In 5 years since investigation, little progress in stopping deaths in San Diego County jails – San Diego Union-Tribune
Summary of In Custody Deaths in San Diego Jails
1. High death rate:
- San Diego County jails have had the highest mortality rate among California's largest county jail systems in recent years.
- Between 2019 and 2023, San Diego County recorded an average of 3.6 deaths annually per 1,000 incarcerated people, the highest rate among the 8 most populated California counties.
- The mortality rate has increased compared to the 10-year period examined in 2019, when it was 2.4 deaths per 1,000 detainees.
2. Number of deaths:
- There were 18 deaths in 2021 and 19 deaths in 2022, setting new records even with reduced jail populations due to COVID-19.
- Over 70 deaths have occurred since a major investigation into jail deaths was published in 2019.
- As of September 2024, 6 people had died in sheriff's custody that year, with a 7th person dying shortly after release.
3. Causes and contributing factors:
- Many deaths were deemed preventable.
- Common issues cited include lapses in medical care, lack of accountability, drug overdoses, suicide, and neglect of inmates with mental illness or in medical distress.
- Specific cases mentioned improper cell checks, drugs entering facilities, and failure to provide timely medical treatment.
4. Lawsuits and costs:
- At least 19 of the 70+ deaths since 2019 prompted lawsuits.
- In the last 5 years, settlements and verdicts in lawsuits related to jail deaths and deputy misconduct have cost taxpayers over $75 million.
5. Attempts at reform:
- The sheriff's department has implemented some changes, like publicly announcing deaths, expressing condolences, and naming family liaison officers.
- A new ADA compliance unit was formed in July 2023 to address needs of incarcerated individuals with disabilities.
- However, families and activists argue that not enough meaningful change has occurred to prevent deaths.
6. Oversight issues:
- The Citizens' Law Enforcement Review Board (CLERB) has limited power to enforce recommendations.
- There have been calls for CLERB to have expanded jurisdiction, including over medical staff in jails.
Despite some reform efforts, in-custody deaths remain a significant and ongoing issue in San Diego County jails, with continued calls from families and activists for greater accountability and more effective measures to prevent deaths.
Causes of Death - What Needs to be Done
1. Drug overdoses:
- Multiple mentions are made of drug-related deaths, particularly involving fentanyl.
- There are concerns about drugs entering the facilities.
- The documents mention high overdose rates, particularly at the Central Jail.
2. Suicide:
- Several cases of suicide are mentioned, particularly involving inmates with mental health issues.
- The case of Matthew Settles, who died by suicide at the George Bailey Detention Facility in August 2022, is specifically discussed.
3. Medical neglect:
- Several cases involve allegations of inadequate or delayed medical care.
- For example, Keith Bach died when staff failed to refill his insulin pump despite his pleas for help.
- Lonnie Rupard's death was ruled a homicide due to pneumonia, malnutrition, and dehydration accompanied by "neglected schizophrenia" and "ineffective" care.
4. Mental health-related issues:
- Several deaths are linked to inadequate care for inmates with mental illnesses.
- The case of Roselee Bartolacci, a developmentally disabled woman who died after rapid health decline in jail, is mentioned.
5. Complications from substance withdrawal:
- Deaths related to inadequate care during drug or alcohol withdrawal are mentioned.
- The case of Vianna Granillo, who died potentially due to complications from opioid withdrawal, is cited.
6. Physical health issues exacerbated by poor care:
- Some deaths are attributed to existing health conditions that were not properly managed in custody.
- For instance, Lonnie Rupard's case involved multiple health issues including pneumonia and malnutrition.
While a comprehensive statistical breakdown of causes is not provided by the county, these appear to be the most frequently mentioned and emphasized causes of death in San Diego County jails. The overall theme is that many of these deaths are considered preventable with proper medical care, mental health support, and more effective policies and procedures in place.
In 5 years since investigation, little progress in stopping deaths in San Diego County jails – San Diego Union-Tribune
In July, after Chase Mitchell died in the custody of the San Diego County Sheriff’s Office, the department issued a news release announcing the seventh death in its jails this year.
That now-customary notice would not have happened five years ago, when The San Diego Union-Tribune published its findings from a six-month investigation into deaths in the local jail system.
