The deaths are so common they’re routine.

Sean, 47, drank himself to death on a bus stop bench in Anaheim.

Bruce, 63, collapsed and died on a freeway off ramp from heart disease and an untreated seizure disorder.

Zachary, 28, overdosed on heroin in a Santa Ana alley.

And Nicholas, 29, hanged himself with a shoe string on a dirt embankment in Fullerton.

Last year, more than 200 homeless men, women and children lost their lives to drugs, alcohol, mental illness, violence and, in many cases, years of neglect and hard living on the streets, according to reports from the Orange County Coroner’s Office reviewed by the Register.

It was the deadliest year on record for homeless people in Orange County.

It was also part of a grisly trend. The death totals for homeless people in the county have jumped in each of the past six years, doubling over the last half decade.

In all, 1,305 homeless people have died in Orange County over the past 12 years, about half coming since 2013.

When viewed en masse, experts say, the numbers tell the story of how increased street homelessness, a scourge of opiate addiction and failures in the public health system have combined to turn an already difficult existence into something more lethal. Many add that at least some homeless deaths locally could have been prevented with better resources.

Strong heroin

The screams ring out nearly every night.

“Does anybody have an (anti-overdose) kit?” said Cristina Beltran, 26, as she re-enacted the desperate cries she has heard during her time camping out at the Plaza of the Flags in the Santa Ana Civic Center, where homeless people have congregated. She remembers constantly hearing people call out for the life-saving, overdose-reversing drug Naloxone.

Beltran, who has been homeless three years and who occasionally uses opiates, said two of her friends have died from drug use in the past two years – one right in front of her.

Drug addiction is at the root of many of last year’s fatalities. Some say a shortage of services to help homeless people end their addictions is partially to blame.

Technically, the 42 overdose deaths reported for 2016 is fewer than the 2015 tally of 58 deaths. But there are 35 toxicology reports from last year still to be resolved by the county coroner. When those cases are final, it’s likely that the number of homeless overdose deaths in 2016 will be an all-time high.

Susan Price, who coordinates the county’s services for the homeless population, said there has been a noticeable shift in the composition of Southern California’s homeless over the past two years.

In addition to the perceived growth of the county’s homeless community – an increase Price expects to see confirmed when the results of last week’s point-in-time homeless count are released – she says the population is younger and more drug addicted than before.

“Something is different in our communities in the last two years, and it aligns with this enhanced substance-abuse population,” Price said.

Price blamed the change on a national heroin epidemic coupled with California’s Prop. 47 prison reform measure, which has reduced sentences on nonviolent drug crimes. She said that law, which passed in 2014, unintentionally increased the number of addicts out on the streets. And while the measure promised to fund programs to help people stay out of prison, the state has yet to distribute any of that money and has said it won’t do so until sometime this spring.

Despite the grim body count, the number of homeless deaths was reduced last year because of a program aimed at keeping addicts alive.

A program run by the Solace Foundation pushed hard to make sure the homeless have access to Naloxone, a drug that can reverse the effects of an opiate overdose. In all, the nonprofit says Naloxone – which is now often carried by county first responders and some police agencies – reversed 420 potentially fatal overdoses last year.

Still, Solace founder Aimee Dunkle chastised county officials for not fully funding efforts to circulate the life-saving drug even wider.

She said there were weeks last year when she had no Naloxone to distribute, and other weeks when her supply was limited, shortages that almost certainly led to some preventable deaths.

Beltran said when a Naloxone kit isn’t on hand people often try a street remedy – packing ice around an overdosing addict’s genitals – in an effort to shock the person back into consciousness. It rarely works.

“Despite appeals to the Board of Supervisors and the OC Health Care Agency we were provided with no funding, or assistance of any kind,” Dunkle said.

“Additionally, we have very limited access to medication-assisted (detox) treatment for our homeless clients who are reliant on county services. … There are waitlists for these services in Orange County.”

