by Jo Ellen Nott

When the men and women incarcerated in San Diego County jails awoke on October 6, 2022, the biggest news was also the grimmest: Nothing had changed. A fellow detainee had been murdered the night before, but his was the 19th jail death in just over nine months, topping by one the previous year’s count of corpses. And just over a week earlier, a lawsuit filed by eight other detainees — seeking to compel jail reforms to prevent them from becoming victims, too — suffered a procedural dismissal, its merits but briefly addressed.

PLN reported the county had “one of the highest mortality rates in California” nine years ago, which was already six years after covering one of the first big payouts for a wrongful death in a San Diego jail, when Marshawn Washington’s family accepted $400,000 to drop claims that guards hogtied him and watched him die. [See: PLN, Feb. 2007, p.24.]

“This thing is out of control,” said Yusef Miller, an advocate with the North County Equity and Justice Coalition. “We are in a crisis.”

But a “crisis” is a “turning point,” according to the dictionary. So how can it last 15 years? In February 2022, the state auditor reported that San Diego had far more jail deaths over that period than all but one other California county — a total that has since climbed higher, to at least 223 dead men and women. Millions have been paid out for legal claims, the auditor noted, and his report didn’t include a new record settlement in June 2022 for $8.1 million awarded to the survivors of another dead detainee.

Even legislative attempts at jail reform have a hit a wall. A bill shepherded through the state Assembly to address problems driving the jail’s high death rate was one of a handful vetoed by Gov. Gavin Newsom (D) on September 29, 2022. The governor gave procedural reasons, but the move was widely seen as an effort to deflect attacks that he’s “soft on crime” as he eyes a potential presidential run.

“The explanation that the governor gave us was such a betrayal,” Miller declared.

Shawn Mills, the surviving sister of another jail victim, called it “a slap in the face.”

Her brother, 58-year-old Kevin Mills, died at Central Jail in downtown San Diego in November 2020, not long after he was found mentally incompetent to stand trial. She believes his untreated mental illness was a primary contributor to his fatal heart attack. The vetoed bill, AB 2343, could have helped, she thinks, with its requirements to beef up jail mental health services and add a licensed mental health care provider to the Board of State and Community Corrections (BSCC).

It was that expansion of BSCC, an independent agency that sets standards for California prisons and jails, which Newsom cited in issuing his veto. Because “BSCC has had a thirteen-member board since 2013,” he was “concerned” that adding new members “unnecessarily grows the board and could impede its ability to timely carry out its mission.” Mills was unpersuaded.

“You would think [Newsom] would have some kind of compassion for us,” she said, “but then for [him] just to veto it — it’s like you don’t care, it’s like losing my brother again.”

Mills and Miller were among a group who stood outside the downtown San Diego jail to protest Newsom’s veto on October 4, 2022. Joining them was Tammy Wilson, widow of Omar Moreno Arroyo, whose death during a mental health crisis at the jail in January 2021 might have been avoided with AB 2343’s reforms, she said. Also in the group were Sundee Weddle and her daughter, Sabrina. Their son and brother, Saxon, suffered a fatal overdose at the jail in July 2021.

“His cause of death was listed as an accidental overdose,” the mother said. “However, there’s nothing accidental about the amount of drugs inside San Diego jails.”

“I’m so tired of being out here,” added her daughter. “How many people does Newsom want to die before he sees change?”

“Scathing Audit” Prompts
Short-Lived Reform Legislation and Lawsuit

One month after she was elected to represent California Assembly District 79 in April 2021, Dr. Akilah Weber (D), a 44-year-old physician, community activist, and mother, requested an audit of the San Diego County Sheriff’s Department (SDSD). When it was released on February 3, 2022, the audit’s title said it all — San Diego County Sheriff’s Department: It Has Failed to Adequately Prevent and Respond to the Deaths of Individuals in Its Custody.

Signed by Acting State Auditor Michael Tilden, the report noted San Diego is one of the state’s five most affluent counties among those with populations exceeding one million, yet it had the grim distinction of recording the second-most in-custody deaths — 185 — from 2006 to 2020. Only Los Angeles County had a higher total, and it has three times the population.

Orange County, with about as many residents as San Diego County, recorded 40% fewer jail deaths, even though its jail system had an average daily population (ADP) nearly 14% higher. Riverside and Alameda counties, with ADPs 29% to 36% lower than San Diego’s jails, saw 46% to 48% fewer deaths in them.

Another finding that jumps out of the report is the sheer number of bookings into SDSD jails: an average of 85,631 every year. That number dwarfs intakes into any other California jail except Los Angeles. It is over 44% higher than similarly sized Orange County.

So what’s wrong?

“Significant deficiencies in [SDSD’s] provision of care to incarcerated individuals likely contributed to the deaths in its jails,” the report read. “Until [SDSD] implements meaningful change to improve its provision of medical and mental health care in its detention facilities, it will continue to jeopardize the safety and lives of individuals in its custody.”

The San Diego Union Tribune called the report “scathing.” Weber responded by introducing AB 2343, the Saving Lives in Custody Act, which passed the state Assembly on August 30, 2022. Among other mandates, it required individual screening during jail intake by a qualified mental health care professional, at least four hours of mental and behavioral health training for guards every year, at least twelve hours of continuing education in carceral health and mental health care for medical staff annually, and adding to BSCC a licensed health care provider and mental health care provider.

A month later, after the governor’s veto, Weber eschewed an angry response, saying instead she was looking forward to working with Newsom to reintroduce the bill next year.

Like her bill, the recently dismissed suit by jail detainees got a significant boost from the auditor’s report, though originally filed two years before its release. Aided by several law firms, detainees Darryl Dunsmore, Ernest Archuleta, Anthony Edwards, Reanna Levy, Josue Lopez, Christopher Nelson, Christopher Norwood, and Laura Zoerner took Dunsmore’s original pro se complaint and turned it into a putative class-action requesting “nineteen mandatory injunctions regarding Defendants’ response to emergencies, overdose prevention and addiction treatment, mental health care and clinical input in placement decisions, and meaningful program access for people with mobility disabilities,” as U.S. District Judge Anthony Battaglia later recalled.

