⚠️ Aviso de traducción: Este contenido ha sido traducido automáticamente. El texto original en inglés es la versión oficial. La traducción puede contener errores.
⚠️ Este contenido ha sido traducido automáticamente. El texto original en inglés es la versión oficial. La traducción puede contener errores.
Findings and Recommendations 7 findings
F1
The Officer Involved Critical Incident Protocol requires that investigations be conducted "free of conflicts of interest." For that reason the investigations were conducted by a law enforcement agency whose employees were not involved in the incidents. The District Attorney's Office also participated in the investigations and had the authority to investigate separately.
Related Recommendations (1)
R1
The Sheriff’s Office should integrate the Records Management System and the Jail Management System to allow inmates’ records of mental health issues to be readily available to jail staff.
F2
Upon completion of each incident investigation, the District Attorney's Office reviewed the physical evidence, the transcribed witnesses interviews, appropriate photographs and all other evidentiary material.
Related Recommendations (1)
R2
The Sheriff’s Office should provide for a female officer to be present during hospital medical exams of female inmates.
F3
Based on the evidence, the District Attorney reached his conclusions and issued a Critical Incident Report for two cases. In each, the District Attorney concluded that there was insufficient evidence for criminal liability.
Related Recommendations (1)
R3
Newly incarcerated inmates should be assigned to cells with doors that are visible from the control desk.
F4
The agencies that employ the involved officers conducted their own administrative investigations of each incident. Administrative investigations have a purpose different from the criminal investigation. They seek to determine if the agency's policies and procedures were followed in the incident and whether there could be improvement in those policies and procedures. They also make a determination as to whether any disciplinary action can be imposed against a particular individual or individuals.
Related Recommendations (1)
R4
The District Attorney’s Office should shorten the time the agency being investigated must wait for written notice of any criminal wrongdoing.
F5
In addition to the two complete Critical Incident reports, the Jury examined an administrative review by the Sheriff’s Office of an inmate death and found it to be a thorough, objective determination about what happened, how it happened and what lessons there were to be learned. The focus of The Sheriff Department’s review focused on preventing such incidents from occurring.
Related Recommendations (1)
R5
The District Attorney should routinely provide the Grand Jury with a copy of each Critical Incident Report in a timely manner, including the “Critical Incident Participation Report” for that incident. Required Responses to Findings None Required Responses to Recommendations The Sheriff: R I, R2, and R3 The Board of Supervisors: R1 The District Attorney: R4 and R5
F6
The District Attorney responded to last year’s Grand Jury recommendation that “Each Critical Incident Report should describe the nature of participation by the District Attorney’s Office in the investigation of the incident.” The prior District Attorney stated that the office would maintain a log or “Critical Incident Participation Report” detailing their involvement in each critical incident case and that they would include the log in each Critical Incident Report. In the two reports written by that office, no log was included.
No recommendations for this finding
F7
For the two incidents reported on by the District Attorney, the time to issued a report varied from three days less than one year to one and one-half years. The incomplete report has taken four and one-half months to date and a statement from the District Attorney’s spokesperson indicated that he was not sure when it would be completed. Conclusions Each of the Critical Incident Reports reflects a thorough, detailed, and unbiased investigation by those assigned to the case to determine whether any criminal liability existed. The conclusion of the District Attorney's Office in each incident is clearly based on the evidence. In addition, for one incident, a Deputy District Attorney went to the scene of the incident, attended the autopsy and was also present during the questioning of a key witness. The District Attorney’s Office takes an inordinately long period of time to complete their reports. The process should be expedited so that no agency being investigated would have to wait such a lengthy time (one and a half years in one case) before learning whether an employee or employees were determined to have violated any criminal law. The Jury concurs with the findings of the District Attorney’s Office that there was no wrong-doing on the part of any officer involved in the incidents reviewed. There are, however, some jail computer software upgrades that would provide information to help jail personnel more accurately assess inmates during booking, and there are some procedures that could be improved. Because the computerized record management system at the main jail does not include past records of inmates in custody, the intake staff was not aware of past suicide attempts or mental health issues for two of the inmates involved in the incidents. The staff relied on the only information they had, the written answers by the inmates regarding suicide attempts and mental health issues on the mandatory “Pre-Booking Medical/Mental Health Screen.” In both inmate deaths the information provided by the inmates was inaccurate or incomplete. Had past records been accessible, at least one death might have been prevented. Also, an inmate who had been booked two days earlier was assigned to a cell whose door was not visible from the control desk. Although he indicated no thoughts of suicide during the booking process, he committed suicide. While suicidal behavior is very difficult to predict when not acknowledged by the inmate, the Jury believes that if the newest prisoners could be housed in cells with doors visible to staff, the potential for problems could be reduced. Finally, a male officer transported a female prisoner to the hospital for a medical exam. He could not be present for nor observe the actions of the prisoner who was disrobing for the exam. During that time, the prisoner hid drugs in a body cavity and was able to smuggle them into the jail. Later she gave them to another prisoner who overdosed. The Jury stresses that all personnel involved in the incidents reviewed were highly competent professionals. Therefore, our recommendations for the agencies focus on process issues, not people issues.
No recommendations for this finding
Conclusions 1
-
CL1 Page 2Each of the Critical Incident Reports reflects a thorough, detailed, and unbiased investigation by those assigned to the case to determine whether any criminal liability existed. The conclusion of the District Attorney's Office in each incident is clearly based on the evidence. In addition, for one incident, a Deputy District Attorney went to the scene of the incident, attended the autopsy and was also present during the questioning of a key witness. The District Attorney’s Office takes an inordinately long period of time to complete their reports. The process should be expedited so that no agency being investigated would have to wait such a lengthy time (one and a half years in one case) before learning whether an employee or employees were determined to have violated any criminal law. The Jury concurs with the findings of the District Attorney’s Office that there was no wrong-doing on the part of any officer involved in the incidents reviewed. There are, however, some jail computer software upgrades that would provide information to help jail personnel more accurately assess inmates during booking, and there are some procedures that could be improved. Because the computerized record management system at the main jail does not include past records of inmates in custody, the intake staff was not aware of past suicide attempts or mental health issues for two of the inmates involved in the incidents. The staff relied on the only information they had, the written answers by the inmates regarding suicide attempts and mental health issues on the mandatory “Pre-Booking Medical/Mental Health Screen.” In both inmate deaths the information provided by the inmates was inaccurate or incomplete. Had past records been accessible, at least one death might have been prevented. Also, an inmate who had been booked two days earlier was assigned to a cell whose door was not visible from the control desk. Although he indicated no thoughts of suicide during the booking process, he committed suicide. While suicidal behavior is very difficult to predict when not acknowledged by the inmate, the Jury believes that if the newest prisoners could be housed in cells with doors visible to staff, the potential for problems could be reduced. Finally, a male officer transported a female prisoner to the hospital for a medical exam. He could not be present for nor observe the actions of the prisoner who was disrobing for the exam. During that time, the prisoner hid drugs in a body cavity and was able to smuggle them into the jail. Later she gave them to another prisoner who overdosed. The Jury stresses that all personnel involved in the incidents reviewed were highly competent professionals. Therefore, our recommendations for the agencies focus on process issues, not people issues.
No Responses Found 3
Government entities assigned to respond to this report. No response documents have been linked in our database.
Sonoma County Board of Supervisors
Elected County Office
Sonoma County District Attorney
Elected County Office
Sonoma County Sheriff
Elected County Office