A woman suffering from a severe mental illness sat locked in isolation in a Yamhill County jail for 10 days awaiting a state psychiatric bed. She was suicidal, hearing voices and unable to get proper medication to treat her psychosis.

She was never charged with a crime. Three judges tried to get her out, but she languished in the jail's medical unit: a casualty of an unprecedented breakdown in Oregon's civil commitment system.

Her experience is an extreme example of the glaring deficiencies in how the state treats people suffering from the most severe mental illnesses, often boarding them in inappropriate locations before they get long-term help.

The 38-year-old woman - homeless and penniless - shouldn't have had to spend a day in jail. She should have gone immediately to one of the state's 15 acute care hospitals or to the Oregon State Hospital, the state's mental hospital in Salem.

But county and state officials said none of them had room for her particular problems. Jurisdictional lines and bureaucratic hurdles also contributed to the delay.

The situation clearly violated the state's legal obligation, mental health advocates said.

Civil Commitments: By the numbers

Civil commitments in 2013-14

: 556

How do civil commitments work?

The court must have clear and convincing evidence that a person is mentally ill and fits at least one of these descriptions: Is a danger to themselves or others; unable to take care of basic personal needs; is chronically mentally ill, in that the person has been placed in a hospital or inpatient facility by the state Mental Health Division twice in the last three years with similar symptoms.

Acute hospital beds

: 386 among 19 hospitals and treatment centers across Oregon for all kinds of mental health patients, including civil commitment patients.

Oregon State Hospital in Salem

: About a third, or 150 beds, are reserved for civil commitment referrals. When a new state mental hospital opens in Junction City, that number will rise to a total of 155 beds.

Civil commitment patients

: Must be at least 18, recently diagnosed with a mental disorder that includes severe psychotic symptoms and must need 24-hour medically supervised psychiatric care.

Oregon State Hospital waiting list

: Daily average of 37 people during the last quarter calculated, from July through September 2014. That covers all patients, including civil commitment patients, people found guilty of a crime except for insanity and people who need care so they can assist in their criminal defense.

Average time on Oregon State Hospital waiting list

: 15 to 28 days.

State law states that people who are under the care of the Oregon Health Authority after a civil commitment "may not be confined'' in a jail, prison or any other place where others are charged with crimes - unless they pose an "immediate and serious danger'' to hospital staff.

The law also says the state "shall'' take people approved for civil commitment into its custody, keep them safe and get them proper care before they're taken to a hospital or treatment center.

"It's just not right," said Yamhill County Circuit Judge Ronald W. Stone, who runs the county's mental health court and intervened in the woman's case. "It's cruel in my opinion. I know money's short, but these are very, very sick people who get committed. They've done nothing wrong.''

Rebeka Gipson-King, a spokeswoman for the Oregon Health Authority, called it "highly unusual'' that someone committed in civil court would go to jail. "This is the first time that I've ever heard of that happening,'' she said.

The state relies on the community mental health program to find someone a psychiatric bed, she said. But if a hospital has no room, neither the state nor the county can order it to admit a patient, she said.

The woman's court-appointed lawyer visited her client in jail each day.

"She would cry because she told me she can't sleep. She said, 'I wish I were dead,' '' recalled her attorney Janmarie Dielschneider. "I'd tell her 'I'm working hard to find a solution,' but I was feeling optionless.''

***

On Jan. 14, the woman, originally from New Hampshire, was brought to Providence-Newberg Medical Center after suffering a mental health crisis. She had been living with an elderly couple in Yamhill County who she met through church, but it was clear she couldn't stay with them any longer, her lawyer said.

The Newberg hospital, though, doesn't have psychiatric beds, so the woman was transferred to Juniper Ridge Acute Care in John Day in central Oregon.

The Yamhill County Health and Human Services Department placed a hold on the woman, which triggered a Jan. 26 civil commitment hearing. The night before, two Yamhill County sheriff's deputies made the nearly six-hour drive to John Day to bring the woman to court in McMinnville the next day.

The woman's far-flung placement in John Day revealed another shortcoming in mental health care - the lack of local treatment centers.

"You've got to ask: What is someone from Yamhill County doing in John Day?'' said Chris Bouneff, executive director of the National Alliance on Mental Illness of Oregon.

