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How Many Inmate Deaths is too Many?

by Dave Maass & Kelly Davis

San Diego CityBeat

Bernard Joseph Victorianne was a 28-year-old black male with a ticking time bomb in his stomach.

Victorianne was arrested on September 12, 2012, less than two blocks from the San Diego Police Department’s Mid-City station on suspicion of driving under the influence. A week later, he was found dead in his cell—the 60th inmate to die in the custody of the San Diego County jail system since 2007.

Immediately after his arrest, Victorianne was taken to Alvarado Hospital to be treated for alcohol intoxication. Even then, police and medical staff believed the suspect—who was on probation for a number of narcotics offenses—likely had swallowed a bindle of drugs. He was observed overnight, then transferred to the San Diego Central Jail. For the next several days, Victorianne was bounced between sobriety cells, secure units and administrative segregation (a normal housing unit reserved for problematic inmates who need to be separated from the general population) due to his lasting, agitated behavior. He was prescribed Haldol, a powerful anti-psychotic, and anti-anxiety medication.

According to the medical examiner’s report, Sheriff’s deputies couldn’t say exactly when they last saw Victorianne alive. Deputies checked on him in the “early evening” of September 18. He was left unmonitored through the night.

At 4:30 a.m., guards who brought breakfast into his cell found him lying on the floor, naked, but didn’t check whether or not he was conscious. Two-and-a-half hours later, guards began their morning rounds and discovered that Victorianne hadn’t moved. By the time they entered his cell, rigor mortis had begun in his lower extremities.

The official cause of death: methamphetamine toxicity—the baggie had busted in his stomach.

Many questions remain unanswered: Why was Victorianne in an administrative segregation cell rather than a cell where he could be more closely monitored? When exactly did deputies last check on his welfare? Why was he left unobserved overnight when he was suspected to have swallowed a potentially lethal amount of drugs? Why didn’t guards check to see if he was OK when they first entered his cell that morning?

Perhaps most important of all: Did Sheriff’s deputies bring Victorianne to the hospital for the visit scheduled the day before he died? The medical examiner’s report states only that “it was unknown if he attended.”

That information still isn’t publicly known. The Sheriff’s Department declined to answer CityBeat’s questions about Victorianne’s death.

What is known is that Victorianne was the latest casualty in a jail system with one of the highest mortality rates in California.

• • •

Between 2007 and 2012, 60 people died while wards of the San Diego County Sheriff’s Department’s five-jail detention system.

They were 56 men and four women. Thirty-six were white, 15 Hispanic, six African-American, one Korean-American, one Native American and one was a Chinese national. Most suffered from substance abuse and/or mental health issues, and many were transient before their arrest.

Their average age was 46. The youngest was 18—Luis Manuel Lopez from Poway. He was arrested on felony vandalism charges in the fall of 2008, around the time other kids his age would’ve been going off to college. He was transferred from one jail to another, ending up at the George Bailey Detention Facility, where he started displaying symptoms of a cold that rapidly grew worse. When his temperature hit 102 and his heart began beating abnormally fast, Lopez was transferred to UCSD Medical Center. His health continued to decline. After almost two weeks in the hospital, he flat-lined and was resuscitated, but his condition continued to deteriorate; his family chose to withdraw care and ease his suffering with pain killers.

Doctors never determined precisely what killed Lopez. The medical examiner’s report concluded it was “most likely” a bacterial infection that was masked by the antibiotics he received in jail. His death was classified as natural.

The oldest was Thomas Alexander Hough, a senile 72-year-old who was stopped by police for refusing to leave a bus station and then booked into jail for failing to register as a sex offender. Classified as “gravely disabled,” he was first involuntarily committed to a psychiatric hospital before being transferred to the Vista Detention Center. Hough suffered from diabetes, dementia and alcohol dependency, which combined to leave him subject to periods of confusion, seizures and delirium tremens (“the shakes”). At the Vista jail, Hough was a basket case for three days. He nearly choked on a bologna sandwich, had frequent angry outbursts at staff and refused to go outside during his allotted recreation time. On his fourth evening in jail, he stopped breathing and couldn’t be revived. The medical examiner classified his death as natural due to hypertensive cardiovascular disease.

Of the 60 deaths, 31 were classified as natural, which is consistent with national ratios for jail deaths. The other 48 percent were classified as suicides, homicides and accidents.

Of the 16 suicides, most inmates hanged themselves, including 38-year-old Sean Wallace, who’d been in and out of safety cells at the Central Jail because of numerous suicide threats, including an attempt to slice his wrists with a butter knife. On April 23, 2011, he was moved out of a psychiatric unit to a regular administrative segregation cell; 47 minutes later, during medicine call, a nurse found Wallace hanging from a sheet tied to a bed bracket.

Others used less-conventional methods. In 2011, Abraham Clark, a 34-year-old man with a history of mental illness, ingested enough water in a short period of time to send his brain into anoxic shock. In 2009, John Kopkowski, an Ohio man accused of having child pornography on his computer, threw himself head-first off the second tier of his unit at George Bailey. According to the medical examiner’s report, inmates allegedly told Kopkowski he “should end his own life before somebody did it for him.”

There were five homicides in the jail system. In 2010, Jeffrey Dunn, a 23-year-old murder suspect, died of an asthma attack during a fistfight. Russell Hartsaw, a mentally ill 70-year-old arrested on a probation violation, was beaten to death in 2010 by other inmates. Three inmates died at the hands of deputies: Two perished—Jeff Dewall in 2008 and Tommy Tucker in 2009—due to oxygen deprivation when guards attempted to restrain them, and a third, Anthony Dunton, was shot to death in September 2012 after breaking free from his restraints during an MRI examination at UCSD Medical Center.

Then there are the accidental deaths. In jail, accidental deaths aren’t accidental like traffic collisions or slipping and breaking one’s neck. All eight of the “accidental” deaths in San Diego’s jails were drug-related, either overdoses or physical complications due to withdrawal. Some inmates obtained drugs in jail or hoarded medications, such as Mark Johnson. The 42-year-old, who’d just been sentenced to 28 years under California’s Three Strikes law, told his cellmate he’d be getting a “shipment of drugs.” Richard Diaz, a 40-year-old addict, died from a stomach obstruction after three days of seizures and vomiting due to heroin withdrawal.

CityBeat obtained and analyzed all 60 medical examiner investigations. We also compared those narratives against findings by the county’s Citizens Law Enforcement Review Board and documents from multiple wrongful death lawsuits against the county. Sheriff Bill Gore denied interview requests, asking for questions in writing, most of which his office did not answer.

• • •

Sixty dead inmates. Is that low or high? How many dead inmates is too many?

In 2000, Congress passed the Deaths in Custody Reporting Act (DCRA) to help address increasing reports of neglect and abuse in U.S. jails and prisons. Under the act, the Bureau of Justice Statistics (BJS), the research and analytical arm of the U.S. Department of Justice, collects reports from correctional facilities and employs a measurement called the mortality rate to compare facilities. As a formula, it’s the number of deaths divided by a jail or prison system’s average daily population (ADP)—the average number of prisoners in the facility on any given day in a year. This formula allows researchers to accommodate for the high turnover and daily fluctuation in local jail populations. It’s also the metric used by the National Institute of Corrections.

“The reason why we use average daily population is that we want to mirror the method that is epidemiologically sound,” BJS researcher Margaret Noonan says.

