Four inmates died in County Jail custody in 2019. The Santa Barbara County Civil Grand Jury found jail staff made errors in three cases.
The jury redacted the names of the deceased inmates from its nine-page report, which was released on June 29.
The jury reviewed written reports from senior deputies, custody deputies, other sworn staff and staff from the jail’s contracted medical and mental healthcare provider, Wellpath.
An inmate identified as A1 died on Jan. 10 2019 from natural causes. According to the jury’s report, A1 was already “seriously ill” when he was arrested and taken into Jail custody on Feb. 20, 2018. He remained in jail custody waiting for trial.
A1 made several sick-call requests while in jail and was attended to by Wellpath staff. Jail staff sent A1 to Santa Barbara Cottage Hospital on Dec. 16 2018. The hospital returned him to the jail 10 days later.
“A plan was developed, including medications and diagnostic tests, but he refused both on several occasions after his return to custody,” the report read.
A1 returned to Cottage Hospital on Jan. 5, 2019, but his condition worsened and he died five days later. The jury found no evidence of mistreatment or negligence by jail staff in A1’s case.
“A1 had been seriously ill for some time, and he frequently refused treatment or diagnostic tests. The Jury found no indication that custody hastened his death,” the report read.
Inmate B1 was booked into County Jail on April 10, 2019 for parole violation. At the time of his booking, B1 was confined to a wheelchair and had a history of diabetes and non-compliance with treatment.
Days before his arrest, paramedics transported B1 to the Santa Barbara Cottage Hospital emergency room by ambulance with heart palpitations, nausea, vomiting and dizziness. Lab tests revealed B1 suffered from hypoglycemia, possibly caused by untreated Type 1 Diabetes.
During his arrest, B1 told officers he was no longer permitted at Santa Barbara Cottage Hospital, People Assisting the Homeless or the Santa Barbara Rescue Mission because of his conduct.
An anonymous source told the jury that B1 should have been referred to an emergency room instead of being admitted to the jail under jail policies.
On April 12, 2019 an officer told a nurse that B1 complained of chest pains. The nurse instructed the officer to bring B1 to a treatment room where she assessed his vital signs and gave him oxygen.
She found B1’s blood sugar levels were high, but could not reach the on-call physician. A Custody Deputy took B1 back to his cell, but hours later inmates found B1 foaming from the mouth in his cell. B1 went into cardiac arrest and died despite lifesaving efforts from custody deputies and paramedics.
The jury found jail staff should have enforced its policy not to admit inmates with life-threatening medical conditions and recommended the Sheriff’s Office require medical staff to transfer inmates to a local hospital emergency room during a life threatening or serious illness when the on-call physician does not respond.
Deputies booked inmate C1 into County Jail on April 10, 2018. C1 remained in jail custody awaiting trial as his case was continued 25 times over 14 months.
The jury noted that under California law, prosecutors must bring a person charged with a felony to trial within 60 days unless the defendant consents to a delay.
“The date of arrest on both the Sheriff’s letter to the Jury and the Coroner’s report incorrectly state 2019, giving the false impression that his incarceration was two months rather than fourteen months,” the report read.
C1 had “decades-long history” of arrests, mental health issues and “suicidal ideations” according to the report.
On June 25, 2019, fellow inmates accused C1 of being a child molester. Later that day, custody deputies removed C1 from his cell after an argument with other inmates and placed him in a temporary cell.
C1 requested a private cell and jail staff told him he must meet with Wellpath mental health staff before rehousing.
C1 told a mental health clinician he would kill himself if he did not get a cell alone. The clinician determined C1 was not a danger to himself. C1 hung himself with his t-shirt minutes later.
“This MH clinician … stated in an interview that they are not required to inform a supervisor or custody personnel upon hearing a patient make a suicidal statement,” the report read.
Jail security video caught C1 standing in his cell with the t-shirt tied to a bar as a custody deputy walked past.
Doctors took C1 off life support on June 30, 2019.
The jury recommended the Sheriff’s Office ensure that all reporting documents “are complete and accurate” on inmate suicides. The report found some interviews conducted by deputies on the case omitted the date of the interview.
Inmate D1 was arrested by Lompoc Police Department officers on Oct. 19, 2019 on suspicion of felony probation violation. He was booked into County Jail the next day.
D1 told jail staff he suffered from mood disorders, anxiety and Post Traumatic Stress Disorder. He claimed he did not use drugs or alcohol.
On Oct. 23, 2019, D1 complained of symptoms consistent with benzodiazepine withdrawal. Medical staff placed him on withdrawal protocol, but he refused monitoring and medication. Later that day, jail staff referred D1 to mental health staff for a welfare check because he displayed bizarre behavior.
On Oct. 31, 2019 D1 killed himself by wrapping a phone cord around his neck and dropping his feet out from under his body. His cell contained a wall phone that had a long cord attached to the receiver.
The jury recommended Wellpath conduct remedial training of medical staff on patients who refuse medication and ensure custody staff do not house inmates in cells with corded phones.