⚠️ Aviso de traducción: Este contenido ha sido traducido automáticamente. El texto original en inglés es la versión oficial. La traducción puede contener errores.
⚠️ Este contenido ha sido traducido automáticamente. El texto original en inglés es la versión oficial. La traducción puede contener errores.
Findings and Recommendations 11 findings
F01
The request by the inmate/decedent to be transferred to the hospital was written in the psychiatric evaluation conducted at 9:30 A.M. on August 4, and repeated in the nurses’ progress notes at 5:00 P.M. (FA-05-07, 11)
No recommendations for this finding
F02
The Sheriff’s inmate monitoring log, the psychiatric evaluation and the nurses’ progress notes do not match. The psychiatric evaluation and the nurses’ progress notes each record the inmate/decedent’s request to In Custody Death 3 transfer to the hospital. The Sheriff’s log did not contain this request. There were discrepancies in the nurses’ progress notes and the psychiatric evaluation. The main discrepancy showed time differences, hours apart, documenting the request for hospital transfer. (FA-03, 05-07, 10)
No recommendations for this finding
F03
Neither the Sheriff’s monitoring log nor the nurses’ progress notes record the psychiatric evaluation that occurred at 9:30 A.M., August 4, 2012. (FA-02-03, 05-07, 11)
No recommendations for this finding
F04
The SVPD followed procedures and policies during the arrest and transportation of inmate/decedent to the main jail. (FA-08-09)
No recommendations for this finding
F05
The inmate/decedent was determined, during the intake process, to be okay to book and be placed in the Medical/Special Housing Unit. (FA-02, 05-07, 11)
No recommendations for this finding
F06
At the time she died, on August 4, 2012, a contributing factor in the inmate/decedent’s death was a lack of timely medical attention while in custody. (FA-02, 05-07, 11)
No recommendations for this finding
F07
Lack of documentation and its discrepancies led to the inability of staff to adequately assess her condition. The inmate/decedent’s medical chart was incomplete. (FA-02, 06, 07, 11)
No recommendations for this finding
F08
There was a debriefing by the VCSD after the death, but no formal document was written or recorded into the inmate/decedent’s record. (FA-01) Recommendations
No recommendations for this finding
F09
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. [Ref-10]
No recommendations for this finding
F10
The VCSD inmate monitoring logs and the CFMG medical records do not match. [Ref-10]
Related Recommendations (2)
R02
In the interim, the CFMG should review and revise their policies and procedures in conformance with this Grand Jury report. (FI-01-03, 06-07)
R03
The VCSD should have significant oversight requirements of any contracted services to the jails; i.e. supervising their strategic plan, policy and procedures to ensure they meet the mission of the VCSD. (FI-01-03, 06-07)
F11
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. [Ref-5, 11] Findings
No recommendations for this finding
No Responses Found 1
Government entities assigned to respond to this report. No response documents have been linked in our database.
Ventura County Sheriff
Elected County Office