SAN BERNARDINO, Calif. — California’s decision to require Riverside County to separate its sheriff and coroner functions raises questions about why neighboring San Bernardino County retains the same combined structure despite recording nearly as many in-custody deaths and operating its jail system under a federal consent decree addressing constitutional violations and deficiencies in mental health care, use of force and disability protections.
Federal litigation involving San Bernardino County’s jails resulted in a court-enforced remedial plan in 2018, followed by a revised agreement in 2023 after the county achieved compliance in some areas but had not yet reached full compliance in others.
The litigation, Turner v. County of San Bernardino, began in 2016 as a class-action civil rights lawsuit challenging conditions inside San Bernardino County jails.
The case resulted in a federal consent decree approved in December 2018 requiring the county to undertake reforms involving medical care, mental health care, dental care, use of force, restrictive housing and disability issues.
But federal oversight did not end when the original decree’s four-year term expired.
In September 2023, U.S. District Judge Virginia A. Phillips of the Central District of California approved a revised consent decree after the parties agreed that San Bernardino County had achieved compliance in some areas but had not yet reached full compliance in others.
“The Revised Consent Decree is significantly reduced in scope given Defendant’s achievement of compliance in several areas of the original Consent Decree and its agreement to create and maintain certain related policies,” the court’s order states.
However, the order also states that the revised decree was necessary to address areas “where compliance has not yet been fully achieved under the original Remedial Plan.”
The continuing requirements were designed to ensure constitutional medical and mental health care, prevent discrimination against incarcerated people with disabilities and address uses of force inside San Bernardino County jails.
The county made a significant admission as part of the revised decree, although the agreement expressly limits that admission to the litigation.
“Defendant admits for the purpose of this lawsuit only that there exists probable cause to believe that violations of the federal rights of Plaintiffs have occurred sufficient to warrant the relief contained herein,” the 2023 federal court order states.
The court retained authority to enforce the agreement.
The revised decree also continued the use of court experts to monitor San Bernardino County’s compliance in two areas: mental health care and use of force.
The court authorized Brian Main, M.D., to advise it regarding compliance with the mental health provisions and former Ada County, Idaho, Sheriff Gary Raney to monitor the use-of-force provisions.
The experts were authorized to advise the court regarding whether the county was complying with the revised remedial plan, assist in resolving disputes and provide testimony if required.
Under the revised agreement, plaintiffs’ counsel was responsible for monitoring compliance with medical care and disability provisions, while dental care and restrictive housing were excluded from the revised remedial plan.
The scope of the case is broad.
The plaintiff class includes “all people who are now, or in the future will be, incarcerated in the San Bernardino County jails,” according to the federal court’s order.
A subclass covers people incarcerated in the county jails who have psychiatric or intellectual disabilities protected by the Americans with Disabilities Act and Section 504 of the Rehabilitation Act.
The federal intervention is particularly notable in light of the number of people who have died in custody in San Bernardino County.
An investigation published by CalMatters in 2024 found that 442 people died in custody in Riverside and San Bernardino counties between 2011 and 2022, based on an analysis by Care First California.
Of those deaths, 216 occurred in San Bernardino County and 226 occurred in Riverside County.
The two counties therefore accounted for approximately 19% of California’s in-custody deaths during the period despite representing roughly 12% of the state’s population.
The comparison has taken on new significance following California’s decision to require Riverside County to dismantle its combined sheriff-coroner system.
Under SB 1379, authored by state Sen. Sabrina Cervantes, Riverside County is required to separate the sheriff and coroner functions and establish an independent medical examiner.
The legislation followed years of controversy surrounding deaths in Riverside County custody and questions about the inherent conflict created when the same law enforcement agency responsible for a person’s custody also oversees the investigation into that person’s death.
But the historical death figures for neighboring San Bernardino County are strikingly similar.
According to the legislative analysis of SB 1379, there were, as indicated, 226 reported in-custody deaths in Riverside County between 2011 and 2022, compared with 216 in San Bernardino County.
San Bernardino County also operated its jail system under federal judicial supervision stemming from a civil rights class action.
The original 2018 consent decree was intended to bring jail conditions into compliance with constitutional and federal statutory requirements.
Under the remedial plan, San Bernardino County agreed to implement policies and practices addressing medical and mental health care, use of force, restrictive housing and disability protections.
The litigation did not simply disappear after the settlement.
In February 2020, the federal court issued an order concerning mental health staffing and required San Bernardino County to hire an additional 20 mental health clinicians, according to the case history maintained by the Civil Rights Litigation Clearinghouse.
As the original consent decree approached its scheduled expiration in December 2022, the parties negotiated extensions while determining which portions of federal oversight remained necessary.
Those negotiations ultimately produced the revised 2023 agreement.
The revised decree narrowed the scope of federal intervention because the county had achieved compliance in several areas, but maintained judicial oversight where the parties agreed full compliance had not been reached.
The federal court found that the continuing remedies were limited to what was necessary to protect the constitutional and statutory rights of people incarcerated in the county.
Phillips found that the relief was “narrowly drawn, extends no further than necessary to ensure the protection of the federal constitutional and statutory rights of Plaintiffs, and is the least intrusive means necessary to accomplish those objectives.”
The history complicates comparisons between Riverside and San Bernardino counties.
Riverside County has faced extensive scrutiny over its in-custody deaths, ultimately prompting state lawmakers to require structural separation between the sheriff and the office responsible for determining how people died.
San Bernardino County, however, recorded nearly as many in-custody deaths during the same 12-year period while operating a jail system that became subject to a federal consent decree.
The Turner litigation did not address whether San Bernardino County’s combined sheriff-coroner structure compromised death investigations. Its focus was on jail conditions and the constitutional and statutory rights of incarcerated people.
Nevertheless, the litigation provides additional evidence of longstanding accountability concerns involving the county’s jail system.
At the same time, California has enacted a broader reform addressing the conflict inherent in sheriff-coroner systems.
Under the state’s Forensic Accountability, Custodial Transparency, and Safety Act, known as the FACTS Act, beginning Jan. 1, 2027, counties with combined sheriff-coroner offices must have covered in-custody death investigations conducted by an independent coroner, medical examiner or qualified outside provider rather than allowing the same sheriff-coroner agency to determine the circumstances, manner and cause of death.
That statewide reform means San Bernardino County’s death-investigation procedures will change even without the structural separation imposed on Riverside.
But it does not eliminate the larger policy distinction.
California lawmakers have determined that the problems in Riverside County warrant completely separating the sheriff from the death-investigation function, while San Bernardino County retains its combined sheriff-coroner structure despite a comparable historical number of in-custody deaths and a documented history of federal court intervention involving its jail system.
The federal record in Turner provides important context for evaluating that distinction.
The litigation establishes that San Bernardino’s jail system required a court-enforced remedial plan beginning in 2018 and that, five years later, the parties agreed continued federal oversight remained necessary in areas where full compliance had not yet been achieved.
The 2023 order documents the need for continued intervention at that time, although the county’s current compliance status would require examination of subsequent federal court records.
Whether those circumstances warrant the same structural response California has imposed on Riverside is a separate policy question.
But the federal court record demonstrates that concerns over accountability and conditions in Inland Empire jails have not been confined to Riverside County.
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