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San Diego County Jails Still No. 1 in Prisoner Deaths

by Douglas Ankney

On July 3, 2009, the first day that Sheriff Bill Gore assumed operational control of San Diego County’s jail system, a prisoner killed himself. In October 2019, Don Jon Ralph became the 14th person held at one of the county’s seven jails to die during that year, and the 142nd prisoner death since Gore took over – an average of more than one death every month for the past decade. [See: PLN, Nov. 2018, p.46; July 2015, p.38].

A September 2019 investigation by the San Diego Union-Tribune found that the county’s jail mortality rate is the highest of California’s largest county jail systems, with an average rate of 245.6 deaths per 100,000 prisoners since 2009. 

That is far higher than the second-highest rate of 157.7 deaths per 100,000 prisoners in Los Angeles County’s jails. San Diego has seen even higher rates during some years, such as 301.5 deaths per 100,000 prisoners in 2014. 

The county also has the dubious distinction of leading the state in prisoner suicides, with a 10-year average of 74.8 suicides per 100,000 compared to Los Angeles’ 44.3 per 100,000. A 2018 report by the nonprofit Disability Rights Organization (DRO) blamed an over-reliance on incarceration for the mentally ill as well as a failure to provide adequate mental healthcare to those in custody. Effective suicide prevention practices and oversight are especially lacking, the DRO found.

“When someone dies by suicide in a system’s highest level of care, there is enormous cause for concern about whether the system is capable of keeping people safe,” said DRO attorney Aaron Fischer.

Under California law, Gore’s department has 10 days to report in-custody deaths to the state’s Department of Justice. After the Union-Tribune articles, however, the sheriff stopped announcing the deaths publicly – leaving the newspaper to file a public records request every 10 days just to keep a current count.

Homicide detectives investigate every in-custody death, along with the county Medical Examiner’s Office and the Citizens’ Law Enforcement Review Board, which creates a lengthy process. Only once it is complete does the Sheriff’s Department now make the results public.

Until then, all that is known about Don Jon Ralph is that he was a 53-year-old white male who died by “hanging/strangulation” and had a long record of mental health problems extending back to 1992, as well as a criminal record dating to 1999.

At the request of county supervisors Dianne Jacob and Nathan Fletcher, a “best practices” review of county jail operations will be completed in 2020, joining similar reports ordered from at least three other consultants who have studied the jail system since 2017.

“The Sheriff’s Department is committed to keeping inmates safe and is continuously looking for best practices in the delivery of mental health care,” Gore’s office said in a May 2019 video. 

But by September 2019 another dozen prisoners had died in custody, including Jeremy Thomas. The 28-year-old former Marine, who became addicted to opioids prescribed after his hand was blown off in Afghanistan, told jail medical staff he was going through withdrawal symptoms. Instead of treating him they returned Thomas to his cell, where he died.

In another case, a 34-year-old prisoner with a serious heart condition died at the jail after he was given cough syrup instead of his heart medication when he complained of difficulty breathing. Four of the jail deaths in 2019 occurred within just six weeks.

On February 7, 2019, 56-year-old Joseph Castiglione suffocated at the Vista Detention Facility after he was found behaving erratically and deputies shackled him face-down on a gurney, rather than on his side as department policy stipulates to prevent suffocation. An autopsy discovered a baggie of meth had burst in his stomach.

On Valentine’s Day 2019, Michael Wilson died at the Central jail of heart failure. The 32-year-old had been found mentally incompetent to stand trial on 2016 charges; his mother had made repeated requests for her son to be moved to the medical unit because he had a defibrillator implanted to regulate a congenital heart defect. Her request was ignored, and her son died while in the jail’s general population.

Two days later, another prisoner died due to colon cancer. Derek King, 45, who was found incompetent to stand trial, recently had been returned to the jail from a state psychiatric hospital.

On March 18, 2019, 26-year-old Ivan Ortiz tried unsuccessfully to hang himself and was moved to the Enhanced Observation Unit, the jail’s psychiatric unit where its highest level of care is provided to mentally ill prisoners. But he was also allowed to have a plastic bag. Surveillance video showed him climbing under a sheet, where he put the bag over his head and suffocated to death. 

Critics called the deaths part of a long-standing pattern of incompetence, understaffing and neglect, pointing to data from the federal Bureau of Justice Statistics that ranked San Diego County’s jail death rate the state’s highest from 2000 to 2007 – even before Gore became sheriff.

One 2013 arrestee, 26-year-old Robert Lubsen, had bright red ligature marks visible in his booking photo from an earlier suicide attempt, but was not flagged as a suicide risk. He subsequently jumped to his death. Another detainee, an active-duty sailor who had been talked out of jumping from the San Diego-Coronado Bridge in 2016, ended up in the George Bailey Detention Facility in Otay Mesa, where he leapt to his death from a second-story ledge. 

Jail medical staff now ask more pointed and direct questions during the intake process to better assess a prisoner’s risk of suicide. Sheriff Gore has also hired a full-time medical officer and is interviewing candidates for a full-time mental health position. His department hopes to have 24-hour mental health coverage as soon as 15 new positions are filled.

Of course, those reforms won’t help prisoners who die at the hands of jail deputies. After a guard found detainee Paul Silva yelling incoherently at a brick wall, he called for backup. Six deputies eventually used a shield to hold Silva down and were told to “put your body weight on it.” In surveillance video, the 39-year-old schizophrenic can be heard yelling, “No, don’t do it, sir,” before his voice becomes faint and unintelligible as he is tased nine times. He was then transported to the UC San Diego Medical Center, where he lapsed into a coma and died. 

Since 2009, the county has paid $7.9 million to the families of prisoners who died. That figure does not include $12 million paid to a North County prisoner who suffered brain damage from a fall after being booked into the jail system.

“It seems like there are ways for the sheriff’s department to fix the problem,” said Julia Yoo, an attorney representing Silva’s family in a wrongful death suit, “but they don’t, and here we go again.” 



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