Despite Conservatorship Protections and Repeated Warnings, a Vulnerable Woman Was Discharged to the Streets — and Later Died
Advocates Say Her Case Exposes a Deadly System of Neglect
On a chilly December afternoon in 2024, staff at a small Skid Row harm-reduction center watched in disbelief as one of their longtime participants, a probate-conserved woman named Jamie Louise Kreitzburg, was released from Los Angeles General Medical Center. Her conservator had begged doctors not to discharge her, warning she was too impaired to survive on her own. Advocates stood by the phone, calling frantically to stop it. But by the time they reached the charge nurse, Jamie was gone.
“She has nowhere to go, and you’re discharging her to a tent,”Jenn Elizabeth, Jamie’s biggest advocate, who co-founded The Sidewalk Project where she serves as Director of Trauma-Informed Services & Engagement, told the hospital. The nurse manager didn’t argue. She admitted it needed to be reported.
Who Jamie Was and Why She Needed Protection
Jamie was 39 years old, struggling with a complex mix of conditions: Sturge-Weber syndrome, bipolar II disorder, and neurosyphilis. She had the mentality of a child, her advocates said, and lived much of her adult life on Skid Row, often targeted by men who raped, beat, and manipulated her.
In January 2024, the Los Angeles Superior Court granted her parents, Wendy and Michael Naylor, a limited conservatorship over her. The order granted them explicit legal authority over her medical care, including the right to place her in locked facilities or board-and-care homes. Under California conservatorship law (§2356.5), no hospital was permitted to release her without the conservator’s permission.
Jamie holds a Barbie bakery playset during a shopping trip arranged by The Sidewalk Project.
What Happened Behind Hospital Doors
On December 18, 2024, Jamie stormed into The Sidewalk Project’s drop-in center naked, screaming, throwing rocks, and attempting to strangle staff with a scarf. Soma Snakeoil, the nonprofit’s co-founder, called 911. Jamie was transported by the Mental Evaluation Unit to Los Angeles General Hospital on a 5150 psychiatric hold.
At the hospital, Jamie was ventilated for respiratory distress and placed on a 5250 hold, an involuntary 14-day psychiatric hold under California’s Lanterman-Petris-Short Act. Her file carried an explicit instruction: “Do not discharge without conservator permission.” Her mother, acting as conservator, was on the phone, begging doctors to keep her daughter in treatment.
Yet the safeguards quickly fell apart. Hospital staff allowed one of Jamie’s known abusers into her room. Social workers stopped answering calls from Soma and Jamie’s care team. When Soma pressed the issue, the charge nurse cut her off.
On December 24, the conservator was informed that Jamie was being discharged because she said she wanted to return to her tent.
“The doctor told us he couldn’t hold her for five months in restraints,” Soma wrote in her same-day complaint. At 12:20 p.m., Jamie had already walked out of the hospital with no plan for care. The nurse manager, Julia, told Soma: “I know, yes, you should report this.”
Escalating Complaints
Soma immediately filed her December 24 complaint letter, attaching conservatorship papers, photographs of Jamie, and text messages from the predator who exploited her. She reported the case to Los Angeles County DHS and the California Department of Public Health, labeling it blatant patient dumping.
Weeks later, on January 20, 2025, she filed a redacted version of the complaint, replacing Jamie’s name with the pseudonym “Polly” to comply with HIPAA, the federal patient-privacy law.
Two days after that, Los Angeles General’s Patient Experience Department responded with a form letter. Signed by Administrator Claudia L. Mata, the January 22 response letter apologized for “any frustration this situation may have caused” but insisted HIPAA barred them from providing details without further forms. Soma shot back an email in frustration:
“Let me understand this — though we have a signed ROI and permission from her conservator, you are choosing to HIPAA us rather than address the patient dumping incident?”
A floral arrangement stands at Jamie’s memorial inside The Sidewalk Project’s community space in Los Angeles.
A Preventable Death
On February 18, 2025, Soma escalated the issue with a formal complaint that widened the scope. She documented how Jamie had been released multiple times in violation of EMTALA and her probate conservatorship, not just the December 24 incident.
“The client has died of a preventable cardiac death,” Soma wrote. “She was required by law to be bridged from hospital to a higher level of care. Her mother repeatedly asked for this and was denied, ignored, and manipulated.”
For Soma and Jamie’s family, the case was simple: the hospital had legal obligations it ignored — and Jamie paid the price with her life.
Accountability Denied
Advocates hoped Jamie’s death would finally force accountability. They reported the incident to Adult Protective Services, the California Department of Public Health (CDPH), and Los Angeles County’s Department of Health Services.
But on April 18, 2025, CDPH closed its investigation.
In a letter signed by Hang Nguyen, RN, MSN — district manager for CDPH’s Orange District Office — the agency said it had conducted an unannounced site visit on April 2. Investigators reviewed documents, conducted interviews, and made direct observations. Still, CDPH wrote, it was “not able to substantiate the complaint” and found no violations of law.
For advocates, it was a crushing blow.
“Even when we hand them conservatorship papers, even when the patient dies, they tell us nothing was wrong,” Soma said.
History Repeats Itself
Just three days later, Soma reported another tragedy. On April 21, 2025, she sent an email to colleagues and advocates describing how another woman she had worked with died of medical neglect. According to Soma’s report, the hospital allegedly refused to treat the woman after she tested positive for fentanyl; she later died of pneumonia.
“The boyfriend is willing to talk with you if you want,” Soma wrote.
For Soma, the timing was unbearable: as regulators cleared one hospital of wrongdoing in Jamie’s case, another woman died in circumstances that, she argued, showed the same systemic disregard for unhoused women with medical and substance-use vulnerabilities.
How the System Enables Patient Dumping
For Soma, these weren’t isolated failures. She described how hospitals often discharge on weekends or shift changes, when no intake facilities are open.
“Weekend discharges are common,” she said. “With no beds open, people get pushed back to the street.”
She also pointed to insurance incentives, noting that hospitals are reimbursed most heavily in the first 72 hours.
“After 72 hours, the incentives change,” she said. “That’s when we see the rush to discharge.”
She noted that providers in Los Angeles’ Level-1 trauma centers are burned out and overwhelmed, fueling a cycle of crisis care rather than long-term solutions.
Jamie Wasn’t the Only One
Jamie’s case was not unique. Soma described another participant with a severe bone infection whose leg required amputation. Instead, the hospital discharged her repeatedly, claiming she had a “plan” to stay at the Salvation Army — even when the facility was closed. Each time, she was sent back to the street, where she was raped by men in her housing and, Soma alleged, even by security guards.
Lived Experience Meets Systemic Failure
Soma speaks not only as a harm-reduction organizer but also from lived experience. Before co-founding The Sidewalk Project, she lived through periods of drug use, sex work, and housing instability, and spent years advocating for her mentally ill brother, who was also repeatedly dumped by ERs. “This isn’t just policy for me,” she said. “I’ve been the one on the other side of that hospital door.”
For advocates on Skid Row, Jamie’s case — and the death that followed just weeks later — encapsulate a grim reality: even when the law recognizes someone’s vulnerability, hospitals and regulators may not. The official ruling of “no violation,” and the fresh report of another woman’s death, leave one unanswered question lingering over Los Angeles:
If this isn’t patient dumping, what is?
