PEOPLE v. GHOBRIAL

Appellant’s Reply Brief

Cal.February 25, 2014

$105908 SUPREME COURT COPY IN THE SUPREME COURTOF THESTATE OF CALIFORNIA ) PEOPLE OF THE STATE OF CALIFORNIA, ) ) Plaintiff and Respondent, ) ) v. ) Orange County ) Sup. Ct. No. 98NF0906 Rt JOHN SAMUEL GHOBRIAL, ) SUPREME COU ) FILE Defendant and Appellant. ) ) FEB 25 2014 ) k: “McGuire Cler APPELLANT’S REPLY BRIEF FrankA Deputy Appeal from the Judgmentof the Superior Court of the State of California for the County of Orange HONORABLEJOHN J. RYAN DEATH reNALTY MICHAEL J. HERSEK State Public Defender DENISE ANTON State Bar No. 91312 Senior Deputy State Public Defender ANNE LACKEY State Bar No. 172969 Deputy State Public Defender 1111 Broadway, 10th Floor Oakland, California 94607 Telephone: (510) 267-3300 Fax: (510) 452-8712 Email: anton@ospd.ca.gov lackey@ospd.ca.gov Attorneys for Appellant TABLE OF CONTENTS Page APPELLANT'S REPLY BRIEF ........ 0... .cc ccc ccucceccecccceu. 1 INTRODUCTION 2.0.0... ccc eee c eee cece cece ene eeeeeecee, I I, THE DEATH JUDGMENT MUSTBE REVERSED BECAUSETHE TRIAL COURT VIOLATED GHOBRIAL’S STATE AND FEDERAL CONSTITUTIONAL RIGHTS TO DUE PROCESS AND A RELIABLE DEATH VERDICT BY FAILING TO INITIATE COMPETENCY PROCEEDINGS SUA SPONTE............00ceccceeeeeeee 2 A. The Evidence Before the Trial Court Raised a Bona Fide Doubtas to Ghobrial’s Competence to Stand Trial ........... 0.0.0. cece eee 3 1. The United States and California Supreme Courts Have Held That Evidence of Mental Illness Characterized by a History of “PronouncedIrrational Behavior” and Psychotic Symptomsis Sufficient to Warrant a Competency Hearing ................. 6 2. Respondent Erroneously Conflates the Evidentiary Showing Warranting a Hearing With the Evidentiary Showing Required at the Hearing to Establish a Defendant’s Incompetence ................... 9 3. A Court Must Hold a Competency Hearing Whena Defendant Presents Evidence That His MentalIllness Precludes Him From Accurately Perceiving, Interpreting, and/or Responding to the World Around Him........... 00.00.00 0cecu ee 11 II. Il. IV. TABLE OF CONTENTS Page 4, Evidence Raising a Doubt About a Defendant’s Competence to Stand Trial Must be Considered in the Aggregate . 0...eee eee eee eee [5 B. The Trial Court’s Failure to Suspend Proceedings to Determine Ghobrial’s Competence Requires Reversal of his Conviction .................4. 23 SUBJECTING A DEFENDANT SUFFERING FROM A SEVERE PSYCHOTIC ILLNESS TO A SENTENCE OF DEATH VIOLATESTHEFIFTH, SIXTH, EIGHTH, AND FOURTEENTH AMENDMENTS AND INTERNATIONAL LAW ......... 000: c eee e eee eee 25 NO REASONABLE AND CREDIBLE EVIDENCE OF SOLID VALUE SUPPORTEDTHEFIRST DEGREE MURDER CONVICTION AND THE SPECIAL CIRCUMSTANCEFINDING ...............005. 36 A. Introduction 2.0... cece ccc ee eee eee eee enes 36 B. No Substantial Evidence Supported a Finding That Ghobrial Premeditated and Deliberated ...... 0.0... cece cee eee eee ences 38 C. No Substantial Evidence of Felony Murder WasPresented .......... 2.0... eee eee ee eee 44 D. COMCIUSION . 0... cece cette eens 49 THE TRIAL COURT VIOLATED GHOBRIAL’S RIGHT TO PRESENT A DEFENSE WHENIT REFUSED TO ALLOW DEFENSE WITNESSES TO TESTIFY THAT THE VICTIM SOUGHT OUT THE COMPANIONSHIP OF ADULT MEN ................ 31 il TABLE OF CONTENTS Page VIII. THE PROSECUTOR COMMITTED PREJUDICIAL MISCONDUCT REQUIRING THE REVERSAL OF THE DEATH JUDGMENT................cccececceecee, 57 X. THE CUMULATIVE EFFECTS OF THE ERRORS REQUIRES REVERSAL OF GHOBRIAL’S CONVICTION AND SENTENCE........................ 65 CONCLUSION 2.0...ccc cece cece teen eeennaeeenes 67 CERTIFICATE OF COUNSEL ........ 0... ccc cc cccceccecccceee 68 ATTACHMENT A TABLE AUTHORITIES Page(s) FEDERAL CASES Atkins v. Virginia (2002) 536 U.S. 304 0...cccen e eee nee passim Balfour v. Haws (7th Cir. 1989) 892 F.2d 556 0... cece cc ee cee tte 13 California v. Brown (1987) 479 U.S. 538 ooocceee eee e eee e nnn 35 Chambers v. Mississippi (1973) 410 U.S. 284 0...ccccee ete ene enanes 51 Chavez v. United States (9th Cir. 1981) 656 F.2d 512 0... eee cee eeeeee 5, 15 Colemanv. Saffle (10th Cir. 1990) 912 F.2d 1217 2.cece eee n nee nes 13 Cooper v. Oklahoma (1996) 517 U.S. 348ooetecece eee eee e cece nee 1B Dickey-O 'Brien v. Yates (E.D. Cal. June 12, 2013) 2:07-CV-1241 WBS CKD 2013 WL 2664418 0... icc ccc cee eee eee eet ee eneeees 23 Donnelly v. DeChristoforo (1974) 416 U.S. 637cece eee eben nee eens 65 Drope v. Missouri (1975) 420 U.S. 162 0... ccceee eee eee eee enes passim Dusky v. United States (1960) 362 U.S. 402... eee ccc cect een e ee ne eens 6, 10, 12 -iV- TABLE OF AUTHORITIES Page(s) Edelbacher v. Calderon (9th Cir. 1998) 160 F.3d 582 2.0... ce cc eee tence ees 36 Enmund v. Florida (1982) 458 U.S. 782........ cede eee eee e eee neue eeeetneenneres 33 Godinez v. Moran (1993) 509 U.S. 389 2... ccc cee ence eee eees 11, 12, 24 Graham v. Florida (2010) 560 U.S. 48 10.kccece cece ence eee eee 31, 32 Indiana v. Edwards (2008) 554 U.S. 164 0...ccc e et ete ene teen n enna 14 Jackson v. Virginia (1979) 443 U.S. 307 0... ccccette te ee een ee eeennes 50 Joshua v. Adams (2007) 231 Fed. Appx. 592 1... cece cece ce teens 29, 32, 35 Kennedy v. Louisiana (2008) 554 U.S. 407 0.ccccece eee eee eeweeeeeaes 32 Lafferty v. Cook (10th Cir. 1991) 949 F.2d 1546... ce ec cece eee eaes 13 Loko v. Capps (Sth Cir. 1980) 625 F.2d 1258 2.0... cece ce cee ence en ees 13 Maxwell v. Roe (9th Cir. 2010) 606 F.3d 561 2.0... ec ec cece eee eee nes 21 Moorev. United States (9th Cir. 1972) 464 F.2d 663 2.0... cece eee eee eens 5,15 TABLE OF AUTHORITIES Page(s) Odle v. Woodford (9th Cir. 2001) 238 F.3d 1084 2.0... cece cee tenes 21, 23 Panetti v. Quartermen (2007) 551 U.S. 930... ccc ccc cee eee ee eee ttn t ene 34 Pate v. Robinson (1966) 383 U.S. 375 0...ceeee e ene enee passim Penry v. Lynaugh 492 U.S. 302 1. ccc cece eee eee ee eee eee e eee eens 30 Riggins v. Nevada (1992) 504 U.S.127eeeeee eens 12 Roper v. Simmons (2005) 543 U.S. 551.........decent eee ee eee eee eens passim Smith v. Phillips (1982) 455 U.S. 209 oo.ccece nee e ent eens 60 Strickland v. Francis (11th Cir. 1984) 738 F.2d 1542 2... ec ee eee teen ees 13 Taylor v.Illinois (1988) 484 U.S. 400 2... eee ee eee ee eee one e eee ene eens 51 Thompson v. Oklahoma (1988) 487 ULS. 815 oteee teen eee es 33 United States v. Duncan (9th Cir. 2011) 643 F.3d 1242 0.0... cece eee ee eee eee 23, 24 United States v. Hemsi (2nd Cir. 1990) 901 F.2d 293 0... ccc eee eect cecee eee 13 -Vi- TABLE OF AUTHORITIES Page(s) United States v. Jones (3rd Cir. 2003) 336 F.3d 245...ecec eee eneeee 11 United States v. Stone (E.D. Mich. 2012) 852 F.Supp.2d 820.00... ... cece cee eee 62-63 Washington v. Texas (1967) 388 U.S. 14 0.ccc cee cee etre ene eee n ee enes 51 STATE CASES People v. Allen (1985) 165 Cal.App.3d 616 1.0... . cece ccc cee cece eee eee eee 49 People v. Anderson (1968) 70 Cal.2d 15 0.0 eee cee eect eee eee ees passim People v. Aparicio (1952) 38 Cal.2d 565 1...ccc cee cece eens 7, 8,9, 11 People v. Ary (2004) 118 Cal.App.4th 1016... 0... eee ccc eee eens 5, 18 People v. Benson (1990) 52 Cal.3d 754 2... cece ee cece eee nee ene enes 58 People v. Bolin (1998) 18 Cal.4th 298 oo ccceeeeenee eet e eens 39 People v. Bolton (1979) 23 Cal.3d 208 0.0... ccc ccc eee eee e ee nee e ne eees 63 People v. Castaneda (2011) S51 Cal.4th 1292 coccece ee cnet eens 28 People v. Combs (2004) 34 Cal.4th 821 ..................ence eee eee e eee eeas 39 -Vii- TABLE OF AUTHORITIE Page(s) People v. Danielson (1992) 3. Cal.4th 691 2...cece eee eee n teens 10 People v. Deere (1985) 41 Cal.3d 353 2... cece ee eeeLace e eee ees 10 People v. Edelbacher (1989) 47 Cal.3d 983 oo... eect cence tenet eee e eens 63 People v. Green (1980) 27 Cal.3d Loo. cece cece cent e eee naee 58, 61-62 People v. Guerra (2006) 37 Cal.4th 1067 2.2... c ccc cece cece eee e een e eee eens 46 People v. Hill (1997) 17 Cal.4th 800 0.00. cc cee cece ete eee e eens 61 People v. Holloway (2004) 33 Cal.4th 96 2... ccc cece cece eet ee enn eens 46 Peoplev. Holt (1944) 25 Cal.2d 59 2... ccc cece eee een n een e ne eeee 38 People v. Holt (1997) 15 Cal.4th 618 0... ccc ccc cette eee renee eaes 36 People v. Johnson (1993) 6 Cal.4th 1...ccc cece cee teen eee eens 46 People v. Jones (1991) 53 Cal.3d 1115 2...ccc cece erence teen eens 22 People v. Jones (1997) 15 Cal.4th 119 oo. ccc ccc cee cece renee eens 63 -Vili- TABLE OF AUTHORITIES Page(s) Peoplev. Kelly (1992) 1 Cal.4th 495 oocccece cette ee eee eeees 47 People v. Koontz (2002) 27 Cal.4th 1041 oocccc cece tee e eee e eee enens 8 People v. Laudermilk (1967) 67 Cal.2d 272 0... cece cece ene eee eeeeeenenes 18 People v. Leonard (2007) 40 Cal.4th 1370 2.2... ccc ccc ccc cece eee eeeenenees 15 People v. Lewis (2008) 43 Cal.4th 415 oo. cece ee cece ee ee ee cane eeees 23 People v. Maury (2003) 30 Cal.4th 342 2... ccc cece cece eee e eee eneeeeees 63 People v. Millwee (1998) 18 Cal.4th 96 2...ccc cece eect ee eeeneee 63 People v. Morales (1989) 48 Cal.3d 527 2...ke cece ect e eee n ee neenenecs 47 People v. Pennington (1967) 66 Cal.2d 508 0...cece teen eee eens 13, 18 People v. Pinholster (1992) 1 Cal.4th 865 2... kk cece ccc cece nen e eae nes 63 People v. Raley (1992) 2 Cal.4th 870....cece ccc ence ee eneneees 38 People v. Ramirez (1990) 50 Cal.3d 1158 0... cece cece eect ete ennees 47 -1X- TABLE OF AUTHORITIES Page(s) People v. Redmond (1969) 71 Cal.2d 745 2...cece een e een ennes 38 People v. Redrick (1961) 55 Cal.2d 282 2...ceceeee eee eee 37, 38 People v. Rogers (2006) 39 Cal.4th 826 1.0... eee ccc cece eee teenies 15 People v. Rundle (2008) 43 Cal.4th 76.0... cee ccc cece eee eee |... 46, 48 People v. Samuel (1981) 29 Cal.3d 489 0... cc cece cee ee teen eee nee es 23 People v. San Nicolas (2004) 34 Cal.4th 614 2...ccc cece eee eee eees 63 People v. Sassounian (1986) 182 Cal.App.3d 361 2... cece cece cece ee tenn eee 63 People v. Schmeck (2005) 37 Cal.4th 240 2...cecece cece eee e en nnes 63 Peoplev. Sellers (1988) 203 Cal.App.3d 1042 20...ecccc cece eee nee 47 People v. Silva (2001) 25 Cal.4th 345 2...eee eee eee ete 39 People v. Stanley (1995S) 10 Cal.4th 764 2...eccece tte een eens 36 People v. Stanworth (1974) 11 Cal.3d 588 2...ccccece cece eee eee eee 47 TABLE OF AUTHORITIES Page(s) Peoplev. Stitely (2005) 35 Cal.4th 514 ooccc ccc cece cence eee enes 39 People v. Thomas (1992) 2 Cal.4th 489 occccc cece cece eee e ees 39, 40 People v. Thompson (1990) 50 Cal.3d 134 0...cece teen cence nee nenees 45 People v. Tripp (2007) 151 Cal.App.4th 951 ......ante eee eee e eee nent nents 38 People v. Welch (1999) 20 Cal.4th 701 oo... ccc cc cece cence eenes 10 People v. Whalen (2013) 56 Cal.4th to...eee eee cece e en eeeeaeeanns 36 People v. Williams (1996) 46 Cal.App.4th 1767 2.00... ec c ccc eee cece eeees 51 People v. Wolff (1964) 61 Cal.2d 795.0... cece cece ccc cent ee eeeeenees 18 People v. Young (2005) 34 Cal.4th 1149 2ccccece cece eens 9, 49 People v. Zurinaga (2007) 148 Cal.App.4th 1248 2.0... ccc ce ccc cece ene nees 62 OTHER STATE CASES Commonwealth v. Baumhammers (Penn. 2008) 960 A.2d 59 oo... ccc cece eee ee acne 26, 29 Corcoranv. State (Ind. 2002) 774 N.E.2d 495 oo.ccc eee eee eee eens 27 -xi- TABLE OF AUTHORITIE Page(s) Edwardsv. State (Fla. Ct-App. 2012) 88 So0.3d 368 0.0... cee cee ee eee eee 13 Flowers. v. State (Miss. 2000) 773 So.2d 309 2... ccc ee eee eee eens 36 Matheny v. State (Ind. 2005) 833 N.E.2d 454 2...ccc eee eee eee Lees 29 People v. Mondragon (Colo. Ct.App. 2009) 217 P.3d 936 21... . cece eee cee ee eee eee 13 State v. Hancock (Ohio 2006) 840 N.E.2d 1032 1.0.0... eeetees 29 State v. Hawkins (Idaho Ct.App. 2009) 229 P.3d 379.0... cee cece eee 13 State v. Haycock (N.H. 2001) 766 A.2d 720 0... ce ccc cee cence eee eee nees 13 State v. Ketterer (2006) 111 Ohio St.3d 48 2...cee eee eens 27, 29 State v. Nelson (N.J. 2002) 803 A.2d 1... ieee ec cece cece een e tence nee 27 STATE STATUTES Cal. Evid. Code § B51 Lice ccc cece eee eee eee e nes 51 -Xii- TABLE OF AUTHORITIES Page(s) Cal. Pen. Code § 190.2, subdiv. (a) (17) (5) oo... cece eee ee 44 190.2, subdiv. (a) (17) (E) ........ 0.0 e eee 53 190.4, subdiv. (e) ......... 0.0. cee eee 56 288 6. eee cece ec eee e nes passim 288, Subd. (a) 6... eeeeens 44 1368 2... eee eee eee 7, 8, 18 1368, subdiv. (a) ........ 0... eee eee 24 1368, subdiv. (b) ....... 0.0 eee eee 21 Welf. & Inst. Code § ro a)|21 OTHER STATE STATUES Conn.Pen. Code, Ch. 952, § 53-a-46a (h) .........beeen ence nea 26 JURY INSTRUCTIONS CALJIC No. 10.41 oo.cece eee 44-45 OTHER AUTHORITIES Bonnie, The Competence ofCriminal Defendants: Beyond Dusky and Drope (1993) 47 U. Miami L. Rev. 539 ......... cece cee eee 12, 24 DSM-IV-TR(4th ed. text revision 2000) .......... cee eee 2, 13, 14, 29 Fleischaker, Dead Man Pausing: The C.ontinuing Need for a Nationwide Moratorium on Executions (2004) 31 Human Rights 14 .......... 00... c cece eee eeee, 31 Izutsu, Applying Atkins v. Virginia to Capital Defendants With Severe MentalIllness (2005) 70 Brook. L. Rev.995 ........... cece eeu eee ewes 31 -Xili- TABLE OF AUTHORITIE Page(s) Francis v. Jamaica, Communication No. 606/1994 U.N.H.C.R. (12 August 1994), available at ......... ccc eee ee ee eee eens 27 Jacobs,et al., Competence-Related Abilities and Psychiatric Symptoms: An Analysis of the Underlying Structure and Correlates of the MACCAT-CA and the BPRS (2008) 32 Law & Hum. Behav. 64 ......... cece cece cee 2 Maroney, Emotional Competence, “Rational Understanding,” and the Criminal Defendant (2006) 43 Am. Crim. L. Rev. 1375 00... cece cece eee eee 12 Mounts, Premeditation and Deliberation in California: Returning to a Distinction Without a Difference (2002) 36 U.S.F. L. Rev. 261 2... cee cece tee eee ees 39 Roget’s International Thesaurus (6th ed. 2001) 2... cece cece tect ee eect eee eee 10 Ryan & Berson, Mental Illness and the Death Penalty (2006) 25 St. Louis U. Pub. L. Rev. 351.6... cece eee eee 14 Sadock & Sadock, eds., Kaplan & Sadock’s Comprehensive Textbook of Psychiatry © (8th ed. 2005) Vol. TW...ccc cece eee eee 11 Slobogin, Mental Iliness and the Death Penalty (2000) 1 Cal. Crim. L. Rev. 3 0.0... ec ce eee eee 31 Slobogin, What Atkins Could Mean for People with MentalIllness (2003) 33 N.M.L. Rev. 293 wo... cece cece ce tence teens 32 -xiv- TABLE OF AUTHORITIES Page(s) The American Heritage Dictionary of the English Language (Sthed. 2011) oo... cece ccc cece cece eee eee nee. 16 U.N. Commission on Human Rights, Question of the DeathPenalty, U.N. Doc. E/CN.4 (1999-2004) 2... ccc ccc eee ee eee 28 -XV- IN THE SUPREME COURTOF THE STATE OF CALIFORNIA ) PEOPLE OF THE STATE OF CALIFORNIA, _) ) Plaintiff and Respondent, ) No. S105908 ) V. ) (Orange County Sup. ) Ct. No. 98NF0906) JOHN SAMUEL GHOBRIAL, ) ) Defendant and Appellant. ) , ) ) APPELLANT’S REPLY BRIEF INTRODUCTION The Attorney General has struggled to preserve this conviction by ignoring pertinent facts, and dismissingall error as harmless. Respondent’s efforts, however, cannotalter the fact that grievous error occurred, and the convictions and death judgment mustbe reversed.' ‘Appellant has found it unnecessary to reply to all the arguments in the response sincerespondentraises very little that is not fully addressed in the opening brief, and appellant has only addressed respondent’s contentions that require further discussion for the proper determination of the issues raised on appeal. Appellant specifically adopts the arguments presented in her opening brief on each and every issue, whether or not discussed individually below. Appellant intends no waiver of any issue by not expressly reiterating it herein. I. THE DEATH JUDGMENT MUST BE REVERSED BECAUSE THE TRIAL COURT VIOLATED GHOBRIAL’S STATE AND FEDERAL CONSTITUTIONAL RIGHTS TO DUE PROCESS AND A RELIABLE DEATH VERDICT BY FAILING TO INITIATE COMPETENCY PROCEEDINGS SUA SPONTE Psychotic disorders, which include schizophrenia and schizoaffective disorder,’ “are significantly correlated with incompetence.” (Jacobs,etal., Competence-Related Abilities and Psychiatric Symptoms: An Analysis of the Underlying Structure and Correlates of the MACCAT-CA and the BPRS (2008) 32 Law & Hum.Behav.64, 65 (hereinafter Competence-Related Abilities).) As outlined in detail in the openingbrief, the trial court had before it abundant evidence, which, when considered in the aggregate, was more than sufficient to raise a reasonable doubt that Ghobrial suffered from the symptomsofan intractable psychotic disorder that impaired his ability to rationally understand the proceedings, consult with counsel, and assist in the preparation of his defense against capital charges. (AOB5-7, 30-45, 56-71.) Respondentdoesnot dispute the facts set forth in the openingbrief. Indeed, respondent attempts to refute Ghobrial’s claim by citing virtually the same evidenceas that cited by Ghobrial in support of his claim (RB 23- 48), thereby conceding its accuracy. Respondent nevertheless asserts that Ghobrial’s claim fails for four reasons: (1) the evidence of Ghobrial’s mentalillness presented during trial did not amountto substantial evidence *The Diagnostic and Statistical Manual of Mental Disorders (DSM) applicable at the time of Ghobrial’s trial, the DSM-IV-TR,includes schizoaffective disorder in the chapter entitled “Schizophrenia and Other Psychotic Disorders.” (DSM-IV-TR (4th ed. text revision 2000), p. 297.) 2 of mental incompetencyto standtrial; (2) no mental health expert gave an opinion that Ghobrial was incompetent; (3) Ghobrial’s trial counsel never declared a doubt about his mental competency; and (4) the trial court’s observations of Ghobrial did not provide any indication of mental incompetency. (RB 49, 57.) These arguments do not withstand scrutiny. A. The Evidence Before the Trial Court Raised a Bona Fide Doubtas to Ghobrial’s Competence to Stand Trial Thetrial court heard evidence that two days after Ghobrial’s arrest and admission to the Orange County Jail, jail psychiatrist Dr. Jasminka Depovic diagnosed him as suffering from a psychotic disorder not otherwise specified (NOS). (10 RT 2428-2430.) Thereafter, Ghobrial was examinedat least once a month, and frequently much moreoften, by multiple membersofthe jail mental health staff. Over the course of the next three and a half years, while his diagnosis was changed from psychotic disorder NOS to the morespecific schizoaffective disorder, Ghobrial never went a month without being plaguedbyat least one, and often more, of the following symptoms: auditory, visual, and olfactory hallucinations; delusional thought processes;labile affect; grossly disorganized behavior, including decompensation in grooming andself-care; suicidal ideation and delusional suicide attempts, including tying a string and sheet aroundhis penis in the belief that he would stop breathing;otheracts of self- mutilation; depression; blunted affect; and internal preoccupation. (See AttachmentA.) Ghobrial also wasprescribed anti-psychotic medication shortly after his arrival at the jail and continued on multiple anti-psychotics and anti- depressants of varying doses throughouthis incarceration, including Haldol, Mellaril, Zyprexa, Seroquel, Depakote, Risperdal, Ativan, Prozac, and 3 Paxil. (See Attachment A.) Dr. Jose Flores-Lopez, a forensic psychiatrist (10 RT 2502) who,at the time of his testimony, was the chief psychiatrist at the Norco Prison (10 RT 2475), initially questioned whether Ghobrial might -be malingering; in April 1999, however, he raised a doubt as to Ghobrial competence,noted that he “needed a competency assessment,” and recommendedthathe besent to a state mental hospital for evaluation. (10 RT 2492.) On December17, 2001, Flores-Lopeztestified before the jury that Ghobrial suffered from chronic schizoaffective disorder, “meaning that he was going to haveit for the rest of his life.” (10 RT 2498.) Neuropsychological testing administered to Ghobrial by forensic neuropsychologist Dr. Ali Kalechstein in early 2001, showed both that Ghobrial put forth his best efforts and was not malingering, and,interalia, that Ghobrial’s executive functioning tested in the impaired range in three out of the four executive functioning tests, placing him in the 1st percentile, and borderline impaired in the fourth, which placed him in the 6th percentile. (10 RT 2525-2548.) Kalechstein testified that Ghobrial’s test results were consistent with a psychotic illness, such as schizophrenia or schizoaffective disorder. (10 RT 2546.) Respondent’s general argumentthat “the evidence of Ghobrial’s mental illness [and the administration of anti-psychotics and anti- depressants] presented during histrial did not include any substantial evidence of mental incompetencyto standtrial” (RB 49) implies that before a hearing is even warranted, a defendant must present evidence that discloses a present inability because of mental illnessto participate rationally in the proceedings. In fact, the only showing necessary to trigger a hearing is evidenceraising a reasonable doubt as to the defendant’s competence.’ At a competencyhearing, a defendant must establish incompetence by a “preponderanceof the evidence.” (§ 1369, subd.(f).) Evidence that is substantial enoughto raise a reasonable doubtas to a defendant’s competence maynotbe sufficient to sustain a finding of incompetence by a preponderanceof the evidence. To the extent that respondent, and this Court’s opinions cited by respondent, equates the quantum of evidence necessary to trigger a competency hearing with the quantum of evidence necessary to prevail at such a hearing, respondent’s argumentviolates the principles established in Pate v. Robinson (1966) 383 U.S. 375, and Drope v. Missouri (1975) 420 U.S. 162. I Hl 3As discussed in the opening brief (AOB 52-54),it bears reemphasizing that whenthetrial court is deciding whether competency proceedings are warranted, the court is not deciding the ultimate issue,i.e. whether the defendantactually possesses the necessary cognitive, emotional, and communicative capabilities. Rather, the court simply is answering the threshold question of whether there is any evidence which, assumingits truth, raises a reasonable doubt about the defendant’s competency. (People v. Ary (2004) 118 Cal.App.4th 1016, 1021 [“Importantly, we are not deciding here whether defendantis, in fact, competentto stand trial, but whether there was evidencesufficientto raise a reasonable doubt as to defendant’s competenceto stand trial. We conclude there was”]; Moore v. United States (9th Cir. 1972) 464 F.2d 663, 666) [sole function oftrial court in applying Pate’s substantial evidencetestis to decide whetherthere is any evidence raising a reasonable doubtas to defendant’s competence]; Chavez v. United States (9th Cir. 1981) 656 F.2d 512, 516 [“We review the record to see if the evidence of incompetence was suchthat a reasonable judge would be expected to experience a genuine doubtrespecting the defendant’s competence’’].) 5 1. The United States and California Supreme Courts Have Held That Evidence of Mental Illness Characterized by a History of “Pronounced Irrational Behavior’? and Psychotic Symptomsis Sufficient to Warrant a Competency Hearing The United States Supreme Court in Pate v. Robinson, supra, 383 U.S. 375, addressed a claim that the trial court’s failure to hold a hearing pursuantto the Illinois statute requiring the judge to conduct a hearing when presented with evidence raising a bona fide doubtas to the defendant’ s competenceto standtrial deprived the defendant of due process. The Supreme Court had no quarrel with the statutory procedures enacted by Illinois to ensure that prior to being putto trial a defendant meets the standards for competencyarticulated in Dusky v. United States (1960) 362 U.S. 402,that is, whether the defendanthas sufficient present ability to consult with his lawyer with a reasonable degree of rational understanding and whetherhe hasa rational as well as factual understanding of the proceedings against him. (Pate v. Robinson, supra, 383 U.S.at p. 385.) The Supreme Court instead focused on the evidence before the trial court and concludedthat the errorlay in the trial and reviewing courts’ failure to find the “uncontradicted testimonyof [the petitioner’s] history of pronouncedirrational behavior”sufficient to warrant resort to the hearing into his competency. (Jd. at pp. 385-386.) Although the Supreme Court’s decision turned on the facts, the High Court did not identify with any specificity, other than reference to the petitioner’s “history of pronounced irrational behavior,” the nature and quantum of evidence mandating a hearing. In Drope v. Missouri, supra, 420 U.S. 162, the Supreme Court’s next opinion addressing whetherthe trial court heard evidencesufficient to concludethat the defendant was entitled to a competency hearing, the Court acknowledged the Pate Court’s disinclination to “prescribe a general standard with respect to the nature or quantum of evidence necessary to require resort to an adequate procedure.” (Jd. at p. 172.) In Drope,as in Pate, the Court recognized the constitutional adequacy of the state’s statutory procedures to determine competence, but focused on the lower courts’ determination that the evidence presented failed to establish “reasonable causeto believe that the accused ha[d} a mental disease or defect excluding fitness to proceed.” (Drope v. Missouri, supra, 420 U.S. at p. 173.) The Court again concludedthat the lower courts erred in finding the facts relevantto the petitioner’s competency inadequate to warrant a hearing, but once moredeclinedtosetstrict standards for the quantum or type of evidence a defendant must present before being entitled to a competency hearing. Stated the Court: “There are, of course, no fixed or immutable signs which invariably indicate the need for further inquiry to determinefitness to proceed; the question is often a difficult one in which a wide range of manifestations and subtle nuances are implicated.” (/d.at p. 180.) In People v. Aparicio (1952) 38 Cal.2d 565 — an opinion presaging Dusky v. United States by eight years and anticipating the decisions in Pate v. Robinson and Drope v. Missouri — this Court found that thetrial court erred in failing to inquire into the defendant’s sanity pursuant to Penal Code section 1368* where one psychiatrist who had examined the defendant testified that “the defendant was suffering from delusions of persecution “The Aparicio Court refers to “sanity” to standtrial rather than competency in keeping with language of section 1368 applicable in 1952. (People v. Aparicio, supra, 38 Cal.2d at p. 567, quoting section 1368.) 7 and hallucinations; another stated that he was ‘paranoid and delusional’; while a third described him as possibly psychotic from a psychiatric point of view even though he wasnotlegally insane.”* (People v. Aparicio, supra, 38 Cal.2d at p. 569.) As with Pate v. Robinson and Drope v. Missouri, notably absent from the evidence beforethe trial court was any evidence specifically stating that the defendant could not understand the nature and purposeof the proceedingsor assist in his own defensein a rational manner. Nevertheless, this Court concluded that the evidence presented, which the Court characterized as “a continuous courseofirrational conduct” — necessitated a hearing. (People v. Aparicio, supra, 38 Cal.2d at p. 570.) The holdings of People v. Aparicio, Pate v. Robinson, and Dropev. Missouri establish that when a defendant presents evidenceraising a reasonable doubtasto his ability to rationally understand the proceedings, communicate with counsel, and assist in his own defense,heis entitled to a hearing, but that the evidence itself need not include documentary or testimonial commenting specifically on the defendant’s competence. The evidence sufficient to raise a reasonable doubtas to a defendant’s incompetence need not be couchedin the terms of incompetence. H HI °People v. Aparicio is cited as authority in People v. Koontz for the proposition that “[w]hen there exists substantial evidence of the accused’s incompetency,a trial court must declare a doubt and hold a hearing pursuantto section 1368 even absent a requestby either party.” (Peoplev. Koontz (2002) 27 Cal.4th 1041, 1064, citing Aparicio, supra, 38 Cal.2d at p. 568.) 2. Respondent Erroneously Conflates the Evidentiary Showing Warranting a Hearing With the Evidentiary Showing Required at the Hearing to Establish a Defendant’s Incompetence Respondent’s claim that Ghobrial must present evidencetothetrial court specifically stating that he currently is incapableofrationally understanding the proceedings, communicate with counsel, and assistin his own defense prior to being afforded a hearing to determine exactly whether he possess those very capabilities is an unconstitutional reading of Pate v. Robinson, supra, 383 U.S. 375, and Drope v. Missouri, supra, 420 U.S. 162. (See also People v. Aparicio, supra, 38 Cal.2d at p. 570 [evidence presenting continuouscourse ofirrational conduct requires competency hearing].) As noted above, respondentcontests neither the credibility of the evidence presented to the trial court nor the severity of Ghobrial’s symptoms; respondent’s disagreementis with the inferences to be drawn therefrom. (See Drope v. Missouri, supra, 420 U.S. at pp. 174-175 [no dispute as to the evidence possibly relevantto petitioner’s mental condition; rather, dispute concerns inferences to be drawn and whetherthe failure to make further inquiry into petitioner’s competence denied petitionera fair trial].) In fact, respondentfails to make any inferences from the evidence before the trial court, and simply asserts repeatedly that Ghobrial has failed to present “substantial evidence of incompetence” because the court heard no testimony specifically finding that Ghobrial was incompetent. (RB 51, 53-55.) | Respondentstates that “evidence of mentalillness aloneis insufficient to raise a doubt as to Ghobrial’s competency” (RB 51) — an uncontroversial proposition (see AOB 57). Respondentrelies on People v. Young, wherethe court found that a psychologist’s testimony about defendant’s mental condition is insufficient “when he did notrelate his finding in terms ofdefendant’s competency to standtrial.” (RB 51, citing People v. Young (2005) 34 Cal.4th 1149, 1218, italics added.) Respondent also relies on People v. Welch, where the Court explained that moreis necessary than that defendant is psychopathic “with little reference to defendant's ability to assist in his own defense.” (RB 51, citing People v. Welch (1999) 20 Cal.4th 701, 742, italics added.) Similarly, respondent asserts that “there was no testimonythat any of the prescribed medications interfered with his ability to understand the proceedingsorto assist with his defense.” (RB 52, citing People v. Danielson (1992) 3 Cal.4th 691, 726- 728, italics added.) Respondentalso asserts that “[e]vidence that merely raises a suspicion’ that the defendant lacks present sanity or competence but does notdisclose a present inability because ofmentalillness to participate rationally in the trial is not deemed ‘substantial’ evidence requiring a competence hearing.” (RB 51, citing People v. Deere (1985) 41 Cal.3d 353, 358, italics added.) Respondent’s reasoning erroneously conflates the evidentiary showing necessitating a hearing to determine a defendant’s competenceto standtrial with the evidentiary showing required at the hearing to establish the defendant’s incompetence. As demonstrated above, respondent’s °Roget’s International Thesaurusidentifies “doubt” as a synonym of “suspicion.” (Roget’s International Thesaurus, (6th ed. 2001) p. 680.) Thus, this Court’s assertion can be read as: “Evidence that merely raises a [doubt] that the defendantlacks present... competence . . . is not deemed ‘substantial’ evidence requiring a competence hearing.” Such a reading violates the the holdings of Dusky, supra, 362 U.S. at p. 402, andits progeny. 