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The state of Tennessee locked Regenia Bowman in solitary confinement for more than six months because she had a skin infection.

Bowman wasn’t violent, and she hadn’t threatened anyone. She was free on bond when she walked into a courtroom in Bledsoe County in April 2014 to answer charges of selling prescription painkillers, a violation of her probation on a similar charge. During the hearing, when it looked like Bowman was headed to jail, her lawyer revealed she was sick with what turned out to be MRSA, an antibiotic-resistant staph infection.

This story was produced in collaboration with the USA TODAY NETWORK – Tennessee

The judge suggested sending her to a “special needs” facility in Nashville. Bowman, now 54, assumed she would be going to a clinic or hospital.

Instead, she was driven more than 120 miles to the Tennessee Prison for Women, which usually houses people already convicted of a crime. There, without understanding why, she was dressed in white, the uniform of maximum security prisoners. She was placed in solitary — locked down 23 hours a day with three showers a week and fed through a slot in her cell door. The MRSA cleared up in about two months, she said, but records show she was held in these conditions for 189 days.

“I was terrified,” Bowman said. “The first two days I was so afraid I wouldn’t even go outside because I had no idea what was going on.”

Bowman had been declared a safekeeper.

Under a state law virtually unchanged since 1858, people awaiting trial in Tennessee county jails can be shipped to state prison if a judge deems the local jail “insufficient” to handle their medical problems, mental illness, or behavioral issues. State policy dictates they are kept in solitary confinement, even if they are mentally unstable or have not committed a disciplinary infraction.

From January 2011 through 2017, more than 320 people in Tennessee were declared safekeepers. The numbers have grown in recent years. In 2013, there were 26 safekeepers; in 2017, there were 86.

The law is intended to relieve a financial burden on local jails and get pretrial detainees necessary care or protect jail staff. Some safekeepers have allegedly attacked guards or fashioned crude weapons. But interviews and court records show people are sent to safekeeping because they are juveniles, pregnant, wrestling with severe mental illness, or simply too notorious to remain in county lockup. They have not been convicted of a crime, but all of them are sent far away from their families and defense lawyers and placed in cells usually reserved for the state’s most unruly, dangerous inmates.

Transfer of "Safekeepers" in Tennessee From 2011 through 2017, Tennessee judges sent 324 jail detainees to state prison for "safekeeping." The Marshall Project obtained court orders explaining the reasons behind the transfers for 171 of them.

* Varies from county to county but frequently refers to “conduct and/or condition” placing “an undue burden” on the county, with no other facility being sufficient. Source: Marshall Project analysis of Tennessee court records

One of at least eight states with a safekeeping law, Tennessee has no formal review process to determine if and when inmates should be returned to their original counties.

That means safekeepers have sat in isolation for months or even years as they await trial, even if their conditions improve. While the state does not track precise release dates, a review of records shows safekeeping stays range from a couple of weeks to more than four and a half years. A snapshot from Dec. 31, 2017, shows the average stay of safekeepers was 328 days. Fifteen of the 57 people in safekeeping on that day had been held longer than a year.

“There’s extreme psychological effects on people who are subjected to solitary confinement,” said Tom Castelli, legal director of ACLU Tennessee. “So you are pouring gasoline on a fire, so to speak, if your reaction to someone who’s got mental health issues or disciplinary issues is to isolate them completely.”

A safekeeping designation generally happens like this: A county sheriff or jail administrator petitions the District Attorney, saying a detainee has unmanageable issues. The DA then applies for a court order to transfer the inmate. A judge approves.

With one exception, safekeepers have gone to one of three state prisons, all in Nashville. Slightly more than half are sent to Lois M. DeBerry Special Needs Facility, an 854-bed hospital prison for men. The remaining men are sent to Riverbend Maximum Security Institution.

All female safekeepers are sent to Tennessee Prison for Women, where Department of Correction spokeswoman Neysa Taylor said “inmates, safekeepers included, have access to the full gamut of mental health and medical care.”

Dr. Ali Winters, a senior clinical therapist hired by Corizon, the private company providing mental health care to Tennessee prisons, worked with women in solitary at TPFW from June 2013 to mid-2016. She said safekeepers had little access to treatment beyond sporadic conversations with her.