Back in 2019, people tracking jail deaths had to submit California Public Records Act requests for copies of the one-page form that sheriff’s departments are required to file with the state Department of Justice within 10 days of every fatality.
The San Diego Union-Tribune routinely filed such requests for several years. Those records helped frame “Dying Behind Bars,” a three-day collection of stories, videos and originally sourced documents that revealed how repeated lapses in medical care, a broad lack of accountability and a host of other conditions had pushed San Diego County jails to become the deadliest lockups among California’s largest counties.
The series sparked public outrage and prompted legislation — including two bills that eventually were signed into law. It helped push the sheriff to pitch a $500 million upgrade and renovation plan and spurred civilian oversight and advocacy work that continues to this day.
But the investigation and the actions it helped prompt ultimately did little to drive down jail deaths, which hit a record with 18 in 2021 and another with 19 the following year, even after the COVID-19 pandemic had reduced the jail population by roughly 25 percent.
Many of the deaths were preventable, and some are disturbingly similar, raising questions about what lessons have been learned from past mistakes.
Of the 70-plus deaths that occurred after the publication of “Dying Behind Bars,” at least 19 prompted lawsuits, costing taxpayers many millions of dollars. In the last five years, settlements and jury verdicts in lawsuits brought by the families of people who died in jail — as well as claims brought by people injured by deputy negligence or misconduct — topped $75 million.
“It’s a pattern,” said attorney Danielle Pena, who has represented more than a dozen families in jail-related litigation over the past decade. “And that pattern is what it was five years ago, which is lack of transparency, lack of accountability.”
Data published by the state Department of Justice show that the San Diego County jail-mortality rate has climbed even higher in the past five years. The percentage of fatalities continues to exceed other county jail systems.
Between 2019 and 2023, San Diego County recorded an average of 3.6 deaths annually per 1,000 incarcerated people, state data show — the highest rate among the eight most populated California counties.
The second-highest region was Riverside County, with an average of 3.5 deaths annually for every 1,000 people in custody. Los Angeles came in at 2.9 and Sacramento was the safest among the largest county jail systems at 2.3 deaths annually per 1,000 people in custody.
State analysts rely on jail-mortality metrics to put counties with vastly differing populations on the same analytical level.
Over the 10-year period examined by the Union-Tribune in 2019, the San Diego County jail-mortality rate was 2.4 per 1,000 detainees — lower than the ratio between 2019 and 2023.
Sheriff Kelly Martinez was out of town last week and unavailable for an interview. Her staff said she remains committed to protecting people in custody and improving conditions inside her department’s jails.
San Diego County jails' mortality rate has risen since The San Diego Union-Tribune publishing a six-month investigation into in-custody deaths in 2019.
A bar chart showing the numbers of in-custody deaths and per-1,000 mortality rate for San Diego County jails between 2009 and 2023. Jail deaths peaked in 2022. The mortality rate has fallen since that year but remains higher than it was before 2020, due in part to smaller jail populations.
Data does not include deaths that occurred during the process of arrest. It also does not include people who were released from custody after being injured or falling ill in jail and subsequently died in a hospital.
California Department of Justice
Publicly announcing jail deaths is only one change the San Diego Sheriff’s Office made in the wake of the investigation.
The agency also now expresses regret and condolences for deaths in custody and names a “family liaison officer” to help guide surviving relatives through a difficult process.
Even so, some family members of people who died in San Diego County jails say officials have not always been helpful.
“From day one, getting information out of the sheriff’s department has been a problem,” A.C. Mills, whose son Kevin died in the San Diego Central Jail in 2020, told the Union-Tribune. “I was stonewalled from the time I began talking to them.”

Mills is part of a support group of sorts, composed of parents and siblings of people who have died in San Diego jails. In 2022, they began holding demonstrations outside of county lockups and attending court hearings tied to jail litigation.
Every month, they fill seats and raise their concerns at meetings of the county’s civilian oversight body, the Citizens’ Law Enforcement Review Board, or CLERB.
“We are always trying to keep our loved ones in the spotlight because [Sheriff] Kelly Martinez is still dragging her feet with safety reforms,” said Sundee Weddle, whose 22-year-old son Saxon Rodriguez died from a drug overdose in the San Diego Central Jail in 2021.
