When the Santa Barbara County Civil Grand Jury investigated four deaths of people in jail custody, it found that each person’s mental health or substance abuse issues were ignored or not communicated across different agencies, contributing to their deaths.
The 2022-23 Grand Jury released its year of reports last week that included several investigations into in-custody deaths.
In those cases, the Grand Jury recommended that the county provide on-site, 24/7 mental health services in the two county jails and mental health training for law enforcement and jail health providers.
The Sheriff’s Office and county should ensure that people in custody with suicidal ideations and severe mental health issues receive immediate professional mental health care after being exposed to traumatizing events, the Grand Jury recommended in its reports.
In many cases, staff with the medical contractor for the jails, Wellpath, did not communicate their findings with custody officials, and the Grand Jury says the county counsel should prepare a legal opinion on whether Wellpath employees are allowed to share an inmate’s mental health information with sheriff’s custody staff.
The new Northern Branch Jail has a specific wing for medical and mental health beds with a nurse’s station.
After investigating two in-custody deaths related to drug overdoses, the Grand Jury recommended that the Sheriff’s Office prepare monthly reports on the number of people in custody with substance abuse and mental health issues. It also recommended that the county work with other agencies to analyze why Santa Barbara County has so many people declared incompetent to stand trial because of mental illness.
New state legislation limited the time incompetent-to-stand trial (IST) defendants can be kept in custody on misdemeanor charges, and imposed a “growth cap” for felony IST defendants with fines levied against counties who exceed it, according to county budget director Paul Clementi. The county expects to pay $6 million in penalties this year for its population of felony IST defendants in custody.
All of the 2022-23 Grand Jury reports can be read online here.
The Board of Supervisors and other entities named in each report will issue responses to the findings and recommendations within a few months.
Deaths in Custody Investigations
In January 2022, Jonathan Paul Thomas died in a jail safety cell within an hour of being booked, and after being forced into an on-stomach restrained position for several minutes, according to a Grand Jury investigation report.
Arresting officers, Wellpath staff and custody deputies knew he was suffering from a mental health crisis, “yet, at no time did any of these professionals attempt to provide effective crisis intervention that could have avoided the custody officers’ use of force that night,” the Grand Jury wrote in its report summary.
“Compounding the problem was that the County of Santa Barbara does not provide on-site, 24/7 mental health services in the jails, although witnesses told the jury it was badly needed. After nine months of working on this report, the jury wholeheartedly concurs.”
When arresting Thomas, the officers were informed of his physical health issues and suicidal ideations, but they did not tell emergency room staff about his mental health crisis. Thomas stated that he suffered from severe mental health issues but no diagnosis was on his medical records, so doctors only examined his physical health, according to the report.
Thomas’ arresting officers thought his mental health issues would be evaluated at the jail, but they were unaware that the county doesn’t contract for mental health services from 11 p.m. to 7 a.m.
The report states that if the hospital had known about Thomas’ suicidal ideations, they would have done a mental health evaluation before he left the hospital.
The intake nurse evaluating Thomas said he threatened to resist being placed in an isolation cell. Someone with advanced mental health training would have asked him why, but no one did, the Grand Jury found.
Instead, the custody staff got a five-person team to force Thomas into a single-person safety cell.
He refused to help officers take off his clothing and they pushed him onto his stomach into a restraint hold, according to the investigation.
For several minutes, one deputy had a knee on Thomas’ lower back and another had a knee on his shoulder near his neck.
“JT said he could not breathe and he made grunting and snorting sounds. For a period of four minutes after he was uncuffed and stripped, three officers continued to hold JT down in the on-stomach prone restraint position. JT continued to struggle and resist. The Jury learned that the officers continued holding him for four minutes in the prone restraint position, in part, to tire him out,” the report says.
Thomas was on his stomach, face down and motionless, for several minutes after deputies left the cell, according to video footage viewed by the Grand Jury.
When he didn’t move, some deputies thought he was “playing possum” and yelled and made noises to try to get a reaction, the report stated.
After six minutes, deputies went into the cell and found Thomas had no pulse.
After attempts at CPR, he was pronounced dead at 2:03 a.m., which was about a half-hour after deputies brought him to the safety cell.
The Sheriff’s-Coroner’s autopsy found that his death was “indirectly caused by the custody staff’s on stomach restraint hold and Thomas’ resistance to it.”