The amended complaint, filed after the audit report was released, contained more than 30 sworn declarations by prisoners and jail policy experts describing deficiencies in conditions of confinement. Among them was a disabled veteran who had a stroke in his cell and was ignored after begging for help via the emergency intercom. Another detainee related how his cellmate died on the floor between their beds without jail staff ever responding to repeated calls for assistance, leaving other prisoners to attempt to resuscitate him with CPR and chest compressions, but to no avail. An opiate addict described repeated medical slips submitted and ignored as he unsuccessfully sought medication and counseling for his addiction. A mental health clinician likened housing for suicidal detainees at the San Diego Central Jail to a Game of Thrones dungeon.

Lawsuit Winds Up and
Then Winds Down

At a press conference before a hearing on the injunction request on August 11, 2022, Mills talked about her brother’s mental health issues, which she called well-documented and well-known by SDSD, saying missteps in his mental health treatment at the jail exacerbated the heart failure that killed him.

Another survivor of a dead jail detainee, Deana Serna, recalled her late 24-year-old sister, Elisa, who was allegedly ignored after a fall and left to die on the floor of her cell in Las Colinas Detention Facility in 2019.

“We’re begging for help,” Serna said. “This needs to end.”

Inside the federal court for the Southern District of California, an attorney for the county listed for Judge Battaglia all the changes SDSD had made subsequent to the auditor’s report, including new kiosks in jail housing units supplied with naloxone to reverse opioid overdoses, as well as audits to monitor prisoner safety checks.

Four days later, on August 15, 2022, Battaglia’s ruling began by saying he “fully appreciates the seriousness of the allegations brought by plaintiffs regarding the conditions and high death rates in the San Diego County jail facilities.”

Importantly, the Court also found that Plaintiffs had not failed to exhaust their administrative remedies, a requirement of the Prison Litigation Reform Act (PLRA), 42 U.S.C. § 1997e. Quoting Ross v. Blake, 578 U.S. 632 (2016), the judge agreed that by failing to respond to grievances, “officials have ‘thwart[ed] inmates from taking advantage of [the] grievance process.’”

In addition, the Court ruled Plaintiffs’ claims were not mooted by the fact some had been released, since “the record contains compelling evidence that Plaintiffs likely will be reincarcerated.” The eight named Plaintiffs “have been incarcerated at the Jail approximately 56 times in total, including Plaintiff Zoerner who has been incarcerated 24 times since 2010,” meaning “this controversy also satisfies the capable-of-repetition prong,” the Court said.

But Plaintiffs’ case was insufficiently pleaded, failing to tie each of the 19 requested injunctions to an injury they faced or to a constitutional obligation that Defendants failed to meet, Battaglia said. Because “Plaintiffs fail[ed] to connect the dots for the Court,” therefore, their injunction motion was denied. See: Dunsmore v. San Diego Cty. Sheriff’s Dep’t, 2022 U.S. Dist. LEXIS 145812 (S.D. Cal.).

A similar failure in dot-connecting then doomed the entire suit on September 27, 2022, when Battaglia dismissed the complaint as a “shotgun pleading” that neglected to distinguish which defendant was accused of what count. However, the Court gave Plaintiffs leave to file an amended complaint. See: Dunsmore v. San Diego Cty. Sheriff’s Dep’t, 2022 U.S. Dist. LEXIS 175476 (S.D. Cal.).

Battaglia extended that filing deadline on October 6, 2022, and PLN will report further developments. Plaintiffs are represented by Berkeley attorney Aaron J. Fischer and co-counsel from DLA Piper US in San Diego and Rosen Bien Galvan & Grunfeld, LLP in San Francisco. See: Dunsmore v. San Diego Cty. Sheriff’s Dep’t, USDC (S.D. Cal.), Case No. 3:20-cv-00406.

Short-Staffing Has “Directly
Led to Jail Deaths”

When the state auditor’s report came out, Sheriff Bill Gore abruptly retired, ten months away from the end of his third consecutive term. That left interim sheriff Anthony Ray to ride herd on SDSD, the chief law enforcement agency in the southern California county of over 3.3 million people. As of October 2, 2022, it incarcerated 3,933 people — mostly pretrial detainees — in seven jails.

Women are housed at Las Colinas Detention and Reentry Facility. Men are held at East Mesa Reentry Facility, George Bailey Detention Facility, San Diego Central Jail, South Bay Detention Facility, Facility 8 Detention Facility, and Vista Detention Facility.

The department’s 4,300 employees include some 2,700 deputies, from whose ranks guards are drawn for the county’s jails. But to keep enough eyes watching over so many detainees, SDSD faces an ongoing challenge to recruit and retain guards, leading to massive amounts of overtime paid to those still on the job — over $14 million in 2021 alone.

Meanwhile employment applications to SDSD decreased 25% during 2021 and 36% from 2018 to 2020, according to two members of the County Board of Supervisors (BOS), Joel Anderson and Jim Desmond. They voted along with other supervisors on January 25, 2022, to force SDSD to address staffing shortages, noting that retirements, resignations, recruitment issues, and vaccine mandates will continue to impact staffing levels.

In the last two years, 98 more deputies left SDSD than were hired, including a record 252 who quit or retired in 2021. Another 200 had hung up their uniforms as of June 7, 2022. In response to the staffing crisis, Undersheriff Kelly Martinez implemented mandatory overtime of 12.5 hours every two pay periods in June 2022, in order to maintain minimum staffing levels in jails and courts. At that time there were around 160 open positions.