Martinez was named acting sheriff in January 2022 by then-Sheriff Bill Gore, a career FBI official before being appointed sheriff in 2009. He was elected three times but retired in the middle of his third term in 2022, on the same day the state auditor released an explosive report examining jail conditions on his watch.
The audit had been requested by a bipartisan group of local state legislators in the wake of the Union-Tribune investigation.
According to the final report, 185 people died in San Diego jails between 2006 and 2020 — a mortality rate that closely matched the 141 people the newspaper found had died in custody between 2009 to 2019.
Conditions inside the county’s seven jails were so substandard under Gore that new legislation was needed to force the department to improve, auditors said.
The analysis also singled out independent bodies like CLERB and the county Board of Supervisors, saying they were not doing enough to hold the sheriff accountable for protecting the people in his custody.

“Given the ongoing risk to the safety of incarcerated individuals, the Sheriff’s Department’s inadequate response to the 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.
Months after the audit was released, Assemblymember Akilah Weber, D-La Mesa, introduced a bill that would have strengthened mental health treatment in jails across California. It also would have added two licensed professionals to the Board of State and Community Corrections, the regulatory body for local detention facilities.
Gov. Gavin Newsom vetoed the legislation that year, saying he worried that a larger board would impede the body’s ability to do its work, and generating a fresh groundswell of dismay among the families and other activists pressing for reforms.
Weber reintroduced the bill last year.
Sen. Toni Atkins, the powerful San Diego Democrat who was then Senate president, authored a reform bill of her own that would have, among other things, given county boards of supervisors the authority to take over the administration of local jails. It also called for internal sheriff’s records on jail deaths to be released publicly.
Newsom signed both bills. But before he did, the plan to award supervisors the ability to take over jail operations was withdrawn amid opposition from law enforcement. It was replaced with a proposal to name a state director to oversee reviews of in-custody deaths.
State officials announced just last week that Allison Ganter, the Board of State and Community Corrections’ deputy director of the Facilities Standards and Operations Division, had been appointed to the position.
Meanwhile, the San Diego County Sheriff’s Office has resisted releasing full findings from jail-death investigations.
During her campaign for sheriff, Martinez had pledged that public release of full reports from the department’s Critical Incident Review Board, or CIRB, “will occur in the near future.”
She reversed course after taking office and continues to fight releasing the full findings from the board, an internal panel of department officials that investigates major events like jail deaths and deputy misconduct.
“I am troubled by Sheriff Martinez’s and the county’s ongoing efforts to keep CIRB documents from the public,” said Timothy Blood, a San Diego attorney representing the Union-Tribune in litigation seeking to force disclosure of the records.
“It shows a lack of true desire to reform San Diego’s jails and an ongoing willingness to waste taxpayers’ money to hide Sheriff’s Department misconduct,” Blood added.
A hearing was held before the 9th U.S. Circuit Court of Appeals last month, and a decision could be issued at any time.
* * *
Martinez, who was elected in November 2022 to a six-year term, insists she’s committed to reducing the number of deaths in her jails.

Early in 2023, one year after the scathing state audit was released, she issued a report outlining changes to the department since she took over.
“Accountability, transparency and the genuine commitment to doing better are the drivers to creating a new level of care to individuals in custody while supporting the needs of our Detentions team,” Martinez said in the 11-page report.
The sheriff also said she is working to improve health- and drug-screening practices during the booking process, and to enhance medical and mental health services.
She issued body-worn cameras for deputies assigned to jails and expanded medication-assisted treatment and access to naloxone to help reduce drug-related deaths.
The department completed initial renovations to the Rock Mountain Detention Facility just north of the George Bailey jail on Otay Mesa in July 2023. The project was already years late and at least $10 million over budget. Only a portion of the facility is being used; on Friday, just 170 men were housed there.
Martinez also unveiled a 10-year, nearly $500 million plan to renovate and upgrade the oldest county lockups, beginning with a massive redesign of the Vista Detention Facility in North County.
Officials also hired NaphCare, the Alabama correctional medical giant, to help streamline medical and mental health care and boost staffing.
