Score: -3 (5/5/8)

Santa Barbara County Grand Jury • 2022-2023

A Death In Custody – Lessons Learned*

Published: July 12, 2023 31 pages

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⚠️ Translation Notice: This content has been automatically translated. The original English text is the official version. Translation may contain errors.

⚠️ Este contenido ha sido traducido automáticamente. El texto original en inglés es la versión oficial. La traducción puede contener errores.

Findings and Recommendations 7 findings

Under the existing agreement between the County and Wellpath, Santa Barbara County does not provide mental health professional care onsite in the Jails from 11 p.m. to 7 a.m. See n 465.

Related Recommendations (1)

Related Recommendations (3)

Whether the custody staff followed Santa Barbara County Sheriff's Office training policies when they employed the on-stomach prone restraint hold on JT. REQUEST FOR RESPONSE Pursuant to California Penal Code Section 933 and 933.05, the Santa Barbara County Jury requests each entity or individual named below to respond to the enumerated findings and recommendations within the specified statutory time limit: Responses to Findings shall be either: Agree; Disagree wholly; or Disagree partially with an explanation. Responses to Recommendations shall be one of the following: Has been implemented, with brief summary of implementation actions taken; Will be implemented, with an implementation schedule; .

R2a

R2b

That by the end of the first quarter of 2023-24, Santa Barbara County amend the existing agreement between the County and Wellpath (or its successors) that requires Wellpath medical staff, when faced with an emergent or urgent mental health case when Wellpath mental health staff is not on duty or available, to be trained on how to obtain outside assistance from a) senior regional Wellpath mental health staff and/or b) an available County Behavioral Wellness Crisis Management Team.

The majority of the Santa Barbara County Sheriff's Office custody staff hired pre-2021 have not been provided 40-hour mental health crisis response training. Although the Santa Barbara County Sheriff's Office offers an advanced mental health 40-hour training course for members of its patrol co-response teams and for Santa Barbara County · . · · ٠. Sheriff's Office custody staff recent hires, it does not mandate this for custodial staff hired before 2021.

Related Recommendations (1)

That by the end of the first quarter of FY 2023-24, Santa Barbara County and Santa Barbara County Sheriff's Office provide funding so that the Sheriff's Office implement effective advanced mental health crisis response training consisting of at least 40 hours of instruction and annual refresher training consisting of at least eight-hours for its custody staff.

F4a

JT's mental health crisis was not adequately evaluated at the local hospital because municipal law enforcement patrol officers did not share with hospital staff available vital information of JT's suicidal threats and ideation.

No recommendations for this finding

F4b

All cities in Santa Barbara County with their own police departments, i.e., cities of Guadalupe, Lompoc, Santa Barbara, and Santa Maria, and the Santa Barbara County Sheriff's Office patrol officers and supervisory personnel would benefit from advanced mental health crisis response training consisting of at least 40 hours of instruction and annual refresher training consisting of at least eight-hours.

No recommendations for this finding

Lawfully shared data collection and analysis among multiple Santa Barbara County law enforcement agencies (Santa Barbara County Sheriff's Office, Santa Barbara County District Attorney's Office, Santa Barbara County Public Defender, Santa Barbara County Probation Department), the municipal police departments in Santa Barbara County (Guadalupe, Lompoc, Santa Barbara, and Santa Maria), mental health (County Behavioral Wellness) and public health (County Public Health) agencies would provide relevant county personnel with better tools to effectively serve community members with mental health illness.

Related Recommendations (1)

That by the end of the first quarter of 2024 Santa Barbara County, the Santa Barbara Sheriff's Office, Santa Barbara County District Attorney's Office, Santa Barbara County Public Defender, Santa Barbara County Probation Department, and all local municipal city councils with police agencies (Guadalupe, Lompoc, Santa Barbara, and Santa Maria), mental health (County Behavioral Wellness), and public health (County Public Health) agencies adopt relevant recommendations for more effective data sharing in the referenced San Diego Association of Governments (SANDAG) study.58

The Santa Barbara County Sheriff-Coroner investigation and the District Attorney's Office review of the medical cause and manner of JT's death that left the Jury with questions: 58 See fn 6. ٠, a) whether within reasonable medical certainty, the custody staff's use of on-stomach prone restraint and JT's vigorous resistance to it was the direct cause of JT's cardiac arrest; and b) whether the custody staff followed Santa Barbara County Sheriff's Office training policies when they employed the on-stomach prone restraint hold on JT.