In other words, since the Centers for Disease Control and other health organizations use an equivalent mortality rate to calculate deaths for large populations, prison researchers can compare the mortality rates in jails to that of society as a whole. Typically, the mortality rate is expressed in number of deaths per 100,000 people.

For example, in 2010, the United States had a mortality rate of 799 deaths per 100,000 people. Jails in the U.S. had an average mortality rate of 125 deaths per 100,000 inmates. Jails in California had a rate of 162 deaths per 100,000 inmates.

“Deaths occur far less in jail than in the general population,” Noonan says. “It’s because [jail] is a microcosm. It’s a smaller subpopulation of the general population and people cycle in and out so quickly, they’re really not in the population long enough to die.”

The San Diego County jail system’s 11 deaths in 2010 resulted in a mortality rate of 237 deaths per 100,000 inmates—90 percent higher than the national average for jails that year and 46 percent higher than the average for California jails. But, Noonan says, since the rate can fluctuate year to year, it’s important to look at the mortality rate over a number of years.

“We don’t want [the public] to look at a certain rate and say, ‘Wow, that seems really high,’ because what could happen is the following year, San Diego might only have four deaths and then, all of a sudden, their rate is right back to where you would expect it to be.”

San Diego County hit its high in 2009 with 12 deaths, followed by two years each with 11 deaths, then dropping to eight deaths in 2012.

“Deaths can certainly vary dramatically from year to year,” says Dr. Ronald Shansky, a jail health consultant and former medical director for the Illinois Department of Corrections. “Over time they tend to be fairly stable, and it does help to compare to other facilities.”

But there hasn’t been much variation for San Diego’s jails. When the BJS released its statistics for 2000 through 2007, San Diego had the second-highest death rate of California’s large jail systems, with 195 deaths per 100,000 inmates. That rate has increased in the years since. Between 2000 and 2012, San Diego County’s mortality rate was 218 deaths per 100,000, putting the county at the top of the list.

CityBeat independently collected six years’ worth of data—2007 to 2012—from California’s 10 largest county jail systems and analyzed it using BJS’s epidemiological model. Our intent was to compare the most recent data among facilities that are similar in size, population and institutional framework (in other words, the same state-level criminal statutes and similar funding relationships with the state government). Further, records indicated that 2006 was the last year the San Diego County jail system underwent changes to prevent deaths.

Of those 10 jail systems, over that period, San Diego County had the highest average mortality rate: 202 deaths per 100,000 inmates.

The next closest was Riverside County, with 198 deaths per 100,000 inmates and Alameda County with 173 deaths per 100,000 inmates.

How many dead inmates is too many? Here’s one way to look at it:

If 17 fewer people died in San Diego County jails over the last six years, that would make the county about average among California’s 10 largest jail systems (or 147 deaths per 100,000 inmates).

The San Diego County Sheriff’s Department challenged the mortality rate method of measuring deaths, specifically with suicides, claiming that it produces “mathematically exaggerated” numbers. Instead, the Sheriff’s Department pointed to a less accepted method, the “at risk” rate. Instead of using the average daily population, the “at risk” rate divides the number of deaths by the total number of bookings. The theory behind this formula is that everyone who enters the facility is at risk of dying. However, very little research exists based on this type of measurement, and the Sheriff’s Department did not provide scientific evidence to support its position.

It’s easy to see why the department prefers this method. Using booking data from 2007 to 2011 (2012 has not yet been compiled), CityBeat found that San Diego County’s inmate mortality rate was better than the average large jail system in California.

However, the more people who are booked and released, the better the rate looks, and San Diego County has a disproportionately large number of bookings for a jail system its size. The BJS doesn’t use bookings-related data for this very reason—high turnover skews the data.

“Obviously, there are other people that use admissions, and we wouldn’t say that’s wrong, per se—it’s just not the way that we do it,” Noonan says. “We want to follow a model that is more epidemiology based, because we are dealing with mortality data.”

“The Bureau of Justice Statistics has been using the calculation of average daily population for 20 or 30 years or more, and no one complains about it unless they have a higher rate than the national average,” says Lindsey Hayes, project director at the National Center on Institutions and Alternatives.

Numbers, however, offer only a bird’s-eye view, and many experts are cautious to base criticism on numbers alone.

“Probably the most important thing to determine is: Do they have an effective review program,” Shansky says. “Because that’s the only thing that’s going to impact the possibility of reducing deaths.”

The Sheriff’s Department did not express concern about the information CityBeat presented to them and did not recognize its validity even though the numbers were based on a model designed by the Department of Justice, the same branch where Sheriff Bill Gore previously worked as an FBI agent.

“You asked if we were aware of [your] statistics as presented,” Sheriff’s spokesperson Jan Caldwell, herself a former FBI agent, says via email. “Our Detentions Services Bureau regularly meets to examine and review all inmate deaths to ascertain the circumstances of death and ensure all of our policies and procedures were followed. The objectives of this assessment are to thoroughly review and learn from the events, make any necessary changes based on these events and ascertain if the events were preventable. The Sheriff’s Department takes each inmate death very seriously, since we are responsible for their safety and well-being.”

• • •

Several agencies are tasked with overseeing jail facilities in San Diego, but few have paid close attention to the mortality rates.

The San Diego County Grand Jury, a body of citizens who inspect the facilities annually, has rarely mentioned jail deaths in its annual reports. The San Diego County District Attorney reviews all officer-involved deaths in custody, but found that the three that occurred in the last six years were within policy. The main body charged with investigating deaths is the county’s Citizens Law Enforcement Review Board (CLERB), which examines allegations of abuse in custody.

When an unnatural death occurs in jail, the Sheriff’s homicide division writes up an investigative report, which is then reviewed by the Sheriff’s internal Critical Incident Review Board. CLERB also receives a copy and decides whether to conduct its own investigation.

“We are finders of fact,” Lt. Glenn Giannantonio of the homicide division tells CityBeat. “We don’t make any policy-issue recommendations. We just say this is what happened and primarily this is why it happened.”

Since 2007, CLERB has completed 24 in-custody-death investigations. Another seven cases are still under review, says Executive Director Patrick Hunter via email.

Hunter says that CLERB doesn’t normally investigate deaths ruled as natural unless there are extenuating circumstances.

The publicly available results of each investigation are little more than a single paragraph; in no cases did CLERB find wrongdoing on the part of the sheriff. However, CLERB has made a number of policy recommendations, several of which the sheriff has rejected.

In 2008, after the suicide of Adrian Correa, a 21-year-old paranoid schizophrenic who’d threatened to kill himself multiple times, CLERB expressed concern about a breakdown in communication during shift changes.

“Briefings at shift changes in the detention facilities should routinely include information about inmates identified as suicide risks,” wrote Robert Winston, CLERB’s chair at the time, to then-Sheriff Bill Kolender. “A checklist that includes the status of at-risk inmates and the Department’s response plan would enhance continuity of care, monitoring and housing,” Winston wrote.

Earl Goldstein, the Sheriff’s medical director, thanked Winston for his letter but rejected the recommendation, saying that the jail’s suicide rate was low—only four suicides total during the 2007-2008 and 2008-2009 fiscal years (July 1, 2007 through June 30, 2009).

“Based on ... the low incidences of completed suicides in our facilities, it is not practical to add these systems to the current program,” Goldstein wrote.

But Goldstein’s numbers were wrong. There were actually six suicides during that period, and a seventh that happened on July 3, 2009—three days into the next fiscal year.