A January 2023 news release said NaphCare was providing assistance in order to help the department secure accreditation from the National Commission on Correctional Health Care, considered the “gold standard” in jail medical care, “in late Fall 2023.”
The accreditation, which the department has been pursuing for years, has yet to happen.
Early this year, attorneys for plaintiffs in a class-action lawsuit challenging jail conditions uncovered documents showing that NaphCare was not abiding by its contract.
Among other deficiencies, the records showed, NaphCare was deploying unlicensed staff, ignoring requests to repair or replace medical equipment and failing to fill hundreds of shifts. The contractor also failed to implement a program to help detainees detox from drugs and alcohol.
The agency brought in a second medical contractor called Correctional Healthcare Partners, which now shares responsibility with NaphCare.
Stricter adherence to withdrawal protocols might have saved Vianna Granillo’s life.

When she was booked into the Las Colinas women’s jail on July 8, 2022, Granillo told a nurse during intake that she struggled with opioid addiction.
That should have triggered placement in the jail’s drug withdrawal protocol, which involves close monitoring and medications to ease vomiting and diarrhea.
Four days after her arrest, Granillo was found unresponsive and gasping for air. According to a lawsuit filed earlier this year by her family, an oxygen tank that was brought to her cell was broken, and deputies waited 12 minutes to administer CPR.
The medical examiner attributed her death to brain damage caused by a lack of oxygen and sepsis from a stomach perforation. Pena, the family’s attorney, said she believes the perforation was caused by persistent vomiting and diarrhea.
Records show Granillo should not have been in jail in the first place. She had been detained for violating a restraining order that had expired, and then deputies found a small amount of drugs.
Under the COVID-19 detention protocols in effect at the time, Granillo was supposed to have been issued a ticket for the small amount of drugs she had in her possession.
* * *
Most people in county jails have not been convicted of the crime for which they are being held. Often, they just can’t raise bail.
The government is legally obligated to provide for the health and welfare of anyone in custody. That means sheriffs, police chiefs and prison wardens are required to make sure people have food, clothing, clean water and basic medical care.

But men and women in San Diego County jails do not always receive basic medical care, according to court records, and the consequences can be extreme when inadequate care is delivered.
Earlier this month, the Medical Examiner’s Office released an autopsy report showing that Keith Bach died from neglect when sworn deputies and jail medical staff failed to refill his insulin pump, even though Bach had been pleading for help and the pump’s warning alarm had been beeping for hours.
Bach’s death was ruled a homicide.
Sheriff’s officials said they could not comment, because the September 2023 death was still under investigation.
Lonnie Rupard died in the same jail as Bach a year earlier.

The coroner also ruled his case a homicide, saying he died of pneumonia, malnutrition and dehydration accompanied by “neglected schizophrenia” and “ineffective” care.
Rupard, who had been placed in administrative segregation, had lost 60 pounds in the three months he had been jailed.
Martinez told the Union-Tribune that the department had made changes after Rupard’s death to better care for incarcerated people with mental illness.
But deaths of people unable to care for themselves have persisted.
Roselee Bartolacci was a developmentally disabled woman in the middle of a mental breakdown in April 2023 when she struck her mother with a hammer.
Her mother sought help from the county’s psychiatric emergency response team. But instead of placing Bartolacci in a mental-health facility and contacting the San Diego Regional Center as required by state law, sheriff’s deputies took her to jail.
Bartolacci, who functioned at the level of an 8-year-old, declined quickly. She refused food, water and medication and lost 44 pounds, according to a lawsuit filed in July. Bartolacci “had a high probability of imminent or life-threatening deterioration,” her medical records said.
Before she died, she had been housed in an isolation cell that had quickly filled with trash, urine and feces.
“They left Roselee in her cell crying and moaning and sucking her thumb, speaking in gibberish and sitting in her own urine,” said Julia Yoo, the San Diego attorney who brought the lawsuit.
Lawyers who represent relatives of people who have died in jail say the sheriff’s department has not learned from the mistakes of its staff — even after the November 2019 death of Elisa Serna led to a $15 million settlement with her family.

Serna, like Granillo, was suffering from severe withdrawal that went ignored by jail staff.
