Embargoed until June 1, 2022

Facts Summary
“Natural Causes?”
59 Autopsies Prove Otherwise
Evaluating the Autopsies of 59 Deaths in
Los Angeles County Jails

2009 - 2019
Report by

Carceral Ecologies Lab
The BioCritical Studies Lab
Principal Investigators:
Nicholas Shapiro, D. Phil.
Terence Keel, Ph.D.

-

FOR

S OCIETY & GENETICS

Executive Summary:
The rising number of jail deaths in the United States1 has left impacted community
members, state actors, media, and scholars questioning if these rates are a reflection of
the overall declining health of the nation or are due to factors specific to the carceral
environment. This fact sheet contributes to this national dialogue through the analysis of
autopsies for 59 deaths that occurred in Los Angeles County Jails over a 10-year period.
Our study shows that the majority of Black and Latinx men are not dying from "natural
causes" but from the actions of jail deputies and carceral staff. Our findings support the
efforts of community members and lawmakers attempting to reform the cash bail
system in Los Angeles County as three quarters of the deaths in our study were
individuals held in pre-trial detention. Moreover, our study supports the urgent need to
reduce the jail population to expedite the closing of Men's Central Jail and the
potential life saving benefits of jail diversion programs for the people of Los Angeles
County.
We focus on autopsies because they are fundamental to establishing the causes and
manner of death in carceral facilities that have limited public accountability.

UCLA INSTITUTE FOR

•• I I II II

SOCIETY & GENETICS

~

•

Nicholas Shapiro
Assistant Professor
Founding Director, Carceral Ec,,log1es Lab

,:'.A.

erence O Keel
Associate Professor
Found ng Director, The B10Cnt1cal Studies Lab

May 2022

Only 59 out of 292 cases between 2009-2019 were accessible at the time of the study
due to security holds.

• From 2009-2019, there were 292 total reported deaths in Los Angeles County jails.
The Los Angeles Sheriff Department likely used security holds to block access to the
remaining autopsies, coroner investigator narrative, and toxicology reports. Securityholds prevent families, scholars, and activists from seeking public accountability and
closure.
Out of 59 cases, 26 (44%) died from "natural" causes.

• Of these 26 "natural" cases, 65% were Black, 23% were Latinx, and 8% were White. 23
of the 26 "natural" cases were men; of these 23 men, 14 were Black, 6 were Latinx
men, and 2 were White. All 3 Black women in the study died from "natural" cases.
Among "natural" deaths, all but 3 involved law enforcement. People who died from
"natural" causes are not significantly older than other manners of death. 85% of these
"natural" cases involved alleged mental illness and 54% included evidence of physical
violence on the body. White and Latinx women were not represented in our sample of
natural deaths.
74% of all Black deaths in the sample were classified as "natural".

• 32% of Latinx deaths, 14% of White deaths, and 33% of Asian (1 of 3) deaths were
classified as "natural". Black deaths were nearly twice as likely (0.489) to be
designated as "natural" compared to Latinx, White, and Asian deaths combined.
Latinx people who die in county jails are more likely to be "undetermined".

• There were 8 total undetermined cases in our sample (Latinx men n=5; Black men
n=3). In fact, every Latinx death in our study classified as undetermined died before
trial. In all undetermined cases, the victims were young with an average age of 24.5
years old at time of death compared to an overall average of 42 years old for all cases.
More than 75% of the cases in our study were deaths that occurred before standing
trial.

• We discovered that 69% of the natural death cases in our sample were pre-trial. Again,
Black people were in the majority and represented 72% of these pre-trial cases.

UCLA INSTITUTE FO R

•SOCIETY
• IGENETICS
Il l
&

N1chc,las Shapiro

•

erence D Keel

Assistant Professor
Founding Director, Carceral Ecologies Lab

Associate Professor

,:!.A.

Found ng Director, The B10Cnt1cal Studies Lab

May 2022

Law enforcement were present during the autopsy in 51 of the 59 cases we analyzed.

• The Chief Physician at the LASO, who has supervisory responsibilities over medical
care in LA jails, attended 14 of the autopsies (24%) across all manners of death.2
Deaths in Los Angeles County Jail have steadily increased since 2016.

• This increase in deaths coincides with an increased number of cases placed on
security hold also beginning in 2016.
There were 292 deaths in Los Angeles County Jails between 2009 and 2019 that were
reported to the Department of Justice.

