Santa Cruz County Grand Jury
• 2014-2015
Five Deaths in Santa Cruz An Investigation of InCustody Deaths 20132014 Santa Cruz County Grand Jury
⚠️ 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 15 findings
F1
County medical staff in 2012 at the Main Jail did not follow accepted standards of care in treating an inmate with complications arising from intravenous opiate abuse.
No recommendations for this finding
F2
There was inadequate communication between Dominican Hospital and the Main Jail medical staff regarding a critical change in diagnostic information.
Related Recommendations (1)
R1
CFMG and Dominican Hospital should create a formal protocol by which a CFMG contact person at the Main Jail is directly notified of any changes to an inmate’s medical record at Dominican Hospital. (F2, F3)
F3
CFMG’s current procedures may fail to detect diagnostic updates by Dominican Hospital under certain situations.
Related Recommendations (1)
R1
CFMG and Dominican Hospital should create a formal protocol by which a CFMG contact person at the Main Jail is directly notified of any changes to an inmate’s medical record at Dominican Hospital. (F2, F3)
F4
CFMG staff failed to identify and treat symptoms of methadone overdose.
Related Recommendations (1)
R2
CFMG should modify its detoxification protocols and training procedures to enable its staff to recognize and treat cases of methadone overdose. (F4)
F5
CFMG staff at the Main Jail has insufficient oversight and treatment facilities for inmates confined in ‘O’ Unit.
Related Recommendations (1)
R3
CFMG should maintain a higher level of monitoring in the Main Jail’s ‘O’ Unit, which should contain at least one hospital bed with monitoring equipment and video/audio surveillance accessible by medical staff. (F5)
F6
Corrections Bureau and CFMG policies differ over when to call CFMG staff for intake screening of inebriated individuals at the Main Jail.
Related Recommendations (1)
R4
Corrections Bureau policy should align with CFMG policy calling for CFMG staff to examine all inmates brought into the Main Jail who are inebriated or detoxing to any degree. (F6, F7)
F7
Corrections Bureau staff at the Main Jail made incorrect judgements regarding the use of monitored housing for inebriated or impaired individuals.
Related Recommendations (3)
R4
Corrections Bureau policy should align with CFMG policy calling for CFMG staff to examine all inmates brought into the Main Jail who are inebriated or detoxing to any degree. (F6, F7)
R7
CIT staff at the Main Jail should be involved in the final determination of monitoring and housing requirements for inmates with mental health conditions. (F7)
R8
CIT staff should be available, in person or by phone, 24 hours a day at the Main Jail to participate in mental health screening, inmate classification decisions, and inmate treatment. (F7, F8)
F8
The availability of CIT staff is not adequate for the proper determination of an inmate’s needs for immediate mental health medication and monitoring during intake at the Main 16 Jail.
Related Recommendations (1)
R8
CIT staff should be available, in person or by phone, 24 hours a day at the Main Jail to participate in mental health screening, inmate classification decisions, and inmate treatment. (F7, F8)
F9
During the period covered by our investigations, CIT had inadequately documented procedures and lax medical record keeping for the mental health care of inmates at the Main Jail.
Related Recommendations (1)
R9
CIT should complete a comprehensive procedural manual of CIT protocols and practices to enable new staff members to perform their jobs without the need for excessive guidance. (F9)
F10
Corrections Bureau regulations for the frequency of cell inspections and the enforcement of rules governing items permitted in cells have not been consistently followed by Corrections Bureau staff at the Main Jail.
Related Recommendations (1)
R5
The Corrections Bureau should have regulations regarding inmate behavior posted in all Main Jail housing units and ensure that these regulations are consistently enforced by every CO. (F10) 17
F11
During the period covered by our investigations, Corrections Bureau protocols and screening practices for individuals entering the Main Jail were insufficient for the interception of illegal drugs.
Related Recommendations (1)
R6
The Corrections Bureau should apply Main Jail screening protocols equally to all visitors. (F11)
F12
CFMG has an extensive catalog of best practices based on decades of experience that are detailed in CFMG protocol manuals and maintained through regular training, review, and audits.
No recommendations for this finding
F13
The addition of a Compliance Officer to the Corrections Bureau staff, and a new regime of accountability, should result in an improvement in regulation compliance and enforcement at the Main Jail.
No recommendations for this finding
F14
CIT record keeping procedures and treatment protocols are undergoing a much needed process of review and improvement.
No recommendations for this finding
F15
CIT has established an improved protocol for gradually transitioning inmates under mental health watch in ‘O’ Unit back into the general population.
No recommendations for this finding
Commendations 1
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CM1C1. We commend the CFMG staff and management for its high degree of dedication and professionalism. (F12) C2. We commend the Corrections Bureau for its addition of a new Compliance Officer. (F13) C3. We commend CIT management and staff for its efforts to improve and fully document its reporting and procedural protocols. (F14, F15)