The Santa Barbara County Civil Grand Jury investigated four recent deaths of Main Jail inmates and found that Sheriff’s Department custody personnel did not follow procedures in three of the cases.

Those cases included two suicides and a man with potentially life-threatening medical issues who, according to department policy, should never have been booked.  

Click here to read the full investigative report.

“The Sheriff’s Department needs to upgrade training and review policies with staff and Wellpath to avoid serious errors,” the jurors concluded, referencing the company contracted for in-jail medical and mental-health services. “The sheriff needs to insist on more adequate psychiatric responses from Wellpath.”

The Sheriff’s Department is required to officially respond to the report’s findings and recommendations within 90 days. Spokeswoman Raquel Zick said the department will respond as required and has no comment.

Joseph Frederick Rose, 47, was booked April 10, 2018, and was in custody at the Main Jail for 14 months while his second-degree burglary case was continued 25 times, according to the Grand Jury report.

Rose, identified as C1 in the report, had a “decades-long history of prior arrests, detention, and mental-health issues with suicidal ideations.”

A jail mental health psychiatrist from Wellpath diagnosed him with schizophrenia and prescribed medications in August 2018, and there was no follow-up when Rose stopped taking the medications, according to the report.

He was assaulted and injured in jail in January 2019, and on June 25, 2019, he was taken to a temporary cell after arguments with other inmates, the report said.

Rose reportedly requested his own cell, and told a mental health clinician that he would kill himself if he did not get a cell alone.

The mental health professional determined that Rose was not a danger to himself, according to the report, about 45 minutes before his suicide. That person did not tell a supervisor or custody staff about the suicidal statement.

Soon after, Rose was seen on video taking off his T-shirt and “experimenting by tying it at varying heights on the bars of his cell.”

A custody deputy walked by the cell while the shirt was tied to the bars, and Rose was standing in the cell, but apparently did not notice.

Rose hanged himself and was discovered by a custody deputy 12 minutes later, according to the report.

No pulse or vital signs were detected, and jail staff performed CPR. An automated external defibrillator (AED) “indicated no shock was needed, as a pulse was detected.”

An American Medical Response ambulance transported Rose to Santa Barbara Cottage Hospital, where he was removed from life support five days later.

“C1’s threats of suicide were inadequately addressed despite the fact he had previously been seriously assaulted at the jail. All threats of suicide must be taken seriously,” the report said.

Inmates threatening suicide should be housed in a safety cell and monitored more frequently, jail staff need to be alert to items hanging from bars and take action, and psychiatric services need to be provided to mentally ill inmates, the Grand Jury concluded.

Rose’s mental illness was not re-evaluated for 10 months before his suicide.

In the death of Isaiah Joey Johnson, the Grand Jury “concluded that many of the pertinent health rules, regulations and policies were not followed by the Sheriff’s Department and its medical provider, Wellpath.”

Lompoc police arrested Johnson, 23, on Oct. 19, 2019, on outstanding warrants and a probation violation, according to the Sheriff’s Department.  

When he was booked, he reported suffering from mood disorders, anxiety and post-traumatic stress disorder, and denied any drug or alcohol use, according to the Grand Jury report.

A review of prior booking records “would have revealed a history of drug use and suicidal ideations,” the report concluded. “D1 was not referred to a psychiatrist at intake, was not started on treatment at first mention of withdrawal, was not scheduled for assessment when medications were refused, and was housed in a cell that was not intended for mental health or medical observation.”

A few days later, after being referred to mental health services for “bizarre behavior,” he was placed in a cell with a corded wall phone.

On Oct. 31, 2019, he committed suicide by wrapping the cord around his neck, according to the Grand Jury investigation.

A custody deputy and registered nurse from the medical unit found no pulse and placed the pads of an AED on his chest, but never used it, since it did not give the order to administer a shock, according to the report.

Fire department staff arrived at the scene a few minutes later and took over CPR, but Johnson died of his injuries.

The Grand Jury investigation found that custody staff did not review Johnson’s prior bookings and assessments during his intake.

The report on the July 2018 jail suicide of Alexander Braid had the same finding, and found the sheriff’s custody staff at fault for Braid’s death.

Deaths of ‘Natural Causes’

Two deaths of Main Jail inmates were found to be natural causes, according to the Coroner’s Bureau, but the Grand Jury concluded jail staff violated their own policy by admitting one inmate with a life-threatening medical condition.

“In addition, errors occurred in the response and treatment of the inmate during his seizure,” the report found.

Eduardo Rodriguez, 62, used a wheelchair and had “a long history of serious illness.”

He had been admitted to the Santa Barbara Cottage Hospital intensive care unit for heart-related issues two times in the week before his arrest and booking into the Main Jail, according to the Grand Jury report. Two days after being booked, on April 12, 2019, he complained of chest pain and was given an EKG and blood test, which revealed high blood sugar levels, the report said.

When the on-call registered nurse could not reach the on-call physician for several hours, she gave Rodriguez some nitroglycerine and sent him back to his housing unit.

Soon after, Rodriguez did not respond for a meal, and custody deputies had another inmate deliver the food. That inmate reported that Rodriguez did not look well.

Rodriguez was foaming at the mouth, according to the report, and the custody deputy called a “code blue” over the radio.  

The responding medical team did not bring an AED or emergency “man down bag” with equipment and medications, so the deputy grabbed them, according to the Grand Jury investigation. An ambulance team arrived and took over CPR, but Rodriguez died, the report said. 

Jail staff did not have Rodriguez transported to the emergency room when the on-call physician was unavailable for hours, or when his blood sugar levels tested high, and did not use the AED, the Grand Jury concluded.

At the time of his death, the Sheriff’s Department reported that Rodriguez had approached a custody deputy “telling him he was not feeling well,” and became unresponsive in the hallway when he was wheeled out of the housing unit.

On Jan. 10, 2019, Jose Curiel, 52, of Santa Maria, died of natural causes related to a medical condition, according to the Coroner’s Office. He had been in jail custody since February 2018 and was admitted to Santa Barbara Cottage Hospital in January 2019.

He and his family asked for him to be placed on comfort care on Jan. 7, 2019, when his condition got worse, and he died three days later, according to the Grand Jury investigation.

“There is no evidence of mistreatment or negligence by any member of either the custody staff or the Cottage Hospital staff. A1 had been seriously ill for some time, and he frequently refused treatment or diagnostic tests. The jury found no indication that custody hastened his death,” the report said.

Editor’s note: Noozhawk does not typically report on a suicide unless it takes place in public or involves a public figure, and coverage often omits details, including the method, due to responsible reporting guidelines. However, regarding the Grand Jury investigation into institutional failures, the details of Joseph Rose’s and Isaiah Johnson’s suicides in the Main Jail are important to understanding the conclusions and recommendations in the report.

Click here for suicide prevention information and resources that are available 24/7.

The National Suicide Prevention Line is available 24/7 at 800.273.8255, and the Santa Barbara County 24-hour, toll-free hotline is 800.400.1572.

Noozhawk managing editor Giana Magnoli can be reached at Follow Noozhawk on Twitter: @noozhawk, @NoozhawkNews and @NoozhawkBiz. Connect with Noozhawk on Facebook.