Sandy Morgan didn't have a receipt when she walked out of the Boothwyn Wal-Mart with more than $500 worth of dolls, toys and girls' clothes. In her mind, she didn't need one. She owned Wal-Mart, she told a manager who tried to stop her.
Sandy knew things others didn't. She knew she owned many stores and she knew the television transmitted demons. She took care to protect her family: She threatened the demons with knives and a broken mop handle; she threw away food she was sure was poisoned.
It was a strain, fighting things no one else saw. Once her sisters watched as Sandy wandered into the street and looked up at the sky. She asked God to take her.
But that February afternoon in 2006, it was the police who took Sandy. Arrested for shoplifting, the 38-year-old college graduate from Aston was ordered held on $10,000 bail and taken to the Delaware County jail.
Within the first hours of Sandy's incarceration, a physician's assistant guessed she might be mentally retarded. Within a day, a doctor diagnosed her as schizophrenic. Within eight days, a psychiatrist declared her incompetent to stand trial.
While the court waited for a competency report, Sandy waited in jail. For five weeks, she saw no visitors. She never went outside. She hid under covers and stared at the walls.
She went two weeks without a shower because the nurses were afraid to go near her.
"Time to get out!" Sandy told a nurse after a week in jail. After two weeks, "Are you here for Jesus?" After a month, "Is [that] a horse over there?"
If a local hospital hadn't released Sandy from its psychiatric ward weeks earlier, she might not have been arrested. If she had threatened to kill the Wal-Mart employees, or herself, the police could have taken her to a hospital.
If jail officials had called Sandy's family, they might have known what was wrong when she collapsed in her cell, her arms and legs flailing, her body cold.
But Sandy wasn't lucky like that.
A grim diagnosis
Later, Sandy's story would come out slowly, in dozens of depositions, after her family sued the jail, the company that runs it, and the hospital that released her weeks before her arrest.
There would be many sides to the tale, a tangle that a jury is scheduled to work out next week.
But it started in 1985, when Sandy was 17 and heading off to York College. That's when her family noticed something was wrong.
The sixth of seven children, Cassandra "Sandy" Morgan had been a bright, fearless child with a vivid imagination. She excelled in school, played field hockey, ran track, and loved writing and singing contests. She wanted to be a nurse.
But the summer after she graduated from Chester High School, she became afraid. She told her younger sister, Erika, that someone was trying to break into their house. In her dorm room, she saw spiders crawling on the walls.
Sandy's brother James, seven years her senior, was a rookie in the York Police Department in 1986 when he received a call from campus that Sandy had been raped. He rushed to the hospital.
But doctors found no evidence of assault. After prolonged questioning and numerous tests, they diagnosed Sandy, then 18, with paranoid schizophrenia. They prescribed Haldol, a psychotropic drug.
Sandy tried to go back to school, but the hallucinations drove her home to her mother and sisters Erika and Jamie. She wrote poetry about her struggle to hold on to her dreams that was published in an anthology in 1988.
At home, Sandy found purpose in caring for her diabetic mother, who was bedridden. Willie Mae Morgan needed insulin shots, which all three sisters helped to administer. Sandy often bathed her mother and helped prepare her meals.
The regular schedule helped Sandy remember when to take her medications. She stayed active. She played piano and attended church. She tried to teach herself how to speak Chinese.
Sandy eventually returned to school, attending class part time until graduating from Neumann College in 1999 with a bachelor's degree in liberal arts.
Her whole family went to her commencement. Erika, three years her junior, watched Sandy smile for the cameras, "chest pumped out and posing."
A mind unravels
In March 2003, Sandy's mother died of pancreatic cancer. Sandy was devastated.
She stopped eating. She slept fitfully. She refused her medications - not just the Haldol, but the Synthroid doctors had prescribed two years earlier for hypothyroidism. The condition was easily manageable with drugs, but if untreated, it could lead to coma, even death.
Without her mother to care for, the hours and days fell out of a recognizable pattern. Without her medication, her hallucinations and delusions flourished.
