It was supposed to be a routine journey inland from the coast.
A sheriff’s van turned onto a rural highway.
Two women, accused of no crimes, were locked in a cage in the back.
The van headed north on S.C. 9 into Nichols, a tiny town an hour from Myrtle Beach where water left behind by Hurricane Florence lapped at the road’s edge. Farther along, it deepened to cover the asphalt.
On a washed-out section of roadway, the van plunged into floodwater. Deputies assigned to the women’s care survived by climbing onto the roof. Trapped inside, the women drowned.
Like thousands of people in South Carolina each year, Wendy Newton and Nikki Green had been ordered into psychiatric care. It was left to law enforcement to drive them to healthcare facilities for treatment.
An investigation into the practice by The News & Observer and The Sun News found that such patients commonly endure hours-long trips in handcuffs or cramped metal cages, even when they’ve shown no signs of violence.
Interviews with law enforcement officials, medical professionals, patients and disability rights advocates portray a makeshift system of care that disorients and demeans the state’s residents when they are most in need of help.
Ensnared in this largely invisible setup are veterans, seniors, first responders and a large number of children.
Nearly a quarter of mental health transports last year in Horry County, where deputies picked up Newton and Green, involved someone under 18, a review of trip logs found. The youngest child was 8.
Almost one in three Horry County trips took longer than two hours. Dozens of Charleston County trips last year stretched to 10 hours and beyond.
At shift change, deputies sometimes hand off patients at gift shops or gas stations.
Just about everyone aware of the system agrees it can be traumatizing. Advocates long have condemned officer transports, saying they discourage people from seeking future care.
“They shouldn’t be shackled with chains and locked in a cage,” said Sen. Marlon E. Kimpson, a Charleston Democrat who proposed changes after Newton and Green died in September. “These people are on our streets, these are family members or relatives, and one day it might be us.”
Some states have begun relying less on law enforcement and restraints.
But in South Carolina, the high-profile deaths and calls to action that followed were not enough to stir lawmakers to devote money to reform.
The bill Kimpson introduced this winter passed out of the Senate only after it was stripped of a provision that encouraged use of unmarked sedans. It then stalled in a House committee on which William H. Bailey, an Horry County Republican with a background in public safety, serves.
Linda Green, Nikki’s mother, was outraged by lawmakers’ tepid reaction.
“They still want to use the van?” she asked, incredulous.
She couldn’t believe a person in need of care would be subjected, by default, to such harsh treatment.
“It’s an illness,” Green said. “It’s a disease. It’s not a crime.”
‘Likely to cause harm’
By the time Newton and Green met in the sheriff’s van, each had dealt with symptoms of schizophrenia for decades. Neither was violent, their families said.
The morning of Sept. 18, Green went to Waccamaw Center for Mental Health expecting a routine counseling appointment. Her 19-year-old daughter, Rose, had driven her from their home in Myrtle Beach to the clinic in Conway, and the two planned to go out to eat afterward.
Rose waited in the car until she got a text from her mother saying the doctor was having her committed. Hours later, she watched her mom get into the van.
The same morning, Newton traveled from Tabor City, N.C., where her mother lived, to an emergency room in Loris. In the days since Hurricane Florence pushed ashore near her home in Shallotte, N.C., Newton had run low on medication, and she was experiencing frightening hallucinations.
Her family arranged for a sheriff’s deputy to take Newton to the hospital, along with her 27-year-old daughter, Abigail, for support.
When Abigail left the hospital around noon, her mother was medicated and asleep.
South Carolina physicians can force someone into psychiatric treatment if they conclude the person has a mental illness and, as a result, is “likely to cause harm” to themselves or others if not immediately hospitalized.
Self harm is defined broadly. The law says it can come “through neglect, inability to care for himself, or personal injury, or otherwise.”
A doctor’s signature authorizes the emergency hospital admission. Review from a judge comes later.
The certificate the doctor signs orders law enforcement to pick the patient up, usually from an emergency room, and deliver the patient to a facility with specialized inpatient care.
But the paperwork makes clear that there’s an exception: A friend or family member may transport the patient if they’re willing to assume the responsibility and the cost. They may also hire an ambulance.
In practice, that rarely happens, experts say, largely due to concerns about liability. Hospitals will usually ask the local sheriff’s office to pick up the patient.
The Green and Newton families said there’s no question they would have accepted responsibility for the drive, if only they had been given the option.
The executive director of the South Carolina Sheriffs’ Association has asked legislators for dramatic reform that would take a medical issue out of the hands of law enforcement.