Dunkle’s program is geared only toward keeping addicts alive until they can seek real, rehabilitative help. Unfortunately, Price said, it’s not easy for homeless addicts to get the medical detox many need.

And when addicts don’t get well, others sometimes suffer.

Three infants were among the homeless people who died in the county last year, matching the number of infant homeless deaths recorded during the previous 11 years. All three were younger than 1 year old, and two were found to have died from their mother’s drug use.

One boy was stillborn after he overdosed on methamphetamine while still in the womb. The other, born prematurely, died at one month after his brain hemorrhaged.

Slow deaths on the street

Over the past two decades Heather Smith has seen her life shift from Fountain Valley soccer mom to a woman living alone on the street. Now, still on the streets, she’s fighting cancer.

Sitting in a motel room she rented for a night across the street from her tent in Orange’s growing riverbed encampment, Smith, 41, told the story of how a car accident in her early 20s sent her down a path she never imagined.

After the crash, she says, back pain drove her to pill addiction. Eventually, her husband left and, by 2008, she says, she was homeless. Within her first year on the street, she said she was gang raped by five men. To numb the pain, she says, she took more drugs. To pay for her addiction, she became a sex worker.

Smith says that she’s given up that work and no longer uses drugs. But three years ago, when she was still an active addict, she was diagnosed with Hodgkin lymphoma. She didn’t seek treatment and her disease has progressed to stage 3 lymphatic cancer.

“I don’t want to go through chemo out here,” Smith said. “People in chemo die from complications, pneumonia. You’re signing your death warrant out here.

“If I find permanent housing, then yeah,” she added. “But you have to come up with the first and last month’s rent. It’s hard enough to get $10 a day to eat. So $1,000? Legally?”

Smith’s predicament is emblematic of another large sector of the homeless population for whom the struggle for shelter, and day-to-day chaos, make it difficult to get the medical or mental-health treatment they need.

Instead, many choose to self medicate with drugs, ignoring long-term health issues while dying slowly on the street.

Last year, at least 75 local homeless people died of natural causes, according to county records. But how natural were those deaths? For the past decade, the average age of death for people who die on local streets has been about 50. Life expectancy in the general population, nationally, is about 79.

And when many of the natural causes are closely inspected, they often hint at ties to long-term homelessness or drug abuse, including frequent deaths from cirrhosis, fatty liver, heart failure, sepsis and pneumonia.

In an effort to address health problems before they become chronic issues, the Orange County Health Care Agency frequently sends public nurses to areas where the homeless congregate. There, nurses attempt to attempt to assess people’s health issues and link them with full-time physicians, psychiatrists and other county health programs.

They even give homeless people bus passes and help them obtain state ID cards so they continue medical treatment.

But all too often, that initial contact is where the county’s help stops, said Paul Leon, a former county public health nurse who now helps the homeless as president of the nonprofit Illumination Foundation.

Leon said the county refers homeless people to doctors, hospitals and nonprofit programs, but often doesn’t follow up to ensure they make it there. And for people who are disproportionately drug addicted, have mental-health issues or who simply decide to ignore long-term health problems, that lack of follow-up can mean they never get treated.

County staff denied Leon’s claim that their work ended with a referral, saying public nurses regularly follow-up with homeless patients.

Eve Garrow, homelessness policy analyst for the American Civil Liberties Union’s Orange County office, said 33 of the county’s 34 cities have anti-camping ordinances that criminalize the act of sleeping in public spaces. This, she said, pushes homeless people to remote locations, far from medical care, leaving them “exposed to the elements and at an increased risk for death.”

Julia Cross, a recuperative-care nurse with the Illumination Foundation, said that lack of stable health care often drives homeless people to hospital emergency rooms. Those visits, she said, typically don’t address the underlying issues that lead to long-term health problems.

Cross told a story of a man who cut his leg on a bike gear and was not provided treatment at local hospitals despite the fact that the wound had become infested with maggots.

