A man spent his final days in isolation in an Oregon jail. Why did he die?

Gaping holes in Oregon’s mental health system may be responsible for a 27-year-old man’s death last month.

Skye Edward Baskin, a Black man who was, according to family members, likely homeless, had been arrested in Roseburg in March for wandering in and out of traffic on the freeway.

He was supposed to get treatment for an undisclosed serious mental illness at the Oregon State Hospital. But as a new federal report details, Baskin was helpless and possibly already dead when two Douglas County sheriff’s deputies escorted him into the state’s most secure psychiatric facility on the morning of April 18, just before 11 a.m.

For about 10 minutes, Baskin slumped in a wheelchair in the admissions area, his head at an unusual angle, without any visible signs of life, according to the report. Nurses and security staff went about business as usual. They removed restraints from his wrists. They took his photograph for identification. They wrapped a blanket around his legs, and lifted them so his feet wouldn’t drag on the ground when he was wheeled to his room.

Nobody checked his vital signs, according to the report. The nurse who accompanied him from the loading bay later couldn’t recall ever seeing his chest rise and fall.

A second nurse took over as Baskin was being transferred to his room, about 11 minutes after he was taken out of the transport van. She noticed he was “more limp than would have been expected from a simply unresponsive” patient. He had no pulse. His pupils wouldn’t dilate.

Staff hooked him up to a defibrillator and gave him epinephrine and Narcan. His heart never restarted. He was officially declared dead 69 minutes after his arrival.

It’s not yet clear what killed Baskin.

Citing patient privacy rights, the Oregon State Hospital has declined to comment on the circumstances of his death. The Oregon Medical Examiner hasn’t released any autopsy records so far.

But in the federal investigation, multiple people at the hospital used the same term to describe Baskin, a term that could be a red herring or a clue: Baskin, they said, was catatonic.

To a layperson, catatonia might just mean unresponsiveness. But it has a more specific medical meaning, a frozen, immobile state that can be a symptom of some types of schizophrenia, and also of other serious medical conditions. In either instance, left untreated for long enough, it can lead to deadly complications.

Federal investigators have criticized the state hospital for disorganization and numerous other lapses in protocol that may have contributed to Baskin’s death.

But their most profound criticism is that the staff, “without reasoning or questioning” accepted, and acted upon a story the Douglas County deputies told them.

The deputies pulled up with a patient who was, according to video surveillance footage, lying unresponsive on the floor of their transport van.

Baskin was, they said, uncooperative. He was “choosing not to walk.” This was his “normal,” the deputies said, according to the report.

The hospital staff appeared to believe that story, as opposed to what federal investigators later saw when they reviewed the video footage from hospital security cameras of Baskin’s arrival: a patient whose condition indicated a medical emergency.

The federal report doesn’t consider what happened to Baskin before his arrival at the Oregon State Hospital. That’s outside of the jurisdiction of the investigators, who work for the Centers for Medicare and Medicaid Services, and investigate conditions at hospitals that receive federal funding.

But other people familiar with the situation are concerned that ultimately fatal neglect and blindness to Baskin’s medical and psychiatric needs started long before he arrived at the state hospital.

He’d been held in isolation in a Douglas County Jail cell for six weeks, with little contact with the outside world.

Angelina Hollingsworth, an attorney with Umpqua Valley Public Defender, was representing Baskin. She’s concerned Baskin may not have been eating or getting adequate medical care in the days leading up to his death. She also questions what happened to Baskin during his van ride to the hospital.

She believes Baskin would still be alive if the state and Douglas County had a functioning mental health treatment system.

“Instead, the police brought him into our jails, assumed custody of him, and left him there, pretty much to die,” Hollingsworth said.

Two additional sources with knowledge of the case spoke to OPB but asked that their names not be used. They shared Hollingsworth’s concerns that Baskin may not have been eating or drinking prior to his death.

A stranger in a crisis

Baskin was arrested on March 1. Hollingsworth was assigned his case on April 6. The file she received on him was thin, a few pieces of paper explaining the alleged charges against him, known as a probable cause affidavit.

The affidavit was written by Oregon State Police Sgt. Ken Terry.

On March 1, 911 callers reported a man on Interstate 5 on the bridge above the North Umpqua River. At least one person thought they saw him jump.

Roseburg has a mobile mental health crisis team, supported by recent investments the Legislature made to shore up Oregon’s mental health system. The crisis team’s goal is to divert people from jail “and into appropriate health services,” according to Adapt, the group that runs it.

But it was Sgt. Terry, and not the mental health team at Adapt, that responded to the 911 calls. Terry found Baskin walking in and out of traffic, and staring down into the river.

“Mr. Baskin seemed in a daze or fog of some sort and would not really communicate with me,” Terry wrote in the affidavit.

“He was able to come back across traffic when asked, although did not seem to recognize the danger of the vehicles present on (l-5).”

Terry tried to detain Baskin, grabbing his wrist.

“Mr. Baskin eventually balled up his fist and I anticipated he was going to start throwing punches,” Terry wrote.

According to Terry’s report, Baskin attempted to “pull away and resist being arrested.”

Terry handcuffed him and charged him with disorderly conduct and resisting arrest. Terry learned Baskin’s name from a hospital bracelet he was wearing.

Two days after she got his file, Hollingsworth met Baskin.

A deputy took her back to the isolation cell where Baskin was held in the Douglas County Jail — a precaution because he wandered and didn’t listen to orders, Hollingsworth was told.

There was a metal door between the two of them.

“What I could see through the metal door was a person with a blanket pulled up over his face,” Hollingsworth said.

