Grand jury investigation into county jail deaths reveals troubling trends
Before Christy Sanders was booked into Santa Cruz Main Jail, she complained of severe pain in the left side of her body, and was sent to the emergency room at Dominican Hospital. There she received a medical examination and an X-ray, but the ER staff did not see anything immediately wrong. They logged their diagnosis into a medical record database, which is shared with the medical staff at the jail. The incident was detailed in a recent grand jury report that investigated Sanders’ death, and those of four others at the county jail.
Deputies had arrested Sanders, a 27-year-old Felton resident, on August 12, 2012, for failing to appear in court on charges of petty theft. The next day, Sanders received medical screenings in the jail, where she declined treatment, including medicine for opiate detoxification. Later that afternoon, she said she was still experiencing chest pain, and saw the jail doctor, who did not find any serious medical issues and sent her back to her cell.
That same day, a Dominican Hospital radiologist revised Sanders’ diagnosis, and noted in the record database that her condition warranted a “close follow-up,” but the information went unnoticed by the jail’s medical staff, and Sanders’ health continued to worsen.
Five days after entering the jail, Sanders showed signs of heroin withdrawal, and acquiesced to taking medication to counter its effects. The next day she suffered a seizure and had trouble breathing. She asked to be sent to Dominican Hospital, but was denied. Instead, she was placed in the jail’s “O” unit, which includes video-monitored cells reserved for inmates with medical issues.
Two days after she was placed in the “O” unit, Sanders again complained of severe chest pain and difficulty breathing. She reportedly developed a blue tint to her lips. Sanders was seen by medical staff at the jail clinic, who told her she was receiving proper treatment.
On August 23, 11 days after she was initially booked, Sanders again asked to be seen at Dominican Hospital, and was again denied. The next day, she complained of fever and asked for medication, but was denied. Sanders threatened to kill herself if she did not receive medication, and was subsequently put on suicide watch. She later signed a “no harm” contract stating she would not commit suicide, and was placed back in a cell in
the jail’s general population.
The next morning, Sanders was seen sleeping in her cell with her head against the wall in a cross-legged position—something she had been doing for three days to ease her labored breathing. Later that morning, her cellmate noticed that she wasn’t breathing anymore. Medical staff was alerted and attempted to resuscitate Sanders, but she did not respond and was later pronounced dead by paramedics.
It would be the first of five questionable deaths at the county jail over an 11-month period— from August 2012 through July 2013. The Santa Cruz County civil grand jury conducted an investigation into the deaths and published a report on its findings on May 21.
The coroner’s report stated that Sanders died due to excess fluid near her lungs that caused them to collapse. The condition had worsened over a period of weeks. Traces of methamphetamines were also found in her system and, judging from the amounts, were likely acquired within the jail.
The 19 grand jurors scoured through case files, mulled over witness testimony transcripts, questioned county officials and toured the Main Jail.
“We felt a responsibility to the community to investigate and see what was behind these deaths,” says Nell Griscom, foreperson of the jury.
The jurors found a lack of communication between medical agencies and jail staff at critical interface points, lax and false documentation, and jail personnel failing to follow and enforce the institution’s regulations.
Sin Barras, a group dedicated to the abolishment of the prison system, organized a rally last year to raise awareness about prison deaths. Courtney Hanson, an organizer for the group, says that the five deaths indicate big systemic problems.
“These deaths should not be looked at individually, but as a pattern—and a very dangerous pattern,” says Hanson.
Two of the deaths were suicides, the first being Amanda Sloan, an inmate who learned from a friend that she would lose custody of her children. Two days later, on July 16, 2013, Sloan was reportedly “agitated and uptight.” Early the next morning, she was found dead, hanging from a pipe that she had reached by digging into the cell’s wall. Corrections officers had not previously noticed the hole because it was covered by a poster, which are not allowed in prisoner’s cells according to Corrections Bureau regulations. Also hidden behind the poster was a razor blade and a pipe used for smoking meth.
