Fact Summary Natural Causes 59 Autopsies Prove Otherwise 2009-2019
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Embargoed until June 1, 2022 Facts Summary “Natural Causes?” 59 Autopsies Prove Otherwise Evaluating the Autopsies of 59 Deaths in Los Angeles County Jails 2009 - 2019 Report by Carceral Ecologies Lab The BioCritical Studies Lab Principal Investigators: Nicholas Shapiro, D. Phil. Terence Keel, Ph.D. - FOR S OCIETY & GENETICS Executive Summary: The rising number of jail deaths in the United States1 has left impacted community members, state actors, media, and scholars questioning if these rates are a reflection of the overall declining health of the nation or are due to factors specific to the carceral environment. This fact sheet contributes to this national dialogue through the analysis of autopsies for 59 deaths that occurred in Los Angeles County Jails over a 10-year period. Our study shows that the majority of Black and Latinx men are not dying from "natural causes" but from the actions of jail deputies and carceral staff. Our findings support the efforts of community members and lawmakers attempting to reform the cash bail system in Los Angeles County as three quarters of the deaths in our study were individuals held in pre-trial detention. Moreover, our study supports the urgent need to reduce the jail population to expedite the closing of Men's Central Jail and the potential life saving benefits of jail diversion programs for the people of Los Angeles County. We focus on autopsies because they are fundamental to establishing the causes and manner of death in carceral facilities that have limited public accountability. UCLA INSTITUTE FOR •• I I II II SOCIETY & GENETICS ~ • Nicholas Shapiro Assistant Professor Founding Director, Carceral Ec,,log1es Lab ,:'.A. erence O Keel Associate Professor Found ng Director, The B10Cnt1cal Studies Lab May 2022 Only 59 out of 292 cases between 2009-2019 were accessible at the time of the study due to security holds. • From 2009-2019, there were 292 total reported deaths in Los Angeles County jails. The Los Angeles Sheriff Department likely used security holds to block access to the remaining autopsies, coroner investigator narrative, and toxicology reports. Securityholds prevent families, scholars, and activists from seeking public accountability and closure. Out of 59 cases, 26 (44%) died from "natural" causes. • Of these 26 "natural" cases, 65% were Black, 23% were Latinx, and 8% were White. 23 of the 26 "natural" cases were men; of these 23 men, 14 were Black, 6 were Latinx men, and 2 were White. All 3 Black women in the study died from "natural" cases. Among "natural" deaths, all but 3 involved law enforcement. People who died from "natural" causes are not significantly older than other manners of death. 85% of these "natural" cases involved alleged mental illness and 54% included evidence of physical violence on the body. White and Latinx women were not represented in our sample of natural deaths. 74% of all Black deaths in the sample were classified as "natural". • 32% of Latinx deaths, 14% of White deaths, and 33% of Asian (1 of 3) deaths were classified as "natural". Black deaths were nearly twice as likely (0.489) to be designated as "natural" compared to Latinx, White, and Asian deaths combined. Latinx people who die in county jails are more likely to be "undetermined". • There were 8 total undetermined cases in our sample (Latinx men n=5; Black men n=3). In fact, every Latinx death in our study classified as undetermined died before trial. In all undetermined cases, the victims were young with an average age of 24.5 years old at time of death compared to an overall average of 42 years old for all cases. More than 75% of the cases in our study were deaths that occurred before standing trial. • We discovered that 69% of the natural death cases in our sample were pre-trial. Again, Black people were in the majority and represented 72% of these pre-trial cases. UCLA INSTITUTE FO R •SOCIETY • IGENETICS Il l & N1chc,las Shapiro • erence D Keel Assistant Professor Founding Director, Carceral Ecologies Lab Associate Professor ,:!.A. Found ng Director, The B10Cnt1cal Studies Lab May 2022 Law enforcement were present during the autopsy in 51 of the 59 cases we analyzed. • The Chief Physician at the LASO, who has