Around midnight on Sept. 5, 2018, guards responded to prisoners banging on their cell doors inside a lockdown unit at Broward County Jail’s main facility in downtown Ft. Lauderdale, Florida. They went to the solitary cell of J.I.* and made a gruesome discovery.

“I have a real medical emergency,” J.I. told an officer. “I just cut my penis off and flushed it down the toilet. I have no need for it anymore.”

J.I. had used a razor blade to cut himself. This grisly act of self-mutilation is just the latest chapter in a series of tragic incidents involving seriously mentally ill prisoners at the jail.

J.I. has a documented history of mental health treatment dating back to 2007. He was booked into the jail in late October 2017. Two months later, he was placed on suicide watch after he told staff he suffered from schizophrenia and bipolar disorder and wanted to harm himself. J.I. was prescribed various mental health medications during his jail stay, which he repeatedly refused in the months leading up to his self-mutilation. These included antipsychotics and an antidepressant that could have helped to prevent J.I.’s condition from worsening.

Prior to his placement in solitary confinement, J.I. had begun showing telltale signs of a mental health crisis. J.I. had public masturbatory episodes, and along with his medication refusals, he also refused food.

These signs should have been a red flag to the doctors supposedly overseeing J.I.’s care. Yet his medical record contains few notes or observations from the jail’s mental health staff. As he deteriorated, his treatment plan was not updated, a glaring omission.

J.I. was initially placed in solitary confinement for yelling at staff members. He had been in solitary for over 112 consecutive days at the time of his mutilation.

Prisoners in solitary confinement are isolated, unable to interact with others or participate in daily activities. Instead, men and women in solitary spend their days alone in a cell that is roughly the size of a parking space. It is well recognized that prisoners experiencing these harsh conditions need to be assessed by a mental health professional prior to and during their placement in solitary, as isolation can exacerbate or even cause mental health problems.

None of these safeguards were followed for J.I.

No psychiatrist assessed him prior to his placement in segregation to determine if this placement could be harmful. He was not adequately monitored while in solitary for the four months leading up to his mutilation. The risks to those like J.I. who already have serious mental illness are acute. There is a consensus that those suffering from serious mental illness should be excluded from long-term solitary confinement altogether.

J.I.’s self-mutilation was just the latest in a series of tragic incidents involving seriously mentally ill prisoners at the Broward County Jail.

In 2012, William Herring, a prisoner diagnosed with schizophrenia and bipolar disorder, starved himself to death under the watch of Broward County Jail officials. A few months before Herring’s death, Raleigh Priester also starved to death at the jail.

Priester, too, suffered from schizophrenia, but he was still placed in solitary confinement where his condition deteriorated. Priester began starving himself and the 6-foot-2-inch man’s weight dropped from 240 pounds when he was first arrested to 139 pounds before any emergency medical intervention was undertaken. He was briefly hospitalized, gaining 11.6 pounds in one week. After his return to the jail, Priester died of starvation in his cell weighing 120 pounds. He was in jail for 155 days.

We have an ongoing civil rights lawsuit on behalf of the men, women, and children confined at the Broward County Jail. Just a week before J.I. mutilated himself, a court-appointed psychiatric expert in our case issued a scathing report finding numerous life-threatening deficiencies in mental health services at the jail. These included a failure to exclude seriously mentally ill patients from solitary confinement, to timely treat patients who refused their medications, and to hospitalize those patients who could not be adequately treated at the jail.

The expert concluded that the mistreatment and neglect of those with mental illness at the jail were “absolutely inhumane.”

Following the expert’s report, the parties crafted a comprehensive decree that will remedy the flaws and failures of the jail’s mental health care system. That agreement awaits approval from the presiding federal judge. Under the agreement, seriously mentally ill patients will be excluded from solitary confinement, and individual treatment plans will be developed and implemented for all mental health patients. The most acutely ill patients will be diverted to psychiatric hospitals rather than being warehoused at the jail.

These remedies came too late to prevent the tragedies that befell J.I., Priester, Herring, and too many others. They must be implemented now to prevent future tragedies at the Broward County Jail.

* “J.I.” is the man’s initials. For his privacy, we have used just his initials throughout this piece.