Sonoma County Grand Jury • 2007-2008

Review of Moses McDowall Fatal Incident On November 6, 2006, Moses McDowall died while in custody at the Sonoma County

7 pages

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Findings and Recommendations 7 findings

The preponderance of forensic evidence and the Protocol specified that this investigation be led by a testimony of several witnesses suggest that Mr. division of the same law enforcement agency in which McDowall expired two to four hours before he was the fatal incident occurred (employer agency). The found dead at 8:18 a.m. on November 6, 2006. lead investigator was a former CO. The Grand Jury had to consider the obvious possibility that

Related Recommendations (1)

The Sheriff’s Department should initiate another investigation of Mr. McDowall’s death. This investigation should be led by an outside law-enforcement agency. The focus of this investigation may be limited to the resolution of the issues (F1, F3, F4, F5) raised in this Grand Jury report.

An independent forensic pathologist, consulted by the Grand Jury, concluded that the preponderance of discrepancies in the investigation may have been evidence indicates that Mr. McDowall died before intentionally overlooked. The appearance of, and possibly the actuality of, an impartial independent 6:00 a.m., and probably much earlier. investigation is destroyed by this exception to the

Related Recommendations (1)

The Sheriff’s Department should develop a procedure to identify the COs performing rounds in MADF modules.

The VCU/DA conclusion that Mr. McDowall was alive Fatal Incident Protocol. at breakfast (sometime after 6:00 a.m.) is

Related Recommendations (2)

The Sheriff’s Department should review the integrity of RATS and provide redundant storage of RATS data.

The statement of one CO (no longer with the this critical time. The unlikelihood of a successful department) that slight movement was noticed at criminal prosecution was given as a justification for 6:56am is questionable in light of the inmate witness’s testimony, the testimony of other the lack of pursuit of these issues. Justifications aside, the Grand Jury found that the Deputy District employees, and the forensic expert’s estimated time Attorney did not identify any of the issues we raised. of death. The testimony (to VCU) by this same CO indicates that he first arrived in Module D at 5:45 a.m. on November 6, 2006. No documentary evidence F8 Our review discovered errors in the investigation, which resulted in false assumptions. Principal among these was provided to indicate his assignment to, or presence in, Module D before 6 a.m. that morning. If were miscalculation of Mr. McDowall’s time of death, the five earlier Module D rounds were done, evidence and a failure to properly investigate events prior to the presumed time of death. indicating which CO conducted those rounds and the nature of those checks is missing from the VCU investigation.

Related Recommendations (2)

The Sheriff’s Department Internal Affairs Unit should investigate independently what occurred in Module D during the time that Mr. McDowall was housed there, specifically findings F1, F3, F4 and F5. This investigation should determine: which COs were involved, if procedures were followed, and if procedures need to be revised. If warranted, recommendations for disciplinary action should be made.