At a February Senate subcommittee meeting, Jarrod Bruder described mental health transports as “an overwhelming burden.” Deputies statewide did between 12,000 and 15,000 transports last year, he estimates, based on a survey that 26 of 43 sheriff’s offices answered.
The bill Kimpson introduced would have had each agency create a “therapeutic transport unit” requiring officers to receive training on how to deal with people in mental health crisis, and as often as possible, drive an unmarked car.
Bruder said short staffing and scant funding at rural agencies makes the reforms impossible.
Historically, sheriff’s deputies have done most of the mental health transports because of their close relationship to the courts, but the law mandates transports by “a state or local law enforcement officer.” State agencies and some local police departments refuse the job, Bruder told lawmakers.
South Carolina officers were formally given the task in 1974, amid a transformation of the mental healthcare system aimed at providing care for patients in their home communities rather than state hospitals. Deinstitutionalization was supposed to mean less confinement for people with psychiatric disabilities, long subjected to bars and cages.
But in the 1970s a major shift in government funding away from health and welfare services and into the criminal justice system was accelerating, said Anne Parsons, history professor at UNC Greensboro and author of “From Asylum to Prison.”
Imprisonment became the default response to all kinds of social disorder, Parsons said, and people with mental illness got caught in the net.
South Carolina law enforcement leaders have protested their prescribed transport duties for decades.
In 1996, the police chief of Ridge Spring told the attorney general he worried that transporting mental health patients in handcuffs violated patients’ civil rights and made his agency vulnerable to getting sued.
The attorney general’s office commended Chief Richard Palmer for his concerns, noting that other departments had also raised the issue, but said unless the General Assembly changed the law, Palmer’s officers had to do the transports.
Richland County turned to the attorney general to clarify the law following a 2016 amendment allowing transports by emergency medical technicians. The sheriff argued that mental health patients should now travel by ambulance, but the state came down on the county manager’s side: Unless there was a special arrangement, deputies still had the job.
A long road to help
The sheriff’s van carrying Green and Newton sank in rural Marion County, just west of the Horry County line.
The van had picked up Green in Conway, stopped at the jail for a shift change, then went on to get Newton in Loris, some 40 miles to the north.
Green’s destination was in Darlington, about 65 miles to the west. Then deputies planned to take Newton to Lancaster, some 80 miles farther.
Sheriff’s office records show that a journey with more than one patient and more than one destination is not unusual. Horry County deputies made almost 50 multi-part trips last year.
Roughly a third of the county’s mental health transports were longer than 100 miles.
When a doctor deems someone in need of emergency inpatient psychiatric care, several factors determine where the person ends up for treatment, among them age, other medical conditions and type of insurance.
In emergency rooms and community mental health centers, case workers are tasked with finding an open bed. Hospitals that provide psychiatric care have admissions coordinators to field calls from the case workers.
The goal is to get a patient to the hospital they prefer or one they have used before, ideally a hospital near their home.
But that can be difficult, especially if a patient is uninsured or, like Newton and Green, insured through Medicaid.
Due to federal regulations dating to the 1960s, Medicaid recipients who are not part of a managed care organization can only get inpatient psychiatric care in a community hospital or state facility.
About a quarter of South Carolina’s inpatient psychiatric beds are in free-standing, private psychiatric facilities and thereby off limits. In Horry County, that share is 78 percent.
Crisis without caretakers
South Carolina is among the hardest places in the country to get psychiatric care.
A recent ranking by Mental Health America, a nonprofit that promotes early intervention to ward off crisis situations, found only Texas and Mississippi are worse.
Experts agree there are not enough mental health professionals, especially in rural areas, where hospitals have been closing. Compounding the difficulty, mental health providers are more likely than other medical providers to decline insurance.
State officials must expand services designed to prevent hospitalization as part of a recent legal settlement. Plans include expanding telepsychiatry and opening crisis stabilization units across the state. They’re also trying to increase the number of inpatient psychiatric beds at community hospitals by offering to pay for them in advance.
But the budget is bleak. South Carolina made some of the country’s most drastic cuts to mental health funding during the Recession — chopping 39 percent between 2008 and 2012, according to a report by a statewide task force. And allocations have been slow to rebound.
The consequences can be seen in emergency rooms. More and more people have been showing up in crisis, experts say, and doctors consider forced psychiatric care, sometimes referred to as involuntary commitment, to be a primary tool.
Tim Smoak, vice president of patient services for McLeod Health, said small hospitals in the company’s network get between 30 and 60 psychiatric visits a month on average and its regional hospital in Florence gets about 300, drawing from the surrounding rural area.