Prosecutors filed criminal charges against a doctor and nurse responsible for her care. One jury acquitted the nurse. The other could not reach a verdict.
Yoo, who also represented Serna’s family in their lawsuit, said local officials have repeatedly shown they do not care about the welfare of people in custody.
“The county’s primary objective over the past five years has been to throw all its resources at covering up the truth,” Yoo said. “The only time a meaningful policy change occurs is when the county gets sued.”
***
Paul Parker had already served as the CLERB executive officer when he was lured back by a remade Board of Supervisors and a pledge that he would be able to do more to hold the sheriff accountable.

He returned in 2020 and set about working to improve oversight and expand his office’s mission.
In case after case, Parker saw lapses in health care that led to preventable deaths, but dismissed them summarily because the jail medical staff is outside of CLERB’s jurisdiction. He lobbied supervisors for permission to oversee jail medical staff but was unable to secure that authority.
He requested permission to launch an auditing function to strengthen civilian oversight and pressured the sheriff to institute body-scanning for everyone entering county jails to prevent illegal drugs from being smuggled inside. It didn’t work.
By March, Parker had seen enough. He quit abruptly and said publicly that he was frustrated with the continuing deaths and lack of accountability he felt was broadly tolerated by the sheriff, elected supervisors, his review board and others.
“CLERB is advisory, and that’s the issue,” he told the Union-Tribune after resigning. “I feel like I’m banging my head against the wall, and the county doesn’t seem to want to do anything to have true oversight.”
For two years, after a spate of overdose deaths, Parker pushed for the department to screen all employees and contractors entering jails for drugs. The sheriff agreed in July to begin randomly scanning for drugs all people entering the jails, including sworn deputies, visitors and lawyers defending people in custody.
It remains unclear how many people will be screened. The checks do not include the body scanning CLERB recommended, and the program does not include all seven county jails.
Martinez has not released details of the program, citing security reasons.
Review board Chair Eileen Delaney stepped away a few months after Parker left. Vice-Chair MaryAnne Pintar took over as chair this summer, and the board last month named longtime FBI agent Brett Kalina the incoming executive officer.
Kalina said he is committed to vigorous oversight of the Sheriff’s Office and Probation Department, the agencies outlined in the board’s mission statement.

“My highest priority is support for our team as it conducts thorough and timely investigations which provide the CLERB board with fact-based reports so it can make informed decisions on misconduct, use of force, discrimination, or policy violations. CLERB is also highly focused on how to prevent injury and deaths in our jails,” he told the Union-Tribune last week.
Nora Vargas, chair of the Board of Supervisors, declined an interview request last week.
She did not respond to questions about whether the board is considering expanding CLERB’s jurisdiction or adopting other reforms proposed by Parker before he resigned.
She also did not respond to questions about the more than $75 million that jail deaths and other deputy negligence or misconduct have cost taxpayers in the past five years.
Vargas’ office issued a statement saying the supervisor has made jail deaths a priority and is working with the sheriff to implement recommendations from the 2022 state audit.
“I’m committed to ensuring that every person in our custody is treated with dignity, and I’m working closely with the Sheriff’s Department to make sure our jails have the proper protocols and staffing,” the statement said.
* * *
Six people have died in sheriff’s custody this year. A seventh person died in a hospital shortly after being released from custody.
If no one else dies in San Diego County jails this year, 2024 will be the least deadly year over the last decade, even when factoring in the smaller jail population.
Experts like Jay Aronson, founder and director of the Center for Human Rights Science at Carnegie Mellon University, said he hopes this proves to be a positive trend.
Fewer people in jail means fewer people at risk of dying in them, Aronson said — and fewer lawsuits that cost taxpayers millions of dollars.
“We know that contact with the criminal legal system is associated with increased mortality and morbidity, like coming into contact with police, spending time in jail, spending time in prison, reduces your overall health, your overall life expectancy and (increases) your likelihood of dying,” he said.
“If we can even further de-carcerate, we can reduce that number even more,” said Aronson, whose latest book, “Death in Custody: How America Ignores the Truth and What We Can Do About It,” was published last year.
He said it is important to talk about what happens to people who die after coming in contact with the criminal justice system.
