On June 6, 1996, the United States Department of Justice (DOJ) notified Los Angeles County that it intended to investigate conditions in the Los Angeles County Jail system (the Jails) pursuant to the Civil Rights of the Institutionalized Persons Act (CRIPA). In August of 1996, the DOJ toured the Jails with correctional mental health experts. The investigation found that the Jails were failing to provide care meeting constitutional standards to mentally ill inmates. On September 5, 1997, the DOJ issued a letter reporting its findings based on the tours and the County's response. The DOJ concluded that mental health care at the Jails violated the inmates' constitutional rights. The DOJ's findings report detailed numerous alleged constitutional deficiencies with regard to mental health care, including inadequate: (1) intake screening and evaluation, (2) diagnosis, (3) referral to mental health professionals, (4) treatment plans, (5) administration of medications, (6) suicide prevention, (7) tracking and medical record keeping, (8) staffing, (9) communication, and (10) quality assurance. The report also noted that mentally ill inmates were abused through excessive force and improper restraint.

The report included a list of recommended remedial measures addressing the screening and treating of mentally ill inmates. The recommendations also included providing adequate and sanitary conditions for mentally ill inmates, providing access to recreation and other privileges, and promptly investigating reports of mistreatment or abuse of mentally ill prisoners. Other recommendations addressed record-keeping systems and suicide watch procedures.

On December 19, 2002, the parties reached a Memorandum of Agreement that required adequate mental health care and suicide prevention at the Los Angeles County Jail System. The Agreement stated that (1) all inmates would be screened for mental illness upon intake to the Jails; (2) all inmates who may be mentally ill would be referred to a mental health professional, and the County should provide adequate mental health treatment, including medication; (3) all inmates under suicide watch would be evaluated by a mental health professional; and (4) the jails would keep detailed medical records with regard to mental health. Also, the County was to provide sufficient mental health staffing to ensure timely access to adequate mental health treatment. Finally, the County had to implement and document a continuous quality improvement program for mental health services, specifying the procedures for medical and administrative review for various events, such as suicides and attempted suicides.

In September 2013, the DOJ had opened a separate investigation of the Jails under CRIPA and The Violent Crime Control and Law Enforcement Act of 1994 to address allegations of use of excessive force against all prisoners at the Jails, not just prisoners with mental illness. During the course of their investigation, the County and the Los Angeles Sheriff’s Department (LASD) entered into a comprehensive settlement agreement to resolve Rosas v. McDonnell, JC-CA-0073. Rosas was a class action lawsuit alleging abuse and excessive force by staff at certain Jails located in downtown Los Angeles. As part of the Rosas settlement agreement, the County and LASD agreed to implement significant measures to protect prisoners from excessive force by staff, including improvements in policies, training, incident tracking and reporting, investigations, resolution of prisoner grievances, prisoner and staff supervision, and accountability.

On June 4, 2014, the DOJ issued a letter stating that, since the entry of the Memorandum of Agreement twelve years before, there had been significant improvement in the delivery of mental health services. However, serious systemic deficiencies remained with regard to some aspects of the Jails' mental health program.

Concerns remained surrounding the Jails' suicide prevention and mental health care—which resulted from from the partial implementation of the 2002 agreement and current conditions within the Jails. To address these issues, the parties developed another settlement agreement. On August 5, 2015, the U.S. filed this lawsuit against the County of Los Angeles and the Los Angeles County Sheriff in his official capacity in the U.S. District Court for the Central District of California. The DOJ sued under CRIPA and the Violent Crime Control and Law Enforcement Act of 1994. It sought equitable and declaratory relief. The case was assigned to Judge Dean Pregerson and referred to Magistrate Judge John McDermott. On the same day the complaint was filed, the Government and the County filed a stipulated settlement.

The court-enforceable settlement agreement provided for a series of new or enhanced policies and practices intended to ensure that the County would provide safe and secure conditions. These policies would ensure the inmates' reasonable safety from harm, including serious risk from self-harm and excessive force, and provide adequate treatment for their mental health needs. The agreement also extended the remedial measures in the Implementation Plan of the Rosas settlement to fully resolve the DOJ’s findings of alleged mistreatment of prisoners with mental illness. It also settled claims under the Violent Crime Control and Law Enforcement Act of 1994, which alleged excessive force against prisoners at all of the Jails. The parties agreed that an independent monitor would issue a report every six months detailing the implementation of this agreement until the defendants remained in substantial compliance with every substantive provision of the agreement for twelve consecutive months or until the monitor and the court determined that the objectives and goals of the agreement were satisfied. On September 3, 2015, Judge Dean D. Pregerson approved the settlement agreement.