Roughly 50 percent of those psychiatric visits end in forced inpatient treatment, Smoak said.
He thinks the numbers are rising “because of concerns with litigation and because of the lack of resources for outpatient providers.”
And there’s another contributing factor — transportation.
“Somebody in rural South Carolina that goes to an emergency room because they’re depressed or they’re drunk or whatever and they don’t have a way,” Smoak said, “they’re going to get committed so that then they can get a ride.”
Stripped of dignity
What a South Carolina firefighter remembers about the process is humiliation. Walking by people he knew in the hospital wearing handcuffs and a belly chain. Asking an officer not to handcuff him in front of his parents. Seeing his mom’s hand pressed against the window of the squad car.
The News & Observer and The Sun News are not identifying him because he fears his co-workers wouldn’t trust him if they knew about his forced psychiatric treatment.
He traces the crisis that landed him in the hospital back to his job.
The traumatic calls stacked up. The ones involving children particularly bothered him. But he didn’t talk about it.
“There’s an area in my mind I call Pandora’s Box,” he said. “You just pack it all away and say it’s okay, it’s okay, it’s okay.”
He said he saw a specialist in therapy for first responders, but his insurance cut him off.
He sent a long emotional text to some friends that they interpreted as suicidal, and they appealed to a probate judge to have him involuntarily committed. He arrived home from work to find a squad car parked in front of his house.
“I felt I lost my rights, not just a human being, but as a citizen,” he said. “And I felt my dignity was stripped away.”
The hospital where he was taken for an evaluation did not give his family the option to drive him to the inpatient facility where he was required to get treatment. So he rode another two hours in handcuffs.
Kimpson and his colleagues on a special corrections committee this winter put forward a relatively modest proposal.
S. 303 would have given officers more time to make transports when conditions are hazardous and made the law more explicit about when a patient can be transported by a friend or family member.
The bill said transporting officers should be part of a specialized unit and must receive “crisis intervention training.”
Since January 2018, officers have been required to complete two hours of mental health training during a three-year cycle as part of maintaining their state certification.
Both of the sheriff’s deputies involved in the deaths of Green and Newton had some mental health training. In 2013, the year after Joshua Bishop was hired, he took a two-hour “Disorder Management” class and a 15-minute class on “Transporting Incapacitated/Disabled Inmates.” Records show that in the subsequent two years, Bishop took seven hours of classes on mental health topics. And in August 2018, he earned Bs in “Mental Health in Jails” and “Suicide Prevention.”
Stephen Flood, a 10-year veteran of the Horry County Sheriff’s Office, has a similar training record, receiving most of his mental health training in 2013 and 2014. Records show his last mental health hours date to November 2015.
Both deputies had satisfactory performance reviews up until October, when Horry County fired them, citing “Giving negligent or substandard care to any patient” as one of the reasons. They have also been indicted. Each faces involuntary manslaughter charges; as the driver, Flood was charged with reckless homicide.
The South Carolina chapter of the National Alliance on Mental Illness, or NAMI, teaches the 40-hour course necessary for certification as a CIT officer, but it also offers two- and four-hour courses, Executive Director Bill Lindsey said.
If lawmakers expected transport officers to take the 40-hour course, Lindsey said, it would cost $125,000 to $175,000, not including the expense to the Department of Mental Health, which provides some instruction, and local agencies, which pay officers’ salaries while they attend the training and have to cover those officers’ shifts. Courses cost about $750 per officer for NAMI.
The overall evidence about how well crisis intervention training works is inconclusive. It’s particularly unclear whether officers are learning to behave in ways that are less traumatic to people being forced into psychiatric treatment, Dinah Miller and Annette Hanson wrote in their 2016 book “Committed.”
Lindsey would like to see expansion of a Charleston program that embeds mental health providers with law enforcement officers to other parts of the state, but lawmakers have declined to fund it.
In an interview in March, Kimpson lamented his colleagues’ reluctance to put serious money into mental health.
“The whole mental health issue,” he said, “we talk about it when there’s a shooting, we talk about in the context of homelessness, but we don’t do a goddamn thing to address it.”
Transport of last resort
Very briefly this winter, a more ambitious reform idea glimmered with possibility.
Senators were interested in creating a regional transportation service under the Department of Mental Health.
Accounts vary on exactly why the idea was buried, but everyone blames cost.
Expenses are currently distributed across local governments and a few hospitals that offer their own transport services. If transports were consolidated under one state agency, the price tag would be visible as a line item in the state budget.
