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Lawsuit Filed Over Death of Pepper-sprayed, Mentally Ill California Prisoner

The father and mother of a mentally ill California prisoner who died at the Mule Creek State Prison (MCSP) have filed suit against a host of prison and Amador County, California officials, alleging that their son’s death was the direct result of being pepper sprayed and then deliberately neglected when he displayed obvious signs of pain and mental instability. Some of the pepper spray entered a tracheotomy tube located in a stoma, or hole, in his throat that he had received during an earlier surgical procedure, which he needed to breathe.

The lawsuit, filed in U.S. District Court in Sacramento on September 4, 2014, names 13 prison officials, 20 unnamed staff members, Amador County Sheriff/Coroner Martin Ryan and a Stockton, California funeral home, and alleges they acted improperly in the “untimely and avoidable” death of prisoner Joseph Damien Duran. The complaint claims the defendants denied Duran medical care and then, after he died, covered-up the circumstances surrounding his death by falsifying officials records, cremating his remains and failing to notify his next of kin.

Steven and Elaine Duran contend in court pleadings that California Department of Corrections and Rehabilitation (CDCR) officials violated their son’s rights under the Eighth Amendment, by using excessive force and being deliberately indifferent to his serious medical needs, health and safety, and under the Fourteenth Amendment by failing to notify his family of his death so they could secure proper religious services for his burial. The lawsuit also seeks damages under California state law.

The details described in the complaint and other pleadings read like the lurid narrative of a gothic horror tale.

Duran suffered from mental illness since his teen years, resulting in behavior that led to constant scrapes with the law and California’s prison system beginning as early as 1997. Prison officials, the suit contends, had a well-documented file listing Duran’s mental conditions, the various psychotropic medications he was taking and his known history of suicidal tendencies, suicidal ideation and self-harm.

On August 30, 2013, Duran was back in prison, undergoing an initial health screening at the North Kern State Prison, where he reported to a nurse “that he was hearing voices in his head and that he had thoughts of hurting himself.” Three days later, he gave a note to prison guards that said, “I need 2 speak 2 a phyciatrist [sic]. I am not doing 2 good. I’ll go downstairs if I got to. My head is not clear right now. I’m in pain. I AM SUICIDAL.”

The facility placed Duran on suicide watch and, two days later, transferred him to a mental health crisis bed in a single cell at MCSP, “specifically because of both the high chronic risk and high acute risk of suicide that he posed,” the lawsuit states. “At approximately 7:00 p.m. on September 5, 2013, Duran requested his psychotropic medications but was told it was not yet medication time,” the complaint continues. “At approximately 9:00 p.m., when offered his medications he refused them, delusionally stating ‘I don’t believe those are my meds.’” Duran refused his medication a second time the following morning.

Clinical psychologist Dr. Richard E. Ortigo, the head of Duran’s treatment team, ordered that he remain in mental health crisis bed placement for ongoing evaluation and treatment, noting that although Duran had been relatively calm, compliant and communicative in his interviews the previous day, he was currently “much worse, anxious, agitated, restless, frantic, refusing to cuff up [agree to handcuffs] in order to be removed from his cell for morning rounds.... He has also been refusing his meds and refusing to eat, communicating his belief that his food and medication are poisoned.”

That afternoon, however, CDCR staff psychiatrist Dr. Karuna Anand ordered Duran removed from suicide watch checks every 15 minutes.

“Dr. Anand discontinued Duran’s suicide precautions without adequately determining whether they were no longer required,” the complaint states. “Dr. Anand did not clinically examine Duran before removing him from suicide precautions. She had not received any reports from medical, mental health or correctional staff suggesting that Duran’s condition had in any way improved or changed.”

At 9:00 p.m., Duran initially agreed to receive his medication but then refused to be handcuffed or to close the food port on his cell door. Sgt. Mark Shepard was summoned to deal with the situation, and after giving “non-verbal approval (a nod), but without giving Duran any warning, Officer Roy C. Chavez inexplicably unloaded his oversized MK-9 can of Oleoresin Capsicum pepper spray (‘OC pepper spray’) by spraying it directly at Duran’s face and neck, which were pressed up against the open food port on his cell door,” the lawsuit states. “A significant amount of OC pepper spray went directly into Duran’s throat through his tracheostomy tube.”

The complaint explains that the “MK-9 is a 16.9 ounce nitrogen propelled aerosol delivery device which is trigger operated and which is fully effective at up to 12 feet.”