“They would be fine, and then within 30 days they wouldn’t be fine because of solitary confinement and what it does to you neurologically,” Winters said. Women experienced depression, mood changes and hallucinations, she said. Her colleague, Lori De Leo, who worked with women in isolation at TPFW from November 2015 to late 2016, agreed that safekeepers would “deteriorate.”

Numerous national studies show the detrimental mental and physical health ramifications of solitary confinement. When an inmate is left in solitary confinement for extended periods of time, he or she may become more anxious or prone to panic attacks, paranoia, and other effects, according to a 2013 study by the American Public Health Association.

People with mental illness placed in solitary confinement “may deteriorate and experience an exacerbation of symptoms,” the study states.

Amanda Beaty has spent more than three years in safekeeping after attempting suicide multiple times while awaiting trial for killing her son in June 2014. In letters to The Marshall Project, she said other safekeepers she saw included two blind women, one pregnant woman, and others who had stopped eating or simply screamed all day. Each name she provided matched state records of safekeepers who were in custody during the time period she described.

Beaty, 34, said when she was put on suicide watch, she had to sleep on a concrete cell floor.

“I was already down in this dark place, and rather than helping me, they just make me feel even worse. It’s horrible,” she said.

One safekeeper, John Raymond Walz, successfully challenged his detention after he was sent to DeBerry on suicide watch in November 2016.

His lawyer, Jeffrey Vires, understood that the local jail didn’t have the resources to keep a close eye on Walz, but he said DeBerry took him off suicide watch after a week — and then held him another seven months before trial, his health deteriorating. The lawyer successfully petitioned a court to release Walz to a Veterans Affairs hospital near his home.

At least seven women have been deemed safekeepers because of issues with their pregnancies, three of them in Fentress County, according to court records. Criminal Court Judge Shayne Sexton, whose jurisdiction includes Fentress and other northeast Tennessee counties, said he didn’t remember specifically signing an order for any pregnant inmates.

But he said he would sign such an order to relieve a rural jail of a potentially steep cost while sending the inmate to what he thought would be a more appropriate facility.

“I would not send anyone on a safekeeping order anywhere if I think where they’re going is a worse place than where they are,” Sexton said.

County jail officials expressed frustration, saying that while safekeeping is not ideal, local jails lack the resources to care for severely ill or difficult detainees.

Mentally or physically ill detainees can jeopardize safety, while slim budgets and skyrocketing health costs prohibit the necessary care at the county level. Some administrators pointed to rising drug use and a lack of adequate mental health facilities straining their resources.

“There’s no room at the inn, figuratively speaking. I can’t put [them] with the other inmates,” said Captain Scotty McKay, jail administrator for Franklin County. “When budgets are cut statewide and nationwide, I think mental health is the first thing to get cut. And I think we’re going backwards.”

In January 2016, Sonya Babb, a woman with a long history of mental health problems, was experiencing severe delusions. She fatally shot her father in his Carter County home because she believed he had killed her son, even though he was alive. Babb’s attorney, Assistant Public Defender Melanie Sellers, said safekeeping was the only option to get the now 56-year-old Babb any help.

“It’s just one of those things where the pure human misery was just overwhelming,” said Sellers, who prepared the letter requesting the transfer.

Babb’s only treatment in TPFW was medication, her lawyer said. She was held in solitary confinement for more than a year before she was found not guilty by reason of insanity and committed to a mental health facility. Sellars said she does not regret asking for the safekeeper designation. The county jail would have been worse.

Cost appears to be a major factor in keeping safekeepers in state custody. While other safekeeping states require the sending county to cover costs, in Tennessee, the state pays the bill.

“Truth is, the county would have to agree [to take a safekeeper back], and most will not,” said Sonya Troutt, jail administrator for the Sumner County Sheriff’s Office.

Circuit Court Judge Thomas Graham, who presided over Regenia Bowman’s safekeeping hearing, said he would prefer to send defendants with serious medical issues to hospitals, but counties cannot shoulder the cost.

