Another Suicide in Santa Barbara County Jail Inmate's Death Should Have Been Prevented

Conclusions 8

• CL1
  CC should not have been transferred to an observation cell with a telephone cord.
• CL2
  Wellpath staff did not obtain critical health-related documentation from Cottage Hospital or Behavioral Wellness and therefore CC did not receive proper treatment in jail.
• CL3
  The Sheriff’s Office did not comply with the Remedial Plan outlined in Murray v. Santa Barbara County because it did not provide enough beds at all necessary levels of clinical care and security to meet the needs of inmates with serious mental illnesses, as in CC’s case.
• CL4
  There was poor communication regarding CC’s mental health history between Jail mental health staff, Mobile Crisis Teams, and outside healthcare providers who treated her.
• CL5
  During CC’s first approximately 23-hour stay in Safey Cell 3, the Sheriff’s Office failed to ensure that Wellpath staff comply with policy requiring that the Mobile Crisis Unit be called after 12 hours in a safety cell.
• CL6
  Wellpath staff failed to comply with existing policy requiring a psychiatric assessment while housed in a safety cell.
• CL7
  A Jail psychiatrist failed to evaluate, diagnose, or treat CC’s severe psychiatric illnesses, which were serious shortcomings.
• CL8
  It is the Jury’s view that the MHPs exhibited integrity and compassion in treating CC given the inherent deficiencies discussed in this Report. Likewise, custody staff demonstrated dedication and sincerity in their mission of safeguarding inmates. But that should not end the discussion. The systems and infrastructure used to evaluate and treat inmates with severe mental health concerns have failed inmates and staff. They must be given the necessary resources to ensure the health and safety of inmates, especially those with mental health conditions, or more individuals will die. If you're having thoughts of suicide, please call the National Suicide Prevention Lifeline at 1-800-273-8255, or call or text 988 (Crisis and Suicide Lifeline). They have caring people available 24/7 to provide free and confidential support. 2024-2025 Santa Barbara County Grand Jury 14 FINDINGS AND RECOMMENDATIONS Finding 1: CC should not have been transferred to an observation cell with a telephone cord. Recommendation 1a: The Grand Jury recommends that the Sheriff’s Office will not place an inmate deemed by mental health staff to have been recently suicidal in an observation cell that contains a telephone cord. To be implemented no later than January 1, 2026. Recommendation 1b: The Grand Jury recommends to the Sheriff’s Office that if no cordless mental health observation cells are available when stepping down a potentially suicidal inmate from a safety cell, a Jail mental health provider should seek to transfer that inmate to the closest facility that can offer adequate protection. To be implemented no later than January 1, 2026. Recommendation 1c: The Grand Jury recommends to the Sheriff’s Office that if no cordless mental health observation cells are available when stepping down a potentially suicidal inmate from a safety cell in the Main Jail, a Jail mental health provider must contact the County's psychiatric holding facility, the Crisis Stabilization Unit, a local hospital, and the Northern Branch Jail to determine if a bed offering an appropriate level of care is available. To be implemented no later than January 1, 2026. Recommendation 2c: Recommendation 1d: The Grand Jury recommends that the Board of Supervisors negotiate a memorandum of understanding with San Luis Obispo County, Ventura County, Los Angeles County, and other neighboring counties in California setting procedures for transferring and accepting inmates with severe mental health disease when no other safe housing options are available. To be implemented no later than January 1, 2026. Finding 2: Wellpath staff failed to comply with existing policy requiring a psychiatric assessment while housed in a safety cell. Recommendation 2: The Grand Jury recommends that while an inmate is housed in a safety cell, the Sheriff’s Office require a Wellpath psychiatrist conduct an evaluation of that inmate. Given that the recommendation is to follow existing policy, to be implemented immediately. Finding 3: A Jail psychiatrist failed to evaluate, diagnose, or treat CC’s severe psychiatric illnesses, which were serious shortcomings. Recommendation 3a: The Grand Jury recommends that if the on-duty psychiatrist is not available to conduct what Jail medical and mental health staff deem to be an urgent evaluation of an inmate, the Sheriff’s Office require Wellpath to designate another backup on-call psychiatrist to conduct such an evaluation. To be implemented no later than January 1, 2026. 