"God is talking to me," she told Erika and Jamie, who also still lived in their mother's house on Jennifer Lane. "Come with me to see God and the angels."
She thought the family dog was the devil. Her sisters caught her choking it.
She worried that Satan had taken over her family and would harm her nephews and nieces. Once she chased Erika down a hallway with an 8-inch butcher knife, screaming, "Who are you?"
Her family sent her to Crozer-Chester Medical Center 13 times in three years, committing her against her will to the psychiatric ward. They wanted the old Sandy back, and they hoped the doctors could persuade her to take her medicine.
But five, 20, even 90 days in the hospital never seemed to be enough. Each time she returned home, Sandy's interactions with the world in her mind became more frightening.
On Jan. 19, 2006, Sandy's sisters heard a loud crash. They ran to the kitchen and saw Sandy break a mop handle across her hip. She swung the broken sections at her sisters, saying, "Demons get out, demons get out!"
Jamie and Erika called the police, who took Sandy to Crozer-Chester, where orderlies stood by ready to restrain her. A social worker noted that Sandy was "psychotic, paranoid, refusing antipsychotic medication, and a danger to herself and others."
Crozer-Chester asked permission to hold Sandy for up to 90 days for treatment, which the Delaware County court granted.
In his reports, Rommel Rivera, Sandy's attending psychiatrist, said she should be forced to take her psychotropic medication. On her first day there, she was given an injection of Geodon. She later agreed to take Risperdal, Klonopin and injections of Haldol. But that wouldn't last.
Rivera suggested that Sandy's frequent hospitalizations showed she might need more help. He suggested sending her to Norristown State Hospital. She could be held at the psychiatric hospital for more than 90 days - long enough, her family hoped, to get her back on her meds.
A social worker met with Sandy and her sisters on Jan. 26 to discuss Norristown. Sandy, who had become less agitated after the injections, agreed to go if she could take her keyboard and her Bible.
The three sisters hugged one another tightly. Sandy smiled, something Jamie and Erika hadn't seen her do in a while.
"You are finally going to get the help that you need," Jamie told her.
But four days after the family meeting, another psychiatrist, Usha Kotihal, inexplicably took over Sandy's care – a change neither doctor was later able to explain.
Kotihal determined that Sandy's mental state had improved and that she no longer posed a threat to herself or others, she later testified in a deposition. She gave Sandy a 100-milligram injection of Haldol decanoate - a long-acting drug with a half-life of three weeks - and sent her home on Feb. 7, 2006.
Erin King, Sandy's case manager, later testified that she couldn't believe it.
During the car ride home, Sandy was laughing and talking to the voices in her head.
"What's so funny?" King remembered asking her. "Wanna let me in on the joke?"
"No," Sandy said.
Nine days later, Sandy, convinced she owned Wal-Mart, was arrested.
Hospital or jail?
More than 70 percent of the patients in state psychiatric hospitals suffer from schizophrenia. Mental-health officials often struggle to get patients adequate treatment, given the national trend away from institutions and toward residential care.
Without medication, schizophrenics relapse within six weeks, on average, said Amy Brodkey, a psychiatrist who directed the mental-health court at Eastern Pennsylvania Psychiatric Institute for six years.
"It affects people's thinking, it affects their emotion, their cognition," Brodkey said. "The prognosis is still not good."
Under state law, a person must pose a "clear and present danger" of bodily harm to himself, herself or others within the last 30 days to be committed to a hospital.
Many wind up in jail, as police officers decide what to do with someone who broke the law but is not necessarily dangerous.
At the police station, Detective Tom McNichol and another officer asked Sandy to empty her pockets and sit on a bench outside the station's three cells. As McNichol called her house, Sandy asked for her Bible back.
Later, McNichol testified that he called Jamie, who told him that Sandy was supposed to be going to the hospital. She gave him a number to contact Erin King. According to McNichol, Jamie told him Sandy was no longer welcome at home.
"What are we supposed to do with her?" McNichol said he asked.
