Geoff Dean Ventura County Sheriff Gary Pentis Sheriff's Office Assistant Sheriff*

Note: Missing finding numbers detected: F4, F9

Comments 7

• CO1 Page 7
  - Grand Jury Report: "A suicide watch was in place for the inmate/decedent." Response: Ms. Stepelton was placed in Level 2 Safety Precautions due to suicidal ideation expressed at booking. A 30 minute monitoring log was established and she was restricted from possessing certain items, such as sheets, and was not allowed to go to the dayroom. "It was determined during intake that the
• CO2 Page 8
  - Grand Jury Report: "The subject was arrested by the SVPD at 8:30 P.M. on August 3, 2012, in her home after she made attempts to evade arrest." According to the Simi Valley Police Department arrest report, they Response: responded to Ms. Stepelton's residence after receiving information she was present at the house; there was an outstanding warrant for her arrest. Ms. Stepelton hid in a closet within the residence in order to avoid arrest. She was eventually located and arrested without incident. Ms Stepelton was transported directly to the Pre-Trial Detention Facility and booked for the warrant. "The VCSD inmate monitoring logs and the CFMG
• CO3 Page 9
  - Grand Jury Report: "Out of forty-eight entries made in the VCSD inmate monitoring logs for the inmate/decedent, there was not one entry of any symptoms of alcohol withdrawal, no mention of illness, and no record of requests for assistance made by the inmate/decedent and others." Response: Deputies are not trained medical professionals and are not expected to note symptoms of alcohol withdrawal or illness; such notations may become speculative in nature. The 30 minute monitoring log was in place because Ms. Stepelton was on Level 2 Safety Precautions due to suicidal ideation expressed in booking, not because she was on an alcohol withdrawal protocol. The monitoring logs are designed to document the actions and statements of the inmate being monitored. In the interactions heard on the Special Housing video, many involve Ms. Stepelton's cellmate. Recording the statements of Ms. Stepelton's cellmate on the monitoring log would not be appropriate. The documentation of medical issues was handled by the CFMG medical professionals. FINDINGS
• CO4 Page 6
  FA-03 - Grand Jury Report: "In her cell, the inmate/decedent experienced diarrhea and other symptoms of withdrawal from alcohol. The inmate/decedent summoned help for breathing difficulties, pain and instability on her feet. No help arrived after several requests." Response: The Grand Jury report lists Reference 5 as support for this statement. Reference 5 is described in the Grand Jury report as "VCSD narrative and audio CD, August 4, 2012". Assuming "VCSD narrative" is defined as those reports written by Sheriff's Office employees after the death, I found only one report that indicates Ms. Stepelton was suffering from diarrhea and other symptoms of alcohol withdrawal. This report was written by Major Crimes investigator, Detective Albert Ramirez. Detective Ramirez' report describes an interview he conducted with Ms. Stepelton's cellmate shortly after the death. In her statement, the cellmate said Ms. Stepelton had diarrhea, was hallucinating, having pains and tremors, problems breathing, and that she had fallen down once in the cell during the course of the day. Most of the above symptoms are associated with alcohol withdrawal, for which Ms. Stepelton was being treated; however, alcohol withdrawal was not the cause of death. Medical staff actually went into the cell and evaluated Ms. Stepelton on four occasions. The psychiatric nurse had a conversation with Stepelton at the cell door during which she answered several questions. Nursing staff administered medications to Ms. Stepelton at the door (they did not enter the cell) on two occasions. None noted anything unusual about Ms. Stepelton's condition. Jail staff provided meals to Ms. Stepelton three times and also visually checked on Ms. Stepelton several times throughout the day. The logs indicate jail staff conducted a
• CO5 Page 2
  Grand Jury Response In Custody Death (May 30, 2013) Page 7 of 13 visual check of Ms. Stepelton about every half hour, a total of 48 checks were recorded on the log during the 23 hours she was in her cell in Special Housing. However, a review of the Special Housing video clearly establishes visual checks were completed much more frequently. At approximately 6:09 p.m., a jail senior deputy entered the cell and spoke with the occupants for a considerable period of time. He also made no notations of anything out of the ordinary. When the Sheriff's Office reviewed the video and audio of the Special Housing area, at the time Ms. Stepelton was found unresponsive, Ms. Stepelton's cellmate could be heard telling the responding deputies that Ms. Stepelton had been having a hard time breathing. This is the only time during the course of Ms. Stepelton's incarceration that the cellmate could be heard making such a comment. In the recording of the interview conducted by Detective Ramirez with Ms. Stepelton's cellmate, the cellmate stated she had told staff that Ms. Stepelton was having