Martinez’s directive is expected to be temporary because BOS Chairman Nathan Fletcher asked for emergency orders in August 2022 to address staffing issues and overdose deaths in county jails. He wants SDSD to use $11.6 million of its over-one-billion-dollar budget on hiring incentives, pay differentials, and other benefits to new and current employees. The request also includes $200,000 for enhanced body scanning to help identify and halt the flow of drugs into the jails. Fletcher said if SDSD needs supplemental funds, they will be granted.

Longtime SDSD Cpt. Dave Myers, a former candidate for Sheriff,  addressed the overtime issue during his failed campaign to win the seat left open by Gore’s departure. In a press interview he agreed with the need for more guards but criticized Martinez’s directive, saying “[m]andatory overtime only makes matters worse” and calling it “a result of a lack of management oversight.”

“Staffing shortages, in my opinion, have directly led to jail deaths,” Myers declared. “I’ve never seen it so bad throughout my career.”

The staffing problem affects more than jail guards. BOS added hundreds of new health care positions to SDSD’s budget in 2021, but the department has been unable to attract and retain professionals to fill them. In June 2022, there were 523 jail medical staff jobs budgeted but only 324 employees filling them, leaving almost 200 positions unstaffed.

Staffing shortages also exist for contracted psychiatrist and physician positions. Records for the year ending June 2020 showed that of 30 positions budgeted, the actual number of doctors working in the jails varied between 12 and 18 per month, rising by June 2022, but not by enough. The availability of psychiatrists was also limited. From July 2019 to May 2022, SDSD contracted 23 full-time psychiatrists, but often only eight were on-hand, leaving two-thirds of severely mentally ill prisoners without psychiatric supervision or treatment.

Jennifer Alonso signed on as a jail mental health clinician in 2019. But she quit in April 2022, fed up with a wildly unmanageable caseload — up to 160 patients at a time. She also cited the disrespect of guards who continually overruled her treatment decisions with their security concerns. Testifying to the dismal and dangerous conditions mentally ill prisoners endure in SDSD jails, Alonso said:

“I have observed my patients decompensate, suffer in what can only be described as filthy, inhuman conditions and, in some cases, die by suicide. My patients were … put at risk of great harm every day, and I felt powerless to give them the care they need and deserve.”

According to the U.S. Bureau of Justice Statistics and research by the San Diego Union-Tribune, in 2019 — the last year for which data is available — San Diego County jails had a suicide rate of nearly 75 per 100,000, over 50% above the national average of 49 per 100,000.

Citizen’s Law Enforcement
Review Board

Unsurprisingly, the failure to provide adequate health care in its jails has cost the county millions of dollars per year in legal fees, jury awards, and settlements. But before a jail death appears in court documents, it is reviewed by the Citizens’ Law Enforcement Review Board (CLERB), which “independently and impartially investigate[s] citizen complaints” against SDSD deputies and probation officers, also issuing findings and recommendations to the Sheriff and the Chief Probation Officer for policy or procedural change.

Founded in 1990, CLERB’s 11 members are appointed by elected county supervisors from each of their five districts. Members serve voluntarily, with a paid staff including Executive Officer Paul R. Parker, III, a former police officer and medical examiner. Their recommendations are advisory and non-binding. CLERB also cannot impose discipline.

In its 2021 Annual Report, CLERB covered each of the 18 deaths that made 2021 the deadliest year in San Diego jails since 1999. Of those, two were homicides, two were suicides, eight were natural deaths — most from COVID-19 — and six were drug-related, most from fentanyl.

Due to public pressure and concern over the sky-high death rate in county jails, CLERB published its first-ever semi-annual report in August 2022. Among its key findings was that San Diego jails have the state’s highest number of “unexpected” deaths — the actual number of deaths in excess of the number that biostatisticians would predict.

But CLERB was also taken to task in the state auditor’s report for not investigating nearly one-third of those 185 jail deaths that were counted, saying this left the review board unable to provide effective, independent oversight in those cases.

Parker acknowledged that CLERB has challenges, noting that the board’s effectiveness is sometimes hindered by its own rules, such as a time limit on allegations that prevents investigating any that are over a year old. That alone caused the review board ultimately to dismiss almost 40% of complaints it received in 2021.

CLERB also lacks jurisdiction to investigate allegations of inadequate medical care, leaving the board hamstrung to provide oversight in the 20% of summarily dismissed allegations that were lodged against medical personnel.

“Without jurisdiction over medical staff, CLERB is unable to fully investigate in-custody deaths, great bodily injury cases, and any other allegation against medical personnel,” Parker insisted.

In addition to his efforts to gain that jurisdiction, the Executive Officer promised to work with County Counsel to align CLERB’s rules and regulations with guidelines in the Public Safety Officers Procedural Bill of Rights, which protects guards and other SDSD deputies.

In its two most recent reports, CLERB made 17 recommendations, of which SDSD implemented nine, including a mandate that guards “document and keep a record of video system checks” in jails. After a jail death, a CLERB staffer “with extensive death investigation experience” is also now present. And when “there are no indications or suspicions of foul play,” a jail death case is no longer sealed, which used to be “standard procedure.”

Other proposed policy changes address the use of “technological devices to identify and subsequently aid inmates who may be in medical distress” — think more surveillance cameras and bio-sensors in cells — as well as making naloxone “readily available” to reverse opioid overdoses in jails, and even training detainees how to administer it. Fentanyl, a synthetic opioid, contributed to most overdose deaths in county jails since 2020, so SDSD is also getting a “fentanyl canine to search for contraband” with “sniffs of all persons” entering or inside one of the county’s jails, “include[ing] visitors, inmates, and staff.”

