Three months after leaving the state hospital, she was to be free. Instead she was dead

Byrhonda Lyons, CalMatters
Mon, 18 Mar 2024 13:41:06 +0000

This story was originally published by CalMatters, nonprofit, nonpartisan media venture explaining California policies and politics.

IN SUMMARY

It was clear 37-year-old Fredreaka Jack needed intense mental and physical health care. Yet California’s publicly funded parole system failed to make sure she got it.

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Each day someone at Patton State Hospital handed Fredreaka Jack her medication: three pills to manage her schizophrenia and bipolar disorder, one or two for her blood sugar, one for hypertension and one for hypothyroidism.

That all changed on April 14, 2022. Jack had been sentenced to 32 months in prison after pleading guilty to second-degree burglary. After successfully petitioning to be paroled into the community, she just had to complete about three months at a state-funded reentry facility known as Walden House and she’d be free.

Jack told her mother she loved the facility and the hints of freedom it offered — trips to the store, access to her phone and the small job she had helping out. She hoped to be reunited with her family in Louisiana soon.

Instead, Jack would be dead within months. She was 37.

In granting her the freedom she sought, the court released Jack into a public parole system so full of holes that Jack’s death was almost preordained, a review of thousands of pages of medical records and court documents reveals.

Jack was battling serious mental illness and coming off nearly a decade and a half of institutionalization. A psychologist for the state hospital warned that she “remains a danger” and was “psychiatrically and behaviorally unstable.” The Board of Parole Hearings denied Jack’s request to be freed.

Yet, after she appealed, a San Bernardino court released her from the state hospital’s care, meaning she couldn’t enter its outpatient program for people with mental illness. Instead, the California Department of Corrections and Rehabilitation sent Jack into a home focused on substance abuse to serve her parole.

Left by state policy to navigate the complex mental and physical health care system on her own, Jack failed at nearly every turn. So did California’s parole system – and the contractors the Corrections Department paid with taxpayer money to operate it.

The state hospital discharged Jack with just 30 days of medication, giving her a month’s time to find a primary care doctor and psychiatrist in a new community and get her long list of prescriptions refilled.

When Jack did find a primary care physician, the medical records do not show that the doctor wrote her a new prescription for diabetes medication. The records do show that tests revealed Jack’s blood glucose level had been nearly three times the normal range. Even when she did have prescriptions filled for her blood pressure, medical logs show that no one at Walden House recorded giving Jack her medication for many days at a time.

And when she ended up in the emergency room again and again, doctors sometimes attributed her physical complaints to mental illness and “drug-seeking behavior,” medical records show. By her last visit, she’d lost nearly 50 pounds in three months. When the hospital discharged her, records say she had no history of diabetes.

She died just 14 hours later. The cause: complications from Type 2 diabetes, according to the autopsy.

Sharon Jack, Fredreaka’s mother, received detailed updates from state hospital workers about Fredreaka’s mental health. But the autopsy report was the first she had heard of her daughter having diabetes, she said.

“I have never expressed to nobody how much this hurts,” Sharon said through tears. “I thought my baby was coming home to me. They took that opportunity away from me.”

Fredreaka Jack was sent to a state-funded reentry home in El Monte known as Walden House to serve her parole. About a week before she was set to be released, Jack passed away. Residents at the facility sent Sharon handmade cards to express their condolences. Photos by Cedric Angeles for CalMatters Fredreaka and her mother Sharon lost touch for nearly 15 years, as Fredreaka was shuffled through the justice and mental health system in California. Sharon created this small altar of mementos in honor of her eldest daughter. Photo by Cedric Angeles for CalMatters

As California has retooled the prison system to emphasize rehabilitation, it has invested more than $650 million in community-based reentry homes and facilities through a public program called Specialized Treatment for Optimized Programming. The program supports about 8,500 parolees a year.

To run the program, the Corrections Department relies on private companies and nonprofits, but a CalMatters investigation found that the program has grown with little oversight from the department.

