Santa Barbara County jails will expand their medical record system and how they share inmate diagnoses in response to civil grand jury reports examining multiple deaths in the county’s jail system.

The county Board of Supervisors voted to approve three response letters to the Santa Barbara County Grand Jury during its meeting this week in Santa Maria.

The Grand Jury reports involve three deaths, including a suicide, a death from a fatal head injury, and a death related to a ruptured ulcer. The reports were issued in June 2025.

The Grand Jury highlighted a lack of communication between healthcare providers and the sharing of medical diagnoses.

Rana Warren, deputy county executive officer, stated that the county has made efforts to address the issues raised by the Grand Jury by adding nearly 22 positions.

She added that the county improved medical oversight in the jails, medication treatment, expanded behavioral health units, and increased data sharing.  

“The county has consistently demonstrated its commitment to serving our criminal justice population, and is continually evolving to best meet the needs of that population,” Warren said.

The first report addressed by county staff involved Antonio Alvarado Orozco, identified in the Grand Jury report as AAO, who died at Marian Regional Medical Center in Santa Maria. Orozco suffered a head injury while in custody and died 19 days later.

The Grand Jury report stated that Orozco had a history of alcohol withdrawal from previous arrests, and he showed signs of anxiety shortly before his fall.

However, the jury report says there is no documentation that staff communicated this history to each other.

The Grand Jury recommended that the county instruct the county Health Department to conduct audits of inmate health records to see if they are accurate and reflect the medical history of inmates.

The jury also recommended that the county issue financial penalties to Wellpath, the county’s contracted medical provider, if the records are not accurate.

The jury also issued a recommendation that the county Sheriff’s Office create a system of automatic health alerts in its system.

The county agreed with all these recommendations and stated that they have been implemented or will be in the future.

The second report discussed a suicide at the Main Jail by hanging.

Cecilia Michelle Covarrubias, identified as CC in the Grand Jury report, died by hanging on Nov. 13, 2024. She used a wall-mounted telephone cord to hang herself four days after she arrived at the jail, according to the report.

The Grand Jury report stated that medical staff at the jail were unaware she had a history of diagnosed mental illnesses, including bipolar disorder and multiple psychoses.

Mental health staff also did not attempt to obtain her medical records from private doctors, according to the report.

The report also cited a lack of proper holding cells for Covarrubias.

County staff informed the board that since the death, the jail staff has removed all cables from the holding cells and increased Wellpath staffing by 34%.

The jails also have followed the report’s recommendation of setting up a system to transfer inmates with mental health needs to neighboring counties if there are no adequate holding cells.

Toni Navarro, director of the county’s Behavioral Wellness Department, said that the county has established the proper channels with other counties if additional crisis beds are needed.

Navarro said her department has established beds in Kern County, and is working on establishing a contract with Vista Del Mar Hospital in Ventura. She added that there are more beds available for inmates in Santa Barbara County.

“Since 2016, we’ve seen a near 400% increase in the number of crisis beds available to us in this county,” Navarro said.

The county also developed new procedures to obtain medical records for inmates, and will conduct training for staff on proper record sharing. The county also reviewed and revised its suicide step-down procedures for inmates.

The final report discussed Caprice Fowler, who died on March 24 after complaining of abdominal pain for days. Fowler later died of peritonitis, an infection of the abdominal cavity caused by a perforated gastric ulcer.

The Grand Jury report alleged that there was no proper documentation of the severity of Fowler’s pain. Even though she was given Tylenol, the report found that the documentation did not assess whether it worked.

As part of its recommendations, the Grand Jury suggested that the county review the quality of Wellpath’s medical care and identify opportunities for systemic improvements.

The county agreed with the suggestion, and stated that the county Health Department now performs audits of medical and mental healthcare services.