Inadequate Observation and Monitoring Are Killing Our Community Members
By Malik and Gale Washington
This is a follow-up to an article published last week entitled, “In-Custody Deaths Still Lacking Transparency and Accountability at Sant Rita Jail and Beyond.” After our piece went to press in the Davis Vanguard, we were contacted by the nonprofit prisoner and human rights organization, Decarcerate Sacramento. In-custody deaths which occur inside Sacramento County Jail and the lackluster transparency/accountability surrounding those deaths has become a special focus of our independent nonprofit news organization. My colleague and partner, Gale Washington, was able to interview members of Decarcerate Sacramento and now we present a factual account of what Gale learned from the organization’s members.
Decarcerate Sacramento is deeply passionate about the “horror that is happening in our county’s jail. At a recent County mental health board meeting, the Adult Mental Heath Team told the Board about their fabulous mental health services they are providing to individuals experiencing incarceration, making it sound like everything’s fine; that people aren’t dying in there or being subjected to horrific conditions.”
They further stated, “We have not noticed any improvement or increase in the Sheriff’s Department sharing information about in-custody deaths. In fact, we observe a deficit in the detailed information being shared. Most often, we hear that the Sheriff’s Department will not comment on cases where there’s a current investigation. These cases stay under investigation for an extended amount of time. They have ‘performative’ dashboards on the Sheriff’s website where they say they’re increasing transparency, but at best ‘performative’; there’s no detailed information; everything says ‘cannot be determined’ or ‘pending investigation’ or ‘not applicable.’ They’re certainly withholding information and there’s also conflicting information. In the past five months, there’ve been five deaths. One inmate’s cause of death was just reported by the coroner last week as ‘Methadone toxicity.’ This individual somehow got way too much Methadone either on purpose or accident. How are you going to overdose on Methadone unless someone wants that to happen to you?”
In a heavily redacted letter to Sarah A. Britton, Deputy County Counsel for the County of Sacramento on August 14, 2024, Madie LaMarre, MN, FNP-BC Angela Goehring, RN, MSA, CCHP; and Susi Vassallo, M.D. stated in their letter, in part, that:
“Adult Correctional Health (ACH) leadership and the Mays court-appointed medical experts have conducted comprehensive reviews of four of the five deaths and met to discuss identified problems. Review of these deaths showed serious system and individual performance issues, including inadequate emergency response, inadequate medical care prior to death, and in one case, callous deliberate indifference to a man who was so obviously gravely ill that even a lay person would see that the patient needed emergent care. We also found that the ACH mortality review process did not recognize and/or omitted critical information that contributed to patient deaths, with resulting inadequate corrective action plans.
“Summary of the Medical Care, Emergency Response, and Mortality Reviews:
The medical experts find that medical care and emergency response was inadequate in three of four recent deaths. Importantly, several ACH mortality reviews failed to identify and address critical issues that, if not corrected, will likely result in future deaths. The ACH mortality review process needs to be more rigorous, and acknowledge the seriousness of critical lapses. In addition, the corrective action plans need to include not only dates that actions are due and completed, but plans to reevaluate the effectiveness of these actions. This might include results of scheduled and unscheduled emergency drills, audits of system issues and/or peer review.
“In summary, we believe that the County must take immediate action to ensure that emergency response is timely and appropriate. As noted above, the quality and effectiveness of ACH mortality reviews is inadequate, and needs to be improved to correct serious problems and prevent future deaths.”
Link to redacted letter: https://www.disabilityrightsca.org/system/files/file-attachments/24.08.14%20Letter%20to%20Sacramento%20County%20Regarding%20Mortalities%20in%202024_Redacted.pdf
In an additional letter to the Sacramento County Sheriff’s Office from the Prison Law Office, class counsel in the Mays v. Sacramento County case, their letter stated in part:
“In the past three months, five people have died in the custody of the Sacramento Sheriff’s Office (SSO). As class counsel in the Mays v. Sacramento lawsuit, we are gravely concerned about these deaths. For years, we have raised concerns about the custody culture of the Sacramento Sheriff’s Office. Having reviewed the surveillance and body-worn camera footage of several recent deaths, we write to again express our deep concern about the SSO’s failure to respond with humanity and decency to people in need.
“This callousness on the part of the Sacramento Sheriff’s Office is consistent with our reporting over the years. We and the court-appointed experts have reported for years about these profound cultural problems. It is commonplace in the jails for custody staff to ignore people in crisis who press the emergency buttons in their cells begging for help. The medical experts recently reported about a man whose face was swollen to the point that his right eye was completely closed requesting assistance from a deputy. The deputy told him that he did not have an emergency and to stop bothering staff.