The department agreed to pay the Amity Foundation roughly $121 million over five years to oversee and review reentry homes in Los Angeles County, including the HealthRight 360’s Walden House, located just east of downtown Los Angeles in El Monte. However, state records show Amity didn’t review the facility in 2021 or 2022 – the year Jack died, even though its state contract required annual site visits and reports.

Taxpayers paid about $5,200 a month per parolee for Walden House to offer a mix of housing, food, substance use disorder treatment, therapy and various other activities.

Three years before Jack’s death, during an unannounced visit, a state inspector from the Department of Health Care Services, which licenses treatment centers such as Walden House, found the facility to be deficient in several areas — including ensuring residents’ medication logs were accurate. HealthRight 360 told the state it fixed the problem and retrained its staff, and the facility was given a clean bill of health by the state.

From 2020 to 2022, more than a third of the 85 medical emergency calls from the facility were related to someone experiencing blood sugar complications, according to emergency service call records from the Los Angeles County Fire Department. Neither the corrections department nor HealthRight 360 responded to questions about the calls.

HealthRight 360 closed Walden House in El Monte in 2023 because of a lack of demand, according to the corrections department, consolidating its operations with another location in Pomona. The company wouldn’t agree to an interview about Jack’s time at the facility.

HealthRight 360’s president and chief executive officer, Vitka Eisen, said in an email that the facility was licensed to provide residential treatment and detox. “All medical care, including primary care, and the prescribing of any medication would have been done via referral with a local community health center,” Eisen said.

The Amity Foundation declined an interview. “The Amity Foundation community is deeply, deeply saddened by the passing of Fredreaka Jack after being discharged from Greater El Monte Hospital,” wrote Chief Operating Officer Carmen Jacinto in a statement. “Our care team relies upon the professional medical expertise of hospitals who determine when a community member can be safely discharged into our care.”

In a statement, Corrections Department spokesperson Terri Hardy said parolees are responsible for their own health care once they enter the parole program.

“Individuals on parole are part of the community and access medical care as every other community member. CDCR does not oversee medical care for individuals on parole, nor does it monitor medication adherence for individuals housed in residential treatment programs as part of the Specialized Treatment for Optimized Programming (STOP) contracts,” Hardy wrote in response to CalMatters’ questions. “Neither CDCR nor STOP providers force an individual to disclose medical information, utilize services, or take medications.

“Providers may assist and/or encourage an individual to seek medical and mental health treatment; however, each participant is ultimately responsible for their own medical care.”

No institution said it had investigated Jack’s case or its policies or practices.

In a final stroke of indignity, Jack was cremated against her wishes since her family couldn’t afford to bury her. Her mother has been unable to make the trip from Louisiana to California to claim her ashes. If she doesn’t do so by Nov. 2025, Fredreaka Jack will be buried among other unclaimed people who died in Los Angeles County.

How Fredreaka Jack ended up in prison

A daughter of Metairie, La., Fredreaka Jack had beaten the odds.

She’d grown up where addiction was rampant and spent time in the foster care system. Still, Jack got her GED and tested into Loyola University New Orleans, her family said. Her aunt, Penny Jack, called her a “gifted” child.

Jack lived on campus and completed one semester of college before she withdrew in 2005. The once vibrant dancer and pianist became overwhelmed with voices in her head, giving way to delusions and behavior that tormented her family.

Young Fredreaka Jack at a wedding with her great-uncle Derrek Bush. Jack lived with Bush before she left New Orleans, heading for New York City. She eventually landed in California. Jack’s family lost contact with her for nearly 15 years as cycled through California jails, prison and Patton State Hospital. Photo courtesy of Derrek Bush

Jack’s great-uncle Derrek Bush, who took her in after she left Loyola, said he hung cans on the door with fishing string so he’d be alerted when she got home. “You had to watch yourself with her,” Bush said. “She was really sick.” He said Jack talked to caterpillars and had a history of vandalizing things while she lived on campus. He was afraid to live with her.

“I just started not coming home too much,” Bush said. Then one day, she was gone. “We went in the French Quarter. We couldn’t find her, and after that everything went dead.”

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

Like so many people with severe mental health issues, Jack’s psychoses soon pushed her down California’s mental-health-to-criminal-justice pipeline.

