San Diego County

San Diego Sheriff's Dept. Failed to Prevent Deaths in Jails: State Audit

The study ran from July to December of last year, looking into every aspect of the Sheriff's Department's record of in-custody deaths, policies, procedures, facility maintenance and staff records

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The California State Auditor released a sobering assessment Thursday of the San Diego County Sheriff's Department's record of unusually frequent jail-inmate deaths, charging that the agency has "has failed to adequately prevent and respond to" the problem and calling for legislative action to solve it.

"The sheriff's department failed to adequately prevent and respond to the deaths of individuals in their custody," noted the state audit, reports NBC 7's Artie Ojeda.

"The high rate of deaths in San Diego County's jails (as) compared to other counties raises concerns about underlying systemic issues with the Sheriff's Department's policies and practices," acting California State Auditor Michael Tilden wrote in an introductory open letter in the report addressed to Gov. Gavin Newsom and state legislative leaders.

"In fact, our review identified deficiencies with how the sheriff's department provides care for and protects incarcerated individuals (that) likely contributed to in-custody deaths. ... In light of the ongoing risk to inmate safety, the sheriff's department's inadequate response to deaths and the lack of effective independent oversight, we believe that the legislature must take action to ensure that the sheriff's department implements meaningful changes," Tilden asserted.

Read the full letter here.

In response, the leaders of the San Diego-area regional law enforcement agency -- whose record of 185 fatalities between 2006 and 2020 in the seven detention centers it oversees is among the highest totals in the state -- asserted that they "take the findings of the audit seriously" and are "taking action" to implement its call for systemic change.

"Many of (the) recommendations are ones that we provided and completely support," sheriff's officials stated. "They also align with our existing practices (and) current and future plans, as well as proactive efforts to continuously improve health care services and the safety of our jails."

Read the department's full response here.

The audit was conducted at the behest of the state Joint Legislative Audit Committee after state legislators requested it last June. The study ran from July to December of last year, looking into every aspect of the Sheriff's Department's record of in-custody deaths, policies, procedures, facility maintenance and staff records, according to state officials.

Some of the inmates who died in the county's jails over the period had been in custody for only a few days or several months, and others were waiting to be sentenced, set to be released or about to be transferred to different facilities, according to the audit.

NBC 7's Catherine Garcia sat down with soon-to-be retired Sheriff Bill Gore about his tenure and some of the biggest cases under his watch.

"Although any death is a tragedy, the high rate of deaths in San Diego County's jails compared to other counties ... suggests that underlying systemic issues with the Sheriff's Department's policies and practices have undermined its ability to ensure the health and safety of the individuals in its custody," the report states.

Over the years reviewed by the auditor's office, the sheriff's staff "did not always provide consistent follow-up care to individuals who requested or previously received medical or mental health services," the document alleges.

"For example, one individual urgently requested mental health services shortly after entering the jail," it states. "However, (a) nurse had not identified any significant mental health issues at intake and determined that the individual did not qualify for an immediate appointment. The individual died by suicide two days later -- only four days after entering the jail."

The audit also found serious lapses in the department's provision of inmate safety checks, which the report described as "a key component of ensuring the well-being of individuals in detention facilities."

"For example, based on our review of video recordings, we observed multiple instances in which staff spent no more than one second glancing into the individuals' cells, sometimes without breaking stride, as they walked through the housing module," the document asserts. "When staff members eventually checked more closely, they found that some of these individuals showed signs of having been dead for several hours."

Unless the Sheriff's Department makes "meaningful change" to how it provides medical and mental health care in the jails it runs, according to the audit, "it will continue to jeopardize the safety and lives of individuals in its custody."

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