Preventable Death at the Northern Branch Jail a Death-in-Custody Investigation

Conclusions 4

• CL1
  Nursing staff at the Northern Branch Jail did not follow an evidence-based process to evaluate or treat CF for her abdominal pain, though such pain assessment forms were available and their use expected.
• CL2
  Inmate CF’s death might have been prevented if she had received appropriate medical assessment in jail.
• CL3
  CF repeatedly complained of abdominal pain for at least two days prior to her death, but these complaints were not assessed by medical staff in accordance with jail medical policy, procedure, and protocol.
• CL4
  After five days of incarceration in the Santa Barbara Northern Branch Jail, inmate CF died because of an untreated perforated gastric ulcer. For at least two days during her jail stay, CF repeatedly complained of pain, yet her pain was never appropriately evaluated. While the jail had established tools and forms to evaluate inmates’ pain, these were never utilized, though their use was expected. Had an appropriate evaluation of CF’s pain occurred, with subsequent treatment rendered immediately, CF’s death could potentially have been avoided. FINDINGS AND RECOMMENDATIONS Finding 1: CF repeatedly complained of abdominal pain for at least two days prior to her death, but these complaints were not assessed by medical staff in accordance with jail medical policy, procedure, and protocol. Recommendation 1: The Grand Jury recommends that the Sheriff’s Office require that qualified medical professionals assess and treat pain according to accepted medical standards and in accordance with existing policy, procedure, and protocol when inmates in the County’s jails complain of pain. Finding 2: Nursing staff at the Northern Branch Jail did not follow an evidence-based process to evaluate or treat CF for her abdominal pain, though such pain assessment forms were available and their use expected. Recommendation 2: The Grand Jury recommends that the Sheriff’s Office instruct all medical staff at the County’s jails to utilize available evidence-based pain assessment forms to evaluate and document inmates’ pain complaints. 2024-2025 Santa Barbara County Grand Jury 7 Finding 3: Inmate CF’s death might have been prevented if she had received appropriate medical assessment in jail. Recommendation 3a: The Grand Jury recommends that the Board of Supervisors direct County Health to thoroughly assess the medical care provided to CF by Wellpath. To be implemented by January 1, 2026. Recommendation 3b: Based on the investigation of the care provided to CF, the Grand Jury recommends that the Board of Supervisors direct County Health make public a report identifying opportunities for systemic improvements in the quality of medical care in the County’s jails. 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 3a, 3b Santa Barbara County Sheriff’s Office – 60 days Findings 1, 2, 3 Recommendations 1, 2 2024-2025 Santa Barbara County Grand Jury 8

Agency Responses 2

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