At lawmakers’ request, the Department of Mental Health started to compile an estimate for expanding its security division. A draft document shows salaries for officers of various ranks; $7,600 per officer for uniforms, guns and restraints; and $1.5 million for a dispatch system. For other items, in place of a dollar figure, there was a red question mark.
The unknowns were massive, Interim Director Mark Binkley said. No one knows the volume of transports across the state because there’s no central database. Law enforcement records capture only part of the picture, and they don’t distinguish between types of involuntary commitments, which can take place under several statutes, not just the one Kimpson and his colleagues proposed to alter.
Before launching an overhaul, Binkley would like a committee to gather data and study what other states have done.
- North Carolina, for example, is trying to encourage alternatives through contracting. A recent change in state law requires law enforcement and healthcare providers to cooperate in drafting transportation agreements, which can designate private companies or volunteers to do all or part of the transports in an area.
- In Wake County, the sheriff has contracted with G4S, a private security mega corporation, to transport patients in Dodge Chargers bearing the company’s name. The county has also allowed UNC police officers and another private security company to do some transports. Wake’s transportation plan says the gender of the driver or attendant must match the patient’s, unless a family member or a NAMI volunteer comes along on the ride, and drivers and attendants must receive crisis intervention training. Still, the plan requires patients to travel in a “car or van cage” or handcuffs with waist chains.
- Virginia just announced a $7 million, two-year contract with the company. G4S will organize services regionally and use unmarked cars with unarmed drivers wearing civilian clothes. Unlike in North Carolina, passengers will not be restrained. Based on the findings of a pilot project, Virginia officials expect the contractor to handle about half of the state’s 25,000 mental health transports. People deemed an active danger to themselves or others would still be transported by law enforcement.
At least one South Carolina House member, Horry County representative Bailey, is interested in exploring contracting with a medical company. He plans to get together with other members of an informal caucus of first responders to come up with a recommendation.
For now, Binkley is in favor of limiting changes to tweaks. He said he’d heard about only a handful of bad incidents over 33 years working in the Department of Mental Health legal office.
On March 20, the chair of the department’s board, Dr. Alison Evans, put the idea to lawmakers simply: “It’s worked pretty well for a long time.”
Senators seemed inclined to agree, pushing off questions about criminalizing and traumatizing mental health patients to a yet-to-be-appointed study group.
Anna Maria Darwin, a lawyer with Protection & Advocacy for People with Disabilities Inc., finds the conclusion that the system is working appalling.
“The whole way that this is set up criminalizes people with mental illness,” she said. “They’re supposed to be on the way to treatment. They’re not supposed to be on the way to jail or prison, and that’s a significant difference. So why can’t we treat them as if they did the right thing by asking for help?”
“If we don’t make changes now,” Darwin said, “we’re just asking for this to repeat, and is it going to be a child next time? Whose relative is it going to be? When? How many people have to die?”
BEHIND OUR REPORTING
Why did we report this story?
The deaths of Wendy Newton and Nikki Green in an inmate transport van prompted immediate questions for readers and reporters alike. How did two women voluntarily seeking health care end up caged in the back of a sheriff’s vehicle? And how many others have been treated similarly?
It’s a core part of our mission to serve as a community watchdog, especially where vulnerable people are concerned. So we decided to look more deeply at the case.
How did we report this story?
Using South Carolina’s Freedom of Information Act, we requested public records from a variety of government agencies. That’s how we obtained dispatch records, vehicle maintenance records and law enforcement policies, among other documents.
Five sheriff’s offices provided records detailing mental health transports. Most of that information came in a format that made analysis difficult. Horry County’s records, for example, were handwritten. So a reporter spent days making usable spreadsheets and checking their accuracy. We’ve made that data available using Google Sheets.
Our reporting also included many interviews. We spoke to the Green and Newton families, lawyers, law enforcement officers, medical doctors and administrators, legislators, lobbyists, researchers, advocates, and other people who have been forced into psychiatric treatment and transported by law enforcement.
We asked to speak with Horry County Sheriff Phillip Thompson, but he declined because the county is expecting lawsuits related to the deaths. The department also refused to answer detailed questions about its vehicle fleet, modifications to the vehicles and transport policies.
How do I share my own stories and concerns?
We’d like to hear from you. You can reach Carli Brosseau at 919-829-4627, firstname.lastname@example.org or through Signal at 971-409-5622. You can reach Alex Lang at 843-297-0659 or email@example.com.