Frank Campos' childhood bedroom still overflows with art: dark charcoal portraits, kinetic abstracts and mixed media sculptures that look like miniature cities.

The artifacts tell his story in fragments: a smiling kid on a middle school ID card. Family photos from Yosemite peeking out of a wooden box of his keepsakes.

“There’s so much: He sketched, he wrote. He wrote for hours and hours,” said his mother, Kathrynne Campos-Gil.

There’s no clear sign of when and where it would all end.

On Feb. 22, 2021, Campos jumped out of the back seat of an SUV into speeding traffic on the 5 Freeway. After walking through lanes of cars streaking past him, a commercial truck struck him, and he died at the scene.

He was 29.

Campos’ death marked an excruciating end to his family’s years-long battle with schizophrenia. They’d tried several doctors, different facilities and numerous medications, but his serious mental illness continued to plague him, family members said.

It’s a struggle many patients and families across California deal with day in and day out: One out of every 26 adults in California live with a serious mental illness such as schizophrenia.

Yet doctors and affected family members say the mental health care system continues to fail the sickest people — people like Frank Campos, who are tormented by psychosis. The failures are both specific and systemic, and there is no easy solution.

More broadly, experts point to a dire shortage of psychiatric beds as well as financial pressures to release and move patients, compounding an intractable problem that too often has deadly outcomes.

A wrongful death lawsuit the Campos family’s attorney filed in April 2022 alleges that his health care providers failed to provide crucial information about his state of mind and history of suicidal ideation to people responsible for moving him from one facility to another.

By sharing their story, Campos’ family hopes something can be done to protect the next person in crisis.

An assault charge and previous suicide attempt

On the morning of the day he died, Campos was arraigned in court via Zoom on felony assault charges for an alleged attack on a nurse at Del Amo Hospital in Torrance. He learned during this hearing, according to the family’s lawsuit, that he could be facing prison time.

That afternoon, he was scheduled to be transferred from Kaiser Mental Health Center to Chapman House, a facility with a lower level of care about an hour’s drive away in Orange County. His mother came to bring him clothes and see him off. The following account of what happens next is documented in the lawsuit:

• The person who came to move him was alone.
• She was in a Jeep Compass, a compact SUV, not an ambulance or other emergency vehicle.
• Campos asked to be seated in the back, saying he was feeling claustrophobic. 
• The driver did not activate child locks.
• As they got close to Pioneer Boulevard, about 30 miles into the trip, he jumped out of the car. The driver was going 60 mph.

Prior to his last admission to Kaiser Mental Health Center, Campos tried to kill himself by walking into traffic, according to his family's account in the complaint. During his stay at the facility, his suicide risk had been as high as "moderate."

The person who drove him, they allege, "reported to officers she had no idea that Frank could have been suicidal."

His family is seeking unspecified damages.

In a statement, Kaiser Permanente extended its deepest sympathies to the Campos family but would not comment further, citing the pending litigation.

In its response in the lawsuit, attorneys representing Southern California Permanente Medical Group, Kaiser Foundation Hospitals and Kaiser Foundation Health Plan denied all allegations. In addition, they wrote “some or all of the injuries and/or damages, were the proximate result of the failure of the plaintiff’s decedent to exercise due care on his own behalf.”

Chapman House did not respond to repeated requests for comment.

The civil trial is currently set for August, according to court records.

Frank's room is filled with his art and writings as well as mementos and photos of his childhood and teenage years.

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Samanta Helou Hernandez

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From loving child to a ‘very lonely life’

It was an unusually green Southern California morning after the rains in the San Gabriel Valley as Kathrynne Campos-Gil opened the door to her son’s room.

She described her son as self-driven and loving as a child. Attending Citrus College and later Cal State Fullerton, he became a voracious reader, his mother said. He got a job tutoring kids in science and math.

“When he looked at you, he was one that would look in your eyes, he was in the moment,” Campos-Gil said.

In one photo of hundreds in his room, there’s Frank, a slender young man with dark hair and a Doors t-shirt.

“The Doors, he really liked The Doors,” Campos-Gil remembered.

As a young man, Campos experimented with drugs, she said. He started reading Timothy Leary and Ram Dass and turned inward.

“He was searching for his purpose,” she explained.