"I don't care what you do with her," Jamie said, according to McNichol.
Jamie denies that. In her testimony, she said she didn't know of Sandy's arrest until she heard a message the police left on her answering machine later that night. She testified that she did not go to the station to see her sister because it was late.
McNichol called King. Could she pick Sandy up and have her committed to the hospital?
King told him it wasn't possible. Sandy wasn't a threat to herself or others, so she could not be committed against her will.
"We can't release her to the streets," McNichol recalled thinking.
The police charged Sandy with retail theft, defiant trespass (she'd been warned previously not to bother employees at the Wal-Mart), and disorderly conduct.
During her video arraignment, Sandy told Judge Stephanie Klein, "I'm the boss. I'll put you in jail," McNichol said in an interview.
The prosecutor wrote "crazy" on her copy of the charges.
Klein ordered a competency evaluation and set bail at $10,000. Sandy was then taken to the George W. Hill Correctional Facility in Thornton, southwest of Media, the state's only privately operated jail.
Ten thousand dollars is a high bail for a retail theft charge for someone with no arrest record, Montgomery County chief public defender Stephen Heckman said.
"If she had no mental-health issues, she would not have gone to jail. Not for retail theft," Heckman said. "It's almost doing them a favor . . . it may be the quickest route to treatment."
A question of competence
The Delaware County jail, a 1,883-bed facility, is required by contract
to adhere to basic national medical guidelines.
Upon arrival, inmates are typically given a physical and mental-health evaluation and tested for communicable diseases such as tuberculosis and HIV.
When Sandy arrived, she told the corrections officers she was innocent. When she struggled, two officers wrestled her to the ground and handcuffed her, according to jail logs.
The officers took Sandy to a physician's assistant, Lisa Black, who asked Sandy about her medical history. Sandy appeared confused and was combative, she noted.
Black asked Sandy whether she was taking medication or under the care of a doctor.
No, was the answer.
Had she ever had high blood pressure, diabetes or a psychiatric disorder?
Had she been hospitalized for an emotional or nervous problem?
"None of your business," Sandy said, according to Black's intake form and testimony.
Black decided Sandy was mentally retarded or mentally ill; she later said she believed Sandy was unable to tell her what her diagnosis was.
Jail medical officials depend almost exclusively on inmates to tell them about their health. At the Delaware County jail, the medical staff is not required to check out inmates' medical histories. Inmates can decline medical care.
Whether an inmate is mentally capable to help manage his or her medical care is for jail staff to decide. According to the policies of the GEO Group Inc., which ran the jail, mentally unstable inmates should be transported immediately to a hospital. But finding beds can be difficult.
Not dangerous enough
Black assigned Sandy to a room in the infirmary on suicide watch, figuring she was mentally ill, she later testified. Officers looked in on Sandy every 15 minutes to make sure she wasn't hurting herself and had not fallen ill.
The next day, Sandy admitted to psychiatrist Grato Paneque that she had been on medication. When Paneque visited again four days later, Sandy said she had been hospitalized, according to Paneque's records.
Sandy did not say she had schizophrenia, but the psychiatrists who visited her during her first days in jail gathered as much and prescribed Risperdal.
Sandy did not mention her hypothyroidism. The last time she is known to have taken her Synthroid prescription was on Feb. 2 at Crozer-Chester. Even in the last five days of her hospital stay, she refused it.
None of the psychiatrists or medical staff who met with Sandy at the jail called her family to determine what medications she was taking. No one contacted the doctors who had treated her at Crozer-Chester, where she had been hospitalized more than a dozen times.
The county employs two mental-health liaisons at the jail to help inmates, yet jail officials say they had no contact with Sandy's caretakers in the infirmary.
Sandy's brother James and three of her sisters said they called the jail to find out what was happening. Lisa and Jamie Morgan testified that they told a jail social worker about Sandy's thyroid condition. They hoped that once Sandy was declared incompetent to stand trial, she would be transferred to Norristown State Hospital.