When inmate Dewall died in 2008 due to excessive restraint, CLERB took nearly three years to issue policy recommendations. By then another inmate, Tommy Tucker, had died due to similar excessive restraint techniques. CLERB did not investigate Tucker’s death.

In 2011, CLERB suggested that the Sheriff’s Department review its training policies and have its tactical team wear numbers on their uniforms so they can be identified when investigators review videotapes. The sheriff conceded to those changes, but denied others.

In a March 2011 letter to the sheriff, CLERB expressed concern that the department did not have formal policies regarding when it would alert CLERB of an inmate’s death, despite county code endowing the board with clear oversight responsibilities. Per state code, CLERB is allowed one year to initiate an investigation; there were cases in 2009 and 2010 that the board didn’t find out about a death in time, Hunter says. CLERB identified five areas where it wanted to be included in the notification process; the sheriff declined all of them.

“We strive to respond with professionalism and a spirit of cooperation to recommendations for improvement to the policies and procedures,” Sheriff’s Department Executive Manager John Madigan wrote in response. “CLERB has significantly contributed to the enhancement [of] these important documents and we appreciate the Board’s insight.”

But, he concluded: “After due consideration, Sheriff Gore respectfully declines to modify the policies and procedures as suggested by CLERB.”

The sheriff did, however, direct the department’s Division of Inspectional Services to notify CLERB of all in-custody deaths.

In questions provided to the sheriff, CityBeat requested further explanation of this decision and how it bodes for transparency and accountability.

“While we appreciate CLERB’s valuable review process, they are not part of the Sheriff Department’s investigatory process and therefore are not contacted,” Caldwell wrote.

Even more inconsistent may be how families are notified of the circumstances of an inmate’s death. When Tucker died in the hospital due to injuries sustained during physical restraint, it was not the Sheriff’s Department that contacted the family; it was representatives of an organ-donation agency. Only after the family received a letter from another inmate describing the incident did they move to press further through a lawsuit. The family of Shane Hipfel, who drowned himself in his cell toilet in 2012, fought for more than a year for information; only after the threat of a lawsuit did the sheriff allow one of the family’s attorneys to view the videotape of the incident.

“We made several verbal requests through various channels to get the videotape, which supposedly shows the incident, but the sheriff’s office refuses to turn it over,” attorney Vince Colella said in an interview in January. “They claimed it’s not their jail policy to do so.... If nothing was done wrong or improper, at least get the family the video so they have closure.”

In mid-March, after CityBeat presented its research to the sheriff, a representative of the family finally was allowed to view the video. A lawsuit is forthcoming, Colella says.

• • •

“Oftentimes I will hear from sheriffs, ‘We’re scratching our head; we’ve had these deaths and we think we have good policies and we didn’t violate our policies,’” says Hayes, a national expert on suicide prevention. “And then I go on-site, and I say, ‘Well, you didn’t violate your policies because you have really bad policies.’”

But, unlike the jurisdictions that invite Hayes in to assess their performance, the San Diego County Sheriff’s Department has yet to acknowledge that its high mortality rate is a problem. True, inmates are a high-risk group: many are longtime addicts, for instance, with myriad health issues as a result of their addiction.

“The analogy is between jail and an emergency room, and a prison is like a doctor’s office,” says Marc Stern, a correctional healthcare consultant and former Health Services Director for the Washington State Department of Corrections. “In jails, people are coming and going all the time; it’s very difficult to operate a jail. It’s hectic and it’s high-risk.”

But, Stern says, San Diego’s high mortality rate is a red flag.

“The best news—if I were writing your article, or if I were investigating this—would be talking to the jail and have them say, ‘You know, we noticed the same thing you did; there’s an unexpectedly high number of deaths and suicides compared to other places, and we are investigating it,’” he says. “That would be kind of the good-news story—to find out that they really are addressing it.”

PART II – Wheels of Force

The diagram looks like two carnival wheels, but it represents the array of options facing San Diego County Sheriff’s deputies when they confront a hostile inmate. It’s part of the “use of force” guidelines issued to guards.

The first wheel is labeled “Suspect’s Actions,” with spokes representing behaviors ranging from “non-compliance” to “active resistance” and “assaultive behavior.” The second wheel is “Deputy’s Response,” with spokes bearing terms such as “verbal directions,” “hands-on control” and “lethal force.” Connecting the wheels is a box that tells the deputy to select a “reasonable response” (underline included) from the second wheel to control the behavior in the first.

Tommy Tucker, a 35-year-old obese inmate in a psychiatric unit at the San Diego Central Jail, spun those wheels on February 22, 2009, and lost his life. His act of defiance: attempting to take a cup of hot water back to his cell while the unit was in lockdown. Within minutes, the perfect storm of brutality—pepper spray, a misplaced chokehold and being handcuffed, facedown on the floor—resulted in his death.

San Diego County has the highest mortality rate among California’s largest jail systems based on data from 2007 to 2012. Tucker was one of 12 deaths in San Diego jail custody in 2009, the highest number of deaths in a single year recorded by the five-facility system during that period.

The official cause of Tucker’s death was anoxic encephalopathy—brain damage due to oxygen starvation. What makes Tucker’s death unique is the secrecy surrounding it.

Tucker’s family in Alabama didn’t know he’d died violently. They were informed through an organ-donation service, which originally had received false information that Tucker died from a traumatic brain injury. It wasn’t until another inmate contacted Tucker’s girlfriend that the family began to suspect foul play. A full 17 months passed before they received the medical examiner’s report. When they read it was a homicide, they hired a lawyer.

“They had no idea,” Alabama-based attorney Stan Morris tells CityBeat. “They weren’t told, ‘Six of the guards jumped your brother and put a carotid hold on him, and then they did this, that and the other.’ They just said he died.”

• • •

A year before Tucker’s death, another obese inmate was mortally injured at the Central Jail. Jeffrey Dewall was acting strangely, running across his cell and banging his head against the wall. Guards pepper-sprayed him, strapped him to a restraint chair, kneed him in the face and held him doubled over for several minutes. When they lifted him, they found he had stopped breathing. Dewall’s family sued and received justice in the form of a $600,000 settlement.

In September 2012, a third inmate from the Central Jail died, but outside of the jail’s walls. Anthony Dunton had been taken to UCSD Medical Center after a fight with deputies. When he broke free of his restraints in the MRI room, deputies first tried TASERs, then shot him twice. Most local news outlets covered the death.

By comparison, Tucker’s death occurred in the dark. Only recently has Tucker’s family learned the details through their lawsuit. In addition to public records, CityBeat was granted access to depositions conducted in December 2012 and video and audio evidence obtained by Morris and his local co-counsel, Julia Yoo, via the discovery process.

Tucker was booked in January 2009 on domestic violence charges. He was placed in a psychiatric unit due to his schizophrenia (he was prescribed two anti-psychotic medications) and a lifelong seizure disorder. He was also obese, asthmatic, visually impaired and partially deaf. One guard testified in his deposition that Tucker normally spoke loudly in a way that could have been mistaken for agitation.

On the day of his death, inmates in Tucker’s unit were ordered to return to their cells because guards needed to transfer a suicidal inmate in another unit to a safety cell. Tucker instead went for a cup of hot water.

The video shows Tucker slowly descending the stairs from the second tier and crossing the empty main floor. He fills his plastic cup with water, returns to the stairs and walks up.

“It’s pretty dadgum obvious this guy is going back to his cell,” Morris says. “There’s not like a door up there where he can go out to a Jack-in-the-Box and get a burger.”