• Consistent with our analysis of the smaller 59 case sample, the large majority of
deaths during this period were classified as "Illness" which is equivalent to "Natural"
(n=161, 55%), followed by "Suicide" (n=50, 17%), "Drugs/Alcohol" (n=26, 9%),
"Undetermined" (n=18, 6%), "Accident" (n=15, 5%), "Unknown" (n=11, 4%), "Homicide"
(n=11, 4%).
Latinx and Blacks constituted the majority of all deaths during this period.

• Latinx deaths (n=109, 37%) led all groups followed by Blacks (n=100, 34%), Whites
(n=62, 21%), Other (n=10, 3%), Asian (n=7, 2%), Pacific Islander (n=2, 1%) and
Unknown (n=2, 1%).
The number of cases placed on security hold dramatically increased beginning in
2016.

• 2019 had the highest number of cases placed on security (90%) followed by 2017
(80%), 2018 (73%), and then 2016 (68%). No cases were placed on security hold
between the years of 2008 and 2014.

209 deaths occurred before standing trial.

• Most pre-trial cases were designated as "Illness/Natural" (n=114, 55%), followed by
"Suicide" (n=39, 19%). Latinx made up the majority of pretrial deaths (n=78,37% ),
followed by Blacks (n=70, 33%), then Whites (n=45, 22%) .

UCLA INSTITUTE FO R

•SOCIETY
• IGENETICS
Il l
&

N1chc,las Shapiro

•

erence D Keel

Assistant Professor
Founding Director, Carceral Ecologies Lab

Associate Professor

,:!.A.

Found ng Director, The B10Cnt1cal Studies Lab

May 2022

78 deaths occurred post-conviction.
• A clear majority were classified as "Natural" (n=47, 60%) followed distantly by
"Suicide" (n=9, 12%). An equal number of Latinx (n=30, 38%) and Black (n=30, 38%)
deaths were classified as "Natural" followed by Whites (n=15, 19%), then Asians (n=2,
3%) .

Deaths per Year in LA County Jails
60

0------------------2008

2010

2012

20 14

2016

2018

2020

Year

2008-2013 Data from LASO Documents prepared for the US Department of Justice, 3 2014-2021 Data from the Los
Angeles County Office of Inspector General. 4

Visual Overview
292 reported
death in LA
County Jails
2009-2019'

Los Angeles County Jails

Custody status
at time of death

]

--==---.::-----c:-C7

Death

j

investigation
documents
produced by
medical
examiner/coroner

Factors
contributing to jail
deaths

Manners

of death

Process of Dying in Los
Angeles County Jails

Access to Death
Documentation

The above figure represents an overview of our preliminary findings. On the left we depict the multiple factors that result
in death inside Los Angeles County Jail. Most individuals in our study were of "pre-trial" status, meaning they were
charged with a crime but had not yet stood trial or accepted a plea bargain. While incarcerated, the individuals in our
study were subjected to one or all of the following factors that led to their deaths: physical violence, issues with mental
health care treatment, or issues with health care. These factors contributed to the loss of life later classified by the
medical examiner-coroner. The most common manner of death in our study was classified by the medical examinercoroner as "natural." "Undetermined" deaths were overrepresented in our sample compared to the average number of
undetermined deaths for all autopsies in Los Angeles County. On the right we depict access to information involving the
deaths of inmates in Los Angeles County jails. During our period of study, Los Angeles County jails were mandated to
report deaths that occurred in their facilities to state and national authorities. However, public awareness of these
deaths are shaped locally by the conflict between communities demanding access to files protected by California's open
record laws and the Los Angeles Sheriff Department denying this access. This number is based on data submitted to
Department of Justice. See footnote two for reference.

UCLA INSTITUTE FOR

•SOCIETY
• IGENETICS
Il l
&

N1chc,las Shapiro
Assistant Professor
Founding Director, Carceral Ecologies Lab

,:!.A.

erence D Keel
Associate Professor
Found ng Director, The B10Cnt1cal Studies Lab

May 2022

Death Classifications of 59 Cases in Los Angeles County
Jails by Race, 2009-2019
Death Cla ssifications of 59 Cases in Los Angele s County Jails by Race, 2009-20 19

20 -

Manner of Death

15-

17

C

5

■
■
■
■
■

4

6

(.) 10 -

4

2

5

6

Lalinx

white

Accident

Homicide
Natural

Suicide
Undetermined

,3
0-

Asian

Bl~ck

Race

Note the disproportionate scale of Black deaths deemed "natural."