Sheriff’s Department Responds With Purchases of More Tech

The California State Auditor’s report reserved some of its harshest criticism for SDSD’s Critical Incident Review Board (CIRB), an analogue for CLERB inside SDSD which is responsible for reviewing in-custody deaths. Except it doesn’t review deaths by “natural causes,” which accounted for nearly half of all deaths during the 15-year study period. CIRB findings are also not public, since SDSD claims they are protected by attorney-client privilege. That left the auditor to conclude, “The primary focus of this board is protecting the Sheriff’s Department against potential litigation, rather than focusing on improving health and welfare of incarcerated individuals.”

The audit report then listed four key areas where the department is failing: insufficient health evaluations at intake; inconsistent follow-up care; inadequate safety checks; and unnecessary delays in performing lifesaving measures. All four areas are significantly affected by staff shortages.

During intake, when a detainee or prisoner is booked, health staff did not always properly identify medical and mental health needs, the audit noted. That meant some individuals did not receive proper care that in turn probably contributed to their deaths.

Beyond intake, guards did not consistently track prisoners and detainees before and after necessary health services. Rather, there was a pattern of inconsistent follow-up that in many cases left serious needs unmet, also contributing to the death toll.

The third area of concern the auditor identified involved safety checks on prisoners in their cells, which guards did not always perform. Several people who died were not found until hours later, making it impossible to render lifesaving aid.

The last area of concern was the swiftness of response to a medical emergency by both healthcare staff and guards. Unnecessary delays prevented prisoners and detainees from receiving lifesaving measures in time, also contributing to their untimely deaths.

SDSD said it has taken steps to address these deficiencies. Working with the county BOS, the agency announced on August 16, 2022, that it purchased a $200,000 state-of-the-art body scanner. Eight additional scanners will be brought online over the next five years to enhance contraband detection.

That purchase follows the announcement on April 26, 2022, that guards must wear body cameras to “increase accountability and transparency during investigations of action that occur within our jails,” said Fletcher, the BOS Chairman.

Another change is in the booking process, which now includes intake urine screenings. Since instituted in June 2022, the screenings show that many of those entering custody have recently used illicit drugs. So an additional change is that SDSD now utilizes two scoring systems — the National Institute of Health’s Clinical Institute Alcohol Withdrawal Assessment Scale and Clinical Opiate Withdrawal Scale — to better manage those under the influence or experiencing withdrawal symptoms.

SDSD says the most significant step it has taken to comply with the audit report is the June 2022 placement of naloxone (or “Narcan”) kits in the common areas of jail housing units, as well as in visitation areas. Administered in the form of a nasal spray, the drug rapidly reverses the effects of opioids so a person can breathe normally again. An instructional video demonstrating how to administer the medication is shown during booking and played repeatedly in the housing units as a reminder. Narcan kits also include photo instructions on their use.

An SDSD spokesperson noted that all jail guards already carry doses of naloxone and that the drug has been used more than 400 times in suspected overdose cases since 2020, consuming more than 1,200 doses — since more than a dozen doses is sometimes required to rouse someone after overdose.

Legal Settlements Total $15.8 Million in the Last Two Years

When the auditor’s report was released in February 2022 and Sheriff Gore abruptly retired, the dark side of his nearly 12-year tenure came into focus: Many of the 185 people who died in custody between 2006 and 2020 did so after Gore took office in 2009. Of 22 lawsuits filed over those 15 years, the county “settled 11 of these, for a total cost of $9.223 million,” the audit noted. But that total does not include at least five others settled since the audit’s publication, with payouts totaling an additional $15.8 million.

March 2021: $3.488 million for Paul Silva’s death was paid by the county to his family. A mentally ill detainee at Central Jail, Silva, 39, was killed in a brutal cell extraction in 2018 during which he was allegedly “Tased between four to nine times while six other members of the [SDSD] Tactical Team held him down with a body shield and pressed down on his torso,” according to the lawsuit suit his mother later filed. The District Attorney’s Office refused to file charges against any jail guards involved. But the incident prompted an update to the jail’s cell extraction policy, for which Julia Yoo, an attorney who is representing Silva’s mother, said she was glad. “Hopefully in the future, it won’t take lawsuits for the county to implement changes in the way jails deal with our most vulnerable citizens,” Yoo added. [See: PLN, Nov. 2022, p.24.]

May 2021: $1 million for Ivan Ortiz’s suicide was paid to his mother by the county. Ortiz, 26 and mentally ill, committed suicide at Central Jail by suffocating on a plastic baggie he hid under a blanket after he was served food in it. “Going to jail in San Diego County shouldn’t be a death sentence, but sadly for too many people, that’s what it’s turning out to be,” said attorney Brody McBride, who represented Ortiz’s mother, Maria Palacios. [See: PLN, July 2022, p.17.]

October 2021: $2.95 million for Heron Moriarty’s suicide was paid by the county to his family. The 43-year-old suffered a psychotic break in 2016 and was involuntary held two times under California Code 5150 before he threw a table through a sliding-glass door, crashed into parked cars while driving away, and then ran into traffic, attempting to get hit by passing vehicles. Once in custody, a series of missteps and neglect at Central Jail and Vista Detention Facility left Moriarty in the latter jail’s general population, despite warnings to jailers by his wife and by a jail nurse, whom a guard overruled. Moriarty then fatally suffocated himself by stuffing a T-shirt in his mouth and tying another around his neck. [See: PLN, Apr. 2022, p.44.]

March 2022: $250,000 for Kristopher NeSmith’s suicide was paid to his wife and young son by the county. The Marine Corps veteran, 21, suffered from mental illness and PTSD before assaulting two strangers, as well as his wife. Locked up for that at Vista Detention Facility — though not in a suicide-prevention cell — he threatened to take his own life. His father and wife repeated those threats to jailers, beseeching them to protect him. They didn’t, and in March 2014 he hanged himself with a bedsheet from a light fixture in his cell. [See: PLN, Nov. 2022, p.18.] Prior to reaching a settlement in the case, SDSD implemented a new suicide prevention policy at its jails, where NeSmith’s suicide was one of six in 2014 — even more than in Los Angeles County, which has triple the number of prisoners.

