Jerod Cook trembled as a pair of correctional officers tightened nylon straps to bind him to a metal chair, naked but for a pair of grungy orange shorts and slathered in dried blood and grime.

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Ninety minutes earlier, officers at Perry state prison in rural Pelzer had discovered the convicted robber face down in his cell, surrounded by a slick of blood leaking from a gash he had carved into his right arm.

Rather than take Cook to a hospital, they slapped a gauze bandage on his wound and carried him on a gurney to a cramped, cinder block room for a four-hour stretch in a restraint chair for acting out.

His body strapped down and his hands cuffed to the base of the seat, Cook, diagnosed with psychotic depression, pleaded for medical attention as blood seeped from his arm and pooled around a pile of soiled rags on the floor.

"I can't feel my arm," he said in a shaky drawl. "Please don't let me die sitting here like this. ... I've lost a lot of blood. I can't see. Everything is white. Please help me."

"I'm trying," an officer flatly replied. "I did all I can."

The September 2009 incident, captured by a prison video camera, is among several horror stories that emerged through a class-action lawsuit that could soon change the way an estimated 3,500 inmates with severe mental illnesses are treated in South Carolina's prison system.

The suit, filed in 2005, took nearly a decade to wind its way to trial and reach a final ruling. By the time Circuit Judge Michael Baxley issued a blistering critique in January that demanded swift, sweeping and radical change, eight mentally ill prisoners had died, six from suicide.

The judge described an underfunded, understaffed and broken system that violated the rights of mentally ill prisoners, exposing them to abuse, neglect and, in some cases, death.

The case exposed numerous stories of mentally ill inmates being gassed, locked in solitary confinement for years at a time, denied effective treatment and caged naked, alone and cold in makeshift crisis cells littered with rotten food, feces and other filth. Prison officials have argued that these were extreme "outlier" cases, troubling but anecdotal evidence that wasn't representative of the system as a whole.

Baxley didn't see it that way, calling the case the most troubling in his 14 years on the bench.

"The evidence in this case has proved that inmates have died in the South Carolina Department of Corrections for lack of basic mental health care, and hundreds more remain substantially at risk for serious physical injury, mental decomposition, and profound, permanent mental illness."

Numerous failings

From Baxley's vantage point, the system broke down right at the starting point, with prisoner screeners failing to properly identify new inmates in need of mental health care.

Evidence indicated these evaluations likely failed to flag hundreds of inmates who needed treatment.

And those receiving care were placed in an overloaded system that had just one psychiatric staff member for every 437 inmates or more on medication - more than double the case load recommended by experts at trial. Similar ratios or worse existed for psychologists and counselors.

At Lieber, Lee and Perry prisons, designated as area mental health institutions, Baxley pointed to numerous instances in which mentally ill inmates went for months without seeing a counselor or a psychiatrist, treatment plans were old and incomplete and medication and therapy records were poorly documented.

At Perry, inmate Robert Hamberg killed himself in his cell in June 2010 after a mix-up led to him receiving only half of his prescribed daily dose of antipsychotic medication.

Other inmates deemed suicide risks were placed naked in crisis intervention cells smeared with trash, blood and excrement, left to sleep on a steel or concrete slab, Baxley stated. Most were not allowed to see a psychiatrist.

Inmate Richard Patterson, in prison for burglary and assault, testified that he tore up pieces of his Styrofoam food trays to form a makeshift mattress so he could sleep in a crisis cell at Lee. He stated that he saw a counselor for five minutes each day and shivered naked under the blast of a nearby air conditioner.

"So you be in a room cold, freezing and that's basically what's (crisis intervention) is down here," he told a paralegal with the law firm of Nelson Mullins Riley & Scarborough in a recorded interview. "It's more deteriorating than it is helpful, I believe."

At Lieber between 2008 and 2010, more than 100 mentally ill inmates in the midst of crisis episodes were placed in makeshift intervention cells fashioned out of recreation cages, shower stalls, visitation rooms and holding cells. Most of these facilities lacked a toilet and none had safeguards to prevent suicide, according to court documents.