a hard time breathing and that she was using a cane due to lack of balance. The Sheriff's Office could find no evidence in the video of the Special Housing area that Ms. Stepelton summoned help for breathing difficulties, pain, and instability on her feet, or that Ms. Stepelton's cellmate informed staff of such conditions. FA-04 - Grand Jury Report: "A suicide watch was in place for the inmate/decedent." Response: Ms. Stepelton was placed in Level 2 Safety Precautions due to suicidal ideation expressed at booking. A 30 minute monitoring log was established and she was restricted from possessing certain items, such as sheets, and was not allowed to go to the dayroom. "It was determined during intake that the FA-05 - Grand Jury Report: inmate/decedent needed monitoring for alcohol withdrawal symptoms and to receive medication for same." Response: Ms. Stepelton was placed on a medical protocol for alcohol withdrawal, and her condition was monitored by medical staff. There is no requirement for a 30 minute monitoring log for inmates on an alcohol withdrawal protocol. However, there was a 30 minute monitoring log established, due to Ms. Stepelton's status on Level 2 safety precautions, and it was followed. . .
• CO6 Page 2
  Grand Jury Response In Custody Death (May 30, 2013) Page B of 13 FA-06 - Grand Jury Report: "The Medical/Special Housing Unit requires a check every thirty minutes by a deputy who should note an inmate's status on a log sheet outside the cell door. This is a visual check from the hallway through the cell window." Response: Not all inmates in Special Housing require a visual check every 30 minutes. Ms. Stepelton required a 30 minute check because she was on Level 2 Safety Precautions due to suicidal ideation, not because she was on an alcohol withdrawal protocol. Her cellmate and many others in Special Housing had no such requirement. FA-07 - Grand Jury Report: "After a routine booking process (approximately 2 plus hours) into the VCMJ, the inmate/decedent was placed in a cell around midnight in the Medical/Special Housing Unit." Response: At booking, Ms. Stepelton was evaluated by a nurse, placed on an alcohol protocol, and placed on Level 2 Safety Precautions for suicidal ideation. Although none of these are uncommon, this would not be considered routine. FA-08 - Grand Jury Report: "At the time of arrest, the inmate/decedent appeared to be intoxicated and the SVPD was informed that she was taking prescription The SVPD indicated the family was concerned about her being medications. incarcerated due to these medical conditions and the possibility of alcohol withdrawal symptoms while in custody." Response: Ms. Stepelton was interviewed by a nurse at booking regarding her medical conditions and was placed on an alcohol withdrawal protocol. FA-09 - Grand Jury Report: "The subject was arrested by the SVPD at 8:30 P.M. on August 3, 2012, in her home after she made attempts to evade arrest." According to the Simi Valley Police Department arrest report, they Response: responded to Ms. Stepelton's residence after receiving information she was present at the house; there was an outstanding warrant for her arrest. Ms. Stepelton hid in a closet within the residence in order to avoid arrest. She was eventually located and arrested without incident. Ms Stepelton was transported directly to the Pre-Trial Detention Facility and booked for the warrant. "The VCSD inmate monitoring logs and the CFMG FA-10 - Grand Jury Report: medical records do not match."
• CO7 Page 2
  Grand Jury Response In Custody Death (May 30, 2013) Page 9 of 13 Response: The recorded times at which medical functions were performed, as noted on the deputy log, often do not match with the times at which CFMG medical personnel documented their findings for the corresponding assessments. The monitoring log is not for medical purposes and is not meant to act as an exchange of medical information between jail and CFMG staff. Medical information is confidential and is for medical personnel only. The functions performed and documented by medical staff are confirmed by the video of the Special Housing area. FA-11 - Grand Jury Report: "Out of forty-eight entries made in the VCSD inmate monitoring logs for the inmate/decedent, there was not one entry of any symptoms of alcohol withdrawal, no mention of illness, and no record of requests for assistance made by the inmate/decedent and others." Response: Deputies are not trained medical professionals and are not expected to note symptoms of alcohol withdrawal or illness; such notations may become speculative in nature. The 30 minute monitoring log was in place because Ms. Stepelton was on Level 2 Safety Precautions due to suicidal ideation expressed in booking, not because she was on an alcohol withdrawal protocol. The monitoring logs are designed to document the actions and statements of the inmate being monitored. In the interactions heard on the Special Housing video, many involve Ms. Stepelton's cellmate. Recording the statements of Ms. Stepelton's cellmate on the monitoring log would not be appropriate. The documentation of medical issues was handled by the CFMG medical professionals.