June 2022: $8.1 million for Nicholas Bils’ killing was paid to his family, the largest payout by the county for an in-custody death in the past two years — even though Bils never made it inside Central Jail but was shot in the back as he tried to flee across the parking lot. [See: PLN, Nov. 2022, p.26.]

That’s $15.8 million paid out over the past two years — which doesn’t include an award to David Collins, a detainee who suffered a brain bleed after he fell inside the same jail where Moriarty died. Booked on suspicion of being under the influence, Collins was actually suffering a viral infection and a near-lethal sodium deficiency. He didn’t die, but he was left impaired with difficulty communicating. A jury awarded him over $12.6 million in damages, which was reduced to $6.26 million in February 2021. [See: PLN, July 2021, p.32.]

That takes the two-year total of payouts to at least $21 million.

More Lawsuits Pending

But there are more pending jail death suits likely to push that number even higher.

Ronaldino Estrada: The latest lawsuit over a jail death was reportedly filed in late August 2022 in state Superior Court for San Diego County by attorney Brodie McBride for the parents of Ronaldino “Charles” Estrada, 24, who died at Vista Detention Facility on July 5, 2021. He had been arrested for driving under the influence just three days earlier. When found unresponsive in his cell, his “remains were cold and grey,” the lawsuit reportedly claims, indicating not only that he “likely lay dead for approximately 12 hours” but also that “multiple inmate checks were either skipped or conducted in violation of department policies.”

The suit also reportedly states that Estrada suffered from “cardio-respiratory arrest” and had a history of hypertension but no “known history of illegal substance abuse.” A preliminary autopsy reported he had fentanyl in his system. But Estrada’s parents say their son’s death was “a result of deliberate indifference and negligence” by SDSD and that the county is “vicariously liable for the damages” they suffer.

Lester Daniel Marroquin: McBride also filed a suit in federal court for the Southern District of California in May 2022 for the mother of 35-year-old Lester Daniel “Danny” Marroquin, who died gruesomely at Central Jail a year before.

Arrested on assault charges in December 2020, Marroquin’s defense attorney raised questions about his client’s mental competence after he made multiple suicide attempts. Over his six-month incarceration, he tried to drown himself in a cell toilet, bashed his head repeatedly into a cell wall, strangled himself with a noose fashioned from his shirt, and even used a Taser barb to attempt self-garroting.

Despite this, the lawsuit claims that Marroquin was never “taken to a hospital for inpatient psychiatric treatment” and that “jail staff repeatedly failed to produce [him] for court-ordered psychiatric evaluations and court dates.”

In the end, the detainee simply drank himself to death — consuming so much water from his cell toilet that it depleted his blood of sufficient sodium to survive.

Just 13 days after the case was filed, Plaintiff voluntary dismissed it on June 6, 2022. PLN will report any new case or settlement when filed. See: de Portillo v. Cty. of San Diego, USDC (S.D. Ca.), Case No. 3:22-cv-00744.

Omar Moreno Arroyo: Attorneys from Julia Yoo’s firm, Iredale & Yoo, filed a suit in the same court for Tammy Wilson, claiming SDSD officials knew her late husband, Omar Moreno Arroyo, 33, “was under the influence of methamphetamine and was behaving in a paranoid and irrational way: looking under the bed, in the closet, and using a drill to make holes in the floor and walls of their home.” That’s because she told them so when she dialed 911 on January 6, 2021, asking them to pick him up for an involuntary hold under Code 5150 and take him to a hospital. She also warned them he had a heart condition and handed them his medication as they clocked his sky-high pulse.

But instead of a hospital they took him to Central Jail, passing along none of that information, Wilson claims. Arroyo was booked on suspicion of being under the influence of a controlled substance and possessing drug paraphernalia, and he was placed in a holding cell despite a body scan that showed a possible baggie of drugs in him.

Arroyo began to choke and display “seizure-like activity,” but allegedly no one came to his aid. He asphyxiated on a face mask and died before his scheduled release that night. But no one told Wilson until early the next morning, after she spent the night waiting in vain in the parking lot to take her husband home. See: Est. of Arroyo v. Cty. of San Diego, USDC (S.D. Ca.), Case No. 3:21-cv-01956.

Michael Richard Wilson: During the same six-week stretch in 2019 that Ortiz died, so did another three other detainees. Iredale & Yoo attorneys have another lawsuit pending in the case of one, Michael Wilson, 32, whose fatal heart condition was allegedly ignored by Central Jail staff even though he informed intake officials that he was on heart medication and wore a pacemaker.

“‘Per the Court’s order,’ Wilson was to be monitored in the medical unit of the jail,” the federal court for the Southern District of California later recalled. But the woman he called his mother, Phyllis Jackson, noticed when she spoke to him on the phone that he was very short of breath. She and other family members began calling the jail to urge them to get Wilson to a hospital because he was at risk for sudden cardiac death. On Valentine’s Day 2019, he collapsed and died.

Jackson filed suit in the Court under 42 U.S.C. § 1983, accusing the county and its jail officials of “systematic failure to adhere to the written policies and procedures with respect to providing adequate health care to inmates in the San Diego County jails” and a “systematic failure to investigate incidents of medical neglect, staff misconduct, and deaths in the Jail.” Jackson also alleged a long-standing “custom and practice of improper and inadequate investigations; cover-up of misconduct; and failure to discipline and train deputies and medical staff.”

On July 10, 2020, the Court granted Defendants dismissal of some of Plaintiff’s claims, but not claims that Sheriff Gore and SDSD Medical Administrator Barbara Lee failed in their duty to properly train and supervise their employees at the jail. Also denied was an attempt to dismiss a claim extending liability for their actions to the County under Monell v. Dep’t of Social Servs. of City of New York, 436 U.S. 658 (1978). A wrongful death claim also survived that was made by Jackson, though one made by her son’s estate was dismissed as improper. See: Estate of Wilson v. Cty. of San Diego, 2020 U.S. Dist. LEXIS 121662 (S.D. Cal.).