10 position eviscerates the protections guaranteed to potentially incompetent defendants established in Pate v. Robinson, supra, 383 U.S. 375, Dropev. Missouri, supra, 420 U.S. 162, and People v. Aparicio, supra, 38 Cal.2d at p. 570. 3. A Court Must Hold a Competency Hearing When a Defendant Presents Evidence That His MentalIllness Precludes Him From Accurately Perceiving, Interpreting, and/or Responding to the World Around Him The evidence sufficient to raise a reasonable doubtas to a defendant’s competenceto stand trial makesclear that “competence” is not a diagnostic category with a checklist of symptomsor behaviors that, when present, manifest incompetence and when absent, demonstrate competence. Each case is unique (United States v. Jones (3rd_ Cir. 2003) 336 F.3d 245, 256-57, citations omitted [court must examine the unique circumstances of the case]), and the defendant’s functional abilities must be considered in the context of the particular case or proceedings. (See Sadock & Sadock,eds., Kaplan & Sadock’s Comprehensive Textbook of Psychiatry (8th ed. 2005) Vol. II, p. 3983 [an individual who is incompetentto standtrial in a complicated tax fraud case may not be incompetentto standtrial on a simple misdemeanor charge].) A trial court must considerall relevant evidencein the aggregate, but also recognize “that even one of the [relevant] factors standing alone may, in some circumstances, be sufficient.” ([bid.) “(T]he crucial componentof the inquiry [into a defendant’s competenceto standtrial] is the defendant’s possession of a ‘reasonable degree of rational understanding.’ In other words, the focus of the Dusky formulation is on a particular level of mental functioning.” (Godinez v. il Moran (1993) 509 U.S. 389, 404 (conc. opn. of Kennedy,J.), citing Dusky, supra, 362 U.S. 402.) At whatever stage competence is examined,“the proper inquiry is whether [the defendant] is capable of makingrational decisions in service of [his or her] defense.”’ (Maroney, Emotional Competence, “Rational Understanding,” and the Criminal Defendant (2006) 43 Am. Crim. L. Rev. 1375, 1382.)® At the most basic level, a defendant must have sufficient contact with reality to be deemed competent to standtrial. “Tt is beyond dispute that the Supreme Court’s legal definition of competency . . . mandates the conclusion that a defendant lacks the requisite rational understanding if his mental condition precludes him from perceiving accurately, interpreting, and/or responding ’This author and others have attempted to formulate a more concrete definition of the ability to communicate with the defendant’s lawyer with a “reasonable degree of rational understanding” and “a rational as well as factual understanding of the proceedings” by referring to competence as “decisional competence.” (See also Bonnie, The Competence of Criminal Defendants: Beyond Dusky and Drope (1993) 47 U. MiamiL.Rev. 539, 567.) 8A defendant competent enoughto standtrial must possesssufficient “mental functioning” to make rational decisions about, inter alia, whether to waivethe privilege against compulsory self-incrimination by taking the witnessstand;if the option is available, whether to waivethe rightto trial by jury; in consultation with counsel, whether to waive the right to confront his accusers by declining to cross-examine witnesses for the prosecution; whether and how to put on a defense and whetherto raise one or more affirmative defenses. (Godinez v. Moran, supra, 509 U.S.at pp. 398-399; see also Riggins v. Nevada (1992) 504 U.S. 127, 139-140 (conc. opn. of Kennedy,J.) [the requirement of competenceat trial is the foundation upon whichthe other constitutional rights afforded the accusedattrial gain meaning]; Cooper v. Oklahoma (1996) 517 U.S. 348, 364 [“[A]n erroneous determination of competence threatens a ‘fundamental componentof our criminal justice system’ — the basic fairnessofthetrial itself.’’].) 12 appropriately to the world around him.” (Lafferty v. Cook (10th Cir. 1991) 949 F.2d 1546, 1551 [sufficient contact with reality is the “touchstone for ascertaining the existence of a rational understanding”], citing Colemanv. Saffle (10th Cir. 1990) 912 F.2d 1217, 1227.)’ Whenevaluatedin light of the specific facts available to thetrial court, respondent’s assertion that Ghobrial failed to present evidence sufficient to raise a reasonable doubtas to his competenceto standtrial against capital charges — that is, his ability to think and respondrationally to the world around him — simply cannot be credited. As discussed above and in detail in the opening brief (AOB 30-45, 54-67), Ghobrial suffered from the time of his arrest and throughoutpretrial proceedings andtrial — and continues to suffer from — either schizoaffective disorder (AOB 57), which is characterized by symptomsof both schizophrenia and a major mood disorder (DSM-IV-TR,Diagnostic criteria for 295.70 Schizoaffective _ Disorder, p.323), or schizophrenia, paranoid or disorganized type (AOB 57- 58). The characteristic symptomsof both schizoaffective disorder and schizophrenia are delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, and negative symptoms such as *Other courts findingthat“sufficient contact with reality”is the touchstone of competencyinclude United States v. Hemsi (2nd Cir. 1990) 901 F.2d 293, 296; Balfour v. Haws (7th Cir. 1989) 892 F.2d 556, 561; Strickland v. Francis (11th Cir. 1984) 738 F.2d 1542, 1551-1552; see also Loko v. Capps (5th Cir. 1980) 625 F.2d 1258, 1267; State v. Hawkins (Idaho Ct.App. 2009) 229 P.3d 379, 383; People v. Mondragon (Colo. Ct.App. 2009) 217 P.3d 936, 940; State v. Haycock (N.H. 2001) 766 A.2d 720, 722; Edwardsv. State (Fla. Ct.App. 2012) 88 So.3d 368, 371; see also People v. Pennington (1967) 66 Cal.2d 508, 514 [psychologist’s testimony that defendant suffering from an acute mental sickness in which he was delusional and out of contact with reality sufficient evidence to warrant a hearing].) 13 affective flattening (restrictions in expression), alogia (restrictions in fluency of thought and speech), and avolition (restrictions in goal-oriented behavior). (DSM-IV-TR,Diagnostic criteria for Schizophrenia, p. 312.) Every one of these symptomssignificantly interfered with Ghobrial’s grasp of reality. “Actively psychotic individuals are typically far more impaired than individuals with mild mental retardation in the areas of understanding and processing information, logical and rational communication, abstraction, logical reasoning, and impulse control. Delusions and hallucinations typically severely compromise the psychotic individual’s ability to appreciate the meaning of one’s environment, including the motives and meaningsof others’ behavior .... Severe perceptual distortion is not uncommonin schizophrenia.” (Ryan & Berson, Mental Illness and the Death Penalty (2006) 25 St. Louis U. Pub. L. Rev. 351, 366.) As noted above, symptomsof psychosis are “significantly negatively correlated with . . .competence-related abilities.” (Competence-Related Abilities, supra,at p. 75.) Although Ghobrial’s florid psychotic symptomsat times abated, he never went symptom free. (Attachment A; see also AOB 57, citing 10 RT 2305 [normal for disease to fluctuate over time]; and Indiana v. Edwards (2008) 554 U.S. 164, 175 [“Mental illness itself is not a unitary concept. It varies in degree. It can vary over time. It interferes with an individual’s functioning at different times in different ways”].) Respondent’s own nearly twenty-six page statement of facts was devoted to the testimony of Ghobrial’s father and the twenty mental health professionals who observedor assessed Ghobrial in the Orange County Jail. It is also a reasonably accurate chronicle of Ghobrial’s long history of erratic behavior; his poor social, educational, and occupational functioning; and his psychiatric treatment in Egypt, including electro-convulsive therapy 14 and unsuccessful treatment with psychiatric medications. Respondent also describes from the point of Ghobrial’s arrest and onward, his auditory and visual hallucinations, delusions, delusional suicide attempts, otherself- harming behavior, profound neglect of hygiene, and other psychotic symptomsand disordered thoughts that substantially impaired his contact with reality. (RB 18-20; 23-48.) On respondent’s facts alone, a reasonable doubt existed as to whether Ghobrial could rationally understand the proceedings, communicate with counsel, and assist in his own defense. 4. Evidence Raising a Doubt About a Defendant’s Competence to Stand Trial Must be Considered in the Aggregate Respondentalso parses the evidence presentedat trial into discreet symptomsor behaviors and then argues how eachindividual symptom is insufficient to raise a doubt. (See e.g. RB 51 [Evidence of mentalillness aloneis insufficient to raise a doubt as to Ghobrial’s competency”], citing People v. Rogers (2006) 39 Cal.4th 826, 849); and RB 54 [“A person with significant brain damage may be nonetheless be competentto standtrial’’], citing People v. Leonard (2007) 40 Cal.4th 1370, 1415-1416.) Respondent’s failure to consider the indicia of Ghobrial’s incompetence in the aggregate violates the mandate articulated in Drope v. Missouri. (Drope v. Missouri, supra, 420 U.S. at pp. 179-180 [state courts failed to give insufficient attention to the aggregate of indicia of petitioner’s incompetence]; see also Moore, supra, 464 F.2d at p. 666; Chavez, supra, 656 F.2d at p. 518 [In determining whetheror notthere is a substantial doubt, the trial judge must evaluate all the evidence and evaluate the probative value of each piece of evidencein light of the others”].) Respondentasserts that “[n]Jone of the mental health expertstestified that they had examined Ghobrial and found him to be incompetentto stand 15 trial.” (RB 53.) In the next sentence respondent acknowledges “Dr. Girgis testified that Ghobrial’s hallucinations interfered with his ability to communicate”(RB 53,citing 11 RT 2599, 2601), but goes on to make the contradictory claim that “Dr. Girgis’s testimony said nothing about Ghobrial’s competenceto standtrial” (RB 53). “Hallucinations” are defined as the “[p]erception of visual, auditory, tactile, olfactory, or gustatory experiences without an external stimulus and with a compelling sense oftheir reality, usually resulting from a mental disorder.” (The American Heritage Dictionary of the English Language (5th ed. 2011)at p. 793.) Whenan individual suffers from false and unreal perceptionsthat the individual believes to be real and which interfere with the individual’s ability to communicate, a reasonable doubt exists that the individual will be able to able to communicate with counsel andassist in his defense in a reasonably rational way. Dr. Girgis described symptomsraising a doubt as to Ghobrial’s competence; that he never wasaskedbytrial counsel to opine specifically on Ghobrial’s competence does nothing to diminish the weight of his testimony. Respondent’s dispute with the inferences to be drawn from Dr. Flores-Lopez’s testimony are equally weightless and demonstrably false. Dr. Flores-Lopez was the only forensic mental health expert to examine Ghobrial and therefore was the one expert well versed in competency requirements. Respondent concedesthat Flores-Lopeztestified that Ghobrial’s psychotic illness led him to doubt Ghobrial’s competence and recommenda full assessment as to Ghobrial’s competence. While acknowledging that Flores-Lopez specifically testified that Ghobrial “needed a competency hearing” (RB 54,citing 10 RT 2492-2493), respondentgoes on to claim that “Dr. Flores-Lopez’s testimony wasbased 16 on his examination of Ghobrial in 1999. Nothingin his testimony suggests that Ghobrial was incompetentat the time oftrial in November - December 2001.” (RB 54.) In fact, Flores-Lopez first described the symptomsof Ghobrial’s psychosis, including his responding to auditory hallucinations and an inability to focus on their conversation, in early April 1998 (10 RT 2477), diagnosed Ghobrial as suffering from psychosis NOS in December 1998 (10 RT 2484-2486), and updated Ghobrial’s diagnosis to chronic schizoaffective disorder in September 1999 (10 RT 2497-2498). In September 2000, Flores-Lopez characterized Ghobrial as “chronic and responding to stressors and having bizarre affect.” ([bid.) Flores-Lopez left the employ of the Orange County Jail around this same time, but affirmed his conclusionattrial that Ghobrial suffered from schizoaffective disorder. Dr. Flores-Lopeztestified on December 17, 2001, that Ghobrial suffered from chronic schizoaffective disorder, “meaning that he was going to have it for the rest of his life.” (10 RT 2498.) Atthe close of his testimony, Dr. Flores-Lopez was asked: Q: Did you end up agreeing with the diagnosis of schizoaffective disorder? A: Yes, I did. Q: Do you continue to agree with that diagnosis? A: Yes, I do. (10 RT 2501.) Respondent’s assertion that “[nJothing in his testimony suggests that Ghobrial was incompetentat the time oftrial in November- December 2001” (RB 54) is controverted by the record. Respondentstates that “Ghobrial’s claim of error is belied by the fact that . .. no mental health expert ever gave an opinion that he was incompetent.” (RB 57.) To the extent that respondentis arguing that a mental health expert musttestify that a defendant is incompetent before a 17 hearing to determine competency is warranted, respondent’s efforts to impose a standard higher than that outlined both in Pate v. Robinson and Dropev. Missouri and mustbe rejected. Although expert testimonythat a defendantis incompetent can certainly constitute substantial evidence triggering the requirementof a hearing into the defendant’s competence to stand trial (see People v. Pennington, supra, 66 Cal.2d at p. 519), the absence of a mental health expert’s opinion does not obviate the need for a hearing if other evidence — documentary or testimonial — raises a reasonable, genuine, or good faith doubt as to the defendant’s competence. (See People v. Ary, supra, 118 Cal.App.4th at p. 1024 [expert testimony that a defendant is incompetent may constitute substantial evidence, butit is not required].) “[T]he question as to what constitutes such substantial evidence in a proceeding under section 1368 ‘cannot be answered by a simple formula applicable to all situations.’” (People v. Laudermilk (1967) 67 Cal.2d 272, 283, quoting People v. Wolff (1964) 61 Cal.2d 795, 805.) Requiring the opinion of a mental health professionalthat a defendantis incompetent prior to ordering a hearing intolerably risks that an incompetent defendantwill be putto trial simply because neitherthetrial court nor counsel, or both — as in Ghobrial’s case — ever posed the relevant question to a competent mental health professional. (See Cooperv. Oklahoma (1996) 517 U.S. 348, 364 [“For the defendant, the consequences of an erroneous determination of competenceare dire”’].) The testimony of a mental health expert is not the sine qua non of a reasonable doubt regarding a defendant’s competencyto standtrial. In neither Pate v. Robinson nor Drope v. Missouri did a mental health professional testify regarding the defendants’ current competencyto standtrial, and nothing in either opinion remotely suggests that the United States Supreme Court 18 meant to impose such a requirementbefore a competency hearing was warranted. In Pate v. Robinson, the Supreme Court held that the testimony of four lay witnesses that petitioner was insane andhis history of pronounced irrational behavior wassufficient to require the trial court to hold a hearing. (Pate v. Robinson, supra, 383 U.S. at p. 385.) In Drope v. Missouri, the Court noted that Pate did not “prescribe a general standard with respect to the nature or quantum of evidence necessary to require resort to an adequate procedure.” (Drope v. Missouri, supra, 420 U.S. at pp. 172-173.) The petitioner in Drope had been examinedpretrial by a psychiatrist who prepared a report containing descriptions of symptomsthat the Court characterized as “suggesting competence, such as the impressions that petitioner did not have ‘any delusion, illusions, hallucinations . . .” was ‘well oriented in all spheres,’ and was able to answer questionstesting judgment.” (/d. at p. 175.) The Court went on to note, however, that the report also contained contrary data showingthat the petitioner, although cooperative in the examination, had a difficult time participating and relating, and was markedly circumstantial and irrelevant in his speech. The report also described “episodic irrational acts” and contained diagnoses of “[b]orderline mental deficiency” and “{cJhronic anxiety reaction with depression.” (/bid.) The Court specifically noted thatit did “not appear that the examining psychiatrist was asked to address himself to medicalfacts bearing specifically on the issue of petitioner’s competenceto standtrial, as distinguished from his mental and emotional condition generally.” (/d. at p. 176.) Rather than finding this omission fatal to the petitioner’s claim, the Court evaluated the nature of the symptoms describedin the report, which — combined with the testimony of petitioner’s wife regarding his erratic and 19 violent behavior and his suicide attempt — “created a sufficient doubtof his competenceto standtrial to require further inquiry on the question.” (Jd.at p. 180.) The Court went on: The import of our decision in Pate is that evidence of a defendant’s irrational behavior, his demeanorattrial, and any prior medical opinion as to competenceareall relevant in determining whether further inquiry is required, but even one factor standing alone, may, in some circumstances, be sufficient. (Drope v. Missouri, supra, 420 U.S.at p. 180.) Respondent’s discussion of the inferences to be drawn from Ghobrial’s suicidal ideation, multiple suicide attempts, and frequentself- mutilation are as oblique as her other arguments. Respondent recognizes that “actual suicide attempts or ideation may, in combination with other factors, constitute substantial evidence raising a doubt as to mental competenceto standtrial” (RB 55, italics added), but continues with an argument wholly untethered to the record by claiming Ghobrial’s suicidal and self-harming thoughts and behavior were unaccompanied by “bizarre behavior, testimony of a mental health professional as to competence, or any indication of an inability to understand the proceedingsor to assist counsel.” (RB 55.) Respondent’s ownrecitation of examples of Ghobrial self-harming behavior include numerous examples of what would qualify as “bizarre behavior” under any definition. Respondent recounts Ghobrial’s multiple efforts throughout the three years and a half years of pre-trial incarceration to commit suicide by tying astring or sheet aroundhis penis (RB 56,citing 9 RT 2149, 2170, 2122, 2215; 10 RT 2286-2287, 2410-2412, 2467, 2485); his hearing of voicestelling him to shave his eyebrows,pickat his face, and then rub his face with butter and coffee grounds (RB 56,citing 20 9 RT 2149, 2212; 10 RT 2410-2412); and his hearing voicestelling him to scratch himself and pull his hair (RB 56-57, citing 10 RT 2236-2238, 2419- 2420, 2356). Respondentstates that “[a]part from these [thirteen] instances of suicidal or self-harming behavior, he denied any suicidal ideation.” (RB 57.) If thirteen different instancesof, or attempts at, bizarre and deluded self-harming behavior do not seem sufficient to respondentto raise a doubt about Ghobrial’s competence, it is hard to imagine the quantum necessary for her to concede that a hearing would be warranted. Respondentalso acknowledges that Ghobrial was under a Welfare and Institutions Code section 5150 “flag” to prevent his release before assessmentof his danger to himself or others, but unpersuasively argues that because he was not involuntarily committed, the evidence should be dismissed rather than considered with the other relevant evidencethat raised a reasonable doubt as to Ghobrial’s competence. (RB 56.) Asto trial counsel’s failure to declare a doubt as to Ghobrial’s competence, respondent herself concedesthat trial counsel’s failure to declare a doubtis not dispositive. (RB 57.) Section 1368, subsection (b) specifically authorizes a court to order a competency hearing despite trial counsel’s stated belief that the defendant is mentally competent. (§ 1368, ee subd. (b).) Trial counsel are not “‘trained mental health professional[s] and failure to raise petitioner’s competence doesnotestablish that petitioner was competent.’” (Maxwell v. Roe (9th Cir. 2010) 606 F.3d 561, 574, quoting Odle v. Woodford (9th Cir. 2001) 238 F.3d 1084, 1089.) Much like defense counsel in Maxwell, whofailed to request formally a competency hearing but “clearly expressed concern about Maxwell’s competence” (Maxwell v. Roe, supra, 606 F.3d at p. 574), Ghobrial’s trial counsel never raised a doubt about his competence on the record, but the penalty phase 21 evidence she presented consisted almost entirely of testimony from mental health professionals regarding Ghobrial’s psychotic symptoms and testimony from Dr. Flores-Lopez that he believed Ghobrial needed to be evaluated for competencyto stand trial. (AOBat pp. 67-68.) Aswith trial counsel’s failure to declare a doubt, respondent’s argumentthatthe trial court’s observations of Ghobrial did not provide any indication of mental incompetencyalso carrieslittle weight on this record. Asnoted in the openingbrief, the trial court hadlittle direct interaction with Ghobrial; Ghobrial neither testified nor engaged in any colloquy with the court beyond agreeing to waive time or his presence. (AOB 69,fn. 29; compare People v. Jones (1991) 53 Cal.3d 1115, 1153 [trial court may appropriately take its personal observations into account when deciding whether competency hearing is required when defendantactively participated intrial, and trial court had opportunity to observe and converse with defendant throughouttrial and posttrial proceedings].) Again, many of Ghobrial’s symptoms were negative symptoms of schizophrenia and schizoaffective disorder. The mental health professionals at the Orange County Jail frequently noted that Ghobrial exhibited throughout the entirety of his pretrial incarceration a blunted affect, which would cause Ghobrial to appear calm and expressionless. (See, e.g., 10 RT 2429 [inappropriate affect, which could be negative symptom of schizophrenic or psychotic illness]; 10 RT 2296-2299, 2386-2387, 2434, 2435, 2437-2441, [flat or blunted affect]; 10 RT 2489-2490 [inappropriate affects, which are negative symptom associated with psychotic illness]; 10 RT 2438 [affect blunted, which is negative symptom of schizophrenia or schizophrenic illness]; 10 RT 2496, 10 RT 2500-2501 [remained bizarre and blunted; blunted affectis negative symptom of schizophrenicillness].) 22 Just as a defendant’s “bizarre behavior” and “strange words” do not themselves mandate a competency hearing (People v. Lewis (2008) 43 Cal.4th 415, 524, citations omitted; RB 51), “calm behavior doesnot necessarily mean a defendant is competent” (Dickey-O'Brien v. Yates (E.D. Cal. June 12, 2013) 2:07-CV-1241 WBS CKD,2013 WL 2664418, citing Odle v. Woodford, supra, 238 F.3d at Dp. 1089). “The reasonable inferences available from a defendant’s calm behavior are necessarily dependent” on the other evidence available. (Dickey-O’Brien v. Yates, supra, 2013 WL 2664418, *22; see also People v. Samuel (1981) 29 Cal.3d 489, 503 [“Evidence that a defendant can obediently walk into the courtroom andsit quietly during the trial does not constitute substantial proof of competence; indeed, it could describe onein a catatonic state”].) Moreover, respondent’s assertion misses the gravamen of Ghobrial’s claim: Ghobrial’s argumentis not that the court should have declared a doubt based on any behavior | evident duringtrial, but on the voluminoustestimony presented during the penalty phase that Ghobrial suffered from, beginning at a young age, at the time of his arrest, throughall pretrial proceedings, and likely throughout trial, a major mental illness whose symptomsraised a reasonable doubtthat he could rationally understand the proceedings, communicate with his lawyer, and participate in his own defense B. The Trial Court’s Failure to Suspend Proceedings to Determine Ghobrial’s Competence Requires Reversal of his Conviction “We begin with first principles. The Constitution provides criminal defendants with the right to be competent duringtrial.”’"° (United States v. '°The right to competence“does not derive exclusively from a desire to protect the defendant’s right to a fair adjudication. The doctrine also 23 Duncan (9th Cir. 2011) 643 F.3d 1242, 1248,citations omitted.) The right to be competent beginsat arraignment (Godinez v. Moran, supra, 509 U.S. at p. 403 (conc. opn. of Kennedy,J.)), and continues to judgment(§ 1368, subd. (a)). The evidence presented during Ghobrial’s penalty phase raised more than a reasonable doubtthathis intractable psychotic illness madeit impossible, from the time of his arrest on, for him to rationally understand the proceedings, communicate with counsel, andassist in his own defense. Becausethetrial court failed to suspend criminal proceedings to evaluate Ghobrial’s competenceto stand trial on capital charges, his conviction must be reversed. I // affects societal interests in moral dignity and reliability of the criminal process.” (Bonnie, Beyond Dusky and Drope, supra, 47 U. MiamiL.Rev. at p. 544.) 24 Il. SUBJECTING A DEFENDANT SUFFERING FROM A SEVERE PSYCHOTIC ILLNESS TO A SENTENCE OF DEATH VIOLATESTHEFIFTH,SIXTH, EIGHTH, AND FOURTEENTH AMENDMENTSAND INTERNATIONAL LAW In Atkins v. Virginia (2002) 536 U.S. 304, and Roper v. Simmons (2005) 543 U.S. 551, the United States Supreme Court concluded that characteristics inherent in individuals with mental retardation, such as their diminished cognitive and psychological capabilities, and juveniles under 18, whoare characterized by undeveloped psychological and emotional maturity, rendered both groupscategorically exempt from the most extreme sanction for criminal conduct: the death penalty. As demonstrated in the openingbrief, no legal or rational reason exists for not also exempting from the death penalty the severely mentally ill, whose symptomsof delusions, hallucinations, disordered thought processes, and disorganized behavior significantly impair their ability to interpret reality, accurately perceive the world, control their impulses, and function in society. (AOB 75-93.) Respondent’s three-page answeris so cursory and unresponsivethat this Court should disregardedit in its entirety. Respondent focuses primarily on a point conceded in the opening brief, that currently no legislative consensusexists that the severely mentally ill should be excluded from the death penalty. (RB 58-60; AOB 81.) Respondentsays nothing, however, about the remaining objective evidence presented in the opening brief outlining the “substantial agreement amongst professional, religious and world communities that defendants with severe mental disorders should be excluded from capital punishment,” along with the doubt expressed by various justices and judges presiding over capital cases about the propriety 25 of subjecting those suffering from severe mental illness to thedeath penalty. (AOB 82-86.) Moreover, additional objective evidence exists of the evolving standards of decency against subjecting the mentallyill to the death penalty beyond that outlined in the opening brief. (AOB 81-86.) Connecticut has enacted legislation prohibiting the applicability of the death penaltyif the defendant’s mental capacity was significantly impaired or ability to conform his or her conductto the law was significantly impaired, but not so impaired as to provide a complete defense. (Conn. Penal Code, ch. 952, § 53-a-46a (h).) Amnesty International USAhasissued a report based on an in-depth study calling for state legislatures to enact legislation which prohibits the | execution of the severely mentallyill." In a concurring opinion in Commonwealth v. Baumhammers(Penn. 2008) 960 A.2d 59, 72-80, Justice Todd of the Supreme Court of Pennsylvania stated that “[a]n individual with a serious mental illness may be just as seriously impaired in his ability to ‘understand and process information’ as an individual with a diminished IQ or an individual who has not yet reached the age of legal majority.” (Commonwealth v. Baumhammers, supra, 960 A.2d at p. 79.) Justice Todd recognized that the manifestations of mentalillness, “such as the delusions that accompany paranoid schizophrenia,” impair the sufferer’s ability to engage in logical reasoning, and noted that the “disconnect” between a paranoid “State legislature should in consultation with experts in the field of criminal law and mental health, adopt legislation prohibiting the execution of people with serious mentalillness or other impairments other than mental retardation at the time of the crime of the time of execution.” USA: The Execution ofMentally Ill Offenders (2006). Available at (as of February 11, 2014). 26 schizophrenic’s basic understanding of the world and those “not similarly afflicted will makeit difficult for the schizophrenic to understand others’ reactions.” (Ibid.) Justice Todd concluded by urging the Pennsylvania legislature to consider whetherthe state’s law was“in line with the demandsof the Eighth Amendmentand of fundamentalfairness, considering the bestscientific evidence of the impact of severe mental illnesses on individual culpability.”’? (Id. at p. 80.) Similarly, the international community condemnsthe execution of the severely mentally ill. In finding juveniles under 18 ineligible for the death penalty, the Roper v. Simmons Court foundit significant that the United States was the only country in the world to continue “to give official sanction to the juvenile death penalty.” (Roper v. Simmons, supra, 543 U.S. at p. 575.) In addition to the European Union’s oppositionto inflicting the death penalty on any person with a serious mentalillness cited in the opening brief (AOB 85-86), the United Nations Human Rights Committee has held that the execution of a mentally disturbed but not “insane” individual amounts to cruel, inhuman or degrading treatmentin violation of Article 7 of the International Covenant on Civil and Political Rights, a treaty ratified by 149 countries, including the United States. (See Francis v. Jamaica, Communication No. 606/1994 U.N.H.C.R. (12 August 1994) available at (as "Justice Todd also expressed support for the opinions against executing the severely mentally ill of Justice Evelyn Lundberg-Stratton of the Ohio Supreme Court in State v. Ketterer (Ohio 2006) 855 N.E.2d 48, cited in the opening brief (AOB 83-84, 86), along with the concurring opinion of Justice Zazzali in State v. Nelson (N.J. 2002) 803 A.2d 1, and the dissenting opinion of Justice Rucker in Corcoran v. State (Ind. 2002) 774 N.E.2d 495, both also cited in the opening brief (AOB 82-83). 