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Home / Articles / News / News /  Death’s in the details
. . . .
Wednesday, Jun 12, 2013

Death’s in the details

Lapses in reporting inmate mortalities raise questions of oversight in San Diego County facilities

By Kelly Davis, Dave Maass
news Illustration by Adam Vieyra

During the past six months, CityBeat has been engaged in an investigation into deaths in San Diego County jails that has revealed an inmate mortality rate substantially higher than both state and national averages.

The investigation, however, has also revealed systemic problems with record keeping and oversight, including the Sheriff’s Department’s failure to report one in 10 deaths to the California Department of Justice as required by state law. Further, these documentation problems, combined with an oppositional attitude toward transparency, have resulted in the department failing to appropriately respond to requests under the California Public Records Act.

These issues raise questions not only of whether the Sheriff’s Department is doing enough to prevent deaths in county detention facilities, but also whether its record-keeping system allows the department, and oversight bodies, to fully grasp the scope of the problem.


State law requires that the death of any person while in law-enforcement custody be reported to the California Department of Justice (DOJ) within 10 days.

For practical reasons, the requirement was boiled down to a standardized form that, while only one page, includes crucial details like the means and manner of death, the location where the death occurred and the custody status of the inmate. Information from the forms is entered into the DOJ’s Death in Custody database, information from which is available to the public upon request. In May 2005, state Attorney General Bill Lockyer released a brief report summarizing 10 years’ worth of data that showed a marked increase in jail and prison inmate deaths. However, no reports have been released since. DOJ spokesperson Lynda Gledhill said such reports are usually legislatively mandated.

In May, CityBeat requested from the Sheriff’s Department all forms for the years 2007 through 2012. There should have been at least 60.

Six deaths—10 percent of the total deaths during that period—weren’t filed with the Attorney General’s office until after CityBeat began asking questions. Sheriff’s spokesperson Jan Caldwell said the missing reports were largely due to lapses in protocol and that the department has recently revised its death-in-custody investigation process to ensure DOJ notification.

“Homicide utilizes an itemized checklist by team sergeants to ensure necessary steps are taken throughout any Homicide investigation,� she said via email. “A checklist entry has been created on this list, to ensure the supervisor makes immediate notification to the person responsible for submitting the DOJ forms on all in-custody deaths in a timely manner.�

Last November, CityBeat requested “all records� related to Russell Hartsaw, an elderly inmate who was beaten to death by other prisoners at George Bailey Detention Facility in July 2011. The sheriff’s legal advisor, Sanford Toyen, denied the request, saying that any records pertaining to Hartsaw were confidential under the California Public Records Act.

The form submitted to the DOJ, however, is, by law, a public record. Six months later, after an additional request, Toyen produced the document, claiming he didn’t intentionally withhold it, but, rather, faulted CityBeat for filing too broad a request and not specifying that Hartsaw was dead.

That response doesn’t sit well with Donna Frye, the former San Diego City Council member who recently stepped down as the city’s director of open government to focus on her role as president of Californians Aware, one of the state’s most influential transparency organizations.

“If the Sheriff’s office was unclear as to what records were being requested, why didn’t they simply ask Ms. [Kelly] Davis what she wanted, rather than attempting ‘to interpret’ her request?� Frye says via email. “Further, it was not the responsibility of Ms. Davis to know the name of the specific forms that the Sheriff keeps related to inmate deaths. It is, however, the responsibility of the Sheriff’s office to keep accurate records of those deaths and provide them in a timely manner.�

The Sheriff’s Department also failed to hand over the individual DOJ reports to family members seeking information on their deceased relatives and to plaintiffs in lawsuits against the county during the discovery process.

