"every Death in Custody is a Failure" - California Grand Jury Reports

Findings and Recommendations 2 findings

F1

Wellpath electronic medical records established that KP had a long history of substance abuse and severe mental health illness. When the Sheriff's Office custody staff decided to house KP with a cellmate, it did not have access to the full extent of KP's well- established severe mental illness history. Inmates' safety and overall health would be better protected if those making classification decisions had access to inmates' vital medical and mental health information.

Related Recommendations (2)

R1a

That Santa Barbara County and the Santa Barbara County Sheriff's Office promptly request that Santa Barbara County Counsel prepare a legal opinion as to whether, consistent with Federal and California law, Wellpath (or its successors) may provide F . * * critical inmate mental health information to Sheriff's custody staff that have an appropriate need to know that information for inmate housing and programming. Recommendation 1b That if County Counsel determines that Wellpath (or its successors) has any legal authority to provide inmate mental health information, then Santa Barbara County shall amend the agreement between Wellpath and the Santa Barbara Sheriff's Office to provide inmate mental health and substance abuse information sharing on an appropriate need to know basis.

R1b

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That if County Counsel determines that Wellpath (or its successors) has any legal authority to provide inmate mental health information, then Santa Barbara County shall amend the agreement between Wellpath and the Santa Barbara Sheriff's Office to provide inmate mental health and substance abuse information sharing on an appropriate need to know basis.

F2

KP was severely mentally ill, was traumatized by witnessing his cellmate's attempted suicide, and should not have been rehoused alone, back into the same cell.

Related Recommendations (1)

R2

That Santa Barbara County and the Santa Barbara Sheriff's Office ensure that inmates with severe mental illness and suicidal ideation histories receive immediate mental health professional care after they are exposed to traumatizing events, including, but not limited to, the suicide attempt of a cellmate. Ji 🚅 😘

Conclusions 4

CL1

Wellpath electronic medical records established that KP had a long history of substance abuse and severe mental health illness. When the Sheriff's Office custody staff decided to house KP with a cellmate, it did not have access to the full extent of KP's well- established severe mental illness history. Inmates' safety and overall health would be better protected if those making classification decisions had access to inmates' vital medical and mental health information.
CL2

KP was severely mentally ill, was traumatized by witnessing his cellmate's attempted suicide, and should not have been rehoused alone, back into the same cell.
CL3

Responses to Recommendations shall be one of the following: Has been implemented, with a summary of implementation actions taken; Will be implemented with an implementation schedule;
CL4

Requires further analysis, with analysis completion date of no more than six months after the issuance of the report; or Will not be implemented, with an explanation of why.

Agency Responses 2

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 • 3 pages • 5 responses • Score: 0 (+1, 3, -1) View Details ▾

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5 responses to findings and recommendations

F1

Wellpath electronic medical records established that KP had a long history of substance abuse and severe mental health illness. When the Sheriff's Office custody staff decided to house KP with a cellmate, it did not have access to the full extent of KP's well- established severe mental illness history. Inmates' safety and overall health would be better protected if those making classification decisions had access to inmates' vital medical and mental health information.

Response: Agree Score: +1

Wellpath electronic medical records established that KP had a long history of substance abuse and severe mental health illness. When the Sheriff's Office custody staff decided to house KP with a cellmate, it did not have access to the full extent of KP's well established severe mental illness history. Inmates' safety and overall health would be better protected if those making classification decisions had access to inmates' vital medical and mental health information. The Board of Supervisors agrees that inmates' safety and overall health is likely to be better protected if those making classi...

R1a

That Santa Barbara County and the Santa Barbara County Sheriff's Office promptly request that Santa Barbara County Counsel prepare a legal opinion as to whether, consistent with Federal and California law, Wellpath (or its successors) may provide F . * * critical inmate mental health information to Sheriff's custody staff that have an appropriate need to know that information for inmate housing and programming. Recommendation 1b That if County Counsel determines that Wellpath (or its successors)...

Response: Implemented

Score: 0

That Santa Barbara County and the Santa Barbara County Sheriff's Office promptly request that Santa Barbara County Counsel prepare a legal opinion as to whether, consistent with Federal and California law, Wellpath (or its successors) may provide critical inmate mental health information to Sheriff's custody staff that have an appropriate need to know that information for inmate housing and programming. This recommendation has been implemented. The Sheriff's Office requested County Counsel's legal opinion concerning whether Wellpath (or its successor) may disclose mental health information. R...

R1b

That if County Counsel determines that Wellpath (or its successors) has any legal authority to provide inmate mental health information, then Santa Barbara County shall amend the agreement between Wellpath and the Santa Barbara Sheriff's Office to provide inmate mental health and substance abuse information sharing on an appropriate need to know basis.