At the top of the tier, Tucker turned as two deputies called to him. According to the initial reports, Tucker cursed and threw hot water at the guard closest to him, but this isn’t clear in the video. The deputy later testified in his deposition that Tucker only tipped his cup forward, splashing water on the ground. The guards claimed they warned Tucker several times to return to his cell, but the inmate took a fighting stance.

The video, however, shows that seconds after the first deputies spoke to him, Tucker turned to flee as a cluster of guards charged up the stairs.

“If you look at what the deputies say actually happened, and time that with the pictures, there’s just not enough time for everything that they say happened to have actually happened,” Morris says. “A total of six deputies basically go up the stairs at a pretty good trot and proceed right to Tucker. Do not pass ‘Go’; do not collect $200. They jumped this guy and—down on the ground, boom. Boom-boom-boom.”

Three guards shot streams of pepper spray at Tucker’s face. Then, using the “swarm” technique, they each grabbed different limbs, with one guard applying a carotid hold, or chokehold. A hood called a “spit sock” was placed over Tucker’s head as deputies pinned him facedown on the floor. They used two sets of handcuffs to chain Tucker’s arms behind his back. When they lifted the inmate, his body was limp. They removed the spit sock and discovered his face was purple.

The guard who used the carotid hold said he held it for only two to five seconds. But when Chief Medical Examiner Glenn Wagner gave his deposition, he described blunt force trauma to the neck, including hemorrhages on the windpipe, muscles, the soft tissue around the thyroid and the carotid body, the nerve ganglion that regulates heart rate.

Wagner testified that the injury was consistent with strangulation, but that alone wasn’t what killed Tucker. It was also the way his breathing was hindered when they laid him on his belly and pulled his arms behind his back. It was also Tucker’s own weight, compounded by that of the guards on top of him. He noted that pepper spray could have caused an asthmatic episode.

“You have anywhere from 1,200 to 1,800 pounds or portions thereof being applied to a person who just by their own weight is going to have a problem,” Wagner said in his deposition. “Then you supersede that with the pepper spray, a carotid hold, which may be either a blood choke or an air choke, depending on how it’s applied, plus his general excitement and the epinephrine and norepinephrine. We know, from the autopsy, that he has an enlarged heart. So you’ve got [cardiac disease] setting the stage for the heart failing, you’ve got the lungs that are failing already and we’ve got a number of things going on, some of which he’s contributing to by the nature of his body and some things that are being contributed to by the circumstances that brought about his collapse.”

The guards said they rolled Tucker on his side into a “recovery” position while waiting for medics. However, the first nurse on the scene said in his deposition that Tucker was on his stomach and remained that way for at least another two minutes before being uncuffed and rolled onto his back.

These details weren’t caught on video, except for personnel running up and down the stairs, then carrying down Tucker’s body in a stretcher.

• • •

The San Diego County District Attorney’s office issued a review letter, as it does for all law enforcement-related homicides. Relying primarily on the Sheriff’s Department’s own investigation, the DA concluded the deputies “acted reasonably under the circumstances.” But the letter is rife with inaccuracies, including reporting Tucker’s age wrong by five years and his date of arrest off by a month. The letter claims Tucker threw the entire cup at the deputy and states that another deputy tried, but failed, to apply the carotid hold. Omitted from the narrative is how Tucker was returning to his cell when the confrontation began.

CLERB didn’t investigate Tucker’s death. CLERB’s executive director, Patrick Hunter, didn’t respond to questions about Tucker, but acknowledged that between 2009 and 2010, the Sheriff’s Department had failed to notify CLERB of several inmate deaths, leading the board to demand that the department amend its policies. The demand was refused.

Mark Lim, the inmate who contacted Tucker’s girlfriend, also sent a letter to the San Diego Union-Tribune, asking then-metro editor Lorie Hearn to “shine light” on the “murder.” The Sheriff’s homicide division intercepted the correspondence: A detective re-interviewed Lim—a Marine awaiting trial for murder—and asked why he hadn’t voiced the allegations during the first interview.

Lim answered that guards threatened him. Hearn says she doesn’t recall receiving the letter and would have investigated the death had she seen it.

The Sheriff’s Department referred CityBeat’s questions to the County Counsel, which in turn responded that it does not comment on ongoing litigation. However, Jan Caldwell, the sheriff’s public affairs officer, did add a remark about psychiatric inmates at the end of an email.

“I believe it is important to note our jail system provides not only excellent medical screening and care, but mental health resources to assist inmates re-enter society well-functioning after their sentences are completed,” Caldwell writes. “The Sheriff’s Department is one of the largest providers of mental health services in the county. At any given time, twenty-five to thirty percent of our inmate population is on psychotropic drugs.

“I hope this information is helpful to you and illuminates the challenges we face every day in caring for a segment of society, who is in the most need of help.”

PART III – Addiction can be Fatal

The last time Shaunda Brummette saw her son, Daniel Sisson, it was in a Vista courtroom late in the afternoon of June 23, 2011. Sisson, a sandy-haired 21-year-old who’d grown up surfing North County beaches, was there to answer to a drug possession charge; Brummette went with him to the hearing.

Sisson had been arrested the week before and posted bail, so he and his mom assumed the court appearance would be routine—he’d plead not guilty and wait for his next hearing.

But that’s not what happened.

Because Sisson was on probation from an earlier conviction—also for drug possession—he was taken into custody. As deputies handcuffed him, he turned to look at his mom.

“It’s the saddest look I’ve ever seen,” Brummette says.

Less than two days later, Sisson was dead. His stay in jail was so short that his autopsy report noted that the ink from his booking fingerprints was still on his fingers. The medical examiner listed the cause of death as asphyxiation from an acute asthma attack, with heroin withdrawal as a contributing factor. A small amount of methamphetamine was also found in his system.

Sisson’s was one of 11 deaths in San Diego County jails in 2011. That year, only Los Angeles County recorded more deaths—19 total—and L.A.’s jail system is triple the size of San Diego’s.

• • •

Alcohol withdrawal, experts say, can
be deadly; cold-turkey withdrawal from opiates, on the other hand, is rarely life-threatening unless an addict has an underlying medical condition—like asthma.

“Somebody who has some other disease, where the stress of withdrawal could make that disease worse, definitely deserves closer monitoring,” says correctional-healthcare consultant Marc Stern. “So, if you know somebody has asthma, and they’re going to go through withdrawal, yes, you have an obligation to monitor them more closely.”

According to the medical examiner’s report, Sisson was last seen alive at 5 p.m. on June 25, roughly 48 hours after he’d been booked into the Vista jail. The report doesn’t say who saw him last.

When Sisson didn’t respond to an 8:10 p.m. welfare check, the report says, deputies entered his cell. By that point rigor mortis had set in, indicating that he’d been dead for at least three hours. A medical examiner investigator found a letter in the cell written by Sisson’s cellmate, addressed “to America,” describing Sisson’s withdrawal symptoms. The report doesn’t go into further detail on the letter; neither does it say whether the cellmate was still in the cell when deputies found Sisson.

Last year, Brummette and her husband, Greg Sisson, filed a lawsuit against the San Diego County Sheriff’s Department. In it, they argue that the jail failed to abide by the California Code of Regulations for correctional facilities, which requires that “health and safety checks” involving “direct visual observation” of each inmate be performed at least hourly.

“They know he has addiction issues, they know he’s detoxed in the past, they know he has asthma and they just throw him in a cell,” says attorney Chris Morris, who’s representing Sisson’s parents.