“We care as a society so little for people who are incarcerated,” Aronson said. “The only way that we get anyone to care is by telling stories, and by making sure that the institutions know that people are paying attention to what’s going on.”
Martinez is aware that a growing number of people are looking to her for improvement.
This Wednesday, she is planning to address the Citizens’ Law Enforcement Review Board for the first time.
Originally Published:
Homicide, In-Custody Deaths, Officer Involved Shootings | San Diego County Sheriff
Homicides by Year
Chart showing the number of homicides from 2014-2024.
Homicides (2024)
Table with victim and suspect information relating to 2024 homicides.
Deputy Involved Shootings by Year
Chart showing the number of deputy involved shooting from 2014-2024.
Deputy Involved Shootings (2024)
Table with information relating to 2024 deputy involved shootings.
*Deputy race/ethnicity has been excluded due to laws governing employee personnel files
In-Custody Deaths by Year
Chart showing the number of in-custody deaths from 2014-2024.
In-Custody Deaths (2024)
Table with information relating to in-custody deaths.
*Data reflects in-custody deaths within detention facilities. Custody status is defined as the custody status of the subject immediately preceding death (process of arrest, in transit, awaiting booking, booked-no charges filed, booked-awaiting trial, sentenced, out to court, other)
Last Reviewed: 09/26/2024
Major Crimes Report Archives
Critical Incident Review Board (2022)
In-Custody Deaths
The Sheriff's Homicide Unit conducts a thorough investigation of every in-custody death. In addition to the investigation conducted by the Sheriff's Homicide Unit, the Sheriff's Critical Incident Review Board (CIRB) conducts a review of in-custody deaths. The CIRB is comprised of department leadership and the Sheriff's Legal Advisor and performs a critical review of each incident. The focus of the CIRB is to assess the department’s civil exposure because of a given incident. The review may identify potential misconduct, criminal negligence or behavior, policy violations, training deficiencies, or other areas where we can improve and make our facilities safer for staff and those in our custody.
These releases are synopses of reviewed incidents and any resultant actions or policy changes intended to improve our operations. In some instances, the information contained in these releases may be fragmentary or incomplete and are subject to update as information is verified or confirmed. The release of information related to a matter involving potential criminal prosecution or civil litigation may delay or limit the amount of information released until the conclusion of the case.
Grieving families call for accountability and action following dozens of in-custody deaths

This brief was written by Daniel Potter, a San Diego Documenters editor.
Grieving San Diego families are calling for action and accountability from the group tasked with investigating the in-custody deaths of their loved ones.
Nearly a dozen family members spoke at the Sept. 3 San Diego County Citizens Law Enforcement Review Board meeting. Many gave harrowing details about the deaths of their loved ones while incarcerated at various San Diego County detention centers, deaths which they say should have been prevented.
A lack of effort to prevent illegal drugs from entering detention facilities was one of the most common accusations leveled against the San Diego County Sheriff’s department. Other accusations include a lack of timely medical treatment, failure to follow procedure regarding cell checks, and an inability to get information about the status of loved ones who were being held.
Brenda Settles’ son Matthew Settles died by suicide at the George Bailey Detention Facility in August 2022. She says she knew her son, who suffered from severe mental illness, was in danger but that her calls for help went unanswered.
“I called and called and said, ‘My son is at risk. I know. I can tell,’ ” Settles said. “Can I talk to someone on his care team? Can I have any connection at all? And they said no.”
Speakers also included Yusef Miller of the North County Equity and Justice Coalition. Miller called the situation a “serious crisis” and says the problem is only going to get worse in light of policies that allow the arrest of homeless individuals. He urged the CLERB to be proactive in protecting the lives and dignity of those in custody.
Among those in attendance was the new executive officer of CLERB, Brett Kalina. He said he is a “huge advocate of transparency” and accountability and would meet with and address the communities concerns once he has had adequate time to get “caught up.”
This brief came from notes taken by Grace Adams, a San Diego Documenter, at a San Diego County Citizens Law Enforcement Review Board meeting this month. The Documenters program trains and pays community members to document what happens at public meetings. Read more about the program here.
Type of Content
Meeting Brief: An account of a public government proceeding, written and edited by the San Diego Documenters.
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