Was Quoyah Carson Tehee failed by Sonoma County’s mental health care system?

Untreated, Quoyah Carson Tehee’s schizophrenia was essentially a death sentence. His parents are angry at a mental health system they say repeatedly failed the Cloverdale man.|

Crisis care: The new mental institutions

Sonoma County has a chronic shortage of psychiatric hospital beds. As as a result, a growing number of mentally ill residents are ending up in local emergency rooms and in the jail system. A three-part series, run on three consecutive Sundays, examines the causes and ramifications of the current state of the county's mental health system, and the people who are impacted the most.

Today - Hospitals: The closure of two psychiatric hospitals in Sonoma County has left a gaping hole.

Aug. 13 - Jail: The Sonoma County Jail has become the largest psychiatric treatment facility in the county.

Aug. 20 - Solutions: Sonoma County explores ways to improve services to people suffering from severe mental illness.

Share your story

We want to hear about your experience with local psychiatric emergency services. What do you do when you or a loved one faces a mental health crisis? Have you or a loved one sat in a hospital bed waiting to be transferred to an out-of-county psychiatric hospital or other mental health facility? Have you or a loved one received psychiatric services in the Sonoma County Jail's mental health unit? Please send a brief account of your experience to Martin Espinoza at martin.espinoza@pressdemocrat.com.

Untreated, Quoyah Carson Tehee's schizophrenia was essentially a death sentence.

The night before he hanged himself at his home in Cloverdale on Dec. 10, 2015, Tehee was plagued by paranoid delusions. The 37-year-old stood in the rain with no shirt and shoes, wielding a pitchfork over his head, screaming and yelling. He threatened his neighbors and accused them of taking his cigarettes. He threw a rock through their car window and assaulted a cyclist after knocking him off his bike.

Public records and interviews with his family paint a portrait of Tehee's final hours.

Tehee was taken to Sonoma County Jail. His mother, Denise Bleuel, says everyone who knew him - his neighbors, the local grocery clerks and especially the Cloverdale police - was aware Tehee had mental illness. That night, however, he was released after spending five hours in the drunk tank.

When he got back to his home, he called his mother and stepfather at 3:15 a.m. and left a voice message that said, “You police stole my computer. Now, I kill myself.”

That morning, police found him hanging from the ceiling at the end of a packaging strap.

“He didn't have to die that night, you know,” said James Warnock, Tehee's stepfather. “He had a terminal disease; he had schizophrenia, and untreated, it's terminal - and he would die eventually from it, but he didn't have to die that night. He didn't have to die that night.”

His life and death illustrate the challenges of caring for people with severe mental illnesses in Sonoma County, as well as the toll it takes on the people who love them.

Bleuel and Warnock are angry. They're angry at the Sheriff's Office, contending that it released their son from jail without providing proper care. They're angry with the county, saying it does not provide enough psychiatric hospital beds.

They are angry at the mental health system, arguing that it repeatedly failed their son by setting such a high bar to obtain emergency psychiatric treatment for someone who does not want it. They say it's a standard that, by definition, withholds care until someone's life is in danger and too often leads to tragic endings, as it did with their son.

And they're angry with the medical industry, saying it views mental illness as undeserving of the same attention, empathy or degree of treatment as cancer, heart disease or other physical illnesses.

“His suicide was not planned. It was a reaction to his inner delusions and voices, and it was an impulsive act,” said Bleuel. “The police were the gatekeepers and had him in the palm of their hands. He was treated like he did not matter. Well, he mattered more than anything to his family and his neighbors.”

Cloverdale Police Chief Stephen Cramer, who is out on medical leave, expressed disapproval in an email Friday that only the family's version of the story is being printed but offered no additional comment. The Press Democrat reached out to the Cloverdale Police Department in October, in February and again this week.

Debbie Latham, chief deputy county counsel, said she could not discuss the details of Tehee's medical treatment in the jail, citing privacy laws. All inmates with mental illness are evaluated before they are released, she said.

“Loss of life by suicide is tragic,” Latham said in a statement. She added, “we can confirm that Mr. Tehee's release from County Jail was done in conformance with County policies.”

Bleuel hopes her son will be remembered not for the illness that killed him but for his brilliance, his passion for nature, his love of fishing and kayaking, his artistic qualities and his willingness to help others.

He had registered himself as an organ donor, so his eyes went to China, where they helped two people see, and his heart valves would also have been used were it not for an infection, Bleuel said.

There was a day - 10 months before he ended his life - that he helped two kayakers, a father and son, stranded in the Russian River after a bad storm in the winter of 2015.

But Bleuel says she feels compelled to tell her son's tragic story, if only to help others.

Tehee was a quiet boy growing up, rarely leaving his mother's side. He had trouble socializing with other kids. In kindergarten and first grade, Bleuel often visited his school during her lunch break, bringing a ball to encourage her son to play with other children.

He played sports, basketball through high school, as well as football and soccer, and he was artistic. But he never seemed to stay with things very long.

“There was always something wrong with somebody else,” she said, citing a common refrain of her son.

He had his first psychotic episode in 1990, when he was 11 and was hospitalized for suicidal thoughts. Tehee, she said, was deeply troubled over his cousin's death six months earlier.