Lack of close monitoring is a thread that runs through the jail system’s addiction-related deaths. Ronald Scimeca, a 61-year-old homeless chronic alcoholic who’d been arrested for being drunk in public, was booked into the San Diego Central Jail at 10:25 p.m. on May 26, 2009, and suffered a seizure shortly after. He was placed in the jail’s medical observation unit, where, a medical examiner’s report says, inmates are to be checked every 20 minutes. But, according to the report, four-and-a-half hours passed between when Scimeca was last seen alive and when he was found facedown in his bunk. According to the medical examiner’s report, “obvious rigor mortis” had already set in. Across from Scimeca’s cell, the report notes, was a nurse’s station “that is not manned with personnel all the time.”

Ray Mullins, a chronic alcoholic, was vomiting bile in the hours before he died on May 3, 2009. At 3 p.m. that day, he was seen lying facedown on his bed, his arm dangling over the edge, but it was 45 minutes before anyone checked on him. Inmates told a medical examiner investigator that they’d tried to alert deputies to Mullins’ condition but were ignored.

Calvin Cole’s first cellmate complained about the 41-year-old schizophrenic addict’s excessive vomiting, as did a second cellmate. Though Cole had been placed in the jail’s medical unit, it was two other inmates who found him unresponsive—after he’d missed breakfast—and attempted CPR.

Marion Lopez, a heroin addict, died the day she was booked into jail. She laid down in her bunk at 7 p.m., but it wasn’t until 11:59 p.m. that a deputy wondered why her cell door was ajar and found her dead.

While Richard Diaz’s autopsy report notes that a deputy was checking on him regularly, the 40-year-old alcoholic and heroin addict with hepatitis C was repeatedly placed in a top bunk despite suffering from tremors and multiple seizures. He fell out of the bunk twice and was vomiting for three days before succumbing to a stomach obstruction.

• • •

Brummette doesn’t know how long her son had been addicted to heroin. As a teen, he was anti-drug, she says. But a friend’s death when Sisson was 16—from a heroin overdose—threw him into a funk and pushed him toward drugs rather than away from them. He was first arrested for drug possession in January 2010. His final stint in jail was his seventh in less than a year and a half.

Sisson tried to get help, Brummette says. He enrolled in an outpatient program created under Prop. 36, the state law that gives nonviolent drug offenders the option of treatment instead of jail, but it didn’t seem to click. Not long before his death, he told his mom he was having a hard time staying clean. She called around to treatment facilities, looking for something she could afford. She finally had him seen by a doctor who prescribed Suboxone, an opiate-replacement medication that eases withdrawal and diminishes cravings without a high.

In February, Sisson was jailed in Vista on a probation violation. Brummette tried to bring him his Suboxone.

“I went out there to let them know that he was asthmatic and he was on Suboxone,” she says. “I brought the doctor’s note. I brought the medication bottle. They looked at me and said, ‘You know what, we’ll handle it our way.’”

Even though medication-assisted withdrawal from opiate addiction—via drugs like methadone or Suboxone—is considered to be the standard of care by the American Psychiatric Association, the American Society of Addiction Medicine, the National Commission on Correctional Health Care and the Bureau of Prisons, it’s rarely used in U.S. jails. Less than 10 percent are licensed to provide it. This means that inmates who aren’t currently on opiate-replacement therapy when they’re incarcerated can’t start a program while in jail. Only pregnant inmates can start on methadone because withdrawal could threaten the life of the fetus.

In San Diego, inmates who are enrolled in a methadone program prior to being incarcerated have to arrange with their clinic to have their daily dosage brought to the jail. The same policy applies to other opiate-replacement drugs like Suboxone. But while methadone must be administered in a clinic setting, Suboxone can be prescribed by private-practice doctors, who might not have the ability to deliver jail doses.

Bottom line: Jail access to opiate-replacement drugs can prove tricky, says Gretchen Burns Bergman, executive director of the addiction-recovery organization A New PATH. Addicts might not be in the best position to arrange for their own care and might not have anyone on the outside to do it for them. When Bergman’s son was arrested, she was the one who called the clinic to make sure his methadone was delivered to the jail—but first she had to settle some of his past-due bills.

“It’s very difficult for family members to get any clear understanding of what’s available,” she says. “The sad truth is that people arrested for drug charges are treated like criminals, rather than people with a chronic relapsing disorder.”

• • •

The county’s response to the Sisson lawsuit places blame on Sisson for not telling jail medical staff during intake that he was addicted to heroin—and for being an addict in the first place.

“Sisson lied about the state of his health when he discussed his medical background with the intake nurse and due to his continual use of heroin (despite having been placed in a drug treatment program), he underwent withdrawal,” says a motion filed by the county on July 25, 2012, seeking to dismiss the lawsuit.

“No one in the jail put him in this position; rather, it was a course of action he alone initiated,” it goes on to say.

According to the medical examiner’s report, Sisson initially didn’t tell the intake nurse that he was an addict because he didn’t want to be prescribed Vistaril, a sedative routinely given to inmates going through withdrawal. However, 14 hours later, the report says, his withdrawal symptoms were severe enough that he sought help, admitting to jail staff that he used heroin daily.

The report describes his withdrawal symptoms as “moderate”—vomiting, diarrhea, tremors and dilated pupils. He was prescribed Tylenol, the painkiller Naproxen and an anti-nausea medication, and given a small “rescue” inhaler. The autopsy report notes that the inhaler was found on Sisson’s bed, though no traces of its active ingredient, Albuterol, were found in his system.

Brummette says it took months to get her son’s autopsy report. Right now, it’s all the information she has, and it’s left a lot of unanswered questions: Even though Sisson didn’t initially tell staff that he used heroin, the medical examiner’s report says that he’d admitted to it during past jail stays; he’d also suffered an acute asthma attack during an earlier incarceration. So why wasn’t staff aware of his history? Then there’s the fact that the emergency inhaler appeared to have gone unused. Brummette says her son suffered from asthma all his life; he knew when an attack was coming on. And, he normally called her from jail; this time, she didn’t hear from him. She wonders if this is evidence of the severity of his withdrawal.

The county’s response to the lawsuit notes that “whether a visual safety check would have made any difference is speculative at best.” But according to the National Commission on Correctional Health Care, which sets recommended standards for correctional facility health services, “high risk” inmates experiencing drug or alcohol withdrawal—meaning inmates with prior histories of withdrawal complications or seizures, older inmates and/or inmates with a history of major medical or psychiatric problems—should be monitored around the clock or, if that’s not possible, transferred to a hospital.

Sisson was booked into jail on a Thursday. Brummette made plans to visit him that Saturday, but she was too tired when she got home from work. She decided to bump the visit to Sunday. Early Sunday morning she got a phone call, letting her know her son was dead.

“They didn’t say I could come see him; it was just done. It’s like it was nothing.”

PART IV – Suicide in the Cell

Ten men and one woman hung themselves in San Diego County jails during the last six years. They used socks or sheets, stringing handmade nooses from sinks, doors and bunks.

One inmate flung himself headfirst over the second tier of his unit. Two men intentionally overdosed on prescription medication. One drowned himself in a toilet. Another purposefully ingested a large amount of water so quickly that he died from acute water intoxication.

All counted, the San Diego County Sheriff’s Department recorded 16 inmate suicides between 2007 and 2012. Among California counties, only Los Angeles, whose jail system is more than three times the size of San Diego’s, recorded more suicides—24—during that period.