Response: Will Not Implement

Score: -1

That if County Counsel determines that Wellpath (or its successors) has any legal authority to provide inmate mental health information, then Santa Barbara County shall amend the agreement between Wellpath and the Santa Barbara Sheriff's Office to provide inmate mental health and substance abuse information sharing on an appropriate need to know basis. All parties agree that sharing of protected health information in a correctional setting is allowed when the information is necessary for the health and safety of inmates, individuals or custody staff. Extra privacy protections exist for substan...

F2

KP was severely mentally ill, was traumatized by witnessing his cellmate's attempted suicide, and should not have been rehoused alone, back into the same cell.

Response: Disagree Partially Score: 0

KP was severely mentally ill, was traumatized by witnessing his cellmate's attempted suicide, and should not have been rehoused alone, back into the same cell. Information about KP's mental health status is not known to the Board of Supervisors. However, based on the information presented it is reasonable to believe he was traumatized by witnessing his cellmate's attempted suicide and further assessment and support for KP was warranted. The Board of Supervisors disagrees partially.

R2

That Santa Barbara County and the Santa Barbara Sheriff's Office ensure that inmates with severe mental illness and suicidal ideation histories receive immediate mental health professional care after they are exposed to traumatizing events, including, but not limited to, the suicide attempt of a cellmate. Ji 🚅 😘

Response: Implemented

Score: 0

That Santa Barbara County and the Santa Barbara Sheriff's Office ensure that inmates with severe mental illness and suicidal ideation histories receive immediate mental health professional care after they are exposed to traumatizing events, including, but not limited to, the suicide attempt of a cellmate. This recommendation has been implemented by the Sheriff's Office. The Sheriff's Department reports that Wellpath issued a written directive and conducted training to ensure that inmates are provided with immediate mental health professional care after exposure to traumatizing events, includin...

Sheriff's Office

September 13, 2023 • 5 pages • 4 responses • Score: 0 (+0, 4, 0) View Details ▾

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4 responses to findings and recommendations

F1

Wellpath electronic medical records established that KP had a long history of substance abuse and severe mental health illness. When the Sheriff's Office custody staff decided to house KP with a cellmate, it did not have access to the full extent of KP's well- established severe mental illness history. Inmates' safety and overall health would be better protected if those making classification decisions had access to inmates' vital medical and mental health information.

Response: Disagree Partially Score: 0

Disagree partially with an explanation. The Sheriff's Office agrees that inmate would be better served if custody staff had access to their medical records. Although, in hindsight, it was determined that there were indications in KP's health records, these were not available to custody staff contemporaneous to his death. There was also nothing within the records to establish that KP had been diagnosed with "severe mental illness." <b>

R1b

That if County Counsel determines that Wellpath (or its successors) has any legal authority to provide inmate mental health information, then Santa Barbara County shall amend the agreement between Wellpath and the Santa Barbara Sheriff's Office to provide inmate mental health and substance abuse information sharing on an appropriate need to know basis.

Response: Requires Analysis

Score: 0

Requires further analysis. To the extent such information can be legally shared, additional research would be needed to ascertain if a WellPath contract amendment would be required due to an expanded scope of work. If so, negotiations would then be needed, as well as Board approval and additional funding, once that process was completed. Even with an aggressive schedule, the full implementation of such an information-sharing procedure will likely take 8 to 10 months.

F2

KP was severely mentally ill, was traumatized by witnessing his cellmate's attempted suicide, and should not have been rehoused alone, back into the same cell.

Response: Disagree Partially Score: 0

KP was severely mentally ill, was traumatized by witnessing his cellmate's attempted suicide, and should not have been rehoused alone, back into the same cell. <b>Sheriff's Office Response</b>: Disagree partially with an explanation. At the time he was in custody, there was no indication that KP, who denied mental health issues, was "severely mentally ill," or was "traumatized" by witnessing his cellmate's attempted suicide. KP was not "re-housed," rather he was returned to his assigned cell once the emergency had resolved. It was KP's cellmate who was rehoused. Due to COVID-19 intake quaranti...

R2

That Santa Barbara County and the Santa Barbara Sheriff's Office ensure that inmates with severe mental illness and suicidal ideation histories receive immediate mental health professional care after they are exposed to traumatizing events, including, but not limited to, the suicide attempt of a cellmate. Ji 🚅 😘

Response: Implemented

Scheduled: within 30 days Score: 0

This has been implemented. Immediately following the multi-disciplinary death review, which was conducted within 30 days of KP's suicide, WellPath issued a written directive and conducted training to ensure that inmates are provided with immediate mental health professional care after exposure to traumatizing events, including, but not limited to, the suicide or attempted suicide of a cellmate. Sheriff's custody staff participated in that training, and a recently issued a critical incident follow-up communication directing custody staff to provide inmates so exposed with enhanced observation,...