During the court hearing, Judge Ladd Wiles found evidence that the woman met the threshold for a civil commitment based on an investigator's report. She was exhibiting symptoms of schizophrenia with suicidal thoughts, her lawyer said. Wiles ordered the woman committed to the Oregon Health Authority for up to 180 days.

By that afternoon, a jail deputy informed Wiles the woman was stuck in jail. She didn't have access to her specialized medication because the jail required a prescription she hadn't had a chance to get, her lawyer said.

"I couldn't believe it,'' the judge said. "That's one of the last spots she should be.''

Court officials declined to release the woman's name, citing confidentiality rules.

On Jan. 27, the state's civil commitment coordinator, Keith Breswick, wrote in an email to Yamhill County officials that the jail couldn't continue to hold the woman without a detention warrant. He suggested she be released into the community and ordered to report to county mental health officials daily, along with other conditions.

Yet Breswick acknowledged that the woman likely wouldn't follow the conditions and "display risks for harming others.'' He said law enforcement and the county's crisis intervention team should be put on notice in case they came into contact with her. He also asked county officials to update him on their efforts to find a psychiatric bed for her.

That infuriated Yamhill County's Presiding Judge John L. Collins, among others. He sent a long email back that night, saying Breswick had misread the law and that releasing the woman without finding a bed for her "not only is contrary to the law, it is contrary to common sense and our governmental and societal duty to protect and serve persons unfortunately affected by acute mental illness.''

Breswick didn't return calls for further comment. He referred questions to the Oregon Health Authority's spokeswoman.

On Jan. 28, Wiles ordered everyone involved back to his courtroom to try to find a solution. Letting the woman out would have defeated the point of having committed her to the state's care, he said.

Over the next several days, judges, a prosecutor and the woman's lawyer tried to understand from county and state health officials what barriers existed and how to overcome them so the woman could leave jail. They also made calls to the state hospital, the governor's office, reached out to NAMI and threatened a lawsuit.

"If they had to rent a motel room and rent a psychiatric nurse, they should have done that,'' said Stone, the mental health court judge. "What I couldn't understand was there was this lack of urgency.''

On Feb. 4, Yamhill County deputies transferred the woman to the Oregon State Hospital.

***

Civil commitments in Oregon, between 2004 and 2014. They're a fraction of the investigations and evaluations conducted each year on people suffering from mental illness.

In the 2013-14 fiscal year, 556 people civilly committed in Oregon. A third of them typically require long-term state hospital care, but the rest can be stabilized at one of the acute care hospitals, Oregon Health Authority officials say.

Silas Halloran-Steiner, Yamhill County's Health & Human Services director, declined to speak about the woman's case, but said in general that the county mental health program works to find open beds and succeeds in most cases.

"It all depends on bed availability statewide,'' he said. Typically, he said, the biggest challenges are people having to wait days in an emergency room before getting an acute care bed. He agreed that jail is not the place for people struggling with complex psychiatric problems.

In this case, the woman lacked "verifiable clinical information" about her diagnosis and her mental health history, and that held up a referral to the Oregon State Hospital, which has strict admission controls, according to state officials.

She also couldn't go back to the John Day treatment center. It wouldn't take her because she'd been accused of slapping a nurse there earlier, according to Judge Stone and Yamhill County jail Capt. Jason Mosiman. Juniper Ridge in John Day also isn't allowed to refer patients to the state hospital.

When people suffering serious mental illnesses are stranded in an ER or any spot other than where they should be, it's called "psychiatric boarding,'' said Dr. Joseph Bloom, dean emeritus of OHSU's medical school, who for 10 years chaired its psychiatry department.

Because the state hospital has an average daily waiting list of 37 people, patients take up more time in acute psychiatric beds as they await an opening, clogging the system.

"We don't have enough beds in this state to meet the need,'' Bloom said. "But they should not be able to hold her in jail. It's just inexcusable.''

Halloran-Steiner said, however, adding more acute psych beds alone isn't the answer. He said it would help if communities had better alternatives such as peer-supported respite care, housing and employment.

A U.S. Justice Department report last year found Oregon lags in providing community treatment to people with serious mental illness.

"This is not what you'd expect from a civil system - that you would incarcerate somebody,'' said Bouneff, of NAMI Oregon. "This one particular incident highlights the horrors we still endure ... This is one of the prices we're paying for a system that has traditionally not been well-structured and not well-funded. My fear is we're going to run into more situations like this.''

--Maxine Bernstein

503-221-8212 ; @maxoregonian