His death was “deemed accidental and blamed on multiple factors, including his morbid obesity, enlarged heart, methamphetamine intoxication and resistance to deputies’ efforts to restrain him,” Noozhawk North County Editor Janene Scully reported last year.
The Grand Jury recommended that Thomas’ case be submitted to the state Attorney General’s Office for re-investigation as to whether the restraints used were a direct or indirect cause of Thomas’ death by cardiac arrest.
In July 2021, Kean Ardie San Juan Pinon was found dead by suicide in his cell. It happened a day after Pinon witnessed his cellmate attempt suicide, according to a Grand Jury report. Pinon was a 35-year-old Santa Maria resident.
Pinon’s conditions and suicidal ideations were recorded in his files, but Wellpath, the jail’s medical care provider, did not share his mental health history with the sheriff’s office custody staff because they thought they were barred by law from doing so, according to the report.
After his cellmate’s suicide attempt, Pinon was rehomed in the same cell by himself. All custody staff and independent mental health professionals told the Grand Jury that if they had known about Pinon’s mental health issues, they would not have had him remain in the same cell, especially not by himself without constant observation.
The investigation also found that Pinon stated that he was going to commit suicide the morning of his death on a recorded phone call. Custody staff also failed to do their routine walk-by observations of the cell every 45 to 50 minutes at the time of Pinon’s death.
The Grand Jury concluded that Pinon should not have been left alone after his cellmate’s suicide attempt and should have been thoroughly debriefed by a mental health professional.
Overdoses in Northern Branch Jail
Edgar Estrada Amezcua and Kristina Marie Chermak died in custody of the Northern Branch Jail last year from fentanyl overdoses, according to a Grand Jury report.
Amezcua was a 37-year-old Santa Maria resident.
Chermak was a 35-year-old Santa Barbara resident.
According to the report, both Amezcua and Chermak had time in jail custody during the past decade. They were both diagnosed with drug addiction and were identified as severely mentally ill, according to the Grand Jury.
In May 2022, Chermak was found incompetent to stand trial. She was committed to treatment at the Department State Hospital (DHS) within 28 days and was ordered to receive medications involuntarily.
According to the report, DHS had no room for Chermak, and the only mental health programs she was allowed at the jail were coloring books. She was not allowed access to other jail programs and primarily stayed in isolation after custody staff said she violated jail rules, according to the report.
In June 2022, Chermak was disciplined for lack of respect, discourtesy, rudeness and causing disruption, and her visitation privileges were suspended through August and then September. She was housed alone.
Chermak was found unresponsive in her cell and pronounced dead on Sept. 9.
Amezcua was arrested in May 2022 and was in and out of restrictive housing because of his suicidal ideations, according to the Grand Jury report. Amezcua requested to be put back into the general population, and that was granted in mid-September.
On Oct. 10, 2022, Amezcua was found dead in his cell from a fentanyl overdose.
Federal authorities have charged two men with allegedly distributing fentanyl that led to his death and serious injury to another man.
“The Santa Barbara County community faces a monumental task of providing effective
treatment options for the mentally ill in place of the arrest-jail-court-arrest cycle. For
those with mental health challenges, including those diagnosed with severe mental
illness, Santa Barbara County faces an enormous challenge to divert individuals into
comprehensive community treatment and services. It is incumbent upon stakeholders to
allocate resources to keep the non-violent mentally ill out of jail,” the Grand Jury wrote.
A New Pathway
In 2022, California passed the Community Assistance, Recovery and Empowerment (CARE) Act.
Instead of the cycle of arrest, release and rearrest, the CARE Act provides a new pathway to allow mental health and substance use services to individuals on the schizophrenia spectrum of psychotic disorders who meet specific criteria, according to a Grand Jury report.
The goal of CARE is to connect individuals with effective treatment and support and create a road map to long-term recovery.
The report specifies that Santa Barbara County will be required to implement the CARE Act by the end of 2024. Individuals in Santa Barbara will develop a “CARE plan” with their legal council and with Santa Barbara County Behavioral Wellness. Plans will include medications, housing plans and behavioral health treatments.
The Santa Barbara County Superior Court will encourage service agencies to participate together and to resolve any conflicts between agencies and participants.
