SAN DIEGO (CNS) – The California State Auditor released a sobering assessment Thursday of the San Diego County Sheriff’s Department’s record of unusually frequent jail-inmate deaths, charging that the agency has “has failed to adequately prevent and respond to” the problem and calling for legislative action to solve it.

“The high rate of deaths in San Diego County’s jails (as) compared to other counties raises concerns about underlying systemic issues with the Sheriff’s Department’s policies and practices,” acting California State Auditor Michael Tilden wrote in an introductory open letter in the report addressed to Gov. Gavin Newsom and state legislative leaders.

“In fact, our review identified deficiencies with how the Sheriff’s Department provides care for and protects incarcerated individuals (that) likely contributed to in-custody deaths. … 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,” Tilden asserted.

In response, the leaders of the San Diego-area regional law enforcement agency — whose record of 185 fatalities between 2006 and 2020 in the seven detention centers it oversees is among the highest comparable totals in the state — asserted that they “take the findings of the audit seriously” and are “taking action” to implement its call for systemic change.

“Many of (the) recommendations are ones that we provided and completely support,” sheriff’s officials stated. “They also align with our existing practices (and) current and future plans, as well as proactive efforts to continuously improve health care services and the safety of our jails.”

Thursday morning’s release of the report landed on the same date — made public last month — of 13-year San Diego County Sheriff Bill’s Gore early retirement, which he opted to take nearly a year before the end of his fourth term in the post.

Ryan Grossi, a spokesman for the auditor, said there was no intention on the part of officials at the state agency to make the release of the document coincide with the sheriff’s departure.

Gore, 74, announced last summer that he would not seek re-election this year.

The audit was conducted at the behest of the California Joint Legislative Audit Committee after state legislators requested it last June. The study ran from July to December of last year, looking into every aspect of the Sheriff’s Department’s record of in-custody deaths, policies, procedures, facility maintenance and staff records, according to state officials.

Some of the inmates who died in the county’s jails over the 15-year study period had been in custody for only a few days or months, and others were waiting to be sentenced, set to be released or about to be transferred to different facilities, according to the audit.

“Although any death is a tragedy, the high rate of deaths in San Diego County’s jails compared to other counties … 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,” the report states.

Over the years reviewed by the auditor’s office, the sheriff’s staff “did not always provide consistent follow-up care to individuals who requested or previously received medical or mental health services,” the document alleges.

“For example, one individual urgently requested mental health services shortly after entering the jail,” it states. “However, (a) 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.”

The audit also found serious lapses in the department’s provision of inmate safety checks, which the report described as “a key component of ensuring the well-being of individuals in detention facilities.”

“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,” the document asserts. “When staff members eventually checked more closely, they found that some of these individuals showed signs of having been dead for several hours.”

Unless the Sheriff’s Department makes “meaningful change” to how it provides medical and mental health care in the jails it runs, according to the audit, “it will continue to jeopardize the safety and lives of individuals in its custody.”

Among proposals for improvements in the report, the auditor’s office — which stated that 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” — include the following recommendations:

  • The Legislature should amend state law to require the Sheriff’s Department to revise its policies to align with best practices related to performing health evaluations — including requiring that mental health professionals perform screenings — as well as providing follow-up medical and mental health care, conducting safety checks, and addressing the other “deficiencies” identified in the report.
  • Legislators should amend state law to require the Board of State and Community Corrections to amend its regulations to ensure that county sheriff’s departments have mental health professionals evaluate inmates at the start of their jail terms, and conduct regular safety checks “that are sufficiently detailed to determine that incarcerated individuals are alive.”
  • State lawmakers also should amend the law to require the San Diego County Sheriff’s Department’s Critical Incident Review Board to review natural deaths and to develop a process to make public facts discovered and recommendations made in response to all in-custody deaths.
  • The San Diego County Citizens’ Law Enforcement Review Board should revise its regulations within the next three months to prioritize investigations of all deaths that occur in the Sheriff’s Department’s custody above all other investigations and to include reviews of natural-cause jail fatalities as part of its responsibilities.

According to the state report, the Sheriff’s Department “generally agreed” with the recommendations but “questioned our audit approach and disagreed with our findings and conclusions,” the Board of State and Community Corrections “agreed with our findings and recommendations but indicated that it would discuss whether amendments to its regulations are warranted,” and the citizens’ review panel and Department of Justice agreed with the proposed remedial actions.

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