2024-2025 Santa Barbara County Grand Jury 15 Recommendation 3b: The Grand Jury recommends to the Sheriff’s Office that if a stepdown inmate refuses to participate in a psychiatric evaluation, the on-duty Jail psychiatrist be required to obtain and review the inmate’s mental health history. To be implemented no later than January 1, 2026. Finding 4: During CC’s first approximately 23-hour stay in Safey Cell 3, the Sheriff’s Office failed to ensure that Wellpath staff comply with policy requiring that the Mobile Crisis Unit be called after 12 hours in a safety cell. Recommendation 4: The Grand Jury recommends that after an inmate spends more than 12 hours in a safety cell, the Sheriff’s Office require that Wellpath staff always call the Mobile Crisis Unit to conduct an evaluation and document the call and its outcome in the Jail electronic health record. Given that the recommendation is to follow existing policy, to be implemented immediately. Finding 5: There was poor communication regarding CC’s mental health history between Jail mental health staff, Mobile Crisis Teams, and outside healthcare providers who treated her. Recommendation 5a: The Grand Jury recommends that the Sheriff’s Office require additional training for Wellpath mental health providers regarding HIPAA regulations concerning inmates, including defining under what circumstances a mental health provider may legally contact outside mental health providers about an inmate’s mental health history. To be implemented no later than January 1, 2026. Recommendation 5b: The Grand Jury recommends that the Sheriff’s Office require the on-duty registered nurses at the County’s jails to request every newly arriving inmate at the time of intake to sign a written authorization to release their medical and mental health records and information. To be implemented no later than January 1, 2026. Finding 6: Wellpath staff did not obtain critical health-related documentation from Cottage Hospital or Behavioral Wellness and therefore CC did not receive proper treatment in jail. Recommendation 6a: The Grand Jury recommends that the Sheriff’s Office require Wellpath staff to contact outside healthcare providers, such as hospitals, physicians, and clinics, to obtain inmates’ health records in a timely manner following intake. To be implemented by January 1, 2026. Recommendation 6b: The Grand Jury recommends that the Sheriff’s Office upgrade its electronic health record system to allow it to receive patient health information from outside providers via an industry-standard means of internet transmission. To be implemented by March 31, 2027. 2024-2025 Santa Barbara County Grand Jury 16 Finding 7: The Sheriff’s Office did not comply with the Remedial Plan outlined in Murray v. Santa Barbara County because it did not provide enough beds at all necessary levels of clinical care and security to meet the needs of inmates with serious mental illnesses, as in CC’s case. Recommendation 7a: The Grand Jury recommends that the Sheriff’s Office provide and maintain safety and observation cells sufficient in number to meet ongoing demands. Recommendation 7b: The Grand Jury recommends that the Sheriff Office require custody staff to consider mental health staff’s clinical input when determining placement upon discharge from a safety cell and document the reasons when clinical input is not followed. 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, 4, 5, 6, 7 Recommendations 1a, 1b, 1c, 1d, 2, 3a, 3b, 4, 5a, 5b, 6a, 6b, 7a, 7b Santa Barbara County Sheriff’s Office – 60 days Findings 1, 2, 3, 4, 5, 6, 7 Recommendations 1a, 1b, 1c, 1d, 2, 3a, 3b, 4, 5a, 5b, 6a, 6b, 7a, 7b 2024-2025 Santa Barbara County Grand Jury 17

Observations 1

• OB1
  The following section provides a chronology of the events leading up to and following CC’s death in the Main Jail. Related Incident Two Weeks Prior to Death On October 28, 2024, approximately two weeks prior to her suicide, CC was visited at her home by a deputy sheriff for a welfare check, and an ambulance was called given her level of agitation. She was taken to the emergency department at Santa Ynez Valley Cottage Hospital evidencing a panic attack, anxiety, and depression. CC was angry, agitated and delusional during the evaluation. CC had a history of suicide attempts. She was diagnosed with psychosis, malingering, conversion, 2024-2025 Santa Barbara County Grand Jury 3 and depression with psychotic features.4 During the examination, CC’s alter ego “Patricia” was manifesting. Patricia was typically more agitated and ruder to people than she was. The Mobile Crisis Team, a unit within Behavioral Wellness tasked with performing psychiatric hold evaluations within the County, was