Three people have died in Sacramento jail since early May. Is the county responsible?

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Three men have died while in custody in the last six weeks at the Sacramento County Main Jail — a facility whose medical team remains so understaffed it violates a federal class action settlement.

Staffing levels were listed in 2023 reports as a factor in inmate deaths. Jail nurses in one report from that year named short staffing as the reason they couldn’t monitor a man who died of an overdose. Since then the number of full-time medical staff working at the jail has remained unchanged, at 251, county spokeswoman Kim Nava said in an email Thursday. Currently the jail has vacancies for one physician, three registered nurses, 10 licensed vocational nurses, two supervising RNs and two medical assistants, Nava said.

As a result, the county is still violating a settlement from a 2019 class action lawsuit called the Mays Consent Decree. That decree outlines a list of requirements for the jail to improve medical and mental health care for inmates.

The county is actively recruiting to fill the vacancies and striving to comply with the decree, Nava added.

The most recent deaths occurred on May 5, May 12 and June 8. Weeks later, details remain unknown about what happened. Sheriff spokesman Sgt. Amar Gandhi did not return repeated emails and phone calls seeking comment for this story. The deaths raise questions about whether people are getting proper medical care while in the jail.

“Without more information it’s hard to know how preventable these deaths were,” said Wanda Bertram of the Prison Policy Initiative. “Are the intake personnel who clear individuals for incarceration doing their jobs? Is the detox wing providing the necessary medication for withdrawal? How often are jail staff checking on people, generally speaking?”

Another detox cell death

On May 5, Lope Elwin Tolosa, 45, died in the detoxification cell three days after arriving at the jail on burglary charges. It’s not the first time someone has died in the detox cell in recent months.

Michael John Prince, 43, died in the detox cell on July 8, 2023. Following Prince’s death, jail nurses told investigators that due to understaffing, they had not conducted his withdrawal monitoring for six days.

“Nurses did not conduct withdrawal monitoring while the patient was in the detox unit,” stated a 2023 report by two medical professionals tasked with independently monitoring medical care of Sacramento inmates under the federal settlement. “Nursing leadership cited staffing issues as the reason. However, for withdrawal monitoring to not have taken place for six days in the detox unit is completely unacceptable and is an (Adult Correctional Health) leadership issue as well as a staffing issue.”

Just a week after Tolosa’s death, David Barefield, 55, died May 12 while he was in the booking area — another part of the jail with documented issues. Delion Johnson, 35, died in the booking area April 5, 2023.

During a news conference in September, Sheriff Jim Cooper said law enforcement officers who bring an arrested person to the jail for booking have to wait an average of 2 ½ hours for the person to be medically screened.

Barefield was booked at the jail sometime after midnight on May 12 on two misdemeanor warrants, the Sheriff’s Office said in a news release. About one hour after he had been medically cleared for booking, at 4:30 a.m., while deputies were trying to fingerprint him, he became unresponsive. Deputies and jail medical staff attempted CPR and administering Narcan, which is used to reverse opioid overdoses. Despite those efforts, he was pronounced dead at the scene.

The coroner Tuesday determined the cause of death was fentanyl and methamphetamine intoxication, with cardiovascular disease as a significant condition.

On June 8, Smiley Martin, 29, was found unresponsive in his cell; he was determined to be dead. The coroner has not yet released the cause or manner of death. Martin was being held on murder charges in connection to the mass shooting that killed six people and wounded 12 in downtown Sacramento in 2022.

Mark Merin, a longtime civil rights attorney, said even with the staff they have, they could do a better job. He said he has reviewed videos from the jail that show deputies and medical staff walking by cells where inmates are in distress.

“We have videos of them just walking by cells,” said Merin, who has filed a claim against the county for Barefield’s death. “They’re supposed to be overseeing what’s going on in the cell, they just walk by without a glance. Sometimes people are in the process of taking drugs or expiring ... they don’t use Narcan or defibrillators in a way that’s effective. Either they don’t have enough trained personnel or they don’t know when to initiate care.”

Jail medical staff has little oversight

In September, Cooper announced his office had found a ring of six people had been smuggling drugs into the jail in exchange for money, including a woman who was working on call at the time for Avid Healthcare Services.

Avid is still one of the county’s 11 jail medical service contractors, Nava said.

The contractors have little oversight. They are overseen by the Board of Supervisors but do not fall under the other oversight mechanisms that oversee deputies — the inspector general, Sacramento County District Attorney’s Office or Community Review Commission.

Newly hired Inspector General Kevin Gardner told The Sacramento Bee on Tuesday he still has no details to share on the deaths. He will investigate them but not until the Sheriff’s Office does, and only to look for wrongdoing by deputies, not medical staff. The Community Review Commission and District Attorney’s Office will also only look for wrongdoing by deputies.

“It’s unfortunate that the people whose job it is to investigate these deaths, like the inspector general, face so many barriers to doing so, because there are a lot of different points at which jail-based medical care can fail,” Bertram said.

Asked if he was concerned about the recent jail deaths or had plans to look into them, Supervisor Rich Desmond said, “I’m going to let (Nava) speak for the county on this. These are extremely important issues, and county staff are working on them with many stakeholders.”

Former inspector general Francine Tournour Kerridge, who served in the position for about two years before leaving in 2023, asked the Board of Supervisors to be able to investigate medical jail deaths. As soon as a death occurs, she said she wanted to get a call and be able to respond, the way she would if it were a homicide.

The county has gone long gaps without an inspector general, including from August to March, and also from February 2022 to August 2022. Former Sheriff Scott Jones notoriously locked former Inspector General Rick Braziel out of an office building before he left in 2018.

Of the 28 people who have died at the Sacramento jails since the start of 2021, none have been from homicide or suicide. While that means the jail has made positive improvements to prevent those types of deaths, it also means the public knows few details of the deaths of any of the inmates who have died there in the past three and a half years.

The DA’s Office so far has not completed its reviews of any of the three deaths this year, and only two of the six deaths from last year. In those deaths it has found no evidence that deputies engaged in criminal misconduct.

The Board of Supervisors last year approved nearly $1 billion for a new mental health and intake annex to the jail, which county officials say will improve medical and mental health care, but it won’t open until 2028. In the meantime, the lack of compliance could result in the county jail being placed into receivership. That would mean a judge would appoint a third party to take control of things like the jail budget, contracts, and staff, instead of the Board of Supervisors.