Psychological well being | California parolee’s loss of life reveals gaps in psychological well being system

Every day somebody at Patton State Hospital handed Fredreaka Jack her treatment: three capsules to handle her schizophrenia and bipolar dysfunction, one or two for her blood sugar, one for hypertension and one for hypothyroidism.

That each one modified on April 14, 2022. Jack had been sentenced to 32 months in jail after pleading responsible to second-degree housebreaking. After efficiently petitioning to be paroled into the group, she simply needed to full about three months at a state-funded reentry facility often called Walden Home and he or she’d be free.

Jack advised her mom she liked the power and the hints of freedom it provided — journeys to the shop, entry to her cellphone and the small job she had serving to out. She hoped to be reunited together with her household in Louisiana quickly.

As a substitute, Jack could be lifeless inside months. She was 37.

In granting her the liberty she sought, the courtroom launched Jack right into a public parole system so stuffed with holes that Jack’s loss of life was nearly preordained, a overview of 1000’s of pages of medical data and courtroom paperwork reveals. 

Jack was battling critical psychological sickness and coming off practically a decade and a half of institutionalization. A psychologist for the state hospital warned that she “stays a hazard” and was “psychiatrically and behaviorally unstable.” The Board of Parole Hearings denied Jack’s request to be freed.  

But, after she appealed, a San Bernardino courtroom launched her from the state hospital’s care, which means she couldn’t enter its outpatient program for folks with psychological sickness. As a substitute, the California Division of Corrections and Rehabilitation despatched Jack into a house centered on substance abuse to serve her parole.

Left by state coverage to navigate the complicated psychological and bodily well being care system on her personal, Jack failed at practically each flip. So did California’s parole system – and the contractors the Corrections Division paid with taxpayer cash to function it.

The state hospital discharged Jack with simply 30 days of treatment, giving her a month’s time to discover a major care physician and psychiatrist in a brand new group and get her lengthy checklist of prescriptions refilled. 

When Jack did discover a major care doctor, the medical data don’t present that the physician wrote her a brand new prescription for diabetes treatment. The data do present that  checks revealed Jack’s blood glucose degree had been practically thrice the traditional vary. Even when she did have prescriptions crammed for her blood stress, medical logs present that nobody at Walden Home recorded giving Jack her treatment for a lot of days at a time. 

And when she ended up within the emergency room repeatedly, medical doctors typically attributed her bodily complaints to psychological sickness and “drug-seeking habits,” medical data present. By her final go to, she’d misplaced practically 50 kilos in three months. When the hospital discharged her, data say she had no historical past of diabetes. 

She died simply 14 hours later. The trigger: issues from Kind 2 diabetes, in accordance with the post-mortem. 

Sharon Jack, Fredreaka’s mom, obtained detailed updates from state hospital employees about Fredreaka’s psychological well being. However the post-mortem report was the primary she had heard of her daughter having diabetes, she mentioned. 

“I’ve by no means expressed to no person how a lot this hurts,” Sharon mentioned by tears. “I assumed my child was coming residence to me. They took that chance away from me.” 

As California has retooled the jail system to emphasise rehabilitation, it has invested greater than $650 million in community-based reentry houses and services by a public program known as Specialised Therapy for Optimized Programming. This system helps about 8,500 parolees a 12 months. 

To run this system, the Corrections Division depends on personal corporations and nonprofits, however a CalMatters investigation discovered that this system has grown with little oversight from the division. 

The division agreed to pay the Amity Basis roughly $121 million over 5 years to supervise and overview reentry houses in Los Angeles County, together with the HealthRight 360’s Walden Home, positioned simply east of downtown Los Angeles in El Monte. Nonetheless, state data present Amity didn’t overview the power in 2021 or 2022 – the 12 months Jack died, regardless that its state contract required annual web site visits and stories. 

Taxpayers paid about $5,200 a month per parolee for Walden Home to supply a mixture of housing, meals, substance use dysfunction remedy, remedy and varied different actions. 

Three years earlier than Jack’s loss of life, throughout an unannounced go to, a state inspector from the Division of Well being Care Providers, which licenses remedy facilities similar to Walden Home, discovered the power to be poor in a number of areas — together with guaranteeing residents’ treatment logs have been correct. HealthRight 360 advised the state it mounted the issue and retrained its workers, and the power was given a clear invoice of well being by the state.