Age by Manner of Death

Undeterm ined

,5
Cll
Ql

0

Su icide

0
aiC:

Natural

C:
Cll

~

Homicide

Accident

0

25

75

50

Age at Death
The graph above depicts age at death by each of the manners of death. Each manner is broken up into quartiles
(meaning that ~25% of all cases fall between each of the vertical lines in the graph), Undetermined deaths show a
statistically significant skew towards youth (p= 0.00003). Natural deaths are not statistically significantly older than
other manners of death (p = .1534). The average American life expectancy was 78.9 years of age in 2019. 5

Jail Deaths by Facility

UCLA INSTITUTE FO R

•SOCIETY
• IGENETICS
Il l
&

Jail

Number of
deaths

Average age
at death

Twin Towers

45

43.33

Century Regional
Detention Facility

6

48

Men's Central Jail

5

30.6

Pitchess Detention
Center

2

38

North County
Correctional Facility

1

47

N1chc,las Shapiro
Assistant Professor
Founding Director, Carceral Ecologies Lab

,"!.A,

erence D Keel
Associate Professor
Found ng Director, The B10Cnt1cal Studies Lab

May 2022

Manner of LA County Jail Deaths, 2009-2019

150 -

Race/Ethnicity

84

c

■
■
■
■
■

100 -

:0

0

u
54
50 -

oI

I

Accident Drugs/Alcohol

-

-

25

I

I

I

Homicide

Illness

Suicide

I

Asian

Black

latinx
Native
Other

■

Pacific Islander

■

White

■

Witheld

I

Undetermined Unknown

Manner of Death

Security holds of LA County Jail Deaths 2009-2019
Security Held

Death Investigation

Year

·--

Percentage
Held

Total Deaths

Documents

2009

0

38

0.0%

2010

0

27

0.0%

2011

0

17

0.0%

2012

0

25

0.0%

2013

0

34

0.0%

2014

0

28

0.0%

2015

1

21

4.8%

2016

13

19

68.4%

2017

20

25

80.0%

2018

-

-

-·-

19

-2019

·-·

29

,~-

32

,._

26

73.1%

-

~-

90.6%

Acknowledgements: We would like to thank the many impacted families that brought this issue to
our attention, trusted us with their truths, and consulted us as we performed this analysis. We are
also grateful for the organizing efforts of Dignity and Power Now and the tireless work of
undergraduate students in Carceral Ecologies and the BioCritical Studies Lab who were involved
in this study.

UCLA INSTITUTE FO R

•SOCIETY
• IGENETICS
Il l
&

N1chc,las Shapiro

•

erence D Keel

Assistant Professor
Founding Director, Carceral Ecologies Lab

Associate Professor

,"!,,&.

Found ng Director, The B10Cnt1cal Studies Lab

May 2022

References
1

Carson, E. Ann. "Mortality in Local Jails, 2000-2018 - Statistical Tables." Bureau of Justice Statistics, 2021.

Dror, ltiel, Judy Melinek, Jonathan L. Arden, Jeff Kukucka, Sarah Hawkins, Joye Carter, and Daniel S.
Atherton. "Cognitive Bias in Forensic Pathology Decisions." Journal of Forensic Sciences 66, no. 5 (2020).
https://doi.org/10.1111/1556-4029.14697.

2

Smith, Grant. "Dying Inside: The Data behind @Reuters Investigation of US Jail Deaths." Reuters, October
16, 2020. https://www.reuters.com/investigates/special-report/usa-jails-graphic/. Data obtained from PRA
requests of LASD.
3

4 Office of Inspector General. "Reform and Oversight Efforts: Los Angeles County Sheriff's Department."
County of Los Angeles, December 2021. https://assets-us-01.kc-usercontent.com/0234f496d2b7-00b6-17a4-b43e949b70a2/736916ea-786c-4bfd-b073-b7de182ebf6c/
Reform%20and%20Oversight%20Efforts%20-Los%20Angeles%20County%20Sheriffs%20Department%20%20October%20to%20December%202021.pdf.

Masters, Ryan K., Laudan Y. Aron, and Steven H. Woolf. "Changes In Life Expectancy Between 2019 and
2021: United States and 19 Peer Countries." Preprint. Public and Global Health, April 7, 2022. https://
doi.org/10.1101/2022.04.05.22273393.
5

UCLA INSTITUTE FO R

•SOCIETY
• IGENETICS
Il l
&

•

N1chc,las Shapiro
Assistant Professor
Founding Director, Carceral Ecologies Lab

erence D Keel

Associate Professor

,:!.A.

Found ng Director, The B10Cnt1cal Studies Lab

May 2022

Embargoed until June 1, 2022

Carceral Ecologies Lab
Twitter: @Carceral_ECO, @zBoratory
The BioCritical Studies Lab Twitter:
@TerenceKeel
terencekeel.com/bcs-lab

Dignity and Power Now Instagram:
dignityandpowernow