“Duran immediately began to exhibit the expected signs of physical distress from the OC pepper spray,” the suit alleges, “including reacting to intense pain at his tracheostomy site and having difficulty breathing and further difficulty communicating. Based on these signs of distress, it was obvious that Duran was in need of immediate and emergent medical treatment.” Duran also began spitting up blood; however, none of the guards or medical staff present summoned any aid or provided him with care.

Further, when the prison’s watch commander was summoned, he deliberately decided to not have Duran medically treated. “Lieutenant [Bryan D.] McCloughan arrived and, contrary to CDCR’s rules regarding OC pepper spray decontamination, did not direct his subordinates to decontaminate Duran or to have him be medically treated,” the lawsuit continues. “Instead, the decision was made to leave Duran in his cell and let him deal with the effects of the OC pepper spray himself.”

When a prison doctor ordered Duran removed from the cell and decontaminated and medicated, security staff twice refused to comply. “Despite the doctors’ orders to evacuate Duran from his cell and decontaminate him, Sergeant Shepard, who has no medical training, arbitrarily decided that Duran had sufficiently decontaminated himself and that custody staff should ignore the doctors’ orders.” Later that night, staff observed Duran “put his finger and foreign objects, including food, into his stoma as if to pack a wound. Staff actually observed food protruding from the stoma opening” in his throat.

At 5:07 a.m. the next morning, Duran was discovered on the floor of his cell, unresponsive and not breathing. It took more than two minutes to administer CPR because no one could find the life-saving equipment. “These resuscitation efforts continued for several minutes, but were obviously fruitless ... due to the significant length of time that had already passed,” according to the complaint. “These already fruitless efforts were further frustrated by nursing staff’s fumbling attempts to locate misplaced or absent items such as a CPR backboard and a replacement tracheostomy tube.”

A psychologist who later conducted an independent review wrote that Duran “... put spaghetti and bread in the stoma not to block the windpipe, but to soothe the irritation he felt from the pepper spray, as he made no attempt to conceal the insertion of food in the stoma from the nurse’s view.” However, because the food he had used to stuff his stoma in an effort to ease the pain blocked his airway, the “Amador County Sheriff-Coroner’s Office determined the cause of death to be ‘Asphyxia’ and classified the death as a suicide.”

The lawsuit contends that prison officials ranking as high as the warden then initiated a series of actions to cover up Duran’s death and the circumstances surrounding it in order to avoid negatively influencing an ongoing class-action suit against the CDCR for alleged mistreatment of mentally ill prisoners.

“The circumstances surrounding Duran’s death implicated CDCR’s policies regarding the use of force (including chemical agents and specifically OC pepper spray) against mentally ill inmates, as well as the issue of preventable suicide by mentally ill inmates, both of which were hotly contested issues in Coleman v. Brown, et al., 2:90-cv-0520 LKK DAD, pending in the United States District Court for the Eastern District of California,” the lawsuit alleges. “If it became known that Duran’s death was the result of gratuitous use of OC pepper spray against a severely mentally ill inmate, then that would dramatically underscore CDCR’s problems with its use of force policy as it relates to mentally ill inmates.” The Coleman suit settled in March 2015. [See: PLN, March 2016, p.43].

The complaint also alleges that Warden William W. Knipp was “acutely aware” that Duran’s death could affect the Coleman case, and therefore directed staff to cover up Duran’s death using two strategies. “First, various internally generated and intentionally obscure MCSP investigations and reports were created and/or altered in manners so as to cover up what really happened,” the complaint claims. Second, “officials avoided finding and notifying Duran’s next of kin, his parents Steven and Elaine Duran, of his death,” even though they were listed in the CDCR’s own paperwork, on the official death certificate and in the local telephone directory.

The lawsuit states that in addition, neither the Amador County Sheriff, who took possession of Duran’s body, nor the funeral home which arranged for and carried out his cremation, attempted to notify Duran’s parents about their son’s death. As a result, the family was denied the opportunity to arrange for proper Catholic services and burial. The cremation also eliminated the possibility of a second autopsy, which the complaint says could have produced “forensic evidence in support” of the wrongful death suit.

Duran’s parents were not notified until January 8, 2014, when contacted by a reporter, that their son had died some four months earlier, just three days after his 35th birthday. Their federal lawsuit remains pending, with the district court granting in part and denying in part the defendants’ motion to dismiss on December 7, 2015. They are represented by Sacramento attorney Stewart Lee Katz. See: Duran v. Chavez, U.S.D.C. (E.D. Cal.), Case No. 2:14-cv-02048-TLN-CKD.

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Related legal cases

Coleman v. Brown, et al.

Duran v. Chavez