The judge was surprised to hear that safekeepers are held in solitary confinement. “The only thing we're trying to do is get them medical care,” he said.

Teriyona Winton turned 16 this year in the maximum security unit at Tennessee Prison for Women, more than 200 miles from home. Just 15 when she was accused of murder in Memphis last May, Winton is one of three teenage girls Shelby County has sent to safekeeping since 2011, records show.

After Winton was charged as an adult and the county said it was not equipped to hold her, the hearing declaring her a safekeeper lasted about two minutes, said her current attorney, Josh Spickler. There was no evidence presented, and she did not have a lawyer.

Her mother, Latosha Winton, 38, saw her daughter this week during a court hearing, the first time since the teen was moved to TPFW in October. Latosha Winton works on Saturdays, the prison's visiting day, and did not have a car to make the six-hour round-trip trek.

An analysis of all safekeepers since 2011 found they were sent an average distance of 117 miles from their home counties, making it difficult to communicate with family and lawyers before a trial. Taylor, the DOC spokeswoman, said that other factors, including safety and medical needs, “take priority over proximity to home.”

Winton can shower three days a week and go out for recreation two days a week, Spickler said. When she leaves her cell, her feet and hands are shackled. Every weekday, teachers instruct her for two hours through the flap in her door, Spickler said.

“She’s just feeling down, basically just ready for it to be over with,” her mother said. Spickler challenged Winton's safekeeping in court, and on Thursday, a judge ordered that Winton be sent back to Shelby County.

Demetria Frank, an assistant professor of law at the University of Memphis, expressed disbelief that the state’s largest county had no facilities for female minors, particularly after a 2012 Justice Department report faulted the county for failing to properly safeguard juveniles in detention.

“They’re on 23-hour lockdown, that’s just unacceptable for anyone, especially if the period is indefinitely,” Frank said. “The state of Tennessee should be ashamed of itself.”

Shelby County Criminal Court judges J. Robert Carter, Jr. and W. Mark Ward, who have signed safekeeping orders for juveniles in the Memphis area, did not respond to requests for comment.

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In 1980, the Tennessee Court of Criminal Appeals unanimously ruled that the intention of the safekeeping law was to send people to another local jail, not state prison. The stigma of going to prison before a conviction is so strong that safekeeper transfers there are allowed only if counties prove to a judge there is no “sufficient” jail nearby, the court ruled. Despite this, a Marshall Project review of jails in seven of Tennessee’s largest counties found that none reported accepting a safekeeper in recent memory, nor had any been offered one.

Taylor, the DOC spokeswoman, said those determinations are made by judges. Graham, the judge in Bowman’s case, said no county likely would be willing to shoulder the burden and cost of an ailing inmate from another county.

Like Graham, F. Lee Russell, a former longtime judge in East Tennessee, and Sexton, the criminal court judge, said they did not realize safekeepers were kept in solitary confinement at the state prison.

“I can’t imagine solitary being good for anyone,” Sexton said.

The practice raised concerns among several Tennessee state lawmakers, including House Health Committee Chairman Cameron Sexton, R-Crossville, and Sen. Ed Jackson, R-Jackson, chairman of the Senate corrections subcommittee.

“Clearly, taking someone and placing them in solitary confinement, that is different than just being in the county jail,” said House Democratic Caucus Chairman Mike Stewart, D-Nashville, a frequent critic of the Tennessee prison system. “That is a severe punishment.” He said it was “unacceptable” for juveniles to be held in solitary before a trial.

Bowman, who was eventually convicted and spent 18 months in prison, said she got out of safekeeping only after she and her daughter repeatedly called Bledsoe and Sequatchie counties, where she had open cases, to pressure them into bringing her back. Her defense lawyer at the hearing did not respond to several requests for comment.

Bowman said she still suffers from the effects of her time in solitary. She is now out on parole and said she tries to avoid being around people.

“I start hyperventilating, I start feeling like the walls are closing in on me. If there are several people, I can do it for five or 10 minutes and then I start finding a way out,” Bowman said.

“The things you see there you don’t forget.”

This story has been updated from its original post to reflect a judge's decision to transfer Winton back to Shelby County.