Santa Barbara County Bill Brown Stations Sheriff - Coroner Headquarters Buellton

F1

One witness who was at the scene of AB's arrest disclosed to the Jury information about AB that the Jury believes might have helped avoid AB's death if Sheriff deputies or medical personnel had obtained it; however, Sheriff's deputies did not interview this witness. Response: The Sheriff's Office is unable to reasonably respond to this finding, because it has not been provided with the specific information the Grand Jury used as the basis of the finding. What we can state is that several Sheriff's deputies were present at and around AB's residence for approximately 1 ½ hours to investigate the incident. During this time, none of the family members or neighbors present informed the deputies of information that would indicate that AB was suicidal or otherwise at risk of committing suicide.

Related Recommendations (1)

R1

That the Sheriff review and improve training for patrol deputies in responding to calls involving persons who appear to be under the influence of drugs or alcohol, or exhibiting symptoms of mental illness, including questioning persons at the scene who may have relevant information about the subject's condition. Response: This Recommendation has been implemented. The Sheriff's Office and the County of Santa Barbara recognize the importance of improving our collective capability to safely navigate the intersection between the law enforcement function and the prevalence of mental illness within our local communities. This commitment is evidenced by our collaboration with other agencies and individuals in implementing policy development and changes at the state and local level, and in our implementation of programs and training in how to interact with, and help, mentally ill persons who are encountered in the field or who are in our custody. Some examples of this include: Creation of the Sheriff's Behavioral Sciences Unit in 2016. Funding and staffing of a dedicated, full time manager, who is a clinical psychologist, for the Sheriff's Behavioral Sciences Unit in 2018. Providing Crisis Intervention Training for all sworn and dispatch personnel from our agency and other local law enforcement agencies, and many other professional staff members, in 8 hour and 40 hour courses. To date, 580 Sheriff's Office personnel have successfully completed the 8-hour CIT course, which was certified by the California Commission on Peace Officer Standards and Training (POST). Additionally, 56 Sheriff's Office personnel have completed the 40 hour CIT course. In collaboration with the Behavioral Wellness Department (BWD), we developed a pilot in-field Co-Response Team pairing a deputy sheriff with a BWD mental health professional to respond to in-progress calls involving mentally ill people in crisis. The County recently obtained a collaborative grant, of which SBSO is a part, which funds this team for a period of at least 3 years. The Sheriff's Office took the lead in establishing our county's Stepping Up initiative to bring stakeholders from throughout the county together to find ways to reduce criminal justice involvement for the mentally ill. Since 2010 the Sheriff has served as a gubernatorially-appointed commissioner on the • State of California's Mental Health Services Oversight and Accountability Commission. The Sheriff's Office will continue to review and improve its many efforts to develop policy and train its personnel in the proper handling of calls involving mentally ill persons.

F2

The transporting deputy radioed ahead to the Jail that AB was 'combative," without disclosing that AB had engaged in self-harming behavior in the patrol vehicle, which the Jury believes was relevant information for Jail personnel to have in determining whether to arrange an immediate psychiatric evaluation. Response: The Sheriff's Office partially disagrees with Finding 2. As mentioned earlier within this response to the Grand Jury Report, the author of this Report has asserted their subjective opinion that AB had engaged in "self-harming behavior" while in the patrol car. However, AB's aggressive and antagonistic behaviors and verbalizations while in the patrol car were an attempt to get the deputies' attention and express his displeasure with being arrested and/ or with the temperature within the car. The comments were not reflective of an attempt to harm himself. As objective evidence of this, the patrol car video documents AB stating, "I'm not combative. I was upset because you didn't have your window rolled down." (Emphasis added.) Whenever a suspect is unusually aggressive or self-harming, deputies should certainly notify dispatch and dispatch should notify custody personnel that such a suspect is enroute to the jail. Having additional custody staff present to control the suspect can prevent injury to both the suspect and Sheriff's personnel. That was done in this case. However, what is most important is that the arresting deputy or officer communicate any observations or communications with the suspect or witnesses regarding the suspect's mental condition with custody staff, and that custody and medical staff properly screen the suspect for a history of mental illness to determine proper housing.

Related Recommendations (1)

R2

That the Sheriff review and improve training for all deputies in recognizing and accurately communicating to Jail staff any self-harming behavior by detainees. Response: The Sheriff's Office implemented this recommendation prior to the Grand Jury Report. Please see response to Recommendation 2. Furthermore, in December 2018, the Sheriff's Behavioral Sciences Unit worked with WellPath to create a form that assists arresting officers in communicating the need for mental health evaluations with Custody staff, including jail medical personnel. The Sheriff's Office and the County of Santa Barbara recognize the importance of improving our collective capability to respond to and serve mentally ill people within our local communities. The Sheriff's Office is committed to regularly reviewing and improving training in this area.

