Jeffrey Cutter's life came to an end in the place where he seemed to finally be protected. Cutter, 37, of Palo Alto, was found dead by his parents in his apartment at Palo Alto's Opportunity Center on June 12.
His death has raised questions for his mother, who feels that her mentally ill son didn't receive the kind of care that could've prevented the tragedy.
Deborah Baldwin spoke recently about her grief and of the inadequately funded and monitored "safety net" system that she believes failed her son.
"We planned to bring him home for dinner," Baldwin said, recalling the day they showed up at his door. "We tried and tried, but we couldn't reach him, or his phone was dead."
On the way up the elevator, at about 5:30 p.m. she didn't have a good feeling.
"I turned to my husband and said, 'We have to understand that one of these times when we go to see him, he'll be dead.'"
When they opened his door, Cutter was lying face down on the floor. Palo Alto police later told her they found a packet that seemed to contain fentanyl, some methamphetamine and syringes.
In the weeks before his death, her son, who had gotten clean of his addiction, had told his mother about a persistent drug dealer, a woman, whom he tried to rebuff.
"I keep on telling her to go away," he'd told Baldwin.
The Santa Clara County Medical Examiner said Cutter died from mixed-drug toxicity: a combination of fentanyl, a powerful synthetic opioid; 4-ANPP, a precursor to fentanyl; and methamphetamine, a powerful stimulant. His death was ruled an accident.
Palo Alto police told Baldwin they had been trying to bust the dealers at the Opportunity Center for more than two years.
There were "people of interest," but they remained elusive, police had said.
Baldwin believes the Opportunity Center should do a better job of keeping the environment safe for marginalized people such as her son and keeping drug dealers out of the housing.
"The management should bring each person in and talk to them. Why has the Opportunity Center allowed this to happen and to continue? Maybe it's one of those things that there's no answer to," she said. "The OC has good people that try to help, but there's not enough manpower and programs that could possibly help."
Louis Chicoine, CEO of Abode Services, which operates the housing at the Opportunity Center, said everyone was hurting after Cutter's death.
But catching drug transactions is often difficult because they aren't done in the open and can take place behind the closed doors in people's apartments, he said.
"We take the security and welfare of our residents and staff seriously," Chicoine said.
Cutter's death, after years of mental illness and more recent drug use — he started self-medicating with methamphetamine a year before his death — was the saddest chapter in his and his parents' long struggle to help him regain his stability.
Afflicted with bipolar and schizoaffective disorder, he had once been a promising student who won a Governor's Scholarship Program award for high academic achievement to attend college after Palo Alto High School, his mother said.
Cutter, an intelligent and passionate person, was 20 years old when his psychiatric problems emerged. Nonetheless, he completed his undergraduate degree in management information systems at California State University, Chico. After that, his condition deteriorated and his delusions increased, Baldwin said.
He bounced in and out of the hospital and often slept outside prior to being housed at the Opportunity Center. Trying to get into county mental health rehabilitation programs proved a difficult and protracted process. So-called "wrap-around" services touted by county programs didn't work for someone as severely ill as Cutter. The programs expected him to answer the phone, schedule and remember appointments and be ready when social workers and other help providers came, Baldwin said.
One example: Cutter was discharged from Stanford Hospital on Sept. 28, 2020. He was given "urgent" referrals to psychiatry and cardiology — the latter due to heart damage from methamphetamine use. More than a week later, Stanford had not sent the paperwork over to the county and then county Behavioral Health didn't send the referral to the addiction center, Baldwin said. Cutter had not received any follow-up treatment and no one had called his parents. When he was ready to engage with the system, it wasn't ready for him, and the window of opportunity closed, she said.
"Santa Clara Health Department, even though they say they will see him quickly because he's a 'high need patient,' still has not reached out. It seems he has to be homeless to receive mental health services, but if he does not receive help, he will be homeless," she wrote at the time in her journal.
"The county had expected him to manage as a normal functioning person, which is ironic because the services are supposed to be for severely mentally ill people, who generally cannot manage their lives," Baldwin said.
Time and again, there seemed to be little continuity to the services her son was supposed to receive, she said. Despite his most recent hospitalization in May, in the weeks before he died, his social worker came just once and decided not to come again because he had not answered the phone, Baldwin said.
"So for a week-and-a-half no one checked on my son, even though they had told me, 'We aren't going to let him fall through the cracks anymore,'" she said.
Cutter was admitted to the hospital on psychiatric holds multiple times, but too often he was swiftly let go. In May, his last referral for a 5150 hold, he was released after eight days, as he was coherent on medication the doctor had prescribed. The doctor wanted him to stay longer, but because he was not "at that moment" in psychosis, the hospital couldn't continue to hold him, Baldwin said.
