreno for a full week after his booking. By then, jail logs showed Moreno hadn't eaten or ingested any fluids for at least four days, according to the suit. Still, the nurse didn't follow policies to check or treat him, the suit alleges.

"Instead, after seeing Marc lying naked on the floor, she walked away and continued her day, failing to take any steps to get him the care he urgently needed," the lawsuit says.

The next day, March 11, jail staff found Moreno dead in his cell. An autopsy recorded his weight at 179 pounds -- 38 pounds less than when he was booked.

In early 2018, lawyers for Moreno's parents notified the jail contractors they intended to file a lawsuit, so all records about Moreno needed to be preserved. But during the case's evidence discovery phase, the contractors turned over few records.

After three attempts to get more, Moreno's family filed a motion seeking a default judgment due to discovery violations. Only afterward did the contractors admit they'd purged employee emails and deleted other records about their contract operations at the Benton County Jail and others nationwide.

Wellpath's chief information officer acknowledged during a sworn deposition the company had recently instituted a new records policy that was partly motivated "to destroy bad emails that could be produced in discovery," according to court documents.

U.S. District Court Judge Rosanna Malouf Peterson ruled in June the contractors had "purposefully destroyed evidence to avoid their legal obligations."

The discovery violations were so outrageous, the judge imposed rare sanctions that resulted in a default judgment against the contractors. On Sept. 28, before a trial to award damages, the contractors agreed to pay Moreno's parents $4.5 million.

Though unrelated to Moreno's case, Kennewick police recently won a federal grant for hiring "mental health professionals who now ride along with our officers," said Clem, the department spokesperson.

"They're now on the street with us and there when we encounter people in crisis," Clem said. "We didn't have that back in 2016."

For Moreno's family, a lack of mental health resources is but one in a series of failures that led to his death.

"I felt like many places failed him," Jessica Moreno told Disability Rights Washington. "The hospital failed him. Crisis response failed him. The jail failed him."

News researcher Miyoko Wolf contributed to this story.

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