Sandy's caseworker, Erin King, indicated in her phone log that on Feb. 23 she spoke with Kirk Benson, a mental-health liaison at the prison. King said she told him that Sandy had schizophrenia and suffered from hypothyroidism.
Benson testified that he didn't remember speaking to King.
A counselor arranged for James Morgan to talk to his sister.
"I don't belong here," Sandy told him.
"I know," James remembers telling her. "I'm working on it." James continued to call Sandy's public defender for updates.
None of her family members posted the $1,000 it would have cost to bail Sandy out of jail. James said he thought he needed the full $10,000. His sisters said they didn't ask about bail because they did not understand the process. They did not try to see Sandy, either, because they thought inmates in the infirmary could not have visitors.
A psychiatrist the county hired evaluated Sandy on Feb. 24 and determined that she was not competent to stand trial.
It took several weeks for the report to be transcribed and sent to her public defender, a delay that is not uncommon.
Meanwhile, Sandy became more withdrawn and hostile. She hid under blankets in her cell. She fought nurses who tried to take her vital signs. They wrote "caution" next to her name in infirmary logs.
One nurse said that Sandy was sometimes "wild-looking."
During 59 nursing shifts, Sandy's vitals were recorded only 17 times. Nursing notes say she would ask for showers and was "malodorous," but was denied because she was too hostile. Records show she showered just four times in five weeks.
On Feb. 26, a nurse wrote in the infirmary log, "needs 302," referring to the state mental-health law that allows for a person to be hospitalized against his or her will. The next day, and again on March 2, nurses noted "302?"
On March 21, a nurse wrote that Sandy was getting worse and refusing medication. On March 22, a nurse scribbled, "Wrote in toothpaste, delusional," and "psychotic, poor impulse control."
Two days later, Michael Harper, another public defender, petitioned the court to have Sandy transferred to Norristown State Hospital. All things considered, Sandy's case was moving along quickly, Harper said.
"A two-month turnaround is about the best we can do," he later testified.
But for Sandy, it wasn't fast enough.
The next day, March 25, Officer Rasheeda Hackett walked past Sandy's cell about 3:15 a.m. and saw her gripping the sink, her legs shaking. Then she fell.
By the time a nurse reached her, Sandy was convulsing. She bit her tongue. Her eyes were open, looking to the right. She was incontinent.
Sandy had no history of seizures.
When she stopped flailing, she was put on a stretcher and taken to another room in the medical wing. Black, the physician's assistant who had placed Sandy in the medical wing five weeks earlier, administered Dilantin, an antiseizure drug.
No one contacted the doctor on call that night or dialed 911. Instead, medical staff took Sandy's blood pressure, pulse and heart and respiration rate. Ammonia revived her somewhat, but she did not respond to pain or to her name.
Seizures in an adult not known to have a history of them should be treated as an emergency, said Christopher Rees, an attending physician in the emergency department at Pennsylvania Hospital.
The patient should be immediately taken to a hospital to determine what caused the seizure and whether it stopped, he said.
About 4:15 a.m., a nurse noticed that Sandy's pupils were not responding to light, indicating possible brain death.
"It means you're dying or dead," Rees said. "That's the end."
But the jail medical staff didn't call 911 until 4:42 a.m., an hour and a half after Sandy collapsed.
In the ambulance, Sandy had another seizure. When she arrived at Riddle Memorial Hospital, her body temperature had dropped to 82.8 degrees.
Machines kept her alive for four days while her family gathered to say goodbye.
Before the hospital disconnected Sandy, before her organs were harvested for transplant, James sat next to his sister and wept. He hugged her, stroking her hand and her face.
"I'm so sorry," he told her.
A long deterioration
The autopsy revealed that Sandy died from profound hypothyroidism with probable myxedema coma, an end stage of hypothyroidism that causes a firm swelling in body tissues. About half of the people who develop myxedema coma die, said David Cooper, director of the Johns Hopkins Thyroid Clinic.
Hypothyroidism means the thyroid gland does not produce enough hormone to maintain body functions at a normal pace. It is one of the most common conditions in internal medicine, said Stephen Rosen, chief of endocrinology at Pennsylvania Hospital.