27 of February 11, 2014).) The United Nations Commission on HumanRights (replaced by the Human Rights Council) has persistently urged countries who continue to impose the death penalty “[nJot to impose the death penalty on a person suffering from any form of mental disorder or to execute any such person.” Although respondent appears to acknowledge that the Supreme Court considers not only objective evidence when reviewing a death sentence under the Eighth Amendment, but also will apply its own judgmentto the issue (RB 59), respondent says nothing to rebut the applicability of the Supreme Court’s analyses in Atkins v. Virginia and Roperv. Simmonsto those suffering from severe mentalillness, analyses whichrested in large part upon the Supreme Court’s own assessmentof the limitations of the mentally retarded and juveniles under 18. Respondent cites to this Court’s conclusion in People v. Castaneda (2011) 51 Cal.4th 1292, 1345, that the defendantthere failed to establish his antisocial personality disorder was “analogous to mental retardation or juvenile status for purposes of imposition of the death penalty.” (RB 58.) | Ghobrial has no dispute with this proposition, but the pointis irrelevant. The defendant in Castaneda suffered from anti-social personality disorder, not a severe psychotic disorder, and noneof the diagnostic criteria for anti-social personality disorder includes symptomsof disorganized thinking, hallucinations, psychotic thought processes, and disconnection from reality; that is, the inherent impairments of the severely U.N. Commission on Human Rights, Question of the Death Penalty, U.N. Doc. E/CN.4/1999/61 (1999); id. at E/CN.4/ 2000/65 (2000); id. at E/CN.4/ 2001/68 (2001); id. at E/CN.4/2002/77 (2002);id. at E/CN.4/2003/67 (2003); and id. at E/CN.4/2004/67 (2004). 28 mentally ill that render them less culpable than those without such impairments in their functioning. (See DSM-IV-TR, Diagnostic criteria for 301.7 Antisocial Personality Disorder, p. 706.) Respondent goes on to state simply that “[n]Jot every mentalillness is comparable to mentally retarded and/or juvenile offenders with respect to reasoning, judgment, and impulse control.” (RB 60.) Ghobrial also has no. quarrel with this position, but respondentfails completely to address Ghobrial’s claim that the severe mental illness from which he suffers, whose symptomsbydefinition substantially impair his reasoning, judgment, and impulse control, lessens his culpability and, as a consequence, imposition of the death penalty would violate the protections of the Eighth and Fourteenth Amendments. Respondent’s citation to ten cases for the proposition that “[o]ther federal and state courts have consistently declined to extend Atkins to the mentally ill” (RB 59) fails to acknowledge that the concurring and dissenting opinions issued in four out of the ten cases all express a belief that the severely mentally ill should be excluded from death penalty eligibility. (See Joshua v. Adams (2007) 231 Fed. Appx. 592, 594 (dis. opn. of Ferguson, J.); Commonwealth v. Baumhammers, supra, 960 A.2d at p. 72 (conc. opn. of Todd, J.); State v. Ketterer, supra, 111 Ohio St.3dat p. 82 (conc. opn.of Stratton, J.); Matheny v. State (Ind. 2005) 833 N.E.2d 454, 458 (conc. opn of Rucker, J.).) In a fifth opinion, State v. Hancock (Ohio 2006) 840 N.E.2d 1032, 1059, the court denied the claim primarily because the claim “appear[ed] to rest on nothing but [the defendant’s] assertion that it is so.” The court chastised the defendantfor failing to offer any basis for concluding that defendants with severe mental illnesses are comparable to those suffering from mental retardation “with respect to reasoning, 29 judgment, and impulse control,” and for failing to offer any definition of “severe mentalillness.” (Ibid.) The court went on, however, to recognize that “[mJental illnesses come in many forms; different illnesses mayaffect a defendant’s moral responsibility or deterrability in different ways and to different degrees.” (/bid.) Three of the remaining casesarise from a single state: Texas. Respondent’s cases, rather than bolstering her argumentthat no national consensusexists for banning the execution of the severely mentally ill, demonstrate the growing recognition that evolving standards of decency demandthat such defendants be exempt from the death penalty. Respondentdismisses the necessity for a categorical ban on death penalty eligibility for the severely mentally ill by noting that “[clapital defendants are permitted to present evidence of mentalillness or impairmentin mitigation.” (RB 60,citing § 190.3, subd. (h).) This option is insufficient to protect the severely mentally ill from being sentenced to death. As the Supreme Court recognized both in Atkins v. Virginia and Roperv. Simmons,there exists a strong likelihood that jurors will treat the characteristic that should be mitigating as a factor in aggravation. In Atkins v. Virginia, the Supreme Court stated that “reliance on mental retardation as a mitigating factor can be a two-edged sword that may enhancethe likelihood that the aggravating factor of future dangerousness will be found by the jury.” (Atkins v. Virginia, supra, 536 U.S.at p. 321, citing Penry v. Lynaugh, 492 U.S. 302, 323-325.) Similarly, in Roper v. Simmons, the Court held that “[a]n unacceptable likelihood exists that the brutality or cold-blooded nature of any particular crime would overpowermitigating arguments based on youth.” (Roper v. Simmons, supra, 543 U.S.at p. 573.) The concernsarticulated in Atkins v. Virginia and Roper v. Simmons apply equally to those suffering from severe mental illness; jurors likely 30 will conclude thatthe intractable nature of a severe mentalillness should be treated as the aggravating factor of future dangerousness, and the brutality or gruesomeness of the murder — as in Ghobrial’s case — should not be considered as evidence of the defendant’s mental illness, but as circumstancesof the crime for which nothing less than the death penalty is the appropriate sanction. (See Fleischaker, Dead Man Pausing: The Continuing Needfor a Nationwide Moratorium on Executions (2004) 31 HumanRights 14, 18 [indicating that juries often consider mental illness as an aggravating factor and “states often fail to monitor or correct the unintended and unfair results of the error’]; see also Izutsu, Applying Atkins v. Virginia to Capital Defendants With Severe MentalIllness (2005) 70 Brook. L. Rev. 995, 1023-1024, fn.13 [opining that “it is the jurors’ perception of the defendant’s future dangerousnessat sentencing that appears to be the decisive factor in the decision to impose the death penalty, regardless of the level of the defendant’s culpability]; Slobogin, Mental Illness and the Death Penalty (2000) 1 Cal. Crim. L. Rev.3, pars. 19-23 [research showsthat one of the best predictors of a death sentence is assertion of an insanity defenseattrial, and that presentation of evidence supporting a claim of extreme mental or emotional stress is much more likely to correlate with a death sentence than a life sentence].) As with mentally retarded and juvenile defendants, the severely mentally ill “in the aggregate face a special risk of wrongful execution.” (Atkins v. Virginia, supra, 536 U.S.at p. 321.) “A central feature of death penalty sentencingis a particular assessment of the circumstancesof the crime andthe characteristics of the offender.” (Roper v. Simmons, supra, 543 U.S. at p. 572,italics added; see also Grahamv. Florida (2010) 560 U.S. 48, 67 [“The judicial exercise of 31 independent judgment requires consideration of the culpability of the offenders at issue in light of their crimes and characteristics, along with the severity of the punishmentin question’”], italics added, citing Roperv. Simmons, supra, 543 U.S.at p. 568, and Kennedy v. Louisiana (2008) 554 U.S. 407, 434-436.) The characteristics of those suffering from a severe mental illness, such as schizoaffective disorder, include by definition symptomsof a “range of cognitive and emotional dysfunctions that include perception, inferential thinking, language and communication, behavioral monitoring, affect fluency and productivity of thought and speech, hedonic capacity, volition and drive, and attention.” (Joshua v. Adams, supra, 231 Fed. Appx.at p. 594 (dis. opn. of Ferguson, J.), quoting Slobogin, What Atkins Could Meanfor People with Mental Illness (2003) 33 N.MLL. Rev. 293, 303-304.) This Court has the authority to and must recognizethat these inherent characteristics render the severely mentally ill less culpable for their crimes andtherefore ineligible for the death penalty. “The penological justifications for the sentencing practice are also relevant to the analysis.” (Graham v. Florida, supra, 560 U.S.at p. 71, citing Kennedy v. Louisiana, supra, 554 U.S.at pp. 434-436, Roperv. Simmons, supra, 543 U.S.at pp. 571-572, and Atkins v. Virginia, supra, 536 U.S. at pp. 318-320.) As noted in the opening brief, the Atkins Court recognizedthat “[i]f the culpability of the average murdereris insufficient to justify the most extreme sanction available to the State, the lesser culpability of the mentally retarded surely does not merit that form of retribution ....” (Atkins v. Virginia, supra, 536 U.S. at p. 319; accord Roperv. Simmons, supra, 543 U.S. at p. 571 [“Retribution is not proportional if the law’s most severely penalty is imposed on one whose culpability or blameworthiness is diminished”].) Just as those with mental 32 retardation and juveniles under 18 are considered less culpable as a consequenceoftheir inherentlimitations and therefore undeserving of the ultimate sanction, the functional impairments caused by severe mental illness diminish the culpability of defendants suffering from such illnesses, making the “most extreme sanction available to the State” unwarranted. — (AOB 93.) The goal of deterrence also is not promoted by executing the severely mentally ill. “Capital punishmentcan serve as a deterrent only when murderis the result of premeditation and deliberation.” (Atkinsv. Virginia, supra, 536 U.S.at p. 319, quoting Enmundv. Florida (1982) 458 U.S. 782, 799.) A severely mentally ill defendant who suffers from symptoms impairing his or her perceptionof reality, thought processes, and volitional control is incapable of engaging in the “kind of cost-benefit analysis that attaches any weight to the possibility of execution.” (Roperv. Simmons, supra, 543 U.S. at pp. 561-562, quoting Thompson v. Oklahoma (1988) 487 U.S. 815, 836-838.) There also exists with the severely mentally ill the same “unacceptable risk of wrongful executions” as exists with the mentally retarded. (See Atkins v. Virginia, supra, 536 U.S. at p. 320.) The severely mentally ill may be as likely as the mentally retarded to falsely confess to a crime, and the disordered thinking, impaired communicationskills, delusions, hallucinations, and distractions of internal stimuli attending a severe mentalillness impede the defendant’s ability to communicate effectively with counsel andassist in the defense, including developing mitigating evidence. Finally, criteria may be developed to meaningfully distinguish those whoshould be exempt from a punishmentof death from those who should not. Respondent’s assertion that Ghobrial is asking this Court to “establish 33 a new,ill-defined category of capital murderers who would be exempt from the death penalty” is unsupported. (RB 60.) As discussed in the opening brief, the Supreme Court’s opinions in Panetti v. Quartermen (2007) 551 U.S. 930, and Ford v. Wainwright (1986) 477 U.S. 399", suggest that “when severe mental illness produces gross delusions or other cognitive effects, significantly distorting the offender’s understanding and appreciation of his conduct and of its wrongfulness, capital punishmentwill serve noretributivist purpose, and therefore would be cruel and unusual.” (AOB 91.) “By stressing gross delusions that significantly impair comprehension,” the Panetti Court suggests that only those suffering from major mental illnesses with psychotic features should be considered ineligible for the death penalty. (Zbid.) The openingbriefalso cites resolutions by the American Bar Association, American Psychiatric Association, American Psychological Association, and the National Alliance for the Mentally Il] exempting those with severe mental illness from the death penalty, and the nearly identical resolutionsall identify criteria by which to identify defendants qualifying for the exemption. (AOB85.) Lastly, as noted above, the Connecticut legislature enacted legislation exempting defendants whose “mental capacity was significantly impaired or ability to conform his or her conduct to the law was significantly impaired, but not so impaired as to provide a complete - Respondent apparently misunderstands the purpose for which these cases were cited in the opening brief. (See RB 60.) As discussed above, Ghobrial cites these cases to demonstrate that the Supreme Court has offered guidance andcriteria by which courts can identify those whose mentalillness is so severe that it renders them less culpable and therefore ineligible for the death penalty. Ghobrial says nothing in the opening brief about incompetence to be executed. 34 defense.” (Conn. Penal Code, supra.) Establishing criteria is a familiar role for the Court, not an insurmountable task that would leave those suffering from severe mental illness unprotected from cruel and unusual punishment. “Tt is an axiom of criminal law that mental illness bears heavily on an individual’s culpability. We have recognized ‘the belief, long held by this society, that defendants who commitcriminalacts thatare attributable... to emotional and mental problems[ ] may beless culpable than defendants who have no such excuse. 598, quoting California v. Brown (1987) 479 U.S. 538, 545 (conc. opn. of (Joshua v. Adams, supra, 231 Fed. Appx.at p. O’Connor,J.).) As outlined in ArgumentI, above, evidence establishes that, from a young age, Ghobrial has suffered from a severe mentalillness that significantly impairs his ability to function socially, educationally, and occupationally. He has been plagued by delusions and hallucinations that substantially impair his cognitive and psychological abilities and ability to comprehend reasonably rationally his world. To execute a defendant disabled by a severe mentalillness through no fault or choice of his ownis a disproportionate punishment. Ghobrial’s death judgment must be reversed. H Hl — 35 Il. NO REASONABLE AND CREDIBLE EVIDENCE OF SOLID VALUE SUPPORTED THE FIRST DEGREE MURDER CONVICTION AND THE SPECIAL CIRCUMSTANCEFINDING A. Introduction The federal and California constitutions provide a criminal defendant with the guarantee that any conviction obtained will be based on substantial evidence. (AOB 94-95; People v. Holt (1997) 15 Cal.4th 618, 667.) The federal Constitution further guarantees that, to meet the heightened reliability requirements of the Eighth Amendment, a death sentence cannot be imposed based on speculative evidence. (AOB 94; Edelbacherv. Calderon (9th Cir. 1998) 160 F.3d 582, 585; Flowers v. State (Miss. 2000) 773 So.2d 309, 317.) To ensure that these constitutional guarantees have been fulfilled, when evaluating whether the evidence wassufficient to support a conviction and death sentence, this Court must “review the whole record in the light most favorable to the judgment to determine whetherit discloses substantial evidence — that is, evidence that is reasonable, credible, and of solid value — from which a reasonable trier of fact could find the defendant guilty beyond a reasonable doubt.” (AOB 95, quoting People v. Stanley (1995) 10 Cal.4th 764, 792; see also People v. Whalen (2013) 56 Cal.4th 1, 55.) Regardless of whether the evidenceis direct or, as in this case, primarily circumstantial, to support a conviction, special circumstance, and sentence of death, the evidence must be substantial and the inferences drawn therefrom reasonable. (See People v. Stanley, supra, 10 Cal.4th at pp. 793-794 [standard of review is same regardless of whether evidenceis direct or circumstantial, but circumstances must reasonably justify trier of fact’s findings].) As demonstrated in the openingbrief, a 36 thorough review of the complete record fails to disclose sufficient evidence that was reasonable, credible, or of solid value on which the jury could find Ghobrial guilty of first degree murder undereither a theory of premeditation and deliberation or a felony murder occurring during the attempted commissionof a lewd act in violation of Penal Code section 288 (AOB 97- 118); the charged crimes andresulting verdict, special circumstance finding, and death sentence were based solely on speculation, suspicion, and conjecture. Respondent’s primary responseis repeated reiteration of the undisputed standard of review applicable to sufficiency of the evidence claims: this Court must presume in support of the judgmentthe existence of every fact the jury could reasonably infer from the evidence. (See RB 61, 62, 66, 69, 72.) Respondent’s repeated citation to the standard of review cannot, however, substitute for the evidence missing from the prosecution’s case. The lion’s share of the prosecution’s case against Ghobrial was circumstantial, as defense counsel recognized explicitly (see 9 RT 1941 [“This is an inference driven case”]) and the prosecution recognized implicitly by focusing primarily during closing argument on the inferences he believed were supported by the evidence (see e.g., 8 RT 1912 [“‘This is circumstantial evidence. ... And so you’re drawing inferences from the evidence’’]). Respondent’s focus on the presumption in favor of the judgment cannotobscurethe fact that no substantial evidence supported the inferences necessarily made by the jurors in order to convict Ghobrial. “Circumstantial evidenceis like a chain which link by link binds the defendantto a tenable finding of guilt.” (People v. Redrick (1961) 55 Cal.2d 282, 290.) Circumstantial evidence requires the trier of fact to draw reasonable inferences from facts proven beyond a reasonable doubt; a 37 999 ‘reasonable inference may not be based on suspicion alone.’” (People v. Tripp (2007) 151 Cal.App.4th 951, 959, quoting People v. Raley (1992) 2 Cal.4th 870, 891 [citations omitted].) Althoughthetrier of fact is tasked with determining the existence and strength of the facts that form the evidentiary links, “‘if there has been a conviction notwithstanding a missing link it is the duty of the reviewing court to reverse the conviction.’” (Id.at p. 956, quoting People v. Redrick, supra, 55 Cal.2d at p. 290.) If the inferences drawn are based on a suspicion that merely raises the possibility of the inferred fact’s existence, there is insufficient evidence to support a conviction. “‘A finding of fact must be an inference drawn from evidence rather than . .. a mere speculation as to probabilities without evidence.’” (Id. at p. 959, quoting People v. Raley, supra, at p. 891.) ““Evidence which merely raises a strong suspicion of the defendant’s guilt is not sufficientto support a conviction.’” (Jd. at p. 958, quoting People v. Redmond (1969) 71 Cal.2d 745, 755.) Respondent unsuccessfully attemptsto fill the gaps in the prosecution’s evidence by “mere speculation as toprobabilities.” B. No Substantial Evidence Supported a Finding That Ghobrial Premeditated and Deliberated The California Legislature has expressed a clear intention that the “unlawful killing of a human being . . . with malice aforethought” (§ 187) be divided into two degrees (§ 189), and that the unjustified killing of a human being is presumed to be second degree murderunless the prosecution proves beyond a reasonable doubt that the defendant premeditated and deliberated (ibid.; AOB 97-98; People v. Anderson (1968) 70 Cal.2d 15, 25). Nevertheless, this Court has acknowledgedthe historical “lack of conceptual consistency” (People v. Holt (1944) 25 Cal.2d 59, 88) in differentiating between murderofthe first degree and murder of the 38 second. (People v. Anderson, supra, 70 Cal.2d at p. 25; see also Mounts, Premeditation and Deliberation in California: Returning to a Distinction Without a Difference (2002) 36 U.S.F. L. Rev. 261.) “Recognizing the need to clarify the difference between the two degrees of murder and the bases upon which a reviewing court mayfind that the evidenceis sufficient to support a verdict of first degree,” the Anderson Court “set forth standards, derived from the nature of premeditation and deliberation as employed by the Legislature and interpreted by [the Court], for the kind of evidence whichis sufficient to sustain a finding of premeditation and deliberation.” (People v. Anderson, supra, 70 Cal.2d at pp. 25-26.) The Anderson analysis established a “frameworkto assist reviewing courts in assessing whether the evidence supports an inference that the killing resulted from preexisting reflection and weighing of considerations” (People v. Thomas (1992) 2 Cal.4th 489, 517), or instead was the result of an unconsidered or rash 'SAs noted in the opening brief (AOB 98, fn. 42), nowhere doesthe Anderson Court suggestthat its articulation of standards be used to define premeditation. Rather, the Court recognized the potential and actual challenges in distinguishing between the two degree of murder and the inconsistencies apparent in reviewing courts’ findings that the evidence was or was notsufficient to sustain a conviction for first degree murder. (See People v. Anderson, supra, 70 Cal.2d at pp. 25-26.) Although this Court cautioned against “[u]nreflective reliance on Anderson”in People v. Thomas,in assessing the sufficiency of the evidence of premeditation, the Court there and in other cases has consistently used the “Anderson analysis as a guide.” (See, e.g., People v. Thomas, supra, 2 Cal.4th at p. 517; People v. Stitely (2005) 35 Cal.4th 514, 543 [when record discloses evidencein all three categories, verdict generally will be sustained]; People v. Silva (2001) 25 Cal.4th 345, 369 [addressing insufficiency claim by reference to the three factors identified in Anderson]; People v. Combs (2004) 34 Cal.4th 821, 850-851 [same]; People v. Bolin (1998) 18 Cal.4th 298, 331-333 [same].) 39 impulse. As discussed in the opening brief, this Court has identified three types of evidence usually found sufficient to sustain a finding of premeditation and deliberation: (1) planningactivity prior to the killing; (2) facts about the defendant’s prior relationship and/or conduct with the victim from which the jury reasonably could infer a motive; and (3) facts about the nature of the killing from which the jury could infer that the mannerofthe killing was “‘so particular and exacting that the defendant must have intentionally killed according to a ‘preconceived design’ to take [the] victim’s life.” (People v. Anderson, supra, 70 Cal.2d at pp. 26-27, quoted in People v. Thomas, supra, 2 Cal.4th at pp. 517; see AOB 97-98.) Appellant’s opening brief analyzed the prosecution’s evidence of premeditation and deliberation admitted against Ghobrialutilizing the Anderson guidelines and established that the jury had before it no substantial evidence on which to find that Ghobrial premeditated and deliberated before the killing. (AOB 99-103.) Respondentalso utilizes the Anderson guidelines to analyze the sufficiency of the evidence of premeditation and deliberation (RB 63), and in so doing, affirms the opening brief’s position that no substantial evidence supports a finding of premeditation and deliberation. First, respondent concedes, as she must, that the prosecution presented no substantial evidence from which the jury reasonably could infer the mannerof killing. (RB 64.) The official cause of death waslisted as “by unspecified means” (AOB 103,citing 7 RT 1460, 8 RT 1926]), and the forensic pathologist who performed the autopsy, Dr. Aruna Singhania, would notdefinitively identify the cause of death, observing only that asphyxia seemed the mostlikely cause (AOB 103, 7 RT 1460, 1479-1483]). The prosecutor himself suggested that the killing could have been accidental. (AOB 103-104,8 40 RT 1927].) Respondent unsuccessfully strains to discover evidence in the two remaining categories: planning activity and preexisting motive. Respondent’s discussion of alleged planning activity is pure speculation. Respondentcites Ghobrial’s statements to Juan of “I am going to kill you. I will kill you and eat your pee-pee,” but does nothing to explain how these statements are evidence of planning. (RB 64.) As discussed in the opening brief, Ghobrial’s mental status, Juan’s teasing of Ghobrialat the time, Juan’s dismissal of any danger, and a witness’s failure to take any action, suggest that these statements more likely were a “disturbed man’s rash and heated response to Juan’s taunts at sometimes, and a bizarre, deranged jest at others.” (AOB 101.) Even if the statements were meantliterally, as the prosecutor himself noted, Ghobrial’s words suggest an intent only, not a plan. (AOB 101, fn. 47, 8 RT 1909].) Missing from respondent’s proposal is any evidence, substantial or otherwise, from which a reasonable fact- finder could infer Ghobrial wasin the process of developing or did develop “a deliberate judgment or plan.” Respondentalso describes Juan’s conduct on the Wednesdayprior to his disappearance, including seeking a place other than his own hometo spendthe night. Respondent does not, however, link Juan’s behavior to evidence of Ghobrial’s planning. (RB 64.) The only reasonable inference from this evidence is that Juan sought out Ghobrial, not that Ghobrial sought out Juan. Whenrespondentfinally does turn to evaluating Ghobrial’s behavior, she points to the evidenceof his actions following, rather than preceding, the killing. Respondent’s inference that Ghobrial “considered the | possibility of homicide from the outset” is dependant on the evidence of two alleged facts being substantial: the threats and Ghobrial’s purchases 41 before Juan’s death. (RB 65.) Although the prosecutorspecifically rejected the theory that Ghobrial purchased the equipment used to dispose of the bodypriorto the killing (AOB 99, 8 RT 1910, 1913]), respondent speculates that the jury could have inferred these purchases took place prior | to the killing. (RB 65.) For such an inferenceto beatall reasonable, there must be some evidencein the record to explain how Ghobrial immobilized Juan while he went shopping alone, and noneof the witnesses saw Ghobrial at either Kmart or Home Depot on March 19, reported that he was accompanied by anyone. Theforensic pathologist found no evidence of a struggle or defensive wounds on Juan (AOB 18, 7 RT 1492, 1499]), and the record is completely devoid of any other evidence suggesting that Juan was alive when Ghobrial made his purchases. As noted above, an inference is only as valid as the evidence upon which it depends. Although Ghobrial did makestatements the jury could construe as threats, there is absolutely no evidence supporting an inference that the purchases were madeprior to the killing. Respondent further claims that Ghobrial’s dismembermentof the bodyafter the killing “would appear to be inconsistent with a state of mind that would have produced a rash, impulsive killing.” (RB 65.) This equivocal and ambivalent conclusion underscores the speculative nature of using post-crime actions to infer a pre-crime state of mind as evidence of premeditation and deliberation. Although post-crime “cover-up” evidence “may possibly bear on defendant’s state of mindafter the killing,it is irrelevant to ascertaining defendant’s state of mind immediately priorto, or during, the killing.” (People v. Anderson, supra, 70 Cal.2d at p. 31; see AOB102,fn. 48.) Respondent’s inability to identify substantial evidence sufficient to support an inference of “preexisting reflection” demonstrates 42 the lack of substantial evidence of premeditation and deliberation available to the jurors. Finally, respondent engages in the same circular reasoning as the prosecutor to ascribe a motive to Ghobrial: thatis, that Ghobrial molested Juan and therefore must have killed him to hide the molestation; and because Ghobrial murdered Juan, he must have molested him. (RB 66.) As demonstrated in the opening brief, the prosecution had no credible evidence sufficient to prove beyond a reasonable doubt that Ghobrial attempted to molest Juan. (AOB 106-118.) Furthermore, even if the jury reasonably could infer that Ghobrial had a motiveto kill Juan, absent evidence of planning activity or the nature of the killing, a defendant’s possible motive is an insufficient basis on which to find premeditation and deliberation beyond a reasonable doubt. (People v. Anderson, supra, 70 Cal.2d at pp. 26-27; AOB 102-103.) Respondentconcludesby asserting that Ghobrial argues in the opening brief for “his version of the events rather than facts and inferences to be drawn in favor of the verdict.” (RB 66.) Once again, respondent misses the gravamen of the claim. Ghobrial does not simply argue that the jury reasonably could have believed a scenario other than the one posited by the prosecution. The opening brief demonstrates that no evidence of any kind existed from which the jurors reasonably could find that Ghobrial plannedthe killing. The assertions that Ghobrial “had no weapon or bindings or anything to suggest he was prepared to harm anyone” (AOB 100), and that he “made no preparations for disposing of the body” (AOB 100) do not describe an alternative scenario; they reveal an absence of evidence of planning. Once more, respondent’s mere parroting of the standard of review doesnot create substantial evidence on which the jury 43 reasonably could have baseda finding of premeditation and deliberation. There simply was none. Respondentutterly fails to respond to appellant’s argumentthat Ghobrial’s sentence is unreliable and in violation of the Eighth Amendment because the jurors were notinstructed that they could not use deliberate premeditated murder for the purposes of factor (a) when considering the appropriate sentence for Ghobrial. (AOB 106.) This Court should construe respondent’s failure as a concessionthat, if this Court finds the evidence insufficient to support a finding of premeditation and deliberation but legally sufficient to support the felony murder and the jury relied on a felony murdertheory,the failure by the trial court to instruct the jury that they could not consider Ghobrial as culpable as one who committed deliberate and premeditated murder warrants reversal of his death sentence. C. No Substantial Evidence of Felony Murder WasPresented In response to appellant’s argumentthat the felony murder conviction is not supported by substantial evidence, respondent once again resorts to repeated recital of the standard of review on appeal, rather than addressing the substance of the claim. (See RB 67, 69.) The prosecution did not charge Ghobrial with a violation of section 288, but argued to the jurors that the killing occurred during the attempted commission of a lewd act on a child in violation of section 288, within the meaning of section 190.2, subdivision (a) (17) (5). (AOB 107, 1 CT 87].) As explained in the opening brief, the prosecution presented no substantial evidence that Ghobrial touched Juan, did so with the specific intent “‘to arouse, appeal to, or gratify the lust, passions, or sexual desires of that person or child, or did so to a child under 14 years of age.” (AOB 107, § 288, subd. (a); CALJIC 44 No. 10.41; 2 CT 420; 9 RT 2018-2019].) Unlike the prosecutor, who clearly harbored reasonable doubt about the evidentiary value of the potential discovery of three to five sperm cells in anal swabs taken from the pelvic section, respondent inaccurately states that “[s]perm cells were found inside Juan’s rectum,” and that their presence wassufficient for the jury to find beyond a reasonable doubtthat Ghobrial committed a lewdact, citing People v. Thompson (1990) 50 Cal.3d 134, 170. (RB 69; AOB 116, 7 RT 1611, 1626, 1628, 1630; 8 RT 1870].) Although the fact of the body’s dismembermentis gruesome and difficult, this fact cannot be used to excuse the requirement that reasonable inferences be based on substantial evidence. If the material identified by Aimee Yap were,in fact, sperm cells, they were not found inside Juan’s rectum. Laurie Crutchfield, the Orange County criminalist who obtained the anal swabs from Juan’s body,testified that the practice of the Orange County criminalists is to obtain samples both from the perianal region and the anus. (7 RT 1622-1624.) When taking swabs from the pelvic remains, she wasable to swab the perianal area only because only the anus and the sphincter were recovered. (7 RT 1621-1624.) This is not a mere technicality. Not only was the sperm not found inside the anus, but also no forensic testing included Ghobrial as a possible source. (Compare People v. Thompson, supra, 50 Cal.3d at 171, fn. 3.) As discussed in the opening brief, although the jurors had the right to accept the prosecution’s assertion that the items identified by Yap were, in fact, sperm — a conclusion strongly contested by the defense — no further evidence existed supporting an inference that the sperm had been deposited by Ghobrial; the sperm could haveoriginated from Juan’s testicles or vas deferens when they were severed, or it could have been deposited by someoneother than Ghobrial. (AOB 118.) The simple fact is that the evidenceis, at best, inconclusive. 