San Diego County
Sheriff ’s Department
It Has Failed to Adequately Prevent and
Respond to the Deaths of Individuals in
Its Custody
February 2022

REPORT 2021‑109

CALIFORNIA STATE AUDITOR
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This report is also available online at www.auditor.ca.gov | Alternative format reports available upon request | Permission is granted to reproduce reports

Michael S. Tilden Acting State Auditor

February 3, 2022
2021‑109
The Governor of California
President pro Tempore of the Senate
Speaker of the Assembly
State Capitol
Sacramento, California 95814
Dear Governor and Legislative Leaders:
As directed by the Joint Legislative Audit Committee, my office conducted an audit of the San Diego
County Sheriff’s Department (Sheriff’s Department) to determine the reasons for in‑custody deaths
of incarcerated individuals and identify the steps it took to address these deaths. The following
report details our conclusion that the Sheriff’s Department has failed to adequately prevent and
respond to the deaths of individuals in its custody.
From 2006 through 2020, 185 people died in San Diego County’s jails—one of the highest totals
among counties in the State. The high rate of deaths in San Diego County’s jails compared to other
counties raises concerns about underlying systemic issues with the Sheriff’s Department’s policies
and practices. In fact, our review identified deficiencies with how the Sheriff’s Department provides
care for and protects incarcerated individuals, which likely contributed to in‑custody deaths. These
deficiencies related to its provision of medical and mental health care and its performance of visual
checks to ensure the safety and health of individuals in its custody.
Furthermore, the Sheriff’s Department has not consistently taken meaningful action when such
deaths have occurred. The department’s reviews of in‑custody deaths have been insufficient and
have not consistently led to significant corrective action. In addition, the Citizens’ Law Enforcement
Review Board (CLERB)—a citizen‑governed board approved by San Diego County voters to restore
public confidence in county law enforcement—has failed to provide effective, independent oversight
of in‑custody deaths. CLERB also failed to investigate nearly one‑third of the deaths of incarcerated
individuals in the past 15 years, which means that dozens of deaths have not been subject to a key
form of review outside of the Sheriff’s Department.
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.
Respectfully submitted,

MICHAEL S. TILDEN, CPA
Acting California State Auditor

621 Capitol Mall, Suite 1200

|

Sacramento, CA 95814

|

916.445.0255

|

916.327.0019 fax

|

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Selected Abbreviations Used in This Report
ADP

average daily population

BSCC

Board of State and Community Corrections

CDCR

California Department of Corrections and Rehabilitation

CLERB

Citizens’ Law Enforcement Review Board

POBR

Public Safety Officers Procedural Bill of Rights

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February 2022

Contents
Summary

1

Introduction

7

Chapter 1
The San Diego County Sheriff’s Department Did Not Take Sufficient
Steps to Prevent the High Number of Deaths in Its Jails

13

Chapter 2
Neither the Sheriff’s Department nor CLERB Has Taken Adequate
Action in Response to the Deaths of Incarcerated Individuals

33

Conclusions and Recommendations

53

Appendix A
In‑Custody Deaths in California’s 15 Largest Counties

59

Appendix B
Scope and Methodology

61

Responses to the Audit
Board of State and Community Corrections

65

California State Auditor’s Comments on the Response From
the Board of State and Community Corrections
Citizens’ Law Enforcement Review Board
California State Auditor’s Comments on the Response From
the Citizens’ Law Enforcement Review Board

71
75
79

California Department of Justice

81

San Diego County Sheriff’s Department

83

California State Auditor’s Comments on the Response From
the San Diego County Sheriff’s Department

115

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Summary
Results in Brief

Audit Highlights . . .

In accordance with federal constitutional law, the San Diego County
Sheriff ’s Department (Sheriff ’s Department) has a responsibility to
provide adequate medical care for individuals while they are in its
custody. Nonetheless, from 2006 through 2020, a total of 185 people
died in San Diego County’s jails—more than in nearly any other
county across the State. Some of these individuals were in custody
for only a few days to a few months; others were waiting to be
sentenced, set to be released, or about to be transferred to different
facilities. Although any death is a tragedy, the high rate of deaths in
San Diego County’s jails compared to other counties raises concerns
and 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.

Our audit of the San Diego County Sheriff’s
Department’s response to deaths of
individuals in its custody highlighted
the following:

Significant deficiencies in the Sheriff ’s Department’s provision of
care to incarcerated individuals likely contributed to the deaths
in its jails. For example, studies on health care at correctional
facilities have demonstrated that identifying individuals’ medical
and mental health needs at intake—the initial screening process—
is critical to ensuring their safety in custody. Nonetheless, our
review of 30 individuals’ deaths from 2006 through 2020 found
that some of these individuals had serious medical or mental health
needs that the Sheriff ’s Department’s health staff did not identify
during the intake process. Some of these individuals died within
four days of their arrest. Moreover, in one case we reviewed, an
incident between two cellmates resulted in one’s death. In this
instance, the intake nurse did not identify that the perpetrator had
a history of mental health issues. Had the perpetrator’s mental
health issues been identified properly at intake, the department’s
staff might have placed this individual in a different cell, leading to a
different outcome.
When we evaluated the intake practices of three comparable
counties, we found that the counties had procedures that are more
comprehensive. For example, the San Diego Sheriff ’s Department
relies on registered nurses to perform the mental health portion of
its intake screening, even though these nurses may not specialize
in mental health care. In contrast, the Riverside County Sheriff ’s
Department’s policy requires that a mental health clinician evaluate
every individual at intake. Implementing similar policies could help
the San Diego Sheriff ’s Department to more effectively identify
mental health needs early.

» Until the Sheriff’s Department
implements meaningful change to
improve its provision of medical and
mental health care in its detention
facilities, it will continue to jeopardize
the safety and lives of individuals in
its custody.
• We found multiple instances of
individuals who requested or required
medical and mental health care
and did not receive it at all or in a
timely manner.
• In our review of deaths that occurred
in the department’s custody, deputies
performed inadequate safety
checks to ensure the well‑being of
those individuals.
» Some of the Sheriff’s Department’s
policy deficiencies are the result of
statewide corrections standards that are
insufficient for maintaining the safety of
incarcerated individuals.
• The Board of State and Community
Corrections should require mental
health evaluations to be performed by
mental health professionals at intake,
and it should clarify and improve
procedures for safety checks.
» The entities responsible for investigating
in‑custody deaths are not doing so in a
thorough, timely, or transparent manner.
• The department’s Critical Incident
Review Board should consistently
review deaths by natural causes,
increase public transparency, and take
substantive steps to prevent similar
future deaths.
continued on next page . . .

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• CLERB should prioritize the
investigations of all deaths that occur
in the department’s custody and
complete those investigations within
the one‑year statutory limit.

In addition, the Sheriff Department’s staff did not always
provide consistent follow‑up care to individuals who requested
or previously received medical or mental health services. Best
practices stress that timely treatment and follow‑up are important
components of any health care system. Although the reasons that
the Sheriff ’s Department did not always follow up consistently—
such as poor policies and communication—varied by case, they
represent deficiencies in its medical and mental health care system
that it needs to address.
For example, one individual urgently requested mental health
services shortly after entering the jail. However, the 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. Although the Sheriff ’s Department’s
policy indicates that a face‑to‑face appraisal with an incarcerated
individual should take place within 24 hours of a mental health care
request to determine the urgency of that request, the department
has not always had this policy. Further, this policy only applies to
mental health requests and not medical health care requests. Thus,
the Sheriff ’s Department does not ensure that it provides prompt
care for all types of needs.
In addition to providing adequate health care, performing safety
checks is a key component of ensuring the well‑being of individuals
in detention facilities. Conducting these checks—which state
law requires hourly through direct visual observation—is the
Sheriff ’s Department’s most consistent means of monitoring for
medical distress and criminal activity. Nonetheless, in our review
of 30 in‑custody deaths, we found instances in which deputies
performed these checks inadequately. 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. When staff members eventually
checked more closely, they found that some of these individuals
showed signs of having been dead for several hours. Although
the Sheriff ’s Department’s assistant sheriff of detentions indicated
that the department has a process for periodically monitoring
whether staff members adequately perform safety checks, it is not
documented in policy. In contrast, the Riverside County Sheriff ’s
Department has a formal policy that requires supervising staff to
regularly review videos of safety checks being performed, and it is
thus in a better position to assess the quality of safety checks.
The problems we identified with the Sheriff ’s Department’s policies
are in part the result of statewide corrections standards that are not
sufficiently robust. The Board of State and Community Corrections

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(BSCC) establishes in regulation the minimum standards that local
detention facilities must follow. Every local jail system throughout
the State uses these standards to create policies for inmate safety
and care. However, some of the standards are insufficient for
maintaining the safety of incarcerated individuals. For example, they
do not explicitly require that mental health professionals perform
the mental health screenings during the intake process. Further,
they do not describe the actions that constitute an adequate
safety check: rather, they simply state that safety checks must be
conducted at least hourly through direct visual observation. Given
that the annual number of incarcerated individuals’ deaths in
county jails across the State increased from 130 in 2006 to 156 in
2020, improving the statewide standards is essential to ensuring the
health and safety of individuals in custody in all counties.
In addition to its failure to adequately prevent the deaths of
individuals in its custody, the Sheriff’s Department has not
consistently taken meaningful action when such deaths have
occurred. The department’s reviews of in‑custody deaths have been
insufficient and have not consistently led to significant corrective
action related to preventing deaths. The Sheriff’s Department’s
internal entity for reviewing critical incidents, such as in‑custody
deaths, and identifying corrective measures—the Critical Incident
Review Board—has not always taken substantive steps to prevent
similar future deaths in the cases we examined. The primary focus
of this board is protecting the Sheriff’s Department against potential
litigation rather than focusing on improving the health and welfare
of incarcerated individuals. Further, this board generally does not
review deaths from natural causes, which represented nearly half of
the deaths of individuals in the custody of the Sheriff’s Department
during the 15‑year period of our review. We are concerned that the
Sheriff’s Department considers the Critical Incident Review Board’s
reviews to be confidential under the attorney‑client privilege and
does not have a process to report the results publicly. Consequently,
the Sheriff’s Department risks conveying to the public that it is not
taking these deaths seriously and making every effort possible to
prevent similar deaths in the future.
The Sheriff ’s Department has also not implemented certain key
recommendations from external oversight entities. From 2006
through 2020, multiple external entities—including the
San Diego County Grand Jury—have made recommendations
to the Sheriff ’s Department in areas related to inmate safety.
Although the Sheriff ’s Department implemented several of these
recommendations, it did not take action on others, even though they
were critical to improving the safety of individuals in its custody.
For example, it did not implement recommendations that involved
enhancing its safety checks and improving the way it communicates
incarcerated individuals’ mental health needs to its staff.

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To restore public confidence in county law enforcement, San Diego
County voters approved the Citizens’ Law Enforcement Review
Board (CLERB) in 1990, a citizen‑governed board. CLERB
is responsible for reviewing complaints of misconduct and
investigating deaths arising in connection with the actions of
officers employed by the Sheriff ’s Department or Probation
Department. However, CLERB has failed to provide effective,
independent oversight of in‑custody deaths. In violation of its
own rules and regulations, CLERB’s investigations of the deaths
of individuals in the Sheriff ’s Department’s custody have not been
independent, thorough, or timely. CLERB has not independently
interviewed witnesses or visited the initial scenes of the deaths.
Further, it has not consistently performed thorough investigations,
and it relies largely on the reviews the Sheriff ’s Department
conducts.
Moreover, CLERB failed to review dozens of deaths in the Sheriff ’s
Department’s jails. State law generally requires that CLERB’s
investigations be performed within a year of discovery of the death
or misconduct. Because CLERB did not consistently prioritize its
investigations of deaths over other complaints of misconduct, it did
not review 13 cases involving deaths in the Sheriff ’s Department’s
jails within the required time limit. Further, CLERB did not
investigate an additional 40 deaths because it did not believe
its rules and regulations required it to review natural deaths.
As a result, it did not identify any weaknesses in the Sheriff ’s
Department’s policies or processes that may have contributed to
these deaths nor develop any recommendations to address these
weaknesses. Although CLERB currently reviews natural deaths, it
lacks specific language in its rules and regulations requiring it to do
so, thus raising concerns about whether its staff could exclude those
reviews in the future.
Given the ongoing risk to the safety of incarcerated individuals,
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. Until the Sheriff ’s Department
makes such changes, the weaknesses in its policies and practices
will continue to jeopardize the health and lives of the individuals in
its custody.

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Summary of Key Recommendations
Legislature
The Legislature should amend state law to require the Sheriff ’s
Department to revise its policies to align with best practices related
to performing intake health evaluations (including requiring that
mental health professionals perform mental health evaluations),
providing follow‑up medical and mental health care, conducting
safety checks, and addressing the other deficiencies that we identify
in this report.
The Legislature should amend state law to require BSCC to amend
its regulations to ensure that county sheriff departments have
mental health professionals perform incarcerated individuals’
mental health evaluations at intake and have staff conduct safety
checks that are sufficiently detailed to determine that incarcerated
individuals are alive.
The Legislature should amend state law to require the Sheriff ’s
Department’s Critical Incident Review Board to review natural
deaths and develop a process to make public the facts discovered
and recommendations made in response to all in‑custody deaths.
CLERB
To ensure that it completes investigations of all deaths that occur
in the Sheriff ’s Department’s custody within the one‑year time
limit, CLERB should revise its rules and regulations by May 2022 to
prioritize these investigations above all other investigations.
CLERB should revise its rules and regulations by May 2022 to
include investigating natural deaths as part of its responsibilities.
Agency Comments
Although the Sheriff ’s Department generally agreed with
our recommendations, it questioned our audit approach and
disagreed with our findings and conclusions. BSCC disagreed
with our findings and recommendations but indicated that
it would discuss whether amendments to its regulations are
warranted. The Department of Justice and CLERB agreed with
our recommendations.

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Introduction
Background
The mission of the San Diego County Sheriff’s
Department (Sheriff’s Department) is to provide
high‑quality public safety services necessary to make
San Diego the safest urban county in the nation. As the
text box describes, the Sheriff’s Department operates a
system of seven detention facilities. It also operates
patrol stations, a crime laboratory, and an array of
support operations. The Sheriff’s Department’s fiscal
year 2020–21 adopted budget includes more than
2,000 employees who work in its detention facilities,
including correctional staff (sworn staff ), medical and
mental health care staff (health staff ), and
administrative staff. In this report, we refer to all of
these staff members collectively as detention staff.

The Sheriff’s Department’s Detention Facilities
• The department operates a system of seven detention
facilities throughout San Diego County.
• Three of the detention facilities both process (book)
individuals entering the jail system and house them.
• The other four facilities house individuals who are
transferred after being booked.
• During our audit period from 2006 through 2020, the
seven facilities collectively housed an average of about
5,200 individuals daily (average daily population) and
booked an average of about 85,000 individuals annually.
Source: Sheriff’s Department documents and BSCC data.

San Diego County residents elect a sheriff to a
four‑year term to serve as the chief executive of the
Sheriff’s Department. The current elected sheriff has been in office
since 2009. Under the elected sheriff’s guidance, the department must
follow standards for jail conditions and treatment of incarcerated
individuals set in regulation by the Board of State and Community
Corrections (BSCC). The board also establishes local corrections
training requirements and performs inspections of local detention
facilities, to which the Sheriff’s Department is subject.
Deaths can happen in detention facilities for various reasons. The
California Department of Justice asks counties to classify in‑custody
deaths into seven main categories: natural death, homicide by law
enforcement, homicide by other inmate, suicide, accidental death,
pending investigation, or cannot be determined/other. Regardless of the
category, different entities in San Diego County have responsibilities to
prevent, respond to, and investigate deaths of incarcerated individuals,
as we discuss below.
The Sheriff’s Department’s Role in Preventing and Responding to the
Deaths of Incarcerated Individuals
As Figure 1 shows, the incarceration process starts when a law
enforcement officer arrests an individual in San Diego County
and brings him or her to a jail for processing, which is also known
as booking. One of the most important steps in the intake process
that follows is the individual’s health screening. This screening is the
Sheriff ’s Department’s first opportunity to identify an individual’s

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Examples of Housing Types in the Sheriff’s
Department’s Facilities
• Safety Cell/Enhanced Observation Housing: Temporary
housing units constructed to maximize safety by removing
physical features that could be used to inflict harm. These
units are recommended for individuals who are actively
self‑harming, assaultive, or at risk of suicide. Staff closely
monitor individuals at random intervals.
• Medical Observation Beds: Beds located close to
a nursing station for individuals whose condition
necessitates hourly monitoring by health staff.
• Segregation Housing: Housing areas where individuals
are placed in cells isolated from the general population
and receive services and activities apart from others. Staff
may place individuals in this housing for their own safety,
staff safety, facility security, or pending a disciplinary
action hearing.
• Mainline Housing: Housing areas for individuals who
are classified as general population and therefore do not
need to be isolated from others for security reasons or for
medical or mental health reasons.
Source:

medical and mental health needs. After this health
screening, the next major step is classification,
which determines an individual’s housing
assignment. As the text box shows, the Sheriff ’s
Department has various types of housing in its
facilities. An individual’s housing assignment is
critical to safety and care because it indicates to
detention staff whether that individual has special
needs or characteristics that warrant precaution.
To determine an initial housing assignment, sworn
staff interview the individual; review the person’s
current booking information, complete criminal
history, and past incidents in custody; and
consider any information or instructions provided
by health staff members regarding restrictions
related to medical or mental health needs.
The department may subsequently change an
individual’s housing assignment if circumstances
require reclassification.

When individuals are in custody, the Sheriff ’s
Department is responsible for providing basic
Sheriff’s Department policies and state law.
health care services and for performing safety
checks at least every hour to provide for their
health and welfare. Incarcerated individuals may
request medical or mental health attention, or
dental care, as needs arise. Providing care on an ongoing basis and
performing adequate safety checks are vital to ensuring the safety of
incarcerated individuals.
When an individual dies in the custody of the Sheriff ’s Department,
its homicide unit (homicide unit) investigates the death and
assists the San Diego County Medical Examiner’s Office (Medical
Examiner’s Office) by attending the autopsy and answering any
questions surrounding the circumstances of the death. The
Medical Examiner’s Office, an agency independent of the Sheriff ’s
Department, investigates all deaths of persons in custody. The
Medical Examiner’s Office’s main function is to determine the
manner of death—such as accidental—and the cause of the death—
such as by drug overdose.
The Sheriff ’s Department also performs other internal reviews of
in‑custody deaths. For instance, within 30 days following a death,
it must review the circumstances surrounding the incident and
pertinent medical and mental health services and reports (30‑day
medical review). It must also complete a critical incident review
for all deaths except natural deaths. Most of these reviews could
result in the Sheriff ’s Department taking corrective action, such as

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changing policies or initiating employee discipline. We discuss
the Sheriff ’s Department’s internal reviews in detail later in
this report.
Figure 1
The Sheriff’s Department’s Booking Process

1

  
    
   

2

      
  
  
 
  

     
      
    

 
     
  

3

  
  
   


4

     
  

Source: Sheriff’s Department policies and procedures.

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The Citizens’ Law Enforcement Review Board’s Responsibilities
Related to the Deaths of Incarcerated Individuals
The Citizens’ Law Enforcement Review Board (CLERB) is a key
county entity that provides external oversight when an incarcerated
individual dies in San Diego County. San Diego County voters
amended the county charter in 1990 to require the County Board
of Supervisors (county board) to establish CLERB to investigate
complaints against officers employed by the Sheriff ’s Department
and Probation Department. CLERB’s mission is to increase the
accountability of and public confidence in peace officers employed
by the San Diego County’s Sheriff ’s Department and the Probation
Department. As the text box describes, CLERB is responsible for
achieving its mission by conducting independent,
thorough, timely, and impartial reviews of
CLERB’s Responsibilities
complaints of misconduct, among other things.
This audit focuses only on CLERB’s investigations
Investigating complaints against peace officers that
of deaths in the Sheriff ’s Department’s jails. The
involve the following allegations:
San Diego County Charter establishes CLERB’s
• Use of excessive force, discrimination, or sexual harassment
power to subpoena, administer oaths, and require
towards members of the public.
the attendance of witnesses and the production of
• The improper discharge of a firearm.
books and papers pertinent to its investigations.
• Illegal search or seizure.

CLERB currently consists of 11 board members
nominated by San Diego County’s chief
administrative officer and appointed by the county
board for three‑year terms. Serving without
compensation, CLERB members must be qualified
electors of San Diego County, possess reputations
for integrity and responsibility, and demonstrate
an active interest in public affairs and service.
County rules prohibit its employees or individuals
employed as peace officers from serving. CLERB
makes advisory findings on complaints and
recommendations for policy and procedure
changes to the sheriff, chief probation officer, and
the county board. CLERB has also established
rules and regulations to further facilitate its
operations, which the county board has approved.

• False arrest.
• False reporting.
• Criminal conduct or misconduct.
Reviewing, investigating, and reporting on the following
incidents, regardless of whether a citizen files a complaint:
• The death of any individual arising out of or in connection
with actions of peace officers.
• Incidents involving the discharge of a firearm.
• Use of force by peace officers resulting in great
bodily injury.
• Use of force by peace officers at protests or other events
protected by the First Amendment.
Source: CLERB rules and regulations.

CLERB’s staff support the CLERB members by
conducting complaint investigations, preparing
written reports with findings and recommended policy changes,
and transmitting the final reports to the Sheriff ’s Department,
Probation Department, and the county board. CLERB’s staff
currently includes five special investigators, one supervising
special investigator, an administrative secretary, and an executive
officer. CLERB members appoint its executive officer, to whom
they have delegated most of their authority over the other staff.
I

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CLERB’s executive officer must possess a bachelor’s degree and
five years of management‑level experience. CLERB’s special
investigators must have five years of experience performing
investigations for a law enforcement agency, district attorney’s
office, or other governmental agency or organization.
The Attorney General’s and County Board’s Oversight of the
Sheriff’s Department
The county board is the governing body of San Diego County and
is composed of an elected supervisor from each of the county’s five
districts. State law gives the county board the authority to supervise
the official conduct of all county officers, as well as officers of all
districts and other subdivisions of the county, including CLERB.
However, the county board’s oversight of the county sheriff has
limitations, as Figure 2 shows. The California Constitution and state
law provide that the county sheriff is an elected county official with
certain independent functions and duties with which the county
board cannot interfere. Nonetheless, state law establishes the
county board’s budgetary authority over the Sheriff ’s Department,
and it also exercises some oversight—albeit minimal—through its
establishment and oversight of CLERB.
Although the county board has limited oversight of the sheriff,
the state constitution designates the State’s attorney general as the
chief law officer of the State. Specific statutes describe the attorney
general’s authority. For example, state law requires the Sheriff ’s
Department to report to the attorney general all facts concerning
the death of an individual while in its custody within 10 days of
that death. To ensure uniform and adequate enforcement of the
laws of the State, the attorney general may also call into conference
all of the sheriffs, district attorneys, and chiefs of police in the State
for the purpose of discussing the duties of their respective offices.
Further, the attorney general may bring a civil action to eliminate
the pattern or practice of conduct by law enforcement officers that
deprives any person of rights protected by law or the constitution.
Finally, when necessary for the public interest, the attorney general
is authorized to direct sheriff activities related to the investigation
or detection of crime within a county.

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Figure 2
The County and State Have Oversight of the Deaths of Incarcerated Individuals

County Board
of Supervisors

      
    

      
       

........... ....................................

   
     
  

Citizens’ Law Enforcement
Review Board
 ƒ  
     „„
    †

  ‡
  ˆ  ‡ 
      
        

‰      
  ‡ 
    

 
    
    Š   


San Diego County
Sheriff’s Department
          
        

€    
‚

€ €   
     
  

€       
     


The state also has oversight . . .
Attorney General
         

           
           

             
  
   ­       

Source: California Constitution, San Diego County charter, state law, CLERB’s rules and regulations, and Sheriff’s Department policies.

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Chapter 1
THE SAN DIEGO COUNTY SHERIFF’S DEPARTMENT DID
NOT TAKE SUFFICIENT STEPS TO PREVENT THE HIGH
NUMBER OF DEATHS IN ITS JAILS
Chapter Summary
From 2006 through 2020, a total of 185 people died in San Diego
County’s jails—one of the highest totals among counties in the
State. The high rate of deaths in San Diego County’s jails compared
to other counties raises concerns about underlying systemic
issues with the Sheriff ’s Department’s policies and practices. In
fact, our review identified deficiencies with the way the Sheriff ’s
Department provides care for and protects incarcerated individuals
that likely contributed to deaths in its jails. These deficiencies
related to its provision of medical and mental health care, as
well as its performance of checks to ensure the safety and health
of individuals in its custody. When we evaluated the policies of
three comparable counties, we found that some have adopted
procedures that could address weaknesses we identified at the
San Diego Sheriff ’s Department. That said, the problems we
identified with the Sheriff ’s Department’s policies are in part the
result of certain statewide corrections standards that are not robust
or specific enough, leaving the establishment of effective practices
to the discretion of the individual counties. Given that the annual
number of incarcerated individuals’ deaths in county jails across
the State increased from 130 in 2006 to 156 in 2020, improving the
statewide standards is essential to ensuring the health and safety of
incarcerated individuals in all counties.
In the Past 15 Years, More Individuals Died While in the San Diego
Sheriff’s Department’s Custody Than in the Custody of Nearly Any
Comparable County in the State
State data on deaths in custody at county jails show that San Diego
County reported the second‑highest number of in‑custody deaths
over the past 15 years.1 It followed only Los Angeles County, which
is significantly larger. Further, there continues to be a substantial
number of deaths in San Diego County’s jails, as Figure 3 shows.
Many of the individuals who died were in the Sheriff ’s Department’s

1

State law requires a law enforcement agency or an agency in charge of a correctional facility,
including county sheriff’s departments, to report any case in which a person dies in its custody
to the Office of the Attorney General within 10 days after the death. We present an interactive
dashboard for viewing statewide data and additional detail regarding deaths in county detention
facilities at https://www.auditor.ca.gov/reports/2021‑109/supplemental.html.

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custody for only a few days to a few months before their deaths.
Some of these individuals were awaiting trial, or scheduled to be
released or transferred to state hospitals.
Figure 3
There Continues to Be a Substantial Number of Deaths in San Diego County’s Jails

Total Deaths
in the Sheriff's Department's Jails (2006–2021)




2006





2007





2008

 

2009



2010

  

2011

  

2012

  

2013

  

2014

  

2015

 

2016

  

2017

  

2018

 

2019

 

2020



2021*

  
0

2

4

6

8

10

12

14

16

18





20

Total Deaths
Source: California Department of Justice in‑custody death data, BSCC data, and Sheriff’s Department information.
* We use the Sheriff’s Department’s information on in‑custody deaths in 2021 because it was not included in the California Department of Justice
data, which is as of May 2021. We use ADP information from the Sheriff’s Department for 2021 because BSCC did not have complete ADP data
for 2021.