Frank Campos as a baby held by his father and his middle school ID card.

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A crisis in his 20s and a devastating diagnosis

His mother said in his young adulthood, Campos started isolating himself, becoming more irritable and crying a lot.

In 2016, in his mid 20s, he was diagnosed with schizophrenia, which began a half-decade long nightmare for him and his family, she said. Campos-Gil stopped working as a court reporter in order to have more time to manage her son’s care. She went to court and was appointed his conservator, which gave her power to guide treatment and medications.

In a family video of Campos’ 26th birthday party, he doesn’t smile when his family tells him to blow out the candles.

Frank Campos

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Courtesy Campos-Gil family

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“You know one thing mental illness is, it’s very lonely,” Campos-Gil said. “It’s a very lonely life, because you don’t connect to people.”

Campos-Gil said doctor after doctor would tell her son to try a new medication and then come back in a month. She thought some of the medications seemed to make him worse. Meanwhile, Campos-Gil helped find experts who would guide her son on more holistic approaches. She said he tried to heal his mind with supplements like kelp extract and digestive enzymes.

Campos had always loved his pets — a cat named DC and a small dog named Rexy Rose. But he began to lose interest, his mom said, and he drifted from friends.

In a journal entry, Campos asked God to help him accomplish the things he still wanted to do in life and help him get “unstuck out of the mud.” He wished for a dream life filled with caring, interesting and creative people. “I can see us gathering rose pedals together under a giant Yosemite tree or under a thousand stars ...” the passage reads.

Campos was referred to an acupuncturist to try to ease some of his pain. He meditated in the family’s back yard to try and calm his mind, his mom said, but in the long term, nothing helped.

What led to the end

In the years since that 26th birthday party, Campos had several stints in psychiatric facilities and board-and-care homes, his mom said.

By the end of 2020, after years of her son's worsening psychotic symptoms and relapsing methamphetamine use, Campos-Gil was scared for his safety and took him to an emergency room in Glendale, medical records show. Campos was later admitted to Kaiser Mental Health Center near Chavez Ravine, according to the family's lawsuit.

They allege, based on Kaiser Permanente medical records, that during a two-month stay in that inpatient psychiatric unit, Campos’ suicide risk was at times raised to the level of "moderate." His psychosis made him so erratic that he sometimes had to have two staff members monitoring him at once, according to the lawsuit. At that time, Campos “had assaulted three individuals within the past week,” the lawsuit recounts.

“Frank needed to be on new medication, he needed to be in a locked facility where he was supervised closely,” Campos-Gil said, recounting her thoughts during that time.

In February 2021, just a day after Campos had to be placed in restraints and less than two weeks after he was on moderate suicide risk, doctors made preparations to transfer him to a lower level of care, the lawsuit alleges.

Kaiser medical records shared with LAist by the family’s lawyer document conversations between Campos-Gil and her son’s doctors. Those records show that on at least two occasions she voiced serious concern about transferring her son and at one point was “upset” about a proposal to discharge him to a lower level of care.

Campos said visiting her son was restricted due to COVID-19 and she wasn’t getting phone calls from him like she used to.

“I didn’t have anything to support to say, ‘I don’t think it’s a good idea, I don’t think my son’s ready,’” Campos said. “I allowed it, because I thought that the doctor, he has the degree, he has the experience.” According to the medical records, Campos-Gil ultimately “approved of the patient going to [Chapman] house.”

His final day

"I feel that I had more resources to work with than the average person and the system still failed me," said Kathrynne Campos-Gil, whose son Frank was diagnosed with schizophrenia in his mid 20s.

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It's impossible to know what was going through Campos’ mind on the day he died.

“I think he was trying to get across to the other side. He made it across I think two lanes and the last lane that’s when he was hit by that utility vehicle,” said his stepdad Robert Gil, fighting back tears.

Matt Meyer, the family’s lawyer, said they believe critical mistakes were made by Campos’ health care providers.

“If anything, he needed a higher level of care. But to just dump him on... another facility that is a drastically lower level of care, that is a death sentence,” said Meyer.

“He was never going to make it there,” Meyer said.

A system with a long history of tragic outcomes

Photos of Frank Campos as an adult.

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Experts we spoke to about California’s mental health care system generally agree that tragic outcomes for people suffering with serious mental illness are common.