“The sad reality is that a person who is determined to commit suicide will commit suicide, and by using the everyday objects within their reach,” Sheriff’s Department spokesperson Jan Caldwell writes in an email. “We train our deputies to look for signs of distress. However, drinking water would not be a recognizable signal for anyone.”

But for correctional health experts, the county’s high suicide and mortality rates signal something could be wrong in San Diego’s five jails.

As noted above, between 2007 and 2012, San Diego County had the highest mortality rate among California’s 10 largest jail systems. Using the statistical method adopted by the U.S. Bureau of Justice Statistics and the National Institute of Corrections—the number of deaths divided by each jail system’s average daily population—CityBeat also found that San Diego had the second-highest suicide rate among the state’s large jail systems: 54 suicides per 100,000 inmates, more than 60 percent higher than the average.

Caldwell described the BJS methodology as “mathematically exaggerated” and argued that it’s more appropriate to compare the number of suicides with the total number of inmates who pass through the jail system annually. Using that method results in a rate of 2.8 suicides per 100,000 inmates.

“If San Diego County wants to calculate their suicide rate based upon yearly admissions, they’re perfectly free to do so,” says Lindsey Hayes, a suicide-prevention expert with the National Center on Institutions and Alternatives. “But then they cannot compare themselves to others because no one else calculates the rate like that. Clearly, the average daily population rate has its drawbacks, but it’s the purest rate.”

CityBeat obtained and analyzed medical examiner reports, oversight-body findings and jail policies and interviewed family members to put together a picture of how suicides happen in jail.

“When I investigate a jail system that’s had [16] suicides in a six-year period, I tend to find that there were either bad practices or preventable deaths in many of the cases,” Hayes says. “You normally come to the conclusion that not all of those 16 deaths were preventable, but many of them were.”

Hayes says he looks for problems with training, intake screening, inadequate medical and mental health staffing, and whether there are enough officers to do rounds at regular intervals.

“There are usually multiple reasons why these problems exist,” he says. “You don’t have to average two or three suicides a year in your jail system.”

• • •

Blame is a hard thing to place when an inmate commits suicide. In a broad context, jail suicides can be viewed as a product of history, with the de-institutionalization of the mentally ill in the 1960s and ‘70s.

“A lot of people have made the observation or argument that with that change in our mental-healthcare system, a lot of the chronically mentally ill who previously resided in state hospitals are now circulating between the streets and correctional settings,” says Dr. Hal Wortzel, a University of Colorado professor who’s examined suicidal behavior among inmates and recently released inmates. “That may, in part, explain why we see so many suicides in correctional settings.”

Caldwell describes the department’s medical screening and care as “excellent.”

She acknowledges the Sheriff’s Department’s role as one of the county’s largest mental health service providers—roughly a quarter to one-third of inmates are on psychiatric medication, she points out.

For the parents of inmates, blame often turns inward. Shane Hipfel had always been bipolar, but at the end of the summer of 2011, the 39-year-old tutor was off his medication and experiencing violent, paranoid-schizophrenic episodes. In October, he was arrested after attacking a gardener who was mowing the lawn near his window.

Shane’s parents, Wayne Hipfel and Peggy Leder, had been flying back and forth from Michigan, where they lived, staying for weeks at a time to check on their son. They’re haunted by their decision not to bail Shane out of jail.

“I wish to heck I had,” Wayne says. “I thought about it, but I wasn’t really ready to do it, either, because I didn’t know what we were going to do when we got him out.”

In jail, they thought he’d be protected from himself and receive treatment. Shane was a “green-banded” inmate, which meant he wore a fluorescent-green wristband to indicate he was highly assaultive. When his parents visited him, he was covered in bruises and abrasions and expressed fear that someone was going to kill him.

“He would never say who,” Wayne says. “We didn’t know if schizophrenia was going on with him or if somebody was threatening him in jail.”

Shane was sentenced to a three-year term at Patton State Hospital in San Bernardino County, but the transfer was weeks away, if not months. The paperwork allowing psychiatric treatment to begin at the jail also was delayed by a backlog at the court.

New Year’s Day 2012 brought good news: Shane finally had been transferred to the jail’s psychiatric security unit, where he could be medicated.

“Boy, that was the best call we got,” Wayne says. “We were so happy about that.”

The next day, another call came. Shane was on life support after attempting to drown himself in his toilet. He died five days later.

Wayne and Peggy have yet to find closure; there’s just not enough certainty. They remember Shane’s fear, his injuries and how an independent pathologist said his autopsy pointed to homicide. But the pathologist never saw the video that reportedly captured Shane’s death.

A San Diego attorney watched a portion of the video on behalf of the family’s lawyer and said it was clearly suicide, but Wayne wants to see it himself, even if it means going to court.

“If they do show me the video of him, I don’t cherish seeing that, but at least I’ll know.”

• • •

In 2007, the Sheriff’s Department—at the recommendation of the county’s Citizens Law Enforcement Review Board—implemented a new suicide-prevention training program to help staff better identify suicidal inmates. An April 2008 letter from CLERB’s then-chair Robert Winston acknowledged the progress but demanded more after 21-year-old Adrian Correa, a schizophrenic who’d threatened suicide in the past, fashioned a noose out of a blanket and hung himself from the top corner of his bunk.

CLERB’s investigation identified significant gaps in how information regarding at-risk inmates is communicated between guards and support staff. The board advised the Sheriff’s Department to include briefings during shift changes and implement a checklist system so deputies could better keep track of suicidal inmates.

“There is no written guidance on the type of information passed from deputy to supervisor, or from supervisor to supervisor,” Winston wrote.

It took the Sheriff’s Department nearly two years to respond to Winston’s letter.

In his response, Earl Goldstein, the jail system’s medical director, downplayed the problem of suicide in county jails, saying that during a two-year period—July 1, 2007 through June 30, 2009—only four inmates had killed themselves.

His count, however, was off by two. Six inmates killed themselves during that period; a seventh committed suicide on July 3, 2009. In 2010, five people killed themselves in San Diego county jails—the most during the six-year period CityBeat reviewed.

The jail system’s written suicide-prevention policies are brief. They state that, during intake, every inmate is to be asked whether they’ve considered suicide, attempted suicide or been hospitalized for suicidal thoughts. Inmates who answer “Yes” to “Are you feeling suicidal?” are either placed in a safety cell or refused entry to the jail and transported to the county’s psychiatric hospital. After intake, “[a]ll reports of suicidal behavior shall be considered serious,” the policy says.

“Once they’re on suicide watch, rarely does an inmate commit suicide,” Hayes says. “Suicides occur when they’re not identified properly and they slip through the cracks or they’re prematurely released from suicide watch and put back into the population, and then hours, days, weeks later, they commit suicide.”

Sean Wallace is one such example. The 38-year-old had been moved back and forth from a safety cell to the general population several times, a medical examiner’s report notes. He was bipolar and schizophrenic, had repeatedly said he planned to kill himself and had reportedly tried to slice his wrists with a butter knife. On April 23, 2011, 48 minutes after he’d been moved back to the general population, he was found hanging from his bunk by a bed sheet torn into strips.

Hayes says the standard of care is to closely monitor suicidal inmates—every 15 minutes for inmates at moderate risk—keeping in mind how quickly someone can kill himself.