One Lieber inmate, held in a crisis cell for 86 hours in 2009, didn't get a bathroom break until nearly halfway through his stay. Others had to relieve themselves in their cells, in the same spaces where they were fed, Baxley stated.

Solitary confinement

Against this backdrop, Baxley found, the prison system came to rely heavily on solitary confinement and the use of force to manage and control mentally ill offenders.

Evidence in the trial revealed that mentally ill inmates were twice as likely as other prisoners to be placed in solitary - often for years at a time. Placed in so-called Special Management Units, they spent 23 to 24 hours each day locked up alone, with limited or no visitation or telephone privileges.

Consider the case of Theodore Robinson, a 52-year-old inmate from Georgetown County who had killed both his parents in 1986 while off his psychiatric medication. Diagnosed with paranoid schizophrenia, he spent almost 16 years locked in solitary confinement due to one infraction or another. Prone to vivid hallucinations and bizarre behavior such as drinking his own urine, Robinson saw a mental health counselor about once a month and often went weeks without receiving prescribed injections of antipsychotic medication.

Another inmate with psychiatric problems, convinced he was being denied "400 million dollars in his bank," racked up 19 years of disciplinary sentences for making threats. A third, age 27, accumulated more than six years of disciplinary sentences and lost all telephone and visitation privileges for eight years, largely for making threats to other inmates and staff, according to Baxley's ruling.

Edward Barton, a convicted robber and rapist serving a 30-year bid, has pulled multiple stretches in solitary for making threats and masturbating, prison records show. In a deposition, Barton said most of his problems result from auditory hallucinations that prompt him to act out, like the time he swallowed six razor blades at Kirkland prison in Columbia.

"I be hearing voices and they tell me to do something," he said. "You could walk by my cell and I thought you said something. Something I didn't like. And I crank up - I start going off."

Excessive force?

Force also played a key role in prisoner management, with mentally ill inmates gassed, restrained and otherwise physically controlled at a rate 2 times that of other prisoners, the judge found.

One expert who reviewed 1,000 incident reports in the state's prisons involving pepper spray testified that corrections staff had violated national standards and the agency's own policies by using spray simply as punishment. He also noted nine incidents in which crowd-control foggers were used to gas inmates in individual cells, using excessive amounts.

Attorneys for the prisoners also documented a number of cases where prisoners were shackled to restraint chairs for hours, at times, like Cook, when they were in need of medical care.

Inmate Steven Patterson, a convicted robber from York County, was strapped down naked in a chair for 12 hours at Perry prison after he cut himself with a spoon in January 2008 following two weeks without his psychiatric medication.

Another inmate, Baxter Vinson, cut his arms and sliced open his abdomen in March 2008 while serving a 30-year sentence at Broad River Correctional Institution in Columbia for rape and burglary. Ninety minutes after he was found bleeding, officers tethered Vinson to a restraint chair, shirtless and with his intestines protruding. He spent two hours there before he was taken to a hospital.

A prison video shows him crying and moaning during the episode, his face contorted in pain, as a nurse tries to press his protruding intestines back into his body. "I was asking them, 'Was I going to die, was they just going to let me die?'" he later told paralegal Tammie Pope of the plaintiffs' law firm.

Vinson explained in a prison interview with Pope that he ended up in trauma surgery at Richland Memorial Hospital after his release from the chair, lost his appendix and contracted a staph infection.

"They (sic) policy is to punish cutters and break them so they'll stop instead of treating it," he said.

Prison staff, he contended, saw those who cut and mutilated themselves in times of crisis as malcontents with behavior problems, not people with mental illnesses. He described how four known cutters had killed themselves in custody in a 12-month period.

"I mean, all this happened in a year's time, you know. It's just like SCDC said 'The hell with them, if they gonna die they gonna die.'"