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February 2022

In comparison to similar counties, more individuals died in the
San Diego Sheriff ’s Department’s custody in the past 15 years as
Figure 4 shows. We identified the Alameda County Sheriff ’s Office
(Alameda Sheriff ’s Office), Orange County Sheriff ’s Department
(Orange Sheriff ’s Department), and Riverside County Sheriff ’s
Department (Riverside Sheriff ’s Department) as comparable
considering their size, geographical location, and other factors. The
text box shows the average daily population (ADP) and bookings
from 2006 through 2020 for each of these four counties.2 From
2006 through 2020, 185 incarcerated individuals died in the
San Diego Sheriff ’s Department’s jails, in comparison
to 99 in the jails of the Alameda Sheriff ’s Office, 111 in
Orange Sheriff ’s Department’s jails, and 104 in
Average Annual ADP and Bookings
Riverside Sheriff ’s Department’s jails. More recently,
From 2006 Through 2020
from 2016 through 2020, 72 people died while in the
care of the San Diego Sheriff ’s Department, whereas
ADP
BOOKINGS
25 people died in the care of the Alameda Sheriff ’s
Alameda Sheriff’s
3,325
51,842
Office, 46 in Orange Sheriff ’s Department, and 37 in
Office
Riverside Sheriff ’s Department. Even when
Orange Sheriff’s
5,877
59,263
considering each of these counties’ jail systems’ ADP
Department
and number of bookings, the rate of deaths reported
Riverside Sheriff’s
3,668
54,025
by the San Diego Sheriff ’s Department still exceeded
Department
that of the comparable counties. In fact, we reviewed
San Diego Sheriff’s
5,162
85,631
Department
data from the 15 largest counties in the State and
found that the rate of deaths in San Diego County was
Source: BSCC data and San Diego Sheriff’s Department
among the highest.3 Although any death is a tragedy,
bookings data.
the high rate of deaths at San Diego County compared
to other counties is particularly concerning.
When we reviewed the manner of death, the San Diego Sheriff ’s
Department had a notably higher number of suicides and natural
deaths than the comparable counties, as Table 1 shows.4 Alarmingly,
a total of 52 individuals in the San Diego Sheriff ’s Department’s
jails died by suicide over the past 15 years, which is more than
twice the number in each of the comparable counties. Additionally,
more individuals died of natural and accidental causes in the
custody of the San Diego Sheriff ’s Department than in the custody
of each of the comparable counties, raising concerns about its
ability to provide adequate safety and medical care to those it
incarcerates. Natural deaths can include deaths from pre‑existing
2

The ADP represents the number of incarcerated individuals housed in a jail system for any given
day over a period of time and is used to determine whether a jail is operating at or near capacity.
Bookings represent the total number of individuals who were processed through the county
jail system.

3

Appendix A provides the number and rate of deaths in the 15 largest counties in relation to their
ADPs and bookings.

4

We present an interactive dashboard for viewing data on the age, race, and gender of the
individuals who have died in each county detention facilities system at
https://www.auditor.ca.gov/reports/2021‑109/supplemental.html.

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medical conditions and deaths resulting from inadequate care.
After adjusting the comparisons based on each county’s ADP, the
San Diego Sheriff ’s Department still has historically had the highest
rate of natural deaths and suicides.
Figure 4
Over the Past 15 Years, More Individuals Died in San Diego County’s Jails Than in Those of Comparable Counties
200
180
160
Total Deaths From 2006 Through 2020

16

140
120
100
80
60
40
20
0

Alameda

Orange

Riverside

San Diego

Taking into consideration the number of bookings and the ADP at
each county jail system, San Diego still had the highest rate of
deaths, both in the past 15 years and in the most recent five years.
Source: California Department of Justice in‑custody death data and BSCC data.
We present interactive dashboards for viewing statewide data and additional detail regarding deaths in county detention facilities at
https://www.auditor.ca.gov/reports/2021‑109/supplemental.html.

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February 2022

Based on data the Sheriff’s Department provided, in the most recent
three years—2018 through 2020—the percentage of deaths of Black
individuals in the Sheriff’s Department’s custody was disproportionately
higher than their overall composition of the jail population. White
individuals died at proportionally higher rates in 2007, 2009 through
2014, 2016, 2017, and 2020. In 2006, 2008, and 2015, the percentage
of deaths among Hispanic individuals exceeded their population
percentage. Although racial bias was not the focus of this report, our
review of the Sheriff’s Department’s policies and procedures identified
widespread deficiencies in its policies and practices for ensuring the
health and safety of the individuals of all races and ages in its care.
Table 1
More Individuals in San Diego County’s Jails Died by Suicide or Natural Causes
Than Individuals in the Custody of Comparable Counties
MANNER OF DEATH

---SAN DIEGO

ALAMEDA

ORANGE

RIVERSIDE

Total Deaths by County Sheriff’s Department From 2006 Through 2020
Accidental

31

19

13

21

Homicide (by law enforcement)

4

0

1

2

Homicide (by other inmate)

8

4

4

6

Natural

88

52

77

51

Suicide

52

22

14

23

Other

2

2

2

1

Totals

185

99

111

104

Source: California Department of Justice in‑custody death data.
We present interactive dashboards for viewing statewide data and additional detail regarding deaths in
county detention facilities at https://www.auditor.ca.gov/reports/2021‑109/supplemental.html.
Note: In San Diego County, accidental deaths mainly included drug overdoses. The two deaths shown as
other include one pending investigation and one undetermined manner of death.

We also found that sheriff ’s departments did not report some deaths
that occurred after incidents in jails because the individuals were
released before their deaths. For example, we found instances in which
the coroner or medical examiner’s offices described individuals dying
in hospitals after incidents in the county jails, such as attempted
suicide or medical emergencies. However, the respective counties did
not report these deaths to the attorney general because the state law
requiring reporting of in‑custody deaths requires sheriff ’s departments
to report only those individuals who died while in custody at the time
of death and not individuals who died after having been released.5
5

For example, state law allows sheriff’s departments to compassionately release individuals from
custody who would not reasonably pose a threat to public safety, and the incarcerated individual
upon diagnosis by the examining physician, is deemed to have a life expectancy of six months or less.

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Example of a Death That State Law
Does Not Require to Be Reported
July 1–An individual attempted suicide in a county jail
but initially survived. The individual was transported to
the hospital.
July 10–The sheriff’s department compassionately released
the individual from custody.
July 15–The individual later died in the hospital as a result
of the injuries from the attempted suicide.
Source: Records from sheriff’s departments.

The text box provides an example in which
sheriff ’s departments would not need to report a
death to the attorney general. Consequently,
sheriff ’s departments may be underreporting to
the attorney general and to the public the number
of deaths occurring from incidents in the jails.
The Sheriff’s Department’s Failure to Consistently
Provide Adequate Care Likely Contributed to Its
In‑Custody Deaths

We selected 30 individuals who died in the
Sheriff ’s Department’s jails from 2006 through
2020, weighted toward deaths that occurred in the
last four years. Our selection included natural deaths, accidental
deaths, suicides, and homicides.6 Our review of the associated case
files identified numerous problems with the Sheriff ’s Department’s
care of these individuals, starting with the inadequate health
screenings it performed upon their initial arrivals through its
insufficient responses to their medical emergencies, as Figure 5
shows. The deficiencies we identified in these areas for all types of
deaths—including deaths classified as natural—suggest that the
problems with the Sheriff ’s Department’s care for incarcerated
individuals are systemic.
The assistant sheriff of detentions at the Sheriff ’s Department
asserted that the department is aware that its policies are not
followed all of the time and recognizes that employees make
mistakes, but it holds employees accountable when violations are
discovered and makes every effort to provide additional training
to prevent a recurrence. However, as the cases in our review show,
failing to follow policies even in limited instances can result in the
loss of life.
When we evaluated the policies at the Alameda Sheriff ’s Office,
Orange Sheriff ’s Department, and Riverside Sheriff ’s Department,
we identified instances in which these entities have procedures that
are more robust than those of the San Diego Sheriff ’s Department.
If the San Diego Sheriff ’s Department followed these procedures,
it could better ensure the health and safety of the individuals in
its custody.

6

To comply with audit standards, we did not select cases involved in active litigation, including
cases related to COVID‑19, in order to avoid interfering with ongoing legal proceedings. Although
the Sheriff’s Department had reported one death in 2020 and one death in 2021 that were related
to COVID‑19, it indicated that the manner of death has not yet been determined for 11 other cases
in 2021, as of January 2022.

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February 2022

Figure 5
Significant Deficiencies in the Sheriff’s Department’s Policies and Procedures Likely Contributed to the Deaths of
Individuals in Its Custody

1
2
3
4

Insufficient Health
Evaluations At
Intake

  
      
      
   

Inconsistent
Follow-Up Care


  
        
     
      

Inadequate
Safety Checks

   
        
  
   

Unnecessary Delays    
       
in Performing
     
Lifesaving Measures
   

Source: The Sheriff’s Department’s jail records, surveillance videos, medical records, medical examiner reports, and homicide investigation
documents related to a selection of 30 deaths of incarcerated individuals.

The Sheriff’s Department Did Not Ensure That It Identified Individuals’
Medical and Mental Health Needs at Intake
Because the Sheriff ’s Department did not always properly identify
the medical and mental health needs of individuals in our review at
intake, some of them did not receive the care they required. Studies
on health care at correctional facilities indicate that identifying
individuals’ health needs at intake is critical to ensuring their safety
in custody. For example, one of the keys to identifying potential
suicidal behavior is through inquiry during the intake screening.

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In at least eight of the 30 cases we reviewed, individuals had
serious medical or mental health needs that health staff did not
identify or communicate to detention staff at intake. Five of these
individuals died within four days of their arrest. For example, in
one case, an intake nurse determined that an individual needed
to have a secondary nurse evaluation because the individual
exhibited possible symptoms of drug withdrawal. However,
there is no evidence in the case records that the intake nurse
communicated this conclusion to other staff. The case records and
video surveillance indicate that the individual died 24 hours after
completing booking from complications resulting from a drug
overdose without having seen another health professional.
In some cases, the Sheriff’s
Department did not promptly
and properly identify individuals’
mental health needs, because
mental health professionals
generally do not participate in its
intake health screenings.

In some of the cases we reviewed, the Sheriff ’s Department did not
promptly and properly identify individuals’ mental health needs
because mental health professionals generally do not participate in
its intake health screenings. Registered nurses perform the medical
and mental health screenings at intake—asking both mental health
and medical questions. These nurses are trained medically but do
not necessarily specialize in mental health, which means that they
may miss key signs of mental health needs. According to policy,
if the registered nurse identifies an individual as having mental
health needs at intake, the nurse refers the individual for further
evaluation by a qualified mental health professional. However, even
if the nurse identifies a need for a further mental health assessment,
the Sheriff ’s Department’s policy may not require the individual to
receive that assessment sooner than 30 days after intake, depending
on the severity of an individual’s symptoms. We noted one county
had adopted more robust intake screening practices. Unlike the
San Diego Sheriff ’s Department, the Riverside Sheriff ’s Department
policy requires that a mental health clinician evaluate every
individual before being housed, which could help to more effectively
identify mental health needs early.
The San Diego Sheriff ’s Department is currently advertising to hire
additional mental health staff, and its director of mental health
indicated that the Sheriff ’s Department is aiming to have a qualified
mental health professional, such as a mental health clinician or
a psychologist, complete the mental health evaluations at intake.
The county board approved additional funding in June 2021 for the
Sheriff ’s Department to hire a substantial number of additional
nurses and mental health professionals.
In addition, the Sheriff ’s Department’s intake nurses sometimes
have not obtained complete medical and mental health history
information on individuals. Although they may ask the individuals
to sign a release of information that provides the department access
to their medical and mental health records, individuals can refuse to
sign. Historically, Sheriff ’s Department nurses have not had

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immediate access to county health records, which
could be key to identifying health needs at intake.
For example, the text box describes a case involving
two cellmates that resulted in one’s death. In this
instance, a different outcome might have resulted
had staff identified the perpetrator’s mental health
history at intake.

In‑Custody Death: Case Example 1
An intake nurse did not identify an individual’s mental
health needs and did not have access to the individual’s
mental health history. Once incarcerated, that individual
killed their cellmate.
After the cellmate’s death, the Sheriff’s Department
discovered the perpetrator’s history of mental illness. Had
staff known about this history, they likely would have placed
the perpetrator in a different cell, where they could better
meet the individual’s mental health needs and better ensure
others’ safety.

The Sheriff ’s Department entered into an
agreement in September 2021 with the county
Health and Human Services Agency to share
behavioral health and medical information. The
assistant sheriff of detentions stated that the
Source: Records from the Sheriff’s Department.
Sheriff ’s Department is in the process of getting
access to this information. However, the Sheriff ’s
Department does not currently plan to require its
intake nurses to look up each individual in the system. We believe
this should be a standard step in the intake process to better ensure
that the Sheriff ’s Department has a more comprehensive health
history for each individual who comes into its care. In fact, the
Riverside Sheriff ’s Department’s policy requires mental health
staff to review Riverside County’s electronic health record system
to determine whether an incarcerated individual has a history of
receiving behavioral health care in Riverside County.
The Sheriff’s Department Did Not Consistently Follow Up With
Individuals Who Needed Medical and Mental Health Services
Our case review found that Sheriff ’s Department staff did not
always follow up after individuals previously received or requested
medical or mental health services, even though these individuals
often had serious needs that, when unmet, may have contributed
to their deaths. Best practices stress that timely treatment and
follow‑up are important components of any health care system.
Although the reasons that the Sheriff ’s Department did not
consistently follow up—such as poor policies and communication—
varied by case, they represent deficiencies in its medical and mental
health care system that it needs to address.
In some of the cases we reviewed, individuals reported to health
staff that they were experiencing persistent symptoms, yet they did
not receive timely evaluations from a physician. For example, in
two cases involving natural deaths, individuals reported symptoms
multiple times over the course of one to three weeks. Although
these individuals were treated for a number of other medical
and mental health issues, medical records show that they did not
receive prompt attention from a physician for the symptoms that
related to their deaths. Nurses originally assessed and treated

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these individuals for these symptoms. However, these individuals’
medical conditions worsened, and medical records show that they
did not receive a physician’s evaluation before dying. Guidelines
from the National Commission on Correctional Health Care
(National Commission)—an organization that establishes standards
for health services in correctional facilities—state that generally if
an incarcerated individual reports to the nurse for evaluation more
than twice for the same complaint and has not seen a physician,
the individual should be scheduled to do so. However, this did not
happen in these two cases. The Sheriff ’s Department’s handling of
these cases raises concerns over its follow‑up process for individuals
experiencing persistent symptoms.
In other cases, potential deficiencies in the Sheriff ’s Department’s
policies related to mental and behavioral health treatment resulted
in individuals not receiving services or needed follow‑up. For
example, in one case, an incarcerated individual who had previously
threatened suicide was released from a safety cell placement and
enhanced observation housing. Although placement in a safety cell
indicates that individuals are a danger to themselves or others, the
Sheriff Department’s policy at that time did not specify time frames
for ongoing follow‑up after such placement. In this case, mental
health staff followed up only once with the individual after release
from enhanced observation housing, and they assessed that the
individual was low‑risk. Two weeks after the individual’s discharge
from enhanced observation housing and about 12 days after the
individual’s lone follow‑up encounter with a mental health clinician,
the individual died by suicide.

While the Sheriff’s Department’s
revised policy for the follow‑up
process after an individual’s
discharge from a safety cell is
an improvement over its past
policy, the department should
reconsider the minimum ongoing
follow‑up required.

Subsequently, the Sheriff ’s Department revised its policy in 2019 for
follow‑up care after release from a safety cell, but studies suggest that
its revised policy may still be inadequate. Its revised policy delineates
the follow‑up process for individuals after discharge from a safety cell
or enhanced observation housing at a variety of intervals depending
on certain conditions—every 24 hours, every three to seven days,
and every seven to 14 days. Individuals may continue to receive
follow‑up care at one of these intervals if certain conditions are met,
including if it is their first time in detention, if they have recently
attempted suicide, or if they have been charged with certain types
of crimes. Although these follow‑ups can decrease in frequency, all
of these individuals must have a follow‑up at least every 90 days.
However, all individuals who have been placed into a safety cell or
enhanced observation housing have demonstrated that they have
significant mental health needs. While this policy is an improvement
over its past policy, the Sheriff ’s Department should reconsider the
minimum ongoing follow‑up required. Reports and studies related to
mental health indicate that more frequent psychological follow‑up,
such as check‑ins performed weekly rather than every 90 days, leads
to faster recovery and is more effective.

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Moreover, although the Sheriff’s Department’s policy indicates that a
nurse should conduct a face‑to‑face appraisal with
an incarcerated individual within 24 hours of a
mental health care request to determine the urgency
In‑Custody Death: Case Example 2
of that request, it has not always had this policy. As
Day 1: At an intake screening, a nurse determined that an
the case example in the text box describes, in one of
individual was mentally stable but initiated a referral for
the cases we reviewed the department’s weak policy
mental health services.
likely contributed to the individual’s death by suicide,
and the department revised this policy several
Day 2: The individual urgently requested mental health
services. Staff denied the request, stating that the individual
months later. However, the revised policy still only
would be seen as soon as their referral was processed.
requires a 24‑hour face‑to‑face appraisal for mental
health requests, not medical health care requests.
Day 4: The individual died by suicide without having seen a
Therefore, inmates with urgent medical needs may
mental health professional.
not get prompt care. Best practices indicate that a
Source: Records from the Sheriff’s Department.
face‑to‑face appraisal should apply to all
nonemergency health care requests.
When we evaluated the policies of other counties, we identified a
number of improvements the Sheriff’s Department should make
to its policies and protocols related to following up on individuals’
medical and mental health care needs. For instance, the Orange
Sheriff’s Department has a policy for assigning a behavioral health
acuity level rating (acuity level rating) to each person who sees a
mental health clinician during intake or whose mental health status
alters during their stay in custody, necessitating a mental health
assessment. This acuity level rating, which rates the severity of mental
health needs, helps to inform housing location, the provision of
mental health services, and discharge planning for when people leave
custody. Such a system could help to identify mental health needs,
track those needs, and communicate this information to appropriate
staff to ensure that these needs are met, likely reducing the risk of
death to the individual or others.
In addition, all three comparable counties have stronger policies for
instances when incarcerated individuals refuse medical or mental
health care. For some of the cases we reviewed, these refusals were
frequent, despite the individual’s need for consistent care. The
San Diego Sheriff’s Department and the three comparable counties
have policies that require detention staff to witness and document an
individual’s refusal to accept medical treatment or care. However, the
Alameda Sheriff’s Office, Orange Sheriff’s Department, and Riverside
Sheriff’s Department also require a health staff member to witness
and sign the refusal. In contrast, San Diego allows a single sworn staff
member to be the only signer if health staff are unavailable to serve
as the second witness to the verbal refusal of care. Consequently,
we identified several instances in which sworn staff were the only
witnesses when incarcerated individuals refused to sign the refusals.
Because follow‑up care is important, it is critical that the desire to
refuse care be shared with health staff who are in a better position

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to ask appropriate questions, explain the adverse consequences to
health that may occur as a result of the refusal, and assess whether an
individual has critical health needs that should be addressed.
The chief medical officer of the Sheriff ’s Department asserted that
many of the issues we identified through our review are case‑specific
and should not be used to draw generalizations about the
department’s provision of health care. He also stated that the Sheriff ’s
Department has made a significant number of improvements to
its health care system in recent years, such as adding an electronic
medical record system and increasing physician and nursing support.
He explained that the Sheriff ’s Department is in the process of
obtaining accreditation from the National Commission. To attain
accreditation, the Sheriff ’s Department must meet certain standards
related to health care services and support, governance and
administration, personnel and training, and other areas.
When the National Commission reviewed the Sheriff ’s Department’s
jails in 2017, it found that they did not meet many of its standards,
particularly those related to mental health. The chief medical officer
indicated that the Sheriff ’s Department plans to contract with an
outside health care organization to consolidate current services and
expand its capabilities for the provision of comprehensive health care
services, which may help it meet the requirements for accreditation.
He further stated that the Sheriff ’s Department is participating in a
university research study that could lead to some facilities receiving
accreditation sooner. Nonetheless, the department may be a couple
of years away from obtaining full accreditation for all of its facilities.
Although seeking accreditation
from the National Commission
may address some of the problems
we identify in this report, the
Sheriff’s Department should not
wait to implement key changes
that would improve the safety of
incarcerated individuals.

Although seeking accreditation from the National Commission may
address some of the problems we identify in this report, the Sheriff ’s
Department should not wait to implement key changes that would
improve the safety of incarcerated individuals. We are concerned that
this trend will continue if the Sheriff ’s Department fails to quickly
implement significant changes. In fact, the Sheriff ’s Department
indicated that the number of in‑custody deaths increased to
18 in 2021—the highest in 15 years.
The Sheriff’s Department Performed Insufficient Safety Checks
Performing safety checks is the Sheriff ’s Department’s most
consistent means of monitoring for medical distress and crime
occurring in its jails. According to state law, local detention facilities
must conduct safety checks at least hourly through direct visual
observation of all incarcerated individuals. They must also have a
written plan to document routine safety checks. Nonetheless, in our

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review of 30 in‑custody deaths, we found that sworn staff did not
always perform safety checks adequately. As a result, they did not
realize several individuals had died until hours afterward.
In fact, in several of the cases in our review for which the Sheriff ’s
Department has video files of safety checks, we found instances
when sworn staff performed checks inadequately for the purpose
of ensuring the safety of the individuals involved. Department
policy requires that staff who are conducting safety checks look for
any obvious signs of medical distress, trauma, or criminal activity.
Although some video files were unavailable or incomplete for the
30 cases we reviewed, we reviewed the safety check logs and available
video surveillance footage of sworn staff conducting checks.
Based on our review of video surveillance footage, we observed
multiple instances of sworn staff who spent no more than one second
glancing into an individual’s cell, sometimes without
breaking stride as they walked through the housing
module, as we describe in the text box. Staff later
In‑Custody Death: Case Example 3
discovered individuals unresponsive in their cells,
2 a.m. Deputy quickly walked past each cell and glanced
some with signs of having died several hours earlier, as
twice into the individual’s cell but moved on after the
detention staff described some of these individuals as
second glance.
stiff and cold to the touch.
In another example, the Sheriff’s Department’s records
indicate that a deputy did not perform a required
safety check in a housing area, in part because of
poor communication between this deputy and the
station deputy. One hour after the deputy should have
performed this check, sworn staff found an individual
in this housing area unresponsive after attempting
suicide. A physician pronounced this individual
deceased at the scene after staff and paramedics were
unsuccessful at saving the individual’s life.

3 a.m. Deputy stopped briefly at the individual’s cell,
glancing through the window for a split second.

4 a.m. Deputy walked quickly past the individual’s cell
without breaking stride, glancing through the window for
less than a second.
5 a.m. Deputies found the individual unresponsive in their
cell during a safety check, with signs of having died several
hours earlier.
Source: Records from the Sheriff’s Department.

Sworn staff conducted safety checks inadequately in part because of
weaknesses in the Sheriff’s Department’s policy. Its safety check policy
does not require sworn staff to determine whether individuals are alive
and well by taking steps such as by observing the rise and fall of their
chest. We recognize that acquiring proof of life in some situations is
difficult and that waking up incarcerated individuals every hour could
be detrimental to their well‑being. However, as described in the case
example above, a safety check that does not involve any meaningful
observation of an individual is ineffective and inadequate.
The Sheriff ’s Department’s assistant sheriff of detentions indicated
that the department’s policy is sufficient but that individual sworn
staff members do not always follow it. The department’s safety check
policy requires supervisors to review logs to ensure safety checks

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were logged and conducted at varying intervals within the required
time periods, but it does not stipulate that this review should include
examining video surveillance to confirm checks were conducted in
a timely and appropriate manner. The assistant sheriff of detentions
indicated that the department has an informal process for assessing
the quality of safety checks, which can include watching video
footage. However, the Sheriff ’s Department has not documented this
assessment process in its policy, and establishing an informal practice
does not ensure that each facility’s management team will consistently
verify the quality of safety checks.
The State and Orange Sheriff ’s Department have more robust policies
or additional detail in their policies that may be more effective in
ensuring that incarcerated individuals are alive and well. For example,
the California Department of Corrections and Rehabilitation (CDCR)
requires staff who perform hourly checks to count a living, breathing
person whom they see in person. Further, the Orange Sheriff ’s
Department requires staff who conduct safety checks to be close
enough to each individual to ascertain the individual’s presence
and apparent physical condition. According to Orange Sheriff ’s
Department’s assistant sheriff of detentions, a safety check must
be performed from a sufficiently close vantage point to determine
the person’s presence in their assigned location and whether the
individual’s visible physical condition indicates the need for medical
treatment or signs of being in medical distress. The detail described in
these requirements could provide clearer expectations to San Diego
Sheriff ’s Department’s sworn staff for what constitutes an adequate
safety check, especially during the night.

Until it strengthens its safety check
policy and formalizes its process,
the San Diego Sheriff’s Department
risks further instances of delayed
responses to medical emergencies.

In addition, the Riverside Sheriff ’s Department has a formal policy
that requires regular video review of safety checks. For example,
supervisors from each shift must randomly review two safety checks
conducted during the prior shift. Establishing a similar process could
help the San Diego Sheriff ’s Department to identify sworn staff who do
not consistently conform to policy when conducting their checks so
that it can designate them for further action, such as additional training
or disciplinary measures. Until it strengthens its safety check policy
and formalizes a process for ensuring that sworn staff adhere to this
policy, the San Diego Sheriff ’s Department risks further instances of
delayed responses to medical emergencies or other crises.
The Sheriff’s Department Did Not Always Provide Prompt Lifesaving
Measures to Unresponsive Individuals
In slightly less than a third of the 30 cases we reviewed, issues with
the response time of sworn staff or medical staff may have resulted
in unnecessary delays in performing lifesaving measures. The early
moments in a medical emergency are critical. A 2020 study found that

California State Auditor Report 2021-109

February 2022

one of the top five predictors of survival in a cardiac arrest occurring
away from a hospital was someone performing cardiopulmonary
resuscitation (CPR) immediately.7 In addition, a 2021 study found
that for each five‑minute delay in calling emergency medical services,
the odds of surviving a cardiac arrest decreased by 41 percent.8
Nonetheless, in some of the cases we reviewed, sworn staff failed to
begin CPR immediately or before the arrival of medical staff, or were
slow to respond to the scene of the medical emergency.
In a number of instances, sworn staff either did not perform or
delayed lifesaving measures. Generally, Sheriff ’s Department’s
policy directs that sworn staff immediately provide basic life
support, such as CPR, to an unresponsive individual, unless they
observe certain obvious signs of death. In some of the cases we
reviewed, Sheriff ’s Department sworn staff did not begin CPR
because they thought the individual was dead. However, when
department medical staff arrived minutes later, they began
lifesaving measures, including CPR. This fact calls into question the
ability of sworn staff to assess whether unresponsive individuals
might benefit from such potentially lifesaving measures.
In contrast to the Sheriff ’s Department, CDCR requires its custodial
staff to provide immediate life support to incarcerated individuals
until medical staff arrive. It revised its policy in response to a 2005
California district court order requiring it to do so. The Sheriff ’s
Department’s chief medical officer acknowledged that sworn staff
are trained to be first responders and agreed that they should begin
CPR while waiting for health staff to arrive.
In addition, in some of the cases we reviewed, we noted a delay in
the response time of sworn and medical staff when an individual
was in medical distress. Sheriff ’s Department policy requires that
all detention staff are responsible for recognizing, reporting, and
responding to an incarcerated individual’s emergency medical
needs. The policy specifically requires that if an individual’s
condition is believed to be life‑threatening, sworn staff must
immediately alert on‑duty health staff, provide basic life support
and first aid care, and place a 911 request for a paramedic
emergency response. In one case we reviewed, the homicide unit’s
investigation reported that an incarcerated individual indicated
to a deputy that they were experiencing shortness of breath. The
individual had recently been seen by health staff several times for
these symptoms. According to the investigation, the deputy was
somewhat familiar with the individual’s medical conditions but
indicated he was not aware of certain treatment the individual
7

Study from the Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine.

8

Study from the American Journal of Emergency Medicine.

The Sheriff’s Department’s chief
medical officer agreed that sworn
staff should begin CPR while
waiting for health staff to arrive.