called and found that she did not meet the criteria necessary to issue a Welfare and Institutions Code section 5150 (5150) 72-hour involuntary hold because she did not express suicidal ideations.5 She was discharged from the hospital the same day. November 8, 2024 On November 8, 2024, CC’s car was pulled over by a Santa Barbara County Deputy Sheriff for driving her vehicle in a reckless manner. Although she initially stopped when the deputy’s overhead lights were illuminated, she suddenly drove off despite being ordered to stop. She nearly collided with parked vehicles, ran through stop signs, and sped through an elementary school parking lot towards a nearby park. A patrol car performed a “PIT” maneuver causing CC’s car to stop. She then reversed and collided with her vehicle into an occupied patrol car, rendering her unconscious. Deputies suspected that CC was overdosing and administered Narcan. Following her arrest, she was then transferred to Santa Ynez Valley Cottage Hospital for further evaluation. She told hospital staff that she may have been diagnosed with bipolar disorder.6 During her brief stay in the Emergency Department, medical staff found her to be at a high risk of suicide. She believed she was the devil and must kill herself to save and protect her children. November 9, 2024 Still under arrest but not yet cleared for transfer to the jail, CC was next transported to Santa Barbara Cottage Hospital on the morning of November 9, 2024, for further psychiatric assessment of her suicidal ideations. While there, she was booked in absentia for evading police officers, assault with a deadly weapon (her car), and driving under the influence of drugs. She reported to staff at the hospital that she tried to choke herself when visiting deceased relatives at a cemetery 4 Malingering is the intentional production or display of false or exaggerated symptoms for a specific benefit or reward. Conversion disorder is a mental health condition that causes real, physical symptoms that a person cannot control. Psychosis is a term for symptoms that happen when a person has trouble telling the difference between what is real and what is not. 5 Pursuant to Section 5150, subdivision (a), “When a person, as a result of a mental health disorder, is a danger to others, or to themselves, or gravely disabled, a peace officer, professional person in charge of a facility designated by the county for evaluation and treatment, member of the attending staff, as defined by regulation, of a facility designated by the county for evaluation and treatment, designated members of a mobile crisis team, or professional person designated by the county may, upon probable cause, take, or cause to be taken, the person into custody for a period of up to 72 hours for assessment, evaluation, and crisis intervention ….” 6 Bipolar disorder, formerly called manic depression, is a mental health condition that causes extreme mood swings. These include emotional highs, also known as mania or hypomania, and lows, also known as depression. See https://www.mayoclinic.org/diseases-conditions/bipolar-disorder/symptoms-causes/syc-20355955 2024-2025 Santa Barbara County Grand Jury 4 that day. She stated that she was taking Xanax but had stopped taking her other medications, including medications for bipolar disorder. CC told hospital staff she was suicidal. A member of the hospital’s mental health staff documented that CC needed psychiatric hospitalization. However, a few hours later, during her interview with a hospital psychiatrist, CC denied suicidal ideations and did not meet the criteria for a 5150 hold. CC was diagnosed with adjustment disorder with mixed disturbance of emotions and conduct and was discharged to the Sheriff’s Office’s (SBSO) custody.7 Later the same day, she was moved to the Main Jail. When entering the Main Jail’s Inmate Reception Center (IRC), there were no prior Jail medical records available to medical staff because she had not been recently incarcerated in a jail in the County. CC indicated that she suffered from bipolar disorder and depression, and mental health staff was notified accordingly. However, bipolar disorder was never diagnosed nor treated by any Jail mental health staff. During the intake interview, CC stated that she had attempted to choke herself the previous day but was no longer experiencing suicidal thoughts. At that time, she was assigned to a cell in the general population unit known as West 6. A psychiatric consultation was not sought. November 10, 2024 On the morning of November 10th, a deputy in West 6 asked a Jail MHP to assess CC because she was having problems with other inmates in her unit. More specifically, those female inmates confronted CC because she was hovering over