By many measures, the current state of care is failing. High costs are one problem area — caring for patients like Campos can cost hospitals thousands of dollars a day.

Alex Barnard, an associate professor at New York University who studies public mental health care, said hospitals face very strong financial pressures to get people down a level of care.

Resources for families

Barnard said when he talks with psychiatrists, they often tell him, “‘If you have a patient who was admitted for a serious suicide attempt, if they haven’t been suicidal for 24 hours, the insurance company is like ‘get them the hell out.'"

The question is more why people stay than why people get out, Barnard explained.

“The default is for people to get out very, very quickly,” he said.

Enrico Castillo, a UCLA psychiatry professor, said adding to a drive to discharge is the fact that right now, L.A. has about half the per capita mental health hospital beds than what is recommended by national medical consensus guidelines.

“So many places today are discharging patients with higher and more acute needs than they might have discharged in the past,” Castillo said.

According to a report from the California Health Care Foundation, in California “the number of acute psychiatric beds per 100,000 people decreased about 30 percent from 1998 through 2017.”

Castillo said the current reimbursement system has “financially disincentivized” facilities to keep patients past a certain point if it’s deemed not medically necessary.

“It adds to the pressure to discharge people and to discharge them to these subacute facilities,” Castillo added.

But, he said, increasing psychiatric hospital bed capacity is an intractable issue because the barriers happen at many different levels. It’s not just an issue of constructing new buildings but also one of payments, reimbursements and decades-old laws that limit reimbursement.

Frank Campos.

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Courtesy Campos-Gil family

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“The things that I’m seeing happening in the county is a tragedy of people with serious mental illnesses falling through the cracks,” Castillo said.

Earlier this year, the L.A. County Board of Supervisors unanimously approved a motion that directs the L.A. County Department of Mental Health to work with a consultant to forecast bed capacity needs.

“Despite our best efforts to build and contract more mental health beds, we remain thousands of beds short of our current need,” motion co-author Kathryn Barger said.

Hospitals under scrutiny

Sean O’Neill is an attorney who said he regularly sees cases where a person living with a serious mental illness or experiencing a mental health crisis dies by suicide while under the care of a hospital or other mental health facility.

“I do think it’s a systemic problem with how people with mental health disorders are treated,” O’Neill said. “And how their diagnoses — their acute ones especially, with suicidal ideation — are kind of disregarded.”

Barnard of NYU said it’s not just financial pressures to discharge patients that hospitals face. There are also legal pressures to maintain the rights of the individual.

“I mean, everyone is supposed to be in the least restrictive option,” Barnard said.

According to the Joint Commission, a non-profit that accredits U.S. health care organizations, the top five behavioral health care requirements that were cited in 2021 all fell under “reduce the risk for suicide.”

Many health care organizations, including Kaiser Permanente, have seen their share of criticism when it comes to providing adequate mental health care.

Last fall, some 2,000 Kaiser clinicians in Northern California and the Central Valley went on strike for more than two months, calling on the insurer to increase staffing, improve access to care and rectify untenable caseloads.

In 2013, the state fined Kaiser Permanente $4 million for not providing timely access to mental health care and the health plan has been cited two times since then for not fixing the problem.

“When you’re in the business of providing health [care] and you’re telling your members, ‘Come here and you can thrive,’ but we’re not going to give you the care we know you need, that’s when you cross into a line that is dangerous,” O’Neill said.

‘The system still failed me’

Kathrynne Campos-Gil hung a heart-shaped ornament with Frank's nickname on a tree in her backyard.

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For her part, Campos-Gil said she doesn’t want her son to be forgotten. And she wants to help as many people as she can with her family’s story.

As his conservator, Campos-Gil had some power over direct care, treatment and medications. However, “conservatorship allows you to say, ‘This person should be in a hospital,’ but every individual hospital still gets to decide whether they’re going to admit or discharge that person,” said Barnard, who’s currently writing a book on involuntary treatment and conservatorships in California.

Campos-Gil said she feels exasperated that even as her son’s conservator and someone who worked tirelessly to understand the mental health system, he isn’t here to tell his own story.

“I feel that I had more resources to work with than the average person and the system still failed me,” she said.

Where to find mental health help