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previously received related to shortness of breath.
Nevertheless, the deputy indicated that he believed
that the individual was experiencing anxiety and
escorted the individual to a different area instead of the
medical unit. Shortly afterward, the individual
collapsed and sworn staff did not respond for a couple
more minutes, as the case example in the text box
describes. A health staff member finally arrived several
minutes later and began lifesaving measures within a
few minutes. The individual was pronounced deceased
shortly after arrival to the hospital.

In‑Custody Death: Case Example 4
6:51 a.m. After the individual informed deputy about
experiencing shortness of breath, deputy escorted the
individual to a different area instead of medical clinic and
then left area.
6:52 a.m. Individual collapsed in that area.
6:54 a.m. Deputies entered area to check on the individual.
7:00 a.m. Medical staff arrived. They began lifesaving
measures within a few minutes.

In another example, our review of video surveillance
footage—in combination with the homicide unit’s
7:33 a.m. Paramedics transported the individual
investigative report containing statements from involved
to the hospital, where a doctor pronounced the
staff and inmate witnesses—found that the first deputy
individual deceased.
did not arrive at the scene of the incarcerated individual
Source: Records from the Sheriff’s Department.
in medical distress until about five minutes after another
incarcerated individual went to alert staff. Sheriff’s
Department medical staff did not arrive until five
minutes after that. Paramedics—who are trained in advanced cardiac life
support measures—did not arrive for another five minutes—a total of
approximately 15 minutes after sworn staff were first alerted. According
to the chief medical officer, some type of communication shortcoming
may have delayed the arrival of medical staff, but the exact cause is
unknown. However, the initial delay followed by the slow response time
of medical staff may have been detrimental to the individual’s likelihood
of survival. In the Sheriff’s Department’s interviews of witnesses,
other incarcerated individuals commented on the slow response of
department staff.
7:10 a.m. Emergency medical personnel arrived.

I

The last two examples we describe emphasize the need for the Sheriff ’s
Department to take action to ensure that it promptly responds to
emergencies. Specifically, sworn staff need additional training for
immediately starting CPR and how to properly alert medical staff.
The Sheriff’s Department’s Inadequate Policies Are in Part the Result of
Weaknesses in Statewide Corrections Standards
As Figure 6 shows, weaknesses in statewide corrections standards
likely contributed to the problems we identified with the Sheriff ’s
Department’s policies. The BSCC establishes in regulation the
minimum standards for jail conditions and treatment of incarcerated
individuals that local detention facilities must follow. Every local jail
system in the State uses these standards as a basis to create policies
for inmate safety and care, although counties may choose to make
their policies more robust. However, some of these standards may not
be adequate for ensuring incarcerated individuals’ health and safety.

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29

February 2022

Further, BSCC’s inconsistent continuing education requirements
may not be sufficient to ensure that sworn staff adequately care for
incarcerated individuals. Given the increase in the annual number
of in‑custody deaths across the State from 130 in 2006 to 156 in
2020, improving statewide standards related to health and safety
and training requirements is essential to ensuring the health and
safety of incarcerated individuals in all counties.
Figure 6
Poor Statewide Standards Contributed to Inconsistencies in the Sheriff’s Departments’ Policies

OJ
l


         
        
 
 
  
   


1'

 
  
     
    
   

1'

For example:

standard: 

   









GJ GJ] ~ ~











Despite variation among counties, none of the policies
nor the bscc standard specify that staff are required
to check for proof of life during safety checks.
Source: State regulations and policies at Alameda, Orange, Riverside, and San Diego sheriff’s departments.

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California State Auditor Report 2021-109

February 2022

The Riverside Sheriff’s Department’s
policy requires a mental health
professional to conduct the mental
health screening in all instances,
which is a best practice.

Although the Sheriff ’s Department’s policies generally align with
BSCC’s standards related to health, safety, and personnel training,
those standards are not specific enough in certain areas to ensure
inmate safety. For example, BSCC’s standards do not explicitly
require that a mental health professional should perform mental
health screenings. As a result, the San Diego Sheriff ’s Department’s,
Alameda Sheriff ’s Office’s, and Orange Sheriff ’s Department’s
policies allow medical nurses and health clinicians rather than
mental health professionals to perform mental health screenings
at intake. In these counties, the health staff generally will refer
an incarcerated individual for a mental health evaluation if they
observe general signs necessitating the referral or if the individual
self‑reports mental health concerns. In contrast, the Riverside
Sheriff ’s Department’s policy requires a mental health professional
to conduct the mental health screening in all instances, which is a
best practice.
In another example, BSCC’s standards do not describe the actions
that constitute an adequate safety check. Instead, the standards
simply state that safety checks must be conducted at least
hourly through direct visual observation of all inmates and that
observation through a video camera alone is not sufficient.
The four counties we reviewed based their policies on different
interpretations of this standard, as Table 2 shows. The Alameda
Sheriff ’s Office and Riverside Sheriff ’s Department require hourly
direct visual observation of incarcerated individuals, but their
policies do not expand much further on the standard. As we discuss
previously, the San Diego Sheriff ’s Department’s policy provides
more detail, defining what staff should look for during the direct
visual observation. The Orange Sheriff ’s Department’s policy is
more robust than the minimum standard: it directs sworn staff to
be close enough to each individual to ascertain their presence and
apparent physical condition. Moreover, CDCR requires its staff to
count living, breathing individuals whom they see in person. This
count is an hourly check that is the equivalent to what BSCC’s
standards refer to as a safety check. Although BSCC is currently
revising the safety check standard, its proposed revision still
does not specify that a safety check must include verifying that
an individual is alive, which is essential to ensuring the safety of
incarcerated individuals across the State.
Additionally, state law does not require that BSCC have medical or
mental health professionals on its board, despite its responsibility
for creating standards in these areas. The qualifications for almost
all of the board member positions are related to law enforcement
in a detention setting. State law requires BSCC to seek the advice
of medical and mental health professionals when establishing
minimum standards and when reviewing and making revisions
every two years. However, because the standards have so much

California State Auditor Report 2021-109

February 2022

impact on the lives of incarcerated individuals, we believe that
having medical and mental health representation on the board
is critical. Similar boards in other states, such as the New York City
Board of Corrections and the Texas Commission on Jail Standards,
have medical experts serving as members.
Table 2
A Lack of Specificity in Statewide Standards Has Resulted in Inconsistencies
Among Counties’ Policies
ENTITY WITH POLICY

SAFETY CHECKS POLICY EXCERPT

BSCC

Safety checks shall be conducted at least hourly through direct visual
observation of all incarcerated individuals. Observation through a video
camera alone does not constitute a safety check.

Alameda Sheriff’s
Office

Supervision of all incarcerated individuals shall include direct visual
observation of each incarcerated individual by a deputy at random
times each hour.

Orange Sheriff’s
Department

A safety check is a direct visual observation of each incarcerated
individual located in an area of responsibility every hour. Safety checks
must be conducted from a location which provides a clear, direct view
of each incarcerated individual. Staff shall be close enough to each
incarcerated individual to ascertain his or her presence and apparent
physical condition.

Riverside Sheriff’s
Department

Security checks shall be completed to ensure there is direct visual
supervision of all incarcerated individuals housed within a jail facility
every hour.

San Diego Sheriff’s
Department

Sworn staff will conduct safety checks of incarcerated individuals every
hour through direct visual observation without the aid of audio and
video equipment. Safety checks of incarcerated individuals consist of
looking at the incarcerated individuals for any obvious signs of medical
distress, trauma, or criminal activity.

Source: State law and policies from the Alameda, Orange, Riverside, and San Diego
sheriff’s departments.

In addition, BSCC’s required training hours for sworn staff working
in local detention facilities do not align with their standards for
similar positions. BSCC’s regulations require only 24 hours annually
of continuing professional education training for adult correctional
officers, supervisors, and managers, even though it requires
40 hours of continuing training for probation officers and juvenile
correctional supervisors and managers. Requiring fewer hours for
adult corrections personnel does not make sense when thousands
of individuals are incarcerated in these facilities and the number
of individuals who have died has increased over the past 15 years.
Based on our review of how San Diego Sheriff ’s Department’s
sworn staff responded to medical, mental health, and safety needs,
we recommend increasing the number of training hours to align
with similar professions to allow sheriff ’s departments to better
protect and keep incarcerated individuals safe. Further, BSCC

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California State Auditor Report 2021-109

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does not require that any of the 24 hours of training cover topics
pertaining to mental health, even though best practices suggest
staff should receive at least four hours of mental health training
annually. Without such a requirement, law enforcement staff may
not be sufficiently prepared to provide care to and properly monitor
individuals with mental health needs.
In response to our concerns that some of its standards are not
robust enough to ensure the safety of incarcerated individuals in
local detention facilities across the State, BSCC’s deputy director of
Facilities Standards and Operations told us it is the responsibility
of each individual county to establish policies that exceed the
minimum standards, should they decide to do so. Further, she
said that BSCC designs the standards to be a minimum that all
counties can achieve, regardless of variation in resources at the local
level. However, this approach enables counties that house large
numbers of incarcerated individuals to provide lower levels of care.
An alternative approach could be for BSCC to establish separate
standards for counties with smaller incarcerated populations,
and set higher standards for counties with larger incarcerated
populations. For example, BSCC could create more stringent
requirements for the larger counties in the State, such as those
with ADPs of more than 1,000 individuals. This threshold would
include the county jail systems housing more than 80 percent of
the State’s jail population in local detention facilities. Further, some
solutions—such as more robust safety checks—do not require
significant resources. Improving statewide standards and training
requirements is essential to ensuring the health and safety of
incarcerated individuals in all counties.

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February 2022

Chapter 2
NEITHER THE SHERIFF’S DEPARTMENT NOR CLERB HAS
TAKEN ADEQUATE ACTION IN RESPONSE TO THE DEATHS
OF INCARCERATED INDIVIDUALS
Chapter Summary
The Sheriff ’s Department has not consistently taken meaningful
action in response when in‑custody deaths have occurred.
Specifically, its reviews of in‑custody deaths have been insufficient
and have lacked transparency. As a result, the Sheriff ’s Department
risks conveying to the public that it is not taking these deaths
seriously and making every effort possible to prevent similar
deaths in the future. In addition, CLERB—a citizen‑governed
board approved by San Diego County voters to restore public
confidence in county law enforcement—has failed to provide
effective, independent oversight of in‑custody deaths. In violation
of its own rules and regulations, CLERB’s investigations of the
deaths of individuals in the Sheriff ’s Department’s custody have not
been independent, thorough, or timely. Moreover, CLERB failed to
investigate nearly a third of the deaths of incarcerated individuals
in the past 15 years, meaning that dozens of deaths have not been
subject to a key form of review outside of the Sheriff ’s Department.
The Sheriff’s Department Has Not Consistently Implemented
the Meaningful Changes Necessary to Respond to the Deaths of
Individuals in Its Custody
The Sheriff ’s Department has not responded to incarcerated
individuals’ deaths in a manner that demonstrates its commitment
to improving health and safety at its detention facilities. Every
death of an individual in its custody should require a thorough
review to determine whether changes to its processes are
warranted. Nonetheless, the department’s reviews of deaths are
insufficient and have not always led to meaningful corrective
action. Further, although the Sheriff ’s Department has implemented
some key recommendations provided by external entities, it did
not implement others that are critical to improving the safety of
incarcerated individuals. San Diego County has paid millions of
dollars in settlements related to deaths in the Sheriff ’s Department’s
jails that highlighted many of the same problems we have identified
related to inadequate safety checks and medical and mental
health care.

San Diego County has paid millions
of dollars in settlements related to
deaths in the Sheriff’s Department’s
jails that related to inadequate
safety checks and health care.

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The Sheriff’s Department’s Processes for Investigating and Reviewing
In‑Custody Deaths are Ineffective, Structurally Problematic, and Lacking
in Transparency
The Sheriff ’s Department has not performed adequate reviews
or implemented sufficient changes in response to the deaths of
incarcerated individuals. As we show in Figure 7, the department
conducts up to four different reviews: a 30‑day medical review, a
Critical Incident Review Board review, a homicide death investigation,
and an internal affairs investigation. However, because all of these
reviews are generated from within the Sheriff ’s Department, they may
be viewed by the public as lacking objectivity. Further, we identified
deficiencies in certain reviews that call into question their ability to
prompt meaningful change to prevent additional deaths.
One of the Sheriff ’s Department’s reviews—the 30‑day medical
review—involves reviewing the circumstances surrounding the
incident and pertinent medical and mental health services and reports.
According to state law, the Sheriff ’s Department must review every
in‑custody death within 30 days to determine the appropriateness
of clinical care; to assess whether changes to policies, procedures, or
practices are warranted; and to identify issues that require further
study. To fulfill this requirement, Sheriff ’s Department policy states
that the medical services administrator, in consultation with the chief
medical officer, is responsible for reviewing all in‑custody deaths
within 30 days. In practice, the chief medical officer—who is a licensed
physician—indicated that he currently conducts the reviews with input
from other health staff regarding the individuals’ clinical histories.
Although the chief medical officer is also required to review suicide
deaths, the department’s policy has specified since late 2018 that the
chief mental health officer will also present findings on suicides.

Most of the Sheriff’s Department’s
reviews of in‑custody deaths did not
document whether recommended
changes to policies, procedures, or
practices had been implemented or
led to the department taking action.

However, the Sheriff ’s Department did not sufficiently document the
results or recommendations from its 30‑day medical reviews. For
22 of the 30 cases we reviewed, the Sheriff ’s Department was unable to
provide us with documentation from these reviews that detailed any
findings or conclusions about the clinical care given; identified whether
any concerns required further study; or stated whether changes to
policies, procedures, or practices were warranted. The documents we
obtained for most of these 22 cases were either presentation slides
or meeting agendas. Neither type of document included findings
about the cases or recommended changes to policies, procedures, or
practices. For some of the more recent cases in 2019 and 2020, the
Sheriff ’s Department provided us with the chief medical officer’s and
medical staff members’ typed notes, which included conclusions about
the medical care its staff had provided to the incarcerated individuals,
as well as some recommendations. However, most of these reviews did
not document whether the recommendations led to the department
taking action, or whether the recommendations had been implemented.

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February 2022

Figure 7
The Sheriff’s Department’s Internal Reviews Have Not Led to Meaningful Action in Response to Individuals’ Deaths

30-day
Medical review

       
      

 

      

       


Sheriff’s
Department’s
Reviews of
In-Custody
Deaths

  


Critical Incident
Review Board
review

               
          
      
            
   
       
 

 

Homicide
Investigation

Internal Affairs
investigation

­         
 


  


€           
   
   

Source: Sheriff’s Department’s policies and procedures and other documentation related to these reviews.

We believe that if the Sheriff ’s Department properly documented
the 30‑day medical reviews, it could better identify and track
instances when it did not provide sufficient medical and mental
health follow‑up care before an individual’s death, such as those
we discuss in Chapter 1. The chief medical officer agreed that the
reviews, if properly documented, could be useful as an educational
and quality assurance tool. However, he indicated that he would

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California State Auditor Report 2021-109

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have reservations about formalizing these reports in a written format
without some form of protection against using these documents
as evidence in litigation. He stated that without such protection,
staff members would be reluctant to point out any form of mistake
or error, leading to lost learning opportunities. Regardless of the
department’s position, we believe the reviews should be formalized
for internal use to help the department better track its identification
of deficiencies and recommendations for improvements to its clinical
care. Other counties we reviewed have policies for documenting these
30‑day reviews.
In addition to the 30‑day medical review, in‑custody deaths—
except natural deaths—are also subject to review by the Critical
Incident Review Board, which is the Sheriff ’s Department’s internal
review committee. The board consists of three voting members—
commanders from the Law Enforcement, Court Services, and
Detention Services bureaus—and two nonvoting members—the chief
legal advisor and a commander from the human resources bureau.
The stated purpose of the board is to consult with the department’s
legal counsel when an incident occurs that may give rise to litigation.
Therefore, it appears that its primary focus is protecting the Sheriff ’s
Department against potential litigation rather than focusing on
improving the health and welfare of incarcerated individuals.
Moreover, the board is an entity within the Sheriff ’s Department, so it
is not independent. The Sheriff ’s Department’s investigators present to
the board the facts and circumstances related to an in‑custody death.
According to department policy, the board then carefully reviews
the incident from multiple perspectives, including training, tactics,
policies, and procedures. Its ultimate goal is identifying problem areas
and recommending remedial actions—such as posting a training
bulletin or changing a policy—so that potential liability can be avoided
in the future. According to policy, if the board votes to determine that
any policy violations exist, it will forward the case to Internal Affairs.
After the Critical Incident
Review Board meets to discuss
in‑custody deaths, it has not
always taken meaningful action
to prevent deaths, even when it
identifies problems with policies
and practices.

However, after the board meets to discuss in‑custody deaths, it has
not always taken meaningful action to prevent deaths, even when it
identifies problems with its policies and practices. Of the 18 cases we
reviewed for which the department held a Critical Incident Review
Board meeting, the board reported taking action related to 13.
However, only six resulted in substantive actions, such as changes to
policy and procedures or training, related to preventing inmate deaths.
The remaining seven resulted predominantly in minor administrative
actions or recommendations for training that would not have
far‑reaching effects on the welfare of individuals in custody.
Moreover, even though the board discussed critical issues in
some meetings, it ultimately concluded them without making
recommendations for addressing these issues. For example, in

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six of the 18 cases, the board indicated that the events surrounding
the deaths in question could merit changes to policy and procedures;
however, it did not recommend any related actions. According to the
assistant sheriff of detentions, the Sheriff ’s Department may make
immediate changes to policies following a death if it identifies a
need, so additional recommendations from the board are sometimes
unnecessary. However, the minutes of the Critical Incident Review
Board meetings do not always discuss these types of policy changes.
We question why the review board did not discuss the need for
changes in some instances or discuss whether any changes made
address the problems identified.
Further, the Critical Incident Review Board generally does not review
natural deaths. Instead, it primarily reviews suicides, homicides, and
accidental in‑custody deaths. According to the Sheriff’s Department’s
chief legal advisor, the board does not review natural deaths in part
because the risk of legal liability in those incidents is low. He further
stated that because the Medical Examiner’s Office has made a
determination that an individual’s death was from natural causes, it
rules out other human factors. However, we found in our review of 30
case files that the Medical Examiner’s Office typically reviews events
preceding individuals’ deaths and their medical records, but it does
not make conclusions about the appropriateness of care provided by
the Sheriff’s Department. We find the Sheriff’s Department’s decision
not to hold critical incident reviews for natural deaths concerning
given that these deaths accounted for nearly 50 percent of all deaths in
the department’s facilities in the period of our review. Further, as we
note in Chapter 1, we identified significant deficiencies in the Sheriff’s
Department’s handling of care leading to all types of deaths, including
natural deaths. By not requiring the Critical Incident Review Board to
review these cases, the department is not doing everything it can to
protect incarcerated individuals.
Finally, the Critical Incident Review Board is not transparent. It
does not make its reports and investigations public. The board’s
reports are classified as attorney‑client privileged, meaning that
they are confidential and cannot be disclosed without the Sheriff ’s
Department’s consent. The purpose of attorney‑client privilege is
to ensure that clients can fully disclose information to their lawyer
without fear that it will be revealed to others, enabling them to
receive competent legal advice. Although we do not disagree with
having a confidential forum to discuss potential litigation matters, we
are concerned that the Sheriff ’s Department does not have a separate
public process to demonstrate that it is addressing deficiencies in
its policies, procedures, and practices after in‑custody deaths occur.
By keeping its findings and recommendations confidential, the
department risks conveying to the public that it is not taking these
deaths seriously, investigating them thoroughly, or acting to prevent
future incidents.

By keeping the findings and
recommendations of the Critical
Incident Review Board confidential,
the Sheriff’s Department risks
conveying to the public that it is
not taking these deaths seriously,
investigating them thoroughly, or
acting to prevent future incidents.

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Although the Sheriff ’s Department’s homicide unit is rarely
involved in developing policy recommendations, it typically
presents facts about in‑custody deaths to the Critical Incident
Review Board. The homicide unit investigates deaths that occur
in custody by, in part, inspecting the scene of the incident,
interviewing any witnesses and detention staff, and reviewing video
surveillance and reports written by sworn staff. Even though the
information that the homicide unit presents to the Critical Incident
Review Board is a key component of the Sheriff ’s Department’s
review of in‑custody deaths, the Critical Incident Review Board
ultimately decides whether to take further action.
The Sheriff ’s Department’s internal affairs unit may also investigate
detention staff—including health staff—for alleged misconduct
related to an in‑custody death. The internal affairs unit receives
complaints that are initiated by a member of the community or by
the Sheriff ’s Department. The Critical Incident Review Board can
also initiate an internal affairs investigation if it votes that a policy
violation may have occurred.

The Sheriff’s Department’s internal
affairs unit indicated that it
investigated staff conduct related
to only 21 of the 185 in‑custody
deaths that occurred from
2006 through 2020.

However, the Sheriff ’s Department has performed very few such
investigations. Specifically, it reported to us that it conducted
only four internal affairs investigations related to the 30 cases
we reviewed, even though we identified a number of potential
violations or concerns in some of the other 26 cases that could
justify further investigation. Further, internal affairs indicated that
it investigated staff conduct related to only 21 of the 185 in‑custody
deaths that occurred from 2006 through 2020.
Thus, the Sheriff ’s Department does not complete internal affairs
investigations frequently enough for it to provide significant
value. Although internal affairs indicates that its investigations are
generally complaint‑driven, the small number of investigations
related to death cases—coupled with the lack of meaningful
changes arising from the 30‑day medical review and the Critical
Incident Review Board meeting—calls into question the Sheriff ’s
Department’s commitment to protecting individuals in its custody.
The Sheriff’s Department Has Not Implemented Key Recommendations
From External Entities Related to Incarcerated Individuals’ Welfare
and Safety
The Sheriff ’s Department has not implemented a number of
key recommendations from external entities that are essential
for ensuring the welfare and safety of incarcerated individuals,
as Table 3 shows. We reviewed recommendations from
2006 through 2020 that the San Diego County Grand Jury,
CLERB, Disability Rights California, and a suicide prevention

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consultant (consultant) made to the Sheriff ’s Department.9 Many of
these recommendations were in response either to a specific death
or to the general health and safety conditions of the jails. When
we looked at recommendations that pertained to the safety of
incarcerated individuals, the Sheriff ’s Department had implemented
a number of them. For example, it modified a use‑of‑force policy
to prevent compromising an incarcerated individual’s ability to
breathe and revised its intake screening to include additional
questions related to suicide prevention. However, some of the
recommendations that the Sheriff ’s Department failed to fully
implement are connected to problems we identify in this report.
Table 3
The Sheriff’s Department Has Not Implemented Certain Key Recommendations From External Entities
ENTITY PROVIDING
RECOMMENDATION

EXAMPLE OF RECOMMENDATION

CURRENT
IMPLEMENTATION
STATUS

San Diego County
Grand Jury–2014/2015

The Sheriff’s Department deputy detention staff has an imbalance in experience levels and facility
assignments, such as too many inexperienced staff at one facility. Develop and implement a staff
rotation policy for all detention facilities.

Not implemented

Consultant reviewing
suicide prevention
practices–2018

Given the strong association between in‑custody suicide and segregation housing and consistent
with national correctional standards, it is strongly recommended that the Sheriff’s Department
give strong consideration to increasing deputy rounds of such housing units from 60‑minute to
30‑minute intervals.

Not implemented

CLERB–2018

Sheriff’s Department staff did not have pertinent information about an incarcerated individual’s
previous suicide attempt and allowed that individual access to something that resulted in
self‑harm and ultimately suicide. The Sheriff’s Department should revise its policy to use
identifying wristbands to indicate a prior suicide attempt.

Not implemented

Disability Rights
California–2018

Revise policies to allow individuals in Enhanced Observation Housing to have access to social visits,
increased out‑of‑cell time, and recreational activities, and to possess clothes and certain personal
property, based on individualized clinical assessments of their condition and safety needs.

Not implemented

Source: San Diego County Grand Jury reports from 2006 through 2019, a consultant’s report on suicide prevention practices, CLERB investigations
and recommendations from 2006 through 2020, and a Disability Rights California report.

Specifically, the Sheriff ’s Department did not implement
recommendations related to safety checks, intake screenings,
and suicide prevention efforts—the last of which is particularly
concerning given the department’s high rate of suicides compared
to other counties. For example, in response to a specific death,
CLERB recommended in 2020 that the Sheriff ’s Department
require additional steps in safety checks of individuals residing in
special mental health housing to ensure that they are alive and well,
such as requiring nurses to accompany deputies on each round to
ensure incarcerated individuals’ safety. However, the department
stated it would not implement this recommendation because it
9

We discuss CLERB’s process for investigating deaths in the sections that follow.

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believed that its current policies were adequate. Additionally,
San Diego County contracted with a consultant in 2018 to assess
suicide prevention practices within the Sheriff ’s Department’s
jail system. One of the consultant’s recommendations was for
the Sheriff ’s Department to consider increasing safety checks of
individuals who are housed in isolated housing units from every
60 minutes to every 30 minutes, given the association between
suicide and isolated housing placement. However, the department
responded that making this change was not feasible because of the
physical layout of its jail facilities, the number of inmates, and the
required staffing.
The Sheriff ’s Department’s justifications for choosing not to
implement crucial recommendations have not always addressed
the underlying issues involved and do not offer alternatives for
addressing the concern. For example, following another death,
CLERB recommended in 2018 that the Sheriff ’s Department
provide identifying wristbands to individuals with prior suicide
attempts. In its response, the department indicated it would not
implement this recommendation because doing so would violate
individuals’ privacy and be contrary to best practices for suicide
prevention. However, the Sheriff ’s Department did not address
or offer an alternative solution to the underlying problem, which
is that sworn staff may not be familiar with the mental health
histories of the individuals they oversee. As we discuss in Chapter 1,
another county has addressed this problem by assigning individuals
with mental health needs an acuity level rating that could help
communicate this information to sworn staff.

Although the department’s policies
and procedures related to facility
maintenance generally align with
state standards, it has not yet
replaced the surveillance system
at its largest detention facility,
even though its age is a major
safety issue.

Another key, recurring recommendation that the Sheriff ’s
Department has not implemented for nearly a decade relates to
updating equipment for monitoring the safety of incarcerated
individuals. In 2014 the San Diego County Grand Jury
recommended that the Sheriff ’s Department update the surveillance
system for monitoring activity at its largest male detention facility,
which is a maximum security jail. The San Diego County Grand
Jury made a similar recommendation in 2017, but the department
has yet to replace the system. Although the department’s policies
and procedures related to facility maintenance generally align
with state standards, we find it concerning that it has not yet
replaced the surveillance system, even though its age is a major
safety issue. In 2021 the Sheriff ’s Department indicated that the
replacement effort would likely not begin until the summer of 2022.
According to the assistant sheriff of detentions, the department
did not implement this recommendation sooner because of its
prioritization of other projects, such as building a new detention
facility. However, we believe that the Sheriff ’s Department should
prioritize implementing or resolving all recommendations intended
to keep individuals in its custody safe.

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Lastly, many of the lawsuits we reviewed that San Diego County
settled have highlighted some of the same problems at the
Sheriff ’s Department that we have identified related to inadequate
safety checks, mental health treatment, and medical care. From
2006 through 2020, there were 22 lawsuits filed related to the
deaths of incarcerated individuals at the Sheriff ’s Department’s
detention facilities. San Diego County has settled 11 of these, for
a total cost of $9.2 million.10 Payments for these cases ranged
from $10,000 to $3.5 million for an average of $838,000 per
settlement. Table 4 compares San Diego County’s settlements to
those in the other three counties we reviewed. By not promptly
addressing the underlying issues on which both litigation and
external recommendations have focused, the San Diego Sheriff ’s
Department continues to place the individuals in its custody at risk.
Table 4
Settlements Related to In‑Custody Deaths Varied Among the Comparable Counties
SETTLEMENTS RELATED TO
IN‑CUSTODY DEATHS (2006–2020)

Number of settlements

ALAMEDA

ORANGE

RIVERSIDE

SAN DIEGO

15

9

7

11

Settlement amount (total)

$17,863,000

$7,799,000

$3,871,000

$9,223,000

Settlement amount (average)

$1,116,000

$867,000

$553,000

$838,000

$10,000 to $5 million

$200,000 to $2.75 million

$46,000 to $975,000

$10,000 to $3.5 million

Range of settlements

Source: Court documents from each of the four counties.