45 Respondentalso cites the fact that the body was found nude, although she concedesa victim’s lack of clothing “is insufficient to establish specific sexual intent.” (People v. Johnson (1993) 6 Cal.4th 1, 41.) Both cases cited by respondentin support of her position are factually distinguishable in significant ways. In People v. Rundle (2008) 43 Cal.4th 76, 139, this Court reiterated that “the circumstanceofthe victim’s being foundpartially or wholly unclothedis notbyitself sufficient to prove a rape or attempted rape has occurred,” and pointed to other indicia of rape present in that case. There, the victim was foundin a secluded area with her arms bound tightly behind her back, and, “most importantly, defendant’s own admission support the conclusion there wassufficient evidence for a rationaltrier of fact to find he attempted to rape [the victim].” (bid.) No similar evidenceexists in the prosecution’s evidence against Ghobrial. People v. Holloway (2004) 33 Cal.4th 96, 139, is also inapposite as this Court found “substantially more [evidence] than the victim[’]s[] nudity” to prove sexual intent. In Holloway, the defendant challenged the sufficiency of the evidence to establish he had attempted to rape the second of his two victims. This Court noted that the defendant had only shortly before sexually assaulted and killed one victim in her car. In addition, pubic hair consistent with defendant’s and inconsistent with the victim’s was foundin the car, and the second victim was found lying nude on her back on her bed, with ligature marks on her neck, wrists, and ankles. (/d., at pp. 105-106.) No similar evidence beyondthe victim’s nudity was presented against Ghobrial. Respondentalso posits that the fact that Juan’s penis was severed from his body and never recovered “strongly suggested that the crime was sexually motivated.” (RB 69, People v. Guerra (2006) 37 Cal.4th 1067, 1131-1132].) Respondent accurately characterizes the strength of the 46 evidence by suggesting that the crime was sexual motivated, but the fact that Juan’s penis was severedfails utterly to establish the elements of a violation of section 288. Recognizing that this Court must view the evidencein the light most favorable to the prosecution, no evidence provides a substantial inferential link from the postmortem removalof the penis to a conclusion that Ghobrial attempted to touch Juan in a lewd manner with the requisite intent while he was alive. The only evidence suggesting Ghobrial’s mentalstate at the time of the crimearehis earlier statements that he wanted to kill Juan and “eat his pee-pee.” As made clear in the openingbrief, the only reasonable inference from Ghobrial’s statement is that Ghobrial “did exactly what he asserted he would do,eat Juan’s penis. While such a violation of the ultimate human taboo suggests compelling evidence of Ghobrial’s mental illness, it does not represent evidence of premortem sexual molestation.” (AOB 116.) A suspicion that the crime was sexually motived does not provide the substantial evidence of the elements of the crime necessary to sustain a conviction. Furthermore, Juan’s clothes showed no signsof having been forcibly removed, and, as addressed below, Juan’s body showed nosignsof forcible sexual assault. To the extent that some evidence exists supporting an inference that some type of sexual activity occurred, such evidence — when considered along with Ghobrial’s statements — only supports the inference that Ghobrial intended to engage in the activity postmortem. A violation of section 288 requires a live victim. (See People v. Kelly (1992) 1 Cal.4th 495, 524, citing People v. Sellers (1988) 203 Cal.App.3d 1042, 1050, People v. Stanworth (1974) 11 Cal.3d 588, 604-605, People v. Morales (1989) 48 Cal.3d 527, 552, People v. Ramirez (1990) 50 Cal.3d 1158, 1176 [applying similar rule to crime of sodomy].) Respondent’s citation to cases holding that the victim need notbe alive to support an attempted lewdactif 47 the defendant intended to commit the lewd act with a live body are inapposite because respondenthasfailed to point to any substantial evidence establishing that Ghobrial harbored an intent to sexually assault Juan while Juan wasalive. (RB 71 [citations omitted].) The forensic pathologist who performed the autopsy on Juan found no evidenceof trauma, other than the dismemberment, to any of the body parts recovered daysafter the killing, no anal tears on the pelvic region discovered approximately one year later, and, upon microscopic examination, no evidence of bruising to the anal region. (7 RT 1461, 1479- 1481; 1459; 1478). Respondenthas no responseto these facts, and instead focuses on Dr. Singhiana’s testimony that she could not say conclusively there were no anal tears based on the condition of the body. Respondent posits that “the absence of such evidence is inconclusive and doesnot tend to eliminate a sexual assault, depending on the nature of the crime scene or whenthe body is found in an advancedstate of decomposition,” again citing People v. Rundle, supra, 43 Cal.4th at p. 139. (RB 70.) As noted above in People v. Rundle, this Court found that the fact that the crime occurred near “a secluded highwayexit in a rural area,” the victim was found nude and with her hands “bound very tightly behind her back,” and the defendant admitted having sex with the victim provided strong evidence of a forcible or attempted rape occurred. (/d. at pp. 138-140.) Considering this other strong evidence that a rape or attempted rape had occurred, this Court found that the absence of evidence of “trauma to the body or sexual organs, or the presence of the perpetrator’s bodily fluids . . . did not tend to eliminate a sexualassault; it simply was inconclusive dueto the nature of the crime scene and the advancedstate of decomposition of [the victim’s] body.” (/d. at p. 139.) Here, in the face of no additional evidence of a sexual assault, respondent is attempting to use the absence of evidence of 48 sexual assault to prove that a sexual assault must have occurred. The requirementthat a reasonable inference be based upon facts proven beyond a reasonable doubt cannotbe turned onits head to allow an inference based upon the absenceoffacts. Finally, as established in the openingbrief, the prosecution failed to present substantial evidence from which the jury reasonably could inferthat Juanwas under 14 at the time of the offense. (AOB 118-119.) Respondent asserts that the testimony of Armando Luna,a classmate of Juan’s, that both he and Juan were 12 years old wassufficient to establish that Juan was youngerthan 14, an essential elementof a violation of section 288. (RB 71- 72.) Respondent must recognize that Armando simply was assumingthat he and Juan were the same age because they were in the same grade together; Armando had noevidenceother than their shared grade upon which to base his assumption. Respondentcites People v. Young (2005) 34 Cal.4th 1149, 1181, and People v. Allen (1985) 165 Cal.App.3d 616, 623, for the proposition that the “testimonyof a single witnessis sufficient of 29 66support a conviction” “unless the testimony is physically impossible or inherently improbable.” (RB 72.) Both those cases, however, address eyewitness testimony andthe sole responsibility of the trier of facts to determine the credibility of a witness. Here, Armando wasnottestifying to any fact that called for a credibility determination; he simply was speculating about Juan’s age based on the fact that he and Juan werein the same grade. Speculation is not substantial evidence sufficient to support a finding of fact that is an elementof a crime. D. Conclusion The United States Supreme Court recognizedthirty-five years ago that “a properly instructed jury may occasionally convict even whenit can be said that no rationaltrier of fact could find guilt beyond a reasonable 49 doubt.” (Jackson v. Virginia (1979) 443 U.S. 307, 317.) The facts of this case must have presented extraordinary challenges for the jurors. A young boy had been killed, dismembered, and the body parts encased in concrete; the defendant was an Egyptian national suffering from a severe mental illness who spoke no English and was missing part of his arm. Jury selection began six weeksafter the attack on the Twin Towers World Trade Center and the Pentagon; by then, the Arab nationality ofthe terrorists, including one Egyptian, was common knowledge. Despite being properly instructed, it may not have been humanlypossible for the jurors to put aside their horrorat the crime and their fear of the defendant to approach the case with dispassionate reason. Although the evidence either was inconclusive or missing entirely, when faced with the gruesomefacts of the crime and in the context of 9/11, perhaps no jury could have found Ghobrial guilty of anything less than first degree murder or sentenced him to anything less than death. This Court must provide the logical reasoning that may have been elusive for the jurors despite their best intentions, and recognize that no substantial evidence exists supporting the guilty verdict, special circumstance finding, and sentence of death. Hf HI 50 IV. THE TRIAL COURT VIOLATED GHOBRIAL’S RIGHT TO PRESENT A DEFENSE WHENIT REFUSED TO ALLOW DEFENSE WITNESSES TO TESTIFY THAT THE VICTIM SOUGHT OUT THE COMPANIONSHIP OF ADULT MEN Theright to offer the testimony of witnesses “is in plain terms the right to present a defense, the right to present the defendant’s version of the facts as well as the prosecution’s to the jury so it may decide wherethe truth lies. Just as an accused hasthe right to confront the prosecution’s witnesses for the purpose of challenging their testimony, he hasthe right to present his ownwitnessesto establish a defense. This right is a fundamental elementof due process of law.” (Washington v. Texas (1967) 388 U.S. 14, 19.) A defendant’s right to present relevant evidence “stands on nolesser footing than the other Sixth Amendmentrights.” (Taylorv. Illinois (1988) 484 U.S. 400, 409, citing Washington v. Texas, supra, 388 U.S.at p. 18.) As a result, a trial court’s authority to exclude a witness mustyield to a defendant’s right to a fair trial if that witness is capable of providing relevant testimony, including evidence of facts from which ultimate facts may be presumedor inferred, and the testimonyis not barred by statute. (AOB 132,citing Evid. Code § 351; People v. Williams (1996) 46 Cal.App.4th 1767, 1777, citing Chambersv. Mississippi (1973) 410 U.S. 284, 302.) Thetrial court violated Ghobrial’s constitutional right to present relevant evidencein his defense. Appellant’s opening brief makes clear that the excluded testimony of eleven different witnesses, who could have described Juan’s escalating efforts in the weeks prior to the homicide to seek out unfamiliar adults to provide him with food and companionship,his endeavors to avoid going home,and his spending a night in a car with an unknown man,all was relevant to dispute the prosecutor’s argumentsthat the jurors should construe Ghobrial’s relationship with Juan as “unnatural” 51 (8 RT 1921); view the pornography found in Ghobrial’s shed as a “magnet” used to “entice and to excite” Juan (8 RT 1924); and concludethat the material identified by the prosecution’s experts as sperm necessarily came from Ghobrial (8 RT 1928). (AOB 136-139.) This testimonyalso further undermines respondent’s claim that Ghobrial engaged in any “planning activity” prior to the homicide. (RB 65.) Respondentfails to understand the relevance of this proposed testimony. Respondentasserts, without citation, that defense counsel argued “the evidence wasrelevant to explain Juan’s motivation for seeking out Ghobrial or accompanying him to the shed.” (RB 77.) In both defense counsel’s offer of proof (2 CT 381-386) and at argument on the motion (5 RT 1237), defense counsel madeclear that evidence wasrelevant not to any motivation of Juan’s. Instead, it was offered to show that Juan actively “approachedandattempted to latch onto strange adults, particularly males, and who,particularly in the weeks leading up to the homicide, did not want to spend the night at home,” from which the jurors could infer that Juan formed his relationship with Ghobrial in the same fashion. (2 CT 385.) The evidence negated an inference that Ghobrial’s relationship with Juan “was a desire for sex.” (5 RT 1237.) In other words, the excluded evidence would haveestablished that Juan had any numberofrelationships with adult men similar to the one he had with Ghobrial. Respondent continues in the same vein by arguing that “Juan’s motivation or intent in spending time with Ghobrial wasnotat issue, and does nothing to prove or disprove whether Ghobrial himself sought out Juan for sexual purposes.” (RB 77-78.) Again, defense counsel never argued that the evidence wasrelated to Juan’s “motivation or intent’; rather, the evidence wasrelevant to Juan’s behavior. If Juan sought out Ghobrial more actively than Ghobrial sought out Juan, the jurors certainly could disbelieve 52 the prosecution’s argument that Ghobrial sought out Juan for an “unnatural” purposes. Furthermore, the ultimate issue for the jurors wasnot whether Ghobrial did or did not seek out Juan, but rather whether Ghobrial premeditated or deliberated prior to the homicide or whether a molestation occurred. If the prosecution wantedthe jurors to infer an “unnatural relationship” from the age difference between Juan and Ghobrial, the jurors were entitled to know that Juan had a numberof relationships with older men,not just Ghobrial. Furthermore, if Juan went to Ghobrial’s shed of his own accord, looking for a place to spend the night, then the pornography found in the shed could not have been the “magnet” the prosecution claimed, used to “entice and excite this little boy.” (RT 1924.) And if Juan wenton his own accord, Ghobrial could not be found to have plannedthe encounter. Asnoted in the openingbrief, the defense also soughtto introduce testimony that Juan sought out and had contact with multiple adult men, which suggested that Ghobrial was not the only possible source of the alleged sperm found in Juan’s anus. ““Given the degraded nature of the alleged sperm, there is no way to know whenit was deposited’ in relation to the time of death” or by whom. (AOB 131, citing 2 CT 385.) Respondent asserts that the “proffered evidence was too tenuous and speculative to be admitted as third party culpability evidence.” (RB 78.) Onceagain, respondenthas missed,or avoided,the point." The defense did not seek to '6Ghobrial was not charged with a violation of section 288; the information alleged only as a special circumstance that the murder was committed while appellant was engaged in the commission or attempted commission of the performanceof a lewd andlascivious act upon a child under 14, in violation of section 288, within the meaning of section 190.2 subdivision (a) (17) (E). (1 CT 87.) Appellant has been unable to discover any authority suggesting that a defendantcan introducethird party culpability evidence to defend against a special circumstanceallegation 53 introduce this evidenceto identify a third party as the sourceofthe alleged sperm, but to underminethe prosecution’s argument that only Ghobrial could be the source. Thetrial court recognized the relevance of the testimony. The court held a side-bar during the defense opening statement after the prosecution objected to the “defense giving a background and history of the victim.” (5 RT 1235.) Defense counsel explained that the information wasrelevant to “negate a presumption that the nature of Mr. Ghobrial’s relationship with Juan was a desire for sex and, therefore,is circumstantial evidence on the issue of whetheror not the killing occurred in the commission of a sexual act.” (5 RT 1237.) After the prosecutor asked, “How canit possibly be relevant?’, the court responded,“Whatis possibly relevant is that somebodyelse might have had a consensual sexual act with him, I suppose.” (5 RT 1237.) The court overruled the prosecutor’s objection, but when the issued wasrevisited during the defense case, althoughstill recognizing the relevance of the evidence, the court — perhapsrealizing that the evidence was damaging to the prosecution’s case — sustained the prosecution’s objection to the testimony of Oscar Leon. (58 RT 1685.) Leon would havetestified that, less than a month before the crime, Juan approached him at a donut shop somewhere between 11 p.m. and 12 a.m. and asked Leonto take him to look for his mother. Juan directed him to two different grocery stores, and after he still could not find his mother and Leon offered to take him home, Juan claimed he could not identify his own house. Juan then cried when Leon suggested taking him to the police station. They returned to the donut shop between 3:30 a.m. and 4:30 a.m. where they spent the remainder of the night in Leon’s car, and Leon drove Juanto the police station at 6:00 a.m. (2 CT 384.) In whenthe underlying felony has not been charged as a separate crime. 34 sustaining the objection to this testimony, the court stated: Mr. Cook, you are barking up the wrong tree. He spends the nightor part of a night in a car with Mr. Leon. Well, you know whatjurors could infer? That maybe something went on in that car. And maybe the boy [m]ight have been promiscuous. ... I don’t think thatis a fair inference, butit is certainly an inference that some people might draw. ... It has nothing to do with what might have gone on in that shed on the night in question. (8 RT 1685.) Of course, the evidence had everything to do with “what might have gone onin the shed on the night in question.” Without accusing Leon of depositing the alleged sperm in Juan’s anus, the jurors reasonably could believe that spending the night with strange adult men was not outside of Juan’s experience and completely separate from his relationship with Ghobrial. As appellant’s opening brief makesclear, the exclusion of this evidenceresulted in prejudice to Ghobrial: had the jurors heard the excluded testimony,it is reasonably probable that at least one juror would have had a reasonable doubt about whether Ghobrial molested or attempted to molest Juan. (AOB 138.) Respondentcites only to an irrelevant issue — the absence of evidence of third party culpability — and an uncontested issue — that “witnesses observed him planning and carrying out the disposal of Juan’s body’— in response. (RB 79.) Respondent’s inability to cite substantial and relevant evidence in rebuttal should be construed as an implicit recognition of the prejudice suffered by Ghobrial from the exclusion ofthis testimony. The prosecution’s case against Ghobrial wasentirely circumstantial and dependantupon inferences. The prosecutor wasable to argue to the jurors inferences from the evidencethat he believed pointed to Ghobrial’s guilt; Ghobrial had a constitutional right to present evidence that undermined the prosecution’s inferences and raised a reasonable doubt. 55 The court’s ruling on Ghobrial’s Penal Code section 190.4, subdivision (e) motion confirmsthe prejudice Ghobrial suffered; by excluding the evidence, the court wasable to accept only the prosecution’s inferences. At the hearing on Ghobrial’s application for modification of the verdict, the court stated that the evidence showed “there was some kind of attachment between Mr. Ghobrial and Juan” (11 RT 2829), and asserted that Ghobrial “lured the child for a particular purpose into the room consistent with his pre-offense statement”’’ (11 RT 2839). The excluded evidence established that Juan sought out attachments with any numberof older men andthat Ghobrial did nothing to “lure” Juan to the shed. More likely, Juan went to Ghobrial’s shed on his own accord, looking for someplace other than home to spend the night. Thetrial court’s refusal to allow the defense to present the excluded testimony violated Ghobrial’s constitutional right to present a defense. His conviction and sentence of death must be vacated. I! Hf '7Presumably the court is referring to Ghobrial’s taunts that he would kill Juan and eat his “pee-pee.” 56 Vill. THE PROSECUTOR COMMITTED PREJUDICIAL MISCONDUCT REQUIRING THE REVERSAL OF THE DEATH JUDGMENT Ghobrial’s trial took place under extraordinary circumstances. One day after jury selection began, terrorists attacked the Twin Towers World Trade Center and the Pentagon. When voir dire resumed on September17, 2001, a substantial numberofjurors disclosed that they could be neither unbiased norfair toward Ghobrial. The court granted the prosecutor and defense counsel’s joint motion to postponethe trial. (AOB 175, 2 RT 539].) Voir dire resumed on October 29, 2001, only 48 days later. (AOB 175, 2 CT 341; 3 RT 557] Defense counsel, the trial court, and the prosecutor were well aware of the challenge they faced finding unbiased jurors in the period immediately following the bombings. (AOB 174-175, 2 RT 537, 539].) As demonstrated in the opening brief, despite the extraordinary risk that the prejudice engendered against Ghobrial could be revived by jurors inaccurately and unfairly connecting him, as a consequenceof his Egyptian nationality and Arab ethnicity, to the terrorists responsible for the September 11 bombings, the prosecutor improperly and prejudicially compared Ghobrial to the terrorists and repeatedly referred to September 11 and Osama bin Laden. (AOB 174-183.) In so doing, the prosecutor deprived Ghobrial of the guarantee of fundamental fairness provided by the Due Process Clause of the Fifth and Fourteenth Amendments. (AOB 176.) Respondentrelegates to a footnote the extraordinary context in which Ghobrial wastried and jurors were selected. (RB 84,fn. 4.) Respondentfurther attempts to dismiss Ghobrial’s claim by repeated references to defense counsel’s failure to object to certain instances of misconduct, a point conceded in the opening brief. (AOB 181.) This 57 Court, however, will excuse the failure to object to prosecutorial misconduct and request a curative instruction when the misconductis of such a characterthatno instruction to the jurors could obviate its prejudicial effect. (See People v. Green (1980) 27 Cal.3d 1, 28, overruled on other grounds in People v. Martinez (1999) 20 Cal.4th 225; see also People v. Benson (1990) 52 Cal.3d 754, 793.) This exception flows “logically from the purpose of the objection rule: if... the requirement of an objection is intendedto give thetrial court the opportunity to cure the harm by an appropriate instruction, objection is an idle act whenit is reasonably probable that no such cure will follow.” (People v. Green, supra, 27 Cal.3d at p. 28.) In Ghobrial’s case, which was“tried less than two monthsafter the terrorist attacks, the prosecutor’s repeated references to September11, his comments regardingterrorists, his comparison of Ghobrial to suicide bombers, his unsupported assertion that the bombers wereall schizophrenic, and his description of Ghobrial as an immigrant who cameto this county to beg for money,”all fueled “an already incendiary situation” that no instruction from the court could cure. (AOB 180.) Unlike respondent, the prosecutor andthe trial court recognized that the effects of the bombingson jurors’ psyches would linger not only beyond the thirty day continuance requested by defense counsel, but likely would intensify. Initially denying the defense request for a continuance on September13, the court questioned its value, asking, “[b]ut how is [a continuance] really going to help? More and more investigation is going to take place, more and moreis going to be discovered and known, more and morepress is going to be solidified.” (2 RT 406.) The court went on to remark that Pearl Harbor continuedto have a significant impactfifty years later, stating “I mean that eventis still vivid in the minds of people, andit has been passed down to new generations.” (2 RT 407.) The prosecutor 58 agreed: “I know the impact of the actual horror of what happened has started, but it is going to keep going for a while. We are goingto retaliate, weare just going to be at war perhaps, we don’t know what’s going to happen. I just don’t see how continuing it for two weeks or four weeks or eight weeks makesany difference.” (2 RT 411.) Predictably, when the court asked of the prospective jurors whether, as a consequenceof the 9/11 bombings, any harbored bias against Ghobrial or believed the events would “ampactor affect your decisions in this case,” 17 jurors revealed they could not befair.'* (AOB 174, 2 RT 523, 527].) At that point the prosecutor stipulated to a continuance, which the court granted. (2 RT 539.) When Ghobrial’s trial resumed, the prosecutor appeared attentive to the continued dangerof bias against Ghobrial based on the events of 9/11. The prosecutor asked the court to “makea short little patriotic speech” informing the prospective jurors that Ghobrial was an Egyptian of the Coptic Christian faith and not Islamic. (3 RT 552.) The prosecutor also suggested that the court tell the jurors that Ghobrial had nothing to do with and had no sympathy towardsthe terrorist bombing,“[a]nd that if they would search their hearts and would be willing to serve. Something short, something patriotic, along the line, let them know weare nothere trying a terrorist. This case is its own case. It happenedyears before. It has nothing to do with those events.” (3 RT 552.) The court granted the prosecutor’s request andstated to each panel of prospective jurors, “Mr. '8After receiving the questionnaires but prior to questioning jurors abouttheir potential biases against Ghobrial arising from the events of 9/11, the prosecutor identified 29 jurors he believed should be dismissed for cause, the defense identified 60 jurors, and thetrial court identified 87. (2 RT 416.) Whenjury selection resumed on October 29, defense counsel noted that “welost a relatively high percentage the last time with the combination of death and a child victim, and that was without factoring in the September 11th event.” (3 RT 610.) 59 Ghobrial was born in Egypt, is a Coptic Christian, and has no sympathy for terrorist philosophy ortheir actions.” (3 RT 560, 570, 577, 586, 596, 603, 615, 622.) The prosecutor’s caution was well founded: “Determining whetherajuror is biased or has prejudged a caseis difficult, partly because the juror may havean interest in concealing his own bias and partly because the juror may be unawareofit.” (Smith v. Phillips (1982) 455 U.S. 209, 221-22.) Nevertheless, despite the prosecutor’s professed concern that the jurors not identify Ghobrial with the terrorist attacks, when the trial began the prosecutor, rather than scrupulously avoiding any suggestion that the two wererelated, improperly and prejudicially invited the comparison. (AOB 178-181.) Ghobrial does not dispute respondent’s argumentthat, when discussing the disputed testimony between the prosecution’s expert and the F.B.I.’s protocol for identifying sperm during guilt phase closing argument, the prosecutor’s statement that he would not take a “shot at” the F.B.I. because “right now . . . [it is] out there trying to hunt downterrorists,” while unnecessarily invoking 9/11, did not itself amount to misconduct. (AOB 178, 8 RT 1929].) The prosecutor did not, however, limit his reference to 9/11 to this one instance, but rather, during the penalty phase, escalated his rhetoric and made explicit his belief that Ghobrial and the terrorists should be linked. In cross-examining Dr. Jose Flores-Lopez, a psychiatrist who treated Ghobrial at the Orange County Jail and diagnosed him as suffering from schizoaffective disorder, the prosecutor soughtto elicit from the doctor a concession that Ghobrial’s symptomsof schizophrenia did not “stop him from being an evil person if he wants to be an evil person.” (10 RT 2509-2510.) When Flores-Lopez declined to validate the prosecutor’s notion of evil, the prosecutor asked whether the doctor considered Osama bin Laden “an evil man.” (10 RT 2509-2510.) Although the trial court 60 sustained defense counsel’s objections, the prosecutor’s line of questioning invited the jury to equate Ghobrial’s moral culpability with that of Osama bin Laden’s. Respondenthas no substantive responseto this instance of the prosecutor’s misconduct, but simply notesthat trial counsel failed to request an admonition and the jurors were instructed they were to neither consider attorney’s statements as evidence nor assumeto be true any insinuation suggested by a question asked of a witness. (RB 89.) As noted in the opening brief and above, however, no instruction bythetrial court could have ameliorated the prejudicial impact once the prosecutor introduced references to September 11 and Osama bin Laden. “As this Court has recognized, ‘You can’t unring a bell.’” (AOB 181, citing People v. Hill (1997) 17 Cal.4th 800, 845-846.) The opening brief demonstrates how the prosecutor’s continued references to Ghobrial’s foreignness and the Al Qaeda suicide bombers during the penalty phase closing argumentreinforcedhis prior efforts to associate Ghobrial with the tragedy of September 11. (AOB 179-180.) Respondentasserts that the prosecutor only invoked Ghobrial’s status as an immigrant from Egypt for proper purposes: one, to argue that, because Ghobrial had been in the country only a short period of time, the jurors could view the absence ofa prior felony conviction under factor (c) as having minimal mitigating effect, and two, to dismiss the disabling impact of his schizoaffective disorder because he “managedto get out of Egypt and to work his way here .. . to beg for money. . . [and pay] $100 a month for a shed.” (RB 92-93.) If these were the prosecutor’s only remarks reminding the jury of Ghobrial’s status as a foreigner and an Egyptian, respondent’s argument might have somevalidity. These references, however, must be evaluated in the context of the entire record. (People v. Green, supra, 27 61 Cal.3d at p. 28.) When combinedwith the prosecutor’s other comments invoking the suicide bombers — whothe jurors knew to be of Arabian ethnicity and that at least one was Egyptian — and Al Qaeda,the jurors likely viewed these remarks as an additional invitation to act on bias and | prejudice when deciding whether Ghobrial should be sentencedto life or death. The prosecutor also improperly and prejudicially equated Ghobrial’s psychotic delusions with what he characterized as the religious delusions of the suicide bombers. (AOB 179-180.) Respondent defends the prosecutor’s likening of Ghobrial’s mental illness to that of the suicide bombers, claiming that “the prosecutor did not compare Ghobrialorhis crimesto those infamousfigures. He simply used those figures to illustrate that a person suffering from delusions couldstill choose to commit criminal acts.” (RB 95.) The figures the prosecutor choseto illustrate his point, however,had,just a little over three monthsearlier, attacked the United States and caused the death of almost 3000 people. As the court noted in People v. Zurinaga (2007) 148 Cal.App.4th 1248, six years after the 9/11 bombings, We. . . considerit naive at best — and disingenuous at worst — to suggest . . . that the mere mention of 9/11 does not continue to invoke fear, dread and angerin the listener.” (Jd. at pp. 1259-1260.) If six years later the ““mere mention” of 9/11 continued to “invoke fear, dread and anger in the listener,” the extremely prejudicial impact of such references only a little over three monthslater cannot be doubted.’” 