From 2020 to 2022, greater than a 3rd of the 85 medical emergency calls from the power have been associated to somebody experiencing blood sugar issues, in accordance with emergency service name data from the Los Angeles County Fireplace Division. Neither the corrections division nor HealthRight 360 responded to questions concerning the calls. 

HealthRight 360 closed Walden Home in El Monte in 2023 due to an absence of demand, in accordance with the corrections division, consolidating its operations with one other location in Pomona. The corporate wouldn’t comply with an interview about Jack’s time on the facility.

HealthRight 360’s president and chief govt officer, Vitka Eisen, mentioned in an e mail that the power was licensed to offer residential remedy and detox. “All medical care, together with major care, and the prescribing of any treatment would have been achieved through referral with a local people well being middle,” Eisen mentioned. 

The Amity Basis declined an interview. “The Amity Basis group is deeply, deeply saddened by the passing of Fredreaka Jack after being discharged from Larger El Monte Hospital,” wrote Chief Working Officer Carmen Jacinto in a press release. “Our care crew depends upon the skilled medical experience of hospitals who decide when a group member might be safely discharged into our care.”  

In a press release, Corrections Division spokesperson Terri Hardy mentioned parolees are chargeable for their very own well being care as soon as they enter the parole program.  

“People on parole are a part of the group and entry medical care as each different group member. CDCR doesn’t oversee medical care for people on parole, nor does it monitor treatment adherence for people housed in residential remedy packages as a part of the Specialised Therapy for Optimized Programming (STOP) contracts,” Hardy wrote in response to CalMatters’ questions. “Neither CDCR nor STOP suppliers pressure a person to reveal medical info, make the most of companies, or take drugs.

“Suppliers could help and/or encourage a person to hunt medical and psychological well being remedy; nevertheless, every participant is finally chargeable for their very own medical care.”

No establishment mentioned it had investigated Jack’s case or its insurance policies or practices.

In a closing stroke of indignity, Jack was cremated towards her needs since her household couldn’t afford to bury her. Her mom has been unable to make the journey from Louisiana to California to say her ashes. If she doesn’t achieve this by Nov. 2025, Fredreaka Jack might be buried amongst different unclaimed individuals who died in Los Angeles County. 

How Fredreaka Jack ended up in jail

A daughter of Metairie, La., Fredreaka Jack had crushed the percentages.

She’d grown up the place dependancy was rampant and frolicked within the foster care system. Nonetheless, Jack bought her GED and examined into Loyola College New Orleans, her household mentioned. Her aunt, Penny Jack, known as her a “gifted” baby.

Jack lived on campus and accomplished one semester of school earlier than she withdrew in 2005. The as soon as vibrant dancer and pianist turned overwhelmed with voices in her head, giving solution to delusions and habits that tormented her household. 

Jack’s great-uncle Derrek Bush, who took her in after she left Loyola, mentioned he hung cans on the door with fishing string so he’d be alerted when she bought residence. “You needed to watch your self together with her,” Bush mentioned. “She was actually sick.” He mentioned Jack talked to caterpillars and had a historical past of vandalizing issues whereas she lived on campus. He was afraid to stay together with her.

“I simply began not coming residence an excessive amount of,” Bush mentioned. Then someday, she was gone. “We went within the French Quarter. We couldn’t discover her, and after that every little thing went lifeless.” 

She made it to New York Metropolis. By 2007, she was in California. 

Like so many individuals with extreme psychological well being points, Jack’s psychoses quickly pushed her down California’s mental-health-to-criminal-justice pipeline.

Her laundry checklist of expenses included disturbing the peace, housebreaking, resisting arrest and assault, amongst different crimes she incessantly dedicated in San Diego and Los Angeles. 

The courtroom and the corrections division typically deemed Jack too mentally sick to face trial or be paroled into the group. She went to Patton State Hospital in San Bernardino for the primary time in 2008. Patton offers psychological well being care to folks admitted by a prison or civil courtroom order, present prisoners and others. State hospitals can maintain folks like Jack indefinitely if the Board of Parole Hearings deems them “offenders with psychological issues” and the state courtroom finds that the individual’s psychological well being doesn’t enhance by the tip of their sentence.

