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Five Deaths in Eleven Months at California Jail Spark Grand Jury Probe

Five Deaths in Eleven Months at California Jail Spark Grand Jury Probe

A Santa Cruz County, California grand jury investigation concluded that a multitude of breakdowns contributed to the deaths of five jail detainees over an 11-month period between August 2012 and July 2013.

Four of the deaths occurred after the county contracted with the for-profit California Forensic Medical Group (CFMG) to provide health care at the jail as a money-saving measure, but the grand jury panel found the company only partly to blame for circumstances surrounding the deaths. The panel noted in a report released in May 2014 that in several cases, jail guards were just as much or more at fault.

On August 25, 2012, Christy Sanders, 27, died of a massive infection between her lungs and ribs which, according to the Sheriff Coroner’s Office, “had been developing over a period of weeks.” Her lungs reportedly collapsed due to a build-up of pus as a result of the infection; she also had hepatitis C and had repeatedly complained of difficulty breathing. The grand jury said the local hospital at first misdiagnosed Sanders and later corrected the diagnosis, but failed to inform the jail.

Medical staff at the jail told the grand jury they felt that they were providing Sanders with appropriate medical care but “discounted the severity of her complaints, possibly because they had all been exposed in the past to inmates engaging in fraudulent, drug-seeking behaviors. This exposure created a dangerous presumption of inmate deceit that was hard to overcome,” given the inaccurate hospital diagnosis, the report stated.

Sanders had been jailed on a probation violation. Her family filed a wrongful death suit in federal court, which partially settled in November 2014 and remains pending. See: Sanders v. County of Santa Cruz, U.S.D.C. (N.D. Cal.), Case No. 5:13-cv-03205-EJD.

On October 6, 2012, Richard Prichard, 59, died of an acute blockage in a cardiac artery. The grand jury found that even though Prichard was intoxicated at more than twice the legal limit when he was first brought to the jail, he was not put in a monitored detoxification cell, known as a sobering cell. Instead he was placed in open seating for over four-and-a-half hours until he was found dead.

The grand jury panel faulted guards for deciding not to place Prichard in the sobering cell – a special padded room which requires 15-minute checks. The panel was told that “on an extremely busy night, these checks can disrupt officer routines,” and that “nurses were often relieved that their late night medication preparation and distribution rounds were not interrupted by calls to the intake area or sobering cell.”

The report noted “the discretionary nature of this process creates the possibility that staff judgments about inmate monitoring may not always give proper attention to inmates’ health and safety.”

The following month, on Thanksgiving morning, the family of Brant Monnett, 47, was notified by jail officials that two days earlier the Santa Cruz tattoo artist had been found unresponsive in a detoxification cell, given CPR and declared dead. Jail Lt. Shea Johnson said medical staff had cared for Monnett quickly.

“We get a lot of [medical] coverage throughout the night,” Johnson stated. “The program manager was there right away.”

Authorities said Monnett had injuries when he was arrested, but none serious enough to take him to the hospital. A jail nurse assessed his condition and asked about prior drug use, and once it was determined he had recently used drugs, he was seen by a doctor. Monnett was then placed on a “detox protocol” that purportedly included checks by medical staff.

However, roughly 7 hours after his arrest, Monnett displayed what the grand jury report said were “clinical features of early symptoms of methadone overdose. At this point ... he should have been either hospitalized or transferred ... for much closer monitoring.”

His death was “a shocker,” said Susie Monnett, Brant’s stepmother. “Naturally, we want to make sure everything was taken care of in the way it should have been.”

On January 11, 2013, Bradley Dreher, 47, was arrested on a felony charge of making criminal threats stemming from a failed attempt to obtain prescriptions for Valium and Xanax at a local clinic. After being examined at a hospital, he was returned to the jail and placed in isolation after making statements about his inability to get along with other prisoners. Two days later he was found dead in his cell with a bed sheet tied around his neck.

Lastly, on July 17, 2013, Amanda Sloan, 30, was found hanging in her cell three days after she had been told she would lose custody of her three children due to her arrest on weapons charges and firing a gun at police. The grand jury report said guards found a poster covering a large hole in her cell wall, exposing an interior pipe to which she had tied a handmade noose. Authorities stated they also found a meth pipe and a razor blade that she had hidden behind other posters.

The grand jury panel faulted the guard on duty for falsifying records about monitoring Sloan every hour as required, noting the log for that night indicated the guard had checked on her five different times, though the video record for the unit showed only one safety check had been performed. The grand jury also pointed out the failure of jail staff to enforce regulations that prohibited posters in the cells, some of which, the report said, blocked views of the prisoners inside.

“In all of the in-custody death cases, we identified failures at critical points in the process. In some instances, individuals were incorrectly classified or not properly monitored. In others, inadequate treatments were applied,” the 19-member panel concluded.

“Certainly, at points, we were pretty shocked,” said grand jury foreperson Nell Griscom, who indicated four of the five deaths were preventable. “But we’re really hoping that with the improvements they’re already making over there, and with our suggestions, we’re hoping they’re going to be able to prevent most, if not all, in the future.”

The deaths also shocked the local community, prompting protest marches and calls for reform. “Some called for an independent investigation by an outside agency. Others noted that all but one of these deaths occurred after CFMG had assumed responsibility for medical care at the jail. Because of the reported controversies and lawsuits surrounding CFMG, the County Board of Supervisors’ decision to outsource medical care came into question,” the grand jury noted.

On April 6, 2013, the Santa Cruz activist group Sin Barras and other organizations staged a protest march which ended with speeches criticizing conditions at the jail and the decision to hire CFMG to supply prisoner medical care. The company has been criticized for providing poor healthcare services at other jails, including in Monterey County, California. [See: PLN, June 2014, p.1].

The grand jury report noted that the number of deaths at the Santa Cruz County jail over the 11-month period was more than four times the national average. Sixty percent of the jail deaths occurred within the first week of custody, nearly double the national average. Further, three of the five deaths were due to heart attacks or suicides, the two leading causes of in-custody deaths, which was only slightly higher than the national average.

The jail has since taken steps to improve medical care for prisoners, including requiring the police to transport suspects with serious injuries to the hospital before they are booked, but critics contend that’s likely because the potential liability would hurt CFMC’s bottom line.

The grand jury report also stated that while efforts are underway to improve prisoner safety at the jail, they might not be enough.

“New leadership is in place in all areas directly involved in inmate care, including the Corrections Bureau, CFMG, and CIT [Crisis Intervention Team]. New staff members have been hired, and protocols have been reviewed and upgraded,” the report said. “Yet, in spite of these improvements, we believe additional changes in protocols and procedures are needed for the protection of the mental and physical health” of prisoners.


Sources: “Five Deaths in Santa Cruz: An Investigation of In-Custody Deaths,” 2013-2014 Santa Cruz County Grand Jury (May 2014);;;;


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Related legal case

Sanders v. County of Santa Cruz