'In a 2012 case, defendants charged with conspiracy to levy war or to oppose by force the authority of the United States governmentfiled a motion in limine to exclude, inter alia, a bumperstickerstating: “Remember 9-11 was an inside job.” The district court granted the motion as to the bumperstickerstating, in part, that “bringing 9/11 into this case risks distracting the jury from the real issues.” (United States v. Stone (E.D. 62 Respondent’s broad defense of the prosecutor’s actions is by citation to cases holding that prosecutors are generally afforded “widelatitude during closing argument.” (RB 97.) Respondent’s effort to minimize the uniqueness of Ghobrial’s situation and normalize the prosecutor’s misconductbyciting to cases addressing garden-variety prosecutorial hyperbole that this Court has found acceptable mustbe rejected.”” The prosecutor began jury selection for Ghobrial’s trial recognizing the enormouspotential for jurors to harbor prejudice and bias against Ghobrial as a consequenceof the September 11 bombings; oncethe trial commenced, however, rather than meticulously and conscientiously avoiding any commentor remark that might connect Ghobrial in the mindsofthe jurors with the events of 9/11, the prosecutor exploited that potential for prejudice and biasin his zeal to obtain a death verdict. Whether he acted in good faith or bad is of no matter; prosecutorial misconduct is measured by the injury inflicted on the defendant as a consequence. (See People v. Bolton (1979) 23 Cal.3d 208, 213-214.) By repeatedly reminding the jurors of the horrifying events of 9/11, the prosecutor encouraged the susceptible jurors to view Ghobrial with the same sense of horror when deciding whether he Mich. 2012) 852 F.Supp.2d 820, 838.) See e.g., RB 90, citing People v. Schmeck (2005) 37 Cal.4th 240, 298-299 [prosecutor described defendant as a “dope dealing lying rat’’]; People v. Sassounian (1986) 182 Cal.App.3d 361, 396 [in a case being tried 23 years later, prosecutor referenced the assassination of President Kennedy]; RB 95,citing People v. San Nicolas (2004) 34 Cal.4th 614, 665- 666 [prosecutor described defendantas “that animal,” “vicious,” and as a “base individual”]; RB 95-96, citing People v. Jones (1997) 15 Cal.4th 119, 180, People v. Millwee (1998) 18 Cal.4th 96, 153, People v. Pinholster (1992) 1 Cal.4th 865, and People v. Maury (2003) 30 Cal.4th 342, 420,all cases in which the prosecutor madereferences either to Nazis, Charles Manson,or both; and RB 99, citing People v. Edelbacher (1989) 47 Cal.3d 983, 1030 [prosecutor called defendanta “snake in the jungle’’]. 63 should live the rest of his life in prison or be executed. In the absence of the prosecutor’s misconduct, it is likely the jurors would have concluded that a punishmentoflife without the possibility of parole was sufficient. As a consequence, Ghobrial’s sentence of death must be reversed. I HI 64 X. THE CUMULATIVE EFFECTS OF THE ERRORS REQUIRES REVERSAL OF GHOBRIAL’S CONVICTION AND SENTENCE Asstated in the opening brief, Ghobrial’s case should never have been sent to the jury. (AOB 3.) Ghobrial suffers from a severe mental illness — schizoaffective disorder — the symptoms of which include auditory and visual hallucinations, paranoia, bizarre delusions, disorganized speech and thought process, profoundly impaired social and occupational functioning, and suicidal ideation. Thetrial court’s failure to suspend proceedings and conduct a competency hearing wasthefirst of multiple errors occurring during Ghobrial’s trial whose cumulative effects require that his conviction and sentence of death be reversed. (AOB 201-203.) Respondent’s meager four paragraph answer must be dismissed. (RB 108- 109.) The likelihood that the cumulative errors so infected “the trial with unfairness” (Donnelly v. DeChristoforo (1974) 416 U.S. 637, 642-643), cannot be underestimated. Once Ghobrial stood before the jury, symptoms of his illness, includinghis flat affect and focus on internal stimuli, would haveleft the jury with the view that he was indifferent to the tragic facts of the crime and lacked remorse. He also stood before the jury as an Egyptian national little over two monthsafterthe terrorist attacks on the Twin Towers and the Pentagon, accused of murdering a child — a crime for which potential jurors frequently admit they cannot be fair and unbiased. The prosecutor presented no substantial evidence on the contested issue of whether Ghobrial attempted to molest Juan, and thetrial court excluded relevant evidence that would have further refuted the unreasonable inferences the prosecutor askedof the jurors. The court also failed to properly instruct the jurors, but even if they had been properly instructed, 65 the symptomsof Ghobrial’s illness, the fact of his Egyptian nationality, and the nature of the crime likely led the jurors to overlook the insufficiency of the evidence and the court to improperly exclude evidence helpful to Ghobrial. Ghobrial’s sentence of death also was infected by the cumulative impact of multiple errors. The prosecutor exploited the factor mostlikely to inflame the jurors’ prejudice against Ghobrial despite their best intentions by referring frequently during closing arguments to Osama bin Laden and the terrorists responsible for the bombings. The jurors not only were swayed bythe prosecutor’s misconduct, they also likely treated Ghobrial’s severe mentalillness as a factor in aggravation rather than as mitigation. The victim wasa child and the crime especially gruesome. Ghobrial should never have beensentto trial and his life put in the hands of the jury. The substantial impairments Ghobrial suffered as a result of his severe mental — illness left him less culpable than those without such impairments, but more vulnerable to prosecutorial misconduct and juror biases. His conviction and sentence of death must be reversed. | / I! 66 CONCLUSION Forall of the reasons stated above, both the judgmentof conviction and sentence of death in this case must be reversed. DATED: February 13, 2014 Respectfully submitted, MICHAEL J. HERSEK State Public Defender Dmen’LeAW DENISE ANTON - Supervising Deput ate Public Defender ANNE LACKEY Deputy State Public Defender Attorneys for Appellant 67 CERTIFICATE OF COUNSEL (CAL. RULES OF COURT, RULE8.630(b)(2)) I, Denise Anton, am the Supervising Deputy State Public Defender assigned to represent appellant, John Ghobrial, in this automatic appeal. | directed a memberofourstaff to conduct a word countofthis brief using our office’s computer software. Onthe basis of that computer-generated word count,I certify that this brief is 18,800 wordsin length excluding tables, certificates and attachments. Dated: February 13, 2014 Dw Ma “DENISE ANTON Supervising Deputy State Public Defender Attorney for Appellant 68 ATTACHMENT A D A T E O B S E R V A T I O N O B S E R V E D B Y R T 3-24- 1998 D '’ s mo od a n d af fe ct w e r e in ap pr op ri at e to th e si tu at io n, th at is , hi s ar re st . H e w a s m u m b l i n g to hi ms el f a n d h a d ra pi d ey e bl in ki ng . He w a s lo ok in g t o th e fl oo r mo st o f th e ti me . Ne ed ed a n in te rp re te r be fo re m a k i n g an y de ci si on ab ou th i s or ie nt at io n, m e m o r y or in te ll ec tu al fu nc ti on in g. S a w D la te r w i t h a n in te rp re te r. U p o n qu es ti on in g, D ad mi tt ed h e h a d se en s o m e o n e in E g y p t fo r hi s me nt al pr ob le ms . S h e as ke d ab ou t au di to ry ha ll uc in at io ns a n d D sa id he h a d h a d c o m m a n d ha ll uc in at io ns te ll in g h i m to hu rt ot he rs a n d hi ms el f. D al so sa id he h a d h a d su ic id al th ou gh ts a n d to ld he r he w a n t e d to b e th ro ug h wi th co ur ts in hi sl if e. D u r i n g th e in te rv ie w, D w a s la ug hi ng , w h i c h wa sa b s o l u t e l y in ap pr op ri at e af fe ct . He u s e d to ta ke me di ca ti on , bu t di dn ’t k n o w th e n a m e a n d w a s n o lo ng er ta ki ng i t . Be li ev es D to ld he r th at hi s fa th er br ou gh t h i m to th e do ct or ea rl ie r. VirginiaSollars, RN 10RT 2404-06 “ D ” r e f e r s to M r . Gh ob ri al . — e r r s - : — DATE OBSERVATION | a lopseevepay l e r | a s — s i a n n a n c i e n 3-25- D i a g n o s e d D as a psychotic disorder N O S ( not otherwise specified). Dr. J a s m i n k a 10 R T 1 9 9 8 S y m p t o m a t o l o g y that caused hert o reach this diagnosis: Depovic, 2 4 2 9 - 3 0 ° D wasdisheveled, alert, and not speaking m u c h English. N o t a w a r e Psychiatrist whether suicidal or homicidal because h e could not answer. ° D told nurses h e w a s hearing voices because he wasseeinga translator. ° Appearedt o h a v e “very brightaffect.” ° Affect w a s inappropriate, w h i c h could b e a negative s y m p t o m of a schizophrenic or psychotic illness. 3-26- D is o n safety status a n d can’t be pulled for interviews. Also will n e e d K a y 10 R T 1998 interpreter. N o treatment history with O C mental health, but past psychiatric Cantrell, N u r s e 2260-61 treatment in Egypt. ° Positive history of auditory hallucination of c o m m a n d n a t u r e telling h i m to h a r m others a n d self. That is not w h a t D said but info she received. ° A p p e a r e d with express suicidal ideation, “wanting to get through with courts, e n d w i t h life.” S h e w a s told h e said that; h e didn’t tell h e r that. . History of suicide attempts but n o specifics k n o w n . 3-28- * D talking to himself. Dr. Teresa Farjalla, 10 R T 1998 . Psychiatrist 2 4 6 4 3-29- | D d r e w a devil with soap for her. S h e asked h i m to d o that. Can’t Dr. Teresa Farjalla, 10 R T 1 9 9 8 recall h o w it c a m e about. Psychiatrist 2 4 6 4 3-31- |e D uncooperative a n d refusing to speak. Dr. Jose Flores- 10 R T 1998 |e D w a s m a k i n g a mess o f h i s cell a n d notf u l l y dressed. Lopez, Psychiatrist 2 4 7 7 2 D A T E O B S E R V A T I O N |O BS ER VE D BY R T 4- 1- 19 98 D un co op er at iv e an d re fu si ng to sp ea k. D w a s m a k i n g a me ss o f h i s ce ll a n d no t fu ll y dr es se d. Dr . J o s e Fl or es - Lo pe z, Ps yc hi at ri st 1 0 R T 2 4 7 7 04 -7 - 19 98 D to ld he r, “I a m no t cr az y. ” Re fu si ng m e d s a n d w a n t e d re gu la r ho us in g. Dr . Ja sm in ka De po vi c, Ps yc hi at ri st 10 R T 2 4 3 3 - 3 4 Saw D wi th tr an sl at or . D se en b y t e a m d u e to in cr ea se d wi ll in gn es st o ta lk . Di ag no si s un cl ea r. D e n y i n g su ic id e id ea ti on , pl an ori nt en t. Hi st or y of in te rm it te nt fe el in g li ke th e de vi l is in hi m. Al so in te rm it te nt au di to ry ha ll uc in at io ns a n d cl ai ms of lo ng pe ri od s of ha vi ng no r e c a l l of hi s ac ti vi ti es . Tr ea tm en t in E g y p t a n d 7 ye ar s tr ea tm en t wi th Dr . Br ah im . D w a s sp on ta ne ou si n in te rv ie w an db r i e f l y te ar fu l co up le of ti me s. Re fu si ng at fi rs t bu t th en wi ll in g to ta ke me ds . N o t e d he ha dr e f u s e d or re fr ai ne d f r o m sp ea ki ng En gl is h wi th he r, bu t le ar ne d he w a s ab le to sp ea k s o m e En gl is h. H e w o u l d us e si gn in g a n d ex pr es si on s. KayCantrell,N u r s e 10RT 2263-65 D A T E O B S E R V A T I O N O B S E R V E D BY. R T 4-2- D informedh e r “ I speak only little English.” Said h e h a d h a d mental health Dr. J a s m i n k a 1 0 R T 1998 treatment. “I a m crazy in Egypt. “Was i n hospital.” Depovic, 2 4 3 1 - 3 2 ° D w a n t e d medication for voices or problemsi n his head. Psychiatrist ° D said sometimes h e l o s e s his English. ° Affect w a s labile. D goes f r o m beingv e r y , v e r y flat to very, very h a p p y or very, very angry. ° D wasc r y i n g . 4-3- N o t d o n e well c o m m u n i c a t i n g with D. D tried to c o m m u n i c a t e with his Dr. Steven 10 R T 1998 hands. Johnson, 2 2 7 3 ° D wasd i r t y a n d disheveled. Psychiatrist ° A p p e a r e d N . A . D . — not in apparentdistress. ° D w a s o n a n d J o h n s o n continued h i m o n Haldol, an antipsychotic, a n d cogentin, to counteract Haldols i d e effects. 4-4- ° D hads i l l y grin that s e e m e d inappropriate or unusual. Dr. Jose Flores- 10 R T 1998 . Interpreted that D w a s responding to auditory hallucinations a n d not Lopez, Psychiatrist 2 4 7 7 focusing o n conversation. 4-6- ° D claimed he wasn o t s e e i n g or hearing anything and he refused meds__| Dr. J a s m i n k a 1 0 R T 1998 for 2 days. Depovic, 2 4 3 2 ° “T w a s scared.” Psychiatrist 4-7- ° D told her, “I a m not crazy.” Dr. J a s m i n k a 10 R T 1998 |e Refusing m e d s a n d w a n t e d regular housing. Depovic, 2 4 3 3 Psychiatrist D A T E | O B S E R V A T I O N O B S E R V E D B Y R T 4- 9- 19 98 D wa s o n n o re st ri ct io ns . Dr . S t e v e n J o h n s o n , Ps yc hi at ri st 10 R T 2 2 7 3 - 7 4 4- 9- 19 98 C a s e m a n a g e m e n t f o l l o w - u p . ° Al er t, sm il in g a n d sp on ta ne ou s b u t ke ep s in di ca ti ng li mi te d En gl is h. * _ N o t wi ll in g to si gn re le as e of in fo fo r ta lk s wi th at ty . At te mp ti ng th is co nv er sa ti on in En gl is h. A s k e d wh yt h e y ne ed ed t o ta lk to hi s at to rn ey a n d in di ca te d th at at to rn ey sp ok e ve ry li tt le En gl is h. K a y Ca nt re ll , N u r s e 10 R T 2 2 6 5 - 6 7 4- 10 - 19 98 Su bj ec ti ve : D wa nt s to sh av e. Ob je ct iv e: Di sh ev el ed ,d ir ty ; C a l m , br oa d af fe ct . A s s e s s m e n t : h a r d to as se ss w / o in te rp re te r. C l e a r fo r L 16 , w h i c h m e a n s mo ve t o le ss ac ut e wa rd . Al re ad y of f ob se rv at io n Dr . S t e v e n J o h n s o n , Ps yc hi at ri st 10 R T 2 2 7 5 4- 11 - 19 98 D is o n no r e s t r i c t i o n . Dr . S t e v e n J o h n s o n , Ps yc hi at ri st 10 R T 2 2 7 5 4- 13 - 19 98 Di ff ic ul t to c o m m u n i c a t e . e Di sh ev el ed . ¢ D e n i e s id ea ti on s or ha ll uc in at io ns , b u t s e e m s un re li ab le . As se ss me nt : pr ob ab ly ps yc ho ti c, de sp it e de ni al s. Re fu se s me ds . Co nt in ue ob se rv at io n. Dr . S t e v e n J o h n s o n , Ps yc hi at ri st 10 R T 2 2 7 5 - 7 6 4-13- 1998 Dhadrefu s e d me di ca ti on a n d me di ca ti on st op pe d o n 4- 7- 98 . S a w n o e v i d e n c e o f ac ut e m e n t a l il ln es s to w a r r a n t ac ut e in te rv en ti on . D o e s n o t m e a n D wa sn o t me nt al ly il l. Dr.JoseFlores- Lopez,Psychiatrist 10RT 2477-78 e e . — = — _ — e e DATE OBSERVATION OBSERVED BY [RT o e E S MN a e 4-23- H e w a s in M o d L, whichi s psychiatric portion ofjail. Jill Savage, C a s e 9 R T 1 9 9 8 |e Alert, a w a k e a n d normal. M a n a g e r 2 1 6 0 - 6 3 ¢ A w a r e of surroundings. ¢ Oriented times 3 ¢ A p p e a r s clean a n d well-groomed. * Smiling. M o o d appears euthymic and affect is congruent. Doesn’t s e e m depressed or angry. “ I ’ m h a p p y because I give myself for G o d . ” * Reports h e eats a n d sleeps well. Denies thoughts of harmings e l f or others. D i s c u s s e d c a s e w i t h t e a m earlier; e n d o f observationsa t that time. 05- ¢ D wasr e f e r r e d b y deputy o n M o d J d u e to “bizarre behavior.” D e p u t y L i n d a KayP r i c e , 10 R T 1998 said D w o u l d not respond to verbal c o m m a n d s . F o o d wasa l l overt h e cell} N u r s e 2256- a n d floor a n d D was“ t a l k i n g to himself.” 2 2 5 8 ¢ W h e n s h e a r r i v e d , D wasi n the rec area, walking u p a n d downt h e s i d e wall, eyes down,talking to himself. D i d not look or respond to her verbal prompts. ¢ H e sat d o w n a n d beganc r y i n g and talking to himself. A p p e a r s to be R.T.LS. — responding to internal stimuli. * Mood i s labile, but he is hard to assess, d u e to u n c o m m u n i c a t i v e behavior a n d possible language barrier. * T o o unpredictable a n d potential danger to himself a n d others. Doesn’t a n s w e r question of being suicidal or intent to h a r m others. Treatment Plan 1. Safety g o w n ; observation; 2. Psychiatrist evaluation; 3. C a s e m a n a g e r DCp l a n n i n g [discharge plan]; 4. 5150. D A T E O B S E R V A T I O N O B S E R V E D BY .. . R T 5- 13 - 19 98 D sa id , “I a m n o t cr az y. ” De ni ed s u i c i d a l id ea ti on a n d ha ll uc in at io ns . Al er t, co he re nt a n d or ie nt ed . T h o u g h t s w e r e or ga ni ze d; sl ee pi ng fi ne ; co op er at iv e. Af fe ct w a s ap pr op ri at e a n d h e wa sf ri en dl y. Ma rg ar et W i g g e n h o r n , M e n t a l He al th Sp ec ia li st 10 R T 2 3 7 2 - 7 3 5- 18 - 19 98 Fr ie nd ly an ds a i d “t he re ar e n o vo ic es in m y he ad .” D e n i e d id ea ti on so r in te nt to hu rt an yo ne . Al er t, co he re nt , or ie nt ed w i t h o r g a n i z e d th ou gh ts . At ti tu de w a s co op er at iv e. Ma rg ar et W i g g e n h o r n , M e n t a l He al th Sp ec ia li st 10 R T 2 3 7 3 - 7 4 5- 20 - 19 98 Ce ll w a s di rt y wi th pa pe rs sc at te re d. S l o w in hi s re sp on se a n d gr in ni ng an d sm il in g in ap pr op ri at el y. T h o u g h t D wa sr es po nd in g t o in te rn al st im ul i. Al er t a n d co he re nt , bu t th ou gh ts s e e m e d co nf us ed . D e n i e d ha ll uc in at io ns or de si re to ki ll hi ms el f. Sa id sl ee pi ng a n d ea ti ng ok . Co op er at iv e. Ma rg ar et W i g g e n h o r n , M e n t a l He al th Sp ec ia li st 10 R T 2 3 7 4 - 7 5 5- 20 - 19 98 Su bj ec ti ve : D sa ys “ I n o si ck .” Re fu se s me ds . Ob je ct iv e: D e n i e s id ea ti on s or ha ll uc in at io ns ; S p e e c h no rm al ; sp ea ks li tt le En gl is h. As se ss me nt : s e e m s st ab le . Al re ad y cl ea re d fo r L 16 . Ra te , r h y t h m a n d v o l u m e of sp ee ch no rm al . N o t sc re am in g, wh is pe ri ng ,e tc . Dr . S t e v e n J o h n s o n , Ps yc hi at ri st 10 R T 2 2 7 6 - 7 7 5-23- 1998 Nocomplai nt s; no t in di st re ss ; n o re st ri ct io ns . Dr.StevenJohnson, Psychiatrist 10RT 2277 D A T E O B S E R V A T I O N — o S e e B Y R T 5-25- * M o o d a n d affect w e r e anxious. Said he felt scared of everything. Margaret 10 R T 1998 |* A d m i t t e d to auditory hallucinations “calling m y n a m e . ” W i g g e n h o r n , 2 3 7 5 - 7 6 ¢ Eating only | meala day. M e n t a l Health e Alert a n d coherent. Specialist ¢ T h o u g h t confused. ¢ Speechc l e a r . ¢ D e n i e d a n y thought of doing h a r m to himself or others. * Cooperative. 5-25- |° Subjective: C o m p l a i n i n g of anxiety. Dr. Steven Johnson, 10 R T 1 9 9 8 ¢ Objective: Anxiousaffect; Psychiatrist 2 2 7 7 - 7 8 ¢ Disheveled; ¢ N o r m a l speech. Assessment: anxiety, psychotic ? Plan: start Mellaril, 10 m g 4x/day. Usually, anxious just m e a n s anxious. B u t a psychotic m a y say that w h e n doesn’t w a n t to admit h e is hearing voices or seeing things. ? after psychotic because D denied psychotic s y m p t o m s , but Dr. suspected h e wasn o t telling wholes t o r y . Mellaril is a n antipsychotic to eliminate voices, hallucinations, paranoid ideations,etc. 5-27- * Subjective: D likes that m e d s h a v e nos i d e effects. Dr. Steven Johnson, 10 R T 1 9 9 8 |* Objective: Disheveled; Psychiatrist 2 2 7 8 - 7 9 ¢ Soft-spoken; ¢ D e n i e d ideations, hallucinations. Assessment: seemsstable. Plan: continue Mellaril, 10 mg/day. D A T E O B S E R V A T I O N O B S E R V E D B Y R T 6- 1- 19 98 e Ap pr op ri at e m o o d an da ff ec t. e N o t sc ar ed or si ck a n y m o r e a n d di dn ’t n e e d me ds . A s k e d to be tr an sf er re d. e Al er t a n d co he re nt . Or ie nt ed . D e n i e d ha ll uc in at io ns or de si re to hu rt hi ms el f. e Ap pe ti te a n d sl ee p w e r e “o ka y. ” Ma rg ar et W i g g e n h o r n , M e n t a l H e a l t h Sp ec ia li st 1 0 R T 23 76 -7 7 “T do n’ t ne ed s me di ca ti on .” No te s sa y: “ D C Ha ld ol . Pa ti en t re fu si ng .” O n 6- 1- 98 c h a n g e d Me ll ar il to 25 at be dt im e. Me ll ar il is fo r ps yc ho ti c th in ki ng . B e t w e e n Ap ri l a n d Ju ne he go t b a c k o n me ds . Dr . Ja sm in ka De po vi c, Ps yc hi at ri st 10 R T 2 4 3 3 19 98 ¢* Mo od a n d af fe ct s e e m ap pr op ri at e. “I n o si ck an ym or e. I g o h o m e . ” ¢ D e n i e d ha ll uc in at io ns or su ic id al id ea ti on . ¢ Co he re nt ; sp ee ch wa sc l e a r wi th n o pr es su re . e Ap pe ti te go od . ¢ Co op er at iv e. ‘M ar ga re t W i g g e n h o r n , M e n t a l He al th Sp ec ia li st 10 R T 2 3 7 7 - 7 8 ¢ D as ki ng w h y he h a d to ta ke me ds , bu t h e w a s ta ki ng th em . ¢ Co op er at iv e. A l w a y s sm il in g du ri ng th is vi si t. Dr . J a s m i n k a D e p o v i c , Ps yc hi at ri st 1 0 R T 2 4 3 4 ¢Daske dt o g o ba ck t o re gu la r ho us in g. \ e Al er t; co he re nt ; cl ea rl y ex pr es se d hi ms el f. ¢ D e n i e d ha ll uc in at io ns . ° Co op er at iv e. Margaret Wiggenhorn, MentalHealth Specialist 10RT 2378 D A T E OBSERVATION _|OBSERVEDB Y _ 6-12- 1998 Hew a s r e f u s i n g psychiatric medications, saying “ I ’ m all better. N o m o r e voices.” D s a w n o reason for m e d s but D will m o s t likely begin to hear voices again without them. M e d s w o u l d h a v e b e e n antipsychotic meds. Jill Savage, C a s e M a n a g e r R T 9 R T 2 1 6 4 6-22- 1 9 9 8 D denies problems. N o medication side effect. D agrees to continue meds. Alert, oriented X 3 , speakslittle English. Broada f f e c t ; cheerful m o o d ; n o fearfulness; n o signs o f depression; n o overt psychosis; n o suicidal ideation, n o homicidal ideation. Noverbalization — m i n i m a l speech. Ability or desire to speak English fluctuated. N o EPS, h a v i n g to d o w i t h med s i d e e f f e c t . Psychomotorn o r m a l . G o o d hygiene. A s s e s s m e n t : stable o n his m e d s ; continue o n Mellaril. Ability or desire to speak English fluctuated. A w a r e that nurses a n d deputies observed D c o m m u n i c a t i n g with other. K r i s t e n W h i t m o r e , N u r s e Practitioner 9 R T 2 1 8 8 - 8 9 7-10-1998 D appeared e v e n m o r e disheveled. Grinning inappropriately. Reported decreased appetite a n d difficulty sleeping. Insists there are four black meni n his cell. Returned to cell a n d pointed to e m p t y cell, insisting they’re in there. Referred h i m to nurse practitioner to evaluate his medication. Jill Savage, C a s e M a n a g e r 9 R T 2 1 6 5 10 D A T E O B S E R V A T I O N O B S E R V E D B Y R T 7- 13 - 19 98 D wa sn o t ac tu al ly se en . De pu ti es to ld he r th at th ey co ul dn ’t al lo w pa ti en t to co me o u t t o se e he r at th e ti me . S h e no rm al ly s a w h i m in th e d a y r o o m ar ea a n d de pu ti es w e r e co nc er ne d ab ou th i s sa fe ty . Ot he r in ma te s wa nt ed t o ki ll hi m. e S h e re ad a no te f r o m th e ca se ma na ge rs a y i n g th at D h a d a de lu si on ab ou t 4 bl ac k me ni n hi s ce ll a n d st at in g ca se ma na ge r’ s ob se rv at io ns th at D w a s ps yc ho ti c. ¢ G o t in fo rm at io n f r o m ps yc hi at ri st Dr . L o p e z th at D w a s se xu al ly pr eo cc up ie d. H e wa si ns is ti ng th at nu rs es pu t an ti fu ng al c r e a m in hi s gr oi n fo r hi m, be ca us e he on ly h a d o n e ar m. D w a s o n me ll ar il a n d sh e in cr ea se d th e do se . It is an an ti ps yc ho ti c to co nt ro l ps yc ho ti c s y m p t o m s . Kr is te n W h i t m o r e , N u r s e Pr ac ti ti on er 9 R T 2 1 7 5 7- 24 - 19 98 ¢ B e c o m i n g in cr ea si ng ly bi za rr e. ¢ A t pr es en t ti me mu te . W o u l d n ’ t re sp on d to qu es ti on s. e Sm il in g in ap pr op ri at el y, un ke mp t, do es n’ t fo ll ow si mp le c o m m a n d s . T o o k ps yc h me ds i n fr on t of h e r . Ji ll Sa va ge , C a s e M a n a g e r 9 R T 2 1 6 7 - 6 8 7-27- 1998 Patientwa s no t se en ag ai n. S h e h a d a co nv er sa ti on wi th Dr . L o p e z a n d no te d th er e w a s s o m e di ff er en t as se ss me nt s b y di ff er en t m e m b e r s of th e t e a m as to wh et he r D w a s ma li ng er in g. Th at is , pr es en ti ng hi ms el f to ap pe ar me nt al ly i l l fo r be ne fi ts h e mi gh t ga in f r o m th at . It is al wa ys a po ss ib il it y in a ja il se tt in g. Al so po ss ib le to ma li ng er we ll ne ss . Me nt al ly il l tr yi ng to d e n y s y m p t o m s . T e a m w a s de ba ti ng wh et he r D w a s ma li ng er in g or tr ul y me nt al ly il l. Di ag no si s wa sn ’t cl ea r at th at po in t. KristenWhitmore, NursePractitioner 9RT 2177-78, 2190 11 O B S E R V A T I O N |O B S E R V E D B Y — R T o s e D ’ s case discussed a m o n g s t W h i t m o r e , case m a n a g e r a n d Dr. Lopez. T h e y decidedt o increase his dosage of mellaril. Discussed that h e w a s understress going to court. N o t unusual for psychotic s y m p t o m s to w o r s e n understress. That is w h a t she thought m i g h t be happening. Also notedt h a t patientstates h e cannot understand English. W r o t e that she w o u l d attempt to see h i m next d a y with an interpreter. K r i s t e n W h i t m o r e , N u r s e P r a c t i t i o n e r 9 R T 2179-80, 2 1 9 1 Tried to interview D to assess his mentalstatus in Arabic. ¢ D w a s uncooperative a n d kept responding “I don’t k n o w ” a n d “I don’t r e m e m b e r . ” ¢ S h e wasa s k i n g to see if D w a s a w a r e of the time a n d asking if h e w a s hearing voices or seeing visions to assess the mental status. D a n s w e r e d h e didn’t remembero r k n o w . * D h a d b e e n taking medicationst h a t interfere with m e m o r y . Possible that that is reason for saying h e didn’t k n o w or r e m e m b e r . N a b e e l B e c h a r a , R N 1 0 R T 2254-55 8-15- 1 9 9 8 D movedt o M o d J, w h i c h is non-psychiatric unit, o n 8-12. * D w a s smearing foodi n cell a n d shaking. D seen outside cell with deputy. D is mute. E y e s makings l i g h t l y jerking m o v e m e n t s , then movingl i p s w / o speaking. ¢ Decompensating. A p p e a r s respondingt o internal stimuli. ¢ Will return h i m to Mod L , p s y c h . unit, a n d observation. Inmates being treated for mentalillness don’t always stay o n the psych unit. It is for m o s t acute patients. Chronic mental illness controlled with m e d s will be movedi n t o non-psych ward. ¢ D wasn o t saying anything in any language. N o t respondinga t all. K a y Cantrell, N u r s e 1 0 R T 2 2 6 7 - 6 8 12 D A T E — — — — — = — O B S E R V A T I O N OB SE RV ED B Y R T 8- 16 - 19 98 © D wa sl i k e l y re sp on di ng t o in te rn al st im ul i, no t ta lk in g to Dr . Fl or es - Lo pe z. ¢ Pa ra no id a n d de lu si on al . Dr . Jo se Fl or es - Lo pe z, Ps yc hi at ri st 10 R T 2 4 7 8 8- 17 - 19 98 e D r e m a i n e d th e sa me . e Tr as hi ng hi s ce ll a n d me ss in g it up . Dr . J o s e Fl or es - Lo pe z, Ps yc hi at ri st 10 R T 2 4 7 8 8- 18 - 19 98 ¢ D di sl ik es co nc en tr at e a n d re qu es ts ta bl et s. ¢ D i s h e v e l e d , u n k e m p t , an xi ou sa f f e c t . A s s e s s m e n t : di sl ik es co nc en tr at e. Pl an : di sc on ti nu e co nc en tr at e. Me ll ar il , 10 0 m g . ta bs 2/ da y. Dr . S t e v e n J o h n s o n , Ps yc hi at ri st 10 R T 2 2 8 0 8- 19 - 19 98 e D ha ds i l l y gr in an d wa sa c t i n g bi za rr el y. ¢ L o o k e d un ke mp t. ¢ St ic ki ng hi s fi ng er s in hi s ea rs a n d is to d r o w n ou t th e no is e. C o m m o n in s o m e b o d y ex pe ri en ci ng au di to ry ha ll uc in at io ns . ¢ A p p e a r s an xi ou s. Pa ci ng i n hi sc el l. ¢ D li ke ly su ff er in g f r o m sc hi zo ph re ni a, bu t co ul d be de lu si on al di so rd er . Ex pl or in g po ss ib il it y of ps yc ho si s, wh et he r sc hi zo ph re ni a or de lu si on al di so rd er . D r . J o s e F l o r e s - L o p e z , Ps yc hi at ri st 10 R T 2 4 7 9 8-20- 1998 Dsentba c k to L- 18 , wh ic hi s th e ac ut e un it . ¢ D w a s ap pa re nt ly sm ea ri ng fo od o n ce ll wa ll wh il e o n re gu la r ho us in g Mo d J . ¢ D di d no t s h o w si gn s of be in g ov er ly ps yc ho ti c. S h e fe lt he w a s in co nt ro l. Dr.TeresaFarjalla, Psychiatrist 10RT 2464-65 13 D A T E O B S E R V A T I O N at OBSERVEDB Y [ R T 9-3- 1998 Reported auditory hallucinations. H e a r d family talking to him. Hears u n s e e n people talking inside hiscell. Affect w a s inappropriate. Constantly smiling, regardless of topic. Jill Savage, C a s e M a n a g e r 9 R T 2166, 2 1 6 8 9-16- 1998 D e p u t y said D understands English perfectly w h e n s p o k e n to b y deputies. Patient insists, “ N o English” w h e n W h i t m o r e asked questions. D trying to tell her h e heard voices. M o d L nursest o l d her that D converses clearly with another inmate. D wasa l e r t a n d oriented to person. Unablet o fully assess orientation or d o complete mental status e x a m . K n e w w h o h e was. B u t wasn’t conversing in English so mental status e x a m not complete. D h a d s i l l y grin. M o o d wase u t h y m i c , basically, normal. N o t depressed, tearful. N o overt signs of depression. Behavior w a s calm. Noo v e r t signs of psychosis or depression. Synopsizes info f r o m deputies a n d nurses about possible malingering. “Per information f r o m deputies a n d nurses the patient is manipulating a n d likely wants a label as mentally ill.” D i d nothing to determine whether opinions w e r e correct or h o w they formulated them. It is not her personal assessment. Continued o n meds. N o dosage change. Kristen W h i t m o r e , N u r s e P r a c t i t i o n e r 9 R T 2181-85 9-19-1998 D tied string tightly around his penis. Doesn’t r e m e m b e r doing so. States h e just w o k e u p andi t w a s there. This has h a p p e n e d m a n y times a n d usually h e can gett h e string off himself. S h e then h o u s e d h i m in a m o r e acute housing in a safety g o w n to prevent h i m f r o m h a r m i n g himself. Jill Savage, C a s e M a n a g e r 9 R T 2 1 6 8 - 6 9 14 D A T E O B S E R V A T I O N a c o OB SE RV ED B Y R T 9- 20 - 1 9 9 8 S a w a f t e r h e w a s re tu rn ed to L- 19 , tr an sf er re d f r o m L - 1 6 se co nd ar y to da ng er ou st os e l f . ¢ D we nt f r o m le ss ac ut e to ac ut e ho us in g be ca us e he w a s da ng er ou s to hi ms el f. ¢ He h a d t i e d a st ri ng ar ou nd hi s pe ni s. D de ni ed he h a d do ne s o . ¢ D ad mi tt ed su ic id e id ea ti on s a n d h e h a d in cr ea se dt a l k i n g to hi ms el f. ¢ Af fe ct wa sf la t. Dr . Ja sm in ka De po vi c, Ps yc hi at ri st 10 R T 24 34 -3 5 9-21- 1998¢ D r e m a i n e d bi za rr e, as so ci at ed wi th sc hi zo ph re ni a or sc hi zo -a ff ec ti ve di so rd er . Be ha vi or do es n’ t le ad to an yt hi ng . ¢ D w a s ma ni pu la ti ng hi s cl ot he s. No tr ea ll y si gn if ic an t to di ag no si s be ca us ei t ha pp en s i n ja il se tt in g w h e r e li mi te d cl ot hi ng a n d te mp er at ur e. ¢ D mi gh tb e se lf -m ut il at in g. Dr.JoseFl or es - Lo pe z, Ps yc hi at ri st 10RT 2480-81 15 DATE O B S E R V A T I O N O B S E R V E D B Y o o R T2 9-22- 1998 * Subjective: D complaining of auditory hallucinations; * Requests translator; a n d * Deniess i d e effects of medications. ¢ Objective: D disheveled; poor hygiene; ¢ Auditory hallucinations; suicidal ideations; ¢ P o o r c o m m u n i c a t i o n d u e to language. Assessment: psychotic. Plan: find translator. Increase mellaril to 100 m g , 3/day to decrease hallucinations. psychotic m e a n s personi s out of touch with reality. Either hallucinating or having delusions, l i k e paranoid ideation. H o l d i n g beliefs not consistent with reality or seeing or hearing things not consistent with reality. Disheveled and hygiene havesignificance in that depressed people often don’t h a v e energy to attend to o w n hygiene. Psychotic people often aren’t e v e n a w a r e of their o w n hygiene. M o r e complicated because D missing an arm. Dr. S t e v e n J o h n s o n , Psychiatrist 10 R T 2280-81 9-23-1998 ¢ Difficult to talk because of language; * Disheveled andd i r t y ; ¢ Talks tos e l f ; ¢ Smiling affect; * Auditory hallucinations. Assessment: still psychotic. Plan: interpreter; continue Mellaril, 1 0 0 m g , 3x/day. D r . S t e v e n J o h n s o n , Psychiatrist 10 R T 2 2 8 2 16 D A T E |O BS ER VA TI ON O B S E R V E D B Y R T 9- 24 - 19 98 Tr yi ng to ge t tr an sl at or . ¢ N o ob vi ou s si gn s of di st re ss . La te r th at da y h e a n d en ti re tr ea tm en t t e a m as se ss ed D wi th in te rp re te r: ¢ D ad mi ts au di to ry ha ll uc in at io ns , su ic id al id ea ti on a n d de pr es si on . e Ag re es t o tr y an ti -d ep re ss an t. De ni es s i d e ef fe ct s. e W a n t s m o r e me di ca ti on s. St ar t Pr oz ac , 2 0 m g in A M . I n c r e a s e Me ll ar il to 10 0 m g 4x /d ay . Dr . S t e v e n J o h n s o n , Ps yc hi at ri st 10 R T 22 82 -8 3 9- 25 - 19 98 Ca n’ t c o m m u n i c a t e be ca us e of la ng ua ge . ¢ D a n d ce ll ar e “e xt re me ly ” fi lt hy . Ce ll “ m u s t h a v e b e e n re al ly aw fu l fo r Dr . to un de rl in e “e xt re me ly ,” be ca us e he wa su s e d to se ei ng ve ry di rt y ce ll s. ” ¢ No a p p a r e n t di st re ss . As se ss me nt : di ff ic ul t to as se ss . Pl an : re qu es t tr an sl at or ; co nt in ue me ds . Dr . St ev en Jo hn so n, Ps yc hi at ri st 10 R T 2 2 8 5 9- 26 - 1 9 9 8 ¢ D th ou gh t me di ci ne w a s he lp in g. e D h a d b e e n en ga gi ng i n se lf de st ru ct iv e be ha vi or a n d mu ti la ti ng hi s o w n ge ni ta ls . Ta lk ed to D ab ou t no t hu rt in g hi ms el f or ty in g an yt hi ng ar ou nd hi s pe ni s. A s s u m e s h e pr om is ed n o t to ot he rw is e sh e w o u l d h a v e in te rv en ed . Dr . Te re sa Fa rj al la , Ps yc hi at ri st 10 R T 2 4 6 5 - 6 6 10-2- 1998 ¢Aske d D wh et he rh e in te nd ed t o ti e an yt hi ng ar ou nd h i s pe ni s a n d he sa id he wa sn ’t . Dr.TeresaFarjall a, Ps yc hi at ri st 10RT 2466 17 = D A T E OBSERVATION O B S E R V E D B Y { R T 10-7- |* Subjective: language problem; Dr. Steven Johnson, 10 R T 1998 |* D says too sleepy o n Mellaril 4 x/day. Psychiatrist 2 2 8 5 ¢ Objective: Somnolent; ¢ Disheveled; a ¢ C a l m a n d cheerful. Assessment: oversedated b y Mellaril. Plan: decrease Mellaril to 2 0 0 m g in p.m. Continue Prozac, 2 0 m g in am. 10-8- ¢ D appeared disheveled. Dr. Teresa Farjalla, 10 R T 1998 Psychiatrist 2 4 6 6 10-9- |* D h a d not e n g a g e d in any m o r e self-destructive behavior since being Dr. Teresa Farjalla, 10 R T 1998 brought b a c k to L-18. Psychiatrist 2 4 6 6 10-13- * D talking to the mirror. D stopped w h e n h e s a w her a n d c a m e over a n d Dr. Teresa Farjalla, 10 R T 1998 tried to talk to her. Psychiatrist 2 4 6 6 - 6 7 10-31- * Disheveled, smiles and nods. Jill Savage, C a s e 9 R T 1998 * Semi-cooperative. Probably d u e to languagebarrier. M a n a g e r 2 1 6 9 ¢ D e n i e d suicidal, homicidal, hearing voices or feeling paranoid. 