“Someone who is either threatening suicide and seemingly very serious about it, someone who has already attempted suicide—those are folks that almost everyone agrees are at high risk and you can’t afford to put them on a 15-minute level of observation because it only takes three to five minutes to successfully commit suicide.”

For some inmates, the warning signs aren’t as clear. They won’t admit suicidal thoughts to jail staff because they don’t want to be placed in a safety cell, or there will be a triggering event—a bad day in court, an upsetting visit with family—that might push an inmate over the edge. Hayes says he’ll do a “psychological autopsy”—go over an inmate’s medical and psychiatric records, talk to jail staff and family members, basically do everything possible to try to get inside a person’s head.

Connie Jones is trying to do that. She doesn’t want to think her son, Christopher Blenderman, killed himself. The medical examiner categorized Blenderman’s death as an accident, not a suicide, concluding that the 40-year-old overdosed on drugs, but not intentionally.

This doesn’t jibe for Jones. Her son always stuck to his drugs of choice, cocaine and alcohol, but it was the odd combination of meth and heroin that was found in his system. And though he was a longtime addict, “Chris never drugged when he was in jail,” Jones says. “He always went to the top of the class, and I would say, ‘Why can’t you live like this on the outside?’”

Blenderman’s criminal history was tied to his addiction—he’d steal, often from family and friends—to buy drugs.

At the time of his death, he’d been in jail for a year and was facing another year, his mother says. The last time she talked to him, he “sounded forlorn.” She wrote him a letter via the jail’s email system, but it didn’t arrive until the day he died.

Prior to his last jail stint, Blenderman, who was bipolar, had been in Tri-City hospital’s psychiatric ward at least twice, Jones says. The medical examiner’s report says he’d tried to commit suicide in the past, though another part of the report contradicts this, saying that he’d admitted to jail staff that he’d thought about killing himself. Early on Sept. 7, 2012, he was found dead from a lethal combination of meth, heroin and antidepressants and anti-anxiety medication, some of which had been prescribed to him, some of which hadn’t. His cellmate told a deputy that Blenderman had been “hoarding” medication.

In its September 2009 review of the death of James Phillips, a sex offender who took a lethal dose of the antidepressant Doxepin, CLERB noted that other inmates had helped Phillips hoard the medication “in defiance of the jail’s ‘watch take’ program, in which medical staff members watch inmates take their prescribed medication.” The review board didn’t, however, offer any policy recommendations.

Jones wants to find her son’s cellmate, to see what exactly he knew. Like other parents CityBeat talked to for this series, Jones has had trouble getting basic information from the Sheriff’s Department.

She says her son “should have been on watch. They knew he’d been in the psych ward. He was on psych meds. So, if he stopped taking those meds on their watch, and if he used something on their watch, then that is their responsibility.”

PART V – (Un)protective Custody

Sitting in his office at the back of downtown’s Popular Market, Jesse Gonzalez reaches under his desk and pulls out a collection of paper-clipped newspaper articles. One from 2007, in CityBeat, features a photo of his friend Russell Hartsaw. Hartsaw is dressed in black slacks and a black button-down shirt; the wind’s blowing the hair on one side of his head almost straight up.

“If he weighed 160 pounds there,” Gonzales points to the page, “he weighed 130.”

That last part refers to another photo—the one Gonzalez gave an investigator from the District Attorney’s office that shows a much frailer Hartsaw, closer to what he looked like in July 2011 when he was beaten to death by inmates at George Bailey Detention Facility who wrongly believed he was a child molester.

Between 2007 and 2012, 60 people died in San Diego County jails, pushing the inmate mortality rate to the top of California’s 10 largest jail systems. Five of the 60 deaths were labeled homicides and, among those, Hartsaw is the only inmate killed by other inmates. While his death raises questions about how jails house—and protect—their most vulnerable inmates, the last several months of Hartsaw’s life offer a glimpse at a man who was perhaps beyond help but whose myriad problems rendered him virtually ineligible for services.

At 70 years old, he’d spent more than half his life in prison; his longest stint of freedom appears to have been his last eight years, when he decided to try to turn his life around. Rulette Armstead, who was an assistant police chief when she met Hartsaw in 2003, recruited him to talk to her San Diego State University criminal-justice students and served on the board of a nonprofit that Hartsaw was trying to start to help homeless kids.

“I couldn’t find 42 years of experience in text books,” says Armstead, who’s since retired from the police department but is still teaching. “He captivated my students—42 years of his life being locked up in prison.”

But it was a struggle. Hartsaw would tell his friends that prison is better than jail and federal prison is better than state prison. And, it seemed, being locked up was better than freedom.

“He told me, ‘You know, sometimes I think about going out and actually pretending to commit a crime so that I could go back to prison,’” Armstead recalls. “‘I’m out here, I don’t have any friends, nobody invites me to Christmas. In jail, I was around people all the time; I was never lonely.’”

“He was trying to adjust,” Gonzalez says, “but how can you adjust after 40-something years in prison?”

In January 2011, Hartsaw landed back in jail after threatening two people with a stun gun. Court records in that case depict a man who was mentally and physically ill. An inmate roster printed on the day he died says he was supposed to be in protective custody. But, instead, Hartsaw was put into the jail’s general population and into a dorm-like unit with a 6-foot-4, 215-pound gang member who rallied four other inmates to attack Hartsaw.

“That seems to be the critical question—what was he doing in the general population?” says Margaret Dooley-
Sammuli, senior policy advocate on criminal justice issues for the San Diego-Imperial Counties ACLU.

• • •

Hartsaw would tell people that at age 9, he came home from school one day to find his parents, his dog and the family’s mobile home gone. He’d spend the next nine years in foster homes, orphanages and juvenile detention facilities. His long rap sheet—all nonviolent crimes—starts with a conviction for misdemeanor theft in December 1959, seven months after his 18th birthday. In all, he’d go on to spend more than four decades behind bars, mostly in federal prisons in California, Ohio and Washington. Though he’d talk candidly about the harsh realities of prison, some of his crimes—like a clumsy attempt to rob a well-guarded bank—seemed to have a prison sentence, not cash, as the end goal. He and Gonzalez would talk for hours about Hartsaw’s life behind bars.

“I guess he liked it,” Gonzalez says. “He was somebody there.”

On January 7, 2011, roughly eight years after he’d been released from prison, Hartsaw was evicted from Trolley Court, the downtown residential hotel where he’d been renting a tiny room since November 1, 2006. The eviction notice, filed in Superior Court, documented a number of incidents in which Hartsaw acted inappropriately toward staff, concluding, “Several employees have expressed fear for their safety because of you [sic] ever increasing aggression, anger, threats and harassment.”

But, by January 7, Hartsaw was already in jail. The day before, he’d pulled out a stun gun and threatened two Trolley Court employees. He was charged with two counts of making a criminal threat.

Hartsaw’s attorney in that case, Marcee Chipman, declined to speak to CityBeat, citing the upcoming trial of two inmates charged in Hartsaw’s murder, but the court file tells the story of a man in poor mental and physical health. Twice his arraignment had to be postponed because he was too sick to come to court. In late January, a judge recommended that Hartsaw be seen by a jail psychiatrist and, in April, requested that he be evaluated by the Probation Department’s Mentally Ill Offender (MIO) unit, which provides intensive supervision and services to adult probationers with a serious mental illness.