Her laundry list of charges included disturbing the peace, burglary, resisting arrest and assault, among other crimes she frequently committed in San Diego and Los Angeles.

The court and the corrections department often deemed Jack too mentally ill to face trial or be paroled into the community. She went to Patton State Hospital in San Bernardino for the first time in 2008. Patton provides mental health care to people admitted by a criminal or civil court order, current prisoners and others. State hospitals can hold people like Jack indefinitely if the Board of Parole Hearings deems them “offenders with mental disorders” and the state court finds that the person’s mental health doesn’t improve by the end of their sentence.

Nearly 10 years after Jack left Louisiana, her family got its first clue into her whereabouts. A Google search of her name turned up a lawsuit filed by Patton State Hospital to force Jack to take her psychotropic medication.

Penny tried calling the hospital to connect with her long-estranged niece. “They said ‘we can’t give you that information,’” Penny said.

State hospital officials told CalMatters that patient privacy laws prohibit them from confirming or denying whether someone is or ever was in a state mental hospital.

It was another dead end for her family.

“I think they should have looked for us,” Penny said. “If a person is that mental, something is wrong and they have family. No one looked at all.”

How the family finally found her

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

Within months, she was in legal trouble again for assault, burglary and intimidating business operators or customers. She took a plea deal. And this time, she was sentenced to nearly three years in prison.

Even then, she was insisting on California transferring her to New Orleans, according to her medical records. “I was born there. My family is there. They have to let me go back,” Jack said, according to the prison therapist’s notes.

After she served her time in the Central California Women’s Facility in Chowchilla, officials transferred her back to Patton, making psychiatric treatment a condition of her parole.

This time, her sister found her — again — in the state hospital. Her mother called.

Sharon Jack wasn’t sure that the person on the other line, who called herself Cleopatra, was her eldest daughter. It took weeks of conversations before Sharon was convinced that she was talking to her “baby.”

The two apologized for their estranged relationship, Sharon Jack said, and picked up where they’d left off after nearly 15 years of separation.

“We talked every day,” she said. “Early in the morning, I would make them go get her up!”

Sharon Jack at her home in Metairie, Louisiana on April 5, 2023. Sharon is standing in front of affirmations she’s taped to her mirror. She told CalMatters the notes help her cope with the void she feels after her daughter’s death. Photo by Cedric Angeles for CalMatters

Their conversations, Sharon Jack said, oscillated between convincing her daughter to take her psychotropic medication, their plans to see each other and Fredreaka Jack’s frequent requests for money to purchase things from the commissary.

After all those years, Sharon Jack wanted to spoil her daughter. So she provided a credit card for Fredreaka’s ‘90s R&B CDs and her junk food cravings, even if it meant missing rent, she said. Little did she know, her daughter was taking Metformin to help regulate her blood sugar and was under doctor’s orders to diet and lose weight, as her medical records show.

A state hospital spokesperson told CalMatters that the hospital’s nutrition services department does not have “any control over patient’s commissary purchases” and that the hospital only reviews canteen orders “for appropriateness” when there’s a court order restricting a patient’s diet.

When Jack was in state prison, tests rendered her blood sugar within normal range, according to her medical records and the Centers for Disease Control’s scale for diabetes. Once she moved to Patton State Hospital, her blood-sugar levels began to increase, according to her medical records. Jack’s recent state hospital records first mention her high blood sugar on July 12, 2021. Soon after, she began taking Metformin to combat pre-diabetes, her medical records show.

The Board of Parole Hearings ordered her to receive psychiatric treatment at Patton. However, she made her own choices about her physical health care, including what she ate.

During her time at Patton State Hospital, Jack took her psychotropic medications religiously because it was required as a condition of her parole. But her medical records show she sometimes refused blood tests, ignored dieting advice and often refused to wear a breathing machine when she slept, against nurses’ advice.

“I don’t want it. It makes me wheeze,” Jack once told her nurse.