them and violating their personal space. During the MHP’s discussion with CC, she appeared to have difficulty keeping her eyes open and was breathing very deeply as though she was about to hyperventilate. She then collapsed to the ground. Medical staff was called to the scene and reported that she was awake, shaking, and speaking nonsensical sentences. She stated that she deserved to die and made other suicidal statements. The MHP then ordered her transferred to Safety Cell 3 (on suicide watch) by wheelchair because she could not walk. In the safety cell, she stated that she needed a pregnancy test and that she loved her babies. She then attempted to choke herself.8 The Jury learned that some MHPs would routinely call the Mobile Crisis Team to assess all inmates placed in safety cells.9 If asked, the Mobile Crisis Team would usually come to the Main Jail within the hour. The Mobile Crisis Team would typically assess safety cell inmates during their routine 7 “Adjustment disorder with mixed disturbance of emotions and conduct” is defined as an extreme reaction to a stressful incident that impacts mental equilibrium and causes negative changes in behavior. See https://www.hopkinsmedicine.org/health/conditions-and-diseases/adjustment-disorders 8 Wellpath’s on-call psychiatrist was not called on November 10th because she did not work on weekends (November 10th was a Sunday). 9 The Mobile Crisis Team is called to assess inmates who need an assessment for an involuntary 72-hour hold. It is staffed by at least one Marriage and Family Treatment Counselor. 2024-2025 Santa Barbara County Grand Jury 5 daily visits to the Main Jail. Here, however, the Mobile Crisis Team inexplicably did not evaluate CC until the evening of November 12th. November 11, 2024 During a safety cell round by medical staff on November 11th at 2:03 a.m., CC was very anxious and was having difficulty sleeping. CC was observably distressed and crying at the time. CC expressed delusional thoughts claiming the devil would harm her children. CC did not make any threats to herself or others. An antihistamine was prescribed to treat these behaviors. At 8:09 a.m. on November 11th, an MHP visited CC in Safety Cell 3. The MHP offered to speak confidentially with CC in a private room, which CC declined. Thus, the MHP briefly spoke with CC through the food slot in the cell door. CC stated that she was not suicidal and would not engage in a Collaborative Safety Plan (CSP).10 She appeared anxious, angry, and hostile and again noted she was concerned about being pregnant. The MHP concluded that CC no longer needed a safety cell and advised the Deputies to move her to an observation cell. Custody deputies then placed her in Holding Cell H-6, which had a wall-mounted telephone and 12-inch cord.11 November 12, 2014 On November 12th, while housed in cell H-6, CC stated that she wanted to kill herself by hanging. At approximately 8:00 a.m., CC told the MHP that prior to her arrest she had been seeing a psychiatrist at a health clinic, where she was prescribed Hydroxyzine and Xanax.12 The MHP did not document CC’s prior history of bipolar disease, nor her history of stopping her previously prescribed anti-psychotic medication. The MHP told CC that the Mobile Crisis Unit would assess her that evening and that she would again be placed in a safety cell in the interim. The MHP noted that CC had not yet been diagnosed but offered a provisional diagnosis of major depressive disorder. CC was then moved to Safety Cell 4. CC was evaluated by the Mobile Crisis Team at 10:30 p.m. on November 12th, which found that she did not qualify for a 5150 hold. The evaluator from the Mobile Crisis Team was not a licensed mental health worker. The Mobile Crisis Team did not document its denial of a 5150 hold in writing. CC was characterized as not volatile, and she denied any suicidal ideations during that encounter. However, the Mobile Crisis Team felt that CC exhibited bizarre behavior that necessitated further evaluation and treatment. Because there was no documentation of this 10 A CSP includes a series of questions used to determine warning signs, coping skills and the patient’s “reasons for living,” for example the extent of supportive family and friends. 11 According to SBSO policy, “the Classification Unit will assign appropriate housing with consideration to those inmates with physical and/or mental disabilities and/or special needs.” 12 Hydroxyzine is an antihistamine used to treat anxiety, tension, and allergic conditions. Xanax is used to help control anxiety and tension caused by nervous and emotional conditions. 