For weeks, Ashley Goldfarb’s parents prayed that she’d land at the county’s psychiatric hospital.
The 25-year-old’s mother heard doctors at the Midway District facility would be the most likely in the region to seek forced residential treatment for her daughter who had bipolar disorder and attention deficit hyperactivity disorder. Ashley was also homeless and sometimes used drugs.
At the time, Ashley was spiraling. Among the warning signs: Her mother had received multiple calls from people trying to help her daughter as she experienced waves of hallucinations and paranoia. She had abandoned her downtown apartment, taken impulsive trips to Mexico and Orange County and lost touch with her longtime treatment program.
Ashley’s parents hoped the county hospital could help save her life.
Then, unbeknownst to her family, Ashley ended up there early Saturday, Feb. 13, 2021.
Records obtained by Voice of San Diego show Ashley was admitted to the county psychiatric hospital after a San Diego police officer watched her run in the middle of the street without shoes on. The officer deemed her a danger to herself and gravely disabled after watching two vehicles nearly hit her.
A doctor put her on an up to 72-hour hold after she got to the hospital, but another doctor discharged her early the next morning.
Records show the doctor who admitted her into the hospital decided that her agitation, rambling and “nonsensical statements” were related to methamphetamine use. But hospital staff didn’t test her for drugs.
Later, an on-call therapist from Ashley’s treatment program wrote that he spoke with another doctor and requested that the hospital keep her until Monday. That doctor ultimately discharged Ashley early the next day after he concluded she had sobered up and no longer met criteria to be held at the hospital.
Ashley left the hospital about 24 hours after she arrived.
Ten days later, on Feb. 24, 2021, Ashley darted into traffic on southbound Interstate 5 near Front Street at about 9 p.m., and collided with a car, according to a state Highway Patrol report. A paramedic pronounced her dead at the scene.
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For Ashley’s family, the release from the county psychiatric hospital and Ashley’s subsequent death were a nightmare that came true.
It’s a nightmare familiar to countless families and friends whose loved ones grappling with mental health crises and addiction repeatedly cycle in and out of local hospitals and programs without getting the care they need to stabilize over the long haul. Many fear their loved ones will eventually succumb to their illnesses. Some do.
Those scenarios spurred SB 43, a state law expanding eligibility for short-term holds and longer-term conservatorships. SB 43, which San Diego County for now expects to implement by 2025, makes people with severe substance use disorders eligible for conservatorships and broadens the definition of gravely disabled to include a person’s inability to ensure their own personal safety or “necessary medical care” rather simply access to food, clothing or shelter.
The change reflects years of increasing frustrations over the high bar for conservatorships and holds for people whose loved ones feared for their safety and the disparate treatment people with addiction challenges have long faced when they end up in the hospital.
Once medical staff decide a person’s symptoms are tied to substance use, they often decide to discharge patients like Ashley once they’re no longer intoxicated even if they may have other health issues. Doctors typically decide that patients are no longer gravely disabled or a harm to themselves or others once they sober up.
Ashley’s mother Lynn Solorzano is convinced that addiction wasn’t the only challenge that engulfed her once spunky, fun-loving daughter’s life. She supports SB 43 and what it could mean for other families. It came too late for hers.
“We kept being told she’s not gravely disabled enough,” Solorzano said.
Roderick Shaner, who for more than two decades served as medical director of Los Angeles County’s Department of Mental Health, said deaths like Ashley’s are a far too common result of demands and restrictions on behavioral health systems statewide, including laws that dictate who is eligible for a hold or conservatorship.
“The pressure to triage is intense and just by odds, it is a set-up for things like this to happen,” said Shaner, now vice chair of the California State Association of Psychiatrists.
Shaner noted that the longtime state conservatorship law – since amended by SB 43 – left many doctors feeling forced to “obsess about whether someone’s flagrant psychosis is due to meth or some underlying other psychotic disorder” despite the similar impacts on patients’ lives.
He expects SB 43 to clear legal hurdles that now keep some patients from being placed on holds or into longer-term conservatorships that can connect them with longer-term care.
Whether the new law ultimately results in better outcomes for patients and thus fewer tragedies will rest on whether the state can deliver more beds, programs and funding to support these patients, Shaner said.