As grand jurors investigated Sloan’s death, they took notice of the pipe log, which is an electronic record of the times that corrections officers check on inmates. According to the jail’s protocol, officers are to administer safety checks on each cell every hour, and record it in the log. According to Sloan’s log, the officer had done so in the hours leading up to her suicide. When the jurors watched the video, however, they found that the corrections officer had only checked on Sloan one of the five times recorded in the log.
When inspecting the jail in January, jurors noticed similar instances of posters in cells, as well as covered windows, which are also a violation of jail regulations.
“We saw pretty egregious failures on the part of corrections. A lot of contraband in some of the areas,” says grand juror Wayne Hendrickson.
Jurors stated that overcrowding in the jails as a result of laws like AB 109, and understaffing due to funding losses from the recent recession has led to the lax enforcement of rules by corrections officers.
“Overcrowding and understaffing—when you have those two things, you have to be able to get along with the inmates, and some corrections officers feel that perhaps that’s the way to do it, is to let the rules relax a little bit,” says Griscom.
The jail typically fluctuates between operating at about 110 and 120 percent capacity, according to Chief Deputy Jeremy Verinsky, who oversees the jail but said he could not comment further for this story. The grand jury report acknowledged the creation earlier this year of a compliance officer position in the Main Jail, who’s responsible for ensuring procedures are followed in the future.
Bradley Dreher suffered from mental health issues, and was taking multiple antidepressants, but was not properly classified by jail staff or adequately monitored after being arrested for threatening employees at a Doctors on Duty clinic. The Crisis Intervention Team (CIT), which deals with mental health issues in the jail, was supposed to screen Dreher upon intake, but they were unavailable at the time of his incarceration, and he was merely given a referral to see CIT staff when they became available.
Dreher was later found dead in his cell, hanging from a sheet tied to the bed.
Dreher’s suicide led to one of the nine recommendations made by the grand jury in their report—to have CIT personnel on call all day, seven days a week. Currently, CIT is unavailable at night and over the weekend. Dreher was arrested on a Friday, and died the following Sunday.
Inmate Brant Monnet, who died in the jail as a result of a methadone overdose in November 2012, was given medication to battle the methadone in his system—a protocol of the California Forensic Medical Group (CFMG), the private contractor employed to handle medical issues in county correctional facilities—but was not put in a monitored cell or transferred to a hospital as the situation necessitated.
The report recommends that the CFMG review and modify its procedures when diagnosing and dealing with methadone overdose.
59-year-old Richard Prichard, suffering from a blockage in his coronary artery, died after being apprehended for driving under the influence of alcohol. Corrections officers decided that his condition didn’t warrant an evaluation by nurses, or monitoring in a sobering cell—which require checks every 15 minutes—despite the fact that his blood alcohol content was twice the legal limit.
While searching for common factors in these deaths, the jurors saw several nexus points—including a lack of communication between medical and jail staff and ineffective health screening procedures. Still, some of the jurors felt that the tragedies could simply be a statistical anomaly.
“Statistics are like that. Sometimes you flip a coin and get five heads in a row,” says juror Steven Strasnick.
While Hanson is concerned about these jail conditions, she and her fellow organizers at Sin Barras do have a different goal in mind. As part of their mission, they believe incarceration is not the best way to prevent and deal with non-violent crime, and would rather governments expand human services. “We ultimately don’t believe it’s humane to cage someone in the first place,” says Hanson.
The grand jury report says that the medical agencies involved in these deaths, such as CIT, have already taken steps to improve their protocol. Until an official statement is released by the Corrections Bureau, there is no way of knowing if any individuals have been held accountable for these five deaths. Deputy Chief Verinsky wrote in an email to GT that the Sherriff’s Office should have an official response to the report by Monday, June 16.
Jury members hope to receive prompt responses from the organizations involved, and that their recommendations are implemented.
“Our hope is that our recommendations are taken very seriously and acted upon as much as is possible given budgets,” says Griscom. “That’s always the difficulty.”