Deaths in Custody in Santa Barbara County Jails Our County Jails Meet Many Needs

Conclusions 13

• CL1
  SP spent over 12 hours confined in a safety cell without a mental health evaluation being conducted by a C.A.R.E.S. Mobile Crisis Unit during that time.
• CL2
  Being placed in a prone position while restrained contributed to JG’s death.
• CL3
  LR's physical injuries and cognitive abilities worsened during his three days of incarceration at the Main Jail. An admitted alcoholic, he was not treated for alcohol withdrawal symptoms when examined by mental health or medical personnel.
• CL4
  The arresting officers failed to inform the intake staff that JG had complained of back and chest pain. This lack of communication was a missed opportunity to ascertain whether JG needed timely and appropriate medical care.
• CL5
  Custody Deputies removed JG from the medical intake screening process before it was 2023-2024 Santa Barbara County Grand Jury 17 completed. The failure to prioritize JG's medical needs at intake raises serious concerns about the potential for harm to individuals in custody.
• CL6
  There were only 11 Custody Deputies on shift at the time of SPs’ death. The level of safety inside jail facilities is directly affected by the number of Custody Deputies on duty. If more than one critical incident were to occur at the same time, it could be extremely difficult to manage.
• CL7
  When the Public Health Medical Advisor position has been filled, this medical professional will be working with Wellpath staff at the jails.
• CL8
  There was a failure to initiate a collaborative safety plan with SP prior to his release from the mental health observation cell which is intended to provide support and decrease the chance of self-harm during a critical period of time.
• CL9
  Ongoing renovations and upgrades within the IRC 300 housing unit had resulted in the in-cell intercom system, certain video surveillance systems, and the electronic locking mechanisms being non-operational at the time of SP’s death, causing delayed response times by custody and medical staff.
• CL10
  The Public Defender’s Office currently conducts an entry interview to establish a connection with newly incarcerated persons booked into the Northern Branch Jail, which continues until the incarcerated persons are discharged.
• CL11
  The Grand Jury investigations of deaths in custody rely heavily on information provided by the Santa Barbara County Sheriff’s Office. Completion of the investigations was impeded greatly by a lack of timely cooperation by the Sheriff’s Office.
• CL12
  Five of the six deaths in this report occurred within the first three days of entering the jail. The main factors for jail deaths involved issues of inconsistent and inadequate observation.
• CL13
  Two overdoses, two suicides, and two medically complicated incidents. These deaths in custody occurred in part due to insufficient observation, occasional lack of effective and timely communications between jail Custody Deputies and healthcare staff, and inadequate resources. In order to help those who enter the jail experiencing medical or mental health issues, there needs to be more custody officers, more healthcare attendants, and better housing and equipment. These improvements are difficult to obtain given the current job market and the burdened County budget. The Sheriff’s Office and the jails can develop solutions by combining resources with other County departments. Behavioral Wellness, the Public Defender’s Office, and Public Health are poised to be collaborative partners in observing, tending, and caring for those inside the jails. Santa Barbara County jails have the opportunity to create a better model for the County’s principal mental health institutions, drug treatment centers, and healthcare centers that we call jails. 2023-2024 Santa Barbara County Grand Jury 16 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. FINDINGS AND RECOMMENDATIONS Finding 1 Being placed in a prone position while restrained contributed to JG’s death. Recommendation 1 The Sheriff’s Office should review and reevaluate the use of prone restraint position with obese individuals. Finding 2 The arresting officers failed to inform the intake staff that JG had complained of back and chest pain. This lack of communication was a missed opportunity to ascertain whether JG needed timely and appropriate medical care. Recommendation 2 The Grand Jury recommends that the Sheriff's Office implement a mandatory communication protocol between arresting officers and jail medical intake staff. This protocol should ensure that arresting officers consistently relay all potentially relevant medical information to intake nurses, including any complaints of pain or existing medical conditions. Finding 3 Custody Deputies removed JG from the medical intake screening process before it was 2023-2024 Santa Barbara County Grand Jury 17 completed. The failure to prioritize JG's medical needs at intake raises serious concerns about the potential for harm to individuals in custody. Recommendation 3a The Grand Jury recommends that custody and medical staff develop improved communication protocols. This collaboration should ensure that medical intake screenings are consistently completed before individuals are removed from the process. Recommendation 3b The Grand Jury recommends revising the medical screening questionnaire to prioritize the most critical information. Specifically, a question like "Are you currently experiencing any pain or are you suffering from an acute condition?" should be placed as the first question on the questionnaire. This simple change could ensure that individuals with immediate medical needs are identified and addressed promptly. Finding 4 LR's physical injuries and cognitive abilities worsened during his three days of incarceration at the Main Jail. An admitted alcoholic, he was not treated for alcohol withdrawal symptoms when examined by mental health or medical personnel. Recommendation 4 Any incarcerated person who has admitted to prolonged and excessive alcohol consumption and begins exhibiting symptoms consistent with alcohol withdrawal must immediately be treated in a manner to reduce symptoms and monitored for continued physical and/or cognitive degradation. Finding 5 When the Public Health Medical Advisor position has been filled, this medical professional will be working with Wellpath staff at the jails. Recommendation 5 The Public Health Medical Advisor shall help oversee and advise treatment for medically compromised individuals entering the jails, especially during the critical first week of incarceration. Finding 6 2023-2024 Santa Barbara County Grand Jury 18 RU and DL suffered