Released: April 19, 1996


On July 13, 1995, this Grand Jury was informed by the Foreperson that an inmate had died on May 4, 1995, at the Santa Barbara County Main Jail. In compliance with California Penal Code Section 919, the Grand Jury investigated the death.


To investigate the circumstances of the inmate's death on May 4, 1995.


The Grand Jury reviewed the Santa Barbara County Sheriff's Department Major Crimes Report, the Coroner's Report, the Autopsy Report, and the Santa Barbara County Jail Medical Department's Policy and Procedure Manual. The Grand Jury inspected areas of the county jail relevant to this investigation.

The Grand Jury interviewed the Santa Barbara County Sheriff, the Chief Deputy of Custody Operations of the Santa Barbara County Sheriff's Department, a Shift Supervisor at the jail, two Santa Barbara County Sheriff's Department Major Crimes Investigators, eight Santa Barbara County Correctional Officers, and two Santa Barbara County Sheriff's Department Detectives.

The Grand Jury also interviewed the following personnel in the Santa Barbara County Health Care Services Department: the Health Officer and Medical Director, the Assistant Director, the Medical Services Director, the Jail Medical Facilities Coordinator, and two medical service personnel who were on duty at the time the inmate was booked.

In addition, the Grand Jury interviewed the Santa Barbara County Forensic Pathologist, an independent trauma physician, the Santa Barbara County Risk Manager, and the inmate's cellmate.


At approximately 2:00 P.M. on May 3, 1995, during a narcotics investigation in Isla Vista, the inmate (a Confidential Reliable Informant) was arrested on an outstanding warrant. He was transported to the Isla Vista Sub-station by the Santa Barbara County Sheriff's Department. At the time of his arrest, the arresting officer observed the inmate was "out of it," "coming down off heroin," and "looked sick." After approximately one and one-half hours the inmate was transported to a Sheriff's Department's interview room. While being interviewed by sheriff's detectives, the inmate continued to experience "obvious signs of (drug) withdrawal."

Because of the inmate's physical condition and his request for medical attention ("drugs for kicking" narcotic addiction), investigating officers terminated the interview. The inmate was walked to the Inmate Reception Center (IRC) at approximately 6:15 P.M. At that time, the detectives informed the correctional officers that the inmate was withdrawing from heroin and that medical staff should be notified.

A Correctional Officer stated to the Grand Jury that at the time of the booking he had checked the box on the Inmate Receiving Screening Form, indicating that the inmate entered the facility "not under his own power." He further stated that after the death of the inmate, the Acting Jail Commander brought the error to his attention and advised that the form be changed, reading "entered under own power." The Grand Jury was informed by the Chief of Custodial Operations, and a Shift Supervisor, that when a form is amended it should be accompanied by a memo explaining the reason for the change. There was no memo attached to explain the change.

While the inmate was lodged in the IRC, the correctional officers made at least five attempts to contact the medical staff, requesting a medical evaluation. On at least two of the attempts oral contact was made. During the five and one half hours he remained in the IRC, the Grand Jury found no evidence the inmate was ever seen by medical staff. The licensed nurse on duty left the jail facility approximately one hour before the end of her shift without being properly relieved. The shift was scheduled to end at 10 P.M.

At approximately 11:00 P.M., the inmate was assigned to a two-person protective custody cell. The lower bunk was occupied, requiring the inmate to occupy the upper bunk which is 67 inches above the cement floor. While the inmate was being moved into his cell, the cellmate told the Grand Jury he overheard the inmate ask a correctional officer to have a doctor see him.

The cellmate reported that at approximately 1:00 A.M., May 4, 1995, the inmate fell from his bunk. Shortly after returning to his top bunk the inmate fell again, landing face first on the cement floor. His cellmate immediately pushed the intercom button and got a response from the Control Center. Correctional officers responded immediately to the call and requested medical attention.

The licensed nurse who responded was unable to perform Cardio-Pulmonary Resuscitation (CPR ) because of the nurse's physical problems. It was reported to the Grand Jury that these problems were excessive weight, bad knees, and back problems. The correctional officers and licensed vocational nurse (LVN) performed CPR. Paramedics were called and the inmate was transported to Goleta Valley Hospital at 2:20 A.M., where staff continued resuscitation efforts without success. The inmate was pronounced dead at 2:42 A.M., May 4, 1995. According to the Santa Barbara County Sheriff-Coroner's Autopsy Report, the causes of death were "combined effects of acute drug toxicity and small vessel coronary disease due to chronic abuse of sympathomimetic drugs."

At the time of the in-custody death, there was a Services Level Agreement between the Sheriff's Custody Department and the Santa Barbara County Health Care Services, dated April 1994. The Grand Jury contacted the Health Care Services, Medical Services Manager, and the Risk Manager and learned that the jail medical staff failed to file a Quality Assurance Incident Report, as was required by the Services Level Agreement. The Health Care Services also failed to conduct a medical review of in-custody inmate death, as is required by the California Medical Association. The Grand Jury's investigation revealed that at the time of the death the Santa Barbara County Jail Health Care Services had lost its accreditation by the California Medical Association.


FINDING 1: California Health and Safety Code, Section 11222, states that for any person confined "medical aid (be provided) as necessary to ease any symptoms of withdrawal from the use of controlled substances." The Santa Barbara County Sheriff's Department Operation Division has no written procedure to deal with arrestees who have medical problems or who are under the influence of alcohol or drugs prior to booking.

FINDING 2: The Grand Jury found that the Health Care Services staff failed to comply with the Services Level Agreement, Section II A-l. (Since July l, 1995 the new contract is entitled Agreement for Services between the County of Santa Barbara and Prison Health Care Services, Inc.) Specifically, the staff failed to respond in a timely manner to calls from the IRC for inmate evaluation. The Health Care Services did not have a licensed nurse on duty at all times. The California Penal Code Section 673 states: "It shall be unlawful ...(to) allow any lack of care whatever which would injure or impair the health of the prisoner, inmate, or person confined."

FINDING 3: The Inmate Receiving Screening Form was changed without any written explanation. The Grand Jury found there is no written procedure as to how to amend documents.

FINDING 4: The inmate was classified and housed in a cell which had the potential to endanger his safety.

FINDING 5: The Grand Jury found the life of the inmate was potentially endangered by the inability of the licensed nurse to perform CPR.

FINDING 6: The Jail Medical Staff Coordinator failed to submit to the County Risk Manager a Quality Assurance Incident Report as required by Jail Medical Procedure # 95-C068. Health Care Services also failed to conduct a medical review of the in-custody inmate death. This action is in violation of the California Medical Association's "Standards for Health Services in Adult Detention Facilities, Section 115."

AFFECTED AGENCIES (California Penal Code 933c requires that comments to Findings and Recommendations be made in writing within 60 days by all affected agencies except governing bodies, which are allowed 90 days. All responses must be supplied in both a printed version and on a computer disk):