2024-2025 Santa Barbara County Grand Jury 6 assessment, the Jury cannot determine whether the Mobile Crisis Team knew of CC’s bipolar disorder or recommended a treatment plan. November 13, 2024 – Day of Suicide On November 13th, at approximately 8:46 a.m., an MHP spoke with CC in Safety Cell 4 for about five minutes. At the time, CC was not in any acute mental distress and stated she did not want to kill herself. She mentioned that her children provided her with a reason for living. CC was scheduled to be seen by a Jail psychiatrist later that morning. The MHP notified custody staff to step down CC from the safety cell to an observation cell. A custody deputy placed CC into cell H-6.13 That cell contained a wall-mounted telephone with a 12-inch cord. All three of the cordless mental health observation cells were occupied when CC was stepped down from the safety cell on November 13th. CC was never evaluated or diagnosed by a psychiatrist during her time in jail. For the first time, on November 13th at approximately 1:39 p.m., a Jail psychiatrist was scheduled to evaluate CC from a remote location via telehealth, but CC refused. She was never assessed by the psychiatrist. Instead, the psychiatrist merely prescribed Hydroxyzine and scheduled a follow up visit for a week later. The psychiatrist took no further actions to address CC’s refusal of that evaluation, made no inquiries of Jail MHPs, did not review any of CC’s prior mental history, did not know CC had been in safety cells for suicidal ideations twice in the previous three days, did not know she had been diagnosed with bipolar disorder, and did not prescribe antipsychotic medication. Jail staff conducted safety checks of CC throughout the day, including at 4:04 p.m., 4:19 p.m., and 4:31 p.m., all of which demonstrated no unusual circumstances. However, while performing rounds at approximately 4:48 p.m., a custody deputy observed CC hanging from a 12-inch telephone cord wrapped around her neck. The deputy radioed a request for additional Deputies to respond to H-6 due to a hanging. The Shift Commander called for an ambulance. Deputies and Jail medical staff continued to administer medical aid until paramedics arrived at approximately 4:57 p.m. At approximately 5:31 p.m., paramedics terminated resuscitation efforts, and CC was pronounced dead. An autopsy was later conducted by the Coroner’s Bureau, which concluded that the cause of death was suicide by hanging. After Death Events As noted above, two holding cells that contained telephones with 12-inch cords were regularly used as observation cells when other options without telephones were not available. Several days after CC’s death, Jail staff removed the telephone cords from cells H-6 and H-7. Since then, all 13 The custody records contain conflicting data regarding which observation cell CC was assigned to. 2024-2025 Santa Barbara County Grand Jury 7 holding cells that contained a telephone with a 12-inch cord have had the phone cord removed. There are now seven holding cells that do not have any phone cords. Photos taken of cell H-6 after CC’s death revealed a wall-mounted telephone with a 12-inch cord emanating from the bottom of the telephone. Based upon the Jury’s research, several options on the market could have been installed to prevent inmate suicides using telephone cords, including telephones with six-inch cords, wireless speaker telephones, and a telephone cord that comes out of the top of the telephone housing, making it more difficult to use as a ligature. Board of Supervisors Hearing Regarding Jail Health Monitoring On March 11, 2025, a hearing was conducted by the Board of Supervisors to provide an update on Jail Health Monitoring activities. According to performance audits conducted by the County’s Health Department and Behavioral Wellness, of 29 combined quality assurance measures reflecting the adequacy of health coverage, the Main Jail was rated “noncompliant” in nine measures, and “persistently noncompliant” in five of the nine. For the Northern Branch Jail there were eight measures of noncompliance, five of which demonstrated “persistent noncompliance.” The measure that generated the most alarm from the County Supervisors was the extent to which Wellpath failed to meet its contractual obligation to medically assess inmates placed in safety cells every four hours, properly doing so as required only 13 percent of the time at the Northern Branch Jail and 73 percent of the time at the Main Jail. Likewise, MHPs failed to timely check on such inmates inside safety cells within 12 hours, as the contract requires, doing so properly only 67 percent of the time at the Northern Branch Jail and 80 percent of the time at the Main Jail. On April 1, 2025, the Board of Supervisors approved a new two-year contract with Wellpath.

Agency Responses 3

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