from drug addiction and died within two days of entering the jails. Recommendation 6a The Sheriff’s Office should contract with Behavioral Wellness for a number of beds in the recently reopened Crisis Stabilization Unit next to the Main Jail, where arrestees can be consistently monitored. Recommendation 6b The Sheriff’s Office shall direct medical staff at the Northern Branch Jail to hold a number of beds in the medical unit for those arrestees entering the jail who exhibit withdrawal symptoms. Recommendation 6c The Sheriff’s Office shall work with Public Health and Behavioral Wellness to increase staffing of the Medically Assisted Treatment program at both jails. Finding 7 SP spent over 12 hours confined in a safety cell without a mental health evaluation being conducted by a C.A.R.E.S. Mobile Crisis Unit during that time. Recommendation 7a To comply with its current policy, the Sheriff's Office should review and revise its protocols to ensure that timely mental health evaluations are conducted by a C.A.R.E.S. Mobile Crisis Unit for individuals retained in safety cells over the initial 12-hour limit. Recommendation 7b The Jury recommends that all procedures that are mandated by policy to be performed prior to the removal of an occupant from a safety or observation cell be incorporated as a checklist into the posted observation logs. A custody supervisor shall review the observation logs together with the checklist to ensure that each required step has been completed and upon such verification, the custody supervisor’s signature releases the occupant. Finding 8 There was a failure to initiate a collaborative safety plan with SP prior to his release from the mental health observation cell which is intended to provide support and decrease the chance of self-harm during a critical period of time. Recommendation 8a 2023-2024 Santa Barbara County Grand Jury 19 The Sheriff’s Office shall ensure that the procedures outlined within its policy and its contract with Wellpath be completed prior to the removal of an occupant from a safety or observation cell. Recommendation 8b The Jury recommends that all procedures that are mandated by policy to be performed prior to the removal of an occupant from a safety or observation cell be incorporated as a checklist into the posted observation logs. A custody supervisor shall review the observation logs together with the checklist to ensure that each required step has been completed and upon such verification, the custody supervisor’s signature releases the occupant. Finding 9 Ongoing renovations and upgrades within the IRC 300 housing unit had resulted in the in-cell intercom system, certain video surveillance systems, and the electronic locking mechanisms being non-operational at the time of SP’s death, causing delayed response times by custody and medical staff. Recommendation 9 The Sheriff’s Office should develop and implement more effective alternatives for visually monitoring incarcerated individuals and enabling emergency communication when the electronic surveillance and intercom systems are not functioning properly, including relocating incarcerated persons to other holding locations within the County jail system, increasing the frequency and duration of in-person safety checks and cell inspections by custody staff when electronic monitoring is unavailable, and stationing custody personnel within the housing unit to enhance direct supervision. Finding 10 There were only 11 Custody Deputies on shift at the time of SPs’ death. The level of safety inside jail facilities is directly affected by the number of Custody Deputies on duty. If more than one critical incident were to occur at the same time, it could be extremely difficult to manage. Recommendation 10 The Sheriff’s Office shall review its minimum staffing levels in the jail facilities. Finding 11 2023-2024 Santa Barbara County Grand Jury 20 SP, who had clearly expressed an intention to harm himself in any way that he could, was nonetheless placed in a cell located in a two-level housing unit, which provided SP with easy access and the means to jump to his death from the second level of the unit. Recommendation 11a The Grand Jury recommends that the Santa Barbara County Sheriff’s Office immediately review and revise its incarcerated housing and classification placement protocols. Going forward, the Sheriff’s Office must ensure that individuals who have made suicidal statements or exhibit a desire to harm themselves are never assigned to cells or housing units that offer ready access to methods of self-harm such as elevated areas from which an incarcerated individual could jump. Recommendation 11b To help mitigate the risk of incarcerated persons jumping or falling from elevated housing areas, the Grand Jury recommends that the Sheriff’s Office explore the feasibility of installing physical barriers, such as safety netting or higher railings, in those locations. Finding 12 The Public Defender’s Office currently conducts an entry interview to establish a connection with newly incarcerated persons booked into the Northern Branch Jail, which continues until the incarcerated persons are discharged. Recommendation 12 The Sheriff’s Office shall work with the Public Defender’s Office to initiate a similar program at the Main Jail. Finding 13 The Grand Jury investigations of deaths in custody rely heavily on information provided by the Santa Barbara County Sheriff’s Office. Completion of the investigations was impeded greatly by a lack of timely cooperation by the Sheriff’s Office. Recommendation 13 The Sheriff’s Office shall promptly provide information to the Grand Jury. 2023-2024 Santa Barbara County Grand Jury 21 Finding 14 Five of the six deaths in this report occurred within the first three days of entering the jail. The main factors for jail deaths involved issues of inconsistent and inadequate observation. Recommendation 14 The Sheriff’s Office, working in conjunction with Wellpath, Behavioral Wellness and Public Health, shall have procedures in place to more closely monitor at-risk incarcerated persons when they enter the jails. Request for Response Santa Barbara County Sheriff’s Office – 60 days Findings 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14 Recommendations 1, 2, 3a 3b, 4, 5, 6a, 6b, 6c, 7a, 7b, 8a, 8b, 9, 10, 11a, 11b, 12, 13, 14 Santa Barbara County Board of Supervisors – 90 days Findings 5, 6, 12, 14 Recommendations 5, 6,c, 12, 14 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: 2023-2024 Santa Barbara County Grand Jury 22 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 ⦁ 2023-2024 Santa Barbara County Grand Jury 23

Agency Responses 2

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