Grand Jury investigates early 2021 death, concludes improvements are needed in suicide prevention process
In the wake of an inmate suicide, the Santa Barbara County Grand Jury published a report regarding suicide prevention and mental health in the county Main Jail.
The Grand Jury investigated the death of an inmate who hanged himself in his cell 18 hours after being arrested in early 2021. This was the fourth suicide at the Main Jail in less than three years.
There was another suicide this summer in the Main Jail, which is located in Santa Barbara. However, this report only investigates the former event.
After the investigation, the jury determined, “the Main Jail intake process requires improvement with respect to recognizing potentially suicidal arrestees, effectively communicating their mental health status to other staff members throughout the process and providing timely mental health services during the nightime hours.”
The jury found that the Sheriff Office’s Intake Screening Implementation Plan was not fully met.
The News-Press couldn’t reach the Santa Barbara County Sheriff’s Office or the Board of Supervisors last week for comment on the Grand Jury’s conclusions.
The jury’s report states that the registered nurse who screened the deceased inmate, referred to in the report as Inmate A, found no evidence of mental illness or past or present drug use.
The nurse determined there was nothing out of the ordinary with Inmate A following the screening, according to the Grand Jury report.
However, the jury noted, the three arresting patrol deputies all reported Inmate A was highly agitated and displayed signs of paranoia when he was interviewed and arrested.
According to the Intake Screening Implementation Plan, suicide risk factors should be considered during the RN’s intake.
The Grand Jury determined the nurse’s intake screening should take into account the transporting officer’s impressions. The report states the transporting deputy said the RN was informed of Inmate A’s paranoia, but the nurse denied being told this information.
The Grand Jury concluded, “The evidence points to the fact that a significant breakdown in communication occurred at that point. As a result, the process from intake through housing failed to protect Inmate A.”
The jury did acknowledge the challenges of maintaining the safety of the growing percentage of inmates with mental health and/or substance abuse issues.
The Grand Jury also acknowledged this is a nationwide trend. Locally run jails across the country are reporting that 41% of incarcerated persons have been diagnosed with mental illness, according to the Prison Policy Initiative.
With these figures in mind, the Grand Jury concluded that, “The best defense against errors in judgment affecting inmate safety are targeted processes and procedures, in-depth training, specified communication requirements, and application of lessons learned from any failures that occurred.”
While the Grand Jury recognizes that the Santa Barbara County Sheriff’s Office has made significant progress, the report concludes with several recommendations, including joint training with all deputies and Wellpath health professionals and 24-hour on-site mental health professionals.
The full report can be viewed at www.sbcgj.org/2021/SuicideSBJail.pdf.