Many advocates across the state – including a chorus who oppose forced treatment – emphasize that people with substance use disorder and mental health conditions who desperately want treatment now often can’t get it. A coalition of activist groups that opposed SB 43 also argued that mandated, locked treatment is traumatizing and ineffective and that the new law could disproportionately affect people of color.
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If Ashley had a theme song, those who loved her are convinced it was Cyndi Lauper’s “Girls Just Want to Have Fun.”
That’s the song they played at her memorial service.
As a teenager, Ashley’s cousin Eric Panattoni recalled her constantly seeking excitement and entertainment. She loved hip hop and rap music. During one of their regular Sunday hangouts in Ashley’s father’s garage in Rancho Peñasquitos, Panattoni recalls laughing as his cousin cranked up the music and danced in the middle of the street.
By then, Ashley was already struggling. At 13, she was diagnosed with bipolar disorder and her family noticed other symptoms they couldn’t pin down. She was impulsive and moody. She chafed at rules, often sneaking out of the house. When she was a high school junior, Ashley’s parents sent her to a Utah boarding school, but it didn’t work out. Almost immediately after she arrived, Ashley hallucinated for the first time and behaved erratically. She was hospitalized for three weeks.
Soon after that, Ashley ended up in juvenile hall after swiping money and iPhones from the girls’ locker room at her high school. Then she terrified her parents by leaving home and moving onto the street.
The county probation department referred Ashley to Pathways Community Services’ Catalyst, which has a county contract to operate a treatment program with teams that work with young adults with serious mental illnesses who are homeless or at risk of homelessness. The team tried to aid Ashley over the next several years as she bounced between the street, independent living facilities, treatment programs, hospitals and for a time, a downtown studio.
Catalyst reports and hospital records show the final months of Ashley’s life were turbulent. She stopped taking medication, walked away from the subsidized downtown apartment and filed a restraining order against a former boyfriend who was reportedly abusive.
She was also repeatedly hospitalized. In a September 2020 discharge note, a county psychiatric hospital social worker wrote that Ashley was “well known to San Diego County Psychiatric Hospital as well as other local facilities in San Diego” and had repeatedly been placed on holds after running into traffic.
By early 2021, the situation was especially dire. Police arrested Ashley for walking into a Hillcrest home and stealing money. She also lost touch with Catalyst. Solorzano repeatedly fielded calls from strangers trying to help Ashley, including a woman who found Ashley in late January appearing disheveled and claiming she had been sexually assaulted.
On Feb. 12, Catalyst therapist Shelley Stout wrote that Ashley had “significantly decompensated.” She reported coaching Solorzano on how to advocate for her daughter to receive inpatient treatment given her homelessness, failure to take medication and “subsequently experiencing a severe psychotic episode” that included hallucinations and paranoia. Stout also wrote that she and other Catalyst staff “would also advocate for Ashley to be hospitalized.”
By the early next morning, Ashley was at the county psychiatric hospital. It was Presidents Day weekend.
Dr. Gary Balian, who saw Ashley when she arrived at about 4:50 a.m., wrote that police initially found her outside an apartment complex “rummaging through the recyclables” and saying she was searching for a lighter. Police later got another call as she combed through a dumpster at a Costco store. This time, Ashley ran into the middle of the street.
“She is in an extreme state of self-neglect with matted hair, wearing filthy clothes and no shoes,” Balian wrote.
Balian noted that Ashley had a history of “wandering into traffic” and that her condition appeared similar to previous hospital visits “involving mood dysregulation and disorganization with evidence of psychosis in the context of active stimulant or other substance abuse.”
Balian signed off on a 72-hour hold. Ashley agreed to take anti-psychotic and anxiety medications and extra-strength allergy medication that likely made her drowsy.
Ashley would be ready to leave the hospital, Balian wrote, after she sobered up “with adequate resolution of psychosis and disorganization” and could share a “cogent plan for self-care.”
Later that day, Dr. Robert Enriquez talked to on-call Catalyst therapist Cameron Mosier.
“(Mosier) stated that if the patient voices no thoughts about hurting herself or other people, he would be comfortable with the patient’s discharge,” Enriquez later wrote. “He also stated that he would inform her specific team that the patient was at this facility, and they would follow-up with the patient on Monday, 2/15/2021.”
Mosier’s notes described the call differently.