F3

The WellPath RN failed to follow established procedure requiring that a medical/mental health evaluation be conducted in a private interview room where the arrestee's computerized records are available for immediate reference. Response: The Sheriff's Office partially agrees with the Finding. While we agree that the WellPath RN failed to follow the evaluation procedure, whenever an inmate is unusually aggressive the evaluation should not be conducted in a private interview room. Instead, it should be completed in an area where enough custody staff can be present to ensure everyone's safety.

Related Recommendations (1)

R3

That the Sheriff require the current contract health care provider, WellPath, to assure that its staff adhere to all policies, procedures, and contractual obligations regarding the assessment of the medical/mental health status of arrestees upon their arrival at the jail. Response: The Recommendation was previously implemented. WellPath issued a training bulletin immediately after the incident reinforcing the proper procedure for handling newly admitted detainees who refuse to answer medical/mental health intake screening questions. The Sheriff's Office also issued a directive that included a procedure for identifying newly admitted arrestees that had not been medically screened and the proper procedure for assigning them to temporary housing.

F4

Custody deputies at booking failed to closely examine AB's prior arrest records, which contained information that might have helped avoid AB's death. Response: The Sheriff's Office disagrees wholly with this finding. The information that the Jury contends was available was not available at the time, since it was not contained in databases that were accessible to custody deputies at the time of booking. They were in fact sealed because of the nature of the call for service.

Related Recommendations (1)

R4

That the Sheriff require custody staff to adhere to its booking policies and procedures, specifically informing themselves as to an arrestee's prior arrest records at booking. Response: This Recommendation will be implemented. The Sheriff's Office has been thoroughly engaged in projects that are aimed at integrating data across all the disciplines of County government. One such project is the Accurint Virtual Crime Center (VCC), a dashboard interface that will give Sheriff's Office staff the ability to access records from law enforcement agencies across the State. Custody deputies will be given the appropriate training and access on how to gather information about previous law enforcement contacts that did not result in admission to the Jail, some of which will be records of calls involving mentally ill persons. This will be accomplished when the VCC goes live in Santa Barbara County in the Fall of 2019.

F5

AB was placed in an observation cell monitored by a video camera that failed to show the portion of the cell where AB committed suicide. Response: The Sheriff's Office agrees with the finding.

Related Recommendations (1)

R5

That the Sheriff either discontinue using Cell C-9 or improve the video equipment there to allow a complete view of the cell. Response: This Recommendation has been implemented. A directive has been issued restricting the use of the holding cells in Front Central (the area that includes the location where AB committed suicide) to staging for medical appointments, transportation, and other movements. Furthermore, it was directed that henceforth no inmate is to be left alone in any of the cells in that area.

F6

Sheriff's custody staff and WellPath staff failed to follow "man down" procedures regarding management and control of responding personnel. Response: The Sheriff's Office disagrees partially with the finding. The fact that a large number of staff members responded, arrived and remained on scene during the incident is irrelevant. It does not indicate that those staff members were not properly tasked or managed. The Jury made that determination without the benefit of an audio record, which is not included in the video of the incident. While the appearance of the involvement of a large number of staff members during this incident did not result in a positive outcome during this emergency, there is no evidence that their presence had any adverse effects on the outcome.

Related Recommendations (1)

R6

That the Sheriff require custody staff to receive continued training regarding policies and procedures to be followed in a "man down" situation, particularly to assure proper management and control of the scene and to release personnel no longer needed there. Response: This Recommendation has been implemented. WellPath and Custody staff conduct a debriefing after every "man down" event. In just the first five months this year (Jan - May 2019), there have been 88 "man down" events. Resource management and scene preservation have been covered in many of those debriefings.

F7

Custody staff failed to properly handle and retain evidence for possible need in the event of further investigation and potential litigation. Response: The Sheriff's Office disagrees wholly. The Jury, in its own words, "[...] believes (emphasis added) the item shown in the video was the T-shirt ligature, a potentially important piece of evidence." This "belief" was not substantiated by any fact. To the contrary, eyewitness testimony was obtained by the Jury that refuted that "belief." Absent any additional evidence that would call into question the veracity of the witnesses, there is no substantive reason to come to that conclusion.

Related Recommendations (1)

R7

That the Sheriff require custody staff to properly handle and preserve evidence connected to incidents occurring at the Jail which later may be needed. Response: This Recommendation has been implemented. Custody Deputies are trained in the proper handling of evidence during the Basic Academy. The Sheriff also requires Custody Deputies to periodically be given refresher courses on the proper handling of evidence.

