LOS ANGELES _ Mia St. John's cellphone lit up with a message from the psychiatrist treating her son. The voicemail shimmered with hope, the first she had felt in months.
The doctor said Julian, admitted to a psychiatric facility with schizophrenia, seemed more cheerful, was talking more with other patients and would soon begin a new art project.
"Very happy to see he's coming around a bit," the doctor said.
It was November 2014, and Julian, 24, had been living at La Casa Mental Health Rehabilitation Center in Long Beach for two months. Mia and her ex-husband, Kristoff St. John, had resorted to involuntarily committing their son after he threatened to kill himself in September.
But three days after Mia received the physician's voicemail, she got another call from La Casa. This time the message offered only despair.
Julian had suffocated himself with a plastic bag. Her son was dead.
How many others die in California psychiatric facilities has been a difficult question to answer. No single agency keeps tabs on the number of deaths at psychiatric facilities in California, or elsewhere in the nation.
In an effort to assess the scope of the problem, the Los Angeles Times submitted more than 100 public record requests to nearly 50 county and state agencies to obtain death certificates, coroner's reports and hospital inspection records with information about these deaths.
The Times review identified nearly 100 preventable deaths over the last decade at California psychiatric facilities. It marks the first public count of deaths at California's mental health facilities and highlights breakdowns in care at these hospitals as well as the struggles of regulators to reduce the number of deaths.
The total includes deaths for which state investigators determined that hospital negligence or malpractice was responsible, as well as all suicides and homicides, which experts say should not occur among patients on a psychiatric ward. It does not include people who died of natural causes or other health problems while admitted for a psychiatric illness.
Like mental illness itself, these tragedies cut across age groups, races and social classes. Among those who died in California's psychiatric wards were a 15-year-old high schooler in marching band, a 27-year-old who spent his free time volunteering at church and a PhD student in criminology. Julian was the child of a celebrity couple: Mia is a champion boxer and Kristoff starred for more than two decades on the soap opera "The Young and the Restless."
Although the number of inpatient deaths in California does not appear to be higher than national averages, the deaths reveal serious lapses in patient safety, experts say.
Mental health experts say that while there are rare cases in which a hospital staff cannot prevent the death of a patient on the psychiatric ward, most people admitted can be kept safe. State officials who investigated these deaths largely attributed them to low staffing levels, staff errors, lack of training, or facilities that were deemed unsafe.
At Aurora Las Encinas Mental Health Hospital in Pasadena, a patient died in 2018 after five staff members restrained him on the ground and he stopped breathing. State investigators determined that the staff had not been properly trained in how to restrain patients, records show.
In 2012, a staff member at Kaiser Permanente Mental Health Center in Los Angeles did not check on a suicidal patient every 15 minutes as required, allowing the patient to fatally hang himself in his room, according to a state investigation.
Experts say these problems persist, in part, because of cost. Hospitals would have to spend heavily to improve safety, both to hire more staff and retrofit rooms so they are less dangerous for suicidal patients.
Julian's death was not the first at La Casa. Two years prior, a 22-year-old hanged himself in his room and died, according to coroner's records. A state investigation found several errors by hospital staff that led to the man's suicide, but officials imposed no punishment.
Following almost every death at a psychiatric facility in California, the facility continues operating and does not face a financial penalty. Meanwhile, families remain unaware of the hospitals' track records.
"Welcome to the black hole," said Benjamin Miller, a psychologist who is chief strategy officer for the Well Being Trust, a nonprofit dedicated to improving the mental health system. "Everyone should be informed as to what type of care they receive, but that's the problem with mental health _ nobody really knows."
In the years since Julian died, Mia has become dedicated to fixing the mental health system that she believes killed her son. Kristoff tried to soothe his grief with alcohol and began drinking excessively after his son's death, Mia said.
"The guilt just weighed on him very heavily," Mia said. "I think he felt like he failed his only son."
In February, Kristoff, 52, was found dead in his apartment. Tests showed that he had been severely intoxicated before he died. Mia believes he drank himself to death.