On April 8, 2022, Jackson’s personal claims were dealt a mortal blow when the Court learned she was neither Wilson’s natural nor adoptive mother. However, the lawsuit’s other claims all survived, and the case remains pending before the Court, which presided over a settlement conference on August 24, 2022. PLN will report that outcome as it becomes available. See: Est. of Wilson v. Cty. of San Diego, USDC (S.D. Ca.), Case No. 3:20-cv-00457.

Elisa Serna: As her surviving sister told reporters gathered outside the court hearing the injunction request in the Dunsmore case, Elisa Serna, a 24-year-old wife and mother, was withdrawing from heroin and suffering from pneumonia when she was arrested on theft and drug-related charges in November 2019. At Las Colinas Detention Facility, Serna was “nauseous, vomiting, and exhibiting symptoms of dehydration,” U.S. District Judge Larry A. Burns later recalled, “but she didn’t receive any treatment for withdrawal until she first saw a doctor four days [later].”

Despite her “abnormally low blood pressure,” Dr. Friederike C. Von Lintig “suspected Serna was staging her ‘fainting spells,’” Burns continued. Von Lintig “declined to take [her] vitals, refused to provide the IV that [she] requested due to her vomiting,” and sent her from the medical unit back into the jail’s general population.

Just 20 minutes later, still in a wheelchair, Serna “stiffened” and became verbally unresponsive. Staff clocked her blood oxygen at a dangerously low level and returned her to Von Lintig. But the doctor still suspected she was “faking her symptoms,” the judge noted, so Von Lintig “didn’t examine [her], didn’t take blood tests, again didn’t take [her] vitals, and didn’t continue [her] treatments for withdrawal.” She was returned to the jail’s general population once more.

After “someone saw [her] slide down a wall,” nurse Danalee Pascua found Serna “on the ground, eyes closed, tensing her arms, and breathing slowly,” the judge wrote, but the nurse “didn’t take her vital signs or provide medical care.” Serna died just over an hour later.

With the aid of Iredale & Yoo attorneys, Serna’s mother, Paloma, filed suit on behalf of her daughter’s estate under 42 U.S.C. § 1983 in federal court for the Southern District of California, accusing the county, Sheriff Gore and Medical Administrator Lee, as well as Von Lintig, Pascua and two of her fellow jail nurses of deliberate indifference to Serna’s serious medical needs, in violation of her Fourteenth Amendment rights.

Ruling for the Court on March 18, 2022, Judge Burns dismissed claims against Gore and Lee. But he denied the nurses’ claims of qualified immunity, quoting Sandoval v. Cty. of San Diego, 985 F.3d 657 (9th Cir. 2021), to say that “failing to provide … life saving measures to an inmate in obvious need can provide the basis for liability under § 1983 for deliberate indifference.” See: Estate of Serna v. Cty. of San Diego, 2022 U.S. Dist. LEXIS 49118 (S.D. Cal.).

Pascua and Von Lintig were both charged with involuntary manslaughter in November 2021 and October 2022, respectively. Pascua pleaded not guilty in April 2022 but was allowed to continue practicing while awaiting trial on bail. A request to stay the civil claims against her until that concludes was granted on April 27, 2022. See: Estate of Serna v. Cty. of San Diego, 2022 U.S. Dist. LEXIS 77789 (S.D. Cal.).

The case is proceeding against the remaining defendants. PLN will report developments as they are available. See: Estate of Serna v. Cty. of San Diego, USDC (S.D. Cal.), Case No. 3:20-cv-02096.

“The Dead Cannot Cry Out
for Justice. It Is a Duty of the Living” – Lois Bujold

No lawsuit has yet been filed over the tragic and preventable death at Vista Detention Facility on Valentine’s Day 2022 of a grandfather suffering early onset dementia and diabetes. After a series of mistakes by law enforcement personnel — who apparently confused his dementia for symptoms of drug use — Gilbert Gil, 67, ended up in a holding cell. He was given five units of insulin and left unattended.He was then found dead 15 hours after that, naked from the waist down, his feet covered with feces.

On the way to jail, cops stopped by a hospital to have Gil cleared for booking. Doctors did so, but they warned Gil needed to be monitored for chest pain or palpitations. At the jail, a check of his blood sugar found it elevated to twice a normal level. Where he was supposed to sign the test, someone noted “patient is willing to sign, but is unable to sign.” There are also no medical notes to indicate that anyone checked on Gil over the next 15 hours.

SDSD was quick to issue a press release the next day, February 15, 2022, announcing that a preliminary autopsy test was “presumptively positive for methamphetamine.” But that’s perhaps because Gil was taking the antidepressant trazodone, which can cause a false-positive result in a test for methamphetamine, medical toxicologists say.

His daughter, Jennifer Schmidt, accused SDSD of trying to cover up the real cause of her father’s death. When she phoned for details, guards asked leading questions about whether Gil had been in a fight in jail. She understood why as soon as she was allowed to see her father’s body and noticed a huge mark on his forehead that went back into his hair.

A second autopsy was performed, its cost covered by the Autopsy Initiative, a program started by former NFL quarterback Colin Kaepernick to help families of those who died in custody or at the hands of police. The results won’t be released until after the county closes its investigation in several months. At that point, though, it’s not unlikely that Gil’s death will result in the next wrongful death lawsuit against San Diego County. [See: PLN, June 2022, p.62; and June 27, 2022, online.]

Of the 37 men and women who have died in county jails since the beginning of 2021, many — like Gil — still don’t have an officially determined cause of death. A few even remain nameless. But each of them deserves justice.

