When Robert Lubsen was booked into the Vista Detention Facility on the afternoon of Feb. 6, 2013, he was first placed in a lower-level cell but later moved to a cell on the jail's second floor. The next morning, after cell doors opened to allow inmates access to a common area, Lubsen climbed onto a walkway railing, leaned over and fell, headfirst, 9 feet to the concrete floor below. He was taken to Palomar Medical Center, where, on Feb. 12, his family decided to take him off life support.
Lubsen, who was 26, was the first inmate to die in San Diego County jails in 2013 and one of four suicides so far this year.
At booking, jail staff documented what looked like ligature marks on Lubsen's neck and, on the morning of his death, his cellmate reportedly tried to warn staff that the young man planned to harm himself but was deemed not credible. While the medical examiner's report says that Lubsen, during the intake process, didn't express an intent to kill himself—inmates are asked to answer "yes" or "no" to "Are you feeling suicidal?"—the jail system's own written policy says that after intake, "[a]ll reports of suicidal behavior shall be considered serious."
Lubsen's family filed a claim with the county on July 26, the first step in a lawsuit. The claim alleges that the Sheriff 's Department knew Lubsen was at risk of harming himself but did nothing about it.
His father, Paul, says his son had struggled with drug addiction for seven years. In 2012, it looked like he'd pulled his life together—he had a girlfriend, a job with a shoring and drilling company and his own apartment. But toward the end of the year, when work dried up, he fell back into addiction. He was arrested for burglary on Feb. 6.
"I always believed that when Rob was using, that the best thing for him was to be in jail and that he'd be safe there," his dad says. "I was wrong. I don't believe the Sheriff's Department took any steps to protect him."
In March, CityBeat reported that from 2007 to 2012, San Diego County had the highest average mortality rate among California's 10 largest county jail systems and the second-highest suicide rate—in all, 60 people died during that period. This followed a Bureau of Justice Statistics finding that from 2000 through 2007, San Diego had the second highest death rate of California's large jail systems.
As of Oct. 14, 10 people have died in jail custody this year, matching the 10-deaths-per-year average that pushed the county to the top of the list for 2007 through 2012. Of the six years CityBeat examined, the highest annual number of suicides was five, in 2011, and the six-year average was just under three per year.
"You don't have to average two or three suicides a year in your jail system," says Lindsay Hayes, a national expert on in-custody suicide prevention.
In addition to the four suicides this year, there were two drug-overdose deaths and two natural deaths, one of which was Alba Cornelio, who in February was found guilty of manslaughter after her two pit bulls attacked and killed her neighbor. Cornelio, who was battling leukemia, collapsed after the verdict and was taken to the hospital, where she died a month later. Though she wasn't incarcerated at the time of her death, because she was in Sheriff's custody—shackled to her bed—both the state Attorney General's office and the federal Department of Justice, which track jail deaths, consider Cornelio to have died in custody.
The remaining two deaths are still being investigated by the Medical Examiner's office. One of those is David Inge, whose daughter, Nichole Johnson, says a homicide detective told her that her father had complained about feeling ill when he was booked into the Vista Detention Facility on Aug. 9.
"But I guess they hear that a lot, because they didn't take it too seriously," she says.
Late on Aug. 9, Inge was found unresponsive in his cell. Johnson hopes her father's autopsy report will offer more information.
Of the 20 suicides in San Diego County jails since 2007, only two have been women, both of them diagnosed with mental illness. Qiongxian Wang Wu fashioned a noose out of a pair of socks and hanged herself on Feb. 27, 2011, and 64-year-old Anna Wade used a bed sheet to hang herself from her bunk on April 28 of this year. Both were at Las Colinas Women's Correctional Facility.
Wade, who was schizophrenic, had been in custody for more than two years after being charged with stalking for sending threatening letters to a former attorney and a police officer who'd arrested her. The letters, which are included in Wade's court file, are largely nonsensical. Written in English, Spanish, Arabic and gibberish, they're filled with anti-Semitic language and references to the Old Testament and the occult. But they were enough to prompt her former attorney to move his family into a hotel.
In May 2012, after being declared incompetent to stand trial, Wade was sent to Patton State Hospital for three months. According to her court file, she'd done at least three stints there since 2004. Back at Las Colinas, she was put in administrative segregation and "green-banded," meaning she wore a fluorescent-green wristband to indicate she was prone to aggressive behavior.
Cmdr. John Ingrassia, jail supervisor for the Sheriff's Department, says Wade was being seen "at least twice a month" by a psychiatrist; her next scheduled evaluation would have been April 30.
Kristin Scogin, the deputy public defender who represented Wade after she was released from Patton, said that, by April, when jury selection began for her trial, Wade "seemed fine." Bailiffs who remembered Wade from previous cases would stop Scogin and tell her they thought Wade was doing really well.
But, on Friday, April 26, after returning from the second day of jury selection, Wade refused to shower or leave her cell for recreation time, according to the medical examiner's report. She remained in her cell on Saturday, too.
Sheriff's Department policy requires deputies to conduct security checks "on an hourly or more frequent basis"; they're supposed to "look in each cell, and observe each inmate for any obvious signs of medical distress, trauma, or criminal activity."
The medical examiner's report notes that at 12:16 p.m. on Sunday, April 28, Wade was observed in her cell during a routine security check. She wasn't checked on again for almost two hours, when she was found hanging from her bunk.
The report notes that Wade had no history of suicide attempts or threats and was given Zyprexa, an anti-psychotic medication, nightly. But the report also suggests that since returning from court on Friday, Wade had quickly gone downhill. In addition to refusing shower and rec time, she'd made a mess of her cell. Her things were scattered all over, she'd drawn a swastika on the wall and, according to the report, "chronic urination was noted to her top bunk bed and the floor."
An investigation by the Citizens Law Enforcement Review Board, the oversight body that reviews jail deaths and officer-related misconduct, found that the deputy whose job it was to notify other deputies to perform a floor check had failed to do so, but there was "insufficient information to determine if a mandated security check that was not performed, could have precluded this suicide in any way."