The Rounds Automatic Tracking System data files were lost due to hard-drive failure 17 days after the fatal incident and are unavailable to verify the paper documents indicating that rounds were completed in Modules C and D (Mr. McDowal l’s module) on the morning of November 6, 2006. The only available paper logs contradict statements of several COs interviewed. There is no reliable system available to identify who performed the rounds in Modules C and D that night. 14 \ Conclusions • The investigation of the in-custody death of Mr. McDowall represents a perfect example of “how not to do it” by all parties involved. Mr. McDowall’s demise was officially recorded in the autopsy as “Alcoholic Withdrawal Syndrome as a result of chronic alcoholism, a natural cause of death.” There is a viewpoint expressed by CO’s and staff in the Sheriff’s Department Detention Division that sick people die everywhere, including in jail. The Grand Jury disagrees with both the attitude and the assessment. Mr. McDowall‘s severe alcoholism had put his health at risk for many years. Until he was incarcerated, he was able to cope with the affliction in his own way. In jail, he does not have that option. It is the responsibility of the Sheriff’s Department to assess Mr. McDowall’s health and take the necessary measures to keep him alive. With appropriate attention and minimal effort, this death was preventable. Neither the initial VCU investigation nor the subsequent Grand Jury investigation indicate that the Sheriff’s Department lived up to its responsibility to sufficiently monitor an inmate whose health was at risk. The Fatal Incident Report sheds no light on the matter. • Mr. McDowall died sometime after he entered his cell at 3:15 am but before he was offered breakfast that morning. Our own research of the evidence and the independent assessment by a forensic pathologist concur. Usually the Coroner’s autopsy report includes no speculation as to time of death. The autopsy was normal in that respect. Several of the doctors we consulted, including the forensic pathologist, commented that the cause of death was unusually non-specific. • The VCU did not competently and impartially • The IA investigation relied on documentary investigate the Detention Division’s role in Mr. evidence from the flawed VCU investigation. No McDowall’s death. The interviews of involved independent interviews were conducted. The parties appeared to be prompted rather than presumption that a specific CO did rounds in interrogatory. The VCU investigator asked leading Module D before 6:00 a.m. on November 6, 2006, questions of the witnesses he interviewed. is unsupported by any documentary or testimonial Misinterpreted testimony led to the failure to evidence in either investigation. explore important issues. • The Law Enforcement Chiefs’ Association Fatal The Sheriff’s Department did not decide on its Incident Protocol generally provides for an own to lead the investigation of its own Detention impartial investigation free from the appearance of Division. That decision is mandated by the impropriety because the inquiry is led by a Association of Law Enforcement Chiefs’ Protocol. separate law-enforcement agency. The For that reason, the inference that the Sheriff’s association’s exemption for jail fatalities leaves Department wanted an in-house investigation for those investigations open to the suspicion of bias some clandestine purpose is not supported by and conspiracy. the Grand Jury. • Sonoma County correctional officers are • The District Attorney’s participation and review of confronted with over 12,000 bookings annually into the Fatal Incident Report was not adequate to a jail system with a constantly changing average conclude that there was no criminal act, unlawful population of 1,100 inmates. COs often view an act, or act of omission. The Deputy District inmate withdrawing from alcohol addiction as “just Attorney’s review of the VCU investigation should another drunk.” This indifference can result in have raised the same questions posed by the cursory security checks and missed opportunities Grand Jury. Several prosecutors indicate that it is for intervention in health crises. An inmate’s death very difficult to prevail in a case involving a may be the byproduct of such apathy. correctional officer. We do not presume that there was a criminal act. However, there could be criminal liability. The unlikelihood of a successful prosecution does not justify failure to investigate. 15

Related Recommendations (2)

The District Attorney should conduct a new investigation into Mr. McDowall’s death, either independently or in concert with the outside agency referred to in R1.

The Association of Joint Chiefs’ Fatal Incident

Related Recommendations (1)

The Law Enforcement Chiefs’ Association should amend the Law Enforcement Employee-Involved Fatal Incident Protocol to require that investigations of deaths in custody be led by an outside law-enforcement agency. The exceptions to the routine prohibition--that the employer agency not lead or directly participate in the investigation-- would be consistent with the procedures mandated for other law-enforcement employee-involved fatal incidents. Required Responses to Findings Requested Responses to Sheriff’s Department F1, F3, F4, F5 Recommendations District Attorney F7 District Attorney R1 Law Enforcement Chiefs’ Association F6 Required Responses to Recommendations Sheriff’s Department R1, R2, R3, R4 District Attorney R5 Law Enforcement Chiefs’ Association R6 16

