Removal of Destitute From The Streets: Lesson From San Francisco, By Theophilus Olusegun Obayemi, II*

“While our prospective litigation asserts the rights of California taxpayers, it’s equally necessary to protect society’s most vulnerable from continued institutional abuse. Homeless psychiatric patients are particularly defenseless from the kind of lawless ‘patient dumping’ practices Nevada officials engaged in. It’s my hope that our investigation and possible class action will send a strong message to public health facilities nationwide that there is a price to pay for such inhumane treatment in the future—especially when California jurisdictions are being victimized, too…reporting helped expose Nevada’s improper patient discharge and busing practices, which may otherwise have gone unnoticed.”

See City Attorney Dennis Herrera’s August 20, 2013 Letter to Nevada State Attorney General Catherine Cortez Mastro

The Nigerian media has become inundated with academic comments on the nuances of the forceful and involuntary removal of persons of eastern origin from Lagos State to their home states. Because most of the “deportees” have various health issues, this practice is inhumane, legally, economically and morally wrong. Our position with this paper is that the Attorneys-General of Enugu, Anambra, Ebonyi and Imo States should (a) file a Class Action on behalf of the deportees before the Federal High Court in Abuja seeking injunction and damages; (b) seek reimbursement for health care costs and expenses associated with taking care of the deportees; (c) Institution of Strict Mental and Medical Health Protocols in hospitals under Lagos State government.

In the end, we shall outline the contents of the proposed Mental and Medical Health Protocols required of Lagos State government.

Similar to Lagos’ deportation of medically challenged persons of eastern ancestry, starting from April 2008, Nevada started to send persons with mental illnesses to California with one-way tickets. The facts were that the Nevada’s Rawson‐Neal Psychiatric Hospital in Las Vegas bused more than 1,500 psychiatric patients to locations throughout the nation. Some of these patients arrived in San Francisco, Sacramento, Oakland, and other cities in California. Thereafter, the San Francisco City Attorney’s office launched an investigation to determine whether any of the

31 Greyhound bus tickets that Rawson‐Neal purchased for trips to San Francisco conveyed improperly discharged patients. According to Herrera, the preliminary conclusion of the investigation is that among 24 patients bused to San Francisco (including some who made multiple trips), 20 sought and were provided emergency medical care shortly after their arrival. Though the City Attorney’s investigation remains ongoing, San Francisco expended nearly half a million dollars for medical care for the patients who were not city residents at the time that they were improperly bused here from Rawson‐Neal.

Earlier on, in March 2013, the Sacramento Bee first reported the story of 48‐year‐old James Flavy Coy Brown, a former Rawson‐Neal patient who was sent on a 15‐hour bus ride to Sacramento—despite having never before visited, having no friends or family members in the area, and with no prior arrangements for his care, housing or medical treatment. The Nevada‐run hospital had discharged Brown in a taxicab to the Greyhound bus station with a one‐way ticket to Sacramento, snacks, and a three‐day supply of medication to treat his schizophrenia, depression and anxiety. Brown was instructed to call 911 when he arrived. A Rawson‐Neal physician reportedly recommended “sunny California” to Brown as a destination, according to the Sacramento Bee, because they “have excellent health care and more benefits than you could ever get in Nevada.”

The American Civil Liberties Union has filed a lawsuit on behalf of Brown and others entitled: Brown v. Rawson-Neal 2:13-cv-01039 before the United States District Court, District of Nevada. According to Brown:

“Defendants knew he was penniless and homeless and defendant Rawson-Neal knew or acted in reckless disregard of the fact that he would be unable to care for himself during the journey or upon his arrival,” the complaint states. “Before he was discharged, he was started on Thorazine, Cymbalta and Klonopin, all psychotropic medications which affect thinking and judgment. While Defendant Rawson-Neal had developed a written treatment plan which included assisting him to locate a group home placement and locating a case worker for him, this treatment plan was intentionally disregarded and violated by his involuntary discharge contrary to the plan.