18 D A T E | OB SE RV AT IO N O B S E R V E D B Y R T 11 -2 - 1 9 9 8 e D sa ys Pr oz ac is go od . Li ke s th e Me ll ar il at ni gh tt im e. e S e e m s to b e m a k i n g in cr ea se d e f f o r t to in te ra ct , th ou gh st il l in si st in g h e do es n’ t un de rs ta nd En gl is h. D is m o r e in te ra ct iv e, ta lk in g mo re . ¢ Af fe ct in cr ea se d, m o r e ap pr op ri at e. ¢ M o o d eu th ym ic . Di dn ’t lo ok de pr es se d. N o t su ic id al . Be ha vi or ca lm . ¢ Cl ai me dt o st il l he ar vo ic es . Po in ts to hi s ea rs a n d ma ke s st at em en ts r e : vo ic es Or ie nt ed . N o t u n c o m m o n f o r me nt al st at e of o n e wi th ps yc ho ti c il ln es s to fl uc tu at e. K r i s t e n W h i t m o r e , N u r s e P r a c t i t i o n e r 9 R T 2 1 8 6 - 8 7 11 -3 - 19 98 n o ob se rv ab le ev id en ce th at D re sp on di ng t o in te rn al st im ul i. S a w no th in g bi za rr e. D r . J o s e F l o r e s - Lo pe z, Ps yc hi at ri st 1 0 R T 2 4 8 1 12-8- 1998¢Dr e f u s e d to gi ve ey e co nt ac t. e N o t re sp on di ng to qu es ti on s. ¢ Co nt in uo us ly ta lk in g to se lf a n d st ar in g at fl oo r. N e x t co ur t da te 1- 27 . Co nt in ue wi th W a r d D. Wi ll di sc us s wi th ps yc hi at ri c M D pe rr e g u l a r nu rs e. W h e n re ce iv es me ds , D is co mp li an t, co op er at iv e an d do es n’ t s e e m in ap pr op ri at e. W h e n in da yr oo m, so ci al iz es wi th ce rt ai n in ma te s in hi s d o r m th ru th ei r ce ll do or . JillSavage,Ca s e M a n a g e r 9RT 2169-70 19 D A T E . O B S E R V A T I O N O B S E R V E D B Y R T 12-14- * D looking into mirror a n d talking to himself w h e n e v e r Dr. w a s in the area. Dr. Jose Flores- 10 R T 1998 * Sometimes s t a f f told h i m that D talked to himself only w h e n he wasthere. Lopez, Psychiatrist 2 4 8 2 - 8 4 R e c e i v e d other info, including f r o m other inmates, that D talked to h i m s e l f w h e n n o o n e w a s around. Hadi n f o that D talked to himself even w h e n n o _ psychiatric staff observed him. * Possibility that D might b e malingering. Indicated that in his assessment, h e w o u l d give D the benefit of the doubt. A s jail psych, m u s t assess possibility of malingering. Everyonei n prison trying to get something f r o m t h e m that they can’t get otherwise. M u s t always be o n the lookout — everyone doesit. N o t specific to a diagnosis. 12-19- D seen at request of C M S a f t e r h e approachedn u r s e ands a i d “I’m hurt.” Jill Savage, C a s e 9 R T 1998 ¢ Abrasion onl e f t scrotum. History of self-mutilative behavior to penis. M a n a g e r 2 1 7 0 ¢ R e f u s e d to respond to questions. H o u s e d in L-14. Safety gowno n l y . 12-20- |* Flat affect Dr. J a s m i n k a 10 R T 1998 Depovic, 2 4 3 5 Psychiatrist 12-21- |* Staff f o u n d abrasions once again to D ’ s genitals. D admitted causing the Dr. Teresa Farjalla, 10 R T 1998 abrasion. Psychiatrist 2 4 6 7 2 0 D A T E OB SE RV AT IO N O B S E R V E D B Y R T 12 -2 2- 19 98 La ng ua ge di ff ic ul ti es . ¢ Mo ve t o L 1 8 du et o se lf -m ut il at io n of ge ni ta li a ag ai n. As se ss me nt : da ng er t o se lf . Pl an : n o tr an sl at or av ai la bl e. In fo rm ed se rv ic e ch ie f of n e e d fo r on e. Co nt in ue su ic id e pr ec au ti on s a n d co nt in ue me ds . D h a d hi st or y in ja il of se lf -m ut il at io n of ge ni ta ls . H e wo ul dt i e st ri ng s ar ou nd hi s pe ni s. K n e w D h a d be en t r e a t e d fo r ty in g a st ri ng ar ou nd h i s pe ni s. Dr . S t e v e n J o h n s o n , Ps yc hi at ri st 10 R T 2 2 8 6 - 8 7 12 -2 4- 19 98 ¢ D h a d be en se lf -m ut il at in g hi s ge ni ta ls . ¢ D al so ta lk in g a n d la ug hi ng to hi ms el f. ¢ As se ss ed D as ha vi ng ps yc ho si s N O S [ n o t ot he rw is e sp ec if ie d. ] ¢ Al so no te d, “r ul e ou t ex ag ge ra te d ma li ng er in g. ” W / o pr op er te st in g or e x a m i n a t i o n , h e co ul dn ’t ru le it ou t. D di d n o t ex hi bi t a n y be ha vi or t h a t ca us ed h i m to th in k h e w a s ma li ng er in g. Dr . J o s e Fl or es - Lo pe z, Ps yc hi at ri st 10 R T 2 4 8 4 - 8 6 12 -2 9- 1 9 9 8 Pa rt ic ip at ed in a t e a m st af fi ng o n D ’ s ca se . A n in te rp re te r wa sa l s o pr es en t. ¢ D wa sn o t sh ow er in g or ch an gi ng h i s cl ot he s. ¢ A s s e s s m e n t wa st h a t D w a s su ff er in g f r o m ps yc ho si s a n d de pr es si on . Dr . Te re sa Fa rj al la , Ps yc hi at ri st 10 R T 2 4 6 7 - 6 8 12-30- 1998 11thday of ob se rv at io n, w h i c h me an sc e l l co nf in em en ta s a su ic id e pr ec au ti on . (F ir st a n d m o s t se ve re le ve l in ce ll co nf in em en ti s a sa fe ty g o w n , w h i c h th ey ca n’ t ri p in to sh re ds to h a n g th em se lv es . Li tt le le ss ac ut e, re gu la r ja il -i ss ue cl ot he s, bu ts ti ll in ce ll co nf in em en t so ca n’ t j u m p of f up pe rt ie r. ) ¢ D i s hi di ng un de r a bl an ke t a n d is un re sp on si ve . Dr.StevenJohnso n , Ps yc hi at ri st 10RT 2288 21 — — — DATE OBSERVATION _| OBSERVED BY | RT 12-31- D a y 12 of observation. Dr. Steven Johnson, 10 R T 1998 {* D says h e is “okay,” but n o meaningful conversation because of language Psychiatrist 2 2 8 9 barrier. * Noa p p a r e n t distress. a 1-1- D r e m a i n e d manipulative re: housing. H e neededt o stay in mental health Dr. Jose Flores- 10 R T 1999 housing, but because of beds, they h a v e to send people to regular housing. Lopez, Psychiatrist 2 4 8 6 - 8 8 Often a person mayb e t r u l y mentally ill, but k n o w s he m a y be attacked or ridiculed in general housing. T h e y fear going to general population a n d will try to r e m a i n mentallyi l l so they stay in mental health housing. Somep r e f e r to stay in mental health housing; s o m e prefer regular housing; s o m e whoa r e mentally ill c h a n g e their minds. Their pattern is to ask for w h a t they don’t have. Psychoticillnesses like schizophrenia a n d schizo-affective disorder are very stress-related illnesses. B e i n g understress can increase the discomforts causedb y t h e illness. General premise is that mentally ill inmate is under mores t r e s s in regular housing. “Absolutely” not unusual for mentallyi l l inmate to g o into regular housing a n d decompensate, e v e n if they remain o n m e d s . 22 D A T E — — — — OB SE RV AT IO N | O B S E R V E D B Y RT 1- 3- 19 99 ¢ D r e m a i n e d un ch an ge d. N o c h a n g e in me ds . D h a d se ve ra l ch an ge s of me di ca ti on th ru ou t hi s tr ea tm en ta t th e ja il , w h i c h is no t u n c o m m o n . Of te n m e d s h a v e br ea kt hr ou gh s. Af te r a ce rt ai n le ng th of ti me o n an ef fe ct m e d , pa ti en t wi ll d e c o m p e n s a t e a n y w a y a n d h a v e to ch an ge to ot he r me ds . C h a n g i n g me ds i s no t un us ua li n a tr ul y ps yc ho ti c pa ti en t. Al so no t un us ua l fo r ps yc ho ti c pa ti en t to re sp on d to on e m e d an dn o t an ot he r. ¢ O n 1- 1- 99 a n d 1- 3- 99 , D w a s o n Z y p r e x a a n d Me ll ar il a n d Pr oz ac . Z y p r e x a a n d Me ll ar il ar e an ti ps yc ho ti c me ds . La te r sw it ch ed to Se ro qu el . D r . J o s e F l o r e s - Lo pe z, Ps yc hi at ri st 10 R T 2 4 8 8 - 8 9 1- 5- 19 99 D sa ys h e i s o k a y bu t di ff ic ul ti es as se ss in g be ca us e of la ng ua ge ba rr ie r. ¢ Ob je ct iv e: D i s h e v e l e d ; ¢ C a l m ; e U n a b l e to co mm un ic at e. As se ss me nt : di ff ic ul t to as se ss . Pl an to “t ea m” pa ti en t wi th tr an sl at or . 1- 5- 99 w a s d a y 17 of ob se rv at io n. W h e n h a v e di ff ic ul t or ch al le ng in g ca se s, tr y to ge t en ti re t e a m to ge th er to de ci de w h a t to do . Th at ha s ha pp en ed s e v e r a l ti me s in D ’ s ca se . Dr . S t e v e n J o h n s o n , Ps yc hi at ri st 10 R T 2 2 8 9 - 9 0 1-6- 1999 Day18of ob se rv at io n. ¢ Ob je ct iv e: P o o r hy gi en e; e Sm il es bu t s e e m s fo rc ed . As se ss me nt : di ff ic ul t to as se ss . Pl an : t e a m wi th tr an sl at or as ap . Se em ed t h a t D wa sn o t re al ly h a p p y bu t w a n t e d to lo ok li ke h e wa s. pr ob ab ly be ca us e o n d a y 18 of co nf in em en t— th at is lo ng ti me fo r ce ll co nf in em en t. M a d e s a m e ob se rv at io ns as o n 1- 5- 99 . Dr.StevenJohnson, Psychiatrist 10RT 2290-91 23 OBSERVATION |OBSERVEDB Y — D r . S t e v e n J o h n s o n , R T 10 R T 1-7- D seen b y t e a m with translator. . 1 9 9 9 | Will discontinue observation a n d increase zyprexa to 2 0 mga t bedtime. Psychiatrist 2 2 9 1 - 9 2 Z y p r e x a is an antipsychotic. 1-8- * Subjective: D says h e is ok; language problems. Dr. Steven Johnson, 10 R T 1999 | Objective: N o apparent distress; Psychiatrist 2 2 9 2 * Disheveled. Assessment: s e e m s i m p r o v e d o n meds. Plan: find translator. Continue Zyprexa, 2 0 mga t bed; Prozac, 4 0 m g in am. 1-15- * Subjective: D denies a n y itching today; Dr. Steven Johnson, 10 R T 1999 ¢ Complains o f increase in auditory hallucinations; wants to r e s u m e m e d s to Psychiatrist 2 2 9 2 - 9 4 decrease them. ¢ Objective: Disheveled; ¢* Nor a s h ; ¢ Auditory hallucinations, n o ideations or other hallucinations; ¢ H a s anxiousaffect; ¢ Increase in psychosis. Assessment: post drug allergy to either prozac, zyprexa or colace. Restarted zyprexa “with caution,” because of drug allergy. Looksl i k e they took a w a y all the medstot r y to alleviate the rash, but because of increase in hallucinations, restarting m e d s at l o w e r dose. 1-17- N o t sure whether D understood his English. D periodically smiled at him. L e o n a r d Luna, 10 R T 1 9 9 9 Attempting to understand English, but always unsure whether D did. L C S W 2381 ¢ T h o u g h t m a y b e D wass a y i n g he h a d auditory hallucinations, but not sure. 2 4 D A T E O B S E R V A T I O N O B S E R V E D B Y R T 1- 19 - 1 9 9 9 S a w D wi th in te rp re te r. Su bj ec ti ve : Co mp la in in go f r a s h in gr oi n se ve ra l mo nt hs ; it ch es ; In cr ea se in au di to ry ha ll uc in at io ns . Ob je ct iv e: Al er t; or ie nt ed x3 ; A u d i t o r y ha ll uc in at io ns , n o id ea ti on s or ot he r ha ll uc in at io ns ; An xi ou s af fe ct ; P o o r hy gi en e; No rm al s p e e c h ; As se ss me nt : ru le ou t ra sh in gr oi n. Ps yc ho ti c. Pl an : in cr ea se zy pr ex a to 2 0 mg a t b e d to de cr ea se ha ll uc in at io ns . Cl ea r fo r L 1 9 or L1 6. D r . S t e v e n J o h n s o n , Ps yc hi at ri st 10 R T 2 2 9 5 - 9 6 1- 20 - 19 99 Su bj ec ti ve : D re po rt s n o si de ef fe ct s; Sl ep t we ll ; Vo ic es l e s s . Ob je ct iv e: D i s h e v e l e d , al er t, or ie nt ed x3 ; No i d e a t i o n s ; Au di to ry ha ll uc in at io ns bu t le ss th an be fo re ; A n x i o u s a f f e c t ; C o h e r e n t . As se ss me nt : le ss ps yc ho ti c. R u l e ou t jo ck ra sh . Co nt in ue zy pr ex a at s a m e le ve l. D r . S t e v e n J o h n s o n , Ps yc hi at ri st 1 0 R T 2 2 9 6 2- 10 - 19 99 Me t. wi th D w / o in te rp re te r. Se em ed t o be re po rt in g he di d no t h a v e pr ob le ms w i t h hi s ho us in g. Ju st he r in te rp re ta ti on as to wh et he r D un de rs to od h e r o r n o t . Be ha vi or ap pr op ri at e. L e o n a r d L u n a , L C S W 10 R T 2 3 8 2 2 5 DATE OBSERVATION _| O B S E R V E D B Y RT 2-11- |* D admitted to hearing voices, but“ j u s t a little.” Dr. Teresa Farjalla, 10 R T 1999 Psychiatrist 2 4 6 8 2-25- |* D w a s respondingt o internal stimuli. Talking to himself in thecell. L e o n a r d Luna, 10 R T 1999 Facing the mirror a n d engaging in conversations with it. H e said nothing L C S W 2 3 8 2 - 8 3 aboutinternal stimuli. H e r observations. ¢ Pleasant to her. * D didn’t report any problems. 3-3- * O b s e r v e d D talking to himself in front of the mirror. Smiled a n d L e o n a r d Luna, 10 R T 1999 acknowledgedh e r . L C S W 2 3 8 3 ¢ T o l d h i m he h a d a 3-12-99 court date. D n o d d e d a n d exhibited n o distress. ¢ Still talking to himself. N o t causing a n y problems. * N e x t court date w a s 9-10-99. There h a d beenarticles about D’sc a s e in the paper that w e e k a n d D h a d cut t h e m out. S h o w e d t h e m toh e r . 3-8- ¢ D h a d s i l l y affect ands i l l y grin. T h e y are inappropriate affects, w h i c h isa Dr. Jose Flores- 10 R T 1999 negative s y m p t o m that can b e associated with psychotic illness. Lopez, Psychiatrist 2 4 8 9 - 9 0 3-25- |* D r e m a i n e d manipulative. Dr. Jose Flores- 10 R T 1 9 9 9 e D said h e h a d diarrhea. Didn’t k n o w whether h e really did, or w a n t e d to Lopez, Psychiatrist 2490-91 c h a n g e meds. That is w h a t h e described as manipulative. D denied auditory hallucinations and denieda l l positive psychiatric _symptoms h e asked D about. 26 D A T E O B S E R V A T I O N O B S E R V E D B Y R T 4- 1- 19 99 D re po rt ed h e w a s he ar in g m o r e vo ic es a n d wa nt ed t o se e th e do ct or . D sp ea ki ng in li mi te d En gl is h. St il l ta lk in g to hi ms el f. N o t ca us in g an y pr ob le ms . N e x t co ur t da te w a s 9- 10 -9 9. Th er e h a d be en ar ti cl es ab ou t D ’ s ca se in th e pa pe r th at w e e k a n d D h a d cu t t h e m ou t. S h o w e d t h e m to he r. L e o n a r d L u n a , L C S W 1 0 R T 23 83 -8 4, 23 96 -9 7 D re po rt ed in cr ea se d au di to ry ha ll uc in at io ns a n d ap pe ar ed to be re sp on di ng to in te rn al st im ul us , on ly w h e n be in g wi tn es se d. De pu ti es re po rt ed th at D ’ s be ha vi or w a s wi th in n o r m a l li mi ts a n d th at D h a d an in cr ea se da bi li ty to sp ea k En gl is h at ot he r ti me s. At o t h e r ti me s, he go ti nf o th at D w a s re sp on di ng t o in te rn al st im ul i e v e n w h e n he di dn ’t k n o w h e w a s be in g ob se rv ed . H e r e c o m m e n d e d t h a t D g o to so me pl ac e li ke Pa tt on St at e Ho sp it al so h e co ul d be fu ll y as se ss ed b y th e ap pr op ri at e sp ec ia li st in th e ap pr op ri at e se tt in g. W a n t e d to ru le ou t ma li ng er in g fo r me ds . In hi s no ta ti on s fo r 4- 7- 99 , h e m a d e r e c o m m e n d a t i o n th at h e w a s n ’ t su re w h e t h e r D w a s co mp et en t. N e e d e d a co mp et en cy as se ss me nt . N o t co mp et en t to st an d tr ia l. N o t co mp et en t to un de rs ta nd th e na tu re of th e pr oc ee di ng s ag ai ns t h i m be ca us e of a ps yc ho ti ci ll ne ss . Dr . Jo se Fl or es - Lo pe z, Ps yc hi at ri st 10 R T 2 4 9 1 - 9 3 4-8- 1999 Dstil l re po rt in g au di to ry ha ll uc in at io ns . St il l ta lk in g to se lf wh il e lo ok in g in th e mi rr or . No o t h e r di st re ss . LeonardLuna, LCSW 10RT 2385 27 DATE OBSERVATION 8 L o u s i n v e p e y lars | e e a a ss — i = - a n a i 4-29- | D again reported he w a s hearing voices. L e o n a r d Luna, 10 R T 1999 |* Other than talking to self, behavior w a s appropriate. L C S W 2 3 8 5 * N o t e d that lack of English limited ability to get all s y m p t o m s . 5-6- ¢ S a w D talking tos e l f . L e o n a r d Luna, 1 0 R T 1999 |* S m i l e d politely to her, then returned to his bunk. Usually h e w o u l d wait L C S W 2 3 8 5 - 8 6 to hear w h a t she hadt o say. ¢ A d m i t t e d to auditory hallucination a n d exhibited them. 3-17- * N o t e d that D remained unchangedo n or off meds. A t that time, D w a s o n Dr. Jose Flores- 10 R T 1999 Z y p r e x a a n d Depakote. Lopez, Psychiatrist 2 4 9 3 2 8 D A T E OB SE RV AT IO N O B S E R V E D B Y R T 5- 19 - 19 99 a — D a y 1 of ob se rv at io n. D w a s mo ve db a c k f r o m Mo d L to M o d J d u e to o d d be ha vi or . M o d J is pr ot ec ti ve cu st od y ho us in g. M o v e d f r o m th er e to M o d L, wh ic hi s ps yc hi at ri c ac ut e ho us in g ar ea , be ca us e of o d d be ha vi or . e Su bj ec ti ve : “D on ’t sp ea k En gl is h. ” * Ob je ct iv e: D w a s di sh ev el ed ; ¢ bl un te d af fe ct ; a n d e L a n g u a g e pr ob le m. ¢ Be ha vi or a b o v e so un ds ps yc ho ti c bu t ot he rs no te s su gg es t D mi gh t be a ma li ng er er . ¢ Be ha vi or th at s o u n d e d ps yc ho ti c w a s f r o m ca se m a n a g e r w h o s a w D im me di at el y be fo re hi m: “C li en t se en o n M o d J. Ap pa re nt ly he ha s b e e n ur in at in g in hi s ce ll . D o e s no t re sp on dt o di re ct io ns a t th is ti me . In ap pr op ri at e fo r M o d J. ” . N u m b e r o f di ff er en t do ct or s w o r k in ja il ’s me nt al he al th te am . Ge ne ra ll y ta ke tu rn s se ei ng cl ie nt s in 2 - m o n t h ro ta ti on s. Ex ac er ba te d w h e n in ma te s m o v e ar ou nd t o di ff er en t ho us in g. D m o v e d f r o m L 1 8 , L 1 9 , L 1 6 , M o d J. E a c h ti me h e m o v e s , di ff er en t ps yc h or nu rs e se ei ng hi m. Dr . S t e v e n J o h n s o n , Ps yc hi at ri st 1 0 R T 22 96 -9 9 5-20- 1999 ¢Repo rt th at D h a d b e e n ur in at in g in hi sc el l. ¢ D wa sr e t u r n e d to ac ut e me nt al he al th ho us in g. ¢ N o t e d th at D h a d no t e n g a g e d in se lf de st ru ct iv e ac ti vi ty fo r ov er 4 mo nt hs . Dr.TeresaFarjall a, Ps yc hi at ri st 10RT 2469 2 9 D A T E O B S E R V A T I O N oe | O B S E R V E D B Y |R T | 5-25- |* D admitted auditory hallucinations. Dr. Teresa Farjalla, 10 R T 1999 | Either responded to her questions re: that or she w o u l d see h i m e n g a g e d in Psychiatrist 2 4 6 9 - 7 0 activities demonstrating that he w a s respondingt o internal stimuli. Like talking into the mirroro r t o himself. * N o t e d o n 5-25-99 that D ’ s hallucinations w e r e not causing a n y behavior problems. 6-3- * D reported that h e w a s feeling very bad. L e o n a r d Luna, 10 R T 1999 |* Voices wereincreasing. L C S W 2 3 8 6 - 8 7 ¢ H e s e e m e d m o r e upset a n d m o r e depressed than in prior sessions. M o r e depressed that she h a d ever seen him. That conclusion based o n w h a t she s a w — his affect, emotion, face. ¢ D e n i e d anyintent t o hurt self or others. ¢ Still talking to himself. D h a d court date of 9-10-99. 6-7- ¢ N o t e d that D r e m a i n e d psychotic, e v e n though h e did nota t that time Dr. Jose Flores- 10 R T 1 9 9 9 report auditory hallucinations. O p i n i o n based o n his observations of D. Lopez, Psychiatrist 2 4 9 3 6-8- * S a w s i t t i n g o n his b e d talking to himself. L e o n a r d Luna, 10 R T 1 9 9 9 |* H e h a d b e e n urinating o n the flooro f his cell. L C S W 2 3 8 7 - 8 9 Cell w a s a mess. D did not respond to her prompting. S h e diagnoses mentalstates in her capacity as a social workeri n thejail. 3 0 DA TE OB SE RV AT IO N. O B S E R V E D B Y R T 6- 14 - 19 99 ¢ T o l d th at D h a d b e e n de fe ca ti ng a n d ur in at in gi n hi s ce ll a n d co ns ta nt ly ta lk in g to hi ms el f. ¢ In di ca te d in no ta ti on th at th er e w a s a st ro ng el em en t of ma li ng er in g. B u t he w o u l d gi ve D th e be ne fi t of th e do ub t. In a ps yc hi at ri c fo rm at , 3 el em en ts us ed to di ag no si s or de fi ne a tr ea tm en t: me nt al st at us e x a m a n d ob se rv at io n of in ma te ; se lf -r ep or ti ng a n d pa st hi st or y a n d me di ca l re co rd s; a n d ac tu al la b a n d ps yc ht es ti ng , in cl ud in g ne ur op sy ch te st in g. Wi th ou t te st in g, he co ul d no t ma ke a “d ef in it iv e ru le -o ut ” of ma li ng er in g. Dr . Jo se Fl or es - Lo pe z, Ps yc hi at ri st 1 0 R T 2 4 9 4 - 9 5 6- 16 - 19 99 ¢ D b a c k in L- 19 . C l a i m e d to h a v e n o id ea w h y h e wa sb a c k t h e r e . ¢ D wa st ra ns fe rr ed fo r ob se rv at io n an dt it ra ti on of me di ca ti on . Pe r Dr . Lo pe z’ s no te , D tr an sf er re d se co nd ar y to no t ea ti ng , de fe ca ti ng a n d ur in at in g o n hi ms el f. D r . J a s m i n k a D e p o v i c , Ps yc hi at ri st 10 R T 2 4 3 5 - 3 6 6-17- 1999 SawD af te r he wa st ra ns fe rr ed to L1 8. D a y 2 of ob se rv at io n. ¢ Su bj ec ti ve : M o v e d to L 1 9 fo r po ss ib le su ic id al id ea ti on . ¢ Re po rt ed ly no t ea ti ng o n L1 6. Pe r R N re po rt , D ha s ea te n 1 0 0 % of h i s me al s in 2 4 ho ur s. ¢ Al er t, tr em bl in g, qu ie t sp ee ch . e A p p e a r s an xi ou s. D e c i d e d to h a v e t e a m me et in g o n h i m th at da y. K e p t o n su ic id e wa tc h. Dr.StevenJohnso n , Ps yc hi at ri st 10RT 2299- 2300 31 D A T E O B S E R V A T I O N OBSERVED BY _ | R T 10 R T 6-18- D a y 3 o f observation. Dr. S t e v e n J o h n s o n , 1999 |¢ Languagebarrier. Psychiatrist 2 3 0 0 ¢ P o o r hygiene. e¢ Trembling. ¢ Eaten all meals since transfer to L18. Assessment: thought suicidal based o n refusal to eat. Since n o w eating, o k to take h i m off safety g o w n . Plan: discontinue g o w n a n d food monitoring. O b s e r v e off g o w n . W e i g h w e e k l y for 4 weeks. G e t translator. T e a m D next week. 6-19- |* D said h e w a s not having any hallucinationsa t the time of the interview. Dr. J a s m i n k a 10 R T 1999 Depovic, 2 4 3 6 Psychiatrist 6-22- C o u l d n ’ t c o m m u n i c a t e . Dr. S t e v e n J o h n s o n , 1 0 R T 1999 ¢ D has b e e n c a l m a n d quiet during time o n L18. Psychiatrist 2 3 0 1 * Nos i g n s of psychosis or depression. ° Eating. 6-23- Nointerpreter. Dr. Steven Johnson, 10 R T 1999 |* Subjective & objectuve: can’t talk because of languagebarrier. Psychiatrist 2 3 0 1 - 0 2 * P o o r hygiene. ¢ Calm; smiles. Assessment: difficult to do. N o behavior p r o b l e m o n M o d L18. Pern u r s e , eating. Plan: clear for L19. Continue zyprexa, 3 0 m g at bed; depakote, 5 0 0 m g 3x/day. T e a m tomorrow. C h e c k v a l p r o i c acid level. 32 D A T E O B S E R V A T I O N = O B S E R V E D B Y R T 6-2 4- Di ff ic ul t to as se ss be ca us e of la ng ua ge ba rr ie r; tr y to ge t tr an sl at or . Dr . St ev en Jo hn so n, 10 R T 1 9 9 9 |e P o o r hy gi en e a n d an xi ou s. Ps yc hi at ri st 2 3 0 2 33 D A T E OBSERVATION 6-25-1999 Notranslator.¢Anxiousaffect.¢Poorhygiene.Assessment:difficult to do. S e e m s stable. Therapeutic depakote level. Plan: clear for L 1 9 or L 1 6 per team’s decision. Continue depakote, 5 0 0 m g , 3x/day. Zyprexa, 3 0 0 m g at bed. S M A — s e r u m metabolic assessment — is 20. A s k M r . G e o r g y at T h e o Lacyt o translate. valproic acid is generic for depakote, w h i c h is a mood stabilizer usually used to treat bipolar illness. A l s o used for schizo-affective disorder. Bipolar is inherited chemical imbalance causing m o o d swings unrelated to w h a t is going o n in their life. Euphoric or crash into extreme depression. Highs: excessive energy; sleep 2 or 3 hoursa nite; involved in multiple projects that they tend not to finish; poor concentration; poor judgment; irritable a n d obnoxious; alienate friends a n d family tend to get into fights, lots of trouble. D u r i n g depression, can becomesuicidal. 1 0 - 2 0 % of bipolars kill themselves. Schizophreniai s also inherited. ~ 1 % of population. C h e m i c a l imbalance that renders t h e m unable to distinguish reality f r o m fantasy. Often h a v e hallucinations a n d delusions, whicha r e fixed false beliefs that are u n s w a y a b l e b e evidence of reality. A n hallucination is seeing something that isn’t there or hearing something that isn’t there. Affects all 5 senses. Sensing something not there in reality. Schizo-affective applies to people w h o h a v e symptoms o f both. R a n g e s f r o m mild to severe. N o r m a l for symptoms t o fluctuate in individuals. M e d s d o not w o r k for all w h o suffer f r o m schizo-affective disorder. S o m e d o not responda t all. | O B S E R V E D B Y =| R T Dr. S t e v e n J o h n s o n , 1 0 R T Psychiatrist 2 3 0 2 - 0 5 3 4 D A T E |O B S E R V A T I O N O B S E R V E D B Y R T 6- 26 - 1 9 9 9 e P l a t af fe ct Dr . J a s m i n k a D e p o v i c , Ps yc hi at ri st 1 0 R T 2 4 3 7 6- 28 - 19 99 ¢ D ha du r i n a t e d o n th e fl oo r. e A f f e c t b l u n t e d . R e c o m m e n d e d D b e pl ac ed o n ob se rv at io n be ca us e of be ha vi or sh e ha ds e e n . Dr . Ja sm in ka De po vi c, Ps yc hi at ri st 10 R T 2 4 3 7 6- 29 - 19 99 ¢ D de ni ed ev er n o t ea ti ng . ¢ D w a s di sh ev el ed a n d af fe ct w a s bl un te d. ¢ D e n i e d ha ll uc in at io ns . Dr . J a s m i n k a D e p o v i c , Ps yc hi at ri st 10 R T 2 4 3 7 6- 30 - 1 9 9 9 e A f f e c t bl un te d. Dr . Ja sm in ka De po vi c, Ps yc hi at ri st 10 R T 2 4 3 8 7- 1- 1 9 9 9 |e Af fe ct bl un te d. Bl un te do r f l a t af fe ct is a ne ga ti ve s y m p t o m of sc hi zo ph re ni a or sc hi zo ph re ni ci ll ne ss . ¢ C o u l d al so be de pr es si on . Dr . J a s m i n k a D e p o v i c , Ps yc hi at ri st 10 R T 2 4 3 8 7-2- 1999¢Dw a s ch ro ni c an ds t a b l e . D w a s o n Z y p r e x a a n d De pa ko te , w h i c h he fe lt w a s ap pr op ri at e tr ea tm en tf o r sc hi zo -a ff ec ti ve di so rd er . H a d ta ke n Z y p r e x a to m a x i m u m do se in di ca te d. Wh at ev er b e n e f i t s D w o u l d ge t f r o m hi s m e d s w e r e pr ob ab ly at a pl at ea u, si nc e D r e m a i n e d sy mp to ma ti c. Dr.JoseFlores- Lopez,Psychiatris t 10RT 2495-96 35 DATE OBSERVATION _|OBSERVEDB Y | 7-6- e A f f e c t flat. Dr. J a s m i n k a 1 9 9 9 D e p o v i c , 2 4 3 8 Psychiatrist _ 7-7- ¢ A f f e c t flat. Dr. J a s m i n k a 1 0 R T 1999 * D reported reduced auditory hallucinations. Depovic, 2 4 3 8 Psychiatrist 7-8- |* Affectblunted. Dr.Jasminka 10RT 1 9 9 9 ¢ S a i d wasn o t h a v i n g hallucinationst h a t day. D e p o v i c , 2 4 3 8 Psychiatrist 7-12- e 6Affect blunted. Dr. J a s m i n k a 1 0 R T 1 9 9 9 Depovic, 2 4 3 8 Psychiatrist 7-13- e A f f e c t flat. Dr. J a s m i n k a 1 0 R T 1999 Depovic, 2 4 3 9 Psychiatrist 7-14- e A f f e c t flat. Dr. J a s m i n k a 1 0 R T 1 9 9 9 D e p o v i c , 2 4 3 9 Psychiatrist 7-15- ¢ A f f e c t blunted. Dr. J a s m i n k a 1 0 R T 1999 Depovic, 2 4 3 9 Psychiatrist 36 D A T E O B S E R V A T I O N O B S E R V E D B Y R T 7- 20 - |e 1 9 9 9 — n i e t — —_ A f f e c t bl un te d. Dr . Ja sm in ka De po vi c, Ps yc hi at ri st 1 0 R T 2 4 3 9 7 - 2 1 - D s e e n in ce ll . 19 99 |e Al er t, sm il in g. N o d s h e i s ok . D e n i e s h a l l u c i n a t i o n s . Cl ea re d fo r m o d L 16 — p s y c h un it bu t su b- ac ut e. S h e h a d c o m m u n i c a t i o n w i t h h i m . N e x t co ur t da te 9- 10 . Ka yC an tr el l, N u r s e 10 R T 2 2 6 9 N o ° da te ju st ° b e f o r e 7- 26 - 9 9 D r e m a i n e d b i z a r r e a n d b l u n t e d . B l u n t e d af fe ct , w h i c h is n e g a t i v e s y m p t o m of sc hi zo ph re ni ci ll ne ss . D ta lk ed ab ou t th e de vi l sp ea ki ng to hi m. D i d no t sa y w h a t de vi l sa id . Dr . Jo se Fl or es - Lo pe z, Ps yc hi at ri st 10 R T 2 4 9 6 7- 27 - |° 19 99 A f f e c t bl un te d. Dr . J a s m i n k a D e p o v i c , Ps yc hi at ri st 1 0 R T 2 4 3 9 7-29-|e 1999 Affec t bl un te d. Dr.Jasminka Depovic, Psychiatrist 10RT 2439 37 OBSERVATION a a a a a n i i n i ~TOBSERVEDBY R T . ¢* D h a d b e e n movingh i s lips as though talking to self w h e n alone. Dr. Teresa Farjalla, Psychiatrist. 