Life in Walden House

After nearly two years in custody and over a year inside Patton, Jack petitioned the court in 2022 to serve her parole in the community instead, according to the corrections department. Months prior, a psychologist for Patton noted that Jack was “psychiatrically and behaviorally unstable” and “remains a danger beyond that which can be safely and effectively monitored in a less restrictive setting,” according to her medical records. The psychologist determined that she was not ready to be released. The state’s Board of Parole Hearings recommended against her release on Jan. 31, 2022, according to the corrections department.

But Jack appealed, and a court granted her wishes. She was paroled into the STOP program and sent to Walden House, a 72-bed facility for women parolees and their children.

About a month before her release, the corrections department changed its medication policy, giving people leaving prisons a 60-day supply. The policy change came after attorneys in a long-running prisoner-rights lawsuit known as Armstrong argued that parolees were often at risk of running out of medications because of “delays with setting up Medi-Cal” and the “lack of assistance from parole agents in navigating access to health care.”

But Jack slipped through the cracks. That new policy did not apply to prison parolees who were released from the state hospital.

The Walden House Rehabilitation Center in El Monte on Feb. 4, 2023. Fredreaka Jack was a resident of the center in 2022, and died of complications from Type 2 diabetes while on parole at the facility. Photos by Larry Valenzuela, CalMatters/CatchLight Local

“This does seem like a gap in the system,” said attorney Ben Bien-Kahn, who represents plaintiffs in the Armstrong lawsuit. “Absent some slip-up in the policy, if she released directly from CDCR prison, she would have had double the medication.”

State hospital officials said the hospital doesn’t give newly released patients refills on prescriptions because the patient “will no longer be monitored by the hospital physician,” the spokesperson wrote. “Unmonitored prescription medication use can be dangerous or even fatal.”

Instead, Jack left Patton State Hospital with a 30-day supply of her medications even though her stay at the STOP program’s Walden House would be at least three months. In discharge summaries, the hospital noted Jack’s “grandiose delusions” and medical risks for “diabetes, cardiovascular, respiratory, and endocrine.”

At Walden House, STOP residents could leave the compound for up to six hours for shopping, medical appointments, looking for a job and more.

For medical treatment, Walden House referred residents to two hospitals and the Southern California Medical Center, according to records from the Department of Health Care Services.

However, medication logs frequently did not document that Walden House staff gave Jack her medication. In her first weeks there, for example, employees documented her taking only half of her Metformin, which is used to treat pre-diabetes, for 11 days.

By mid-June, she was at Southern California Medical Center, a non-profit community clinic, complaining of knee pain and seeking to have her medications refilled and adjusted, according to her medical records from the clinic.

Jack wanted to know what medications “she should continue and what should be stopped,” according to the medical records. The doctor noted that she had not taken her blood pressure medicine “for weeks.”

Records say she was given two new prescriptions for her blood pressure medications and the doctors ordered several lab tests for her, which revealed her glucose level was 395. The normal range: 60-140, according to the blood test included in Jack’s medical records.

SoCal Medical’s chief medical officer and founder, Dr. Mohammad Rasekhi, said it’s the company’s policy to call patients after receiving their test results. Jack’s records from SoCal Medical, where the Walden House referred its clients for medical care, do not mention that anyone contacted her about the results. The records say the clinic filled some of her prescriptions, but do not indicate that she got a new prescription for Metformin or any other medication to treat diabetes.

Rasekhi said he depends on places like Walden House to contact the clinic, which caters to low-income patients, about follow-up visits and medication changes.

“We did our best,” Rasekhi said.
Sharon Jack holds a painting of her daughter, Fredreaka Jack, at her home in Metairie, Louisiana on April 5, 2023. Photo by Cedric Angeles for CalMatters
In July, Walden House employees didn’t record giving her the new blood pressure medications for 10 days.

The records do not indicate that staff gave Jack 11 morning doses of Haloperidol, an antipsychotic that she was supposed to take twice a day. No one signed the log for giving Jack her morning dosage on the day she died.

Neither the Amity Foundation, HealthRight 360, nor the California Department of Corrections and Rehabilitation responded to CalMatters’ questions about why Jack’s medication logs were missing signatures.