CLERB Has Failed to Provide Effective Oversight of the Deaths of
Individuals in the Sheriff’s Department’s Custody
Despite its mission to increase public confidence in county law
enforcement officers, CLERB has failed to provide effective,
independent oversight of the deaths of individuals in the Sheriff ’s
Department’s custody. In violation of its own rules and regulations,
CLERB’s investigations are not independent, timely, or thorough, as
Figure 8 shows. Our review found that CLERB rarely independently
interviews witnesses or visits the initial scenes of the deaths, has not
consistently prioritized cases involving deaths, and has sometimes
failed to thoroughly investigate or follow up on discrepancies it
discovers in the course of its investigations of deaths. CLERB’s
failure to conduct adequate investigations has resulted in a lack
of independent scrutiny of dozens of deaths of incarcerated
individuals, calling into question its effectiveness as a key oversight
body for San Diego County law enforcement.
10

The other 11 lawsuits are either ongoing or have been appealed.

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Figure 8
CLERB Has Failed to Provide Adequate Oversight of the Deaths of Individuals
in the Sheriff’s Department’s Custody

CLERB's rules and regulations
require it to be:
Independent

 
    
 
  

Timely



 

Thorough

 
  

 

 

Ethical

  



 

Fair/Impartial   





Source: CLERB’s rules and regulations, county policies, and analysis of CLERB investigations.

CLERB Does Not Conduct Independent Investigations
San Diego County voters established CLERB to provide
independent oversight of the county’s law enforcement agencies.
However, CLERB’s investigations of in‑custody deaths are not
independent. In particular, it does not conduct interviews with
Sheriff ’s Department sworn staff or visit the initial scene of the
death. Rather, it relies almost entirely upon documents that
the Sheriff ’s Department provides. The county charter—as well
as its own rules and regulations—establishes CLERB’s power to
issue subpoenas, administer oaths, and require the attendance
of witnesses and the production of books and papers pertinent

California State Auditor Report 2021-109

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to its investigations. CLERB’s rules and regulations further
state that its investigations may include interviewing witnesses
and subject officers, examining the scene, and reviewing and
preserving other physical evidence. However, in practice, CLERB’s
investigations of in‑custody deaths reflect neither its authority nor
its stated processes.
We reviewed a selection of six CLERB investigations of incarcerated
individuals’ deaths in the Sheriff ’s Department jails occurring
from 2016 through 2019 that had investigations performed in 2017
through 2020. We found that for all of these cases—which, in total,
included dozens of potential witnesses—CLERB investigators
referenced conducting an interview of an incarcerated individual
in only one instance. They did not independently interview staff
from the Sheriff ’s Department in any of the six cases, although
in a few limited instances, they used written questionnaires to
obtain information from sworn staff about their involvement in an
incident leading up to an incarcerated individual’s death.
CLERB uses these questionnaires in lieu of performing in‑person
interviews as the result of an agreement it reached with the
Sheriff ’s Department and the Deputy Sheriff ’s Association of
San Diego County (labor organization). However, this agreement
has hindered CLERB’s independence and undermined voters’
approval of CLERB’s creation. As we show in Figure 9, the erosion
of CLERB’s independence began in the 1990s. According to its
current executive officer, CLERB was concerned at that time that
its investigations were one‑sided and lacked legitimacy without
participation by Sheriff ’s Department sworn staff. According to
CLERB annual reports and internal documents, CLERB attempted
to interview Sheriff ’s Department sworn staff in the course
of its investigations to seek their perspective. Although both
San Diego County’s Administrative Code and CLERB’s rules and
regulations entitle CLERB to complete and prompt cooperation
from the Sheriff ’s Department, the sworn staff members refused
to participate in interviews with CLERB investigators. In response,
CLERB exercised its power to subpoena and administer oaths by
calling sworn staff members to testify in public hearings. However,
CLERB documents indicate that the sworn staff continued to refuse
to answer any questions, invoking their Fifth Amendment right
against self‑incrimination.

In practice, CLERB’s investigations
of in‑custody deaths reflect
neither its authority nor its
stated processes.

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Figure 9
CLERB’s Ability to Conduct Independent Investigations Has Been Eroded Over Time

1990

1991–95

  
  

  


 
   
   

 
 

 

1998

  ­
 € 
   
   

2003

  

   
‚   

2021

 
  

‚ 
  

]

Source: Proposition voter materials, agreement documents, legal documentation, and CLERB’s investigations documentation.

Faced with the prospect of more costly litigation and continued
legal challenges, CLERB discussed a framework with the Sheriff ’s
Department and the labor organization in 1998 that ultimately led
to an agreed‑upon process for CLERB investigators to question
Sheriff ’s Department sworn staff through interviews or written
questionnaires (1998 agreement). Further, in 2003, CLERB adopted
a waiver form for sworn staff, allowing them to opt out of in‑person
interviews with CLERB investigators altogether (2003 waiver form).
The 1998 agreement and 2003 waiver form constitute CLERB’s
current process for involving Sheriff ’s Department sworn staff
in its investigations. Consequently, CLERB investigators do not
conduct independent interviews of sworn staff but rather request

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February 2022

responses from specific department employees through a written
questionnaire. This approach has hindered CLERB’s ability to
perform independent investigations.
CLERB’s executive officer acknowledged that having its
investigators conduct independent interviews would be preferable
but also asserted that they are generally able to obtain necessary
information through the questionnaire process. However, we
question this position. Although written responses may provide
some pertinent information, they do not allow investigators to
assess the credibility of a witness or to ask immediate follow‑up
or clarifying questions. In fact, CLERB’s current process allows
department staff up to 14 days to respond to the questionnaires.
CLERB’s executive officer indicated that investigators generally
submit another questionnaire with the same turnaround time
if they have any subsequent inquiries or clarifying questions to
the responses from the initial questionnaire. Such protocol is
counterintuitive to the nature of an investigation, which requires
interactive communication and prompt responses.
Moreover, although the Sheriff ’s Department generally notifies
CLERB of in‑custody deaths, it does not do so until after various
department entities have processed the scene. As a result, CLERB
investigators are not able to be present at the initial scene of the
death. Instead, shortly after receiving notification of an in‑custody
death, CLERB issues a subpoena to the Sheriff ’s Department for
the homicide unit’s investigation file. The Sheriff ’s Department
forwards it to CLERB once it has completed its criminal
investigation, usually about two to eight months after the death
occurs. As a result, CLERB’s investigators generally do not learn
about potential witnesses or have the opportunity to visit the scene
until months after the death of an incarcerated individual, severely
limiting their ability to conduct an independent and thorough
investigation. In fact, when we reviewed a selection of CLERB’s
investigations, we found that its investigators either did not visit the
scenes of the deaths at all or did not do so until more than a year
after the death occurred.
Without the ability to independently interview witnesses or the
opportunity to visit the initial scenes of the deaths, CLERB must
conduct its investigation based primarily on information that
the Sheriff ’s Department’s internal investigators provide, such
as photographs and videos. For the cases we reviewed, CLERB’s
investigators’ only other sources of evidence were statements from
the decedents’ families, reports from the medical examiner, and—in
only one case—a direct interview with an incarcerated individual
who was a witness.

CLERB’s investigators generally do
not learn about potential witnesses
or have the opportunity to visit the
scene until months after the death
of an incarcerated individual.

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CLERB’s nearly exclusive reliance
on evidence provided by the
Sheriff’s Department precludes
its investigators from reaching
independent conclusions on
in‑custody deaths and providing
truly external oversight of county
law enforcement.

San Diego County voters established CLERB in response to perceived
inadequacies in the Sheriff ’s Department’s internal investigations,
yet CLERB’s nearly exclusive reliance on evidence provided by the
department precludes its investigators from reaching independent
conclusions on in‑custody deaths and providing truly external
oversight of county law enforcement. For CLERB to carry out this
function, its processes must change and the Sheriff ’s Department must
fully cooperate.
CLERB’s members and its executive officer are currently pursuing
several policy changes to increase its independence, including issuing
a policy recommendation in October 2021 to the Sheriff ’s Department
requesting that it allow a CLERB staff member with extensive death
investigation experience to be present at the initial scene of the death.
However, CLERB’s recommendations to the Sheriff ’s Department
are advisory and require the Sheriff ’s Department’s approval for
implementation. CLERB’s members and executive officer are also
working with the county board to expand CLERB’s authority to
investigate complaints against non‑sworn staff, including medical
personnel. However, such an expansion of CLERB’s authority requires
approval by the county board. Furthermore, although these changes
would increase the independence of CLERB’s investigations, they
would not enable CLERB’s investigators to directly interview sworn
staff, which we believe is critical.
CLERB Failed to Investigate 57 In‑Custody Deaths From 2006 to 2017
CLERB failed to investigate a significant number of deaths of
individuals in Sheriff ’s Department custody. For example, CLERB
failed to investigate 13 deaths of incarcerated individuals from 2011
through 2016 because it misinterpreted a state‑mandated deadline
for completing its investigations and did not properly prioritize its
caseload. The Legislature established a one‑year statute of limitations
for investigations of law enforcement misconduct when it amended
the Public Safety Officers Procedural Bill of Rights Act (POBR) in 1997.
As the Introduction explains, CLERB is responsible for investigating
complaints, as well as deaths arising out of or in connection with
actions of peace officers, which can include deaths in custody.
As a result of the amendment to POBR, CLERB must complete its
investigations within one year after it receives a complaint against a
peace officer or notification of an in‑custody death.11

11

POBR requires the investigation to be completed within one year of discovery of the alleged
misconduct, and the one‑year deadline may be suspended under certain circumstances,
such as when the misconduct is the subject of a criminal investigation. Because the Sheriff’s
Department performs a criminal investigation of every in‑custody death, CLERB’s one‑year time
frame to complete its investigation does not start until after the Sheriff’s Department completes
its investigation.

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February 2022

Nevertheless, CLERB did not realize until 2010 that the one‑year
time frame applied to its investigations of complaints, at which time
it started to dismiss cases for expiration of this time limit. In fact,
from 2010 through 2016, CLERB reported that it had to dismiss nearly
100 complaints against county law enforcement members because it
did not complete its investigations within the required time frame.
Although CLERB did not report that any of these 100 complaints
involved in‑custody deaths, its failure to conduct these investigations
demonstrates that it has struggled to effectively perform its duties in a
timely manner.
Further, CLERB’s records and San Diego County Grand Jury
documents indicate that CLERB staff were not aware that the POBR
statute of limitations also applied to its investigations of in‑custody
deaths until 2017. Consequently, it did not always prioritize these
cases, and it reported that its backlog of open investigations of deaths
steadily increased from seven cases in 2010 to 46 cases by 2016. After
CLERB learned in 2017 that the one‑year time limit also applied to
investigations of deaths, it had to dismiss 22 of these cases because they
had exceeded the time limit. Of these 22 deaths, 13 occurred while the
individuals were in custody at Sheriff’s Department detention facilities.12
Because of CLERB’s failure to investigate these 13 deaths, it did not have
the opportunity to identify problems with the Sheriff’s Department’s
policies and procedures and to make policy recommendations that
could have helped prevent future in‑custody deaths.
CLERB did not investigate an additional 40 in‑custody deaths
classified as natural from 2006 through 2016 because it was not
conducting investigations of this type during that time. According to
CLERB’s current executive officer, it did not review deaths classified
as natural during this period because its former executive officers
generally interpreted its jurisdiction over in‑custody deaths to exclude
these types of deaths. In fact, CLERB’s rules and regulations do not
clearly specify whether CLERB should investigate natural deaths.
However, the concerns we discuss with the Sheriff Department’s
inadequate prevention of natural deaths underscore the importance of
CLERB providing external oversight of these cases. Since 2017 CLERB
has been consistently reviewing natural deaths. However, the lack of
specificity in its rules and regulations could result in CLERB reverting
to its past practice in the future.
In addition, CLERB did not investigate four other in‑custody
deaths—two that were classified as accidental, one as homicide by law
enforcement, and one as suicide—from 2009 through 2011. CLERB’s
executive officer said that it did not investigate these deaths because

12

The remaining nine deaths occurred in San Diego County law enforcement areas and
probation facilities.

Since 2017 CLERB has been
consistently reviewing natural
deaths. However, the lack of
specificity in its rules and regulations
could result in CLERB reverting to its
past practice of not reviewing natural
deaths in the future.

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the Sheriff’s Department failed to inform CLERB of their occurrence.
Although the Sheriff’s Department indicated that it did not have
information on notifications for this period, we find the lack of review of
these cases concerning. In 2011 CLERB made a policy recommendation
requesting that the Sheriff’s Department include it in all in‑custody
death notifications. Although the Sheriff’s Department declined to
modify its policies to include CLERB in its initial death notifications,
which includes the county district attorney and Medical Examiner’s
Office, it did direct a specific unit to inform CLERB of all in‑custody
deaths, usually within a few days of their occurrence. However, as we
discuss above, when the Sheriff’s Department does not notify CLERB of
deaths immediately, CLERB investigators do not have the opportunity to
visit the initial scenes of the incidents shortly after the death occurred.
As we show in Figure 10, CLERB failed to investigate a total of 57 deaths
of incarcerated individuals in Sheriff’s Department jails from 2006
through 2017—nearly a third of all its in‑custody deaths in the past
15 years. This is unacceptable given that CLERB is a key county entity
outside of the Sheriff’s Department that reviews in‑custody deaths.
Although CLERB recently added policies and procedures establishing
its prioritization of death cases over all other cases, it did not do so until
August 2021. Moreover, because policies can easily be changed when
leadership changes, it is important that CLERB include requirements in
its rules and regulations for how it prioritizes cases.
Figure 10
CLERB Did Not Investigate Nearly a Third of All In‑Custody Deaths in the Past 15 Years

57 Out of 185 Deaths

in San Diego County Jails Not Reviewed

13 deaths



     
  


40 deaths


 
 
 



4 deaths




   
    


l

c::::::a 57 Deaths
c::::::a Not Reviewed

Source: California Department of Justice in‑custody death data, CLERB list of investigations, and CLERB investigative reports.

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Despite CLERB’s efforts since 2017 to ensure that it appropriately
prioritizes and fully investigates in‑custody deaths, it has still
struggled to complete its investigations in a timely manner. As
we previously explained, CLERB investigators generally begin
investigating an in‑custody death after the Sheriff ’s Department’s
homicide unit has completed its own investigation and forwarded the
homicide investigation file to CLERB. Upon receipt of the homicide
investigation file, CLERB must complete its investigation within one
year to meet the POBR time limit. However, our review of the six
in‑custody death investigations found that CLERB investigators did
not begin their casework until an average of seven months after they
received the homicide investigation file from the Sheriff ’s Department.
As we note earlier, the Sheriff ’s Department usually does not provide
the file to CLERB until two to eight months after the death of an
incarcerated individual. Consequently, CLERB investigators did not
complete their investigations of the cases we reviewed until an average
of nearly a year and a half after the death occurred.
CLERB’s executive officer indicated that CLERB staff have not
historically prioritized beginning investigations of deaths, but he
has made recent efforts to ensure that staff start their investigations
as soon as they receive a homicide file. Although CLERB’s policy
does not provide instruction for how quickly the staff must start
working on investigations of deaths, the executive officer told us that
his goal is for these investigations to be complete within 90 days of
CLERB receiving the homicide investigation file. To make relevant
recommendations and hold individuals accountable for wrongdoing,
CLERB must take steps to complete its investigations of in‑custody
deaths in a timely manner.
CLERB Did Not Always Thoroughly Investigate In‑Custody Deaths
CLERB’s rules and regulations require its investigations to be
thorough. However, in some of the cases we selected, CLERB’s
investigators did not appear to consider all the circumstances
leading up to the deaths, did not examine all the relevant Sheriff ’s
Department policies, and did not follow up on discrepancies they
discovered in the course of their investigations. For example, in
one case, an altercation between two cellmates resulted in the death
of one of the individuals. However, the investigator did not appear
to scrutinize or independently verify evidence, such as the victim’s
mental health history, that might have affected their classification
status. Without this information, the investigator could not
sufficiently determine whether the Sheriff ’s Department had violated
policies or procedures by housing these individuals in the same cell.
Consequently, the investigator found that there was no evidence
to support an allegation of a procedural violation, misconduct, or
negligence on the part of the Sheriff ’s Department.

To make relevant recommendations
and hold individuals accountable
for wrongdoing, CLERB must take
steps to complete its investigations of
in‑custody deaths in a timely manner.

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When failing to thoroughly examine all the evidence in a case,
CLERB investigators may miss important opportunities to identify
deficient policies and practices and to make recommendations
to improve the safety of incarcerated individuals. CLERB’s
executive officer explained that because CLERB investigators are
often working against the POBR statute of limitations, they do
not consistently follow up on discrepancies they discover in the
course of their investigations. However, we find this explanation
problematic given the critical nature of the investigations. Further,
as we previously discuss, investigators often failed to begin their
investigations until months after receiving the homicide files. By
starting their investigations sooner, they could increase the time
available to them.

CLERB should develop a
comprehensive training manual
for its investigators that includes
guidance for evaluating the
circumstances leading up to
the death.

Although CLERB developed policies and procedures in
August 2021 that outline specific documents—such as medical
records—investigators should obtain in the course of an in‑custody
death investigation, we believe further action is necessary.
Specifically, CLERB should develop a comprehensive training
manual for its investigators that includes guidance for evaluating
the circumstances leading up to the death, such as the decedent’s
mental health history and the appropriateness of the decedent’s
housing assignment. Such changes could help ensure that its
investigations are complete and thorough.
Until Recently, the County Board Provided Insufficient Oversight
of CLERB
The county board has a number of responsibilities related to
CLERB. It appoints CLERB members and can remove individual
members by a majority vote at any time. The county board also
establishes CLERB’s duties and approves its rules and regulations.
However, despite its critical role in overseeing CLERB, the county
board rarely discussed in‑custody deaths or raised concerns about
CLERB, based on its meeting minutes from 2006 through 2019,
including after CLERB dismissed 22 death cases in 2017.
The county board has only recently begun to discuss in‑custody
deaths. Its current chair stated that the board’s composition
changed recently and that it now has an increased interest in
addressing deaths in San Diego County jails. In 2020 the county
board approved changes intended to strengthen CLERB’s oversight
of the Sheriff ’s Department and Probation Department, including
increasing the number of investigative staff. It also approved a
request for CLERB to revise its member nomination process to
make it more transparent and better incorporate community input.

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Although the current county board has recently been more engaged
in monitoring in‑custody deaths, CLERB has not effectively
communicated the pressing issues related to deaths in county
jails to the county board. The county charter requires CLERB to
prepare an annual report for the county board, the sheriff, and
the county probation officer that summarizes its activities and
recommendations, including the tracking and identification of
trends with respect to complaints received and investigated. Even
though CLERB has included in its annual reports year‑to‑year
comparisons of the number of new death cases and complaints,
its reports lack critical information that would enhance their
usefulness. For example, the reports summarize information on the
causes of death and certain categories of allegations of misconduct
but do not include any significant discussion or analysis that
might point to deficiencies in the Sheriff ’s Department policies
or practices. Further, they do not include any demographic
information related to deaths that CLERB investigates.
Although CLERB’s reporting and recommendation practices
generally align with requirements in its rules and regulations, it
could make its annual reports and recommendations more useful.
Other law enforcement oversight entities in the State include more
robust information in their annual reports, such as comprehensive
analyses and discussions of overall trends in discrimination,
misconduct, and excessive force allegations, as well as demographic
information. Additionally, as an advisory board, CLERB’s primary
means of improving the safety of incarcerated individuals and
providing oversight of in‑custody deaths is the recommendations
for policy or procedural changes that it makes to the Sheriff ’s
Department based on the deficiencies it detects in the course of its
investigations. However, CLERB generally makes recommendations
based on individual cases rather than on trends it identifies
through analysis of its investigations. Making recommendations
based on trends could help resolve more systemic concerns at the
Sheriff ’s Department.
CLERB’s executive officer indicated that he would like to include
more analyses of overall trends in the annual report but explained
that he has prioritized other issues, such as resolving the case
backlog and developing training materials for new investigators.
As a key oversight entity for county law enforcement, CLERB
must improve its reporting and analyses to better inform county
leadership and the public. Even more importantly, it must make
recommendations that address systemic issues to help prevent
deaths of incarcerated individuals.

CLERB must improve its reporting
and analyses to better inform
county leadership and the public.

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Blank page inserted for reproduction purposes only.

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Conclusions and Recommendations
The San Diego Sheriff ’s Department has a constitutional
responsibility to provide adequate medical care to the individuals
whom it incarcerates. Nonetheless, more people have died while in
its custody over the past 15 years than in nearly any other county
in the State—an average of about one death per month. Our audit
found that deficiencies in the Sheriff ’s Department’s policies and
practices related to intake screenings, medical and mental health
care, safety checks, and responses to emergencies likely contributed
to these deaths. The high rate of deaths in San Diego County jails
compared to other counties’ jails suggests that these systemic
deficiencies have undermined the Sheriff ’s Department’s ability to
ensure the health and safety of the individuals in its custody. We
are concerned about whether the Sheriff ’s Department will make
meaningful changes to address these systemic problems. Although
external entities—such as CLERB and the San Diego County Grand
Jury—have made recommendations in the past to address some
of the deficiencies we describe, the Sheriff ’s Department has not
implemented a number of them.
No single entity has sufficient oversight authority over the Sheriff ’s
Department to require it to make meaningful changes. Absent
explicit legislative direction, neither the county board nor the
State’s attorney general is well positioned to compel the Sheriff ’s
Department to implement the recommendations we include in this
report. Given the ongoing risk to incarcerated individuals’ safety, we
believe that the Legislature should direct the Sheriff ’s Department
to implement the changes we detail below.
Recommendations
Legislature—All Sheriff’s Departments and the California Department
of Justice
To ensure that all sheriff ’s departments accurately report deaths
that occur from incidents or conditions in county jails, the
Legislature should amend state law to require sheriff ’s departments
to report to the attorney general individuals who are released from
custody after being transported directly to a hospital or similar
medical facility and subsequently die in the facility. It should also
amend state law to require sheriff ’s departments to provide the
attorney general with all facts concerning the death, such as the
cause and manner. The California Department of Justice should
annually publish this information on its website.

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Legislature—San Diego Sheriff’s Department
To ensure that the San Diego Sheriff ’s Department identifies
individuals’ medical and mental health needs at intake, the
Legislature should require it to revise its policies to better align with
best practices, as follows:
• Revise its intake screening policy to require mental health
professionals to perform its mental health evaluations. These
evaluations should include a mental health acuity level rating
scale to better inform individuals’ housing assignments and
service needs while in custody. The Sheriff ’s Department should
communicate the acuity level rating it assigns to individuals to all
detention staff overseeing them.
• Create a policy requiring health staff to review and consider each
individual’s medical and mental health history from the county
health system during the intake screening process.
To ensure that the Sheriff ’s Department provides the necessary
medical and mental health care to individuals incarcerated in its
facilities, the Legislature should require it to do the following:
• Revise its policy to require that nurses schedule an individual for
an appointment with a doctor if that individual has reported to
the nurse for evaluation more than twice for the same complaint.
• Revise its policy to require that a nurse perform and document
a face‑to‑face appraisal with an individual within 24 hours
of receipt of a request for medical services to determine the
urgency of that request.
• Revise its policy to require more frequent psychological
follow‑up after release from the inmate safety program,
including at least monthly check‑ins.
• Revise its policy to require that a member of its health staff
witness and sign the refusal form when an individual declines to
accept necessary health care.
To ensure that sworn staff properly perform safety checks,
the Legislature should require the Sheriff ’s Department to do
the following:
• Revise the safety check policy to include the requirement for staff
to check that an individual is still alive without disrupting the
individual’s sleep.

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• Develop and implement a policy requiring that designated
supervising sworn staff conduct audits of at least two randomly
selected safety checks from each prior shift. These audits should
include a review of the applicable safety check logs and video
footage to determine whether the safety checks were performed
adequately. In addition, the policy should require higher‑ranking
sworn staff to conduct weekly and monthly audits of safety
checks. The policy should also require each facility to maintain a
record of the safety check audits that staff members perform.
To ensure that department staff promptly respond to unresponsive
individuals, the Legislature should require the Sheriff ’s Department
to revise its policies to require that sworn staff members
immediately start CPR without waiting for medical approval, as
safety procedures allow. The Legislature should also require that
the Sheriff ’s Department provide sworn staff with additional
training for starting CPR immediately and how to properly alert
medical staff.
To ensure that the Sheriff ’s Department properly assesses the
reasons for each in‑custody death and makes prompt changes as
necessary in response, the Legislature should require it to revise its
policy to specify the following:
• Staff will provide a written report of each 30‑day medical review
to its management.
• When warranted, the report should specify recommendations
for changes to prevent further deaths.
• The 30‑day medical review should determine the appropriateness
of clinical care; assess whether changes to policies, procedures,
or practices are warranted; and identify issues that require
further study.
To improve oversight of in‑custody deaths and encourage
meaningful action to prevent future deaths, the Legislature should
require the Sheriff ’s Department to revise its policy to require that
the Critical Incident Review Board review natural deaths.
To increase the transparency of the Sheriff ’s Department’s reviews
of in‑custody deaths, the Legislature should require the Sheriff ’s
Department to either make public the facts it discusses and
recommendations it decides upon in the relevant Critical Incident
Review Board meetings or to establish a separate public process for
internally reviewing deaths and making necessary changes.

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To ensure that the Sheriff ’s Department provides complete and
prompt assistance to CLERB’s investigations, the Legislature should
require the Sheriff ’s Department to do the following:
• Revise its policy to include CLERB in its immediate death
notification process.
• Revise its policy to allow a CLERB investigator to be present at
the initial death scene.
• Revise its policy to encourage its staff to cooperate with CLERB’s
investigations, including participating in interviews with
CLERB’s investigators.
The Legislature should implement the recommendations related to
the Sheriff ’s Department described above in a manner consistent
with the form of governance applicable to San Diego County.
Legislature—BSCC
To ensure that standards of care for incarcerated individuals are
adequate and consistent across the State, the Legislature should
amend state law to require BSCC to amend certain regulations to
address the following:
• County sheriff ’s departments with jails that have an average
daily population of more than 1,000 must have a mental health
professional perform mental health evaluations at intake.
• Safety checks must include a procedure for checking to see that
each individual is alive.
To ensure the involvement of experts in the areas of medical
and mental health care in approving BSCC’s regulations and
training standards related to the health and safety of incarcerated
individuals, the Legislature should change the composition of BSCC
to include a medical professional and a mental health professional.
To ensure that BSCC’s regulations, guidance, and training align
with medical and mental health care best practices, the Legislature
should require BSCC to evaluate and update all of its regulations
and training as needed once its composition includes a medical
professional and a mental health professional.
To ensure that all local correctional officers in the State receive
sufficient continuing professional education, the Legislature
should require BSCC to amend its regulations to require that local
correctional officers working in local detention systems with an

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average daily population of more than 1,000, complete 40 hours
of training annually and that at least four of those hours relate to
mental and behavioral health.
CLERB
To ensure its investigations are independent, timely, and thorough,
CLERB should do the following by May 2022:
• Discuss and modify its current agreement with the Sheriff ’s
Department and the labor organization to allow CLERB’s
investigators to conduct independent interviews of Sheriff ’s
Department sworn staff.
• Develop a comprehensive training manual for its investigators
that outlines standard procedures for investigations. The manual
should include a specific section dedicated to investigations
of in‑custody deaths, including guidance for evaluating the
circumstances leading up to an in‑custody death, such as the
decedent’s mental health history and the appropriateness of the
decedent’s housing assignment.
• Create policies and procedures to require its investigators to
finish casework on in‑custody death investigations within three
months of receiving the homicide investigation file. These
policies and procedures should also require investigators to
attempt to independently verify any information they receive
from the Sheriff ’s Department, to thoroughly review deputy
statements and reports from the homicide investigation file, and
to request interviews with relevant detention staff and other
witnesses in all instances in which they identify discrepancies or
missing information.
To ensure that it fully investigates all in‑custody deaths, CLERB
should revise its rules and regulations by May 2022 to include
the following:
• Prioritization criteria for investigating in‑custody deaths above
all other investigations.
• Clarification that its investigations of in‑custody deaths includes
those classified as natural deaths.
To ensure that it provides effective oversight of the deaths of
individuals in the Sheriff ’s Department’s custody, CLERB should
perform an analysis of overall trends related to these deaths,
including demographic information, and determine whether the
trends suggest deficiencies in the Sheriff ’s Department’s policies

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and procedures. Based on these trends, it should also identify policy
recommendations for improving the safety of the individuals in the
Sheriff ’s Department’s custody. To increase transparency, CLERB
should include these trends and analyses in its annual reports
starting with its 2021 report, which it should publish in 2022.