Practically 10 years after Jack left Louisiana, her household bought its first clue into her whereabouts. A Google search of her title turned up a lawsuit filed by Patton State Hospital to pressure Jack to take her psychotropic treatment.  

Penny tried calling the hospital to attach together with her long-estranged niece. “They mentioned ‘we will’t offer you that info,’” Penny mentioned.

State hospital officers advised CalMatters that affected person privateness legal guidelines prohibit them from confirming or denying whether or not somebody is or ever was in a state psychological hospital. 

It was one other lifeless finish for her household.

“I feel they need to have seemed for us,” Penny mentioned. “If an individual is that psychological, one thing is unsuitable they usually have household. Nobody checked out all.”

How the household lastly discovered her 

After six years, Jack was launched from Patton in 2018. 

Inside months, she was in authorized bother once more for assault, housebreaking and intimidating enterprise operators or prospects. She took a plea deal. And this time, she was sentenced to almost three years in jail. 

Even then, she was insisting on California transferring her to New Orleans, in accordance with her medical data. “I used to be born there. My household is there. They should let me return,” Jack mentioned, in accordance with the jail therapist’s notes.

After she served her time within the Central California Ladies’s Facility in Chowchilla, officers transferred her again to Patton, making psychiatric remedy a situation of her parole. 

This time, her sister discovered her — once more  — within the state hospital. Her mom known as. 

Sharon Jack wasn’t certain that the individual on the opposite line, who known as herself  Cleopatra, was her eldest daughter. It took weeks of conversations earlier than Sharon was satisfied that she was speaking to her “child.” 

The 2 apologized for his or her estranged relationship, Sharon Jack mentioned, and picked up the place they’d left off after practically 15 years of separation.

“We talked on daily basis,” she mentioned. “Early within the morning, I’d make them go get her up!” 

Their conversations, Sharon Jack mentioned, oscillated between convincing her daughter to take her psychotropic treatment, their plans to see one another and Fredreaka Jack’s frequent requests for cash to buy issues from the commissary.

In any case these years, Sharon Jack needed to spoil her daughter. So she offered a bank card for Fredreaka’s ‘90s R&B CDs and her junk meals cravings, even when it meant lacking lease, she mentioned. Little did she know, her daughter was taking Metformin to assist regulate her blood sugar and was underneath physician’s orders to eating regimen and shed pounds, as her medical data present. 

A state hospital spokesperson advised CalMatters that the hospital’s diet companies division doesn’t have “any management over affected person’s commissary purchases” and that the hospital solely critiques canteen orders “for appropriateness” when there’s a courtroom order proscribing a affected person’s eating regimen. 

When Jack was in state jail, checks rendered her blood sugar inside regular vary, in accordance with her medical data and the Facilities for Illness Management’s scale for diabetes. As soon as she moved to Patton State Hospital, her blood-sugar ranges started to extend, in accordance with her medical data. Jack’s current state hospital data first point out her excessive blood sugar on July 12, 2021. Quickly after, she started taking Metformin to fight pre-diabetes, her medical data present. 

The Board of Parole Hearings ordered her to obtain psychiatric remedy at Patton. Nonetheless, she made her personal decisions about her bodily well being care, together with what she ate.

Throughout her time at Patton State Hospital, Jack took her psychotropic drugs religiously as a result of it was required as a situation of her parole. However her medical data present she typically refused blood checks, ignored weight-reduction plan recommendation and infrequently refused to put on a respiratory machine when she slept, towards nurses’ recommendation.

“I don’t need it. It makes me wheeze,” Jack as soon as advised her nurse.

Life in Walden Home 

After practically two years in custody and over a 12 months inside Patton, Jack petitioned the courtroom in 2022 to serve her parole in the neighborhood as a substitute, in accordance with the corrections division. Months prior, a psychologist for Patton famous that Jack was “psychiatrically and behaviorally unstable” and “stays a hazard past that which might be safely and successfully monitored in a much less restrictive setting,” in accordance with her medical data. The psychologist decided that she was not able to be launched. The state’s Board of Parole Hearings beneficial towards her launch on Jan. 31, 2022, in accordance with the corrections division.