“Therapist attempted to advocate for the hospital to discharge Ashley on Monday emphasizing that it would give her treatment team an opportunity to coordinate with the hospital on an ideal discharge plan and that her treatment team is not available over the weekend to coordinate an ideal discharge,” Mosier wrote.
In notes Enriquez signed at 6:20 a.m. on Sunday, Feb. 14, he wrote that he discharged Ashley following a significant improvement in her condition after she was given hours to sober up. He wrote that three other doctors including Balian agreed on the discharge.
“At discharge, the patient was not suicidal, homicidal, intoxicated or gravely disabled. The patient reports that she can support herself through panhandling and recycling,” Enriquez wrote. “Although the patient exhibited some disorganization, her disorganization did not cause her to be suicidal or homicidal or gravely disabled.”
Enriquez wrote that Ashley was told she could remain in the hospital until later that morning so she could be connected to a crisis house, treatment facility or homeless shelter but she declined.
“The patient was then discharged to self with appropriate resources,” Enriquez wrote.
Reached by Voice, Enriquez declined to comment. Catalyst did not return multiple messages.
It’s not clear where Ashley went immediately after she left the Midway hospital on Valentine’s Day three years ago. Her family never saw her again.
Solorzano learned her daughter had been hospitalized – and released – the next day.
Irma Lucero, Ashley’s longtime Catalyst case manager, broke the news that Monday.
“The writer notified the client’s mother of the attempts made by the after-hours team over the weekend to advocate for Ashley not to be released,” Lucero wrote. “The writer notified the client’s mother of the hospital’s decision to release Ashley and the team’s inability to coordinate care due to Ashley being released back into the streets.”
Solorzano was devastated.
“Her dad and I and everyone that knows and loves her live in constant fear that she’s living her last days on the streets due to the fact that she’s gravely disabled and is unable to care for herself in any way,” Solorzano wrote in a grievance letter she sent the county the day after she learned of the discharge.
Solorzano’s fears were valid.
Days later, Ashley was pronounced dead on Interstate 5. She had run into traffic again. This time, it was fatal.
In a statement, county spokesman Tim McClain declined to provide specifics on Ashley’s case but noted that any death is a tragedy – and that county hospital staff must weigh multiple factors as they consider whether to discharge patients.
“The dedicated staff of the county’s psychiatric hospital work tirelessly to help those in the midst of an acute psychiatric crisis regain stability and link them to services in the community,” McClain wrote. “Holding an individual against their will is a serious matter. Thoughtful decisions are made every day by our staff to balance psychiatric stabilization and the rights of members of our community to be free from excessive involuntary detainment.”
Shaner, the former Los Angeles County mental health official, declined to comment on whether county hospital staff made the right call to discharge Ashley early on Valentine’s Day a few years ago. He emphasized the need for systemic solutions.
“I don’t think that we could solve these problems in California by second-guessing individual clinical decisions,” Shaner said. “People are making difficult clinical decisions all up and down the state all the time and these things are the result.”
So you are suggesting that drug addicts be locked up permanently because they are a danger to themselves and others. This is what many people have suggested for a long time.
Despite the confusing use of the conjunction “and” in the article above, nothing in Ashley’s case (and numerous others with severe mental disorders), has anything to do with substance abuse. The constant equivalency of mental health issues with substance abuse confuses the narrative, as suggested by the unempathetic comment above.
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It’s not uncommon for people with bipolar disorder to self-medicate with legal and illegal substances.
Census of a facility often drives decisions about who to keep and who to release. I wonder if a FOIA request to the County for the census before, during, and after Ms. Goldfarb’s stay would shed more light on the decision making process for the facility.
Such a tragedy. We need to fund more for mental health facilities and programs that help after a stay.
Problem is persons can’t follow them around to insure their safety.
There has to be a solution.. that can be solved if people would think outside the box.
It’s a Catch-22. The parent of someone with mental illness has no control after their child reaches 18. The best parents can do is petition the courts for conservatorship (by someone else if not themselves) to be able to advocate for their treatment. But someone experiencing mental crisis often won’t tell anyone they have a conservator.
Honestly, the biggest obstacles to mental health are the poor treatment options. Most medications are only marginally effective, have to be taken regularly (generally daily), and also have many undesirable side effects (like weight gain for antidepressants, facial or other muscular ticks/cramping for antipsychotics, the supression of emotions including happiness–aka flattened affect–etc.), all of which discourages patient compliance.