The condition usually results when the immune system mistakenly attacks the thyroid gland.
In the days leading to Sandy's death, her heart rate must have slowed and her blood pressure may have dropped, Cooper said. She likely started breathing more slowly. Her voice may have lowered or become hoarse as her larynx became engorged from the swelling. Her extremities were probably cold to the touch as her body shifted blood flow to preserve her vital organs, Rosen said.
Four days before Sandy collapsed, a nurse recorded her temperature at 92.7 degrees, according to jail records. The nurse, Maureen Hoffman, testified that it was a transcription error.
But Cooper, who is not involved in Sandy's case, said hypothyroidism takes a long time to kill, probably longer even than the five weeks Sandy was in jail. A check of Sandy's vital signs should have indicated to nurses that something was wrong.
"I can guarantee you her temperature was not normal the day before," he said. "I can guarantee you it was not normal a week before."
Body temperature that drops to 95 degrees or lower is a red flag, Rosen said.
Suicide-watch logs kept by jail officers who looked in on Sandy every 15 minutes are missing for the final three days she was at the George W. Hill Correctional Facility.
Records listing the drugs Sandy was offered are missing for March, legal documents show.
In July 2007, Sandy Morgan's family filed a lawsuit in federal court against several jail staff, Delaware County, Crozer-Chester Medical Center, Usha Kotihal, and GEO.
In August, GEO announced that, in part due to the high cost of litigation, it would end its involvement at the jail at the end of the year.
The lawsuit is set to go to trial next week.
Harold Goodman, the lead attorney representing the Morgan family, accuses Kotihal of "abandoning" Sandy, discharging her without proper prescriptions, a post-treatment plan, or a call to the family explaining why she was not being sent to the state hospital.
Morgan's family argues that the jail was ill-prepared to care for their sister and should have sent her to a mental-health facility.
Amalia Romanowicz, a lawyer representing Kotihal and Crozer-Chester, declined to comment. In her court motions she argued that Kotihal and the hospital did what was required of them by law: They treated Sandy until she was no longer a threat to herself and others.
Kotihal, in her deposition, said that although Sandy was still showing signs of psychosis upon discharge, she had returned to her "base line."
In their court motions, lawyers for the GEO Group and jail staff dispute the cause of death, saying that Sandy showed no signs of medical distress until she collapsed. They said it was her and her family's responsibility to inform them of her thyroid condition.
Throughout Sandy's 38-day incarceration, corrections officers looked into her cell every 15 minutes and noted her activities using codes. On the morning of Feb. 25, Sandy was Code 2, "yelling or screaming." On March 5, she walked around for much of the afternoon, singing, cursing, and talking to herself.
But most times, officers looked in to see that Sandy, who had only a toothbrush and a Bible in her cell, wasn't doing anything. During entire eight-hour shifts, officers noted Sandy was Code 8, standing still, or Code 10 and 11, sitting or lying quietly in bed.
Sandy Morgan, who was dangerous enough to be locked up in jail on suicide watch but not dangerous enough to be sent to a hospital, died in front of officers who checked her every 15 minutes of each day.
This story was reported using more than 20 interviews, 27 depositions, medical records and jail logs entered as evidence over the summer in a lawsuit the Morgan family filed. The family is suing the George W. Hill Correctional Facility, the Geo Group Inc., the Delaware County Board of Prison Inspectors, Crozer-Chester Medical Center, and Usha Kotihal, a psychiatrist at Crozer-Chester. The family is also suing several staff members at the jail.
Pablo Paez, spokesman for the GEO Group, did not return calls or e-mails seeking comment. Carolyn Short, a lawyer representing GEO, the jail, and the county prison board, said GEO does not comment on pending litigation. John Gonzales, who represents five jail employees named in the suit, did not return calls for comment. Amalia Romanowicz, who represents Crozer-Chester and Kotihal, declined to comment. Calls to Crozer-Chester were not returned.