“He went to three different hospitals, three days in a row, and all three sent him out and did nothing,” Cross said. “They said, ‘You need to go see your doctor.’

“We have world-class health care here,” she added. “But there are barriers.”

Gaps in service

Harley Thompson doesn’t know how long he’s been homeless. The 78-year-old with Alzheimer’s disease can barely remember where he was last week.

But despite that, staff members at the recently opened Orange County “Courtyard” homeless shelter in Santa Ana say Thompson was dropped there without warning on a Friday night in January, holding nothing but his hospital discharge papers, by a taxicab that sped off afterward.

These covert, hospital-initiated taxi drop-offs are commonplace at the shelter, where all manner of homeless patients – from a wheelchair-bound woman to a suicidal man – have recently been left with minimal or no information about how to care for them.

That disconnect is common in Orange County, where gaps in services and poor communication between health-care providers can neglect homeless people’s longstanding health problems.

That can be especially dangerous for people with mental illness.

At least 13 homeless people committed suicide in Orange County last year. Methods ranged from leaping off a bridge, to jumping in front of a train, to a man taping a bag over his head, to a middle-aged woman lighting herself on fire in a Buena Park motel room.

Suicide has been the fourth leading manner of death among Orange County’s homeless over the past 12 years, accounting for 109 fatalities. And the 34 homeless people who killed themselves over the last two years are the county’s highest total during any such stretch in that period.

That surge comes during a time when the county is spending more than ever on mental health services.

This year, the county’s mental-health budget is $367 million – a 14 percent increase from last fiscal year. That money goes to the county’s more than 200 mental health programs and services, supporting a robust system that includes scores of counseling programs, substance-abuse treatments, inpatient and outpatient psychiatric care, the operation of 496 housing units for the mentally-ill and hotlines to link people with those providers.

But the system still has gaps.

Most notably, the county has by some estimates only 7 percent of the crisis-stabilization beds it needs for people suffering sudden psychiatric episodes. Those patients who can’t get beds wind up flooding hospital emergency rooms, where they sometimes are held without treatment.

Orange County also has only a few small recuperative care facilities – which give mentally-ill patients shelter for up to two weeks while doctors balance their medications – leaving hospitals mostly to discharge people to the street. And even when hospitals send ill homeless people to a shelter, they don’t alert the shelter’s staff or communicate how to care for that individual, according to county staff.

“There’s no warm hand-off between agencies,” Leon said. “There are just too many places where there are gaps in service.”

Glenn Raup, executive director for emergency and behavioral health services at St. Joseph Hospital in Orange, agreed that there aren’t enough residential recovery facilities to which local hospitals can discharge the homeless. But he also noted homeless people frequently decline follow-up treatment, even when it’s available, in favor of pursuing short-term goals of searching for shelter or remaining with their friends.

Leon commended the county’s action last year in securing a $3.1 million state grant to open its first emergency centers for psych patients in several decades. Those facilities should ease the burden on hospitals while providing treatment to people in crisis. But Leon said at a recent meeting with the county, staff still couldn’t answer a simple follow-up: Where do we send patients after their short-term care ends?

The county’s point person on homelessness, Price, said she’s talking with representatives from local hospitals to improve patient hand-offs. Soon, she said, the county will participate in a “whole person care” state pilot program to improve coordination between social services and health-care providers for the homeless. A soon-to-open county homeless shelter in Anaheim should help that process.

Ultimately, Price, like most homeless advocates, thinks the solution lies in more housing: more low-income apartments countywide and more specialized apartments linked with services for the homeless and mentally ill.

Asked if Orange County has the money to do everything it needs to help the homeless and prevent their deaths, Price paused for a moment.

“Yes,” she said.

But it’s a complex problem.

“There’s 2,200 different stories of how people became homeless,” Price said. “And the causes of death are emblematic of that.”

Contact the writer: jgraham@scng.com or 714-796-7960