The Santa Barbara County Civil Grand Jury determined that three recent deaths of people in jail custody could have been avoided if there was better communication among health care providers, and if providers had a better understanding of inmates’ medical histories. 

The Grand Jury released reports last week on three in-custody deaths, including someone who died by suicide, someone who died after a head injury and someone who died after a ruptured ulcer. One of the deaths occurred in the Main Jail, and two were in the Northern Branch Jail.  

In the three cases, the Grand Jury found that health care providers didn’t follow proper procedure, didn’t have the inmates’ full medical histories, and that there was a lack of communication among health care staff.

Several previous Grand Jury reports have investigated in-custody deaths and found problems with communication and a need for 24/7 mental health staff.

‘Unaddressed’ Complaints of Pain

One woman, identified as CF in the Grand Jury report but previously identified as Caprice Fowler by the Sheriff’s Office, complained for days of abdominal pain before she died of peritonitis, an infection in the abdominal cavity, caused by a perforated gastric ulcer on March 24.

At the time, the Sheriff’s Office determined she had died of “natural causes.”

On March 23, four days after her arrest, Fowler, 57, a Lompoc resident, was found hyperventilating, moaning and screaming in her cell, and complaining of intense abdominal pain and arm pain. She said she thought she was having a heart attack, according to the report. 

On the evening of March 23, Fowler continued to complain about her pain. When she was evaluated by medical staff, they determined she was experiencing opioid withdrawal symptoms.

The report claims that nursing staff did not use the required pain assessment forms when Fowler complained about her pain.

On the morning of her death, Fowler asked to go to the emergency room, but medical staff did not act upon her request, the Grand Jury report states. That afternoon, Fowler was supposed to go to an exam room for another withdrawal symptom assessment, but when she couldn’t walk to the exam room, it was noted that she refused clinical services.

At 5 p.m. on March 24, deputies delivered food to Fowler’s cell that went untouched. At 5:35 p.m., she was discovered unresponsive in her cell, slumped over with blue lips. Medical staff were unable to revive her.

The Grand Jury found that there was no medical documentation about the severity of her pain, and even though she was repeatedly given Tylenol, there was no documentation that the Tylenol helped her pain. 

“CF’s persistent complaints of pain were repeatedly left unaddressed by medical staff because they attributed her pain to the diagnosis of narcotic withdrawal,” the Grand Jury report stated. “This perception led nursing staff to not appropriately assess her repeated pain complaints.” 

When the Sheriff’s Office announced Fowler’s death, spokeswoman Raquel Zick said it was a “tragic but unavoidable death.”

The Grand Jury report states that if there was appropriate evaluation of her pain, her death could have been avoided. The title of the report is “Preventable Death at the Northern Branch Jail.”

The Grand Jury recommended that the Sheriff’s Office require that qualified medical professionals assess and treat pain, instruct all medical staff at the county’s jails to use the evidence-based pain assessment forms, and for the Board of Supervisors to direct county Public Health to thoroughly assess the care provided by Wellpath, the jail health care provider. 

Investigating a Suicide at the Main Jail

The Grand Jury also questioned Wellpath’s care in another case when health care providers failed to provide necessary care for a woman who died of suicide in the county Main Jail. 

Cecilia Michelle Covarrubias, identified as CC in the Grand Jury report, hanged herself using a wall-mounted telephone cord in a mental health observation cell on Nov. 13, 2024, just four days after she arrived at the facility, according to the report. 

“Inmate’s death should have been prevented,” the report states.

In the days leading up to her death, Covarrubias made several suicidal statements to mental health providers and attempted to choke herself. 

The mental health staff at the jail were unaware that she had been previously diagnosed with severe mental illnesses, including bipolar disorder and psychoses, and they did not try to obtain her medical history from private doctors, according to the report. 

After Covarrubias’ arrest on Nov. 8, she was taken to Santa Ynez Valley Cottage Hospital for evaluation, and Emergency Department medical staff found her to be at a high risk of suicide. She reportedly told staff that she believed she was the devil and must kill herself to save and protect her children, according to the report. 

Once she was in jail, Covarrubias made several suicidal statements and was transferred to a safety cell for suicidal watch, where she attempted to choke herself. 

During her incarceration, Covarrubias went back and forth from making suicidal statements to telling mental health providers that she was not suicidal. As a result, she was moved twice from a safety cell for suicide watch to a holding cell that had a wall-mounted phone with a cord, the report said.

On the morning of Nov. 13, Covarrubias told a mental health provider that she didn’t want to kill herself and she was transferred out of a safety cell to a holding cell with a wall-mounted phone. 

That day, she was scheduled to be evaluated by a jail psychiatrist, but she denied the evaluation. The psychiatrist did not review her prior mental health history, didn’t know she had been in safety cells for suicidal ideations twice in three days, and didn’t know she had been diagnosed with bipolar disorder, according to the report. 

That evening, a custody deputy found Covarrubias hanging by the telephone cord, and she was later pronounced dead by paramedics.

The Grand Jury report concluded that the Sheriff’s Office’s inability to provide Covarrubias with a suitable holding cell ultimately led to her death. 

Since her death, jail staff have removed the telephone cords from the holding cells.

The Grand Jury recommended that future suicidal inmates should be transferred to another facility if there are no adequate holding cells. 

They also recommended that if an inmate refuses to participate in a psychiatric evaluation, the on-duty jail psychiatrist must be required to review the inmate’s mental health history. The Sheriff’s Office should require Wellpath staff to contact outside health care providers to obtain inmates’ medical records, the Grand Jury said.

Fatal Head Injury

In another case, the Grand Jury also found that if jail staff had an inmate’s full medical history and communicated their medical findings, they could have prevented the inmate’s death.

On Sept. 17, 2024, Antonio Alvarado Orozco, identified in the Grand Jury report as AAO, died at Marian Regional Medical Center in Santa Maria, succumbing to the complications of a head injury. 

On Aug. 29, the day Orozco was arrested and taken to the Northern Branch Jail, medical staff noted that he had a history of alcohol withdrawal, which was reported in his last incarceration. The intake medical staff also noted that he was anxious. However, there was no documented communication amoung staff about Orozco’s alcohol withdrawal history or anxiety, the Grand Jury report stated.

Within a minute of walking into his housing unit, Orozco became unresponsive and fell, hitting his head and seizing on the floor as blood flowed from his head. He died 19 days later from his injuries, and the cause of his seizure remains unknown, according to the report.

Because of the lack of communication about Orozco’s medical history, the Grand Jury recommended that the Sheriff’s Office require jail nurses to communicate health screening information to the relevant on-duty deputy. 

The jury found that because of an incomplete master problem list in Orozco’s electronic health record, Wellpath staff couldn’t make fully informed decisions regarding his health care needs. 

They recommended that county Public Health conduct systematic audits of inmates’ charts in the electronic health record to determine whether Wellpath’s master problem list is accurate.

The Sheriff’s Office will have 60 days to respond to the findings and recommendations, and share whether and why they will be implemented. The Santa Barbara County Board of Supervisors will have 90 days to respond to the recommendations.

On Tuesday, a swearing-in ceremony was held for the 2025-26 Civil Grand Jury.