Oct. 5, 2022: Raymond Vogelman, 52, the most recent to die, had almost no criminal history, according to court records, other than a restraining order by a 76-year-old neighbor. Arrested on suspicion of burglary on March 3, 2022, Vogelman was transferred to George Bailey Detention Facility (GBDF), where he was fatally assaulted for unknown reasons by other detainees. Discogs.com identifies Raymond “Raybo” Vogelman as a musician with a California streetpunk band, Bonecrusher.

Sep. 21, 2022: Male, name unknown, 33, died three days after he was found at Central Jail along with another unresponsive male, 38, who has since recovered, but who is also not named.

Sep. 13, 2022: Male, name unknown, 56, was found unresponsive atGBDF by his cellmate, who alerted guards then unable to save him.

Aug. 16, 2022: Settles, first name unknown, 54, died after he was found in “medical distress” by guards atGBDF.

July 27, 2022: James Bousman, 23, was found alone and dead in his cell at Vista Detention Facility (VDF). He was arrested in March 2022 on charges of assault, vandalism, resisting arrest, and battery on a police officer resulting in injury.

July 22, 2022: Abdiel Sarabia, 35, died at GBDF. He was jailed with bail set at one million dollars after a violent knife attack on an aunt and two cousins in May 2021. For that he was charged with attempted murder, aggravated mayhem, assault with a deadly weapon, and burglary.

July 21, 2022: Good, first name unknown, 64, died a year after he was hospitalized for unspecified “medical issues” and one day after he was granted compassionate release because of them. He was arrested on unspecified charges in January 2021.

July 13, 2022: Vianna Granillo, 25, died a day after she was found unresponsive at Las Colinas Detention Facility (LCDF). She had been jailed three days earlier for violating a court order.

July 2, 2022: Erika Wahlberg, 40, died after going into medical distress during intake at LCDF. She had been at VDF since her arrest six days earlier on a drug-charge warrant.

May 25, 2022. Reynolds, first name unknown, 64, died at Central Jail.

May 5, 2022: Chaz Guy Villasenor, 31, was found “slumped over” in a holding cell at Central Jail. He had been arrested just the day before on a probation violation.

Apr. 27, 2022: Omar Ornelas, 25, was found unresponsive in his cell at GBDF along with another detainee, who was revived with naloxone. Ornelas was one of two alleged gunmen in a group of five Varrio San Marcos gang members accused of a drive-by shooting at a child’s baptismal party in Oceanside in April 2018.

Apr. 11, 2022: Jerrell Lacy, 38, died in an ambulance racing him to a hospital from Central Jail, while a blood clot traveled from his leg to his lung. The clot won the race. His mother received a letter from him four days after his death that described an altercation with guards who hit him on the head and broke his eyeglasses. SDSD said Lacy’s “history of violent and assaultive behavior” included an attack on a guard on April 2, 2022. He was jailed in August 2021 on charges of grand theft auto and driving under the influence. His mother said he had been diagnosed with bipolar disorder and schizophrenia which drove him to act out.

Mar. 29, 2022: Derek Baker, 56, died from injuries sustained in a brutal assault 17 days earlier at Central Jail. While hospitalized, his charges were dismissed and he was ordered released, but he left in a body bag. His cellmate Patrick Ferncase, 28, is suspected of his murder. Ferncase was initially incarcerated in December 2021 on charges of attempted murder, assault with a deadly weapon not a firearm, and elder abuse causing injury or death.

Mar. 17, 2022: Lonnie Newton Rupard, 46, was found alone and unresponsive in his cell at Central Jail. No cause of death has been announced. He was arrested in December 2021 for violating terms of his conditional release from a state prison, where he had been serving a two-year sentence for a 2019 assault conviction.

Mar. 16, 2022: William Schuck, 22, was found alone and unresponsive in his cell at Central Jail, six days after his arrest on suspicion of driving under the influence following a car crash. No cause of death has been announced, but SDSD said a preliminary test for cocaine was positive.

Feb. 14, 2022: Gilbert Gil, 67, died at VDF of causes still under investigation. He was never charged, and his family has sued the county, saying he should not have been jailed (see above).

Feb. 11, 2022: Rafael Ruiz, 73, died at a hospital of complications from COVID-19 due to diabetes and end-stage renal disease, one day after he was granted compassionate release from Central Jail. He was arrested the previous September on suspicion of child sex abuse.

Feb. 10, 2022: Doyle Nyles Marler, 63, died of esophageal cancer in the VDF medical unit. He was arrested in May 2020 on suspicion of attempted murder and committed to Patton State Psychiatric Hospital two months later. But the transfer never happened, due to COVID-19 restrictions. When he was finally admitted to a hospital over a year later in August 2021, his cancer was discovered. After treatment at the VDF medical unit, he was on palliative care until he died.

Dec. 29, 2021: Dominique James McCoy, 38, was fatally beaten at Central Jail. His cellmate, John Roman Medina, 18, is charged with his murder. McCoy had been held at the jail six days on drug-related charges. Medina had been there half that long on suspicion of child cruelty, assault with a deadly weapon, and cruelty to animals.

Dec. 19, 2021: Jerry Borunda, 63, died at a hospital of a fentanyl overdose and blunt-force trauma to his torso caused by attempts to resuscitate him when he was found unresponsive in his cell at Central Jail. He received a compassionate release two days before his death. Before that he was being held on suspicion of attempted murder.

Dec. 1, 2021: Gumercindo Aldava Alamos, 72, died at VDF of COVID-19 and heart disease, with non-small cell lung cancer and diabetes as contributing factors. He was arrested in mid-October 2021 on three counts of lewd and lascivious acts on a child under 14.

Nov. 27, 2021: Robert Dwayne Moniger, 57, died at Central Jail of COVID-19 and viral pneumonia, with heart disease as a contributing factor. He had been in jail just over a month on suspicion of felony vandalism.

