With 185 deaths over 15 years, San Diego County jails are so unsafe and deficient that state lawmakers should intervene by forcing the Sheriff’s Department to change course, the California State Auditor said in a scathing report issued Thursday.
The audit, released on Sheriff Bill Gore’s final day in office, also said local oversight of the Sheriff’s Department should be toughened and the standards for correctional care statewide should be strengthened.
“Our review identified deficiencies with how the Sheriff’s Department provides care for and protects incarcerated individuals, which likely contributed to in‑custody deaths,” Michael Tilden, acting state auditor, wrote. “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.”
The audit said the Sheriff’s Department “did not consistently follow up with” inmates who needed medical and mental health services, and concluded that lack of attention may have contributed to their deaths.
The report noted that when deputies did check up on inmates, these “safety checks” often amounted to inadequate glances that sometimes missed inmates in distress.
“In our review of 30 in‑custody deaths … 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 audit said. ” When staff eventually checked more closely, they found that some of these individuals showed signs of having been dead for several hours.”
In their written response, Sheriff’s Department officials agreed with some of the State Auditor’s Office findings. But as they have in the past, they questioned the data methodology of the independent reviewers.
They also said San Diego is not much different from other counties when it comes to people dying behind bars and stressed that they are making strides toward reducing in-custody deaths, the review said.
The long-anticipated report took the unusual step of rebutting the department’s response to the audit. State auditors called parts of the response “disingenuous” and raised questions about the department’s internal controls.
The auditors said San Diego County jails can only be fixed by legislation requiring the Sheriff’s Department to implement a series of recommendations spelled out in the 126-page report.
“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 the Legislature must take action to ensure that the Sheriff’s Department implements meaningful change,” the report said.
The audit was commissioned last year by a group of San Diego County legislators in response to a rising tide of complaints from constituents that too many people have died in local jails.
The groundswell of criticism followed a six-month investigation by The San Diego Union-Tribune that found the mortality rate in San Diego County jails was significantly higher than other large California counties.
The stories noted that lapses in inmate care cost millions of dollars in court fees, legal settlements and jury awards over the years — money that comes directly from taxpayers because San Diego County is self-insured.
State auditors also said the department has yet to meaningfully implement recommendations made by independent experts over the last several years — an assertion disputed by the Sheriff’s Department.
Department officials rejected several of the State Auditor’s Office findings and questioned the methodology used in the report.
“The San Diego County Sheriff’s Department has taken appropriate and reasonable measures to prevent and respond to deaths of individuals in custody,” the department response states.
“The Auditor’s conclusion that the in-custody deaths were the result of inadequate medical care is misleading,” it adds.
Gore, who vacated the corner office at the Sheriff’s Department’s Kearny Mesa headquarters on Thursday, declined to comment on the findings. The department issued a statement saying it takes the audit findings seriously.
“Many of (the audit) recommendations are ones that we provided and completely ,” it said. “They also align with our existing practices, current and future plans, as well as proactive efforts to continuously improve healthcare services and the safety of our jails.”
AC Mills, whose son Kevin Mills died in San Diego Central Jail in 2020, said he was not surprised by the state audit findings, based on how his son was treated while in the sheriff’s custody. The younger Mills, 58, died of what was ruled as natural causes, but AC Mills questioned whether his son received proper medical care.
“He was just thrown away,” said the father, who just this week received medical records related to his son’s death that he requested more than a year ago. “They didn’t care about him. He was left to die there.”
Mills said he does not think Gore set a strong example as the elected sheriff. “I’m disappointed with his job performance, very dissatisfied,” he said. “I think he failed at his job. I hope Sheriff Gore understands the damage he left behind. I really do. And I hope the lawmakers get something done.”
State auditors examined deaths in local jails between 2006 and 2020, identifying 185 people who died in sheriff’s custody from suicides, homicides, accidents or natural causes.
They singled out suicides as being among the most pressing problems vexing county jails.
“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,” the report said.
The review focused largely on department trends and practices rather than on some of the high-profile deaths, including those that resulted in criminal charges against one nurse last year and a series of multimillion-dollar legal payouts.
“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,” the audit said.
The audit was also skeptical of the department’s Critical Incident Review Board, an internal that convenes regularly to consider and respond to major events and problems.
“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,” the review found.
Auditors said the Legislature should include in its reform bill a provision requiring the Sheriff’s Department’s internal review board to also examine natural deaths. Many of the fatalities officially recorded as natural deaths might have been avoided if the department had provided more rigorous medical and mental health treatment, the audit said.
The state report was also critical of the county’s Citizens’ Law Enforcement Review Board, or CLERB, a volunteer created in the early 1990s after a public vote to improve oversight of the Sheriff’s and Probation departments.
Auditors said CLERB has not always provided effective and independent oversight of the Sheriff’s Department and had failed to prioritize investigations of in-custody deaths.
Among other things, the audit said, the citizens’ review board wrongly allows department employees to avoid interviews with investigators and instead bases its findings on written responses to questions.
The oversight board also systematically dismissed 22 death investigations in 2017 — 16 jail deaths and six deaths during the process of arrest — due to a backlog that pushed the cases past a one-year deadline, auditors said.
“The county charter — as well as its own rules and regulations — establishes CLERB’s power to issue subpoenas, ister oaths, and require the attendance of witnesses and the production of books and papers pertinent to its investigations,” auditors said.
The audit noted that more recently the review board has taken steps to strengthen its oversight of the Sheriff’s Department.
The review board, which is conducting its own investigation into local jail deaths, said in its audit response that it agreed with all six recommendations and had already begun implementing those it could implement directly.
“In the last quarter of 2021, the current CLERB executive officer, the Deputy Sheriff’s Association 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,” the board replied.
Paul Parker, the review board’s executive officer, is already seeking approval from the County Board of Supervisors to increase the ’s oversight authority to include jail medical staff.
The audit also was critical of the Board of State and Community Corrections, a group of state and local law enforcement officials and others that sets the state rules for operating jails and prisons.
Auditors said the state board should adopt stricter standards when it comes to developing rules for managing county jails.
“A lack of specificity in statewide standards has resulted in inconsistencies among counties’ policies,” the review found.
For example, mental-health screenings are not required during the inmate booking process in jails across the state. Also, regularly scheduled safety checks do not always call for deputies to make sure the detainee is alive and breathing, the audit said.
“The Sheriff’s Department’s inadequate policies are in part the result of weaknesses in statewide corrections standards,” the audit said.
The state corrections standards board, where Gore served as the county sheriffs’ representative for years, resisted most of the recommendations put forward in the audit.
“The ‘inconsistencies’ noted in the report are deliberate decisions based on the differences in positions,” the response said in part. What’s more, “we question the premise that more hours of annual training, regardless of the topic or need, will always yield better results.”
The review recommended that new legislation require the Board of State and Community Corrections to demand that sheriff departments assess the mental health of inmates at the time they are booked into jail.
It was not immediately clear how state lawmakers would respond to the auditor’s call for new legislation upgrading statewide standards and requiring the Sheriff’s Department to implement additional recommendations.
Assemblywoman Dr. Akilah Weber, the La Mesa Democrat who requested the audit early last year, indicated on Thursday that she may introduce a bill to require the Sheriff’s Department to adopt the suggested reforms.
In a t statement with Sen. Toni Atkins, D-San Diego, Weber called the findings “deeply disturbing” and said the two lawmakers are committed to ability and ensuring the recommendations are implemented.