“It’s not the loved ones’ responsibility to call [these records] by a certain name,� Frye says. “It’s not the obligation of the requester, because they wouldn’t know this.�

Frye says the Sheriff’s Department should be well aware of the names on the list and have the public records available whenever someone asks for information about the person. She described the Sheriff’s attitude on this as “disrespectful� and “cavalier.�

Of the forms the department did provide to CityBeat, 16 describe the manner and means of death as “pending investigation.� In only two instances was the Attorney General’s office provided with an amended form once the manner and means of death had been determined. Many of the deaths for which no amendment was filed were ones that raised red flags during CityBeat’s research for its investigative series. For instance, the county medical examiner listed inmate Gregory Jewell’s cause of death as natural, resulting from congestive heart failure. The Citizens Law Enforcement Review Board (CLERB)—which is tasked with investigating non-natural inmate deaths—currently has Jewell’s name on its list of open cases and the cause of death as “excessive force.�

No amendment was filed for Tommy Tucker or Jeff Dewall, two inmates who died while being restrained by deputies. Daniel Jordan died within four hours of being booked into San Diego’s Central Jail in 2009; he’d reportedly called his wife to tell her he’d been beaten up by the Chula Vista police officers who arrested him, and he sounded “very drugged� over the phone, his wife told a medical examiner’s investigator. No amended report was filed for Jordan nor for James Phillips, who somehow ended up with a lethal dose of the antidepressant Doxepin.

Inmate deaths are also reported to the Bureau of Justice Statistics (BJS), the research arm of the federal Department of Justice. Counties fill out a form that tallies the total number of deaths each year and individual forms for each death that ask for more information than the state forms—for instance, whether an inmate had ever been held in a psychiatric-observation unit or hospitalized for mental illness, and whether the inmate had been seen by medical staff, had any diagnostic tests or was receiving medication.

CityBeat requested those forms—2007 through 2012— from the Sheriff’s Department on March 20, a week before publication of the first piece in our jail-deaths series. Toyen took until April 2 to respond, saying the department needed an additional two weeks to compile the records. After CityBeat sent a reminder email on April 16, Toyen produced only two documents—the year-end summaries for 2010 and 2012, explaining that that’s all that was available because the forms were submitted electronically.

“The Sheriff’s Department is not required by federal law to complete CJ-9 or CJ-9A forms, nor to retain copies of any forms submitted,� he wrote.

His response seems to contradict the county’s official policy for data retention: “Courts have held that there is a duty to preserve electronic records, including emails… that may be needed as evidence in future litigation. This duty arises when the user knows or has reason to know that the records may be evidence relevant to probable future litigation.�

The county has faced several lawsuits over inmate deaths, as well as threats of others.

On May 6, more than six weeks after our initial request for the federal forms, and in response to another request, Toyen emailed to say that the 2009 individual forms had been located after being “apparently misfiled.�

Caldwell blamed “human error� for the misfiled reports, explaining that the federal forms had been filed along with state forms and turned up only after CityBeat requested copies of the state forms. No other federal forms were located.


In San Diego, there are two citizen boards tasked with overseeing conditions in county jails—the San Diego County Grand Jury, which inspects detention facilities annually, and CLERB.

Neither oversight body has paid much attention to inmate-death rates.

CLERB has, in the past, not been notified of inmate deaths, triggering a request for policy change in 2011, and, in 2010, was provided with an inaccurate count on inmate suicides after expressing concern about policies.

The Grand Jury’s annual detention-facilities reports, compiled after on-site inspections, either ignore inmate deaths—despite the Grand Jury being tasked with obtaining tallies—or grossly undercount deaths. The 2007-2008 Grand Jury, for instance, made a point of noting that there’d been no deaths at one juvenile facility, Camp Barrett, but said nothing about adult facilities. There’s no mention of deaths in the 2008-2009 Grand Jury report despite there being 11 deaths the previous year. The 2010 Grand Jury recommended changes to a juvenile facility to deter suicide attempts via strangulation but was apparently unaware that, in less than two months, three men had hung themselves at San Diego’s Central Jail.

This year’s grand jury reported only four deaths—two of them suicides—between July 1, 2011, and Aug. 1, 2012. The true count for that time period is significantly higher—11 total deaths, five of them suicides. The Grand Jury’s foreman insisted to CityBeat that the numbers came the Sheriff’s Department. Caldwell said the Grand Jury asked for numbers for the Central Jail only. Either way, the count is wrong: While there were four deaths during that period, three, not two, were suicides— two hangings and one drowning.

After CityBeat brought the error to the foreman’s attention, the Grand Jury revised its report but has yet to post it on its website.

Email or follow her on Twitter at @citybeatkelly.

Email or follow him on Twitter @Maassive.