Jack also frequently ended up at the Greater El Monte Hospital’s emergency room, where Walden House sent its clients, complaining about vaginitis – a potential symptom of diabetes – and various types of pain and discomfort. In July, she went to the emergency room four times in 11 days and dropped nine pounds in 10 days.

On her first of five ER visits, three days after tests at SoCal Medical revealed Jack’s high blood sugar, doctors at the emergency room also found a high amount of glucose in her urine, said Victor Lange, the hospital’s risk management director. Medical experts told CalMatters the high glucose could be a sign that someone has diabetes.

Jacks’ emergency room records don’t indicate that anyone drew her blood during her many visits to the emergency room. Lange said it’s not standard care to draw blood on every patient who visits the emergency room.

“If blood pressure is normal, blood oxygen, and all of these factors are aligning properly, the doctor doesn’t need to order a blood draw,” he said. However, on Jun. 18, 2022, Jack was given a urine test, which revealed that she had a high amount of glucose in her urine, Lange said. “We recommended that she see a primary care physician.”

Jack went back to SoCal Medical on July 1, 2022, as an “er follow up,” according to her medical records. The clinic counseled Jack on managing her diet and referred her to a gynecologist. The medical records do not indicate if anyone checked her blood sugar again or gave her a new prescription for medication to treat diabetes.

By July 11, 2022, she was back in the emergency room, complaining of vaginal pain and itching. The emergency room doctor wrote that his clinical impression was that Jack had vaginitis, drug-seeking behavior and a history of substance abuse, medical records show.

By July, she’d lost 48 pounds, a red flag for diabetes symptoms, according to several doctors CalMatters spoke with for this story.

Around July 20, she was complaining to her mother, Sharon, of left arm spasms, which she attributed to a side effect of her new psychiatric medication. At Sharon’s urging, Jack went back to the hospital.

The emergency room doctor referred Jack back to her psychiatrist.

“Patient did not appear to be a reliable historian and has delusional speech,” the medical records state.

“She has a history of schizoaffective disorder, and this is her 4th visit to this emergency room this month,” the emergency room physician said in the hospital’s records.

The doctor’s notes say that Jack didn’t have a history of diabetes. The records also do not indicate that the hospital checked her blood pressure, heart rate, blood sugar, weight or temperature.

Emergency room records stated that there were “no vital signs available.”

Fourteen hours later, she was dead, according to the autopsy report.

On April 11, 2023, a SoCal Medical physician’s assistant reached out to Jack to schedule a follow up appointment for her hypertension, Rasekhi said.

She had been dead for almost nine months.

A mother searches for answers

As soon as Sharon Jack found out the cause from the autopsy report — diabetes complications — she blamed herself for giving Jack free rein at the commissary. And she blamed the state hospital for never telling her about Jack’s diabetes.

Sharon Jack realized she had been buying her daughter “all kinds of stuff a diabetic is not supposed to have.”

“I feel robbed,” she said. “It make me feel like I was killing my baby.”

Within weeks of Jack’s death, her sister, Frenada Jack, created a GoFundMe campaign to help pay for retrieving Fredreaka Jack’s body from the state and “put her to rest peacefully.” “She would be so joyful being that she asked … not to be cremated and any donations will be fine and sincerely appreciated,” Frenada wrote.

The $10,000 campaign didn’t raise any money, and Jack was indeed cremated.
Sharon Jack holds a portrait of her daughter Fredreaka Jack at her home in Metairie, Louisiana on April 5, 2023. Photo by Cedric Angeles for CalMatters
On a humid Louisiana afternoon in April 2023, nine months after Fredreaka Jack’s death, Sharon Jack was still searching for answers about what happened to her daughter. Inside her Metairie apartment, she rocked back and forth, sobbing and sweating as she stared at the small altar of mementos she created in honor of her daughter.

Sharon Jack pulled out stacks of papers and dozens of cards she’d received from people who lived in the facility with her daughter. “Rest in Peace you were like sunshine,” read one.

Six months after Jack’s death, Sharon’s only living daughter, Frenada, passed away too. Sharon created another altar, alongside Fredreaka’s.

“I’m so lonely. I gotta make it to heaven to see my two daughters again,” said Sharon through tears.