His family rushed from California to find him unconscious in a hospital intensive care unit, where he lay until his death.

“We touched his cold hands. I talked to him but he had no life – it was just machines,” said his mother, Maria Olga Zavala. “Even with all that, they had him there handcuffed with a guard.”

Replaying that image inside her Southern California home, she asked: “Why wasn’t that guard in the jail, looking after my son before he took his own life?”

It’s a question asked often of the parish jail, where 25 inmates died from 2012-2016, at least five of whom were diagnosed with a serious mental illness or showed signs of one, jail and court records show. Fano became the sixth inmate since 2012 to die amid a mental health crisis; none had been convicted of the charges that jailed them.

From 2012 to 2016, the jail’s rate of death was 2.5 times above the national prison average, a Reuters analysis found. The East Baton Rouge Sheriff’s Office, which oversees the jail, blamed most deaths on drug use, “poor health and pre-existing conditions,” and noted Louisiana has long ranked low on public health metrics.

A private consultant hired to assess treatment found the jail was substantially understaffed, with 61 percent of the psychiatric staff hours found in comparable jails. Isolation units, transformed into de facto inpatient mental health wards, were “woefully inadequate physical environments for the most unstable mentally ill.”

Men on suicide watch were given paper gowns and no sheets or blankets, but the unit was kept so cold some inmates risked hypothermia. One sought warmth by squeezing himself inside the plastic covering of his mattress.

The East Baton Rouge Parish Prison is a vivid example of how local jails struggle to treat the masses of mentally ill filling their dank cells.

Mentally ill and incarcerated

Had a naked and hallucinating Fano stumbled off the Greyhound Bus a few years earlier, he likely would have received treatment at Baton Rouge’s Earl K. Long charity hospital. In the two years before its closure in April 2013, police brought 1,800 mentally disturbed detainees there for treatment, said Jan Kasofsky, Baton Rouge’s top mental health official.

Earl K. Long was part of Louisiana’s network of 10 public charity hospitals that provided medical and psychiatric care to the poor and the imprisoned. It cost the state $76 million a year to treat prisoners in these hospitals. In the spring of 2013, former Governor Bobby Jindal began privatizing or closing nine of the 10 and that $76 million cost has since been cut by two-thirds, said Raman Singh, until recently the corrections department’s medical director.

Jindal declined interview requests. Timmy Teepell, chief of staff during much of the Republican’s first term, said the system was closed for good reason.

“It was outdated, underfunded, and produced the nation’s worst healthcare results,” Teepell said. “I am surprised it lasted as long as it did into the 21st Century.”

But the shutting of the hospitals left local governments struggling to provide medical care behind bars. Cat Roule, who spent 12 years as a nurse supervisor at the East Baton Rouge Parish Prison, told Reuters, “Once Earl K. Long shut down, everything got much worse. There were people piling up in the intake unit. It was just madness.”

Dennis Grimes, the current warden, acknowledged the jail can’t properly treat those in need in a facility where some 800-900 of 1,500 inmates are currently on mental health medication.

“The prison is equipped to deal with disciplinary behavior, not mental health patients. It doesn’t have the things that it really needs in order to function for those who have a mental health problem.”

Medical staff, he said, “burn out, they don’t know what to do, they need some relief – and there are no mental health hospitals out there.”

Five men in crisis who died in jail

DAVID O’QUIN: Schizophrenic, died strapped to a chair

On February 13, 2013, as operations at Earl K. Long wound down, David O’Quin, a 41-year-old paranoid schizophrenic, was picked up by police after his father reported he was off his medications and behaving erratically. He was booked into East Baton Rouge jail on charges of disturbing the peace. Per jail policy for the mentally ill, he was placed in isolation, where inmates have little access to visitors and spend 23½ hours a day, court records show.

When O’Quin disobeyed orders, guards strapped him to a chair by his ankles and wrists and left him caked in feces and urine, the family alleged in a lawsuit. A jail nurse noted he suffered “serious psychosis” and needed to see a doctor. He didn’t see one for six days, the family said. Guards found him nude in his cell, ignoring orders and spitting, and stormed the cell with shields and mace, records say.

A day later, the jail’s psychiatrist diagnosed him suffering from serious psychosis. O’Quin spent much of the next seven days restrained to a chair in isolation. He died in that chair February 26.

An autopsy found he had died from a pulmonary embolism from a blood clot that developed in his lower legs, likely due to the prolonged period of restraint, as well as from bacterial infection likely from contact between his open wounds and feces. O’Quin’s family has reached an undisclosed lawsuit settlement with the sheriff’s office.

After his death, the sheriff’s office reviewed policies and procedures, said Casey Hicks, a spokeswoman for the East Baton Rouge Sheriff’s Office. Among the changes: new guidelines for using the restraint chair. “It is still used when necessary, though it now requires approval directly from the Warden or designee,” she wrote.

Howell Andrews, a Senior Special Assistant to the Parish Attorney of East Baton Rouge, which was responsible for jail medical care at the time, pointed to a review panel’s findings: “The personnel of the Prison Medical Services acted within the standard of care within the regulations and restrictions in place in this environment.”

ANTWOIN HARDEN: Bipolar disorder, died from blood clot

In July 2014, Antwoin Harden, 28, was picked up by police for trespassing on the grounds of the Drury Inn, telling officers he was homeless and would rather be in jail than on the streets. In jail, Harden refused to take his medication for bipolar disorder and sickle cell anemia, said his mother, Angelo Moses. He died that month from a blood clot in his lung, related to not taking his medications, she said.

Citing confidentiality restrictions, Andrews said he could not discuss Harden’s case. But he noted: “We are unable to forcibly medicate the individuals.”

PAUL CLEVELAND: Complained of failing health, found dead in his cell

Months later, on September 19, 2014, 72-year-old Paul Cleveland was arrested after verbally threatening a court clerk and booked into the jail. On his intake forms, the nurse noted he was bipolar and on antipsychotic medications, and suffered maladies including diabetes, heart pain and rheumatoid arthritis.

Once inside, Cleveland was unable to stand in the hours-long line for patient medications due to his arthritis. His doctor sent a note to the jail saying Cleveland needed a wheelchair, and his family brought one to the front gates. But jailers never let it inside, according to court filings in a family lawsuit against the city, jail and sheriff.

Cleveland filed eight emergency medical request forms, complaining of chest pain, trouble walking to get medication, and suicidal thoughts. When he felt the requests went unheeded, he filed three formal grievances.

Once, a doctor refused to see him because he was behaving belligerently, his medical records show. Other pleas were dismissed as the ranting of a madman. “Banging on window,” said a nurse, who assigned him to a lockdown cell “for his own safety.”

Cleveland’s prescribed daily medications included the antipsychotic Seroquel, Metformin for diabetes, and Cardura for blood pressure. When he was unable to rise and walk to receive them, a jail nurse told him to “stop playing and come get your medication,” a guard testified as part of the family’s ongoing lawsuit.

“Look, they killin’ me,” Cleveland told his family, in his last jailhouse call. “I can’t hardly stand no more.”

At 2:32 the morning of November 12, deputies found Cleveland naked on the floor of his cell, covered in feces. He said he was too weak to shower. A nurse told guards Cleveland was faking “because he wants to get back to the infirmary,” a guard testified in a deposition. Two hours later, at 4:05 a.m., he was found dead in his cell. An autopsy found extensive gastrointestinal bleeding likely caused by cardiovascular disease. The following imagery shows guards transporting Cleveland from his cell.