SAN DIEGO — The San Diego County Sheriff’s office has released the autopsy report of 46-year-old Lonnie Rupard, who died in their custody on March 17, 2022. The county medical examiner’s office ruled the manner a homicide.

The 22-page autopsy report laid out the cause of death and what happened during Rupard’s time in custody leading to his death.

“We are absolutely committed and dedicated to improvements,” said Kelly Martinez, San Diego County Sheriff.

Martinez said she wants more transparency and more accountability for in-custody deaths.

The autopsy report for Rupard shows San Diego Central jail staff found Rupard unresponsive in his cell. Staff gave him CPR, and transferred him to the hospital where he died shortly after arriving.

“I really feel for the family to have it drawn out this long has got to be really difficult. I am very sympathetic to everything that they are going through,” Martinez said.

The autopsy report showed the causes of death are pneumonia, malnutrition and dehydration from neglected schizophrenia. Contributing factors show a COVID-19 infection, pulmonary emphysema and a duodenal ulcer.

The autopsy showed Rupard had no known medical conditions, other than schizophrenia. The report shows Rupard had a history of psychotic disorders with combative, assaultive, and hostile behavior sometimes.

The report found Rupard had minor acute and healing blunt force injuries to the head, neck, torso, and extremities.

The report showed family members did not recall Rupard taking any illicit drugs or medications.

Rupard had been in custody since December 2021, when officers arrested him for a parole violation.

The report showed during Rupard’s time in custody, staff requested multiple psychiatric calls, but noted Rupard was uncooperative and refused some visits and medications.

The sheriff said they are streamlining the courts to get conservatorship orders for people who can’t care for themselves.

“So we can make those medical decisions for them and basically force care so that we can save their lives,” Martinez said.

The report showed staff last saw Rupard alive an hour before finding him unresponsive. At the time of his death, the report shows Rupard lost 60 pounds since his arrest.

The medical examiner wrote Rupard had care available to him in the form of meals, water, psychiatric medicine and medical evaluations but the ineffective delivery of that care led to his death.

The examiner wrote elements of self-neglect were present but said Rupard was dependent on others to take care of him, therefore ruling the death a homicide.

“We need to have a little more, pay a lot more attention to them while they’re in our jail to make sure they don’t deteriorate and have issues,” Martinez said.

The sheriff said they are doing a top-to-bottom look at where they can do better. In January 2022, Martinez added a lieutenant that responds directly to her after each death. The lieutenant will present to Martinez their findings with recommendations on preventing that type of death.

The office has added family liaisons to work with family members after a loved one dies in custody.

Martinez said she recognizes that the department is still working on improvements from a state audit in February 2022, that found the department failed to adequately prevent and respond to in-custody deaths.

Click here to view the California State audit of the San Diego County Sheriff’s Department.

FOX 5 asked Martinez “Do you think you dropped the ball here?”

“Really that is what we are investigating. We are trying to figure out where that lies and that’s where the investigations are at,” Martinez explained.

Now that the Medical Examiner’s Office has finished its report, the Sheriff’s Homicide Unit and the administrative investigation can be conducted.

The sheriff’s office will turn their findings over to the San Diego County District Attorney’s Office which will decide if criminal charges should be filed.