We conducted this performance audit in accordance with generally accepted government auditing
standards and under the authority vested in the California State Auditor by Government Code
sections 8543 et seq. Those standards require that we plan and perform the audit to obtain sufficient,
appropriate evidence to provide a reasonable basis for our findings and conclusions based on the audit
objectives. We believe that the evidence obtained provides a reasonable basis for our findings and
conclusions based on our audit objectives.
Respectfully submitted,

MICHAEL S. TILDEN, CPA
Acting California State Auditor
February 3, 2022

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Appendix A
In‑Custody Deaths in California’s 15 Largest Counties
The Joint Legislative Audit Committee (Audit Committee) directed
us to compare the in‑custody death rate in San Diego County
to the rates in other comparable California counties for the past
15 years—2006 through 2020. Table A.1 presents the rate of deaths
per average daily population (ADP) in each of these county sheriff
jail systems from 2006 through 2020. As we previously explain, the
ADP represents the number of incarcerated individuals housed in a
jail system on any given day over a period of time.
Table A.1
In‑Custody Deaths and ADPs From 2006 Through 2020
COUNTY SHERIFF’S
DEPARTMENT

San Diego

ADP 15‑YEAR AVERAGE
(2006–2020)

TOTAL
DEATHS

AVERAGE DEATHS
PER YEAR

AVERAGE DEATHS
PER 1,000 ADP

5,162

185

12.33

2.39

Fresno

2,752

86

5.73

2.08

Ventura

1,537

47

3.13

2.04

Kern

2,266

69

4.60

2.03

Alameda

3,325

99

6.60

1.98

Contra Costa

1,446

43

2.87

1.98

Riverside

3,668

104

6.93

1.89

San Francisco

1,492

39

2.60

1.74

San Joaquin

1,367

34

2.27

1.66

Los Angeles

17,044

421

28.07

1.65

San Bernardino

5,490

124

8.27

1.51

Santa Clara

3,732

84

5.60

1.50

Orange

5,877

111

7.40

1.26

Tulare

1,510

26

1.73

1.15

Sacramento

4,008

62

4.13

1.03

Source: California Department of Justice in‑custody death data and BSCC data.

We present information on additional counties in our interactive
dashboards at https://www.auditor.ca.gov/reports/2021‑109/
supplemental.html.

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Table A.2 presents the rate of deaths per the number of individuals
booked in each county sheriff ’s jail system from 2006 through 2020.
The number of bookings is the total number of individuals who
were processed through the jail system.
Table A.2
In‑Custody Deaths and Bookings From 2006 Through 2020
COUNTY SHERIFF’S
DEPARTMENT

TOTAL
BOOKED

AVERAGE BOOKED
PER YEAR

Los Angeles

1,970,654

131,377

Fresno

TOTAL
DEATHS

TOTAL DEATHS
PER 100,000 BOOKED

421

21.36

551,624

36,775

86

15.59

1,284,462

85,631

185

14.40

Kern

520,074

34,672

69

13.27

Riverside

810,376

54,025

104

12.83

San Diego

Alameda

777,627

51,842

99

12.73

Orange

888,951

59,263

111

12.49

Santa Clara

682,010

45,467

84

12.32

1,027,195

68,480

124

12.07

San Bernardino
Contra Costa

370,299

24,687

43

11.61

Ventura

424,978

28,332

47

11.06

San Francisco

353,521

23,568

39

11.03

San Joaquin

392,895

26,193

34

8.65

Sacramento

733,275

48,885

62

8.46

Tulare

333,941

22,263

26

7.79

Source: California Department of Justice in‑custody death data, BSCC data, and San Diego Sheriff’s Department bookings data.

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Appendix B
Scope and Methodology
The Audit Committee directed the California State Auditor
to conduct an audit of the San Diego Sheriff ’s Department to
determine the reasons for in‑custody deaths of incarcerated
individuals and identify the steps taken by the Sheriff ’s Department
to address these deaths. The table below lists the objectives that
the Audit Committee approved and the methods we used to
address them.
Audit Objectives and the Methods Used to Address Them
AUDIT OBJECTIVE

1 Review and evaluate the laws, rules, and

regulations significant to the audit objectives.

2 Evaluate the Sheriff’s Department’s policies

and procedures on personnel training, facility
maintenance and safety, and the provision
of health care to incarcerated individuals. To
the extent possible, determine whether these
policies and procedures align with minimum
standards established through state law
and any other applicable guidance. As part
of this evaluation, also determine whether
any of these policies delay or otherwise
impair the ability of medical personnel
to provide appropriate medical care to
incarcerated individuals.

3 To the extent possible, for a selection of

METHOD

Reviewed and evaluated the laws, rules, and regulations related to detention facilities and
significant to the audit objectives.
• Interviewed staff and reviewed the Sheriff’s Department’s documented policies and
procedures regarding personnel training, facility maintenance and safety, and the
provision of health care to incarcerated individuals. Determined whether those policies
and procedures meet the requirements established by BSCC and state law, including
reviewing BSCC’s biennial inspections.
• Reviewed the Sheriff’s Department’s policies and procedures, in combination with
reviewing in‑custody deaths under Objective 3, to determine whether its policies delay or
otherwise impair the ability of medical personnel to provide appropriate medical care to
incarcerated individuals.
• Reviewed BSCC’s board composition and whether BSCC’s standards are strong enough to
ensure the safety of incarcerated individuals.
• Interviewed staff of BSCC regarding its review process to update and revise standards.

a. The circumstances, such as the cause for
each death.

• Using a complete list of in‑custody deaths in the Sheriff’s Department’s jails, selected
30 deaths for review from 2006 through 2020 taking into consideration factors such
as gender, race, age, location of death, type of death, and date of death. The Sheriff’s
Department did not report any in‑transit deaths related to its jails. In accordance with
audit standards, we did not select cases involved in active litigation in order to avoid
interfering with ongoing legal proceedings.

b. Whether correctional facility staff followed
applicable policies and procedures related to
in‑custody safety.

• For the selection of 30 in‑custody deaths, reviewed jail files, medical records, and other
relevant reports to determine the circumstances around each death—including the
cause of each death, such as suicide, homicide, or natural death.

c. Whether the Sheriff’s Department reviewed
the circumstances of these deaths
and took corrective action to improve
in‑custody safety.

• For the selection of 30 in‑custody deaths, reviewed case file documentation to determine
whether detention staff followed applicable policies and procedures related to the safety
of and the provision of health care to incarcerated individuals.

in‑custody deaths from the past 15 years—
including suicides, murders, and in‑custody or
in‑transit deaths—determine the following:

• For the selection of 30 in‑custody deaths, reviewed investigative reports from
various entities and units to identify whether the Sheriff’s Department reviewed the
circumstances of each death. Evaluated whether it took appropriate corrective action to
improve in‑custody safety in response to the death.

continued on next page . . .

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AUDIT OBJECTIVE

4 To the extent possible, evaluate available

demographic information—including the race
and age of the incarcerated individuals—and
identify any relevant trends for all in‑custody
deaths from the past 15 years. Compare
the in‑custody death rate in San Diego
County to the rates in other comparable
California counties.

METHOD

• Identified three comparable county sheriff’s departments—the Alameda Sheriff’s Office,
Orange Sheriff’s Department, and Riverside Sheriff’s Department—considering relative
size, geographical location, and other factors.
• Interviewed staff at each county’s sheriff’s department to understand its policies
and practices as well as to identify challenges with ensuring the health and safety of
incarcerated individuals.
• For comparative analysis to identify best practices, obtained and reviewed policies and
procedures related to in‑custody health care and detention facilities from the three
comparable sheriff’s departments, along with the policies at CDCR.
• For all deaths of incarcerated individuals from 2006 through 2020 at the San Diego
Sheriff’s Department and the three comparable county sheriff’s departments, compared
the number and types of deaths, and interviewed staff knowledgeable about the data.
• Obtained data from the California Department of Justice and BSCC, including race
of incarcerated individuals, age of incarcerated individuals, and the frequency and
cause of death. We used these data to create interactive dashboards that present this
information. We present those interactive dashboards at https://www.auditor.ca.gov/
reports/2021‑109/supplemental.html. We did not identify any notable trends in the
deaths of incarcerated individuals by age but include information about their ages in an
interactive dashboard.

5 Review allegations from the past 15 years that

led to wrongful death suits and determine
the number of settlements, the average
settlement amount, and, to the extent possible,
how settlement awards compare to similar
settlements from other comparable counties
in California.

• Obtained and reviewed documentation from San Diego County and each of the three
comparable counties to identify all settlements related to deaths in detention facilities
from 2006 through 2020. For all settlements, we determined the average settlement
award and the type and circumstances of the death.
• Interviewed staff at the comparable counties regarding the total number of settlements
in response to in‑custody deaths.
• Compared the settlements in San Diego County to the three comparable counties.

6 To the extent possible, determine which

policies specified in settlement agreements
or in grand jury recommendations have been
implemented and which have not. As part of
this determination, also identify whether the
Sheriff’s Department has suspended, revoked,
or amended any such policies in a manner
inconsistent with past settlement agreements
or grand jury recommendations.

• Identified recommendations regarding policy changes from various entities, including
the San Diego County Grand Jury, from 2006 through 2020. For key recommendations
related to in‑custody health and safety, we determined whether the Sheriff’s Department
implemented the recommendations. If it did not, we documented and evaluated
its rationale.
• Reviewed current policies and determined that the Sheriff’s Department has
not suspended, revoked, or amended its policies in a manner inconsistent with
past recommendations we reviewed.
• Determined that the county’s settlement agreements generally did not
include recommendations.

7 Evaluate the extent to which CLERB has

provided recommendations to the Sheriff’s
Department regarding in‑custody safety
and followed up to determine whether the
Sheriff’s Department has implemented
those recommendations.

• Reviewed recommendations from CLERB to the Sheriff’s Department from
2006 through 2020 and identified key recommendations related to the safety of
incarcerated individuals.
• Reviewed policies and other relevant documents to determine whether the Sheriff’s
Department implemented key recommendations from CLERB.

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AUDIT OBJECTIVE

8 Evaluate CLERB’s review of in‑custody death

cases in 2017 and assess whether CLERB had
sufficient staff and resources to perform its
oversight role appropriately.

METHOD

• Obtained a complete list of death cases CLERB investigated from 2006 through 2020 and
compared it to the lists of deaths from the Sheriff’s Department and Medical Examiner’s
Office. Although we found that CLERB did not investigate 57 deaths during this period, as
we discuss beginning on page 46, the list of investigations it did perform was sufficient
for our purposes. Using the list, we selected six cases from 2016 through 2020 for review
based on factors such as the year the investigation was performed, type of death, and
result of investigation.
• For the six selected cases, reviewed the full investigative file to determine whether
CLERB’s staff followed its rules and regulations and other relevant standards when
investigating the cases.
• CLERB’s rules and regulations require its investigations to be ethical, fair, and impartial.
CLERB follows the county’s Conflict of Interest Code and Incompatible Activities Rules,
which require its members and certain staff members to disclose certain income,
employment, economic interests, and gifts. CLERB also has its staff members review and
sign the county’s code of ethics. We did not identify concerns with the ethics, fairness or
impartiality of the CLERB investigations we reviewed.
• Interviewed staff and reviewed documentation to determine why CLERB summarily
dismissed 22 death cases in 2017 and whether staff appropriately prioritized death cases.
• We did not evaluate CLERB’s investigators’ caseloads and staffing because we found
issues with the thoroughness and prioritization of its investigations.
• Reviewed the county board’s oversight of CLERB and whether it took action to increase
oversight in response to increases in deaths of incarcerated individuals.

9 Review and assess any other issues that are

None identified.

significant to the audit.

Source: Audit workpapers.

Assessment of Data Reliability
The U.S. Government Accountability Office, whose standards
we are statutorily obligated to follow, requires us to assess the
sufficiency and appropriateness of computer‑processed information
we use to support our findings, conclusions, and recommendations.
In performing this audit, we relied on electronic data files that
we obtained from the California Department of Justice related to
in‑custody deaths in jails of the San Diego Sheriff ’s Department,
the Alameda Sheriff ’s Office, the Orange Sheriff ’s Department, and
the Riverside Sheriff ’s Department from 2006 through 2020. To
evaluate the data, we reviewed existing information about the data,
interviewed staff knowledgeable about the data, and performed
testing of the data. Specifically, we compared data from the counties
and the California Department of Justice to data we obtained
from the Medical Examiner’s Office and coroner’s office in each
respective county.
Although the state law requiring reporting of in‑custody deaths
does not require sheriff ’s departments to report deaths after an
individual is released from jail, as we discuss on page 17, we found

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that the data supporting the number of in‑custody deaths from the
California Department of Justice related to the San Diego Sheriff ’s
Department and the Orange Sheriff ’s Department to be sufficiently
reliable for our audit purposes. We found some inaccuracies in
the categorization of manner of death, but the inaccuracies do
not change our conclusion, and therefore the data are sufficiently
reliable for our audit purposes. We performed limited testing of the
Alameda Sheriff ’s Office’s and the Riverside Sheriff ’s Department’s
data and found them to be of undetermined reliability because
of how the counties record and track the information. Although
this determination may affect the precision of the numbers we
present, there is sufficient evidence in total to support our findings,
conclusions, and recommendations.
In addition, we obtained data from BSCC related to the ADPs
and annual bookings of the San Diego Sheriff ’s Department, the
Alameda Sheriff ’s Office, the Orange Sheriff ’s Department, and
the Riverside Sheriff ’s Department. We used these data to identify
and compare the number of in‑custody deaths at each department,
taking into consideration the number of individuals incarcerated
in its jail facilities. We interviewed staff knowledgeable about the
data and performed general testing of the data. We found the data
to be of undetermined reliability because the data are self‑reported
from each county to BSCC. However, we found that the San Diego
Sheriff ’s Department overreported to BSCC the bookings data for
2006 through 2010. Therefore, we obtained additional data from
the Sheriff ’s Department to more accurately reflect bookings in
our analyses. Although this determination may affect the precision
of the numbers we present, there is sufficient evidence in total to
support our findings, conclusions, and recommendations.
Lastly, we obtained statewide data from the California Department
of Justice and BSCC related to in‑custody deaths and ADP for
presentation on our interactive dashboards. We found the data to
be of undetermined reliability because the data are self‑reported by
each county. The dashboard is for informative purposes only; we do
not present findings, conclusions, or recommendations on it.

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\ @c~ , ~ IBOARD OF STATE AND COMMUNITY CORRECTIONS

January 14, 2022
Honorable Michael S. Tilden*
Acting California State Auditor
621 Capitol Mall, Suite 1200
Sacramento, California 95814
SUBJECT: RESPONSE – SAN DIEGO COUNTY SHERIFF’S DEPARTMENT AUDIT
REPORT 2021-109
Dear Mr. Tilden,
The Board of State and Community Corrections is required to establish minimum
standards for local detention facilities. (Pen. Code, § 6030.) Providing for safe and
constitutional facilities is central to the Board’s regulations, which are continuously
examined and revised on a biennial basis. The Audit of the San Diego County Sheriff’s
Department (Report 2021-109) focuses on deaths in custody, which is a topic of utmost
concern that merits serious attention. Having not been given an opportunity to review
the findings in San Diego as part of this response, we are unable to comment on
whether the deaths in custody in San Diego County were caused by the county
adhering to BSCC regulations that were deficient or whether other operational or
personnel issues may have contributed to the audit findings. The Board will undertake
a review once the unredacted findings are available to determine to what extent the
Board’s existing regulations merit revision. However, we disagree with the Auditor’s
conclusions that the Board’s existing training standards are inadequate and that the
BSCC’s regulations for the operation of adult local detention facilities that are proposed
to be revised are insufficient for maintaining the safety of people who are
incarcerated.
Mental Health Screenings

01

The Auditor states the Board’s standards are insufficient to maintaining the safety
incarcerated individuals, specifically citing that the regulations “do not explicitly require
that mental health professionals perform mental health screenings.” We assume the
Auditor is referring to “intake screenings,” where Section 1207 of Title 15 of the
California Code of Regulations provides:
With the exception of inmates transferred directly within a custody system with
documented receiving screening, a screening shall be completed on all inmates
at the time of intake. This screening shall be completed in accordance with
written procedures and shall include but not be limited to medical and mental

Linda M. Penner, Chair
Kathleen T. Howard, Executive Director

*

California State Auditor’s comments begin on page 71.

WWW.BSCC.CA.GOV

Gavin Newsom
California Governor

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Tilden, Michael
Page 2

health problems, developmental disabilities, tuberculosis and other
communicable diseases. The screening shall be performed by licensed health
personnel or trained facility staff, with documentation of staff training regarding
site specific forms with appropriate disposition based on responses to questions
and observations made at the time of screening. The training depends on the
role staff are expected to play in the receiving screening process.
This regulation is aligned with National Commission on Correctional Health Care
(NCCHC) J-E-02 which allows for “receiving screening to be conducted by healthtrained correctional staff members when health staff are not on duty.” NCCHC
standards are nationally recognized as best practice.
In addition, Sections 1206 and 1209 of Title 15 of the California Code of Regulations
detail requirements of additional mental health screenings that may occur after the initial
screening at intake. These requirements do require licensed medical and mental health
care professionals to conduct mental health screening and require facilities to provide
care for persons with mental health needs.
The Auditor appears to recognize that it may be impractical or impossible for all local
detention facilities to have mental health professionals on staff 24/7 for intake, so the
report recommends that facilities with average daily populations of 1,000 be required to
have these requirements because counties with smaller incarcerated populations have
“less risk.” While larger counties may be able to provide a higher level of service than
other counties, establishing lesser standards for smaller counties is problematic and
would create additional inequities within county criminal justice systems.

02

Safety Checks
The Auditor argues that the current safety check regulation (and proposed revisions)
are insufficient to protect the safety and welfare of inmates. The Auditor points to the
fact that some counties’ policies are more detailed than the Board’s regulations. In
addition, the Auditor notes the California Department of Corrections and Rehabilitation
(CDCR) requires its staff to count “living, breathing” individuals. The fact that some
counties may elect to explicitly detail what goes into a safety check in its policies does
not mean the Board’s minimum standards do not provide for adequate safety. The
Board’s regulations are designed to give counties flexibility to address their needs while
adhering to constitutional standards. In addition, it is important to note that the
requirements for counting individuals in the CDCR Department of Operations Manual
(§§ 52020.5.5 and 52020.5) are not “safety checks.” They are merely instructions on
staff to ensure a proper population count.
Section 1027.5 of Title 15 of the California Code of Regulations requires a written plan
at each facility that includes documentation of safety checks. Title 15 section 1006,

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Tilden, Michael
Page 3

Definitions, provides detail for how safety checks must be conducted and defines both
direct visual observation and safety checks:
“Direct visual observation” means direct personal view of the inmate in the
context of his/her surroundings without the aid of audio/video equipment.
Audio/video monitoring may supplement but not substitute for direct visual
observation.
“Safety checks” means direct, visual observation performed at random intervals
within timeframes prescribed in these regulations to provide for the health and
welfare of inmates.
As part of the most recent regulation revisions adopted at the most recent BSCC board
meeting, the Board revised section 1027.5 to require enhancements to safety checks,
which, once approved by the Office of Administrative Law, will read, as follows:
§ 1027.5 Safety Checks.
The facility administrator shall develop and implement policy and
procedures for conducting safety checks that include but are not limited to
the following:
Safety checks will determine the safety and well-being of individuals and
shall be conducted at least hourly through direct visual observation of all
people held and housed in the facility.
(a) There shall be no more than a 60- minute lapse between safety
checks.
(b) Safety checks for people in sobering cells, safety cells, and restraints
shall occur more frequently as outlined in the relevant regulations.
(c) Safety checks shall occur at random or varied intervals.
(d) There shall be a written plan that includes the documentation of all
safety checks. Documentation shall include:
(1) the actual time at which each individual safety check occurred;
(2) the location where each individual safety check occurred, such
as a cell, module, or dormitory number; and,
(3) Initials or employee identification number of staff who completed
the safety check(s).
(e) A documented process by which safety checks are reviewed at regular
defined intervals by a supervisor or facility manager, including methods
of mitigating patterns of inconsistent documentation, or untimely
completion of, safety checks.
In this revision, the regulation will explicitly require that safety checks "determine the
safety and well-being of individuals." The BSCC revised regulation exceeds many other
states' safety check regulations, and is aligned with best practices for safety checks.

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Tilden, Michael
Page 4

In short, safety checks allow for potential interventions when people are in distress, but
it is also important to balance the needs of people who are incarcerated from overly
intrusive and unnecessary checks. Counties have been subject to litigation over
allegations of failing to conduct adequate safety checks and also for unnecessarily
interrupting sleep as part of rigorous safety check programs. The Board’s regulation
and proposed revision strikes the appropriate balance in providing for the safety of
people who are incarcerated and meeting county operational needs.

03

Training Standards
The Auditor states that the BSCC’s training standards are insufficient for maintaining the
safety of incarcerated individuals. The Auditor solely relies on the total increase in the
number of deaths in county jails from 2006 to 2020 to conclude training is
insufficient. Based on the information provided in the redacted report, the BSCC is
unable to determine whether a lack of specific training caused any of the deaths
examined in San Diego and to what extent additional training requirements would have
been beneficial or prevented these situations. Instead, the report states that
“weaknesses in statewide corrections standards likely contributed to the problems we
identified with (redacted) policies” without any specific detail. Without a clear nexus
between a deficiency in the training standards and a bad outcome such as a
preventable death, it is incorrect to assume that higher standards will better ensure the
health and safety of incarcerated individuals.
The Auditor states that the Board’s continuing education requirements across job
classifications (adult correctional officer, juvenile correctional officer, and probation
officer) are inconsistent and recommends that the adult correctional officers should
receive 40 hours of annual training on par with probation officers. In addition, the
Auditor recommends that agencies with average daily populations of 1,000 or more
should require 4 hours of mental health training annually.
The characterization of the continuing education requirements as inconsistent is
incorrect. BSCC sets standards for adult corrections officers, juvenile corrections
officers, and probations officers and their managers and supervisors. Those jobs are
not interchangeable nor are their training requirements. The “inconsistencies” noted in
the report are deliberate decisions based on the differences in positions. Requiring the
same number of hours across all classifications is arbitrary and not based on jobspecific requirements. Furthermore, the number of required hours for the adult
corrections officer is on trend nationally and exceeds the number of continuing
education hours required by the California Commission on Peace Officer Standards and
Training for other peace officer positions.
The report recommends that continuing education include a minimum of 40 hours
training annually and at least four hours of mental health training for adult corrections
officers for agencies with an ADP of 1,000. First, it should be noted that the BSCC
standards already require 21 hours of Behavioral Health training for every officer upon

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Tilden, Michael
Page 5

hire. It includes training in suicide prevention, stigma and bias, trauma, emotional
survival, interventions and resources, and recognizing signs and symptoms of mental
illness and trauma.
Second, we question the premise that more hours of annual training, regardless of the
topic or need, will always yield better results. Continuing education hours are
deliberately left to the discretion of the agency so that they can identify the specific
training needs of an employee, including performance management, and to support
organizational priorities or training gaps. Training is not a static need and it should
remain flexible to ensure critical gaps are addressed. Training is a critical tool that can
improve employee performance and organizational success. However, it is only
effective when used appropriately. Problems must be assessed to determine if training
can be an effective part of the solution. Culture, ineffective policies, and employees
deliberately acting outside of policy are some examples of when training is not an
appropriate solution. The portions of the audit we were able to review do not provide
an assessment that shows that what was at issue in San Diego was a training failure
that will improve by mandating four hours of mental health training each year for all
adult corrections officers.
Finally, as with the recommendation to have lesser screening standards for smaller
counties, we also disagree with setting lesser training standards for correctional officers
in smaller counties.
To be sure, the BSCC continually evaluates the need for entry-level training and annual
training. We will take the recommendation under advisement when evaluating the next
revision of our training standards to determine whether adding annual mental health
training would be beneficial.
In closing, the BSCC appreciates the Auditor’s review of its standards and
recommendations. At the time of responding to the draft audit, the Board itself has not
had the opportunity to meet and discuss. We will discuss the final report with the Board
upon release and whether amendments to the BSCC regulations are warranted.
Sincerely,

KATHLEEN T. HOWARD
Executive Director

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Comments
CALIFORNIA STATE AUDITOR’S COMMENTS ON
THE RESPONSE FROM THE BOARD OF STATE AND
COMMUNITY CORRECTIONS
To provide clarity and perspective, we are commenting on the
BSCC’s response to our audit. The numbers below correspond to
the numbers we have placed in the margin of its response. Rather
than comment on all of the individual areas of its response that
we believe are deficient or misleading, we have summarized our
comments according to the respective sections in its response.
We stand by our recommendation that the Legislature should
amend state law to require sheriff ’s departments with larger jail
populations to have mental health professionals perform mental
health evaluations at intake. We based this recommendation on
the problems identified in our review of the San Diego Sheriff ’s
Department and the variation of policies among the three
comparable counties. As we state on page 20, in some of the cases
we reviewed, the Sheriff ’s Department did not promptly and
properly identify individuals’ mental health needs because mental
health professionals generally do not participate in its intake health
screenings. In contrast, we noted that one county has adopted
more robust intake screening practices, as we state on page 20.
For example, Riverside Sheriff ’s Department policy requires that
a mental health clinician evaluate every individual before being
housed, which could help to more effectively identify mental health
needs early.