10 R T 2 4 7 1 S a w w i t h translator o n L19. ° Subjective: C o m p l a i n s of tremor; dry mouth, auditory hallucinations and excessive sleep. W a n t s haircut. ¢ Objective: Positive coarse tremor; * L o n g , disheveled hair; ¢ Auditory hallucinations; * Smiles; quiet a n d soft-spoken;polite. Assessment: still psychotic [underlined] after m o n t h s o n zyprexa. T r e m o r despite cogentin. D r y m o u t h 2ndary to cogentin. H y p e r s o m n o l e n t 2ndary to zyprexa. Plan: discuss with Dr. Depovic. Discontinue zyprexa becausef a i l e d to rid D of hallucinations after m a n y months. Discontinue cogentin. Discuss case at treatment t e a m meeting to discuss trying seroquel to decrease hallucinations. Continue depakote a n d paxil. Seroquel is another antipsychotic. N o t unusualt o try different ones to see whati s effective. Also not unusual forp a t i e n t to h a v e different levels of symptoms, a l t h o less so w h e n already o n meds. Should b e less variation if the m e d s are working. If not working, m a y be fluctuation b e t w e e n psychotic non-psychotic states. D r . S t e v e n J o h n s o n , Psychiatrist 1 0 R T 2 3 0 6 - 0 8 U p d a t e d diagnosis. ¢ In M a r c h 1 9 9 8 diagnosed as psychotic disorder, not otherwise specified. * O n 8-5-99, after t e a m meeting, given diagnosis of schizo-affective disorder. Dr. S t e v e n J o h n s o n , Psychiatrist 1 0 R T 2 3 0 8 - 0 9 3 8 D A T E OB SE RV AT IO N O B S E R V E D B Y R T 8- 13 - 19 99 As se ss me nt t h a t D w a s su ff er in g f r o m ps yc ho si s. N O S , li ke ly sc hi zo - af fe ct iv e di so rd er . D h a d b e e n tr an sf er re d b a c k to L- 19 , ac ut e wa rd . W h e n as ke d, D co ul d no tt el l h i m w h y h e h a d be en tr an sf er re d. Hi s as se ss me nt w a s th at D w a s su ff er in g f r o m th at il ln es s. Dr . J o s e Fl or es - Lo pe z, Ps yc hi at ri st 1 0 R T 24 96 -9 7 8- 20 - 19 99 S e e n wi th Dr . Gi rg is , Eg yp ti an sp ea ki ng ps yc h, ye st er da y. ¢ Li ke s n e w me ds be tt er . Do es n’ t m a k e h i m sh ak e. e St il l he ar s au di to ry ha ll uc in at io ns . Di sc us se d ca se wi th Gi rg is . Su gg es te d in cr ea se in se ro qu el do se . If th at fa il s, cl oz ar il , an ot he r an ti ps yc ho ti c. Pr ob ab ly be st , bu t la st re so rt be ca us e 1 % of th os e ta ki ng it de ve lo p ag ra nu lo cy to si s — b o n e m a r r o w st op s pr od uc in g bl oo d ce ll s. As se ss me nt : st il l ps yc ho ti c. Pl an : in cr ea se se ro qu el to 2 0 0 m g , 2x /d ay ; de pa ko te , 5 0 0 m g , 3x /d ay ; pa xi l, 2, h. s. “I mi gh t ad dt h a t th e fa ct th at w e w e r e e v e n co ns id er in g cl oz ar il re al ly is an in di ca ti on of ou r de sp er at io n as a tr ea tm en t t e a m to he lp hi m. ” Ob je ct io n; ed it or ia li zi ng ; n o n re sp on si ve . Su st ai n. St ri ck en . T e a m co ns id er ed D se ri ou sl yi l l at th is po in t. D r . S t e v e n J o h n s o n , Ps yc hi at ri st 1 0 R T 23 10 -1 1 8- 27 - 19 99 ¢ S a w n o m o v i n g di so rd er or tr em or , w h i c h ar e si de ef fe ct s of an ti ps yc ho ti c m e d s a n d de pa ko te . Dr . S t e v e n J o h n s o n , Ps yc hi at ri st 10 R T 2 3 1 2 8-30- 1999 eAffec t b l u n t e d . Dr.Jasminka Depovic, Psychiatrist 10RT 2439 39 * G o o d hygiene; n o distress. T h e t e a m whoc o n s i d e r e d seriously i l l consisted of all the psychiatrists w o r k i n g onh i s case, nurse practitioners, psychologists, case m a n a g e r s a n d service chief. DATE OBSERVATION __ OBSERVED BY _ 8-31- |* Affect blunted. Dr. J a s m i n k 1 0 R T 1999 e D reported n o hallucinations. M e a n i n g , she asked h i m a n d D said no. S h e Depovic, 2 4 3 9 always asked him.[ i.e., D never volunteered info.] Psychiatrist 9-1- ¢ Affect blunted. Dr. J a s m i n k a 1 0 R T 1999 Depovic, 2 4 4 0 Psychiatrist 9-3- ° D wasc h r o n i c , m e a n i n g h e remainedi l l with chronic schizo-affective Dr. Jose Flores- 10 R T 1999 disorder. Chronic m e a n i n g that D m o s t likely w o u l d goingt o havei t for Lopez, Psychiatrist 2 4 9 7 - 9 8 the rest of his life. * A l s o noted poor personal hygiene. P o o r hygiene is another negative s y m p t o m of a schizophrenicillness. 9-7- ¢ Affect blunted. Dr. J a s m i n k a 10 R T 1999 ¢ D reported reduced auditory hallucinations. Depovic, 2 4 4 0 Psychiatrist — 9-9- S a w D w / o interpreter. Dr. Steven Johnson, 10 R T 1999 ¢ A p p e a r e d in goodspirits. Psychiatrist 2 3 1 2 4 0 D A T E O B S E R V A T I O N O B S E R V E D B Y R T 9- 15 - 19 99 e A f f e c t b l u n t e d . e D d i s h e v e l e d . Dr . Ja sm in ka De po vi c, Ps yc hi at ri st 2 4 4 0 9-17- 1999 ¢Dwas st il l ha vi ng au di to ry ha ll uc in at io ns . S h e ob se rv ed h i m in hi sc e l l ta lk in g to se lf . ¢ D ap pe ar ed u n k e m p t a n d di sh ev el ed ; re fe rr in g to pe rs on al hy gi en e. ¢ D wa st a l k i n g to hi ms el f in th e ce ll . D c a m e to th e do or bu t it ap pe ar ed h e un de rs to od ve ry li tt le of w h a t sh e sa id . H e an sw er ed y e s to al mo st a l l of he r qu es ti on s, so sh e wa sn ’t su re h e un de rs to od th e qu es ti on s. Leonard L u n a , L C S W 10RT 2389-91 41 DATE OBSERVATION 10-27- D just transferred for L-16. U n a b l e to obtain subjective statementa s patient 1999 repeatedly states n o speak English. [ A s k h i m abouts i d e effects to m e d s ? ] H e said no. [To w h a t ? Side effects or questioning?] W o u l d normally b e asking D if h e w a s having hallucinations or s y m p t o m s . N o t e indicates D w a s not telling her whether having hallucinations or delusions. Said couldn’t speak English. ¢ Alert a n d oriented a n d responded to c o m m a n d s f r o m deputies to close doors. ¢ Presents inappropriate with bizarre bright grin. H e looked bizarre. N o t normal. Affect isn’t matching perceived m o o d . ¢ M o o d euthymic. E u t h y m i c m e a n s n o r m a l or n o m o o d . T h e kind y o u can’t pick up. * Cooperative. ¢ Clothes unbuttoned; hair closely cropped; groomingf a i r ; walks with slight limp. * Doesn’t appear to c o m p r e h e n d m u c h English. T h o u g h t s questionable. S e e m i n g l y attentive. Doesn’t appear to b e responding toi n t e r n a l stimuli as before. ¢ D e t e r m i n e d he didn’t h a v e auditory or visual hallucinations. S a w n o symptoms o f paranoid or suicidal thoughts. Assessment: appeared stable o n psych m e d s yet does appear mentally ill via affect. Antipsychotic medst r e a t positive s y m p t o m s of psychoticillness. Meantt o diminish or eliminate things like hallucinations, delusions, etc. C a n present other symptoms o f illness e v e n though m e d s are working. O n e such s y m p t o m m i g h t b e inappropriate affect. S u c h as she observedh e r e . O B S E R V E D B Y April Barrio, N u r s e Practitioner 9 R T 2198- 2203 4 2 D A T E O B S E R V A T I O N O B S E R V E D B Y R T 11 -2 3- 1 9 9 9 D o i n g a me di ca ti on re ne wa l. H e w a s in M o d J ho us in g. Ap ri l Ba rr io , N u r s e Pr ac ti ti on er 9 R T 2 1 9 4 11 -2 9- 1 9 9 9 A g a i n as se ss ed th at D w a s su ff er in g f r o m ch ro ni c me nt al il ln es s. D h a d b e e n de co mp en sa ti ng in re gu la r ho us in g. A s no te d be fo re , so me on es ta bi li ze d in me nt al he al th se tt in g ca n re ac t to st re ss or s of re gu la r ho us in g a n d b e c o m e m o r e sy mp to ma ti c. Th at ’s c o m m o n . Dr . Jo se Fl or es - Lo pe z, Ps yc hi at ri st 10 R T 24 98 -9 9 12 -7 - 1 9 9 9 ¢ D ha db e e n ob se rv ed t a l k i n g to hi ms el f m o r e of te n. Th at w a s mo st ly he r ow np e r s o n a l ob se rv at io ns . W h i l e ta lk in g, D wa sn ’t a c k n o w l e d g i n g w h a t sh e as ke d h i m a n d w a s “p re tt y m u c h pr eo cc up ie d in hi s o w n ps yc ho si s. ” ¢ D s e e m e d pr eo cc up ie d, a s if hi s th ou gh ts w e r e tu rn ed el se wh er e. ¢ H e in di ca te d ph ys ic al pa in on h i s le ft si de . L e o n a r d L u n a , L C S W 10 R T 2 3 9 1 - 9 2 12-17- 1999 e D w a s ag in pr eo cc up ie d. * D wa sr e c e p t i v e to he r de sp it e hi s li mi te d En gl is h. LeonardLun a , L C S W 10RT 2392-93 4 3 D A T E . |O B S E R V A T I O N 12-25- |* D w a s complaining of pain, pointing to side of a b d o m e n . 1999 |* Cell wastrashy; toilet area w a s a mess; c a m e out with clothes unkempt; shoes w / o laces. Jumpsuit unclean. U n k e m p t . ¢ Appeared to be respondingt o internal stimuli. Voices or hallucinations of s o m e kind. A psychotic s y m p t o m . H e w a s movingh i s l i p s as if carrying o n a conversation w / o a n y o n e around. * H e wasalert. * Questioned whether h e wasoriented. * M o o d euthymic with blank stare. ¢ S p e e c h nonspontaneous. W a s n ’ t really listening or speakingt o her. ¢ W r o t e positive hallucination. Auditory hallucinations, zero paranoid ideation. Z e r o behaviors indicative of suicidal or homicidal ideations. ¢ Deputies report patient compliant — not giving problems. H e r conclusion re hallucinations w a s based o n her observations of him. D did nottell her about a n y hallucinations. B l a n k stare but m o o d s e e m e d normal. Assessment: slightly increased in his psychosis, with decompensation of g r o o m i n g a n d self-care. Non-acute, m e a n i n g he didn’t s e e m to b e in danger at that m o m e n t . L o o k at decompensation of g r o o m i n g andself-care to determinei f getting w o r s e psychiatrically. Sign symptoms a r e getting worse. Renewed h i s seroquel, depakote a n d paxil. Seroqueli s a neuroleptic antipsychotic.. D o s e of 3 0 0 m g twice a day. D e p a k o t e is mood stabilizer and anti-seizure m e d . D o s e of 5 0 0 m g twice a day. Paxil is antidepressant. 2 0 m g at nite. R e c o m m e n d e d a transfer. H e transferred to L - 1 6 w/orestrictions for closer psychiatric monitoring. |OBSERVED BY April Barrio, Nurse Practitioner 9 R T 2 1 9 4 - 9 8 D A T E O B S E R V A T I O N O B S E R V E D B Y R T 12 -2 9- 1 9 9 9 D ag ai n ta lk in g to se lf in fr on t of th e mi rr or i n hi s ce ll . N o si gn s of se lf - de st ru ct iv e be ha vi or . W h e n sh e as ke d ab ou t hi s me ds , D re sp on de d, y e s . D re po rt ed n o pr ob le ms L e o n a r d L u n a , L C S W 10 R T 2 3 9 3 1- 13 - 2 0 0 0 D ap pe ar ed t o b e in a g o o d m o o d . H e w a s sm il in g a n d an sw er in g qu es ti on sp ol it el y. He s a i d hi s me ds w e r e a l l ri gh t. N o co mp la in ts of ph ys ic al pa in . D wa st a l k i n g to hi ms el f “c on st an t. ” L e o n a r d L u n a , L C S W 10 R T 2 3 9 3 - 9 4 1- 27 - 2 0 0 0 D ap pe ar ed to h a v e n o di st re ss . Sa id he h a d n o pr ob le ms . He w a s st il l se en ta lk in g to hi ms el f. N e x t c o u r t d a t e w a s 7 - 2 8 - 0 0 . L e o n a r d L u n a , L C S W 10 R T 2 3 9 4 1-29- 2000 Impr o v e d wi th ad di ti on of ri sp er da l. Le ss au di to ry ha ll uc in at io ns a n d in cr ea se d sl ee p. A x i s I, sc hi zo -a ff ec ti ve di so rd er . C o m p l a i n i n g of de pr es si on . W e i g h t ga in re qu ir es mo ni to ri ng . Co rr ec ti on al me di ca l se rv ic es do es no t th in k D is di ab et ic . G o a l to in cr ea se ri sp er da l to ta rg et au di to ry ha ll uc in at io ns . K e p t re gu la r m e d s ; in cr ea se d co la ce a n d in cr ea se d ri sp er da l to 2 m g at ni gh t. “ K e e p hi s 5 1 5 0 fl ag , pa ti en t da ng er to ot he rs a n d gr av el y di sa bl ed . Re tu rn wi th ps yc hi at ri st s in t w o we ek s. ” AprilBarrio,Nurs e Pr ac ti ti on er 9RT 2192- 2248 4 5 7 — _ —_ — — — _ — D A T E O B S E R V A T I O N O B S E R V E D B Y { R T 1-31- |* D m i g h t respondt o the increaseds t r e s s of trial, m e a n i n g court dates. Dr. Jose Flores- 10 R T 2 0 0 0 Court dates can be a stressor that can cause deterioration. “Absolutely, Lopez, Psychiatrist 2 4 9 9 absolutely.” ¢ S a w symptoms o f psychosis that day. “Psychosis” wasi n “ ” because they h a d not completely ruled out other things. W h i c h w o u l d neverb e ruled out until they h a d a history a n d neuropsychological testing. 2-18- |* Characterized D as chronic a n d respondingt o stressors a n d having bizarre Dr. Jose Flores- 10 R T 2 0 0 0 affect. Lopez, Psychiatrist 2500-01 ¢ H e b e c a m e awaret h a t D wasdiagnosed a s suffering f r o m schizo-affective disorder after t e a m meetings ofa l l the mental health professionals that s a w him. H e agreed with schizo-affective disorder diagnosis a n d continuest o agree with it. 4 6 + D A T E O B S E R V A T I O N O B S E R V E D B Y | R T 3- 9- Ob se rv at io ns : s a w h i m o n Mo d J , tr an sf er re d f r o m L - 1 6 2 w e e k s ag o. 2 0 0 0 Co nt in ue s to h a v e po or c o m m u n i c a t i v e ca pa ci ty in En gl is h bu t el ab or at ed more.Shaking he ad af fi rm at iv el y re pr ef er en ce fo r Mo d J . A d m i t t e d he ar in g vo ic es . “C al ls m y na me . Te ll s me t o ki ll my se lf .” H e a r d su ch a vo ic e 1 w e e k ag o. De ni es s i d e ef fe ct s to me ds . B u t no te d we ig ht ga in . A n oc ca si on al si de ef fe ct of se ro qu el a n d de pa ko te . 9 0 0 m g of se ro qu el a da y. Al er t a n d or ie nt ed . Gr oo mi ng be tt er . Le ss di sh ev el ed . Ce ll st il l tr as hy , ac co rd in g to de pu ti es . S p e e c h mo no sy ll ab le s. N o r m a l ra te . M o o d eu th ym ic ; af fe ct br oa d — ap pr op ri at e. Do es n’ t s e e m to be re sp on di ng t o in te rn al st im ul i. N o t ta lk in gt o s e l f . O p e n g o o d ey e co nt ac t. T h o u g h t s h a r d to as se ss . S e e m s co he re nt . N o ha ll uc in at io ns ; n o pa ra no ia ; de ni es su ic id al or ho mi ci da l id ea ti on . As se ss me nt : st ab le ch ro ni c o n me ds . M u c h i m p r o v e d si nc e 11 -9 9. M e a n s h e ’ s st ab le bu ts t i l l m a n i f e s t s m e n t a l il ln es s. C h r o n i c , n o t ac ut e. R e n e w e d m e d s . AprilBarrio,Nu r s e Pr ac ti ti on er 9RT 2203-05 AT DATE OBSERVATION _ OBSERVED BY RT 4-7- * G r o o m i n g improved. April Barrio, N u r s e 9 R T 2 0 0 0 |* E y e contact good. Practitioner 2205- ¢ Attempting to interact. 2 2 0 6 ¢ N o auditory hallucinations; n o paranoid ideation; denies suicidal ideations. ¢ Appears s t a b l e chronic. R e s p o n d i n g to meds. R e n e w e d seroquel, depakote a n d paxil. 4-25- S a w D with an interpreter. Dr. J a s m i n k a 10 R T 2 0 0 0 |* S h e h a d received report that D h a d defecated in the shower. Depovic, 2440-41 ¢ D claimed that 1 w e e k a g o h e w a s hurting himself b y tying the knot o n his Psychiatrist penis. Hed i d so to stop breathing. D i d not m a k e sense so she put a question m a r k byt h a t . 4-25- |¢ Affect appropriate. Dr. J a s m i n k a 10 R T 2 0 0 0 Depovic, 2 4 4 1 Psychiatrist 4-26- |° Affect blunted. Dr. J a s m i n k a 10 R T 2 0 0 0 Depovic, 2 4 4 1 Psychiatrist 4-27- |* D reported reduced hallucinations, e v e n though his medication h a d b e e n Dr. J a s m i n k a 1 0 R T 2 0 0 0 reduced. Depovic, 2441 Psychiatrist 5-4- ¢ D denied hallucinations or suicidal or homicidal ideations. Leonard Luna, 10 R T 2 0 0 0 |* Buth e wasstill talking to himself a n d appeared disheveled. L C S W 2 3 9 4 - 9 5 4 8 D A T E O B S E R V A T I O N | OB SE RV ED BY _ R T 5- 5- 2 0 0 0 D se en wi th he lp of Eg yp ti an sp ea ki ng in ma te , Mr . H a n n a h . De ni es pr ob le ms . D in st ru ct ed to cl ea n u p hi s r o o m a n d ta ke a sh ow er b e c a u s e h i s ce ll w a s in “v er y” m e s s y co nd it io n, as wa sh e . Dr . J a s m i n k a D e p o v i c , Ps yc hi at ri st 10 R T 2 4 4 2 5- 10 - 20 00 D sa id he h a d n o pr ob le ms . D e n i e d ha ll uc in at io ns or de si re to hu rt hi ms el f. O b s e r v e d h i m ta lk in g to hi ms el f in th e ce ll m o s t of th e ti me . A p p e a r e d u n k e m p t an dd i s h e v e l e d . Pr et ty m u c h sa id h e w a s ha vi ng n o pr ob le ms w i t h hi s me ds . N e x t co ur t da te 7- 25 -0 0. L e o n a r d L u n a , L C S W 1 0 R T 2 3 9 5 5- 16 - 2 0 0 0 S a w D w / o tr an sl at or . Su bj ec ti ve : Au di to ry ha ll uc in at io ns ; wa nt s m o r e me ds . Ob je ct iv e: Ta lk s to hi ms el f co ns ta nt ly ; au di to ry ha ll uc in at io ns ; n o id ea ti on s; P o o r hy gi en e; C a l m . As se ss me nt : st il l ps yc ho ti c. Pl an : in cr ea se se ro qu el to 2 0 0 m g 3x /d ay . | C h e c k va lp ro ic ac id le ve l. Co nt in ue de pa ko te a n d pa xi l. D r . S t e v e n J o h n s o n , Ps yc hi at ri st 10 R T 2 3 1 3 5- 17 - 2 0 0 0 D wa sd e p r e s s e d . Hi s af fe ct wa sf la t. S a u n d r a K i n g , C a s e M a n a g e r 1 0 R T 2 4 0 9 5- 31 - 2 0 0 0 D w a s w i t h d r a w n . H i s af fe ct wa s f l a t . S a u n d r a Ki ng , C a s e M a n a g e r 10 R T 2 4 1 0 49 T y a e n DATEO B S E R V A T I O N | O B S E R V E D B Y 6-17- S a w h i m o n M o d L - 1 6 while m a k i n g rounds. Presents as always. U n a b l e to April Barrio, N u r s e 9 R T 2 0 0 0 speak English. Practitioner 2206- ¢ Cell fairly clean c o m p a r e d to w h e n he wasi n regular housing. 2 2 0 8 P ¢ Diagnosis: psychosis N O S , provisional schizo-affective. Schizo-affective indicates symtoms o f schizophrenia and m a j o r moodd i s o r d e r . Subjectively: h e says n o problems. Meds o k . ¢ O b s e r v e d h i m talking to himself in dayroom. Positive auditory hallucinations. * G r o o m i n g better but inappropriate affect. * R e s p o n d i n g to internal stimuli. H e did not report hallucinations. S h e observed them. Assessment: partially stable. R e m a i n s bizarre a n d inappropriate but i m p r o v e d self-care a n d cell care d u e to increase of mood stabilizer — or closer monitoring b y deputies. N o t sure. He’s in different housing. Repeats provisional diagnosis of schizo-affective disorder. 6-20- |* D h a d poorh y g i e n e . Saundra King, 10 R T 2 0 0 0 C a s e M a n a g e r 2 4 1 0 6-27- |* D ’ s hygiene h a d improved. S a u n d r a King, 10 R T 2 0 0 0 C a s e M a n a g e r 2 4 1 0 50 D A T E |O B S E R V A T I O N O B S E R V E D B Y R T 7- 1- 2 0 0 0 D o n L - 1 6 a n d sp ea ki ng En gl is h to da y. Re po rt s h e re ad hi s bi bl e. W o r d s f r o m g o d ev er y da y. Re po rt sh e i s he ar in g vo ic es . De ni es se lf -d es tr uc ti ve be ha vi or . Do es n’ t w a n t me ds in cr ea se d. Sl ee pi ng da y an dn i g h t , bu t le ss at ni gh t. Ce ll is cl ea ne r. H e is m o r e ap pr op ri at e a n d s e e m s m o r e re sp on si ve . Al er t. Or ie nt ed . M o o d i s la bi le — va ri ab le , fl uc tu at in g. Pr eo cc up ie d, ch ee rf ul wi th in ap pr op ri at e af fe ct . In cr ea se d c o m m u n i c a t i o n in En gl is h. T h o u g h t s co he re nt . Po si ti ve re li gi os it y. Po si ti ve au di to ry ha ll uc in at io ns . N o vi su al . N o pa ra no id id ea ti on s. N o su ic id al or ho mi ci da l id ea ti on s. As se ss me nt : ch ro ni c, sl ig ht ly i m p r o v e d f r o m la st vi si t. Se ro qu el ne ed ed . Co nt in ue d Pa xi l, de pa ko te a n d se ro qu el . Pa xi l n o w at 4 0 mg a t ni gh t. D e p a k o t e 1 0 0 0 m g tw ic e a da y. Se ro qu el is 2 0 0 mg , 3 ti me sa da y. Ap ri l Ba rr io , N u r s e Pr ac ti ti on er 9 R T 22 08 - 2 2 1 0 7- 5- 20 00 D ’ s m o o d wa sp l e a s a n t a n d hi s af fe ct w a s ap pr op ri at e. S a u n d r a K i n g , C a s e M a n a g e r 10 R T 2 4 1 0 7-11- 2000 Drepor te d th at a co up le of da ys ea rl ie r, he ’d h a d a ha ll uc in at io n c o m m a n d i n g h i m to w r a p a sh ee t ar ou nd h i s pe ni s. D sa id h e he ar d vo ic es te ll in g h i m to d o it . H e re po rt ed h a p p y vo ic es a t pr es en t. SaundraKing, CaseManager 10RT 2410-11 51 DATE OBSERVATION | S e : a OBSERVEDB Y . [Rr 7-12- | D o n L - 1 6 . April Barrio, N u r s e 9 R T 2 0 0 0 |* D complained of increased auditory hallucinations resulting in sexual — Practitioner 2210- preoccupation a n d impulses to indulge in self-destructive behavior. 2 2 1 2 * S y m p t o m s : positive auditory hallucination, reduced sleep, positive sexual preoccupation. ¢ O b s e r v e d he wasa c t i v e l y respondingt o stimuli. ¢ Subtherapeutic neuroleptic. Subtherapeutic neuroleptic m e a n s she suspects D is not o n e n o u g h antipsychotic. S h e increased his seroquel to 2 0 0 m g m o r n i n g a n d n o o n a n d 3 0 0 mga t night. 52 D A T E OB SE RV AT IO N O B S E R V E D B Y R T 7- 15 - 20 00 D o n L- 16 . e A d m i t s sh av ed ey eb ro ws b e c a u s e au di to ry ha ll uc in at io ns to ld h i m to . * C o m p l a i n i n g of no t sl ee pi ng a n d in cr ea se d ha ll uc in at io ns . * O b s e r v e d m e d si de -e ff ec ts : sl ee pl es sn es s; po or re sp on se to m e d s ; g o o d co mp li an ce to me ds . e A p p e a r e d di sh ev el ed , un ke mp t, re sp on di ng t o in te rn al st im ul i. ¢ N o re dn es so n pe ni s. ¢ B r o a d in ap pr op ri at e gr in . * N o su ic id al , h o m i c i d a l or p a r a n o i d id ea ti on s. As se ss me nt : ps yc ho ti c. N o t sl ee pi ng . La st in cr ea se of se ro qu el in ef fe ct iv e. Me ds : i n c r e a s e d pa xi l to 4 0 mg i n a. m. t o in cr ea se ni gh tt im e sl ee p. H e l d ni gh t do se . R e n e w e d de pa ko te , 1 0 0 0 m g tw ic e a da y. In cr ea se d se ro qu el to 2 0 0 m g in mo rn in g; 2 0 0 m g at n o o n a n d 4 0 0 mg a t n i t e to ta rg et sl ee p a n d au di to ry ha ll uc in at io ns . Al so go in g to co ns ul t wi th ps yc hi at ri st re be ha vi or a n d la ck of re sp on se to ne ur ol ep ti c. Co ns id er a d d e d se co nd a t y p i c a l an ti ps yc ho ti c. Ap ri l Ba rr io , N u r s e Pr ac ti ti on er 9 R T 22 12 - 2 2 1 4 7-20- 2000 Consulte d wi th Dr . Jo hn so n. As a re su lt , a d d e d at iv an fo r sl ee p. Co ns id er at io n of 2 n d at yp ic al ne ur ol ep ti c. 7- 15 -0 0 ob se rv at io ns : Te le ph on ec a l l p a g e d to on -c al l ps yc hi at ri st to re qu es t st at at iv an fo r sl ee p to re du ce au di to ry ha ll uc in at io n ac ti vi ty . O k pe r co ns ul ta ti on wi th Dr . Fa rj al la . St at or de r at iv an to ni te a n d 2 ni te s on ly fo r sl ee p. Wi ll di sc us s ca se in me et in g a n d re ch ec k. AprilBarrio,Nurs e Pr ac ti ti on er 9RT 2214-15 53 OBSERVATION D A T E O B S E R V E D B Y | RT. 7-20- |* “Patient mostly rocking in his bed. Refusing tot e l l m e if he’s suicidal.” Dr. J a s m i n k a 10 R T 2 0 0 0 |* D wasv e r y disheveled. “Positive for b o d y odor. R o o m messy. F o o d all Depovic, 2 4 4 2 - 4 3 over. Psychiatrist ¢ Respondingt o internal stimuli. Questionable if dangeroust o self or questionable if dangeroust o others. ¢ Insight a n d judgmentp o o r . ” 7-21- |* D starting to feel better. Eating. Smiling. Dr. J a s m i n k a 10 R T 2 0 0 0 |* D e n i e d ideations, but hearing voices. Depovic, 2 4 4 3 Psychiatrist 7-22- | D starting to feel better. Eating. Smiling. Dr. J a s m i n k a 10 R T 2 0 0 0 |* D e n i e d ideations, but hearing voices. Depovic, 2 4 4 3 Psychiatrist 7-22- |¢ Anxious affect. Dr. J a s m i n k a 10 R T 2 0 0 0 A t s o m e point, D ’ s diagnosis w a s changedt o schizo-affective disorder. S h e Depovic, 2 4 4 3 wasi n agreement with that diagnosis. R e m a i n s in agreementt h a t D suffers Psychiatrist f r o m psychotic illness. 7-23- |* D starting to feel better. Eating. Smiling. Dr. J a s m i n k a 10 R T 2 0 0 0 |* D e n i e d ideations, but hearing voices. Depovic, 2 4 4 2 Psychiatrist 54 D A T E O B S E R V A T I O N O B S E R V E D B Y R T 7- 25 - 20 00 — — e s D h a d be en p i c k i n g hi s fa ce . S h e s a w ab ra si on s o n D ’ s fa ce in th e mi dd le of hi s fo re he ad , b e t w e e n hi s ey eb ro ws . He r e p o r t e d th at vo ic es we re te ll in g h i m to pi ck a t hi s fa ce , th en to ru b bu tt er a n d co ff ee gr ou nd so n th e ab ra si on s. S a u n d r a Ki ng , C a s e M a n a g e r 10 R T 2 4 1 1 - 1 2 7- 26 - 2 0 0 0 D a g a i n t r a n s f e r r e d b a c k to a c u t e m e n t a l h e a l t h h o u s i n g , b e c a u s e h e w a s sm ea ri ng bu tt er a n d co ff ee o n ab ra si on s he ca us ed t o hi s fo re he ad b y pi ck in g hi s sk in . St re ss pr ob ab ly h a d so me th in g to d o wi th D ’ s be ha vi or . Tr ie s to co rr el at e tr an sf er to ac ut e un it wi th be in g m o r e st re ss ed . St re ss ca n af fe ct a _ ps yc ho ti c il ln es s a n d ca n m a k e th e s y m p t o m s wo rs e. Sc hi zo ph re ni a or sc hi zo ph re ni c il ln es s is a st re ss -r el at ed il ln es s an d ca n fl uc tu at e. Dr . T e r e s a Fa rj al la , Ps yc hi at ri st 10 R T 24 70 -7 1 7-30- 2000 D re po rt ed th ru sa me in te rp re te r th at h e h a d a po or s l e e p pa tt er n th e ni gh t be fo re a n d re gr et te d th at he ’d as ke d h i m to re du ce th e ev en in g do sa ge of o n e of th e me ds . S o h e in cr ea se d D ’ s do sa ge . Dr.Juventin o Lo pe z, Ps yc hi at ri st 10RT 2517 55 D A T E O B S E R V A T I O N : : |OBSERVED BY _ RT 7-31- 2 0 0 0 D w a s h o u s e d in M o d L. H e wasa l e r t a n d oriented; spoke b r o k e n English; soft-spoken but goal directed. D e n i e d suicidal or intent to h a r m self. A d m i t t e d auditory hallucinations of hearing his n a m e being called. H e h a d b e e n hearing c o m m a n d hallucinationst o tie things o n his penis a n d r u b his forehead, b u t d e n i e d t h e m at that m o m e n t . S a i d h e ’ d h a d t h e m in the past. D e n i e d having anything tied to his penis. D h a d vaseline onh i s lips a n d forehead. Said h e h a d not b e e n sleepinga t night. S h e noted thata flag is to remain in place. A flag is a c o m m u n i c a t i o n b e t w e e n mental health a n d sheriff’s dept a n d medical staff that D ’ s to be evaluated for a 72-hour hold uponr e l e a s e f r o m thefacility. 72-hour is an involuntary psychiatric hold d u e to dangert o self or others or grave disability. H e w o u l d bee v a l u a t e d a t t h e t i m e ofr e l e a s e . i n i R a c h e l l e G a r d e a , R N 9 R T 2 1 4 8 - 5 0 8-3-2000 D reported depressions a n d anxiety. C o n c e r n e d aboutl e g a l issues. A s k e d whenh i s court date w a s a n d it w a s 8-11. H e r note that D w a s concerned aboutl e g a l issues could h a v e b e e n based o n such questions. S a u n d r a King, C a s e M a n a g e r 1 0 R T 2412, 2422-23, 2 4 2 5 - 2 6 5 6 D A T E OB SE RV AT IO N | O B S E R V E D B Y R T 8- 12 - 2 0 0 0 O b s e r v a t i o n s o n M o d L - 1 6 r o u n d s . D ad mi ts au di to ry ha ll uc in at io ns te ll in g h i m to pu t bu tt er o n hi s m o u t h a n d co ff ee b e t w e e n hi s ey eb ro ws . S h e s a w po si ti ve au di to ry ha ll uc in at io ns . Sl ee pi ng be tt er . De pr es si on is u p a n d d o w n . De ni es su ic id al id ea ti on . A d m i t s wa st y i n g hi s pe ni s. Z e r o de si re to ti e pe ni s of f n o w . N o t e in di ca te s th er e w a s a cl ot h o n th e fl oo r he wa st y i n g to hi s pe ni s. S h e re me mb er s a li tt le cl ot h a n d k n e w h e h a d be en t y i n g hi s pe ni s. C l o t h e s o n th e fl oo r. D i s h e v e l e d ; ce ll is tr as he d. R e s p o n s e to me ds : pa rt ia ll y st ab le . P o o r re sp on de r to me ds , no t su re w h y . Ax is I I , o n di ab et ic di et on ly . Ze ro me ds . In cr ea se d we ig ht . Ap ri l Ba rr io , N u r s e Pr ac ti ti on er 9 R T 2 2 1 5 - 1 8 8-24- 2000 Dhad ga in ed a l o t of we ig ht . H e w a s un ke mp t. Tr as hy c e l l . B r o a d af fe ct . A b l e to c o m m u n i c a t e wi th tr an sl at or . T h o u g h t s co he re nt b u t il lo gi ca l. Po si ti ve au di to ry ha ll uc in at io ns . As se ss me nt : pa rt ia ll y st ab le on ly . Ps yc ho ti c st il l. P o o r re sp on de r to me ds . P u t a lo t o f q u e s t i o n s b e c a u s e w o n d e r i n g i f h e h a d di ab et es , a n d w h e t h e r th at wa sa ff ec ti ng hi s me nt al st at us . “H e’ ss ti ll so ps yc ho ti c. ”’ R e n e w e d pa xi l, de pa ko te , at iv an a n d se ro qu el . A s k e d ca se ma na ge rt o in cr ea se co nt ac t wi th D. AprilBarrio,Nurse Practitioner 9RT 2218-19 5 7 DATE OBSERVATION — | a | OBSERVEDB Y | ler 8-26- M o d r o u n d s . April Barrio, N u r s e 9 R T 2 0 0 0 |* Hears voices, motherc a l l i n g his name, telling h i m nott o kill himself. Practitioner 2 2 1 9 - 2 0 ¢ Deniest y i n g his penis. ¢ Z e r o further fixation with coffee groundso r cutting eyebrows. ° Nos i d e effects to meds. Fair response to a n d compliance with meds. * Cell cleaner; calmer; better g r o o m e d . e Speaking m o r e English. ¢ Less preoccupied with internal stimuli. e S e e m s m o r e appropriate. ¢ Positive auditory hallucinations. N o ideations. Assessment: chronic, mostly stable o n meds b u t still psychotic. R e n e w e d paxil, depakote, ativan a n d seroquel. Paxil, 4 0 m g . Depakote, 1 0 0 0 m g twice a day. Seroquel, 2 0 0 m g in morning; 2 0 0 mga t n o o n a n d 4 0 0 mga t nite. That is m a x dose. N o t e d 5 1 5 0 definitely. Fits the 5 1 5 0 criteria, w h i c h is dangert o self or others or gravely disabled. It w o u l d be not able to care for self d u e to mental illness. 9-6- ¢ D reported auditory a n d visual hallucinations. D reports auditory Saundra King, 10 R T 2 0 0 0 hallucinations“ a l l the time.” Oneo f hallucinations he reported o n 9-6-00 C a s e M a n a g e r 2 4 1 3 - 1 4 wast h e soundo f footsteps. A ¢ D reported h e felt a w o m a n touching h i m while heslept. ¢ H e h a d n u m e r o u s somatic complaints. S h e wrote d o w n headaches. 58 D A T E O B S E R V A T I O N O B S E R V E D B Y R T 9- 10 - 2 0 0 0 Ob se rv at io ns du ri ng m o d L - 1 6 ro un ds . Ce ll st re wn wi th c a n d y wr ap pe rs , un ke mp t. De sc ri be s so un ds a n d no is es f r o m w i n d o w s . S o m e o n e i s to uc hi ng hi m. De ni es se lf -d es tr uc ti ve vo ic es or im pu ls es . De ni es s i d e ef fe ct s. No d y s k i n e s i a , bu t ob es it y si de ef fe ct . G o o d co mp li an ce wi th me ds . S t o m a c h , i n c r e a s e d fa t. E a t i n g c a n d y ba rs . Mo od i s up . Sm il in g ch ee rf ul . Br oa d, in ap pr op ri at e af fe ct . P o o r En gl is h. N o t su re if th ou gh ts co he re nt . Po si ti ve au di to ry ha ll uc in at io ns . N o id ea ti on s. As se ss me nt : ch ro ni c, pa rt ia ll y st ab le . Sc hi zo -a ff ec ti ve . St il l ps yc ho ti c de sp it e me ds . R e n e w e d de pa ko te , at iv an , pa xi l a n d se ro qu el . Ap ri l Ba rr io , N u r s e P r a c t i t i o n e r 9 R T 22 21 9- 13 - 2 0 0 0 D ’ s hy gi en e w a s po or a n d h i s ce ll w a s ve ry di rt y. Hi s m o o d wa sa n x i o u s a n d h i s af fe ct w a s ap pr op ri at e to hi s m o o d . Sa un dr a Ki ng , C a s e M a n a g e r 1 0 R T 2 4 1 4 9-19- 2000 D’ s mo od w a s eu th ym ic , th at is , bl un te d, a n d hi s af fe ct wa sf la t. Ce ll st il l me ss y; hy gi en e wa sb et te r. SaundraKing, CaseManager 10RT 2414-15 59 D A T E OBSERVATION OBSERVED B Y R T 9-25- 2000 Observations during M o d L rounds. L y i n g supine o n b a c k with h e a d hanging off e n d of bed. Lips movinga s i f chanting or talking with someone. N o t responding w h e n door opened. J u m p e d u p after n a m e called. Seemed d i s o r i e n t e d with decreased c o m p r e h e n s i o n of English orability to communicate. U s i n g hands to motion. Appearedstartled b y soundo f his n a m e . Asked i f h e w a s hearing voices: “Voices, food, John, eat.” O b s e r v e d positive auditory hallucinations a n d positive confusion. Assessment: only partially stable. R u l e out subtherapeutic meds. R e n e w e d depakote, ativan, paxil a n d seroquel. S a m e dosages. Ativan at 1 m g atnight. O r d e r lab w o r k to c h e c k liver function, g l u c o s e andf o l i c acid level. Indicated 5 1 5 0 flag should stay in place. That’s a warning sign to alert others h e should not b e released w / o assessmentf o r mental health. April Barrio, N u r s e Practitioner 9 R T 2 2 2 2 - 2 4 9-26-2000 D reported olfactory hallucinations; reported smelling something she did not think wasthere. D also c o m p l a i n e d of problemssleeping. H y g i e n e w a s poor. M o o d wasp l e a s a n t a n d affect w a s appropriate. 