However Jack appealed, and a courtroom granted her needs. She was paroled into the STOP program and despatched to Walden Home, a 72-bed facility for ladies parolees and their kids.

A few month earlier than her launch, the corrections division modified its treatment coverage, giving folks leaving prisons a 60-day provide. The coverage change got here after attorneys in a long-running prisoner-rights lawsuit often called Armstrong argued that parolees have been typically vulnerable to working out of medicines due to “delays with organising Medi-Cal” and the “lack of help from parole brokers in navigating entry to well being care.”

However Jack slipped by the cracks. That new coverage didn’t apply to jail parolees who have been launched from the state hospital.  

“This does look like a niche within the system,” mentioned lawyer Ben Bien-Kahn, who represents plaintiffs within the Armstrong lawsuit. “Absent some slip-up within the coverage, if she launched straight from CDCR jail, she would have had double the treatment.” 

State hospital officers mentioned the hospital doesn’t give newly launched sufferers refills on prescriptions as a result of the affected person “will now not be monitored by the hospital doctor,” the spokesperson wrote. “Unmonitored prescription treatment use might be harmful and even deadly.”

As a substitute, Jack left Patton State Hospital with a 30-day provide of her drugs regardless that her keep on the STOP program’s Walden Home could be a minimum of three months. In discharge summaries, the hospital famous Jack’s “grandiose delusions” and medical dangers for “diabetes, cardiovascular, respiratory, and endocrine.”

At Walden Home, STOP residents may depart the compound for as much as six hours for procuring, medical appointments, searching for a job and extra. 

For medical remedy, Walden Home referred residents to 2 hospitals and the Southern California Medical Middle, in accordance with data from the Division of Well being Care Providers.

Nonetheless, treatment logs incessantly didn’t doc that Walden Home workers gave  Jack her treatment. In her first weeks there, for instance, workers documented her taking solely half of her Metformin, which is used to deal with pre-diabetes, for 11 days.

By mid-June, she was at Southern California Medical Middle, a non-profit group clinic, complaining of knee ache and looking for to have her drugs refilled and adjusted, in accordance with her medical data from the clinic. 

Jack needed to know what drugs “she ought to proceed and what needs to be stopped,” in accordance with the medical data. The physician famous that she had not taken her blood stress drugs “for weeks.” 

Information say she was given two new prescriptions for her blood stress drugs and the medical doctors ordered a number of lab checks for her, which revealed her glucose degree was 395. The conventional vary: 60-140, in accordance with the blood take a look at included in Jack’s medical data. 

SoCal Medical’s chief medical officer and founder, Dr. Mohammad Rasekhi, mentioned it’s the corporate’s coverage to name sufferers after receiving their take a look at outcomes. Jack’s data from SoCal Medical, the place the Walden Home referred its shoppers for medical care, don’t point out that anybody contacted her concerning the outcomes. The data say the clinic crammed a few of her prescriptions, however don’t point out that she bought a brand new prescription for Metformin or some other treatment to deal with diabetes.  

Rasekhi mentioned he relies on locations like Walden Home to contact the clinic, which caters to low-income sufferers, about follow-up visits and medicine adjustments.

“We did our greatest,” Rasekhi mentioned.

In July, Walden Home workers didn’t document giving her the brand new blood stress drugs for 10 days.

The data don’t point out that workers gave Jack 11 morning doses of Haloperidol, an antipsychotic that she was purported to take twice a day. Nobody signed the log for giving Jack her morning dosage on the day she died.

Neither the Amity Basis, HealthRight 360, nor the California Division of Corrections and Rehabilitation responded to CalMatters’ questions on why Jack’s treatment logs have been lacking signatures.

Jack additionally incessantly ended up on the Larger El Monte Hospital’s emergency room, the place Walden Home despatched its shoppers, complaining about vaginitis – a possible symptom of diabetes – and varied sorts of ache and discomfort. In July, she went to the emergency room 4 instances in 11 days and dropped 9 kilos in 10 days.