01

Further, BSCC infers our recommendation is to establish lesser
standards of mental health staffing for smaller counties. On the
contrary, we did not propose any changes to these standards for
smaller counties, but instead recommend that BSCC should raise
the standard for the larger counties, as we describe on page 32.
BSCC suggests that counties electing to have more robust safety
checks policies does not mean that its minimum standards are
inadequate. We disagree. As we state on page 30, BSCC’s standards
do not describe the actions that constitute an adequate safety
check. Instead, the standards simply state that safety checks must
be conducted at least hourly through direct visual observation of all
inmates and that observation through a video camera alone is not
sufficient. Consequently, we found the four counties we reviewed
based their policies on different interpretations of this standard.
Further, as we state on page 25, based on our review of video of
San Diego Sheriff ’s Department, we observed multiple instances of
sworn staff who spent no more than one second glancing into an
individual’s cell, sometimes without breaking stride as they walked

02

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through the housing module. Staff later discovered individuals
unresponsive in their cells, some with signs of having died several
hours earlier.
Further, as we state on page 25, we concluded that sworn staff
conducted safety checks inadequately in part because of weaknesses
in the San Diego Sheriff ’s Department’s policy. In particular, its
safety check policy does not require sworn staff to determine
whether individuals are alive and well by taking steps such as
by observing the rise and fall of their chest. We recognize that
acquiring proof of life in some situations is difficult and that waking
up incarcerated individuals every hour could be detrimental to
their well‑being. However, a safety check that does not involve
any meaningful observation of an individual is ineffective
and inadequate.
Moreover, BSCC asserts that our report references a CDCR policy
that merely serves as instructions for a proper population count.
However, CDCR’s policy is a requirement for an hourly check that
is equivalent to what BSCC refers to as a safety check. We revised
the report text on page 30 to be more explicit that the CDCR policy
is for an hourly check of incarcerated individuals.
Finally, BSCC states that its proposed regulations exceed the
standards in other states and are aligned with best practices.
However, it falls short of the State’s best practice. For example,
as we state on page 30, CDCR requires its staff during its hourly
checks to count a living, breathing individual whom they see in
person. BSCC’s proposed regulations are insufficient because, as we
state on page 30, it fails to specify that a safety check must include
verifying that an individual is alive, which is essential to ensuring
the safety of incarcerated individuals across the State.

03

Our recommendation to increase the required number of
continuing education hours for local correctional officers is based
on concerns observed in our review of how San Diego Sheriff ’s
Department sworn staff responded to medical, mental health, and
safety needs. Further, as we state on page 29, given the increase in
the annual number of in‑custody deaths across the State from 130
in 2006 to 156 in 2020, improving statewide standards related to
health and safety and training requirements is essential to ensuring
the health and safety of incarcerated individuals.
BSCC’s statement that its standards require 21 hours of behavioral
health training is misleading because this training pertains only
to initial hires. The point of continuing education is to provide
local correctional officers with ongoing training to expand their

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foundation of knowledge to promote health and safety within the
jails and to stay up‑to‑date on new information that would help in
that effort.
We stand by our conclusion that the continuing education
requirements are inconsistent. As we state on page 31, BSCC’s
required training hours for sworn staff working in local detention
facilities do not align with their standards for similar positions.
Requiring fewer hours for adult corrections personnel does not
make sense when thousands of individuals are incarcerated in
these facilities and the number of individuals who have died has
increased over the past 15 years. Further, BSCC does not require
that any of the annual training cover topics pertaining to mental
health, even though best practices suggest staff should receive
at least four hours of mental health training annually. Increasing
the number of training hours to align with similar professions,
including mandating mental health training hours, could allow
sheriff ’s departments to better protect and keep incarcerated
individuals safe.
Similar to our recommendation for having mental health
professionals perform mental health assessments at intake, BSCC
should increase the required continuing education hours for
counties that house the majority of individuals in the county jail
systems. Moreover, contrary to BSCC’s assertion, we did not
propose any changes to these standards for smaller counties but
instead recommend that it should raise the standard for the larger
counties, as we describe on page 32.

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BOARD MEMBERS
SUSAN N. YOUNGFLESH
Chair
EILEEN DELANEY
Vice Chair
ROBERT SPRIGGS JR.
Secretary
BUKI DOMINGOS
NADIA KEAN-AYUB
BONNIE KENK
MARYANNE PINTAR
TIM WARE
GARY I. WILSON

EXECUTIVE OFFICER
PAUL R. PARKER III

County of San Diego

CITIZENS’ LAW ENFORCEMENT REVIEW BOARD
555 W BEECH STREET, SUITE 220, SAN DIEGO, CA 92101-2938
TELEPHONE: (619) 238-6776
FAX: (619) 238-6775
www.sdcounty.ca.gov/clerb

January 14, 2022
Michael S. Tilden, CPA*
Acting California State Auditor
621 Capitol Mall, Suite 1200
Sacramento, CA 95814
RE:

Response to California State Auditor’s Draft Report 2021-109: San Diego County Sheriff’s Department

Dear Mr. Tilden:
The Citizens’ Law Enforcement Review Board (CLERB) welcomes the opportunity and has authorized me to
respond to the California State Auditor’s (CSA) draft report, titled, “San Diego County Sheriff’s Department,” in
which analyses and recommendations about CLERB were documented.
CLERB’s responses to your specific recommendations, of which the CSA proposes completion by May 2022,
are set forth below:
•

Recommendation One: Discuss and modify its current agreement with the Sheriff’s Department
and the labor organization to allow CLERB’s investigators to conduct independent interviews of
Sheriff’s Department sworn staff.
Agree. In the last quarter of 2021, the current CLERB Executive Officer (EO), the Deputy Sheriff’s
Association (DSA) President, DSA Counsel, and CLERB Outside Counsel met to discuss the
agreement for the purpose of conducting in-person interviews with Sheriff’s Department sworn staff.
Additional discussions are forthcoming.

•

Recommendation Two: Develop a comprehensive training manual for its investigators that
outlines standard procedures for investigations. The manual should include a specific section
dedicated to investigations of in-custody deaths, including guidance for evaluating the
circumstances leading up to an in-custody death, such as the decedent’s mental health history
and the appropriateness of the decedent’s housing assignment.
Agree. While it is true that there does not exist a physical stand-alone comprehensive training manual,
new CLERB Special Investigators are currently provided with copies of CLERB’s internal documented
policies and procedures (P&P), database user guide, investigative report templates, and a
comprehensive resource manual containing the following materials:
o County structure
o CLERB historical perspective
o County Charter, Section 606
o County Administrative Code, Section 340
o CLERB Rules and Regulations
o Civil Service Commission Rule XV
o Case Law Including and impacting CLERB
“SERVING THE COMMUNITY AND THE JUSTICE SYSTEM”

*

California State Auditor’s comments begin on page 79.

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o
o
o
o
o

Public Safety Officer Procedural Bill of Rights (POBOR)
Statutes Pertaining to Peace Officer Records
San Diego County Grand Jury Reports Pertaining to CLERB
Ralph M. Brown Act
San Diego County Operational Plan Pertaining to CLERB

The P&P, user guide, report templates, and topics contained within the resource manual are thoroughly
discussed and reviewed with the trainee during his/her training program. These materials will be
incorporated into the referenced stand-alone training manual, which will also include evaluations of a
trainee’s performance and documentation as to his/her progress, or lack thereof.
The comprehensive training manual will also include a specific section dedicated to investigations of incustody deaths. Despite the current absence of the stand-alone training manual, trainees are
specifically instructed, during their training programs, to evaluate the circumstances leading up to an incustody death, and to include a review of the decedent’s mental health history and the appropriateness
of the decedent’s housing assignment. In addition to these critical topics, trainees are also instructed to
evaluate the timeliness and thoroughness of welfare checks conducted on the decedent by deputies
and assess whether deputies appropriately determined that a life-threatening emergency existed and
responded accordingly.

01

•

Recommendation Three: Create policies and procedures to require its investigators to finish
casework on in-custody death investigations within three months of receiving the homicide
investigation file. These policies and procedures should also require investigators to attempt to
independently verify any information they receive from the Sheriff’s Department; to thoroughly
review deputy statements and reports from the homicide investigation file; and to request
interviews with relevant detentions staff and other witnesses in all instances where they identify
discrepancies or missing information.
Agree. The current CLERB EO directed that the completion of in-custody death investigations within
three months of receiving the homicide investigation file would take effect when CLERB filled its third
and final CLERB Special Investigator vacancy. As that vacancy was filled on January 10, 2022, this
mandate will now be incorporated into existing CLERB Policy #300.5, entitled, “Death Investigations.”
The independent verification of information received from the Sheriff’s Department and the already
existing practices of thoroughly reviewing deputy statements and reports from the homicide file and
requesting interviews from witnesses, when contact information is known and time constraints do not
exist, will be codified into P&P.

02

•

Recommendation Four: CLERB should revise its rules and regulations to include prioritization
criteria for investigating in-custody deaths above all other investigations.
Agree. The Policy Statement in CLERB Policy #300.5, entitled, “Death Investigations,” issued by the
current EO on August 27, 2021, indicates that it is the policy of CLERB “that death cases will take
priority over any other CLERB case.” During the current EO’s previous tenure as EO from June 2017 to
September 2018, he implemented this practice, and all death cases were made the highest priority.
During his absence from September 2018 to November 2020, for unknown reasons, death cases were
not handled as the highest priority. To ensure that the investigation of death cases remains the highest
priority after any future executive management changes, a five-tiered case categorization system
should be documented in the Rules and Regulations, with “Category I” being the highest priority and
“Category V” being the lowest priority. Death investigations should be classified as “Category I.”

03

•

Recommendation Five: CLERB should revise its rules and regulations to include clarification
that its investigations of in-custody deaths includes those classified as natural deaths.
Agree. During the current EO’s previous tenure as EO from June 2017 to September 2018, he
implemented the practice of invoking CLERB’s jurisdiction on every in-custody-related death, to include
“SERVING THE COMMUNITY AND THE JUSTICE SYSTEM”

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those that the Medical Examiner’s Office determined to be due to natural causes. To ensure that the
investigation of all in-custody-related deaths continue after any future executive management changes,
CLERB’s Rules and Regulations should not only be revised to clarify that in-custody natural deaths are
within CLERB’s jurisdiction, but that all deaths occurring in the custody of the Sheriff’s Department or
related to instances or occurrences within the Sheriff’s Department detention facilities are within
CLERB’s jurisdiction. As these proposed Rules and Regulations changes may first require the
amendment of the County Charter and/or the County Administrative Code, the CLERB EO will need to
work with CLERB’s legal counsel to pursue implementation of this recommendation.
•

Recommendation Six: CLERB should perform an analysis of overall trends related to these
deaths, including demographic information, and determine whether the trends suggest
deficiencies in the Sheriff’s Department’s policies and procedures. It should also identify policy
recommendations for improving the safety of individuals in the Sheriff’s Department’s custody.
CLERB should include these trends and analysis in its annual reports starting with its 2021
report.
Agree. The current EO has prioritized in-custody death investigations and the analysis of overall trends
related to the deaths, to include demographic information. Upon his return to CLERB in late 2019, he
authored CLERB’s 2020 Annual Report and provided a detailed breakdown of the 18 death cases
CLERB opened in 2019 and the 15 death cases CLERB opened in 2020 (this breakdown is
documented on pages 10 and 11 of the Annual Report). In addition, he provided a list of all death cases
opened by CLERB in 2019 and 2020 and closed by CLERB in 2019 and 2020. The list included the
decedent’s name, type of death, detention facility/patrol area, and cause of death (this list is
documented on pages 28 thru 33 of the Annual Report). After the finalization of the 2020 Annual Report
and its presentation to the Board of Supervisors, the current EO committed to expanding the reporting
to include an analysis of overall trends related to deaths, including demographic information, in the
2021 Annual Report.
CLERB has averaged 10 policy recommendations per calendar year over the past three years. The
majority of the recommendations pertained to the Sheriff’s Department’s detention facilities. Finally, it
should be noted that CLERB will, for the first time in its 30-plus year history, conduct detention facility
inspections in 2022. The scope of the inspections will be specifically tailored to each detention facility
based upon the complaints received from its inmates, great bodily injuries received from deputies’ uses
of force, and deaths occurring at or stemming from incarceration within it.

We look forward to updating the CSA on progress made within six months. Our commitment to continuing the
proactivity started at the end of 2020 to improve upon the invaluable civilian oversight role we provide to the
public, the Sheriff’s Department, and the County is unwavering. The implementation of the CSA
recommendations will assist with CLERB’s provision of independent, timely, full, and thorough investigations
into in-custody deaths which may, in turn, prevent future deaths.
Thank you for the opportunity to provide this response and for the professionalism and courtesy shown by your
staff throughout this process.
Sincerely,

Paul R. Parker III
Executive Officer, CLERB

cc:

CLERB Members
Shiri Hoffman and Aurelia Razo, Senior Deputies County Counsel
James Sandler; Sandler, Lasry, Laube, Byer & Valdez LLP
“SERVING THE COMMUNITY AND THE JUSTICE SYSTEM”

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Comments
CALIFORNIA STATE AUDITOR’S COMMENTS ON THE
RESPONSE FROM THE CITIZENS’ LAW ENFORCEMENT
REVIEW BOARD
To provide clarity and perspective, we are commenting on CLERB’s
response to our audit. The numbers below correspond to the
numbers we have placed in the margin of its response.
Although CLERB states that it provides various materials and
training to its staff, we found some cases in which CLERB’s
investigators did not appear to consider all the circumstances
leading up to the deaths, did not examine all the relevant Sheriff ’s
Department policies, and did not follow up on discrepancies they
discovered in the course of their investigations, as we discuss on
page 49. Accordingly, our recommendation is for CLERB to develop
a comprehensive training manual to ensure that its investigations
are complete and thorough.

01

Contrary to its response, we found that CLERB did not always
independently verify information from the Sheriff ’s Department.
As we note in the example on page 49, when investigating an
altercation between two cellmates resulted in the death of one of
the individuals, we found the CLERB investigator did not appear
to scrutinize or independently verify evidence that could have
sufficiently determined whether the Sheriff ’s Department’s actions
violated policies or procedures. Further, we question CLERB’s
statement that it thoroughly verifies deputies’ statements. As we
state on page 43, CLERB did not independently interview staff from
the Sheriff ’s Department in any of the six cases we reviewed.

02

As we state on page 48, although CLERB recently added policies
and procedures establishing its prioritization of death cases over
all other cases, it did not do so until August 2021. Moreover,
because policies can easily be changed when leadership changes,
it is important that CLERB include requirements in its rules and
regulations for how it prioritizes cases.

03

CLERB’s statement that it has averaged 10 policy recommendations
per calendar year is primarily referring to the recommendations it
makes based on individual cases. As we state on page 51, CLERB
generally makes recommendations based on individual cases rather
than on trends it identifies through analysis of its investigations.
Making recommendations based on trends could help resolve more
systemic concerns at the Sheriff ’s Department.

04

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Rob Bonta
Attorney General

State of California
DEPARTMENT OF JUSTICE
1300 I STREET
SACRAMENTO, CA 95815-4524
Public: (916) 210-5000
Fax (916) 227-3079
Email: Joe.Dominic@doj.ca.gov

January 14, 2022
Michael S. Tilden, CPA
California State Auditor
621 Capitol Mall, Suite 1200
Sacramento, CA 95814
Re:

Draft Audit Report - California State Auditor Report 2021-109; San Diego County
Sheriff’s Department –Inmate Custody Death

Dear Mr. Tilden,
The Department of Justice (DOJ) appreciates the opportunity to review the above-mentioned
draft audit report.
The audit recommends that to ensure that all sheriff’s departments accurately report deaths that
occur from incidents or conditions in county jails, the Legislature should amend state law to
require sheriff’s departments to report to the attorney general individuals who are released from
custody after being transported directly to a hospital or similar medical facility, and
subsequently dies in the facility. It should also amend state law to require sheriff’s departments
to provide the attorney general with all facts concerning the death, such as the cause and
manner.”
DOJ supports increased transparency of data reporting. As the audit notes, there is currently no
statutory requirement in place to require sheriff’s departments to report individuals released from
custody after being transported directly to a medical facility who subsequently dies in the
facility. Express authority from the Legislature and funding is needed to implement this new
data reporting recommendation. Furthermore, should the Legislature implement the
recommendation requiring sheriff’s department disclose the cause and manner of the death, DOJ
will work with the Legislature to ensure that any policies comply with all applicable
confidentiality laws.
If you have any questions or concerns regarding this matter, you may contact me at the
telephone number listed above.
Sincerely,

2022.01.14 16:46:08
-08'00'

Joe Dominic, Chief
California Justice Information Services Division

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January 14, 2022
California State Auditor Report 2021-109
Page 2
For

ROB BONTA
Attorney General

cc: Venus D. Johnson, Chief Deputy Attorney General
Chris Prasad, CPA, Director, Office of Program Oversight and Accountability

California State Auditor Report 2021-109

February 2022

San Diego County Sheriff's Department
Po t Office Box 939062

•

an Diego, Califomi 92 193-9062

William D. Gore, Sheriff

January 14, 2022

Ms. Elaine M. Howle *
California State Auditor
621 Capitol Mall, Suite 1200
Sacramento, California 95814
State Auditor Howle:
Attached please find the response from t he Sc1n Diego County Sheriffs Department in reference to your

draft audit report on the San Diego County jails.
Sincerely,

William D. Gore, Sheriff

Keeping the Pea e Since 1850
*

California State Auditor’s comments begin on page 115.

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Preliminary Comment

01

THE CALIFORNIA STATE AUDITOR DID NOT PROVIDE SUFFICIENT OPPORTUNITY FOR THE SAN
DIEGO COUNTY SHERIFF'S DEPARTMENT TO REVIEW AND RESPOND TO THE AUDIT

02

the San Diego Sheriff's Department received a draft copy of the State
for the stated purpose of allowing the
Auditor's Report 2021-109
Department to review and respond to the audit. The Sheriff's Department was afforded less
than five (5) days to review and respond to the draft report, as the audit was received late in
the morning on Monday and the response was due back by 5:00 p.m. on Friday.

03

01

The 2018 revision of Government Auditing Standards, commonly referred to as generally
accepted government auditing standards (GAGAS), is effective for performance audits
beginning on or after July 1, 2019, such as the instant engagement. GAGAS section 9.50
provides that "Auditors should obtain and report the views of responsible officials of the
audited entity concerning the findings, conclusions, and recommendations in the audit report,
as well as any planned corrective actions." The highly redacted version of the draft report,
coupled with the short time afforded for review and response, and the lack of supporting
documentation, makes it difficult for the Sheriff's Department, as the audited entity, to submit
a meaningful, comprehensive response to the draft report.
Accordingly, the Sheriff's Department reserves the right to submit a more comprehensive
response after the final report and any supporting documentation and information are
published, as none of the supporting documentation and information was included with the
draft report transmission.
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Introduction
The gravity and seriousness of in-custody deaths and the importance of identifying and
improving deficiencies when they occur is not lost on the San Diego Sheriff's Department. We
have been transparent in our response to the Joint Legislative Audit Committee's
recommendation that the California State Auditor review in-custody deaths in San Diego
County. During the audit, we cooperated fully and provided complete access to our records,
facilities, and personnel.
The Sheriffs Department was pleased to see that the auditors' findings confirm that the
Department's policies and procedures align with the minimum standards established through
state law and other applicable guidance. That said, while the Sheriff's Department appreciates
the work and recommendations of the auditors, the Department maintains concerns regarding
the findings, as well as the conclusions and recommendations contained in the draft report and

O4
05

the way the audit was conducted.
I.

THE AUDIT FAILED TO CONFORM WITH GENERALLY ACCEPTED GOVERNMENT
AUDITING STANDARDS

06

California Government Code section 8546.l(c) requires that the State Auditor "complete any
audit in a timely manner and pursuant to the 'Government Auditing Standards' published by the
Comptroller General of the United States." While the State Auditor recognizes that the instant
engagement is undertaken pursuant to GAGAS, it failed to conform to the requisite standards.

A. The auditors failed to comply with reporting standards for performance audits
GAGAS section 9.03 provides, "[w]hen auditors comply with all applicable GAGAS requirements,
they should use the following language, which represents an unmodified GAGAS compliance
statement, in the audit report to indicate that they conducted the audit in accordance with
GAGAS:
We conducted this performance audit in accordance with generally accepted
government auditing standards. Those standards require that we plan and perform the
audit to obtain sufficient, appropriate evidence to provide a reasonable basis for our
findings and conclusions based on our audit objectives. We believe that the evidence
obtained provides a reasonable basis for our findings and conclusions based on our
audit objectives.
The section 9.03 compliance statement is notably absent from the draft report.

Page 2 of 31

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In the event auditors do not comply with all applicable GAGAS requirements, section 9.05
provides, "they should include a modified GAGAS compliance statement in the audit report. For
performance audits, auditors should use a statement that includes either (1) the language in
paragraph 9.03, modified to indicate the requirements that were not followed, or (2) language
indicating that the auditors did not follow GAGAS.'1
Similarly, a section 9.05 alternate compliance statement is also absent from the draft report.

06

B. The auditors have declined to adopt the GAGAS report quality elements of
accurate, objective, complete, convincing, and timely in developing and writing the
audit report
Chapter 9 of the GAGAS addresses the reporting standards for performance audits such as the
instant engagement. GAGAS section 9.17 provides that "[t]he auditor may use the report
quality elements of accurate, objective, complete, convincing, clear, concise, and timely when
developing and writing the audit report as the subject permits." For purposes of the instant
engagement, the auditors failed to adopt the report quality elements of accurate, objective,
complete, convincing and timely in developing and writing the audit report.

07

a. Accuracy
Section 9.17(a) regarding report quality element "Accurate" states, in pertinent part, "(a]n
accurate report is supported by sufficient, appropriate evidence with key facts, figures, and
findings being traceable to the audit evidence. Reports that are fact-based, with a clear
statement of sources, methods, and assumptions so that report users can judge how much
weight to give the evidence reported, assist in achieving accuracy."
Consistent with this standard, the Auditor makes recommendations to the legislature for policy
revisions "to better align with best practices, as follows.'' There is no data or evidence cited to
support the best practices recommendations. Data and evidence-based approaches to medical,
mental health and correctional care policies are necessary to ensure the best health and safety
outcomes for incarcerated individuals. In other sections, the auditor states "[r]eports and
studies related to mental health indicate that ... " There is no reference to which studies and
reports are being relied upon for the assertions.
The audit states, "that deficiencies in the Sheriff's Department's policies and practices related
to intake screenings, medical and mental health care, safety checks, and responses to
emergencies likely contributed to these deaths," the report is devoid of any evidence that the
deaths were cause by a failure of the department's policies or practices.

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While no death is acceptable, the Sheriff recognizes that some incarcerated individuals have
pre-existing conditions, age or other maladies which lead to natural death. These deaths made
up nearly half of all the deaths that occurred during the 15-year audit period. The report does
not explain if a failure on the part of the department caused the death or if those individuals
could have died in the community from the same pre-existing condition.
The Sheriff's Department has implemented extensive programs, training, and policies to
prevent suicide in the jails. The jails disproportionately house individuals suffering from mental
illness, and substance use disorder. The identification of individuals who wish to do themselves
harm is one key to prevention and removing the ability to commit self-harm is the second.
Individuals bent on harming themselves creates obstacles to identification and prevention.
Similarly, substance use disorder is an enormous driver for behavior. It could be argued that incustody individuals are even more driven to use substances to alleviate the strain and
monotony of incarceration. The Sheriff's Department has created extensive layers and policies
to interdict and prevent contraband from being smuggled into the jail system. We have
instituted the use of naloxone to save lives when someone is successful in circumventing those
interdiction efforts. While the Sheriff's Department can always do better, the audit does little
to document or provide context for those efforts and the complexity of keeping individuals safe
from themselves.

b. Objectivity

06

Section 9.17(b) regarding report quality element "Objective" states, in pertinent part,
"[o]bjective means that the presentation of the report is balanced in content and tone. A
report's credibility is significantly enhanced when it presents evidence in an unbiased manner
and in the proper context. This means presenting the audit results impartially and fairly. The
tone of reports may encourage decision makers to act on the auditors' findings and
recommendations. This balanced tone can be achieved when reports present sufficient,
appropriate evidence to support conclusions while refraining from using adjectives or adverbs
that characterize evidence in a way that implies criticism or unsupported conclusions."
(Emphasis added).
Despite the fact that section 9.17(b) specifically counsels against using such adjectives and
adverbs, the draft report is replete with such unsupported criticism (e.g. "likely contributed to
the deaths," "inadequate response to deaths," "might have placed this individual," "lack of
effective independent oversight," "meaningful changes," "meaningful corrective action," "few
substantive steps," "have not consistently led to significant corrective action," "failure to
adequately prevent the deaths," "could help," and "could be useful"). Use of such terms, in
contravention of the GAGAS guidance, calls into question and undercuts the objectivity of the
engagement and the resulting instant report.

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Section 9.17(b) goes on to provide, "[a]udit reports are more objective when they demonstrate
that the work has been performed by professional, unbiased, independent, and knowledgeable
personnel." (Emphasis added). As discussed more fully below, the auditors lack the requisite
knowledge, skills and abilities necessary to competently conduct the instant engagement.

06

c. Completeness
Section 9.17(c) regarding the report quality element "Complete" states, in pertinent part,
"complete means that the report contains sufficient, appropriate evidence needed to satisfy
the audit objectives and promote an understanding of the matters reported. It also means the
report states evidence and findings without omission of significant relevant information
related to the audit objectives. Providing report users with an understanding means providing
perspective on the extent and significance of reported findings, such as the frequency of
occurrence relative to the number of cases or transactions tested and the relationship of the
findings to the entity's operations." (Emphasis added).

08

The auditors' summary of the event outlined in Case Example 4 illustrates the omission of
significant relevant information in an effort to paint a picture that deputies stood idly by while
CPR was medically indicated for the incarcerated individual. Based on our review of Case
Example 4, we believe the auditors are referring to Sheriff's case number

02

08

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The auditors' description of the event depicted in the chart above misleads the reader, is an
example of the lack of completeness and objectivity that is present in the draft report and fails
to meet the report quality elements outlined in GAGAS sections 9.17(b) and 9.17(c).

06

d. Convincing
Section 9.17(d) regarding report quality element "Convincing" states, in pertinent part,
"convincing means that the audit results are responsive to the audit objectives, that the
findings are presented persuasively, and that the conclusions and recommendations flow
logically from the facts presented. The validity of the findings, the reasonableness of the

conclusions, and the benefit of implementing the recommendations are more convincing
when supported by sufficient, appropriate evidence."
While the draft report speaks to best practices, the draft contains no such policies, best
practices, or sample language, nor the jurisdiction(s) where such best practices were or are
being implemented. As discussed in Section C. below, while good intentioned, best practices
suggested by auditors without the requisite knowledge, skills, and abilities, may violate the
constitutional rights of incarcerated individuals, cause harm to the mental health of
incarcerated individuals and ultimately result in increased liability to the County. By not
including copies of the best practices referenced throughout the draft report, it is difficult for
the Sheriff's Department to ascertain whether the suggested best practices comport with state
law, Title 15 regulations and the constitutional rights guaranteed to incarcerated individuals.
The draft report does contain one table (Table 2) with excerpts of safety check policies,
however, while excerpts from the BSCC policy and the Sheriff's Department policy are

03

unredacted, the policies and names of the three other entities are redacted in their entirety.

02

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03

I. The Auditor Improperly Redacted Public Documents and Refused to
Provide the Documents to the Sheriff's Department Necessary for
the Department to Provide a Meaningful Response

02

For purposes of an engagement under GAGAS, the terms "auditee" and "audited entity" are
interchangeable. GAGAS section 1.27(e) defines an "audited entity" as "[t]he entity that is
subject to a GAGAS engagement, whether that engagement is a financial audit, attestation
engagement, review of financial statements, or performance audit."
The Joint Legislative Audit Committee (JLAC) charged the auditor with conducting an audit of
the San Diego Sheriff's Department and the County of San Diego Citizens Law Enforcement
Review Board (CLERB). The auditor confirmed the scope of its engagement in the document
entitled 2021-109 Audit Scope and Objectives, identifying the audited entities as the San Diego
County Sheriff's Department and the CLERB. No other agencies were identified as audited
entities (or auditees).

O9

Based upon the GAGAS standards, and the JLAC referral, Alameda, Orange County, and
Riverside are not auditees. However, even if they were, the information relied upon should
have been given to the Sheriff's Department, as the auditee, to respond to the draft report,
because it is public information.