supervisory responsibilities over medical care in LA jails, attended 14 of the autopsies (24%) across all manners of death.2 Deaths in Los Angeles County Jail have steadily increased since 2016. • This increase in deaths coincides with an increased number of cases placed on security hold also beginning in 2016. There were 292 deaths in Los Angeles County Jails between 2009 and 2019 that were reported to the Department of Justice. • Consistent with our analysis of the smaller 59 case sample, the large majority of deaths during this period were classified as "Illness" which is equivalent to "Natural" (n=161, 55%), followed by "Suicide" (n=50, 17%), "Drugs/Alcohol" (n=26, 9%), "Undetermined" (n=18, 6%), "Accident" (n=15, 5%), "Unknown" (n=11, 4%), "Homicide" (n=11, 4%). Latinx and Blacks constituted the majority of all deaths during this period. • Latinx deaths (n=109, 37%) led all groups followed by Blacks (n=100, 34%), Whites (n=62, 21%), Other (n=10, 3%), Asian (n=7, 2%), Pacific Islander (n=2, 1%) and Unknown (n=2, 1%). The number of cases placed on security hold dramatically increased beginning in 2016. • 2019 had the highest number of cases placed on security (90%) followed by 2017 (80%), 2018 (73%), and then 2016 (68%). No cases were placed on security hold between the years of 2008 and 2014. 209 deaths occurred before standing trial. • Most pre-trial cases were designated as "Illness/Natural" (n=114, 55%), followed by "Suicide" (n=39, 19%). Latinx made up the majority of pretrial deaths (n=78,37% ), followed by Blacks (n=70, 33%), then Whites (n=45, 22%) . UCLA INSTITUTE FO R •SOCIETY • IGENETICS Il l & N1chc,las Shapiro • erence D Keel Assistant Professor Founding Director, Carceral Ecologies Lab Associate Professor ,:!.A. Found ng Director, The B10Cnt1cal Studies Lab May 2022 78 deaths occurred post-conviction. • A clear majority were classified as "Natural" (n=47, 60%) followed distantly by "Suicide" (n=9, 12%). An equal number of Latinx (n=30, 38%) and Black (n=30, 38%) deaths were classified as "Natural" followed by Whites (n=15, 19%), then Asians (n=2, 3%) . Deaths per Year in LA County Jails 60 0------------------2008 2010 2012 20 14 2016 2018 2020 Year 2008-2013 Data from LASO Documents prepared for the US Department of Justice, 3 2014-2021 Data from the Los Angeles County Office of Inspector General. 4 Visual Overview 292 reported death in LA County Jails 2009-2019' Los Angeles County Jails Custody status at time of death ] --==---.::-----c:-C7 Death j investigation documents produced by medical examiner/coroner Factors contributing to jail deaths Manners of death Process of Dying in Los Angeles County Jails Access to Death Documentation The above figure represents an overview of our preliminary findings. On the left we depict the multiple factors that result in death inside Los Angeles County Jail. Most individuals in our study were of "pre-trial" status, meaning they were charged with a crime but had not yet stood trial or accepted a plea bargain. While incarcerated, the individuals in our study were subjected to one or all of the following factors that led to their deaths: physical violence, issues with mental health care treatment, or issues with health care. These factors contributed to the loss of life later classified by the medical examiner-coroner. The most common manner of death in our study was classified by the medical examinercoroner as "natural." "Undetermined" deaths were overrepresented in our sample compared to the average number of undetermined deaths for all autopsies in Los Angeles County. On the right we depict access to information involving the deaths of inmates in Los Angeles County jails. During our period of study, Los Angeles County jails were mandated to report deaths that occurred in their facilities to state and national authorities. However, public awareness of these deaths are shaped locally by the conflict between communities demanding access to files protected by California's open record laws and the Los Angeles Sheriff Department denying this access. This number is based on data submitted to Department of Justice. See footnote two for reference. UCLA INSTITUTE FOR •SOCIETY • IGENETICS Il l & N1chc,las Shapiro Assistant Professor Founding Director, Carceral Ecologies Lab ,:!.A. erence D Keel Associate Professor Found ng Director, The B10Cnt1cal Studies Lab May 2022 Death Classifications of 59 Cases in Los Angeles County Jails by Race, 2009-2019 Death Cla ssifications of 59 Cases in Los Angele s County Jails by Race, 2009-20 19 20 - Manner of Death 15- 17 C 5 ■ ■ ■ ■ ■ 4 6 (.) 