Related Recommendations (1)

That the County of Santa Barbara and the Sheriff-Coroner's Office request an independent review from the State Attorney General of all facts and circumstances leading up to the death-in-custody of JT, and any legal consequences that result from that review to include the following questions: 1. Whether within reasonable medical certainty, the custody staff's use of on-stomach prone restraint and JT's vigorous resistance to it was the direct cause of JT's cardiac arrest; 2. Whether the custody staff followed Santa Barbara County Sheriff's Office training policies when they employed the on-stomach prone restraint hold on JT.

Agency Responses 3

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

Board of Supervisors

December 05, 2023 • 5 pages • 9 responses • Score: -4 (+2, 1, -6) View Details ▾

PDF

9 responses to findings and recommendations

Under the existing agreement between the County and Wellpath, Santa Barbara County does not provide mental health professional care onsite in the Jails from 11 p.m. to 7 a.m. See n 465.

Response: Agree Score: +1

Under the existing agreement between the County and Wellpath, Santa Barbara County does not provide mental health professional care onsite in the Jails from 11 p.m. to 7 a.m. The Board of Supervisors agrees.

Response: Will Not Implement

Scheduled: FY 2023-24 Score: -1

That by the end of the second quarter of FY 2023-24, Santa Barbara County amend the existing agreement between the County and Wellpath to provide Jail inmates, in both the north and south facilities, with overnight (24/7) mental health professional onsite services. Overnight mental health assistance for jail inmates will begin soon. The Department of Behavioral Wellness recently developed a pilot program to station a mobile crisis team at the jails during the overnight hours to assist with intakes and providing de-escalation and stabilization services in conjunction with Wellpath medical staff...

Response: Disagree Partially Score: 0

Wellpath medical staff do not receive advanced training on mental health crisis intervention, which can be critical in circumstances when mental health staff are not on duty or not otherwise available and is required under a federal court order. Wellpath provides all its staff with mental health-specific training at hire and annually after that, including suicide prevention and risk reduction, which is required per their contract. The Sheriff has indicated that Wellpath is open to incorporating additional trainings in line with the Grand Jury's focus on this issue and will continue to work wit...

R2a

Response: Will Not Implement

Score: -1

That by the end of the first quarter of 2023-24, Santa Barbara County amend the existing agreement between the County and Wellpath (or its successor) to provide all medical staff with advanced 40-hour mental health crisis response training. The current contract agreement does not require modification to accomplish this recommendation as the existing contract provisions allow Wellpath to be trained by both the Sheriff's Office and the Probation Department. The departments are working with Wellpath to explore additional training needs, but in terms of amending the existing agreement, this recomm...

R2b

Response: Will Not Implement

Score: -1

Response: Will Not Implement

Scheduled: Fiscal Year 2023-2024 Score: -1

That by the end of the first quarter of 2023-24, Santa Barbara County and Santa Barbara County Sheriff's Office provide funding so that the Sheriff's Office implement effective advanced mental health crisis response training consisting of at least 40 hours of instruction and annual refresher training consisting of at least eight-hours for its custody staff. The end of the first quarter of Fiscal Year 2023-2024 is too short of a timeline to conduct the analysis needed and determine the level of funding required. But perhaps more importantly, the Board of Supervisors also lacks the authority to ...

Response: Agree Score: +1

Lawfully shared data collection and analysis among multiple Santa Barbara County law enforcement agencies (Santa Barbara County Sheriff's Office, Santa Barbara County District Attorney's Office, Santa Barbara County Public Defender, Santa Barbara County Probation Department), the municipal police departments in Santa Barbara County (Guadalupe, Lompoc, Santa Barbara, and Santa Maria), mental health agencies (County Behavioral Wellness) and public health (County Public Health) agencies would provide relevant county personnel with better tools to effectively serve community members with mental he...

Response: Will Not Implement

Score: -1

That by the end of the first quarter of 2023-24, Santa Barbara County, the Santa Barbara County Sheriff's Office, Santa Barbara County District Attorney's Office, Santa Barbara County Public Defender, Santa Barbara County Probation Department, and all local municipal city councils with police agencies (Guadalupe, Lompoc, Santa Barbara, and Santa Maria), mental health (County Behavioral Wellness), and public health (County Public Health) agencies adopt relevant recommendations for more effective data sharing in the referenced San Diego Association of Governments (SANDAG) study. The County alrea...