At that time, he was admitted on an involuntary psychiatric hold for 10 days at an East Bay psychiatric hospital, one that would be closed 10 years later. He was diagnosed with depression.

Even before his first hospitalization, and for years after, Bleuel had her son in counseling. As a teenager, Tehee had problems off and on, but his condition dramatically deteriorated after he turned 20. He suffered delusions, fearing people were talking about him, following him, trying to kill him by running him off the road when he drove, his mother said.

Each time Bleuel and her husband talked to Tehee about seeing a counselor, talking to a psychiatrist or taking medication, the young man would become agitated or angry, in some cases violent.

“Even when he was in psychiatric care - I had him in for three years - he would never go see the doctor by himself,” Bleuel said. “He refused.”

In 2009, she purchased a house in Cloverdale for Tehee to live in. It was close to Highway 128, which connected him to both the coast and his family in Napa, and he was close to the Russian River, where he could fish.

But his condition soon worsened. He heard threatening voices outside the house, people telling him they were going to burn him, his mother said, recounting phone calls where he spoke of his fears.

Tehee was diagnosed with the bipolar type of schizoaffective disorder in 2012. His mother said he suffered from anosognosia, a condition that prevented him from acknowledging his illness.

He agreed to seek help only when Bleuel threatened to cut off financial support, she said.

The unraveling that led to his death started several years earlier. In the summer of 2012, Tehee's illness had him punching holes in his ceiling drywall, looking for a place to secure a rope.

In 2015, there were at least 10 separate incidents where police either came in contact with Tehee or were asked to check on his welfare. Police reports tell the story of a troubled man whose illness was widely known.

On June 7, employees at Cotija's Market hit the “panic alarm” after Tehee attempted to steal beer. He was banned from the store but returned a week later. Two weeks later, on July 2, police responded to a report that Tehee, wearing glasses, a peach-striped shirt and long pants, was harassing customers.

During welfare checks, Bleuel said police could see the squalor Tehee lived in at his Cloverdale home.

Bleuel and Warnock saw this for themselves in the summer of 2015, when the city of Cloverdale ordered them to clean the exterior and the interior of the home. There were broken windows and trash everywhere; torn clothes and shards of glass covered the floors; mice and rat droppings covered kitchen surfaces; “psychotic writings” were scrawled on a wall, she said. There were numerous backpacks, animal bones and bottles inside. Sofas and beds were outside and many other items were up on the roof.

Police and mental health workers told her there was little they could do if he did not want to be helped. She would have to wait until he was a “danger to himself or others.”

That threshold - what the “system” required in order for her to help Tehee - frightened Bleuel to her core, and it came finally in late 2015.

Bleuel, who had once again reported him missing, was informed on Nov. 2 that Tehee had been arrested in Healdsburg for public intoxication and vandalism.

The following day, they drove to his court hearing, hoping this time maybe Tehee could get the help he needed, maybe get on the right medication, possibly hospitalization. But on the way to Santa Rosa, they learned that he had been released.

“We were so frustrated, angry … oh, my God, they had him in their hands and they let him go,” she said. “I was so relieved he was alive, but at the same time I felt like there was an opportunity to get him help, to get him treatment.”

In five weeks, he would be dead.

The last time Bleuel and Warnock saw Tehee was in Cloverdale. He was in good spirits, excited, and said he wanted to cook the turkey he had gotten from a food pantry. Bleuel went to the grocery store for the organic ingredients he had requested, while Warnock helped put up new curtains. Tehee told the couple he liked the new curtains.

“That last visit we felt very hopeful,” she said. “He was in a good place, loving, feeling like we're there to support him still.”

She said she presented Tehee with a contract laying out the conditions he must meet to remain in the house. He signed it and they went out to lunch. She told him it was her “dream” for Tehee to have the house in Cloverdale as his own.

“He said, ‘It's my dream, too,'?” she said.

He hanged himself three days later.

You can reach Staff Writer Martin Espinoza at 707-521-5213 or martin.espinoza@pressdemocrat.com. On Twitter @renofish.

Crisis care: The new mental institutions

Sonoma County has a chronic shortage of psychiatric hospital beds. As as a result, a growing number of mentally ill residents are ending up in local emergency rooms and in the jail system. A three-part series, run on three consecutive Sundays, examines the causes and ramifications of the current state of the county's mental health system, and the people who are impacted the most.

Today - Hospitals: The closure of two psychiatric hospitals in Sonoma County has left a gaping hole.

Aug. 13 - Jail: The Sonoma County Jail has become the largest psychiatric treatment facility in the county.

Aug. 20 - Solutions: Sonoma County explores ways to improve services to people suffering from severe mental illness.

Share your story

We want to hear about your experience with local psychiatric emergency services. What do you do when you or a loved one faces a mental health crisis? Have you or a loved one sat in a hospital bed waiting to be transferred to an out-of-county psychiatric hospital or other mental health facility? Have you or a loved one received psychiatric services in the Sonoma County Jail's mental health unit? Please send a brief account of your experience to Martin Espinoza at martin.espinoza@pressdemocrat.com.

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