Nov. 23, 2021: Earl Benjamin Smith, 63, died from complications due to COVID-19, two weeks after he was taken to a hospital from VDF. He was arrested in April 2021 on suspicion of assault with a deadly weapon. As of early December 2021, SDSD was still looking for his family to notify them of his death.

Nov. 8, 2021: Richard Eshback, 58, died from complications of COVID-19, with liver cirrhosis and emphysema as contributing factors. He had been hospitalized three weeks earlier, after being booked into GBDF in September 2021 on suspicion of stalking and violating court orders.

Oct. 13, 2021: Rafael Hernandez, 39, died two days after he was granted compassionate release from Central Jail, which was the same day he was found hanging in his cell there, making him another victim of suicide in county jails. He had spent almost a year in custody on burglary and vandalism charges.

Sep. 28, 2021: Teresita Manialung Tuazon, 61, died at LCDF from complications of diabetes, heart disease, and liver cirrhosis. She was arrested earlier in the month for allegedly violating a protective order. Her history included three mental health cases.

Sep. 16, 2021: John Edward Wright, 63, died at VDF of complications from diabetes and heart disease. The mentally ill Marine Corps veteran, described by his family as homeless on-and-off, was arrested in March 2021 for violating parole from an arson conviction earned when a fire he set to keep warm ignited a blaze at an abandoned building.

Aug. 30, 2021: Glenn William Davey, 55, died at Central Jail of heart disease, to which his obesity was a contributing factor. He was arrested three days earlier for violating his parole from an unspecified conviction.

Aug. 22, 2021: Richard Lee Salyers, 46, was fatally strangled at Central Jail four days after his arrest on a contempt-of-court warrant. Cellmate Steven Young, 32, is charged with his murder. Young was originally arrested for failing to register as a sex offender and violating parole.

July 20, 2021: Saxon Rodriguez, 22, died from an overdose of fentanyl and methamphetamine in a cell he shared with two other men at Central Jail. He had been arrested three days earlier on suspicion of assault with a deadly weapon and indecent exposure.

July 5, 2021: Ronaldino Estrada, 24, died of a fentanyl overdose at VDF three days after his arrest for driving under the influence. His parents have filed a wrongful death lawsuit against the county (see above).

June 9, 2021: Jerry Aleman, 41, died of a fentanyl overdose at GBDF. He was arrested in January 2021 for forgery, identity theft, receiving stolen property, and defrauding an innkeeper.

May 30, 2021: Lester Daniel Marroquin, 35, committed suicide by water intoxication at Central Jail after an arrest on assault charges. His mother has sued the county (see above).

Apr. 27, 2021: Jonathan Robert Whitlock, 35, died at GBDF of a fentanyl overdose, with his obesity listed as a contributing factor. He had spent 14 months at the jail on suspicion of arson, as well as being under the influence of a controlled substance and violating probation.

Mar. 14, 2021: Luis Ahyule Gomez, 43, died at VDF of complications of COVID-19. He was arrested the month before for assault with intent to commit a felony and attempted forcible rape. CLERB’s investigation faulted an unnamed guard for failing to “conduct [a] hard count or COVID-19 temperature check in accordance with policy.” But that was based on second-hand information since the guard also “exercised his option to decline participation in an interview pursuant to a long-standing agreement between CLERB and the Deputy Sheriffs Association.”

Jan. 7, 2021: Omar Moreno Arroyo, 33, choked to death on his face mask at Central Jail after he was picked up on a Code 5150 involuntary hold. His widow has sued the county (see above).

How to Stem the Tide of Death?

On August 23, 2022, CLERB put forth proposals to address the on-going crisis in SDSD jails. Chief among them was to require all people entering county lockups to be physically searched or go through a body scanner to detect contraband, including illicit drugs. Right now, only detainees and prisoners go through scanners to enter jails. But under the new proposal, so would SDSD and county employees, contractors, and others conducting county-related business. All social and professional visitors would also be subject to scanning, even attorneys.

After accepting earlier CLERB recommendations to deploy fentanyl-sniffing canines and Narcan kiosks in housing units, SDSD said it would not support CLERB’s recommendation to search or scan everyone entering and exiting jails. Spokeswoman Lt. Amber Baggs insisted that evidence uncovered by jail staff shows illicit drugs enter the jails via the detained population. She also said SDSD does not have sufficient staff to search everyone entering the jails, creating unmanageable operational delays. So the department will continue to “direct resources towards the interception of drugs being brought into the jails by our incarcerated population,” Baggs added.

At a CLERB meeting on August 9, 2022, Detentions Investigations Unit Lt. Karen Mullins said that mail and smuggling by incarcerated people are the top two ways drugs get into jails, though tossing drugs onto jail grounds and staff smuggling were two other methods. Added Sheriff Ray to the BOS: “In five years we have found no proof, no evidence, and no cases sustained of any (employees) bringing drugs in.”

That’s probably just luck. A report by The Marshall Project found that during the pandemic, “even though visitation from family and friends was suspended, attorney visits were restricted, and teachers, tutors, and volunteers stayed home, drugs got into many prisons anyway.” In fact, “the number of incarcerated people disciplined or charged for drugs actually increased during the pandemic in Texas prisons” — meaning the contraband probably came in through the staff entrance.

So much finger-pointing likely means solutions remain elusive. And the doorways into San Diego County jails will lead more detainees to their deaths, even as the lockups stockpile high-tech gadgetry they’re too short-staffed to effectively use. More than $30 million paid out in lawsuits over the past 17 years — plus an amount probably equal for litigation expense — means every resident of San Diego County is paying up to one dollar a year to ignore this long-running “crisis.” If that doesn’t motivate them to demand change, what will it take?  

Additional sources: Chicago Tribune, CLERB, Courthouse News, East County Magazine, KFMB, KGTV, KNSD, KPBS, Los Angeles Times, The Marshall Project, San Diego Union-Tribune, Times of San Diego

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