Response: Will Not Implement

Score: -1

That the County of Santa Barbara and the Sheriff-Coroner's Office request an independent review from the State Attorney General of all facts and circumstances leading up to the death-in-custody of JT, and any legal consequences that result from that review to include the following questions: 1. Whether within reasonable medical certainty, the custody staff's use of onstomach prone restraint and JT's vigorous resistance to it was the direct cause of JT's cardiac arrest; 2. Whether the custody staff followed Santa Barbara County Sheriff's Office training policies when they employed the on-stomac...

District Attorney

September 13, 2023 • 3 pages • 2 responses • Score: 0 (+1, 0, -1) View Details ▾

PDF

2 responses to findings and recommendations

Response: Agree Score: +1

The Santa Barbara County District Attorney agrees with Finding 5.

Response: Disagree Score: -1

the on-stomach prone restraint hold on JT. The Santa Barbara County District Attorney disagrees wholly with Finding 6(a).

Sheriff's Office

September 13, 2023 • 7 pages • 8 responses • Score: +1 (+2, 4, -1) View Details ▾

PDF

8 responses to findings and recommendations

Under the existing agreement between the County and Wellpath, Santa Barbara County does not provide mental health professional care onsite in the Jails from 11 p.m. to 7 a.m. See n 465.

Response: Agree Score: +1

Agree. <b>

Response: Disagree Partially Score: 0

Disagree partially with an explanation. WellPath disagrees that there is any causal relationship between the training of its staff and patient JT's unfortunate death, which was determined by the medical examiner to have been accidental and due to somatic medical causes, including morbid obesity, dilated cardiomyopathy, acute methamphetamine intoxication, and active resistance. WellPath does not oppose providing additional mental health training to jail medical staff. WellPath does provide all staff with mental health-specific training at hire and annually after that. While this training does ...

R2a

Response: Requires Analysis

Scheduled: first quarter 2024 Score: 0

Requires further analysis. WellPath will work to create more in-depth training for medical staff, which will include de-escalation techniques and crisis intervention. WellPath's Regional Mental Health team will develop this. This proposed training program will not replace the annual mental health training provided at hire and will supplement existing training. The hours needed to train staff will be determined by the regional team. We aim to develop this training by the end of the first quarter 2024.

R2b

Response: Requires Analysis

Score: 0

Requires further analysis. Jail medical staff currently work with the County's Mobile Crisis management team for patients with emergent needs. The Mobile Crisis team will respond to the jail when needed to assist WellPath with patients who require a higher level of care. Medical can request that the team evaluate a patient when WellPath mental health staff are not onsite after contracted hours. Furthermore, the Sheriff's Office and the Department of Behavioral Wellness have come to a collaborative agreement to station both the north and south county Mobile Crisis tea at the Main Jail and the ...

Response: Disagree Partially Score: 0

Disagree partially with an explanation. The Sheriff's Office continually offers advanced mental health 40-hour training for coresponse and certain other patrol and allied staff. Custody staff hired since 2021 have each received 40 hours of CIT training in their Core basic training course. In addition, some other patrol, custody, and dispatch staff have received additional advanced mental health training from 8 to 40 hours. <b>

Response: Agree Score: +1

Agree <b>

Response: Unknown

Score: 0

Agree The County has a committee dedicated to sharing data amongst the criminal justice partners and public health and behavioral health agencies. They report their progress regularly to the Board of Supervisors. We will present the Grand Jury's recommendation to the CJ data-sharing committee for consideration and ask for a response by January 13, 2024.

Response: Disagree Score: -1

Disagree wholly. In this case, the Sheriff's Office concurs with the forensic pathologist's finding of JT's cause of death, which he opined was due to the five factors: morbid obesity, dilated cardiomyopathy, acute methamphetamine intoxication, active resistance, and restraint. His opinion is that all five of those factors acted in synergy, and he emphatically believes that any one of them (i.e., physical restraint, as questioned by the Jury) cannot stand alone as the primary cause of death. <b>

No Responses Found 5

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

Guadalupe City

Lompoc City

Santa Barbara City

Santa Barbara County Public Defender Elected County Office

Santa Maria City

* This report's PDF did not contain easily extractable text and required Optical Character Recognition (OCR) for analysis. There may be minor errors in the extracted findings and recommendations due to OCR limitations with scanned documents.