No one took into account that he was severely paranoid, his mother said, and he had a history of stopping his medications within a few weeks. Baldwin had pleaded with the doctor to hold him at least over the weekend, fearing for his life.
"I had kept on asking to have Jeff declared mentally incompetent, but as I was made aware, using drugs was not considered a factor or reason. And because he used drugs, there was the stigma that that was the reason he wasn't competent, not his mental illness," she said.
Sadly, Cutter didn't survive long enough for a new law to take effect that might have made it easier to compel his care. The Santa Clara County Board of Supervisors voted unanimously on May 25 to opt in to a state law that involves mandatory treatment for those suffering from severe mental illness and to create an "assisted outpatient treatment program."
Called Laura's Law, proponents say the law helps keep people out of the criminal justice system and psychiatric hospitals. The law allows a judge to issue a court order to compel people with severe mental illness to seek outpatient mental health treatment. Laura's Law also gives families more leverage to ask the court to compel the treatment.
The law is restricted to those who are a serious risk to themselves or others and who have a history of rejecting voluntary treatment. Candidates for the mandatory order must have had a serious mental illness that caused them to be hospitalized or incarcerated two times in 36 consecutive months or caused violent behavior or attempts by the patient to harm themselves or others.
With eight hospitalizations in a year and a history of stopping his medications, Jeff Cutter would have been a likely candidate.
Baldwin's experience with the fragmented mental health system is supported by the stories of other families with severely mentally ill loved ones.
In March, former Mountain View resident Jeffrey Middlebrook told the Mountain View Voice that his son, a veteran suffering from severe post traumatic stress disorder, also struggled with drug addiction and couldn't stay on treatment regimens. He said the court system failed his son; his son's loose and voluntary mental health treatment plan was doomed to fail. After multiple mental episodes and arrests, his son is now in prison. Middlebrook supported the adoption of Laura's Law.
Palo Alto police said they conducted a thorough investigation into Cutter's death, including who might have sold him the drugs. While they thought they had a suspect, they were unable to charge her with anything other than possession of drug paraphernalia. The department is beefing up patrols at the Opportunity Center, acting Lt. Brian Philip said.
Chicoine, of Abode Services, said that if someone is involved in drug dealing at the center, that's a lease violation and there are procedures to get people out. But catching them is tricky, and the housing center does have security measures.
"There is 24-hour desk check-in of anyone going in, and guests must sign in and show identification. During off hours, they have additional security and cameras in various places to monitor suspicious activity," he said.
Deaths do happen at the Opportunity Center. People who are so vulnerable and are served there often have physical conditions, disabilities and layers of mental illness and concurrent drug addiction.
Chicoine said he concurs with Baldwin regarding service failures. There's a reactionary system at play when it comes to mental health treatment. Although the California voter-approved 2004 Mental Health Services Act, which added dedicated funding for programs, has helped, there need to be more clinical services and funding, including for services at the Opportunity Center, he said.
Earlier intervention could help to reduce some of the escalating issues people experience, he said.
"Mental illness is often a disease that comes in young adulthood and there are not enough available services. People get off to a bad start," he said.
Baldwin said she has had to learn many things about the mental health system, albeit now it's too late for her son. Most addiction help revolves around the 10-step Narcotics Anonymous programs instead of around medication nor harm-reduction strategies, even though they have a higher efficacy rate, she said.
"Plus, the programs are not set up to help the dual-diagnosis patient," instead having patients address only one problem at a time, she said.
"Santa Clara behavioral health ... said, 'Well, he should do that program and then get mental health treatment,'" Baldwin recalled. "Really? Expect a person hallucinating to talk to others?
"I had kept on believing in a system that I have come to see is broken," she said.
Baldwin also learned the drug epidemic affects all classes of people, from rich and powerful to the homeless, yet "'stigma" or shame stops so many from asking for help or because people characterize them as "morally weak."
"I have come to realize that no particular person is 'to blame.' Indeed, many really are attempting to help. It's only when society has come to the point of saying 'enough' will we find the money, effort and drive to truly help these people," she said.
Chicoine agreed with Baldwin that stigma around mental health issues has been the biggest hindrance to getting people the care they need and the funding for services.
"It's about resources. Why aren't we valuing this (disease)? It's still viewed as a moral failure," he said.
Help is available
Any person who is feeling troubled can call 800-784-2433 to speak with a crisis counselor. People in Santa Clara County can call 855-278-4204. Spanish speakers can call 888-628-9454.
Anyone who is struggling with substance use can call the Santa Clara County Department of Behavioral Health Services at 800-488-9919.
For a list of local substance use treatment services, visit bhsd.sccgov.org.
People can reach trained counselors at Crisis Text Line by texting 741741.
Read more: How to help those in crisis