“On February 13, defendant psychiatrist Dr. Anurag Gupta (hereinafter ‘Gupta’) ordered Brown discharged, physically escorted from the facility, and placed in a taxi which had been ordered by the defendants. Plaintiff Brown was then transported to the Greyhound Bus Station, where a pre-paid ticket had been purchased by the defendants to take Brown to Sacramento, California, a city which he had no prior contact, and where he knew no one. There was no follow-up plan and no prior contact had been made with any institutions in Sacramento from which Brown could obtain medical and psychiatric care. He was given three days of powerful anti-psychotic medications and bottle of Ensure for the 15 hour bus ride.

It was against this background that, on August 20, 2013,  San Francisco—City Attorney Dennis Herrera vowed to file a class action lawsuit against the State of Nevada on behalf of California local governments to recover costs they incurred to care for indigent patients Nevada improperly bused from its state‐run psychiatric hospital, and to secure a court‐ordered injunction to bar Nevada State officials from continuing to transfer patients into California without prior arrangements for their care, housing or medical treatment.

Herrera argued that Nevada’s patient discharge and busing practices constituted a misappropriation of California taxpayers’ funds in destination cities and counties. Further, investigations showed that the improper transfers unlawfully burdened California local government resources, because, in order to provide care and services “which Nevada was legally obligated to provide to its own indigent residents.” Herrera’s letter left open the door to avoid litigation, providing Nevada officials respond by September 9, 2013 to negotiate a reimbursement agreement with California local governments, and adopt binding protocols to ensure that the improper patient busing practices end for good. In the words of Herrera:

By busing to California indigent patients whom the State of Nevada knew were non California residents in need of ongoing medical care and other services, Nevada officials intentionally misappropriated the resources of the destination cities and counties in California which had to provide medical care and basic necessities to these non-resident patients. Accordingly, Nevada must reimburse the destination California cities and counties for their expenditure of public resources to provide medical care and basic necessities to the patients that Nevada improperly bused to us.

Apart from the public costs borne by California taxpayers for Nevada’s unlawful patient discharge and busing practices, the manner in which these patients were transported was inhumane and unacceptable. These patients were transported without escorts; without prior arrangements for a responsible party to receive them at their destination; without adequate provisions of medication or food; and without proper instructions for these patients’ follow-up medical care, housing or support services. In order to avoid the improper transfer of patients in the future, I demand that the State of Nevada stipulate to an enforceable contract governing the future transfer of mentally ill patients from Nevada to California pursuant to protocols consistent with its obligations under the law.

In concluding, there are suggested protocols to be followed before patients could be bused interstate, and this now involvesPlacement Coordination for Interstate Discharges By Originating State Health Facilities

The first step to be taken that the originating state must prepare a discharge plan for each patient for whom interstate transfer is contemplated. In other words, before Lagos can send destitute to Anambra, Lagos must ensure that there is a discharge plan from a Lagos Hospital.

a. The discharge plan must include an evaluation of the likelihood of a patient’s capacity for self-care or of the possibility of the patient being cared for in the environment to which the patient is being transferred.

b. If the patient is not able to provide some or all of the required self-care, the evaluation must also address whether the patient has family or friends available who are willing and able to provide the required care at the times it will be needed, or who could, if willing, be trained by the hospital sufficiently to provide the required care.

c. The discharging hospital will take reasonable steps to identify the medical and/or mental health services that will be available to the patient at the destination city or location.

d. The discharge plan must include an evaluation of the patient’s ability to payout of pocket for services, insurance coverage, or reliance on community services or public assistance.

Lagos State must also assess appropriateness of discharge destination.

a. Lagos State must determine and confirm that patient has at least one of the following connections to destination city or location:

i. destination city or location was patient’s place of residence at time client entered medical facility and at time of discharge;

ii. patient has family in destination city or location who are willing and able to care for patient;

iii. non-family member responsible adult who is willing and able to care for patient resides in the destination city or location, and has agreed to care for patient.

b. Lagos State must confirm availability of appropriate mental health treatment services within or near the destination city or location.

The adoption of a Placement Coordination for Interstate Discharges By Lagos State Health Facilities will greatly solve the health problems and inconveniences at the destination states.

* Dr. Theophilus Olusegun Obayemi, II is an attorney licensed in California and Federal Republic of Nigeria.