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The Sheriff's Department must meet Title 15 standards for its detention facilities, as do other
local detention facilities throughout the State of California. For the redacted policy excerpts to
be relevant to the auditors' engagement, the redacted excerpts are presumably from other law
enforcement agencies in the state.
Policies of a California law enforcement agency are public record . Senate Bill 978 (SB 978)
added section 13650 to the Government Code, which requires " ... each local law enforcement
agency shall conspicuously post on their Internet Web sites all current standards, policies,
practices, operating procedures, and education and training materials that would otherwise be
available to the public if a request was made pursuant to the California Public Records Act
(Chapter 3.5 (commencing with Section 6250) of Division 7 of Title 1 of the Government Code)."
As such, each California law enforcement agency is required to publicly post, on its website, all
its policies and procedures, such as its detention facilities safety check policy.
It is well settled that a governmental agency cannot shield records that are subject to public
disclosure simply by putting those publicly available records in a file it stamps "confidential."
Therefore, the auditor should have provided the policies which it relied on in creating its report.
Similarly, it was improper for the auditor to redact and withhold from disclosure settlement
information it obtained, admittedly, from publicly available court documents regarding the
three selected counties it designated as comparable counties.

010

010
02

e. Timeliness
Section 9.17(g) regarding report quality element "Timely" states, in pertinent part, "[t]o be of
maximum use, providing relevant evidence in time to respond to officials of the audited entity,
legislative officials, and other users' legitimate needs is the auditors' goal. Likewise, the
evidence provided in the report is more helpful if it is current."

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011

While it is certainly helpful from a historical perspective to discuss changes in policies or
procedures, it is unclear whether the auditors' findings and conclusions are based on the
policies and procedures as they existed at the time of the incident under review or present-day
policies and procedures. For example, the draft report states, " ...although the Sheriff's
Department's policy Indicates that a nurse should conduct a face-to-face appraisal with an
incarcerated individual within 24 hours of a mental health care request to determine the
urgency of that request, it has not always had this policy." The Sheriffs Department believes
this change in policy was a positive step, but it is unclear whether the auditors' findings and
recommendations are based on current policies and procedures, or policies and procedures
that were in place at the time of the incident under review.

06

C. The Auditors' Lack of Requisite Knowledge, Skills and Abilities Necessary to
Conduct the Instant Engagement Raise Ethical and Competence Issues under the
Generally Accepted Government Auditing Standards
Chapter 3 of the GAGAS sets forth fundamental ethical principles for auditors in the
government environment.
Section 3.04 relating to ethical principles provides that "[p]erforming audit work in accordance
with ethical principles is a matter of personal and organizational responsibility." The section
goes on to clearly state that ethical principles apply in "taking on only work that the audit
organization is competent to perform ... "
To ensure that an audited entity is afforded a fair, unbiased and meaningful audit, Chapter 4 of
the GAGAS requires that the auditors collectively possess the competence needed to address
the engagement objectives and perform their work in accordance with GAGAS. The knowledge,
skills, and abilities needed when conducting an engagement in accordance with GAGAS include
the understanding necessary to proficiently apply a. GAGAS; b. standards, statutory
requirements, regulations, criteria, and guidance applicable to auditing or the objectives for the
engagement(s) being conducted; and c. techniques, tools, and guidance related to professional

expertise applicable to the work being performed. (Emphasis added). (GAGAS section 4.07).
GAGAS section 4.08 provides, "[a]chieving the knowledge, skills, and abilities needed to
conduct a GAGAS engagement may include: a. having prior experience in the subject matter or
type of engagement; b. completing [continuing professional education] related to the subject
matter or type of engagement; and c. obtaining degrees or certifications relevant to the subject
matter or type of engagement."
The instant engagement requires knowledge, skills, and abilities regarding varied areas in the
detentions or corrections environment including, but not limited to, detentions custodial
operations, detentions medical services and detentions mental health functions.

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This knowledge is so important that state law requires that a deputy complete an introductory
training course by the Commission on Peace Officer Standards and Training, additional training
by the Board of State and Community Corrections, and specialized training for custodial
personnel of local detention facilities pursuant to Title 15 of the California Code of Regulations.
In addition to this initial 16 weeks of academy training, deputies are next assigned to phase
training where they are paired up with seasoned training officers before they can function on
their own. After these initial academy and training phases, detentions deputies are required by
state law to complete a minimum of 24 hours of annual training to maintain their proficiency
and certification.
The professional qualifications necessary for detentions medical doctors, registered nurses,
licensed vocational nurses, and mental health clinicians must satisfy not only the educational
requirements of their field which often includes many years of studies, and successfully passing
the tests required by their licensing authority, but also continuing professional education in
order to maintain their license or certification.
Additionally, the field of corrections is a highly regulated field of law comprised of state and
federal Constitutional standards and laws, as well as case law issued by the U.S. Supreme Court,
federal, and state courts. Changes in department policies can impact an inmate's constitutional
rights, and a lack of knowled ~;G1!.ll.U:
· __•_____
· • ____._._,_ _ _ _-_._.__•_ _._,_,_._._,_._._ ·_ ·_ _ _ _•

•

•

•

•

The requisite knowledge, skills, and abilities necessary to render an informed opinion regarding
detentions custodial operations would be satisfied by either an auditor, or a specialist1 engaged
1 "Some engagements may necessitate the use of specialized techniques or methods that call for the skills of
specialists. Specialists do not include Individuals with special skill or knowledge related to specialized areas within
the field of accounting or auditing, such as income taxation and information technology. Such individuals are
considered auditors." (Emphasis added). GAGAS section 4.13.

"The competence and qualifications of specialists significantly affect whether their work will be adequate for the
engagement team's purposes and will meet GAGAS requirements. Competence of specialists relates to the nature
and level of expertise. Qualifications of specialists relate to their professional certifications, reputations, and
previous work in the subject matter. Other relevant factors include the ability of specialists to exercise competence
in the circumstances of the engagement and the effects that bias, conflict of Interest, or the influence of others
may have on the specialists' professional judgment." GAGAS section 4.14.
"Sources that may inform the auditors' assessment of the competence and professional qualifications of a
specialist include the following: a. the professional certification, license, or other recognition of the competence of

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0

2

to assist the audit team, who was certified by the State of California, Bureau of State and
Commun it Corrections BSCC), Standards and Trainings for Corrections (STC).
it does not appear that any of the audit team members possess
such training or certification.
It is further generally recognized that the function of providing medical services in the
correctional setting is different than in a public setting. According to the American Academy of
Family Physicians, "[i]nmates in correctional facilities have significantly higher rates of disease
than the general population, and ... tend[] to suffer in greater numbers from infectious disease,
mental health problems, and substance use and addiction." The requisite knowledge, skills, and
abilities necessary to render an informed opinion regarding detentions medical services would
be satisfied by either an auditor, or a specialist engaged to assist the audit team, who is, or was,
a medical doctor or registered nurse in a detentions or corrections environment. In our
discussions with the auditors, it does not appear that any of the audit team members possess
such training or experience.
Similarly, the requisite knowledge, skills, and abilities necessary to render an informed opinion
regarding detentions mental health functions would be satisfied by either an auditor, or a
specialist engaged to assist the audit team, who is or was a qualified mental health provider

O2

(QMHP) or mental health clinician (MHC) in a detentions or corrections environment. it does not appear that any of the audit team members
possess such training or experience.
By way of example, the Sheriff's Department was previously reviewed by subject matter experts
who possessed the requisite knowledge, skills, and abilities necessary for the scope of their

the specialist in his or her field, as appropriate; b. the reputation and stand ing of the specialist in the views of peers
and others familiar with the specialist's capability or performance; c. the specialist's experience and previous work
in the subject matter; d. the auditors' assessment of the specialist's knowledge and qualification based on prior
experience in using the specialist's work; e. the specialist's knowledge of any technical performance standards or
other professional or Industry requirements In the specialist's field (for example, ethical standards and other
membership requirements of a professional body or industry association, accreditation standards of o licensing
body, or requirements imposed by law or regulation); f. the knowledge of the specialist with respect to relevant
auditing standards; and g. the assessment of unexpected events, changes in conditions, or the evidence obtained
from the results of engagement procedures that indicate it may be necessary to reconsider the Initial evaluation of
the competence and qualifications of a specialist as the engagement progresses." (Emphasis added). GAGAS
section 4.15.
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engagement. One review was conducted by Mr. Lindsey Hayes 2, the other review was
conducted by the National Commission on Correctional Health Care (NCCHC) 3 •

02

Lindsay M. Hayes is a Project Director of the National Center on Institutions and Alternatives (NCIA) and is
nationally recognized as an expert in the field of suicide prevention within jails, prisons, and juvenile facilities. He
has been a consultant to the U.S. Justice Department's Civil Rights Division in its investigations of conditions of
confinement in both adult and juvenile correctional facilities throughout the country. He has also been appointed
as a Federal Court Monitor in the monitoring of suicide prevention practices in several adult and juvenile
correctional systems under court jurisdiction. He has served as an expert witness/consultant in litigation cases
involving the suicide of incarcerated individuals, and his expertise has allowed him to conduct training
seminars and assessments of adult and juvenile suicide prevention practices within correctional
facilities throughout the country.
2

Hayes is a published author with over 60 publications in the area of suicide prevention within adult and juvenile
correctional facilities and has conducted the only five national studies of jail, prison, and juvenile suicide (And
Darkness Closes ln ... National Study of Jail Suicides in 1981, National Study of Jail Suicides: Seven Years Later in
1988, Prison Suicide: An Overview and Guide to Prevention in 1995, Juvenile Suicide in Confinement: A National
Survey in 2004, and National Study of Jail Suicide: 20 Years Later in 2009).
Hayes has reviewed over 3,000 cases of suicide in jail, prison, and juvenile facilities throughout the country over
the past 30 years. He was awarded the National Commission on Correctional Health Care's Award of Excellence in
2001, for his contribution in the field of suicide prevention in correctional facilities. His work has been cited
in several state and national correctional health care standards, and numerous suicide prevention training
curricula, including the National Institute of Correction (NIC).
3 The

National Commission on Correctional Health Care (NCCHC) is a non-profit 501(c)(3) organization whose
mission is to improve the quality of health care in jails, prisons, and juvenile confinement facilities. The NCCHC
establishes standards for health services in correctional facilities, produces resource publications, conducts
educational conferences, offers a certification for correctional health professionals and a voluntary accreditation
program for institutions that meet their standards. The NCCHC is supported by numerous major national
organizations in the fields of health, law, and corrections.
The NCCHC has a multidisciplinary governing structure, which addresses the complexities of correctional health
care, and whose standards for health services in correctional facilities is widely recognized . NCCHC's standards
address areas of care and treatment, health records, administration, personnel and medical-legal issues; and offer
voluntary health services accreditation based on its standards. NCCHC also hold conferences with educational
programs that address topics such as mental health and substance abuse services. The NCCHC publishes
periodicals such as the Journal of Correctional Health Care and CorrectCare, which are the leading periodicals in
this field. The NCCHC offers consultation and assistances to facilities with issues preparing for accreditation,
developing policies and procedures, and assessing alternative solutions to problems.

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In order to demonstrate that the auditors assigned to this engagement possessed the requisite
knowledge, skills, and abilities in detentions custodial operations, detentions medical services
and detentions mental health functions, as required by GAGAS, the Sheriff's Department
requests that the State Auditor include in its final report the curricula vitae for each auditor and
specialist assigned to the instant engagement, including any relevant continuing professional
education regarding the subject matter of the engagement.

II.

07

THE SAN DIEGO COUNTY SHERIFF'S DEPARTMENT HAS TAKEN APPROPRIATE AND
REASONABLE MEASURES TO PREVENT AND RESPOND TO DEATHS OF INDIVIDUALS
IN CUSTODY

a. The Auditor's Conclusion That the In-Custody Deaths Were the Result of
Inadequate Medical Care is Misleading
While the first sentence of the draft report begins with the recognition that the Sheriff's
Department is responsible for providing medical care to individuals in its custody, the next

O7

sentence goes on to state: "Nonetheless, from 2006 through 2020, 185 people died in San
Diego County jails- more than in nearly any other county across the state." The transition from
the statement that the Sheriff's Department is responsible for providing adequate medical care
to the statement that "nonetheless" 185 people died in San Diego County jails is misleading and
implies that the deaths were the result of inadequate medical care.
The draft report does not identify which deaths were the result of "inadequate" medical care.
Natural death
·
·
·
·
··

02

the auditors.
the draft report does not identify what medical care was inadequate, nor does it
identify what medical care the Sheriff's Department should have provided that would have
avoided individuals from dying of natural causes, such as heart disease, cancer, chronic lower
respiratory disease (COPD, emphysema, chronic bronchitis), and stroke. Just as individuals with
these conditions die from their conditions in the community setting, incarcerated individuals
with these conditions often die from their conditions while in custody, not as the result of
incarceration or the medical care they receive while incarcerated but as a natural and expected
progression of their condition.
Similarly, while accidental deaths account for 31 of the total in-custody deaths during the
audited period, the draft report does not identify any medical care that was "inadequate"
resulting in an individual's death. As the auditors are aware, most of the accidental deaths
were the result of individuals overdosing on drugs, not due to "inadequate" medical care. In
response to the opioid epidemic, the San Diego Sheriff's Department was one of the first
departments in the state to equip not only its detentions medical staff but also detentions
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deputies with NARCAN$ (naloxone HCL) nasal spray to combat the surge in opioid overdoses.
To ensure immediate availability of this highly effective opioid antagonist, NARCAN is not only
available in detentions medical areas and in deputy control stations but detentions deputies are
also required to carry NARCAN on their person during their shifts. During calendar years 2020
and 2021 alone, Sheriff's Department employees in the jails responded to 314 incidents of
suspected opioid overdose deploying 848 doses of NARCAN and saving countless lives. In
conjunction with its community partners, the Sheriff's Department also makes this lifesaving
drug available to incarcerated individuals upon their discharge from Sheriff's custody.

b. The Number of In-Custody Deaths Experienced by the San Diego Sheriff's
Department Is Consistent with its Position of Having the Second Highest
Number of Total Bookings and Overall Deaths in California Counties
The San Diego Sheriff's Department's position as having the second highest number of incustody deaths of counties in the state is consistent with its position as having the second
highest number of bookings of counties in the state. As demonstrated by Table 1 below, the
trend is consistent for at least the top six counties, exhibiting that as the number of bookings
goes up, so do the number of in-custody deaths. Additionally, as demonstrated by Table 2
below, as the second most populous county in the state, the County of San Diego also
maintains the position as having the second highest number of deaths in the community.

i. Table B is intentionally misleading
The auditors chose to include a table in APPENDIX A which they identify as focusing on two
primary categories, "In Custody Deaths and Bookings From 2006 Through 2020." In so doing,
they state that the table "presents the rate of deaths per the number of individuals booked in
each of the county sheriff's jail systems from 2006 through 2020." They go on to state that
"[t]he number of bookings is the total number of individuals who were processed through the
jail system." (Emphasis added). However, when the auditors sort the chart, they don't sort it by
the column entitled "Total Booked", or even the "Total Deaths" column, both of which would
clearly show the correlation between the two (see resorted Table 1 below), but instead they
chose to sort by the "Total Deaths per 100,000 Booked" which makes the first three columns
appear to have no correlation.

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However, the exact same data sorted by the "Total Number of Bookings" column, or the "Total
In-Custody Deaths," column clearly shows a correlation between bookings and the number of
actual deaths for the six counties with the most bookings in the State of California.

013

Table 1

~

County
Sherfff's Department
1

Los Angeles

2

Son Oiego

3

Son Bernardino

4

Orange

5

Riverside

6

Alomeda

7

$aC'1)mento

8

Santa Clara

9

Fresno

10

Kom

11

Ventura

12

Son Joaquin

13
14

Contra Cosio

15

Tulare

San FrancisGo

Tot.It Number
of

BOOktngs
1,970,654
1,284,462
1,027,195
888.951
810.376
777.627
733.275
682,010
551,624
520,074
424.978
392,895
370,209
353,521
333,941

Average
Bookings
Per Year

131,377
85,631

~

Total
In-Custody
Death•
421
185

Deaths per

12◄

100,000
Booklnga

21.36
14.«>

88,480
59,263
54,025

111

12.07
12.49

104

12.83

51.842

99

12.73

48.885
45,467
36,775

62

8 .46

84

12.32

86

15.59

3◄ ,872

70

13."'6

28,332
26,193

47

11 .06

34

8 .65

24,687

43

11 .61

23,568

39

22,263

28

11.03
7,79

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ii. The top s counties with the most deaths countywide are also the same
As jails are a microcosm of the communities in which they are located, it should come as no
surprise that as deaths in the community increase, deaths in-custody will increase as well. This
is particularly true for in-custody deaths due to natural causes, suicide, and accidental deaths
due to overdose. As greater numbers of individuals in a community are sick, experience suicidal
ideations or are afflicted by substance use disorders, those increased numbers can be expected
to replicate themselves in the detention systems serving those communities. As reflected in
Table 1 above, the number of in-custody deaths experienced by the Sheriff's Department is not
disproportionate to the number of deaths experienced in the San Diego County community
regardless of custody status (See Table 2).

012

Table 2

013
Deaths in California Counties From 2006 Through 2020
Est.County
Population
(2020)

Average County
Populatlon
(2008-2020)

Total

Average

County

De-.ths
(2006-2020)

Deaths
Per Year

Deaths per
100,000
PopulatlOn

1

Los Arigeles

10,135,614

9,991,660

939,073

62,605

626.6

2

San Diego

3.331,279

3,181,752

320,562

21,371

671 .7

3

Orange

3,180,491

3,084,349

292,178

19,479

631.5

4

Riverside

2,440,719

2,251 ,242

224,078

14,939

663.6

5

San Bernardino

2,175,424

2,079,014

206,764

13,784

663.0

6

Sacramento

1,553,157

1,457,469

170,958

11,397

782.0

7

Santa Clara

1,945,186

1,848,744

157,224

10,482

567.0

8

Alameda

1,663,114

1,568,059

144,734

9,649

615.3

9

Fresno

1,020,292

955,030

104,127

6,942

726.9

This dala table report$ the annual number of deaths that occurred In each County regardle» ot the place or residence (by occurrence).

Ill. The Comparator Counties Selected by the Auditors Do Not Accurately
Reflect the Relevant Peer Group Departm.ents
Considering county size, geographic location and "other factors" the auditors selected the
Alameda County Sheriff's Office, Orange County Sheriff's Department and Riverside County
Sheriff's Department as comparator departments. From the report, it is unclear how
geographic location factored into the selection of the Alameda Sheriff's Office as a comparator
department as the county seats of San Diego County and Alameda County are approximately
490 miles from each other. Similarly, the auditors' selection of similar counties, based on what
appears to be total county population, rather than similar booking numbers is inappropriate. It
is unclear how total county population factored into the selection of the Alameda Sheriff's
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Office as a comparator department when the County of Alameda has less than half the average
county population of San Diego County.
The comparator peer group should be based on the total number of individuals encountered
(booked) by each department rather than county population. As reflected in Table 3 below, an
analysis of the departments, based on total number of bookings, reveals that the statistically
relevant departments are the Los Angeles Sheriff's Department, San Bernardino Sheriff's
Department and Orange County Sheriffs Department. The San Diego County Sheriff's
Department's total bookings for the reviewed 15-year period are within 65% of what the Los
Angeles County Sheriff's Department booked for the same period. Similarly, San Bernardino
and Orange County Sheriff's Departments booked at least 65% of the total number of bookings
that the San Diego County Sheriffs' Department booked .
However, the Riverside County Sheriff's Department and Alameda Sheriff's Office, each booked
less than 65% of the total number of bookings that the San Diego County Sheriff's Department
booked for the same time . By excluding the Los Angeles Sheriff's Department and San
Bernardino Sheriff's Department, in favor of Riverside County and Alameda County, the
auditors excluded the only other departments in the state that booked in excess of 1,000,000
individuals during the audit period. By excluding the Los Angeles Sheriff's Department and San
Bernardino Sheriff's Department, the auditors also excluded the other two departments with
the highest number of in-custody deaths in the state during the audit period in favor of
departments having the fifth and sixth highest number of in-custody deaths.

013

TABLE 3
Top Three Counties With Total Bookings
Witllin35 Pertent of San Diego County Bookings

Or.11ngc

Alameda

• -- ~~
,...n,
I

1

SM Bemlnlino

Rlvmkk

l.027.1'S

110.11,

Sacnmento

nun

2096

3596

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c. The San Diego Sheriff's Department's Review of In-Custody Deaths Exceeds the
Standards Set by the State of california

O4

The Auditor's stated purpose4 for the instant engagement is, in pertinent part, to "[e]valuate
the San Diego Sheriff's policies and procedures on personnel training, facility maintenance and
safety, and t he provision of health care to inmates. To the extent possible, determine whether
these policies and procedures align with minimum standards established through state law and
any other applicable guidance. As part of th is evaluation, also determine whether any of these
policies delay or otherwise impair the ability of medical personnel to provide appropriate
medical care to inmates." (Emphasis added).
The auditors' findings confirm that the San Diego Sheriff's Department not only meets the
minimum standards established through state law and other applicable guidance but, in fact,
exceeds those requirements regarding its review of in-custody deaths.

i. The Auditor's Conclusion that the Department's Review of In-Custody
Deaths has been Insufficient is Misplaced
The auditors' findings confirm that the Sheriff's Department meets and exceeds the minimum
state standards for review of in-custody deaths.
As noted by the auditors, state law requires the Sheriff's Department to conduct a clinical care
review within thirty (30) days of every death. The Sheriff's Department meets this requirement
by conducting a Mortality/Morbidity Review. The auditors' findings did not reveal any failure
on the part of the Sheriff's Department to comply with applicable law with either the timeliness
or the substance of the Department's reviews.
Except in the case of a suspected homicide, no other review or investigation is requ ired. In the
case of an in-custody death in which homicide is suspected, the Sheriff is statutorily required to

4

2021-109 AUDIT SCOPE AND OBJECTIVES

San Die10 County Sheriffs Department
The audit by the California Stat• Auditor will provld11 independently developed and verified
information related to the death of Inmates in the custodv of the San Diego County Sherlfrs
Department (San Diego Sheriff). The audit's scope will include, but not be limited to, the following
activities:
1. Relllew and evaluate the laws, rules, and regulatlons significant to the audit objectives.
2. Evaluate the San Diego Sheriff's policies and procedures on personnel training, facility
maintenance and safety, and the provision of health care to Inmates. To the extent posslble,
determine whether these policies and procedures alisn with minimum standards established
through state law and any other applicable guidance. As part of this evaluation, also determine
whether any of these policies delay or otherwise impair the ability of medical personnel to provide
appropriate medical care to Inmates.

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investigate the death. That investigation is conducted by the Sheriff's Homicide Unit. The
auditors' findings did not reveal any failure on the part of the Sheriff's Department to
investigate any in-custody death in which homicide was suspected.
No other reviews by the Sheriff's Department are mandated by state law for in-custody deaths.
While no other reviews are mandated, the Sheriff's Department created and implemented its
own multilayer review above and beyond the minimum state standards for review of in-custody
deaths.
Although not required for in-custody deaths where homicide is not suspected, the Sheriff's
Department, as a matter of practice, conducts an investigation by the Homicide Unit into every
in-custody death, not just those deaths where homicide is suspected.
In addition to the Homicide Unit investigation, the Sheriff's Department created its own Crit ical
Incident Review Board (CIRB). The CIRB's role is not limited to reviews of in-custody deaths but
includes the review of a variety of critical incidents including uses of force, pursuits, K-9
deployments, overdoses, and other significant events. In-custody deaths due to natural causes
are generally not reviewed by the CIRB, unless other issues are identified, as deaths due to
natural causes are more appropriately reviewed by the statutorily mandated thirty (30) day
Mortality/Morbidity Review conducted by the Department. A further discussion regarding the
recommendation that the CIRB review natural deaths is discussed below.
If the CIRB or any member of the Sheriff's Department believes an in-custody death implicates
potential misconduct or a failure to meet standards on the part of an employee, the CIRB or any
member of the Sheriff's Department can file a Department Generated Complaint requesting
that Internal Affairs investigate the matter.
Penal Code section 832.5 requires every law enforcement agency in the state to establish a
procedure to investigate complaints lodged by members of the public against personnel of the
agency. In addition to investigating complaints from members of the public, the Sheriff's
Department investigates "department generated" complaints, which can be lodged by any
member of the department, in the same manner as it investigates a complaint by a member of
the public. If there is potential misconduct or a failure to meet standards on the part of an
employee related to an in-custody death, the Sheriff's Department does not wait for a member
of the public to file a complaint but can and does initiate an Internal Affairs investigation based
on a department generated complaint.
As the auditors' findings make clear, the reviews conducted by the Sheriff's Department not
only meet the minimum standards established by the state, the multi layered approach adopted
by the Sheriffs Department far exceeds those minimum standards. Any deficiencies in the
state's minimum standards regarding the review of in-custody deaths is most appropriately
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addressed to the Legislature and/or the BSCC, not to the Sheriff's Department as the audited
entity.

ii. The Critical Incident Review Board's Roles of Preventing Future
Litigation and Improving the Health and Welfare of Incarcerated
Individuals are Not Mutually Exclusive
The auditors stated there should be more transparency regarding the process and findings of
the Sheriff's CIRB Board. The CIRB reviews occur within the confines of the attorney-client
relationship and are not reported out publicly. Every governmental entity, even those such as
the State Legislature or a Board of Supervisors, both of which are subject to the Brown Act's
open meeting requirements, are afforded the opportunity to engage in candid conversations
with its counsel within the confines of the attorney-client relationship.
Notwithstanding the auditors' particular concern regarding the existence of the attorney-client
privilege, the CIRB's role of preventing future litigation compliments rather than undercuts the
Department's goal of improving the health and welfare of incarcerated individuals entrusted to
the care and custody of the Sheriff. As items of concern are identified during a critical incident,
such as an in-custody death, the CIRB review Is focused with an eye towards what changes have
already been implemented by the chain of command to remedy any deficiencies before the
matter made it to the CIRB for review, as well as any changes the chain of command may not
have already identified and/or implemented to minimize the risk of a recurrence. If the CIRB
identifies any best practices or changes not previously identified and implemented by the chain
of command prior to its review, the CIRB is empowered to make such recommendations.
As it relates specifically to in custody deaths, the CIRB concentrates not only on the death itself,
but also considers the handling of the inmate from the time the inmate was originally booked.
The Board looks to determine whether any warning signs existed, whether appropriate and
timely safety checks occurred, and whether there were any risk reduction lessons that could be
derived from the incident.
While the focus of the CIRB may be risk management, the mechanism by which risk
management is ultimately accomplished is clearly through the promotion of best practices and
policies that improve the health and welfare of incarcerated individuals and holding staff
accountable.
While the Auditor was "particularly concerned" that the Sheriff's Department does not publicly
report out its CIRB discussions, all Sheriff's Department policies, procedures, training, and
education materials are published on the Sheriff's Department's website. Any changes to
Sheriff's policies, procedures, training, or education, whether recommended by the CIRB or
implemented by management prior to or without the need for a CIRB review, are published and
available for the public to access on the Sheriff's Department's website. In addition to the
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attorney-client privileged nature of the CIRB discussions, the Sheriff's Department would also
be prohibited by state statutory and constitutional privacy considerations from disclosing any
discussions by the CIRB regarding employee misconduct or Internal Affairs investigations.