“Last month, we wrote to the SSO about a person with acute mental illness who had been housed on the most restrictive floor of the jail. When we visited the jail, numerous people told us that this person had been screaming at all hours of the day and night, refusing meals, and urinating on the floor of his cell. People told us that deputies’ response to his decompensation was simply to place a towel down outside of his cell so that his urine did not leak out of his cell.
“The recent deaths in the jails are a symptom of a larger and long-standing cultural problem with the Sacramento Sheriff’s Office. The Sheriff must take accountability for the apathy and callousness that pervades the jail and exercise leadership to make immediate changes. Sacramento County should demand decency for the people it incarcerates.” [Emphasis added.]
Link to heavily redacted letter: https://www.disabilityrightsca.org/system/files/file-attachments/24.08.19%20Mays%20Counsel%20to%20Sheriff%20Cooper%20re%20Recent%20Jail%20Deaths_Redacted.pdf
When I asked if Sheriff Cooper was also the Coroner, I was told that the Coroner is “under the purview of the Sheriff.”
I asked this question because of the 58 counties in California, in 48 of them the sheriff of that county is also the coroner (See link below). We believe because the sheriff of these counties is also the coroner, there is an insurmountable conflict of interest in the sheriff holding both of these positions. It makes common sense that if there was deliberate indifference, excessive use of force, lack of monitoring/observation, or other form of inaction by the deputy or other law enforcement staff member at a jail, for the obvious reasons those interactions and cause of death will absolutely not be stated in the coroner’s report because of the liability potential posed against the sheriff’s office. Why is this allowed? To whom is the duty of protection owed by the sheriff? I believe we all know the answer to this: THE INCARCERATED INDIVIDUAL!
Link: https://www.counties.org/county-office/sheriff-coroner
While housed at the Santa Rita Jail in Dublin, California, I spoke with attorney Kara Janssen of Rosen, Bien, Galvan & Grunfield, LLP about the “culture” inside the jail. Attorney Janssen said that it takes at least 10 years to change an abusive culture among deputies at any jail. There is much work to be done in Sacramento County.
As a journalist, I spend much of my time studying case law that illustrates the responses of local, state, and government officials when human beings are detained in their prisons or jails that are abused, neglected, or die. You rarely ever see a law enforcement or a county entity like Sacramento County Sheriff’s Office admit a wrong. On the contrary, these law enforcement agencies use taxpayer dollars in order to defraud family members of deceased prisoners from receiving anything that remotely resembles a just outcome, including monetary compensation. The “game” is to skirt liability by any means necessary and sometimes, sadly, even federal judges join in on the act.
INADEQUATE MONITORING OR OBSERVATION
In April 2023, Delion Johnson was booked into the main jail in Sacramento County.
Link to court pleadings/information: https://www.courtlistener.com/docket/67559879/estate-of-delion-johnson-v-county-of-sacramento/
Multiple jail staff were involved and responsible for the processing and alleged search of Mr. Johnson. On information and belief after being “thoroughly” booked and searched, Mr. Johnson was placed in a holding tank with other detainees. On a surveillance video in the jail, Mr. Johnson can be seen passing out what appears to be an illicit substance from a small bag. After ingesting some of the illicit substance himself, Mr. Johnson had a medical emergency and he died. Although the Sacramento County Jail deputies were supposed to be monitoring the surveillance cameras in the holding cell, the jail employees failed to do the following:
- Jail staff failed to respond to the emergency in a timely manner;
- Jail staff failed to administer Narcan;
- Jail staff failed to administer CPR; and
- Jail staff failed to timely observe Mr. Johnson having a medical emergency in the first place.
Mr. Johnson’s mother, Michelle Cooper (no relation to Sheriff Cooper) retained, in my opinion, one of the best civil rights attorneys in the State of California, Mr. Mark E. Merin.
Attorney Merin delved deep into his research into the customs, policies, and practices of Sacramento County Jail employees and here is what he found:“To support their allegations of inadequate supervision, monitoring and observation of inmates and untimely safety and cell checks, Plaintiffs have similarly identified prior incidents of other inmate deaths and injuries while in Defendant’s custody. Many of the incidents overlap with the incident above. Plaintiffs have identified 15 incidents within the past 10 years where they say a lack of monitoring and observation of inmates have resulted in delays in care and ultimately death from overdose, withdrawal, and assault by other inmates. Twelve of the alleged incidents occurred between April 2019 and February 2022. They all occurred within four to five years prior to Mr. Johnson’s death. Although the specifics are distinguishable, they all support the allegation that the same conduct contributed to the incident: inadequate supervision, monitoring, and observation within the jail.” [Emphasis added.]