The District Attorney’s review of the VCU investigation unsupported by the testimony of the only inmate witness to the incident. This erroneous assumption concludes that no criminal acts, unlawful acts, or acts of omission occurred between 3:15 a.m. and 6:00 on the part of the lead investigator (a former CO) diverted and minimized the investigation of events a.m., which in all probability was when Mr. McDowall earlier that morning. Furthermore, this died. There is no clear evidence indicating which, if misinterpretation was an important premise of the IA any, CO performed the five required cell checks during this period. Any one of these security checks, if investigation. done, may have saved his life. The DA and the VCU investigation failed to look into what occurred during

No recommendations for this finding

Conclusions 6

CL1 Page 6

The investigation of the in-custody death of Mr. McDowall represents a perfect example of “how not to do it” by all parties involved. Mr. McDowall’s demise was officially recorded in the autopsy as “Alcoholic Withdrawal Syndrome as a result of chronic alcoholism, a natural cause of death.” There is a viewpoint expressed by CO’s and staff in the Sheriff’s Department Detention Division that sick people die everywhere, including in jail. The Grand Jury disagrees with both the attitude and the assessment. Mr. McDowall‘s severe alcoholism had put his health at risk for many years. Until he was incarcerated, he was able to cope with the affliction in his own way. In jail, he does not have that option. It is the responsibility of the Sheriff’s Department to assess Mr. McDowall’s health and take the necessary measures to keep him alive. With appropriate attention and minimal effort, this death was preventable. Neither the initial VCU investigation nor the subsequent Grand Jury investigation indicate that the Sheriff’s Department lived up to its responsibility to sufficiently monitor an inmate whose health was at risk. The Fatal Incident Report sheds no light on the matter.
CL2 Page 6

Mr. McDowall died sometime after he entered his cell at 3:15 am but before he was offered breakfast that morning. Our own research of the evidence and the independent assessment by a forensic pathologist concur. Usually the Coroner’s autopsy report includes no speculation as to time of death. The autopsy was normal in that respect. Several of the doctors we consulted, including the forensic pathologist, commented that the cause of death was unusually non-specific.
CL3 Page 6

The VCU did not competently and impartially • The IA investigation relied on documentary investigate the Detention Division’s role in Mr. evidence from the flawed VCU investigation. No McDowall’s death. The interviews of involved independent interviews were conducted. The parties appeared to be prompted rather than presumption that a specific CO did rounds in interrogatory. The VCU investigator asked leading Module D before 6:00 a.m. on November 6, 2006, questions of the witnesses he interviewed. is unsupported by any documentary or testimonial Misinterpreted testimony led to the failure to evidence in either investigation. explore important issues.
CL4 Page 6

The Law Enforcement Chiefs’ Association Fatal The Sheriff’s Department did not decide on its Incident Protocol generally provides for an own to lead the investigation of its own Detention impartial investigation free from the appearance of Division. That decision is mandated by the impropriety because the inquiry is led by a Association of Law Enforcement Chiefs’ Protocol. separate law-enforcement agency. The For that reason, the inference that the Sheriff’s association’s exemption for jail fatalities leaves Department wanted an in-house investigation for those investigations open to the suspicion of bias some clandestine purpose is not supported by and conspiracy. the Grand Jury.
CL5 Page 6

Sonoma County correctional officers are
CL6 Page 6

The District Attorney’s participation and review of confronted with over 12,000 bookings annually into the Fatal Incident Report was not adequate to a jail system with a constantly changing average conclude that there was no criminal act, unlawful population of 1,100 inmates. COs often view an act, or act of omission. The Deputy District inmate withdrawing from alcohol addiction as “just Attorney’s review of the VCU investigation should another drunk.” This indifference can result in have raised the same questions posed by the cursory security checks and missed opportunities Grand Jury. Several prosecutors indicate that it is for intervention in health crises. An inmate’s death very difficult to prevail in a case involving a may be the byproduct of such apathy. correctional officer. We do not presume that there was a criminal act. However, there could be criminal liability. The unlikelihood of a successful prosecution does not justify failure to investigate. 15

No Responses Found 2

Government entities assigned to respond to this report. No response documents have been linked in our database.

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