F8

WellPath medical staff and Sheriff custody staff responding to the "man down" announcement was (sic) unaware of the location of life-saving resuscitation equipment and that it was not functional. Response: The Sheriff's Office partially agrees with the finding. Medical and custody staff were aware of the location of the equipment, but once obtained, the suction machine was inoperable.

Related Recommendations (1)

R8

That the Sheriff require WellPath to inspect, repair and replace emergency life-saving equipment on a regular schedule; maintain a service log; and train custody staff regarding the location of life-saving equipment. Response: This Recommendation has been implemented. The resuscitation equipment in question is inspected, repaired, and replaced on a regular schedule. Records are kept of those inspections. In addition, "man down" debriefings are frequently conducted, as previously discussed under Recommendation 6.

F9

The Jail is operating without National Commission on Correctional Health Care (NCCHC) accreditation, contrary to the contract requirement. Response: The Sheriff's Office agrees with the finding.

Related Recommendations (1)

R9

That the Board of Supervisors closely examine the provisions of the existing medical provider contract and enforce all of the current provider's obligations, especially with regard to the continuing failure to obtain National Commission on Correctional Health Care (NCCHC) accreditation for the Jail. Response: This Recommendation has been implemented. The Sheriff, along with representatives from WellPath, are docketed to provide the Board of Supervisors with an annual report of their provision of health care at the Jail, which will include a report of their progress in securing NCCHC Accreditation, on September 17, 2019. CLOSING Any time someone takes their own life, whether inside the jail or elsewhere in our community, it is a tragedy. People take their lives because they believe the only way to end the unbearable pain they feel is to end their lives. They die because they don't have the words to express the deep psychological and biological turmoil they are experiencing, and often their burdens go unnoticed and untreated by others in the community. Although we will never be able to stop all those who are determined to commit suicide from doing so, we in the Sheriff's Office are committed to studying cases such as this one to seek ways that might result in successful preventative measures, more effective future interventions, and positive outcomes. We are determined to do what we can to insure that people in crisis receive proper mental health care and treatment. The Sheriff's Office has reviewed this case and we are committed to making improvements in our procedures, in our policies, in our training and in our equipment, and to do what we can, whenever we can, to safeguard life whenever possible, particularly with those who are in our custody. We understand and respect the Jury's authority and responsibility to conduct its investigations. We view the Grand Jury as a catalyst for quality assurance and improvement, and we are committed to fully cooperating with the sitting and future Grand Juries in their investigations. Lastly, our hearts go out to the family of AB. Mental illness is a pervasive and insidious disease for which relief is, sadly, sometimes elusive. It has a profound effect on others, especially loved ones. On behalf of the men and women of the Sheriff's Office, I extend to them our collective sympathies and condolences. BILL BROWN Sheriff Santa Barbara County COMPLETE THIS SECTION ON DELIVERY SENDER: COMPLETE THIS SECTION A. Signature ■ Complete items 1, 2, and 3. Agent ■ Print your name and address on the reverse X omero ☐ Addressee so that we can return the card to you. B. Received by (Printed Name) C. Date of Delivery Attach this card to the back of the mailpiece, 22/19 8 Sara Romero or on the front if space permits. 1. Article Addressed to: D. Is delivery address different from item 1? Yes If YES, enter delivery address below: ☐ No Honorable Michael J Carrozzo 1100 Anacapa Street Santa Barbara, CA 93121 3. Service Type Adult Signature Adult Signature Restricted Delivery Certified Mail® Certified Mail Restricted Delivery ☐ Priority Mail Express® ☐ Registered Mail™ ☐ Registered Mail Restricte Delivery 9590 9403 0119 5077 0918 01 ☐ Return Receipt for Merchandise ☐ Collect on Delivery ☐ Signature Confirmation™ ☐ Collect on Delivery Restricted Delivery 2 Article Number (Transfer from service label) ☐ Signature Confirmation 1 Mail 7015 0640 0000 0909 5697 Restricted Delivery Mail Restricted Delivery 500) PS Form 3811, April 2015 PSN 7530-02-000-9053 Domestic Return Receipt UNITED STATES POSTAL SERVICE PITE First-Class Mail Postage & Fees Paid USPS CA 9d3 24 ALIG'19 Permit No. G-10 151 F 64 CS Sender: Please print your name, address, and ZIP+4® in this box 4434 Calle Real Santa Barbara, CA 93110 Santa Barbara Sheriff Office Exec office USPS TRACKING# 3-1002-3540 9403 0114 5077 0918 16111114141411114111411114

Santa Barbara County Bill Brown Stations Sheriff - Coroner Headquarters Buellton*

Findings and Recommendations 9 findings