Fatal Head Injury at the Northern Branch Jail a Custody-Related Death Investigation

Conclusions 1

• CL1
  The first 72 hours of an inmate’s arrival at jail is a time of particular sensitivity, requiring careful attention from medical staff and custody staff. In the course of this custody-related death investigation, the Jury identified a number of areas relating to the screening and observation of new arrivals at the County’s jails that require improvement. An incomplete master problem list in the electronic health record, which meant that medical staff could not accurately assess whether AAO needed alcohol withdrawal monitoring or not, encompasses important areas where AAO’s case demonstrates shortcomings in provided medical care at the County’s jails. Two Service Level Agreements in the County’s new contract with Wellpath demonstrate that the County is taking steps to correct these deficiencies. A lack of communication regarding withdrawal risk between medical staff and custody staff, or between their respective information systems, was also identified as an area of concern by the Jury. With increased oversight by County agencies over Wellpath’s operations at the County’s jails following the signing of the new contract in April 2025, the Jury is increasingly hopeful that the concerns it raises in this Report will result in system-wide improvements at the jails.

Commendations 4

• CM1
  AAO’s known medical history at the jail provided clear indicators for serious alcohol withdrawal risk, but no such identification occurred.
• CM2
  Custody staff were not aware that AAO had an alcohol withdrawal alert or history because it was not communicated to them by medical staff or by means of an alert in the Jail Management System, though such communication would have been valuable.
• CM3
  Because of the lack of an accurate and comprehensive master problem list in AAO’s electronic health record, Wellpath medical staff did not make fully informed decisions regarding AAO’s health needs and risks when he came to the Northern Branch Jail on August 29, 2024.
• CM4
  The County has taken important steps to implement oversight mechanisms at the jails to improve Wellpath’s compliance with the new contract and the jails’ adherence to national care standards. The Jury commends the Santa Barbara County Board of Supervisors, the Sheriff’s Office, the County of Santa Barbara Health Department, the Santa Barbara County Department of Behavioral Wellness, and their staff for their recent work in these pursuits. 2024-2025 Santa Barbara County Grand Jury 11 FINDINGS AND RECOMMENDATIONS Finding 1: Because of the lack of an accurate and comprehensive master problem list in AAO’s electronic health record, Wellpath medical staff did not make fully informed decisions regarding AAO’s health needs and risks when he came to the Northern Branch Jail on August 29, 2024. Recommendation 1a: The Grand Jury recommends that the Board of Supervisors instruct the County of Santa Barbara Health Department to conduct systematic audits of inmates’ charts in the electronic health record to determine the extent to which master problem lists maintained by Wellpath accurately and comprehensively reflect inmates’ known health problems. To be completed by July 1, 2026. Recommendation 1b: The Grand Jury recommends that if non-compliance is discovered in the form of incomplete or inaccurate master problem lists so as not to meet performance measures established by the Wellpath contract, the County exact monetary penalties pursuant to the Service Level Agreement (Area 5. Incarcerated Person Problem List) in the new contract. Finding 2: AAO’s known medical history at the jail provided clear indicators for serious alcohol withdrawal risk, but no such identification occurred. Recommendation 2a: The Grand Jury recommends that the Board of Supervisors instruct the County of Santa Barbara Health Department to conduct audits to determine if Wellpath staff are appropriately identifying, monitoring, and treating at-risk inmates consistent with the U.S. Department of Justice’s Guidelines for Managing Substance Withdrawal in Jails. To be completed by July 1, 2026. Recommendation 2b: The Grand Jury recommends that if non-compliance is discovered in the form of missed cases of withdrawal monitoring or treatment, or performance of monitoring or treatment duties inconsistent with the U.S. Department of Justice guidelines so as not to meet performance measures established by the Wellpath contract, the County exact monetary penalties pursuant to the Service Level Agreement (Area 1. Withdrawal Management). Finding 3: Custody staff were not aware that AAO had an alcohol withdrawal alert or history because it was not communicated to them by medical staff or by means of an alert in the Jail Management System, though such communication would have been valuable. Recommendation 3a: The Grand Jury recommends that the Sheriff’s Office require a standardized verbal communication process upon inmate handover from the registered nurse performing the health receiving screening to the relevant on-duty classification deputy, specifically 2024-2025 Santa Barbara County Grand Jury 12 requiring the sharing of health-related findings or history insofar as necessary to provide for the health and safety of the inmate or others. To be implemented by January 1, 2026. Recommendation 3b: The Grand Jury recommends that the Sheriff’s Office develop a comprehensive and automatic system of shared health alerts between the healthcare contractor’s electronic health record and the Jail Management System so that critical health-related alerts appear automatically in the Jail Management System. To be implemented by January 1, 2026. This report was issued by the Grand Jury with the exception of a Grand Juror who wanted to avoid the perception of a conflict of interest. That Grand Juror was excluded from all parts of the investigation, including interviews, deliberations, and the writing and approval of this report. REQUIREMENTS FOR RESPONSES Pursuant to California Penal Code §933 and §933.05, the Grand Jury requests each entity or individual named below to respond to the findings and recommendations within the specified statutory time limit. Responses to Findings shall be either: - Agree - Disagree with an explanation - Disagree partially with an explanation Responses to Recommendations shall be one of the following: - Has been implemented, with a summary of the implementation actions taken - Will be implemented, with an implementation schedule - Requires further analysis, with an analysis completion date of fewer than 6 months after the issuance of the report - It will not be implemented with an explanation of why Santa Barbara County Board of Supervisors – 90 days Findings 1, 2, 3 Recommendations 1a, 1b, 2a, 2b, 3b Santa Barbara County Sheriff’s Office – 60 days Findings 1, 2, 3 Recommendations 3a, 3b 2024-2025 Santa Barbara County Grand Jury 13

Agency Responses 2

Government agencies' official responses to this report's findings and recommendations. Click on a response to see the structured breakdown.