017

d. In Addition to Its Own Internal Reviews, the Sheriff's Department is Already
Subject to Independent Oversight by Multiple External Organizations
local detention facilities are subject to a myriad set of regulations and laws based on statutory
law, constitutional guarantees, and case law. In order to ensure county detention facilities,
comply with these requirements, the BSCC promulgates regulations under Title 15 of the

O4

California Code of Regulations, establishing statewide standards for detention facilities. In
order for facilities to maintain their certification to operate, counties are subject to bi-annual
inspections by the BSCC. The auditors' findings confirm that the Sheriff's Department meets
the standards established by the BSCC under Title 15.
In addition to the bi-annual inspections by the BSCC, pursuant to its authority under Penal Code
section 919, the San Diego County Grand Jury conducts an annual inspection of the Sheriff's
Department detention facilities.
The San Diego County Citizens law Enforcement Review Board, pursuant to its County Charter
authority, is also empowered to, and does, Investigate in-custody deaths.

017

e. In its continuing efforts to enhance medical and mental healthcare, and exceed
the standards set by the State of California, the Sheriff's Department engaged
reviews by multiple separate external entities specializing in correctional
healthcare
The Sheriff's Department was reviewed by two entities in pursuit of enhancing system
operations related to medical and mental health care. These included a look at suicide
prevention practices by nationally recognized expert, Mr. Lindsay Hayes, and a preliminary
review by the National Commission on Correctional Healthcare (NCCHC). Both entities
produced reports for the Sheriff's Department that have been used to enhance policies and
procedures to align with best practices and meet recommendations. The reports are available
on the Sheriff's Department public website at www.sdsheriff.gov.

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Ill.

05

RECOMMENDATIONS
a.

Intake Screening

CSA Recommendation:
Revise its intake screening policy to require mental health professionals to perform its mental
health evaluations. These evaluations should include a mental health acuity rating scale to
better inform individuals' housing assignments and service needs while In custody. The Sheriff's
Department should communicate the acuity rating as it assigns to individuals to all detentions
staff overseeing them.

The Sheriff's Department concurs with the auditor's assessment that Qualified Mental Health
Providers (QMHP) are the more appropriate staff to conduct the mental health screening
portion of the intake process. The Medical Services Division (MSD) received funding for
additional staffing in July 2021 and is currently in the process of recruiting and hiring from a
limited pool of candidates. Additional staffing will allow us to provide a comprehensive
screening process utilizing the electronic health record, in accordance with National
Commission for Correctional Health Care (NCCHC) standards. Some identified QMHP staffing
duties would be to conduct the Behavioral Health (BH) screening, complete a risk/needs
assessment, to include substance use disorder (SUD). The assessment would determine a
behavioral health acuity rating, schedule psychiatric appointments, schedule follow up QMHP
appointments, assess for the need of placement into our Inmate Safety Program (ISP) and
obtain Release of Information authorizations. QMHPs and nursing staff working in
collaboration at the initial intake assessment and throughout a patient's incarceration
promotes a comprehensive whole person model of care.
Ongoing effective communication between medical staff and sworn staff is paramount in
ensuring the safety and wellbeing of our patients. Our plan is to implement bidirectional
communication with our Jail Information Management System to ensure sworn staff are aware
of the mental health recommendations. All staff are responsible for the appropriate and timely
care of our patients. Further analysis will need to be done to evaluate the impact this acuity
rating system would have on our system of jail classification and housing needs.

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CSA Recommendation:
Create a policy requiring health staff to review and consider each individual's medical and
mental health history from the county health system during the intake screening process.

San Diego County does not have an interconnected health information exchange. Hospital
centers and medical systems Independently manage their data systems and may or may not
voluntarily participate or contribute to a health information exchange. Our health staff
currently have access to the following county databases:

i. Health and Human Services Agency- Cemer Community Behavioral
Health (CCBH)
C~rner Community Behavioral Health is a behavioral health-specific electronic health record
-~[·:at specializes in the delivery of community mental health, inpatient mental health, outpatient
meri~al health, substance use disorder and developmental disabilities care. Although there may
i:;~~ st;::.1~ patients who are not in the database and do not have data entered, we continue to
.'~:view :md enter data referencing our patient encounters while in our care.
As t;'f April 2021, all QMHPs {mental health clinicians, psychologists, psychiatrists, psychiatric
technicians) have "read" access to Cerner Community Behavioral Health (CCBH). QMHPs can
review records at any point in the patient's stay. The planned integration of a QMHP into the
intake process for behavioral health screening will fulfill this recommendation . In addition to
having access to review community behavioral health records, the Sheriff's Detention Services
Bureau contributes to this community database by recording and entering mental health care
provided while the patient is in our custody as part of the county's continuum of care. The
Sheriff's Medical Services Division intends to adhere to the NCCHC standards for the referral
process.

ii. Health and Human Services Agency - San Diego Immunization Registry
The San Diego Immunization Registry (SDIR) is a County system that offers Sheriff's Department
health staff the ability to verify a patient's vaccination status. SDIR is limited to vaccinations
given in San Diego County. If a patient receives an immunization outside of San Diego County or
opts to "lock" their record, health staff will not have the ability to verify vaccination status.
Currently we have sufficient access to SDIR.

iii. San Diego Health Connect
San Diego Health Connect was originally designed to allow for medical information to be
exchanged between community clinics. The database only covers medical (not mental

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health/behavioral health issues) and each patient must consent to participate. Very few
patients are registered in the system, and the system is undergoing restructuring.

b. Medical & Mental Health Follow-Up

CSA Recommendation:
Revise its policy to require that nurses schedule an individual for an appointment with a doctor if
that individual has reported to the nurse for evaluation more than twice for the same complaint.

The Sheriff's Department concurs with the auditors' assessment that a revision is necessary to
address the process for medical/mental health referral after two requests. The Sheriff's
Medical Services Division intends to implement a health care requests and services process in
accordance with NCCHC standards. Patients will be referred to a provider to be evaluated.
When a patient presents for health care services more than two times with the same complaint
and has not seen a provider, they will receive an appointment to do so. Some mental health
patients need assistance with advocating for their medical care. Regular follow-up and ongoing
engagement with QMHPs is essential to identifying patients who face these challenges.

CSA Recommendation:
Revise its policy to require that a nurse perform and document a face-to-face appraisal with an
individual within 24 hours of receipt of a request for medical services to determine the urgency
of that request. Revise its policy to require that a member of its health staff witness and sign the
refusal form when an Individual declines to accept necessary health care.

The Sheriff's Department concurs a timely medical response to patient concerns is extremely
important, and that repetitive patient refusals or an abject delay in follow-on scheduling of
medical care are concerning issues and could potentially precipitate an adverse condition or
event. We are committed to the health and well-being of our patients, and are developing
safeguards to ensure a timely, efficient re-engagement of both medical and mental health
services.
The Sheriff's Department is currently focused on a more nursing centric model. For health staff,
we are in the process of embedding nursing staff at the ward level, assigning nursing staff to
most housing units in support for the Primary Care nursing model. Nurses will be there to
perform face-to-face assessments of their assigned patients (on the floors and during sick call)
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and involved in counseling and advocacy efforts for every refusal. We have worked with our
contracted medical providers to develop daily rounds in designated modules to address acute
and ongoing assessments for specified patients. We continue to pursue accreditation from the
NCCHC which requires a face-to-face assessment withing 24 hours of a medical request being
filed (NCCHC Standards J-E-07).

CSA Recommendation:
Revise its policy to require more frequent psychological follow up after release from the inmate
safety program to at least monthly check-ins.

The Sheriff's Department will reevaluate our policies on psychological follow-up. Our current
Inmate Safety Program policy reflects the recommendations from Mr. Lindsey Hayes regarding
our follow up protocol. Mr. Hayes is nationally recognized as an expert in the field of suicide
prevention within custodial settings and has served as a Federal Court Monitor. While
placement into any of our Inmate Safety Program specialized housing requires a mental health
response and establishes a basis for continued follow-up; the Sheriff's Department's current
planned expansion and hiring of additional mental health professionals will allow for more
frequent encounters and the investment of time necessary for higher quality mental health
care.

018

Mr. Hayes specifically states, "it is recommended that the follow-up schedule be simplified and
revised as follows: follow-up within 24 hours, again within 72 hours, again within 1 week, and
then periodically as determined by the clinician until release from custody." As a nationally
recognized expert, SDSD has adhered to Mr. Hayes' recommendation.

c. Safety Checks

CSA Recommendation:
Revise the safety check policy to include the requirement for staff to check that an individual is
still alive without disrupting the individual's sleep.

The Sheriff's Department will reevaluate current policy and incorporate best practices. SDSD is
exploring technologies to assist with monitoring a "proof of life" for all incarcerated individuals
with minimal sleep interruption through staff contact. The Sheriff's Department is evaluating
industry capabilities, and in the process of developing a more robust facility Wi-Fi system
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capable of supporting technological advancements in monitoring the welfare of our population.
The Sheriff's Department's planned integration of Bodyworn Cameras (BWC) into the custodial
setting will greatly assist in showing the point of view each deputy has during the safety checks.

CSA Recommendation:
Develop and implement a policy requiring that designated supervising sworn staff conduct
audits of at least two randomly selected safety checks from each prior shift. These audits should
include a review of the applicable safety check logs and video footage to determine whether the
safety checks were performed adequately. In addition, the policy should require higher-ranking
sworn staff to conduct weekly and monthly audits of safety checks. The policy should also
require each facility to maintain a record of the safety check audits that staff perform.

Sheriff's Department line supervisors conduct electronic log reviews every shift. This review
includes ensuring the timeliness of safety checks in accordance with established Policy &
Procedures. The Sheriff's Department's current practice requires supervisors conduct video
audits of random safety checks and will formalize this into policy.

d. Sworn Discovery of Medical Emergency

CSA Recommendation:
Revise its policies to require that sworn staff members immediately start CPR without waiting
for medical approval, as safety procedures allow.

Sworn staff does not require approval from medical to start CPR. Current DSB P&P M.S 1.8.
states, "When the severity of the medical emergency requires it, and as soon as it is safe to do
so (unless death is obvious, such as decapitation, obvious rigor mortis, etc.), deputies acting as
first responders will provide basic life support and first aid. Upon arrival, facility health staff will
assess the severity of the inmate's injury/distress, provide first-aid, and may assist or take over
cardiopulmonary resuscitation (CPR) responsibilities as directed and/or needed." This policy in
its current form has been in effect since January 2012.
The Sheriff's Detention Services Bureau In-Service Training Unit distributed a training bulletin
on Signs of Medical Distress and Life-Threatening Emergencies on June 18, 2021. The purpose
of the training bulletin was to familiarize staff with signs of death or near death and appropriate
actions of sworn staff when observing such signs of medical distress. Per DSB Policy and
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Procedure section M.6, "Any life-threatening medical emergency shall trigger a 911 request for
a paramedic emergency response team. Sworn and health staff shall initiate emergency
response and basic lifesaving measures until relieved by the paramedic emergency response
team."

e. In-Custody Death Follow-Up

CSA Recommendation:
Staff will provide a written report of each 30-day medical review to its management.

The Sheriff's Department concurs with this recommendation.

CSA Recommendation:
When warranted, the report should specify recommendations for changes to prevent future
deaths.

The Sheriff's Department concurs with this as it relates to the perspective of the Chief Medical
Officer or the Director of Mental Health's review of the case.

CSA Recommendation:
The 30-day medical review should determine the appropriateness of clinical care; assess
whether changes to policies, procedures, or practices are warranted; and to identify issued that
require further study.

The Sheriff's Department concurs with this as it relates to the perspective of the Chief Medical
Officer or the Director of Mental Health's review of the case. There are other processes
currently in place to look for policy, training, or accountability issues following critical incidents.

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f. Critical Incident Review Board

CSA Recommendation:
Revise its policy to require that the Critical Incident Review Board review natural deaths.

In July of 2021, the Division of lnspectional Services (DIS), Sheriff's Legal Affairs, and CIRB board
members evaluated potential updates to policy and procedures section 4.23 - Department
Committees and Review Boards. This assessment included reviewing in-custody deaths
deemed natural by the Medical Examiner's Office, as the auditors recommend. This, along with
other changes are anticipated to be in a pilot phase beginning February 2022. Historically, if a
natural death is deemed to have potential issues of any nature it may be presented to CIRB at
the discretion of the board members. Also, the Chief Medical Officer and appropriate medical
staff conduct a mortality/morbidity review of each in-custody death for their determination of
any changes that are needed related to medical care for incarcerated individuals.

CSA Recommendation:
Require the Sheriff's Department to make public the facts it discusses and recommendations it
decides upon in the Critical Incident Review Board meetings to establish a separate public
process for reviewing deaths and making necessary changes.

CIRB presentations allow the Sheriff's legal advisor and the various commands the ability to
review critical incidents to identify issues that should be addressed in various areas, Including,
but not limited to, training, policies, procedures, staffing, and equipment. The confidential
environment provided by the CIRB is essential to the free exchange of ideas, and concerns, in
anticipation of future litigation because of a given incident, and in order to avoid future
litigation through implementation of best practices. Effectiveness and thoroughness of
presentations would likely be diminished if the attorney-client privilege is removed, or
information is required to be disclosed during pending, or anticipated litigation. Much of the
information presented in CIRBs is intended for individuals who have a vast familiarity and
understanding of law enforcement or detention operations, department policies, and state and
federal laws, and may contain confidential information including criminal history, medical
history, and peace officer personnel records.

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g. Citizen's Law Enforcement Review Board Integration

CSA Recommendation:
Revise its policy to include CLERB in its immediate death notification process.
Revise its policy to allow a CLERB investigator to be present at the initial death scene.

The Sheriff's Department is currently evaluating a process to integrate the CLERB investigator
into the initial notification and response to in-custody deaths, to include a scene walkthrough
and incident brief.

CSA Recommendation:
Revise its policy to encourage its staff to cooperate with CLERB's investigations, including
participating in interviews with CLERB's investigators.

The CLERB has subpoena powers for in person sworn staff interviews. In 2003, the CLERB
discontinued issuing Sheriff's Department sworn staff interview subpoenas and opted for
written responses due to Public Safety Officers Procedural Bill of Rights {POBAR) conflicts where
ultimately the interviews did not benefit the CLERB's investigations. The CLERB continues to

020

have subpoena powers. This recommendation should be re-directed to the CLERB for its
review to change its current practice and exercise its authority to issue subpoenas to Sheriff's
sworn staff.

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IV.

05

CONCLUSION

The Sheriff's Department takes seriously its responsibility to maintain a safe and healthy
environment in the county jails.
The Sheriffs Department has welcomed and consistently made itself available for, and
cooperated with, reviews by numerous entities including the Disability Rights California, Lindsay
Hayes, the NCCHC, the San Diego County Grand Jury, and the Citizens law Enforcement Review
Board. We did the same with the California State Audit. After every review, the Department
seriously considers every recommendation and implements those that are appropriate and
possible, given existing laws, infrastructure, staffing limitations, and best practices. During the
15-year audit period the Department has taken numerous steps towards providing the best
care for those detained in the jail system. To date, the following improvements have been
made:
•
•

Changing our pharmacy business processes
Implementing a new electronic health record system

•

The continuous review and updates to both Detentions Services and Medical Services
policies and procedures.

•

Increased medical service provider coverage
Enhanced communication and collaboration between medical and sworn staff which
includes the:
o Implementation of a medical "scene manager" to ensure relevant
communication during critical incidents
o Issuance of facility communication equipment in the nursing stations to expedite

•

•

response
o Development of collaborative training between sworn and health staff related to
health emergencies
Developing and mandating an 8-hour suicide prevention training and a 2-hour refresher
training

•
•
•

Enhancing our suicide assessment and monitoring
Enhancing the continuity of care for inmates removed from suicide precautions; and
Enhancing the quality assurance process for intake screening related to suicide
prevention

We recognize that we cannot rest on the things that we have done. As the Sheriff's
Department shared with the auditors, the Department is pursuing accreditation by the National
Commission on Correctional Health Care (NCCHC). The Sheriffs Department currently meets
the standards established by the State of California, final accreditation by the NCCHC would add
yet another layer of continuing, independent, external oversight. However, our goal is to
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exceed all standards. We strive to provide a better than community standard in the medical
and mental health care of incarcerated individuals.
The San Diego Sheriff's Department recognizes that comparisons will be made among counties
in California. We regularly confer with other counties in the state and across the country to
identify best practices. We remain focused on what we can improve and are committed to do
so. It is with this attitude that the San Diego County Sheriff's Department will go forward in
assessing the recommendations made by the auditor in the draft report.

Sincerely,

William 0. Gore, Sheriff

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Comments
CALIFORNIA STATE AUDITOR’S COMMENTS ON
THE RESPONSE FROM THE SAN DIEGO COUNTY
SHERIFF’S DEPARTMENT
To provide clarity and perspective, we are commenting on the
Sheriff Department’s response to our audit. The numbers below
correspond to the numbers we have placed in the margin of the
Sheriff ’s Department’s response. In certain areas of its response,
we have summarized our comments according to the respective
sections in its response rather than comment on all of the individual
areas of its response that we believe are deficient or misleading.
We provided the Sheriff ’s Department five business days to
review and provide a formal response to the draft audit report,
which is our standard practice for all audited entities. As part
of our audit process and in accordance with generally accepted
government auditing standards, we also met with the staff of the
Sheriff ’s Department, including the Sheriff and other executive
management personnel, on numerous occasions during the audit
to ensure they were fully briefed on our findings, conclusions, and
recommendations.

01

We have redacted portions of the Sheriff ’s Department’s response
containing information that is deliberative in nature or reflects
confidential discussions not used in support of the audit report.
Additionally, some of the redacted text contains excerpts from the
draft report. In accordance with Government Code sections 6254,
8545, and 8545.1, it was necessary for us to make these redactions to
protect our confidential work and because the improper disclosure
of draft audit documents is a misdemeanor.

02

The Sheriff ’s Department states that the highly redacted version
of the draft report made it difficult for it to submit a meaningful,
comprehensive response. On the contrary, the report that we
provided contained all findings, conclusions, and recommendations
pertaining to the Sheriff ’s Department—all of which we had
previously shared with its management on numerous occasions.
The sections we redacted pertained to other audited entities, such
as CLERB, which were not relevant for the Sheriff ’s Department’s
response. Further, because state law makes it a crime to improperly
disclose ongoing audit information, when the California State
Auditor’s Office sends draft sections of an audit report to an
audited agency for its comment, we redact from the draft those
provisions that concern the other agencies being audited. Moreover,
the Sheriff ’s Department misunderstands the purpose of an
audit report, which is to summarize the results of our audit work
that the Audit Committee directed us to perform. Our working

03

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papers contain the documentation and analyses that support the
findings, conclusions, and recommendations in the audit report.
Additionally, Government Code section 8545, prohibits the public
release of any work papers pertaining to an audit that has not yet
been completed. Until the audit report is published, we are required
to hold any supporting work papers in strict confidence.

04

Although we concluded that the Sheriff ’s Department’s policies
generally align with BSCC standards, we found significant
deficiencies that we discuss throughout the report. Moreover, as
we state on page 32, BSCC designs the standards to be a minimum
that all counties can achieve, regardless of variation in resources at
the local level. However, we found that BSCC’s approach enables
counties that house large numbers of incarcerated individuals to
provide lower levels of care. Therefore, to improve the level of care
in local detention facilities, we made recommendations to address
weaknesses in the Sheriff ’s Department’s policies and procedures as
well as in BSCC’s standards.

05

The Sheriff ’s Department’s concerns related to our findings and
conclusions contradicts its agreement with our recommendations.
Under generally accepted government auditing standards, which we
are required to follow, the findings and conclusions of an audit form
the basis for recommendations.

06

The Sheriff ’s Department incorrectly states that we do not comply
with audit standards, which it asserts on pages 85 through 96.
We conducted this audit in accordance with generally accepted
government auditing standards, which we are required to follow,
and the California State Auditor’s thorough quality control process.
In following audit standards, we are required to obtain sufficient
and appropriate audit evidence to support our conclusions
and recommendations. As with all of our audits, we engaged
in extensive research and analysis for this audit to ensure that
our report presented a thorough and accurate representation
of the facts, and included all relevant information. We stand
by the statements in our report, which are based on sufficient
and appropriate evidence. Further, as with all of our audits, our
public report includes the required statement indicating that we
performed this audit in compliance with audit standards.
Moreover, as part of our adherence to audit standards, our
staff possess the collective knowledge, skills, and abilities to
conduct performance audits, including those of local law
enforcement entities.

07

The Sheriff ’s Department’s comments questioning the accuracy
of our report are unfounded. As we state on page 13, the high
rate of deaths in San Diego County’s jails compared to other

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counties raises concerns about underlying systemic issues with
the Sheriff ’s Department’s policies and practices. Throughout
Chapter 1 we provide numerous examples of deficiencies in the
department’s policies and procedures that likely contributed to the
deaths of some incarcerated individuals and how these policies
and procedures do not align with certain best practices used by
comparable counties and other entities. Specifically, in the examples
on pages 21 through 24, we describe how the Sheriff ’s Department
did not consistently follow up with individuals who needed
medical and mental health services, and that lack of attention may
have contributed to their deaths. Finally, although the Sheriff ’s
Department indicates that our audit does little to document or
provide context of its efforts to respond to deaths, we describe
on page 39 the improvements the Sheriff ’s Department has made.
Because we found that weaknesses continue to exist in the Sheriff ’s
Department’s policies and procedures, we made recommendations
to address those weaknesses.
Because the Sheriff ’s Department’s response included specific
details about an in‑custody death, such as the case number and
a more detailed description of the incident, we redacted this text
because it contained confidential information and to protect the
privacy of the individuals involved. We clarified our report to make
it clear that our concern in this case is related to timeliness of its
response to the emergency and not the issue of who provided CPR.

08

The Sheriff ’s Department incorrectly states that it was not given
information about the Alameda Sheriff ’s Office, the Orange
Sheriff ’s Department, and the Riverside Sheriff ’s Department. The
draft report that we sent to the San Diego Sheriff ’s Department
contained primarily publicly available information for these
counties to provide context for the Sheriff ’s Department’s findings.

09

When multiple entities are examined in an audit, the California
State Auditor’s Office is required under state law to maintain
confidentiality with each of those entities. Maintaining
confidentiality among multiple subjects of an audit is essential
to ensuring the integrity and quality of the evidence upon
which the audit’s conclusions are based. Moreover, based on its
misunderstanding of state law, the Sheriff ’s Department wrongly
asserts that our office was required to provide it with supporting
documentation pertaining to other auditees because they are public
records. Government Code section 8545 prohibits the public release
of any work papers or documents pertaining to an audit that has
not yet been completed. Until the audit report is published, any
supporting documents are held in strict confidence.

010

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011

The Sheriff ’s Department’s concern regarding which version of
policies and procedures we based our findings on is unfounded.
Our analysis included identifying the policies applicable at the time
of the incident we reviewed and determining whether they were
subsequently updated to address our concerns. For example, as
we state on page 23, we identified a weak policy for mental health
services that contributed to an individual’s death by suicide and
determined that the Sheriff ’s Department subsequent revision to
that policy did not fully address our concerns.

012

The Sheriff ’s Department’s approach does not allow for a fair
comparison between counties. In Table A.2 on page 60, we
present the rate of in‑custody deaths based on the relative size of
15 counties. We believe that this objective presentation allows a
reader of the report to compare the counties in a more meaningful
way. Nevertheless, in both presentations, the Sheriff ’s Department
is among the highest in number and rate of deaths in its jails.

013

Table 1, Table 2, and Table 3 on pages 98 to 100 were created by
the Sheriff ’s Department and are not part of our report. We do not
attest to the accuracy of the information the Sheriff ’s Department
presents.

014

We stand by our selection of the comparable counties referenced in
our audit. As we state in the Scope and Methodology on page 62,
we selected these counties considering relative size, geographical
location, and other factors. We also used professional judgement
in selecting a large county in a different region to obtain broad
perspective. Our selection of counties satisfied the audit objectives
and resulted in sufficient and appropriate evidence to support our
findings, conclusions, and recommendations.

015

We stand by our conclusion that the Sheriff ’s Department’s reviews
of in‑custody deaths are insufficient. As we state on page 34, the
Sheriff ’s Department did not sufficiently document the results
or recommendations from its 30‑day medical reviews. For 22 of
the 30 cases we reviewed, the Sheriff ’s Department was unable to
provide us with documentation from these reviews that detailed
any findings or conclusions about the clinical care given, identified
whether any concerns required further study, or stated whether
changes to policies, procedures, or practices are warranted. We
believe that if the Sheriff ’s Department properly documented the
30‑day medical reviews, it could better identify and track instances
when it did not provide sufficient medical and mental health
follow‑up care before an individual’s death, such as those we discuss
in Chapter 1.

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Further, as we discuss on page 38, the Sheriff ’s Department does not
complete internal affairs investigations related to in‑custody deaths
frequently enough for it to provide significant value. The small
number of these investigations related to deaths—coupled with
the lack of meaningful changes arising from the Critical Incident
Review Board meeting and the 30‑day medical review—calls into
question the Sheriff ’s Department’s commitment to protecting
individuals in its custody.
The Sheriff ’s Department mischaracterizes our point about
its Critical Incident Review Board. To clarify, as we state on
page 36, the stated purpose of the board is to consult with the
department’s legal counsel when an incident occurs that may give
rise to litigation. Therefore, it appears that its primary focus is
protecting the Sheriff ’s Department against potential litigation
rather than focusing on improving the health and welfare of
incarcerated individuals.

016

Further, after the board meets to discuss in‑custody deaths, it has
not always taken meaningful action to prevent deaths, even when
it identifies problems with its policies and practices. Specifically, as
we state on page 36, even though the board discussed critical issues
in some meetings, it did not always make recommendations for
addressing these issues.
Moreover, as we discuss on page 37, although we do not disagree
with having a confidential forum to discuss potential litigation
matters, we are concerned that the Sheriff ’s Department does
not have a separate public process to demonstrate that it is
addressing deficiencies in its policies, procedures, and practices
after in‑custody deaths occur. By keeping its findings and
recommendations confidential, the department risks conveying to
the public that it is not taking these deaths seriously, investigating
them thoroughly, or acting to prevent future incidents. Further, the
Sheriff ’s Department is disingenuous in its response that it provides
all changes to policies, procedures, training, or education on its
website. The policies posted on its website do not communicate
changes it made in response to in‑custody deaths. Having its
policies available online in their entirety without specifically
identifying those changes that it made in response to in‑custody
deaths is not transparent in this respect.
Even though the Sheriff ’s Department was reviewed by external
entities, we found it has failed to implement key recommendations
from external entities, including recommendations from the
San Diego County Grand Jury, CLERB, Disability Rights California,
and a suicide prevention consultant, as we describe on page 38.
Some of the recommendations that the Sheriff ’s Department
failed to implement are related to weaknesses in its policies and

017

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procedures that we identify in this report. Accordingly, we are
concerned about whether the Sheriff ’s Department will make
meaningful changes to address these systemic weaknesses.

018

The timeframes that the Sheriff ’s Department refers to are
unrelated to our recommendation. Our recommendation is for the
Sheriff ’s Department to update the minimum ongoing follow-up in
its policy from 90 days to at least monthly. As we state on page 22,
reports and studies related to mental health indicate that more
frequent psychological follow‑up, such as check‑ins performed
weekly to rather than every 90 days, leads to faster recovery and is
more effective for individuals with mental health needs.

019

Although the Sheriff ’s Department asserts that its current policy
appropriately addresses safety concerns regarding sworn staff
administering CPR to incarcerated individuals, we had concerns
with this policy during our audit. As we state on page 27, in
some instances, sworn staff did not perform lifesaving measures
because they thought the individual was dead. However, when
department medical staff arrived minutes later, they immediately
began lifesaving measures on the individual, including CPR. This
fact calls into question the ability of sworn staff to assess whether
unresponsive individuals might benefit from such potentially
lifesaving measures.

020

We explain on pages 42 through 45 our concerns with CLERB
not directly interviewing sworn staff. Our recommendation to
the Sheriff ’s Department to encourage its staff to cooperate with
CLERB’s investigations aligns with our recommendation on page 57
to CLERB.