One night two weeks after being booked into jail for a probation violation, Patrick Russell started hyperventilating and throwing up.

“I can’t breathe,” the 30-year-old told a nurse. “I’m having an anxiety attack.”

He was wrong. So was the jail’s medical staff, who apparently didn’t recognize his intense and radiating chest pain, numbness, continued vomiting and pleas for help as signs of a life-threatening condition.

Fifteen hours later, Russell was dead of an aortic rupture.

He was one of almost 500 people to die in Southern California jails in the past decade. His case was also part of a grand jury report that found almost half of the deaths in Orange County jails from 2014 to 2017 may have been preventable if the inmates had received adequate medical care.

“Why not get him to the hospital? A simple EKG would have told them that he was having heart problems and they could have saved him,” said his mother, Lynne Russell. “Why did he have to go through hours and days of this pain? I can’t grasp it … It’s just – it was so wrong.”

Across Southern California, inmates and their advocates have argued for decades that people are suffering and dying inside county jails that aren’t providing the constitutionally required level of medical and mental health care.

But jail officials say their task has gotten harder in recent years because of factors largely out of their control.

A recession cut their budgets. A new state law started sending them felony inmates serving longer sentences than they’d ever had to deal with before. A voter initiative reclassified a list of felony crimes as misdemeanors, reducing the incentive for many inmates to go to drug rehab in exchange for reduced sentences. Mental health resources in the community continued to dwindle, leaving jails as de facto treatment facilities.

“When inmates come in off the streets now, they have highly comprehensive problems, much more difficult problems,” San Bernardino County Undersheriff Shannon Dicus said. “And we’re holding inmates longer.”

In the past decade, jails in Los Angeles, Orange, Riverside and San Bernardino counties reported more than 3 million inmate bookings, 4.8 million sick calls, almost 400,000 new mental health cases and 345,000 dental visits.

Jail officials estimate between 70 and 80 percent of their populations come in with substance abuse issues. And increasing numbers, they say, have chronic diseases and mental illnesses that are difficult – and expensive – to treat.

“Having these patients in jails and prisons are the most ineffective way to treat and care for them – and probably the most expensive,” Jackie Clark, director of Correctional Health Services for Los Angeles County, said of mentally ill inmates.

Inmate-rights advocates don’t deny the challenges, but say they don’t excuse poor care.

“You can’t lock people up if you don’t have the capacity to treat them humanely,” said Sara Norman, an attorney for the Prison Law Office, a nonprofit firm that works to improve inmates’ conditions.

Jails and prisons have a constitutional duty to provide health care; it doesn’t have to be the most sophisticated care money can buy, as one expert said in a case brought by Norman’s firm, but it has to be adequate. Not doing so amounts to cruel and unusual punishment.

In recent years, class-action lawsuits have been forcing some counties to make changes, and advocates say they’re starting to see a difference – even if there’s still a long way to go.

The number of deaths is trending downward in Los Angeles County jails along with the overall inmate population, and one decrepit old jail is going to be torn down and replaced with a facility dedicated to mental health.

Riverside County is making systemic changes in how sick inmates are cared for and has more than tripled how much it spends on inmate health services. San Bernardino County has begun adding desperately needed programs for the mentally ill.

Orange County, which isn’t under any court orders related to jail health care, is planning some renovation and construction at two jails, which it says will help the Sheriff’s Department provide care for more inmates with mental health and substance abuse problems.

Daisy Ramirez, the American Civil Liberties Union’s jails policy and conditions coordinator for Orange County, said she supports efforts to improve care to everyone in custody. However, she thinks the goal shouldn’t be to expand jails but to reduce the number of incarcerated people with chronic medical and mental illness by diverting them to get treatment elsewhere.

“We don’t believe those types of people should be criminalized and behind bars,” Ramirez said. “We wouldn’t lock up a person who has seizures because they had a seizure, but we do time and time again lock up someone for something they did while they’re in a mental health crisis.”

‘Patch and go’ care

California’s county jails were not built to provide the kind of care that today’s inmate population requires.

Traditionally, county jails only housed inmates who were just arrested, waiting for trial or serving short misdemeanor sentences. Almost no one was there for more than a year. Most got out within hours or days of being booked.

That meant for the most part, county jails provided only “quick patch-and-go” health care, Norman said. (Jail officials agree, though they call it “episodic.”) They counted on inmates with chronic conditions being either released relatively quickly or shipped off to state prisons for longer felony sentences.

Jails simply didn’t have the physical space for comprehensive medical clinics or mental health therapy. Many didn’t provide things like glasses, hearing aids or routine dental care.

In 2011, that became a big problem.

California’s prisons had been suffering from an overcrowding crisis that overwhelmed their health care system, and a federal court ordered them to shrink their population.

The state’s answer was a new law, AB109, often called realignment. Starting in October 2011, inmates sentenced for non-violent, “non-serious” and non-sex-related felony crimes were kept in county jails, even if their sentences were years long.

Realignment has improved conditions in the state prisons, experts say. It’s also reshaped county jail populations.

Before realignment and still today, the majority of people in jail are pre-trial – they haven’t been convicted. But that percentage shrank and the share of inmates who were convicted felons jumped almost instantly after realignment took effect.

Today, about one-quarter of jail inmates are there because of AB109, give or take by county. Officials say they see more violence, gang problems and smuggled-in drugs. Health-wise, the population is also getting older with more substance-abuse problems, mental illness and chronic diseases.