She yelled through a small hole in the door. She asked if he needed medications, if he was being taken care of and if he was eating or drinking.

Baskin did not respond or seem to recognize she was there, Hollingsworth said.

That was the only time Hollingsworth saw Baskin in person. For the rest of the month, he appeared in court remotely over an iPad.

On March 14, based on their first meeting, Hollingsworth filed paperwork with the court saying Baskin was too mentally ill to aid and assist in his own defense. The judge agreed. On March 26, the local community mental health program returned its evaluation.

That document is sealed. But Hollingsworth says Compass recommended Baskin go to the Oregon State Hospital, based on the intensity of his mental illness symptoms.

Hollingsworth didn’t think Baskin’s charges justified continuing to keep him in jail, or sending him to Salem. The state hospital no longer takes most patients who’ve only been charged with misdemeanors.

So on April 1, Hollingsworth filed a motion asking Judge Robert Johnson to dismiss Baskin’s charges, saying there were no services in the community that could restore him to competency. At that point, he’d been jailed and in isolation for 32 days.

The deputy district attorney argued that Baskin’s charge of resisting arrest was a more serious misdemeanor, on a list of charges that qualifies inmates in jail for treatment at the state hospital for up to 90 days to restore their mental health enough so they can stand trial.

Johnson sided with prosecutors. On April 11, he signed the order sending Baskin to the state hospital.

Baskin spent seven more days in the Douglas County jail. That’s the maximum number of days people can stay in custody in Oregon between an order committing them to the state hospital and their actual admission.

On April 18, Douglas County deputies loaded Baskin and another patient into a van and drove them two hours north.

Arrival at the state hospital

At about 10:55 a.m., the van transporting Baskin first appears pulling into a secured entrance to the Oregon State Hospital, according to federal investigators who reviewed the video surveillance footage.

Investigators reported Baskin himself appears on the video feed a few minutes later, after deputies open the two rear doors of the van.

The other patient they’re transporting hops out. Baskin doesn’t move. Investigators described what they could make out on the video. He’s lying on the floor of the van, “at the very end of the floor where the door closure was, their left leg was observed to be bent at the knee and had partially fallen outside of the van.”

“The two deputies picked Patient 1 up off the van floor and in awkward and uncoordinated movements took the patient out of the van,” the investigators wrote. “There was no indication that Patient 1 was assisting or resisting. The parts of their body that could be visualized were limp.”

The federal investigators concluded that there were no signs, in the video footage they reviewed, that Baskin was alive.

“At no time while in the admitting room did the patient assist or resist, nor did they open their eyes or demonstrate any observable movement,” they wrote. “At no time was there any meaningful touch or other activity by any staff that could be construed as a patient assessment.”

One nurse who spoke to the investigators did report seeing a potential sign of life. Baskin’s eyes, she said, opened and closed when the deputies moved him from the van into the wheelchair.

A spokesperson for the Douglas County Sheriff’s Office says Baskin did not die during transport. “He was alive when transferred from our agency’s custody to that of the staff of the Oregon State Hospital,” said Lt. Brad O’Dell. He referred all other questions to the Oregon State Police.

The Oregon State Police are investigating the death. So is the nonprofit Disability Rights Oregon, under their federal authority to investigate the abuse and neglect of people suffering from mental illnesses.

To date, their attorneys haven’t been able to confirm the time of Baskin’s death, or who had legal custody of him when he died.

“He may have died in nobody’s custody,” said Dave Boyer, managing attorney of Disability Rights Oregon’s Mental Health Rights Project.

“It’s bad enough to die, but to die alone in some loading dock or whatever is just tragic.”

Hollingsworth didn’t find out about Baskin’s death until their next scheduled court hearing. A colleague in the courthouse pulled her aside and informed her that her client had arrived, deceased, in Salem.

“He was only 27,” she said. “I definitely felt like I failed him.”

What happened?

Baskin is one of two Douglas County jail inmates who died that week. The other was found unresponsive in a cell and died after he was transported to Mercy Medical Hospital. Douglas County officials told the local press they suspected a fentanyl overdose.

Fentanyl has been implicated in numerous jail deaths in Oregon over the last year. Hollingsworth, though, believes it is unlikely Baskin would have been able to get fentanyl, given his mental state and his isolation from other prisoners.

Hollingsworth has also heard troubling reports of Baskin’s physical condition. The van deputies used to transport him to Salem had a video camera in it. Hollingsworth hasn’t seen the recording of Baskin’s trip, but other people have.

Baskin was able to stand up when Hollingsworth visited him in jail. But he was in a wheelchair when he left the Douglas County jail, according to Hollingsworth.

Hollingsworth says she’s concerned, based on accounts she’s heard of that video footage, that Baskin may have lost a significant amount of weight while in jail.

She believes deputies were offering food and water to her client, but she says she’s not sure if he was actually eating or drinking.

Hollingsworth says Baskin, who grew up in the South and California, was an outsider who ended up in Roseburg, needing help. Police could have taken him back to the hospital, she said, called the mobile crisis unit, or tried to figure out how to get him home.

Baskin’s sister, Gia Bouie, is a social worker in Georgia. Bouie says she was a “pseudo-parent” to Skye when they were kids in the foster care system in Georgia.

He’d told her he was hanging out at soup kitchens in Portland. She’d talked to him about coming back to Georgia to stay with her.

Bouie has so many questions about her brother’s death. She doesn’t understand why he was held for six weeks on such minor charges. And, she said:

“Why did they allow him to be deceased on their watch?”