People facing criminal charges who are deemed too mentally ill to stand trial or ordered by a judge to a psychiatric hospital are waiting 180 days or more to be admitted, blowing past the 10-day deadline set by Maryland law.

The Maryland Department of Health on Wednesday made its case in court that it was doing as much as it could to alleviate the long-standing problem, but Baltimore County Circuit Judge Nancy M. Purpura was not convinced.

The only way to compel the health department to treat its obligation to hospitalize people in the criminal legal system with severe mental illness more urgently, she concluded, would be to hit it in the wallet. In the cases of five Baltimore County detainees who have been awaiting hospital transfers, Purpura imposed a combined $608,000 in sanctions — $1,000 for every day beyond the deadline each of them has spent in jail. That number will keep climbing as long as the delays continue.

The attorney representing the health department argued that monetary sanctions would only hinder the agency’s efforts to comply with state law, not incentivize it to act more quickly. Purpura responded, “I don’t believe that for a number of reasons.”

She referred to a 2018 amendment to state law mandating the 10-day deadline for mental health jail transfers, which allowed judges to impose sanctions. Though the department has faced sanctions over the issue in the past during civil contempt hearings, those were overturned on appeal before the 2018 amendment, she said. The health department has yet to pay any monetary cost for its failures.

“The mere fact that efforts were made in 2018 to start to address the problem in itself cries out for a sanction,” Purpura said. “Because, prior to that, the department really never was sanctioned monetarily.”

The ruling by Purpura has the potential to change how the state manages its teetering psychiatric hospital system, which has five adult facilities where people stay hospitalized for more than 850 days, on average. Most people transferred from jails go to the lone maximum-security facility, the Clifton T. Perkins Hospital Center in Howard County.

All five facilities, with a total of 1,056 beds, are maxed out. Meanwhile, court orders to house patients have “hit an exponential curve” since the pandemic, the state argued in court, fueling a record-high waitlist of 202 people as of this week.

Bryan Mroz, deputy secretary of operations in the MDH Healthcare System for the Maryland Department of Health, testified that, four or five years ago, there were about 500 court orders every year. The latest data shared by the state recorded 1,126 admission orders in 2023, a sharp increase even from the year before, which totaled 865.

“That number is going up at an unprecedented rate,” Mroz said during the hearing Wednesday.

In trying to dissuade the judge from imposing sanctions, Musa Eubanks, the attorney representing the health department, made a litany of arguments about the state’s efforts to cull the waitlist by tweaking workflows and external obstacles such as a lack of places to discharge patients.

Eubanks also spoke about the health department’s efforts to add beds, including a project to create 44 additional beds at the Thomas B. Finan Center in Allegany County by the end of 2025. There are also plans to expand bed capacity at the Perkins hospital, but that would require an additional construction project to be completed first and is a long way off, according to the state.

In discussing her ruling, the judge called those plans inadequate.

“The department didn’t even start engaging in talks to deal with some of these things until 2020,” Purpura said.

In a statement, Chase Cook, a spokesperson for the health department, said the agency “remains committed to providing the best care for justice-involved individuals.”

The conditions in Baltimore County

During the two-hour hearing Wednesday, Purpura heard testimony from two employees of the Baltimore County Department of Corrections about the difficulties of staffing the detention center’s mental health unit and caring for the detainees.

Tanya Smith Barrow, the mental health coordinator for the detention center, said there are about 52 people in the mental health unit, 44 of whom are participating in programming. The rest, she said, are unable to participate due to their “instability.” Of that group, five are on the waitlist to be transferred to state-run psychiatric hospitals.

Barrow said those in the unit with the most acute mental illnesses typically do not shower and do not clean their cells, leaving the floors littered with food and paper, the walls often smeared with feces.

She spoke about one individual who was so paranoid that he got into an altercation and is now in another unit awaiting transfer.

“When they’re not taking their medications, it becomes problematic,” Barrow said.

Unlike state-run psychiatric hospitals, detention centers do not have the legal authority to force patients to take prescribed medication.

Baltimore County District public defender James Dills, who argued for the health department to face sanctions, expressed his frustration with the delays beyond the numbers, space and bureaucratic processes.

Families frequently call him, he said, checking to see when their loved ones might get into the hospital. Correctional officers struggle with the constant tasks of cleaning and caring for people with severe mental illness.

“When you have that human side added onto this, when you hear what the correctional officers have to do at the detention center, it adds a whole other layer to this,” he said.

A mental health system in disarray

The lack of space in state-run psychiatric hospitals for people facing criminal charges or unable to stand trial goes back years, spanning multiple administrations.

Courts have ruled repeatedly that delays for court-ordered mental health assessments and care violate the law.

Evaluations typically are ordered to determine if prisoners should be deemed not criminally responsible, similar to a finding of insanity, or incompetent to stand trial, when they are considered too sick. They are also sent to psychiatric facilities in lieu of a prison sentence.

Mental health advocates have warned the situation could worsen after Spring Grove Hospital Center in Catonsville, one of the largest psychiatric hospitals with about 355 beds, was deemed obsolete. State officials say its lease runs until 2032 with possible extensions, but it’s slated to eventually close. .

Dan Martin, senior director of public policy for the Mental Health Association of Maryland, said it’s not just people in the criminal legal system who have a hard time accessing inpatient psychiatric care. It’s a “systemwide problem,” including for people with commercial insurance.

“People in jail awaiting an evaluation are caught up in a much larger issue,” Martin said.

Martin pointed to a recent report from the nonprofit research institute RTI International that shows Maryland ranks near the bottom for access to inpatient beds and other mental health and substance use treatment.

That is among the reasons the jails are full of people with mental health issues, largely for low-level crimes.

“We really need to take a broad look at how the state hospital and general hospital beds are used and why people can’t get one when they need one,” he said. “Everyone needs to expand their capacity to meet the challenge.”

He said there is a legislative task force charged with looking at this over the next four years. But he said the needs are urgent.

“We’re working with the state. Hopefully, we see some changes on the front end, improving quality and access, before people end up in jail.”

He said jail “doesn’t help anyone’s mental health, and when we see people sent to solitary confinement, that can create mental health issues where there weren’t problems before and exacerbate existing mental health problems.”