A 2012 Orange County grand jury report on the changes brought about by realignment didn’t quantify how many more inmates with specific chronic diseases were being treated in jails – and sources interviewed for this story weren’t able to do that either. But that report did point out the high costs required to treat diseases like hepatitis C ($85,000 a year), kidney disease ($100,000 a year for dialysis) and cancer ($1,950-$195,000 a year for chemotherapy).

‘A death sentence for a DUI’

Patrick Russell’s death of an aortic rupture is the worst-case scenario of what critics see as a fundamental problem in jails: Health care is too often delayed or inadequate, and tends to be crisis-driven.

Russell had been sentenced to six months in jail followed by probation for a 2014 felony domestic violence case and a misdemeanor case of driving under the influence of drugs, court records show. A probation violation – his mother said it was another DUI – landed him back in the county’s James Musick Facility in January 2016.

His health crisis began late on Jan. 23, according to the Orange County District Attorney’s Office, which reviews all in-custody deaths.

As it worsened over the next 12 hours, his chest pain rose to the top of the pain scale, 10 out of 10. It radiated to his arm and jaw. His hands, feet and then both arms went numb. He continued vomiting until the spasms turned to dry heaves.

In his first four visits to nurses, he was given antacids for the nausea; a referral to a mental health assessment, where a physician instructed him in breathing exercises for anxiety; and nitroglycerine and Motrin for his pain. Each time he was sent back to his cell.

On his fifth visit, he was kept in the medical ward for two hours. When a nurse saw him gasping for air, staff finally summoned paramedics. It was too late.

The district attorney concluded that medical staff “clearly … were wrong in their assessments” but determined their care of Russell was not criminally negligent.

His parents’ attorney disagrees.

“It was certainly criminal conduct. They ignored the patient’s cries for help,” said Cameron Sehat, who filed a lawsuit against the county.

The Orange County Sheriff’s Department declined to comment, its policy on pending litigation.

According to the Mayo Clinic, aortic ruptures are uncommon, especially in people as young as Russell, and they can be hard to diagnose — but when detected early and treated promptly, “the chance of survival greatly improves.”

Russell’s mother, who lives in Pennsylvania, said the family remains devastated that the jail didn’t take care of him.

“He got a death sentence for a DUI.”

‘They think I am faking’

Over and over, inmates express frustration that jail staff doesn’t listen or believe them when they complain about health issues.

Indeed, in a 2014 federal court order granting class-action status to the Prison Law Office’s lawsuit against Riverside County, the judge wrote that the county “argues that inmates often lie, so a grievance or a declaration written by an inmate is not reliable” and contends “that an inmate is an inherently untrustworthy person.”

Angela Zuniga’s family thinks a similar attitude led to her death in a San Bernardino County jail in 2015.

The 33-year-old was pregnant when she went to jail that January on suspicion of shooting at an inhabited dwelling. On Feb. 10, she gave birth at the hospital to her seventh child, a boy she named Exodus. She had a C-section and then a hysterectomy. Three days later, she returned to West Valley Detention Center.

According to an active lawsuit filed on behalf of her children, her surgical wound appeared to have gotten infected. She told a friend who visited her, “I have been trying to ask them for help, they ignore me and they won’t give me no help in here. … They said they think I am faking. I’m not faking it!”

On the afternoon of Feb. 27, Zuniga went to the infirmary to ask to be taken to the hospital, but was turned away, attorney Vicki Sarmiento said. That evening, she passed out in her cell and was taken back to the infirmary. Though Zuniga was having chest pain and trouble breathing, Sarmiento said, it took more than two hours for an ambulance to arrive.

She died at the hospital the next morning. It wasn’t an infection that killed her – it was multiple pulmonary embolisms, or blood clots that traveled to her lungs.

Sarmiento said anyone who had undergone major surgery would be at higher risk of blood clots and should have been monitored.

Instead, “She was put in general population without any followup by an OB-GYN or medical doctor,” Sarmiento said. “A doctor would have noticed that she was declining and showing symptoms of someone who was at risk of pulmonary embolism.”

Public agencies as a rule don’t comment on pending litigation. But when the general topic of lawsuits came up in an interview with San Bernardino County sheriff’s officials, they said jails are easy targets for attorneys who specialize in inmate cases and said some of the allegations made in lawsuits aren’t true.

“Patients don’t get ignored. They do get seen in a timely manner,” said Terry Fillman, the sheriff’s health services administrator. When there’s a negative outcome, though, families don’t want to believe that, he said.

He gave an example, and although he tried to avoid details that might identify the inmate he was talking about, the case he described paralleled Zuniga’s.

He spoke of an inmate who underwent two lifesaving surgeries, then had a fatal complication — a pulmonary embolism, which he said are so dangerous that they can kill patients no matter how closely they’re being monitored. But he said her family was focused on an infection that they thought got ignored.

“Of course they would try to say there’s nothing they could have done, but what do you expect them to say,” Sarmiento said. “If that continues to be an explanation (in situations like Zuniga’s), no changes will be made, and more people will die or have serious medical complications.”

Next: Treating mental health is jails’ biggest challenge

This article is part of a series on jail health care that was produced as a project for the Data Fellowship, a program of the USC Annenberg Center for Health Journalism.