The District Attorney agreed to give Hartsaw probation, so long as he sought anger-management counseling and stayed away from Trolley Court. On May 20, 2011, Chipman filed a statement with the court outlining Hartsaw’s probation options. He’d been rejected by MIO “because of his criminal history, and other undisclosed reasons,” she wrote. She’d tried to get Hartsaw into the county’s Behavioral Health Court, which, similar to MIO, offers mentally ill offenders treatment and other services. He was rejected there, too. He was too old for two other programs.

All Chipman could find was a clinic in Mission Valley where Hartsaw could get counseling and a program in Pacific Beach that offered walk-in services between 9 and 11 a.m., four days a week. Hartsaw didn’t have a car and struggled with public transportation. Gonzalez recalls Hartsaw getting lost during a bus trip to Rolando, even after Gonzalez had given him explicit instructions.

“Unfortunately, there were no county probation-court services available,” Chipman wrote to the judge. “This is the best that I could provide for Mr. Hartsaw.”

Hartsaw was put on probation in late May, but it didn’t last long. Within a month, he was arrested and jailed on a probation violation. While his court file doesn’t say what the violation was, it does note that Hartsaw was homeless.

Gonzalez saw him during the brief time he was out of jail. Hartsaw, who usually wore slacks and a black, button-up shirt, was dressed in shorts and had dyed his hair. “I didn’t recognize him,” Gonzalez says. “I knew he was going over the edge.”

• • •

According to court records and
Hartsaw’s autopsy report, around 9:30 p.m. on July 17, 2011, he asked to be transferred to another quad—basically, a large dorm-style cell—in the jail’s medical unit. He wasn’t getting along with inmates in his quad, he told Deputy David Ulloa.

Ulloa went downstairs, to Quad 101, and asked Mario Lopez for permission to move Hartsaw into his quad. Lopez, a gang member with a rap sheet only slightly longer than Hartsaw’s, was the quad’s leader, or “tank captain.” Lopez later told investigators that Ulloa told him that Hartsaw “had a mouth” and was calling other inmates “punk” and “bitch.” Lopez gave Ulloa the OK to transfer Hartsaw in and, as a reward, received two inmate-welfare kits.

According to a motion by the DA seeking to exclude the Sheriff’s Department from culpability in Hartsaw’s death, “Deputy Ulloa did not have concerns about placing Hartsaw in #101 after speaking with Hartsaw.”

According to the DA’s complaint, after the 12:50 a.m. bed check, Lopez and four other inmates assaulted Hartsaw. Lopez, the complaint alleges, took the lead and, after an initial beating, told other inmates, “It’s not over. Let me show you how it’s done.” Hartsaw was still alive at that point, a witness told police. Lopez, the complaint says, continued to “kick, stomp and jump on Hartsaw’s head and body.” When he was done, the men dragged Hartsaw to the floor near his bunk and made it look as if he’d fallen. But deputies didn’t buy it; Hartsaw’s injuries were too severe. In a court brief, prosecutors describe the damage to his face alone:

“Hartsaw’s face was distorted, his nasal bones were fractured such that his face was concave.”

On July 23, five days after Hartsaw’s death, a deputy intercepted a note from Lopez to another inmate. In it, Lopez refers to himself as a “187”—the state penal code for murder. He refers to a “chomo”—jail slang for a child molester—and says his “obligation was to smash all trash.”

“I took care of a fuck’n chomo that ain’t gon to hurt kids no more,” the note says. He signed it “Evil One.”

How Lopez concluded that Hartsaw was a child molester isn’t clear. Hartsaw’s rap sheet includes a conviction in 1967 for violating California Penal Code 288a, which, back then, involved getting caught giving or receiving oral sex. In an April 6, 2011 letter agreeing to allow Hartsaw to be sentenced to probation, Deputy District Attorney Greg McClain explained why the PC 288a charge shouldn’t factor into the sentencing recommendation.

“What remains of the court file indicates that the case involved consensual conduct between adults that is no longer a violation of California law, but was under the statute as it existed in 1967.”

It’s possible that, if someone took a quick look at Hartsaw’s rap sheet, the 288a could be confused with 288(a)—committing a “lewd or lascivious act” with a child under the age of 14. But, in a court brief, prosecutors dismiss that possibility: “There is no evidence that any defendant saw Hartsaw’s rap sheet or knew the extent of his criminal history.”

Ulloa told prosecutors that Hartsaw told him he was required to register as a sex offender.

Both Armstead and Gonzalez recall that not long after Hartsaw’s release from prison in 2003, he was notified that he needed to register as a sex offender for the 1967 crime. But, both say, he filed a protest with the state Attorney General’s office and was relieved of the requirement.

On April 19, 2013, CityBeat asked the Attorney General’s office whether there’s any record of Hartsaw having to register as a sex offender. We were told on April 26 to file a public records request. By press time, we hadn’t received a response.

A roster of inmates included in the court file shows Hartsaw’s housing status as “protective custody.” According to jail policies, protective custody can be voluntary or involuntary and is reserved for inmates whose lives have been threatened, inmates who are developmentally disabled and inmates who “by virtue of his/her small size, advanced age, or other characteristic may be in danger of abuse from inmates in general population.”

Hartsaw was also classified as “Keep Separate All” (KSA)—“a housing status that further restricts housing options within Protective Custody” (PC), policies say.

The investigative report included with Hartsaw’s autopsy says that he’d insisted on being put in the general population.

Cmdr. John Ingrassia, the Sheriff’s Department’s jail supervisor, said via email that inmates can ask to be removed from both protective custody and “keep safe all” status, “but not all requests are honored.”

Jail Population Management Unit staff “review the requesting / insisting inmate’s history and reason for the PC or KSA status to determine whether or not any changes have occurred to support a decision to return the inmate to general population housing,” Ingrassia explains.

Hartsaw, he says, asked to be removed from PC and KSA, and his request was approved.

The Sheriff’s Department rejected City-Beat’s request for Hartsaw’s inmate file.

• • •

Three of the inmates involved in Hartsaw’s death pleaded guilty to lesser charges—Enrique Huerta and James Houlsen to voluntary manslaughter and John McGrogan to being an accessory to murder. Lopez and a fifth inmate, David Donas, are facing trial.

With prison realignment—Governor Jerry Brown’s plan to reduce inmate overcrowding by shifting responsibility for lower-level felons from state to local control—comes opportunities for counties to take a closer look at who they’re holding in jail and why, says the ACLU’s Dooley-Sammuli.

“Who is a risk to public safety and who can be safely monitored in the community?”

But the services need to be there for tough cases like Hartsaw.

“As awful as what happened in the jail, it’s a problematic finding that the system knew what he needed and told him that he was not going to be allowed to get those services,” she says.

A news brief in the July 20, 2011 issue of the San Diego Union-Tribune mentioned a 70-year-old inmate who’d died at George Bailey Detention Facility, but not by name. Gonzalez knew it was Hartsaw. He wonders if Hartsaw, who’d told Gonzalez he’d had thoughts of killing himself, intentionally violated probation, landed himself back in jail and got into a situation where he knew he’d get killed.

“He couldn’t make it on the outside,” he says. “In my heart, I think he had a death wish.”

Armstead says she’d begged Hartsaw to stay out of custody. “You don’t want to die in prison,” she’d tell him.

“He was tormented,” she says, “and I don’t think he could ever get past that.”

This article was originally published as a five-part series by San Diego CityBeat, from March to May 2013; it is reprinted with permission. The series can be viewed online at: According to San Diego County Sheriff’s Department Commander John Ingrassia, from January through early September 2013 there were 7 prisoner deaths in the county’s jail system, including three suicides.

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