10-3-00: hygiene w a s okay; cell was messy. S a u n d r a K i n g , C a s e M a n a g e r 1 0 R T 2 4 1 5 - 1 6 60 D A T E OB SE RV AT IO N | O B S E R V E D B Y R T 10 -8 - 20 00 Su bj ec ti ve : Re la te s po si ti ve co nt in ue d s a m e au di to ry ha ll uc in at io ns : w o m a n ’ s vo ic e te ll in g h i m wh en t o ea t; co ns ta nt c o m m e n t i n g o n hi s be ha vi or s; Re po rt s po si ti ve vi su al ha ll uc in at io n of a w o m a n ru nn in g by ; Fe el s so me on ei s to uc hi ng hi s sh ou ld er ; Sl ee p is n o w ok ; De ni es se lf -d es tr uc ti ve be ha vi or or co mm en ta ri es to d o so . Ob je ct iv e: D ly in g o n b a c k wi th h e a d ha ng in g of f bu nk ; In cr ea se d En gl is h to da y; sp on ta ne ou s; sp ee ch no rm al . In cr ea se d En gl is h sp on ta ne ou s me an s o f f e r i n g or at te mp ti ng to re la te d in fo w / o pr od di ng . R e d u c e d sp on ta ne it y af fe ct m e a n s he ’s no t as re la xe d or ex pr es si ve as us ua l. Fl at or n o n m o v i n g . T h o u g h t s co he re nt a n d or ga ni ze d; In cr ea se d gr oo mi ng ; Eu th ym ic ; N o id ea ti on s. H a d h a d ha ll uc in at io ns bu t no t th en . As se ss me nt : ch ro ni c wi th ps yc ho ti c s y m p t o m s . R e s p o n d s to a n d co mp li an ce w i t h m e d s ; n o si de ef fe ct s. R e n e w e d s a m e m e d s a t sa me l e v e l s . C o u r t da te 1- 19 . Ap ri l Ba rr io , N u r s e Pr ac ti ti on er 9 R T 2 2 2 5 - 2 7 10-11- 2000 Dwas“ h y p e r ta lk at iv e. ” H e w a s ra mb li ng . M u m b l i n ga l o t , o n a n d on . W h a t h e sa id di dn ’t ma ke a lo t of se ns e. So me ti me s t a l k e d in b r o k e n En gl is h, so me ti me s i t wa sc le ar . He s a i d hi s m o t h e r a n d si st er c a m e to se e h i m a n d th at th ey ca me o f t e n . SaundraKing, CaseManager 10RT 2416-17 61 D A T E O B S E R V A T I O N O B S E R V E D BY. 10-21-2000 Observations while o n M o d L rounds. ¢ D says he’s ok. ¢ Hears voices; lady touching him. Auditory hallucinations continue. * B r o a d inappropriate affect. ¢ Sleep ok. ¢ Observations: lying flat o n back. M o r e appropriate. * Cheerful. B r o a d inappropriate affect. * Not y i n g off of penis. E ¢ English still poor. ¢ T h o u g h t s coherent a n d organized. N o hallucinations. N o ideations. N o t as bizarre as previously noted. Assessment: chronic. Still psychotic, but maintaining in L-16. Stabilized s o m e w h a t . April Barrio, N u r s e Practitioner R T 9 R T 2 2 2 7 - 2 9 62 D A T E O B S E R V A T I O N ~ | O BS ER VE D B Y R T 11 -4 - 20 00 F r o m M o d L - 1 6 ro un ds . D de ni es pr ob le ms . Au di to ry ha ll uc in at io ns . L a d y ca ll in g hi s n a m e , “J oh n, Jo hn .” Oc ca si on al ta ct il e ha ll uc in at io ns . Sl ee p ok . No T . D . — ta rd iv e dy sk in es ia . In vo lu nt ar y mo ve me nt s th at a r e si de ef fe ct of an ti ps yc ho ti cs . U n k e m p t , bu t no t as b a d as be fo re . Br oa d, in ap pr op ri at e, ch ee rf ul m o o d . T h o u g h t s co he re nt , qu es ti on ab le . Or ga ni za ti on , qu es ti on ab le . Li mi te d En gl is h. N o ha ll uc in at io ns . N o id ea ti on s. Di dn ’t ob se rv e an yt hi ng to su gg es t he w a s ha vi ng ha ll uc in at io ns or de lu si on s wh il e ta lk in g to hi m. As se ss me nt : pa rt ia ll y st ab le ; sc hi zo -a ff ec ti ve di so rd er wi th ps yc ho se s. Ax is II I, in cr ea se d gl uc os e. N o t e d la b re su lt s o n 10 -3 1. In cr ea se in gl uc os e a n d to ta l pr ot ei n. R e n e w e d m e d s at s a m e do sa ge s. Ap ri l Ba rr io , N u r s e Pr ac ti ti on er 10 R T 2 2 3 1 - 3 2 11 -7 - 2 0 0 0 Mo od w a s eu th ym ic an da f f e c t wa sf la t. D wa sa c t i v e l y ha ll uc in at in g. D u r i n g th e in te rv ie w, D w a s m u m b l i n g a n d ta lk in g to hi ms el f. Sa un dr a Ki ng , C a s e M a n a g e r 10 R T 24 17 , 2 4 2 3 11 -1 2- 2 0 0 0 Mo od w a s p l e a s a n t a n d af fe ct ap pr op ri at e. S a u n d r a K i n g , 10 R T 2 4 1 7 63 CaseManager | O B S E R V E D B Y R T | D A T E | O B S E R V A T I O N 11-14- |* Continued complaint of auditory hallucinations. “Go, John; eat, John; April Barrio, N u r s e 10 R T 2 0 0 0 J o h n bad.” Practitioner 2 2 3 4 - 3 6 ¢ C o m p l a i n i n g h e wants to shower. Not i m e o u t . * Deputies report D refuses to g o to d a y r o o m w h e n givent h e time. ¢ Target s y m p t o m s : Reported auditory hallucinations. Slightly increased tactile hallucinations. F e m a l e touches him; increased poor grooming; unkempt clothing; cell unclean. ¢ S h e observed: unkept; diminished grooming; dysthymic; diminished spontaneity of affect. Even. S p e e c h is soft a n d whispering. P o o r English. T h o u g h t s coherent but sparse d u e to lack of language capabilities. S e e m s organized, but auditory hallucinations. N o ideations. Assessment: status quo. C h r o n i c schizo-affective; poor responder to psych meds. R e n e w e d s a m e meds. 11-16- |* D h a d a n u m b e r of somatic complaints. S a u n d r a King, 10 R T 2 0 0 0 C a s e M a n a g e r 2 4 1 7 11-22- * M o o d wasp l e a s a n t a n d affect appropriate. S a u n d r a King, 10 R T 2 0 0 0 ° D wasa c t i v e l y hallucinating. D u r i n g the interview, D w a s m u m b l i n g a n d C a s e M a n a g e r 2417, talking to himself. 2 4 2 3 64 ea te at an as es ap an am na ne ne n — — _ a D A T E |O B S E R V A T I O N o e : e e | O B S E R V E D B Y [R T 12-2- |* C o m p l a i n i n g of au di to ry ha ll uc in at io ns te ll in g h i m to sc ra tc h hi ms el f a n d Ap ri l Ba rr io , N u r s e 10 R T 2 0 0 0 pu ll hi s ha ir . Pr ac ti ti on er 2 2 3 6 - 3 7 e S y m p t o m s : au di to ry ha ll uc in at io ns ; o k sl ee p. N o de pr es si on . In ap pr op ri at e af fe ct . ¢ Ob se rv at io ns : sl ee pi ng ; un ke pt ; ce ll no t to o me ss y. Al er t, or ie nt ed , eu th ym ic . Br oa d, in ap pr op ri at e sm il in g af fe ct . P o o r En gl is h; l o w to ne . T h o u g h t s co he re nt a n d or ga ni ze d. Au di to ry ha ll uc in at io ns . N o id ea ti on s. 12 -2 -0 0 as se ss me nt : su bt he ra pe ut ic m e d le ve ls . P o o r re sp on de r. De sp it e m a x le ve ls o n me ds , st il l ps yc ho ti c. Ax is I, sc hi zo -a ff ec ti ve di so rd er . R e n e w e d m e d s at s a m e do se s. Co ns id er ed ad di ng ri sp er da l. 6 5 — — euerararasemsmemmeusnmenn-msesmenamares o e DATE O B S E R V A T I O N | a e o e | OBSERVED BY [RT ae — — 7 — 12-15- * Continues to complain of auditory hallucinations telling h i m to pull hair April Barrio, N u r s e 10 R T 2 0 0 0 o n top of head. N o t e d thinning of hair. Also tells h i m to pull off his Practitioner 2 2 3 8 - 4 0 toenails. S a w thinning o n front of his head. ¢ Alsotactile hallucinations of s o m e o n e touching him. ¢ Notsleeping. ¢ Constipated for 4 days. * R e s p o n s e to meds i s fair to poor. ¢ Observations: alert, oriented, cheerful, broad, inappropriate affect. T h o u g h t s coherent a n d organized; “J a m not sure about that.” S h e has a ? o n her notation. Auditory hallucinations. N o ideations. Assessment: only partially stable.. P o o r responder to treatments. Schizo- affective with positive psychotic s y m p t o m s . Consulted with psychiatrist Dr. Depovic. re target symptoms a n d p o s s i b l e use of risperdal. Decision to a d d risperdal. O n e mga t nightt o target hallucinations. Renewed r e s t of medsa t s a m e doses. Started colace, 2 5 0 m g , twice a day, and 3 0 cc’s of milk of magnesia, both for constipation. 6 6 D A T E OB SE RV AT IO N. O B S E R V E D B Y R T 12 -2 9- 2 0 0 0 * “V oi ce s ar e be tt er , no t so m u c h . “S om et im es I fe el sa d. ” e St at us of ta rg et s y m p t o m s : re du ce d au di to ry ha ll uc in at io ns te ll in g h i m to pu ll hi s ha ir . Di mi ni sh ed vi su al ha ll uc in at io ns . Di mi ni sh ed ta ct il e ha ll uc in at io ns . ¢ In cr ea se d sl ee p. “B et te r n o w . ” ¢ U p a n d d o w n m o o d sw in gs — sa d, ha pp y. M o o d up ;s ti ll in co ng ru en t wi th co nt en t. ¢ D i m i n i s h e d co mp ul si ve ha ir pu ll in g be ha vi or . ¢ R e d u c e d co ns ti pa ti on . ¢ “B et te r su bt he ra pe ut ic ne ur ol ep ti c of ri sp er da l. ” I. e. , su sp ec ts no t an ad eq ua te le ve l. e Sm il in g in ap pr op ri at el y. Fe el in g sa d bu t sm il in g. Co nt en ti s sa id wi th di mi ni sh ed au di to ry ha ll uc in at io ns . N o au di to ry w h e n sh e s a w hi m. N o id ea ti on s. Ap ri l Ba rr io , N u r s e P r a c t i t i o n e r 10 R T 2 2 4 0 - 4 3 ¢ M o o d w a s eu th ym ic an da ff ec t fl at . Sa un dr a Ki ng , C a s e M a n a g e r 1 0 R T 2 4 1 7 eSom at ic co mp la in ts . H e a d a c h e s an dj o c k it ch . e H y g i e n e po or . D ha dt o n s o f h a i r in hi s ce ll a n d ba ld sp ot s o n hi s he ad , so sh e as ke d h i m if he ’d b e e n pu ll in g it ou t. D sa id no . . SaundraKing, CaseManager 10RT 2417-18 6 7 D A T E O B S E R V A T I O N | OBSERVED BY 1-9- * Subjective: D has cold. H e a d a c h e gone. Dr. Steven Johnson, 10 R T 2 0 0 1 |. Obj: alert a n d oriented x3. Languagebarrier. Disheveled. Auditory Psychiatrist 2 3 1 4 - 1 5 hallucinations per case manager. Assessment: upperrespiratory infection. Still psychotic. Headacher e l a t e d to paxil. Plan: discontinue paxil. Decrease colace to 2 5 0 m g 2x/day 1-23- |* D w a s anxious andrestless. Saundra King, 10 R T 2 0 0 1 ¢ H y g i e n e poor. C a s e M a n a g e r 2418, 2 4 2 3 - 2 4 1-26- Administered neuropscyht e s t s to D. Dr. Ari 2 5 3 0 2 0 0 1 Kalechstein, Neuropscyhologist 2-1- ¢ D having headaches. Dr. Steven Johnson, 10 R T 2 0 0 1 ¢ Objective: alert a n d oriented x3; poor English; Psychiatrist 2 3 1 5 - 1 7 ¢ Disheveled; ¢ Denies ideationso r hallucinations. Assessment: headache. D e p a k o t e ? Plan: discontinue depakote. start depakote extended release., 1 0 0 0 m g at bedtime. Continue Colace a n d metamucil. Risperdal, 2 m g at bed. Ativan 1 m g at bed. 2-5- Administered neuropscyht e s t s to D. Dr. Ari 2 5 3 0 2 0 0 1 Kalechstein, Neuropsychologist 6 8 D A T E | O B S E R V A T I O N O B S E R V E D B Y R T 2- 13 - 2 0 0 1 ¢ M o o d pl ea sa nt a n d af fe ct ap pr op ri at e. Sa un dr a Ki ng , C a s e M a n a g e r 1 0 R T 2 4 1 9 2- 16 - 20 01 ¢ D n o lo ng er ha vi ng s i d e ef fe ct s. e Sl ee pi ng ok . e Al er t a n d or ie nt ed . ¢ G o o d hy gi en e a n d ch ee rf ul m o o d . ¢ Li mi te d En gl is h. D e n i e d id ea ti on s a n d ha ll uc in at io ns . ¢ D s e e m e d to be im pr ov in g. Co nt in ue d me ds . D r . S t e v e n J o h n s o n , Ps yc hi at ri st 10 R T 2 3 1 8 - 1 9 2- 27 - 2 0 0 1 e St il l n o si de ef fe ct s. e Al er t a n d or ie nt ed . ¢ C a l m a n d co he re nt . ¢ P o o r hy gi en e. ¢ D e n i e d id ea ti on s a n d ha ll uc in at io ns , bu t ca se ma na ge r’ s no te s sa id D h a d ex pr es se d au di to ry ha ll uc in at io ns . As se ss me nt : st il l ps yc ho ti c. In cr ea se d ri sp er da l to 3 m g at be d. Re st of m e d s th e sa me . D r . S t e v e n J o h n s o n , Ps yc hi at ri st 10 R T 21 39 - 23 20 2-27- 2001 ¢Dwa sa c t i v e l y ha ll uc in at in g. D u r i n g th e in te rv ie w, D w a s m u m b l i n g a n d ta lk in g to hi ms el f. SaundraKing, Case Manager 10RT 2423 69 O B S E R V A T I O N OBSERVED B Y | R T > ¢ D told her h e h a d b e e n pulling outh i s hair. ¢ Said h e w a n t e d medication to m a k e h i m feel happier. * Said h e w a s getting m o r e sleep than he h a d been. Also reported that hallucinations occurred mostly at night. e H y g i e n e wasp o o r . S a u n d r a K i n g , C a s e M a n a g e r 3-16- 2 0 0 1 * D c o m p l a i n e d of depression a n d requested the happypill. C o u l d not express it a n y m o r e articulately. A s s u m e d he meantpaxil. ¢ Reported n o side effects but frequent headaches. ¢ Alert a n d oriented. ¢ D e n i e d ideations or hallucinations. * G o o d hygiene. * Quiet a n d soft spoken. C o n c l u d e d headaches n o t d u e to paxil. Restarted paxil a n d increased seroquel to 6 0 0 mga t bed. Increased risperdal to 4 m g at b e d a n d c h a n g e d depakote to 5 0 0 m g 4x/day to minimizes i d e effects. D r . S t e v e n J o h n s o n , Psychiatrist 1 0 R T 2320-22 3-16- 2 0 0 1 ¢ D continuedt o pull out chunkso f hair. S a w bald spots o n h i m andh a i r o n the floor. * M o o d w a s euthymic andaffect flat. ¢ H y g i e n e poor. Saundra King, C a s e M a n a g e r 10 R T 2 4 1 9 - 2 0 3-20- 2 0 0 1 ¢ D wasstill pulling out chunkso f his hair. ¢ D e p r e s s e d with sad affect. S a u n d r a K i n g , C a s e M a n a g e r 1 0 R T 2 4 2 0 3-29-2001 * D reported he felt m u c h better. ¢ Nol o n g e r p u l l i n g out hair a n d she did not observe indication that he was. S a u n d r a K i n g , C a s e M a n a g e r 1 0 R T 2 4 2 0 7 0 D A T E O B S E R V A T I O N - OB SE RV ED BY R T 4- 3- 20 01 ha ir . Dr . Ju ve nt in o Lo pe z, Ps yc hi at ri st 1 0 R T 2 5 1 7 4- 10 - 20 01 ¢ D wa ss t a b l e wi th mo de ra te re si du al de pr es si ve s y m p t o m s . Fi rs t ti me he ’d in te rv ie we d D wi th a co ll ea gu e w h o sp ok et o D in hi s na ti ve to ng ue . e Af te r th at , a s s e s s m e n t th at D h a d sc hi zo -a ff ec ti ve di so rd er w i t h i m p r o v e d st ab il it y a n d mo de ra te re si du al de pr es si ve s y m p t o m s . ¢ D ’ s af fe ct w a s bl an d. Af fe ct w a s bl an d wh en t r y i n g to de sc ri be hi s em ot io na lt o n e . ¢ De pr es si on , o n sc al e of 1 - 10 , w a s in th e mi dd le . Dr . Ju ve nt in o Lo pe z, Ps yc hi at ri st 10 R T 2 5 1 8 - 1 9 4- 17 - 2 0 0 1 ¢ D’ sc e l l w a s “m od er at el y ma lo do ro us .” Dr . J u v e n t i n o Lo pe z, Ps yc hi at ri st 10 R T 2 5 1 9 4- 20 - 20 01 ¢ M o o d p l e a s a n t a n d af fe ct ap pr op ri at e. S a u n d r a K i n g , C a s e M a n a g e r 10 R T 2 4 2 0 4-27- 2001 ¢M o o d de pr es se d a n d af fe ct sa d. e H y g i e n e po or S a u n d r a K i n g , C a s e M a n a g e r 10 R T 2 4 2 0 71 D A T E O B S E R V A T I O N | u e cn N e a O B S E R V E D B Y R T 5-8- S a w D w i t h interpreter. Dr. S t e v e n J o h n s o n , | 1 0 R T 2 0 0 1 * C o m p l a i n e d of headaches a n d auditory hallucinations at ~ n o o n everyday. Psychiatrist 2 3 2 2 - 2 3 ¢ Also tremor and insomnia. Mild tremor. * No i d e a t i o n s or other hallucinations. ¢ Coherent. N o r m a l speech. ¢ Disheveled. Increased seroquel to 2 0 0 m g at n o o n a n d 6 0 0 mga t bedtime. Increased risperdal to 4 m g at n o o n a n d bedtime. Switched paxil f r o m morningt o bedtime. R e n e w e d depakote. 5-16- O b s e r v e d D o n M o d L-16. Interviewed h i m as a psychiatrist a n d talked to Dr. E b t e s a m 1 0 R T 2 0 0 1 h i m in Arabic. Khaled, Psychiatrist 2 3 4 7 - 4 9 ¢ Subjective: D said h e w a s feeling better a n d hearing less voices. Sleeping better. N o t shaking because Dr. L o p e z c h a n g e d someo f his meds. ¢ Objective: Alert; oriented x3; h a d fair eye contact. * W h e n f i r s t s a w D, he w a s notbright; he w a s shaking; having s o m e problem. D o i n g muchb e t t e r o n today than he w a s a m o n t h earlier. F e w e r hallucinations a n d less depressed m o o d . ¢ H e h a d poori n s i g h t a n d p o o r judgment. Didn’t h a v e insight about w h a t w a s going o n with him. Looka t insight to determine whether person has recognition of howi l l h e is. Assess D as suffering f r o m schizo-affective disorder a n d continued meds. 5-16- |* M o o d euthymic anda f f e c t flat. Saundra King, 10 R T 2 0 0 1 ¢ P o o r hygiene. C a s e M a n a g e r 2421 7 2 D A T E OB SE RV AT IO N O B S E R V E D B Y R T 5- 21 - 20 01 D sa id st il l sh ak in g. Sh ak in g so ba dl y K h a l e d re vi ew ed la b wo rk . It w a s ok . D wa so th er wi se a l e r t a n d or ie nt ed ; fa ir ey e co nt ac t; fa ir ly g r o o m e d ; cl ai me d vo ic es no t bo th er in g h i m as m u c h . Le ss de pr es se d m o o d a n d br ig ht er af fe ct . N o id ea ti on s. Ju dg me nt a n d in si gh t re ma in ed po or . Co nt in ue d m e d s bu t a d d e d co ge nt in be ca us eo f th e sh ak in g. Dr . E b t e s a m K h a l e d , Ps yc hi at ri st 1 0 R T 23 49 -5 0 5-31- 2001 D sa id vo ic es w e r e th e sa me . Le ss sh ak in g. Al er t, or ie nt ed , fa ir e y e co nt ac t. Mo od a n d a f f e c t w e r e bl un t. B e c a u s e h e is on ly o n e w h o ca n sp ea k Ar ab ic wi th D, D is us ua ll y li tt le br ig ht er w h e n he vi si ts , bu t no t th at da y. C o m p l a i n i n g of vo ic es . D e n i e d id ea ti on s. R e m a i n e d po or i n s i g h t a n d ju dg me nt . C o n t i n u e d m e d s . Dr.Ebtesam Khaled,Psychia tr is t 10RT 2351 73 D A T E O B S E R V A T I O N a i e . O B S E R V E D B Y R T 6-4- ¢ D reported that his auditory hallucinations w e r e getting better. A Dr. Juventino 1 0 R T 2 0 0 1 reflection of the fact that they h a d increased D ’ s medication — o n e of the Lopez, Psychiatrist 2 5 1 9 - 2 0 m a j o r tranquilizers. D h a d b e e n taking 4 m g . of Risperdal 2x/day. E v e n thoughi t decreased D ’ s reported hallucinations, it caused adverse m u s c l e stiffness a n d incoordination, so h a d to reduce dosage. Thati s an antipsychotic medication. * Also taking Seroquel, another antipsychotic medication. A n d Depakote, w h i c h is moodstabilizer. ¢ A n d Paxil, a n antidepressant, that h e ’ d increased f o r m 2 0 to 3 0 m g a m o n t h earlier. 6-13- ° Interviewed D with Dr. Khaled. N o t e d that D ’ s m o o d w a s anxious a n d Dr. Juventino 10 R T 2 0 0 1 affect wasflat. Lopez, Psychiatrist 2 5 2 0 6-15- * M o o d euthymic a n d affect appropriate to his m o o d . Saundra King, 10 R T 2 0 0 1 ¢ H e talked about tremors in his hands a n d an unsteadyg a i t . C a s e M a n a g e r 2 4 2 1 6-21- |* D said: “the voices are o n a n d off, half a n d half.” Dr. E b t e s a m 10 R T 2 0 0 1 ¢ D waso n l y oriented x2. Khaled, Psychiatrist 2352-53 * D wasfalling off a lot a n d complained of being dizzy. C o n c e r n e d he w a s falling d o w n . * Noideations; poor judgment; poorinsight. R e v i e w e d lab w o r k a n d noticed blood sugar low. M a y be whyh e wasd i z z y a n d falling d o w n . 6-22- |* D ’ s j u d g m e n t andi n s i g h t w e r e poor. Insight into his illness. Didn’t h a v e Dr. Teresa Farjalla, 10 R T 2 0 0 1 g o o d recognition that h e wass i c k . Psychiatrist 2 4 7 2 74 D A T E O B S E R V A T I O N O B S E R V E D B Y R T 6- 25 - 20 01 ¢ D sa id “I ca n’ t si t up . If fe el di zz y. ” “I fe ll th re e ti me s. ” e Al er t, bu t no t ab le to ta lk a lo t. La yi ng d o w n . Sa id h e co ul d no ts i t u p a n d ta lk . e St il l he ar in g vo ic es . D e n i e d id ea ti on s. ¢ P o o r in si gh t a n d ju dg me nt . Co ns ul te d wi th M. D. t o se e if ph ys ic al re as on D wa sf al li ng . S h e sa id bl oo d su ga r st ab le . S h e vi si te d D wi th do ct or a n d fo un d n o re as on fo r D’ s fa ll s a n d di zz in es s. Co nt in ue d me ds . D h a d co ur t da te of 6- 29 . Dr . E b t e s a m Kh al ed , Ps yc hi at ri st 10 R T 2 3 5 3 - 5 4 6-25- 2001 ¢Dw a s es co rt ed f r o m hi s se ct or b y de pu ty a n d st ag ge re d an ds ta rt ed t o fa ll to th e fl oo r, us in g h a n d to br ac e hi ms el f. ¢ D wa sa l e r t a n d or ie nt ed . A t t e m p t e d to ta lk to h i m a b o u t wh yh e f e l l , b u t h e w a s un ab le to ex pl ai n h o w he h a d be en fe el in g. ¢ D e n i e d su ic id al th ou gh ts . ¢ H e ad mi tt ed to co nt in ue d au di to ry ha ll uc in at io ns . H e a r d a vo ic e th at sa id hi s n a m e a n d so me ti me s hi s mo th er ’s vo ic e ta lk in g to hi m. ¢ H e h a d b e e n ta ki ng me di ca ti on as pr es cr ib ed . H e fe lt me di ca ti on di mi ni sh ed th e vo ic e bu t th ey ne ve r st op pe d al l to ge th er . H e ad mi tt ed th at h e h a d be en p u l l i n g hi s ha ir ou ta li tt le bi t, bu t co ul d no t gi ve a re as on w h y . H e de ni ed an y an xi et y ab ou t up co mi ng tr ia l. RachelleGardea , R N 9RT 2150-53 7 5 D A T E O B S E R V A T I O N O B S E R V E D B Y 6-26- |* D c o u l d n ’ t r e m e m b e r h o w manyt i m e s h e hadf a l l e n the d a y before. Said Dr. E b t e s a m 1 0 R T 2 0 0 1 h e could notstands t r a i g h t e v e n to g o to the bathroom. Khaled, Psychiatrist 2 3 5 4 - 5 5 e Alert with fair eye contact. Sitting d o w n . C l a i m e d h e couldn’t stand w / o feeling dizzy. ¢ Admitted, w h e n asked, that hearing voices, butless. e S h a k i n g a r m is alsol e s s . ¢ Still paranoid. Guarded. ¢ D e n i e d ideations. ¢ Still p o o r insight a n d judgment. 6-27- |* D still complaining of dizziness a n d inability to sit u p in bed. Dr. E b t e s a m 10 R T 2 0 0 1 Decidedt o present case to treatment t e a m to see if they could help h i m more. Khaled, Psychiatrist 2 3 5 5 - 5 6 6-28- |* D reported he h a d b e e n pulling his hair more. Doesn’t k n o w why. Dr. E b t e s a m 10 R T 2 0 0 1 e Feeling better o n 6-28, but d a y before wasn’t well. Khaled, Psychiatrist 2 3 5 6 - 5 7 Alert; fair eye contact; claimed auditory hallucinations, butless. Guarded, preoccupied. E v e r y o n e noticed it. Thinks because of court the next day. Deniedideations. Poori n s i g h t a n d judgment. Also poor m e m o r y . After discussed D ’ s case with treatment plan, they r e c o m m e n d e d c l o s e r observation of vital signs, blood pressure, blood sugar. Continued meds. 7 6 D A T E e s — OB SE RV AT IO N’ O B S E R V E D B Y R T 7- 2- 2 0 0 1 D sa id h e co ul dn ’t re me mb er i f he ’d fa ll en d a y be fo re . Al er t; fa ir ey e co nt ac t; fa ir ly gr oo me d. D e n i e d id ea ti on s; sa id vo ic es w e r e le ss , bu t co ul dn ’t re me mb er a l o t of th e qu es ti on s, so no te d po or m e m o r y . St il l gu ar de d a n d su sp ic io us a n d po or i n s i g h t a n d ju dg me nt . M e d s t h e s a m e . Dr . E b t e s a m Kh al ed , Ps yc hi at ri st 10 R T 2 3 5 7 - 5 8 7- 3- 2 0 0 1 “T w a n t e d to ki ll my se lf . A n d I lo ok ed ar ou nd , a n d I ca n’ t fi nd an yt hi ng to ki ll my se lf wi th .” In re sp on se to qu es ti on : “Y es , I he ar vo ic es .” Al er t a n d or ie nt ed x2 . Pr eo cc up ie d wi th hi s de pr es si on a n d w a n t e d to hu rt hi ms el f. Au di to ry ha ll uc in at io ns a n d su ic id al id ea ti on . P o o r m e m o r y , in si gh t a n d ju dg me nt . As se ss me nt : st il l su ic id al a n d ps yc ho ti c; fe ll d o w n 4 x in th e m o r n i n g pe r de pu ty — D co ul dn ’t r e m e m b e r . Co nt in ue d o n su ic id al pr ec au ti on . Dr . E b t e s a m Kh al ed , Ps yc hi at ri st 1 0 R T 2 3 5 8 - 5 9 Dapp ea re d an xi ou s. L a n g u a g e pr ob le m. D e n i e d fa ll in g d o w n , bu t no te s su gg es t he h a d b e e n fa ll in g do wn p r i o r to th is . D e n i e d su ic id e id ea ti on s. Di sh ev el ed . Di ff ic ul t to as se ss . Co nt in ue d o n me ds . Dr.StevenJohnson , Ps yc hi at ri st 10RT 2323-24 7 7 O B S E R V A T I O N | ¢ Reported auditory hallucinations. * U n a b l e to sit up. V e r y sleepy. Snoring. D A T E O B S E R V E D B Y R T 7-5- * “ T a m not going to hurt myself. Voicesstill c o m i n g f r o m the w i n d o w a n d Dr. E b t e s a m 10 R T 2 0 0 1 the doors. I look a n d nobodyi s there.” Khaled, Psychiatrist 2359-60, e Alert a n d oriented x2. _ 7 0 ¢ C o m p l a i n e d of auditory hallucinations. ¢ V e r y paranoid. L o o k i n g aroundc e l l . ¢ V e r y poor insight a n d judgment. Assessment: still psychotic but not suicidal. Continued o n suicidal precaution observation. 7-6- ¢ D h a d milk a n d cereal spilled over his table. Dr. Teresa Farjalla, 10 R T 2001 Psychiatrist 2 4 7 2 7-9- * Dssaid h e keepsfalling. Feels knees are giving u p o n him. Doesn’t feel Dr. E b t e s a m 10 R T 2 0 0 1 dizzy anymore. Khaled, Psychiatrist 2360-61 ¢ Oriented; h a d full eye contact; fairly groomed. * Auditory hallucinations but denied ideations. ¢ Preoccupied with physical illness. A n d falling d o w n . ¢ P o o r insight a n d judgment. Reducedp a x i l a n d depakote. 7-10- |* D s a i d h e f e l t tired. A Dr. E b t e s a m 10 R T 2 0 0 1 * lert; fair eye contact; fairly groomed. Khaled, Psychiatrist 2 3 6 1 7 8 D A T E 7- 11 - 2 0 0 1 O B S E R V A T I O N ‘O BS ER VE D BY . R T D sa id h e ke pt he ar in g 2 pe op le ta lk in g to ea ch ot he r, bu t no t to hi m. Al er t a n d or ie nt ed x2 . O n l y pa rt ia ll y or ie nt ed . C l a i m e d h e co ul dn ’t re me mb er a l o t of th in gs . A n s w e r e d m a n y qu es ti on s wi th “I ca n’ t r e m e m b e r . ” No id ea ti on s. Sa id he fe lt de pr es se d. Po or i n s i g h t a n d ju dg me nt . Dr . E b t e s a m Kh al ed , Ps yc hi at ri st 10 R T 2 3 6 1 - 6 2 7- 12 - 2 0 0 1 D sa id th e vo ic es we re st il l th er e. Al er t; or ie nt ed x2 ; fa ir ey e co nt ac t; fa ir gr oo mi ng . ‘S ai d he fe lt de pr es se d a n d sa d — in re sp on se to qu es ti on s. Po or i n s i g h t a n d ju dg me nt . N o id ea ti on s. D i s c o n t i n u e d su ic id al ob se rv at io n, b e c a u s e 4 d a y s in a r o w c l a i m e d n o t su ic id al . B u t co nt in ue d n o sh ar p ob je ct s inc e l l . Dr . E b t e s a m Kh al ed , Ps yc hi at ri st 10 R T 2 3 6 2 - 6 3 7- 16 - 20 01 D re po rt ed im pr ov em en t. No tf al li ng as mu ch ; n o t p u l l i n g ha ir as m u c h ; vo ic es no t as m u c h . D e n i e d id ea ti on s, bu t ad mi tt ed he ar in g vo ic es . Dr . E b t e s a m K h a l e d , Ps yc hi at ri st 1 0 R T 23 63 -6 4 7-17- 2001 He’dcha n g e d bl oo d su ga r me di ca ti on a n d al re ad y fe el in g be tt er . Al er t; fa ir ey e co nt ac t; m o r e aw ak e. St il l h a d au di to ry ha ll uc in at io ns bu t le ss de pr es se d m o o d . A f f e c t bl un te d, b u t sa id n o t de pr es se d. Po or i n s i g h t a n d ju dg me nt . Dr.Ebtesam Khaled,Psychiatri st 10 RT 2364 79 D A T E O B S E R V A T I O N O B S E R V E D B Y : : c o 1 7-17- |* D-was slightly disheveled, but h a d b e e n requesting a shave. Rachelle Gardea, 9 R T 2 0 0 1 ¢ S p e e c h w a s sparse. N o t talking mucht o her. R N 2 1 5 3 - 5 4 ¢ D e n i e d feeling suicidal. * D admitted to hearing voices — his m o t h e r a n d his sister. D e n i e d a n y type of c o m m a n d hallucinations. C o m p l i a n t with meds. ¢ D e n i e d anxiety about u p c o m i n g court date. ¢ Said he’d h a d occasionalfalling, but it h a d decreased sincel a s t time. * His behavior o n the unit h a d b e e n appropriate. R e c o m m e n d e d t h a t flag remain in place. S h e suggested that the psychiatris a n d she, as case manager, follow up. 7-18- ° Fairly groomed. Dr. E b t e s a m 10 R T 2 0 0 1 ¢ Auditory hallucinations; still paranoid; guarded and suspicious; denied Khaled, Psychiatrist 2 3 6 4 - 6 5 ideations. Felt D w a s paranoid because s o m e days D c o m m u n i c a t e d freely a n d o n other days h e w a s blocking a n d guarded. 7-19- |* Dhadn’t f a l l e n at all. C o m p l a i n e d his ankle w a s swollen. Dr. E b t e s a m 1 0 R T 2 0 0 1 ¢ Sameo b s e r v a t i o n s as those o n 7-18-01. Continued o n s a m e meds. Khaled, Psychiatrist 2 3 6 5 7-23- |¢* D said notsuicidal, but still hearing voices. Dr. E b t e s a m 10 R T 2 0 0 1 ¢ Sameo b s e r v a t i o n s as those o n 7-19-01. Khaled, Psychiatrist 2 3 6 5 - 6 6 7-24- ¢ D said felt ok; not suicidal a n d voicesstill there. Dr. E b t e s a m 1 0 R T 2 0 0 1 ¢ Said he h a d b e e n feeling anxious. Khaled, Psychiatrist 2 3 6 6 e O t h e r t h a n that s a m e o b s e r v a t i o n s a s b e f o r e . 8 0 D A T E O B S E R V A T I O N O B S E R V E D B Y R T 7- 25 - 2 0 0 1 ¢ D sa id fe lt g o o d a n d n e e d e d a sh ow er . e S e e m e d m o r e aw ak e. ¢ N o t e d D h a d b e e n m o r e an xi ou s. St il l gu ar de d bu t n o in di ca ti on of pa ra no ia . D wa st a l k i n g mo re t h a t da y. ¢ Ot he r th an th at , s a m e ob se rv at io ns a s be fo re . Dr . E b t e s a m Kh al ed , Ps yc hi at ri st 10 R T 23 66 -6 7 7- 26 - 2 0 0 1 e D sa id vo ic es w e r e n ’ t th at ba d; fe lt be tt er ; w a n t e d a sh av e. V o i c e s w e r e le ss . e Fe we rf al li ng sp el ls . ¢ O t h e r w i s e s a m e ob se rv at io ns . Dr . E b t e s a m K h a l e d , Ps yc hi at ri st 1 0 R T 2 3 6 7 7- 31 - 2 0 0 1 ¢ D s a i d vo ic es l e s s bu tf e l t li tt le a n x i o u s . e N o t e d fe we r pa ra no id s y m p t o m s . e O t h e r w i s e , s a m e ob se rv at io ns . Dr . E b t e s a m Kh al ed , Ps yc hi at ri st 1 0 R T 2 3 6 7 8- 13 - 2 0 0 1 ¢ D h a d n o co mm en ts t o sh ar e re 8- 10 co ur t ap pe ar an ce . N o t an xi ou s; ne ut ra l m o o d . Af fe ct bl an d. Dr . Ju ve nt in o Lo pe z, Ps yc hi at ri st 1 0 R T 2 5 2 1 8- 14 - 20 01 e Af fe ct bl an d. Pr im ar il y mo ni to ri ng D’ s me ds . D h a d b e e n th er e 1 ye ar be fo re h e st ar te d se ei ng D. Ob je ct iv e w a s to ad dr es s D ’ s me ds . Dr . Ju ve nt in o Lo pe z, Ps yc hi at ri st 10RT 2521 81 D A T E O B S E R V A T I O N | O B S E R V E D B Y R T 8-20- ° Staff reported D w a s m o r e quiet a n d withdrawn. Dr. Juventino 1 0 R T 2 0 0 1 ° Cell w a s m a r k e d l y m a l o d o r o u s with food spilled onf l o o r . Lopez, Psychiatrist 2 5 2 2 ¢ D not registering any complaints. _ ¢ Increased depressive s y m p t o m s . ¢ Assessedt h a t D b y history h a d schizo-affective disorder a n d appeared to b e regressed with m o r e repressive s y m p t o m s . 8-22- S a w D with Dr. Khaled. Dr. Juventino 1 0 R T 2 0 0 1 ¢ Cell still malodorous. Lopez, Psychiatrist 2 5 2 3 - 2 4 ¢ D ’ s h e a d w a s covered underh i s blanket. e D wase a s i l y aroused a n d madef u l l eye contact. 8-24- N o side effects. Sleeping well. Dr. Steven Johnson, 10 R T 2 0 0 1 ¢ D h a s n o t b e e n put o n clozaril. Rarely used in the jail. H a v e neverstarted Psychiatrist 2 3 2 4 - 2 6 a n y o n e o n clozaril. In rare case w h e r e s o m e o n e comes t o jail already takingi t , they will continue it. W o u l d never consider prescribingi t to s o m e o n e whoh e d i d not consider to be seriously mentally ill. 8-27- |* D said heh e a r s h i s father’s voice cursing at h i m thru the T V . Still hearing Dr. E b t e s a m 10 R T 2 0 0 1 v o i c e s but deniedsuicidal. Khaled, Psychiatrist 2 3 6 8 ¢ Guarded, but n o notation about paranoia. * Otherwise, similar observations. 8-28- | D said hef e l t fine. Dr. E b t e s a m 10 R T 2 0 0 1 ¢ V o i c e s better. K h a l e d , Psychiatrist 2 3 6 8 Depressionbetter. O t h e r w i s e , s i m i l a r o b s e r v a t i o n s . 8 2 D A T E O B S E R V A T I O N O B S E R V E D B Y R T 8- 30 - 20 01 - ¢ M o o d eu th ym ic an da ff ec t fl at . ¢ H y g i e n e un ke mp t. e S p e e c h wa s s l o w bu t c le ar . D h a d go ne t o co ur t th e d a y be fo re . S a u n d r a Ki ng , C a s e M a n a g e r 10 R T 2 4 2 1 S a w D af te r h e re tu rn ed f r o m co ur t. ¢ D wa s a l e r t a n d c o h e r e n t . ¢ Mo od w a s p l e a s a n t a n d af fe ct ap pr op ri at e S a u n d r a K i n g , C a s e M a n a g e r 1 0 R T 2 4 2 1 - 2 2 ¢ D ’ s in si gh t a n d j u d g m e n t w e r e po or . S h e ha s b e e n in vo lv ed in st af fi ng or te am in g of D in w h i c h di ag no se s h a v e b e e n di sc us se d. A w a r e th at D ha s b e e n di ag no se d wi th sc hi zo -a ff ec ti ve di so rd er fo r s o m e ti me . S h e pa rt ic ip at ed in th e t e a m me et in gs t h a t re su lt ed in th at co nc lu si on . A g r e e s wi th it . Dr. Teresa Fa rj al la , Ps yc hi at ri st 10RT 2472 83 DECLARATIONOF SERVICE Re: People v. John Samuel Ghobrial CA Supreme Ct. No.S105908 Orange County Superior Ct No. 98NF0906 I, Tamara Reus, declare that I am over 18 years of age, and nota party to the within cause; my business addressis 1111 Broadway, 10th Floor, Oakland, California 94607. I served a true copyof the attached: APPELLANT’S REPLY BRIEF on the following, by placing same in an envelope addressed asfollows: Collette C. Cavalier, Deputy Attorney Habeas Corpus Resource Center General 303 2nd Street, Suite 400 South Office of the Attorney General San Francisco, CA 94107 110 W. “A’ Street, Suite 11000 San Diego, CA 92101 John Samuel Ghobrial, # T-50232 Capital Case Clerk (Appellant) Orange County Superior Court CSP-SQ Room L-100 2-EB-66 700 Civic Center Drive West San Quentin, CA 94974 Santa Ana, CA 9270 Eachsaid envelope wasthen, on February 14, 2014, sealed and deposited in the United States Mail at Oakland, Alameda County, California, the county in which I am employed, with postage thereon fully prepaid. I declare underpenalty of perjury that the foregoingis true and correct. Signed on February 14, 2014, at Oakland, California. 7 — MeaorEe CKerou DECLARANT