On September 28, 2015, individuals with mental illnesses and disabilities—individuals frequently cycled between the City's jails and streets—sought to intervene, arguing that paragraph 34 of the settlement agreement, covering discharge procedures, violated the Americans with Disabilities Act, and their Fourth and Eighth Amendment rights. The individuals alleged that Paragraph 34 facially discriminated against disabled prisoners whose disability stemmed from personality disorders, substance abuse and dependence disorders, dementia, or developmental disabilities, as well as all disabled prisoners who spent seven days or fewer in jail. The individuals further alleged that Paragraph 34's discharge procedures were inadequate, as many disabled prisoners would be unable to obtain needed medication or services if provided with nothing more than a prescription or list of referrals upon discharge.

On December 15, 2015, Judge Pregerson granted the motion to intervene. 2015 WL 8783449. On January 14, 2016, the intervenor plaintiffs filed an amended complaint. On March 14, 2016, the defendants filed a motion for judgment on the pleadings with regard to the intervenor’s first amended complaint. The defendants argued the intervenors lacked standing to assert injunctive relief claims because none of them were incarcerated at that time or had suffered any harm as a result of the policies. The defendants also claimed that the intervenors’ allegations of inadequate medical treatment failed to state a claim because the ADA and the Rehabilitation Act did not create a remedy for deficient medical services. Finally, the defendants argued that the intervenors’ allegations did not state any viable constitutional claims because, by their own admissions, none of them had been deprived of constitutional rights. Judge Pregerson disagreed. The court found that the intervenors had adequately alleged constitutional violations and denied the motion on May 17, 2016. 2016 WL 2885855.

On May 16, 2016, the defendants filed a motion to disqualify the intervenors’ counsel for violation of the rules of professional conduct. On the same day, the defendants filed for review of Magistrate Judge McDermott’s April 27, 2016 minute order allowing the intervenors to depose the Director of the Los Angeles County Health Agency. 2016 WL 4060314. On July 27, 2016, the court denied the defendant’s motion to disqualify the intervenors’ counsel and affirmed the court decision allowing the intervenors to depose the Director. 2016 WL 4059712.

During the duration of the intervenors’ case, the monitor continued reporting on the implementation of the 2015 settlement agreement.

The monitor’s first report, published on May 1, 2016, found that of the 69 provisions in the Settlement Agreement subject to monitoring, the defendants were in substantial compliance with 5 provisions and in partial compliance with 16 provisions. The monitor found that the defendants were in substantial compliance with housing and sanitation, suicide intervention and first aid kits, and weekly rounds in restricted housing modules. The defendants were only in partial compliance with suicide hazard mitigation plans, suicide prevention training, staffing requirements, and inmate safety checks in mental and non-mental housing.

The monitor published a second report on September 1, 2016. The defendants were in substantial compliance with mental health assessments, maintenance plans, investigation of staff misconduct, and law enforcements investigations of suicides. But the defendants were in partial compliance with suicide hazard mitigation plans, screening for mental health care and suicide risk, and initial treatment plans. And the defendants were not in compliance at all with provisions regarding reporting of self-injurious behavior and threats, therapeutic services in mental health housing, and active mental health caseloads.

The monitor’s third report was published March 1, 2017. The defendants were in substantial compliance with suicide hazard mitigation plans, initial treatment plans, and weekly rounds in restricted housing modules. The defendants were in partial compliance with suicide prevention training, identification and evaluation of suicidal inmates, and disciplinary policies. And the defendants were again not in compliance with reporting of self-injurious behavior and threats, active mental health caseloads, and referral for mental health care.

The monitor published a fourth report on September 1, 2017. The defendants were in partial compliance with reporting of self-injurious behavior and threats suicide prevention training, identification and evaluation of suicidal inmates, and disciplinary policies. The defendants again were not in compliance with provisions on active mental health case loads and referrals for mental health care.

A fifth report was published on March 1, 2018. There were 34 provisions that no longer required monitoring because the defendants were in substantial compliance for twelve consecutive months. The monitor also found the defendants were in substantial compliance with investigation of staff misconduct; in partial compliance with disciplinary policies, interruption of self-injurious behavior, and staffing requirements; and were not in compliance with active mental health caseloads.

The monitor’s sixth report was published on August 31, 2018. A total of 38 provisions no longer required monitoring because the defendants were in substantial compliance for twelve consecutive months. The monitor found the defendants in partial compliance with identification and evaluation of suicidal inmates, initial mental health assessments and treatment plans, and interruption of self-injurious behavior. The defendants were still not in compliance with staffing requirements.

As of October 2018, the defendants had not maintained compliance with the 2015 settlement agreement for twelve consecutive months. The settlement agreement remained in effect and the defendants were continued to be monitored.

David Terry - 03/08/2006
Jessica Kincaid - 02/04/2016
Hannah Greenhouse - 10/30/2018


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