10 - 4 2 5 6 Lalinx white Accident Homicide Natural Suicide Undetermined ,3 0- Asian Bl~ck Race Note the disproportionate scale of Black deaths deemed "natural." Age by Manner of Death Undeterm ined ,5 Cll Ql 0 Su icide 0 aiC: Natural C: Cll ~ Homicide Accident 0 25 75 50 Age at Death The graph above depicts age at death by each of the manners of death. Each manner is broken up into quartiles (meaning that ~25% of all cases fall between each of the vertical lines in the graph), Undetermined deaths show a statistically significant skew towards youth (p= 0.00003). Natural deaths are not statistically significantly older than other manners of death (p = .1534). The average American life expectancy was 78.9 years of age in 2019. 5 Jail Deaths by Facility UCLA INSTITUTE FO R •SOCIETY • IGENETICS Il l & Jail Number of deaths Average age at death Twin Towers 45 43.33 Century Regional Detention Facility 6 48 Men's Central Jail 5 30.6 Pitchess Detention Center 2 38 North County Correctional Facility 1 47 N1chc,las Shapiro Assistant Professor Founding Director, Carceral Ecologies Lab ,"!.A, erence D Keel Associate Professor Found ng Director, The B10Cnt1cal Studies Lab May 2022 Manner of LA County Jail Deaths, 2009-2019 150 - Race/Ethnicity 84 c ■ ■ ■ ■ ■ 100 - :0 0 u 54 50 - oI I Accident Drugs/Alcohol - - 25 I I I Homicide Illness Suicide I Asian Black latinx Native Other ■ Pacific Islander ■ White ■ Witheld I Undetermined Unknown Manner of Death Security holds of LA County Jail Deaths 2009-2019 Security Held Death Investigation Year ·-- Percentage Held Total Deaths Documents 2009 0 38 0.0% 2010 0 27 0.0% 2011 0 17 0.0% 2012 0 25 0.0% 2013 0 34 0.0% 2014 0 28 0.0% 2015 1 21 4.8% 2016 13 19 68.4% 2017 20 25 80.0% 2018 - - -·- 19 -2019 ·-· 29 ,~- 32 ,._ 26 73.1% - ~- 90.6% Acknowledgements: We would like to thank the many impacted families that brought this issue to our attention, trusted us with their truths, and consulted us as we performed this analysis. We are also grateful for the organizing efforts of Dignity and Power Now and the tireless work of undergraduate students in Carceral Ecologies and the BioCritical Studies Lab who were involved in this study. UCLA INSTITUTE FO R •SOCIETY • IGENETICS Il l & N1chc,las Shapiro • erence D Keel Assistant Professor Founding Director, Carceral Ecologies Lab Associate Professor ,"!,,&. Found ng Director, The B10Cnt1cal Studies Lab May 2022 References 1 Carson, E. Ann. "Mortality in Local Jails, 2000-2018 - Statistical Tables." Bureau of Justice Statistics, 2021. Dror, ltiel, Judy Melinek, Jonathan L. Arden, Jeff Kukucka, Sarah Hawkins, Joye Carter, and Daniel S. Atherton. "Cognitive Bias in Forensic Pathology Decisions." Journal of Forensic Sciences 66, no. 5 (2020). https://doi.org/10.1111/1556-4029.14697. 2 Smith, Grant. "Dying Inside: The Data behind @Reuters Investigation of US Jail Deaths." Reuters, October 16, 2020. https://www.reuters.com/investigates/special-report/usa-jails-graphic/. Data obtained from PRA requests of LASD. 3 4 Office of Inspector General. "Reform and Oversight Efforts: Los Angeles County Sheriff's Department." County of Los Angeles, December 2021. https://assets-us-01.kc-usercontent.com/0234f496d2b7-00b6-17a4-b43e949b70a2/736916ea-786c-4bfd-b073-b7de182ebf6c/ Reform%20and%20Oversight%20Efforts%20-Los%20Angeles%20County%20Sheriffs%20Department%20%20October%20to%20December%202021.pdf. Masters, Ryan K., Laudan Y. Aron, and Steven H. Woolf. "Changes In Life Expectancy Between 2019 and 2021: United States and 19 Peer Countries." Preprint. Public and Global Health, April 7, 2022. https:// doi.org/10.1101/2022.04.05.22273393. 5 UCLA INSTITUTE FO R •SOCIETY • IGENETICS Il l & • N1chc,las Shapiro Assistant Professor Founding Director, Carceral Ecologies Lab erence D Keel Associate Professor ,:!.A. Found ng Director, The B10Cnt1cal Studies Lab May 2022 Embargoed until June 1, 2022 Carceral Ecologies Lab Twitter: @Carceral_ECO, @zBoratory The BioCritical Studies Lab Twitter: @TerenceKeel terencekeel.com/bcs-lab Dignity and Power Now Instagram: dignityandpowernow
