Santa Barbara County Grand Jury
• 2020-2021
• Agency Response
Response to:
DEATHS IN CUSTODY IN 2019: Santa Barbara County
Santa Barbara County Stations Bill Brown Sheriff - Coroner Headquarters Buellton*
⚠️ 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 8 findings
F1
BI was accepted into the Main Jail despite his potentially life-threatening condition and inability to walk. Response: Agree.
Related Recommendations (1)
R1
That the Santa Barbara County Sheriff enforce the policy regarding not admitting inmates to the Main Jail with life threatening medical conditions. Response: Has been implemented. WellPath provided updated training to reinforce the requirement of refusing admittance to inmates with potentially life-threatening conditions. reinforce
F2
When the on-call physician was unable to be reached on April 12, 2019, at 2:30 p.m., the inmate was not transferred to the local hospital emergency room. Response: Agree.
Related Recommendations (1)
R2
That the Santa Barbara County Sheriff require all medical staff be instructed to transfer inmates to the local hospital emergency room when there is an emergency that is a life threatening or serious injury or illness and the on-call physician does not respond. <b>Response:</b> Has been implemented. WellPath provided updated training to reinforce the requirement of immediate transfer to local hospital emergency room for inmates with potentially life-threatening conditions, if the on-call physician is unavailable.
F3
When the blood sugar level was determined to be 587mg/dl at 5:00 p.m., and the on-call physician did not respond, the inmate was not sent to the emergency room. Response: Agree.
Related Recommendations (1)
R3
That the Santa Barbara County Sheriff ensure that medical staff follow policy and procedures when the on-call physician does not respond. <b>Response:</b> Has been implemented. WellPath provided updated training to reinforce the requirement of immediate transfer to local hospital emergency room for inmates with potentially life-threatening conditions, if the on-call physician is unavailable.
F4
When Wellpath personnel responded to a man down emergency, they did not bring an emergency kit to the scene. Response: Agree.
Related Recommendations (1)
R4
That the Santa Barbara County Sheriff ensure that Wellpath personnel bring an emergency kit whenever they respond to a man down notification. <b>Response:</b> Has been implemented. WellPath has completed training with man-down drills. They have also implemented a debriefing process for all man-down incidents, that focuses on appropriate responses, responsibilities, and equipment protocols. 3.0 C1 Death in Custody June 25, 2019
F5
An inmate suicide threat was not reported to a supervisor. Response: Agree.
Related Recommendations (1)
R5
That the Santa Barbara County Sheriff ensure that all detention facility personnel inform their supervisor of any threats of suicide. <b>Response:</b> Has been implemented. The Sheriff's Office completed in-service training for all Custody staff in Suicide Prevention for the final quarter of 2019. WellPath completed a suicide prevention policy review training with all healthcare staff during the same time period. Both trainings included instruction on the requirement to report all threats of suicide to supervisory staff.
F6
C1's mental illness was not reevaluated for the ten months prior to his suicide. Response: Agree.
Related Recommendations (1)
R6
That Santa Barbara County Board of Supervisors provide psychiatric services to better serve mentally ill inmates in detention. Response: Has been implemented. WellPath implemented new policies which require all psychiatric patients to have face to face visits with the psychiatrist before discontinuation of psychiatric medication. Patients with a serious mental illness diagnosis who refuse medication will be placed on a "special needs" population list. Patients on the special needs list are seen once a month by mental health clinicians. 4.0 D1 Death in Custody October 31, 2019
F7
The radio call of Code 33 did not identify the nature of the emergency. Response: Agree.
Related Recommendations (1)
R7
That the Santa Barbara County Sheriff direct all radio calls for medical emergencies be in plain language, including details of the symptoms encountered such as suicide by hanging, bleeding wounds, suspected overdose, etc. Response: Has been implemented. Sheriff's staff have been directed to utilize "plain language" when radioing medical emergency calls for assistance.
F8
The required Responder Defibrillator (AED) Report was not found in the files provided to the Jury. Response: Agree.
Related Recommendations (1)
R8
That the Santa Barbara County Sheriff ensure that Wellpath test all AEDs monthly and after each use and keep logs of the dates of these checks. Response: Has been implemented. WellPath conducted remedial training for all staff on this topic.
* 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.