On her first of 5 ER visits, three days after checks at SoCal Medical revealed Jack’s excessive blood sugar, medical doctors on the emergency room additionally discovered a excessive quantity of glucose in her urine, mentioned Victor Lange, the hospital’s threat administration director. Medical specialists advised CalMatters the excessive glucose might be an indication that somebody has diabetes. 

Jacks’ emergency room data don’t point out that anybody drew her blood throughout her many visits to the emergency room. Lange mentioned it’s not commonplace care to attract blood on each affected person who visits the emergency room. 

“If blood stress is regular, blood oxygen, and all of those components are aligning correctly, the physician doesn’t must order a blood draw,” he mentioned. Nonetheless, on Jun. 18, 2022, Jack was given a urine take a look at, which revealed that she had a excessive quantity of glucose in her urine, Lange mentioned. “We beneficial that she see a major care doctor.”

Jack went again to SoCal Medical on July 1, 2022, as an “er comply with up,” in accordance with her medical data. The clinic endorsed Jack on managing her eating regimen and referred her to a gynecologist. The medical data don’t point out if anybody checked her blood sugar once more or gave her a brand new prescription for treatment to deal with diabetes. 

By July 11, 2022, she was again within the emergency room, complaining of vaginal ache and itching. The emergency room physician wrote that his scientific impression was that Jack had vaginitis, drug-seeking habits and a historical past of substance abuse, medical data present. 

By July, she’d misplaced 48 kilos, a purple flag for diabetes signs, in accordance with a number of medical doctors CalMatters spoke with for this story.

Round July 20, she was complaining to her mom, Sharon, of left arm spasms, which she attributed to a facet impact of her new psychiatric treatment. At Sharon’s urging, Jack went again to the hospital. 

The emergency room physician referred Jack again to her psychiatrist. 

“Affected person didn’t look like a dependable historian and has delusional speech,” the medical data state.

“She has a historical past of schizoaffective dysfunction, and that is her 4th go to to this emergency room this month,” the emergency room doctor mentioned within the hospital’s data. 

The physician’s notes say that Jack didn’t have a historical past of diabetes. The data additionally don’t point out that the hospital checked her blood stress, coronary heart price, blood sugar, weight or temperature. 

Emergency room data acknowledged that there have been “no very important indicators obtainable.”

Fourteen hours later, she was lifeless, in accordance with the post-mortem report. 

On April 11, 2023, a SoCal Medical doctor’s assistant reached out to Jack to schedule a comply with up appointment for her hypertension, Rasekhi mentioned. 

She had been lifeless for nearly 9 months.

A mom searches for solutions

As quickly as Sharon Jack discovered the trigger from the post-mortem report — diabetes issues — she blamed herself for giving Jack free rein on the commissary. And she or he blamed the state hospital for by no means telling her about Jack’s diabetes.

Sharon Jack realized she had been shopping for her daughter “every kind of stuff a diabetic shouldn’t be purported to have.” 

“I really feel robbed,” she mentioned. “It make me really feel like I used to be killing my child.” 

Inside weeks of Jack’s loss of life, her sister, Frenada Jack, created a GoFundMe marketing campaign to assist pay for retrieving Fredreaka Jack’s physique from the state and “put her to relaxation peacefully.”  “She could be so joyful being that she requested … to not be cremated and any donations might be positive and sincerely appreciated,” Frenada wrote.

The $10,000 marketing campaign didn’t elevate any cash, and Jack was certainly cremated.

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On a moist Louisiana afternoon in April 2023, 9 months after Fredreaka Jack’s loss of life, Sharon Jack was nonetheless looking for solutions about what occurred to her daughter. Inside her Metairie condo, she rocked forwards and backwards, sobbing and sweating as she stared on the small altar of mementos she created in honor of her daughter.

Sharon Jack pulled out stacks of papers and dozens of playing cards she’d obtained from individuals who lived within the facility together with her daughter. “Relaxation in Peace you have been like sunshine,” learn one. 

Six months after Jack’s loss of life, Sharon’s solely residing daughter, Frenada, handed away too. Sharon created one other altar, alongside Fredreaka’s.

“I’m so lonely. I gotta make it to heaven to see my two daughters once more,” mentioned Sharon by tears.