Our independent nonprofit news organization would like to send out a message to anyone who knows the wife of Asaiah Germone Washington. Her name is Tonette. We strongly believe that Tonette should be familiarized with the Johnson case and, possibly, if she hasn’t already, have her contact attorney be Mark Merin. Tonette asked the question when interviewed by ABC10 News: How do you overdose in Sacramento County Jail? Where did it come from? Well, this article answers some of her questions and it can probably be used to bolster her claims of wrongful death so that she can receive some type of justice for the death of her husband.
It is important to emphasize that these incarcerated individuals are human beings dying inside Sacramento County Jail. They don’t relinquish their status as “human” at the door of the jail. Nevertheless, our society has allowed us to be relegated to the classification of “subhuman.”
As a last Editor’s note – Gale Washington: As an individual who has been in several jails and prisons as a visitor, I can speak on what I’ve observed. The first prison I was a visitor at was High Desert State Prison in Indian Springs, Nevada. While waiting to be allowed entrance into the prison, I observed many correctional officers beginning their shifts. What caught my attention was the lack of staff search protocols. These COs were allowed to place their backpacks, lunch containers, and briefcases on the counter adjacent to the metal detector when they walked through. They then picked up their belongings and proceeded into the prison to begin their shift. There was NEVER any physical search of their belongings. I believed this to be a serious defect in prison management, potentially allowing contraband such as drugs, cell phones, and who knows what else to enter the prison unmonitored. I know that in some prisons during Covid, drugs and cell phones were coming in. Well, if there was no visiting, how were those contraband items entering the prisons? There is one way…drones. This has happened several times in some prisons across the country. The more practical way is through the deputies/correctional officers and other jail staff because their belongings are not searched….except for Colorado.
Because of the non-existence of the physical search of deputies/correctional officers’ belongings and the fact that some jails and prisons do not allow in-person visits, it’s pretty clear how this contraband is getting into the jails and prisons. San Diego County Sheriff Kelly Martinez just recently (July 2024) changed the policy for screening jail staff which was a much-needed improvement from her prior stance of rejecting recommendations by the County’s oversight committee to put this policy in place.
The point is this: the responsibility of not allowing contraband (of any kind) into these jails and prisons lies at the feet of the sheriffs and wardens of the various facilities…regardless of whether it is their staff or visitors OR if their staff fails to THOROUGHLY search arrestees/prisoners prior to their entrance into the facilities, they are the responsible party AND if a detainee/prisoner dies from ingesting Fentanyl or other illegal drugs, they’re liable….PLAIN AND SIMPLE. This is a fact they cannot explain away or point the finger somewhere else.
Past Sacramento County Jail Deaths:
Peter Yee (died by suicide – Sacramento police officers failed to advise jail staff Yee stated he wanted to die when arrested) – 1998, Vincent Yee, Plaintiff, v. Sacramento County Main Jail, et al., Defendants. Yee v. Sacramento Cnty. Main Jail, 2:14-cv-02955-KJM-DB, (E.D. Cal. Mar. 3, 2023)
Irma McLaughlin (died at a hospital after allegedly falling from top bunk bed in cell; daughter believes she was beaten – 2018)
Current Sacramento County Jail Deaths:
Smiley Martin: “On June 8, Smiley Martin, 29, was found unresponsive in his cell; he was determined to be dead. The coroner has not yet released the cause or manner of death. Martin was being held on murder charges in connection to the mass shooting that killed six people and wounded 12 in downtown Sacramento in 2022.”
https://www.kcra.com/article/sacramento-cause-of-death-smiley-martin-k-street-shooting/62059281
Lope Elwin Tolosa: “On May 5, Lope Elwin Tolosa, 45, died in the detoxification cell three days after arriving at the jail on burglary charges. It’s not the first time someone has died in the detox cell in recent months.”
David Barefield: “David Barefield, 55, died May 12 while he was in the booking area — another part of the jail with documented issues. Barefield was booked at the jail sometime after midnight on May 12 on two misdemeanor warrants, the Sheriff’s Office said in a news release. About one hour after he had been medically cleared for booking, at 4:30 a.m., while deputies were trying to fingerprint him, he became unresponsive. Deputies and jail medical staff attempted CPR and administering Narcan, which is used to reverse opioid overdoses. Despite those efforts, he was pronounced dead at the scene. Mark Merin – attorney filed a claim against the county for Barefield’s death.”
Here are some comments from a post on Reddit, “Three people have died in Sacramento jail since early May. Is the county responsible?”
Destination Freedom extends their condolences to the families and friends of community members who have died inside Sacramento County Jail. We are just beginning our investigation and research. To the grieving families we send out this video and song by Zecardi Cortez entitled, “You Don’t Know.” We won’t stop covering these issues until the deaths stop.
Malik Washington is a freelance journalist and Director at Destination: Freedom and Destination Freedom Media Group. For approximately 12 years, Malik has been a published journalist and news reporter focusing on criminal justice issues, conditions of confinement in jails and prisons, as well as hot-button political issues.
