April 23 2014 10:10 AM

We update our reporting on deaths behind bars

The note from Dennisforweb
Elaine Lane received this note in the mail from her son Dennis the day before he died.

When Dennis Lane drove his truck into a concrete pillar at Grossmont Hospital last December, he told police he'd blacked out. His mother, Elaine, believes her mentally ill son, who'd been taken to a psychiatric hospital in October by friends and again in November by police, was trying to get help. Regardless, he was put in jail for destruction of property and died there exactly one month after his arrest.

Lane is one of five people who've died in San Diego County jails so far this year, following 12 deaths in 2013. To put those two numbers into perspective, between 2007 and 2012, the county jail system averaged 10 deaths a year, resulting in San Diego having a jail mortality rate far surpassing the national average and the highest inmate mortality rate of California's 10 largest counties, as we reported in our 2013 series, "60 Dead Inmates."

Lane's was the second death of 2014, coming 10 days after a suicide in San Diego's Central Jail. According to the medical examiner's report, Lane died from an "acute gastrointestinal hemorrhage." A chronic alcoholic earlier in life, the 62-year-old had been sober for three decades, his mom said. Alcohol abuse and hepatitis C had done damage to his liver, the autopsy found, but not to the point of it being end-stage disease.

Elaine Lane says her son Dennis needed to be in a psychiatric facility, not jail, where he died on Jan. 28.
Photo by Kelly Davis

The dinner table at Elaine Lane's mobile home in Santee is strewn with paperwork about Dennis—most of it handwritten notes detailing her son's recent mental decline.

"Dennis taken to Grossmont Hospital," she wrote on Oct. 5. "Psychiatrist interviewed, told [Dennis' friend] Chris she saw all she needed to know. Transferred to API"—Alvarado Parkway Institute, a psychiatric hospital in La Mesa, where he stayed for eight days.

Elaine said that every five years, Dennis seemed to spiral out of control. In the last dozen years, he'd twice—in 2002 and 2007—been committed to Patton State Hospital, an inpatient psychiatric facility, after being found incompetent to stand trial. The 2007 case, stemming from Dennis threatening a friend and the friend's wife with toy guns, resulted in a stint at Atascadero State Hospital.

On Dec. 13, two weeks before Dennis drove his truck into Grossmont Hospital, his mother sent a letter to the judge who'd overseen his 2007 case.

"You, your honor, are my last hope," she wrote. "He needs to be in a locked mental hospital."

On Jan. 9, a judge ordered that Dennis be evaluated by a psychiatrist to determine whether he was fit for trial. That exam was scheduled for Feb. 4. Elaine visited her son at the Central Jail a few days before he died.

"He was screaming, clawing, begging me to get him out of there," she said.

On Jan. 27, she received a letter from Dennis with a sketch he'd drawn of himself and this written under it: "25 day no meds. They are killing me. Please call API. Help!!!" 

According to his autopsy report, Dennis had Trazodone in his system, a drug used to treat depression and anxiety. Elaine said this wasn't one of the medications her son had been taking prior to his arrest.

According to the medical examiner's report, Lane was having seizures two days before he died and visited a jail doctor less than 24 hours before his death. The report doesn't state the purpose of the visit; it says only that on the way to the appointment, Lane "became uncooperative and was trying to sit on the floor." When he made a threatening move toward deputies, the report says, he was placed in a headlock and handcuffed.

Marc Stern, an expert in correctional healthcare and former Health Services Director for the Washington State Department of Corrections, reviewed Lane's autopsy for CityBeat. Stern said that the altercation with police wouldn't have caused the gastrointestinal bleeding that killed him. But, Stern noted that the autopsy doesn't identify the source of the bleeding—only that Lane's intestines were filled with blood.

"There are questions that still need to be answered," Stern said. "What was the nature of the [medical] visit, and what was the source of the bleeding?" 

The autopsy says that the sheriff's deputy who interviewed Lane's cellmate told a medical-examiner investigator that the cellmate described Lane as being "in intensive pain" from 4 to 5 a.m. that morning. The report says Lane and his cellmate were seen in their cell at 8:53 a.m. during a routine check. The report doesn't say what they were doing at that point—whether they were in their bunks or elsewhere in the cell. During another routine check at 9:51 a.m., Lane, who'd been assigned to the top bunk, was found on the cell floor, dead. Lividity—skin discoloration that happens after a person dies—had set in, the report notes, meaning he'd been dead at least 15 to 20 minutes.

Here, information from the cellmate would seem critical: Did Lane fall from his upper bunk? Did the cellmate call for help? Was the cellmate even there? The report doesn't say.

CityBeat sent questions to the Medical Examiner's office. In an email, Mike Workman, a county spokesperson, said the Medical Examiner's office stands by both Lane's autopsy report and a second report CityBeat asked about.

"They reflect the typical thorough autopsy examinations by our office's doctors and the on-scene investigations needed to help the office's doctors make cause and manner of death determinations," Workman wrote.

That other autopsy report is on Dervin Bowman. The 50-year-old was found hanging in his cell on Nov. 17, 2013, but still alive. He was taken to UCSD Medical Center, where, on Nov. 23, his family made the decision to remove him from life support.

The medical examiner's report notes that Bowman had been placed in a cell equipped for people with disabilities, though he wasn't disabled. The cell included a moveable chair. The report suggests that this allowed Bowman, who was nearly 6 feet tall, to affix a bed sheet to an overhead fire sprinkler and hang himself. "Several apparent suicide notes" were found in his cell, the report says.

Jason Shanley, who talked to CityBeat on behalf of Bowman's family, who lives in Milwaukee, first met Bowman in 2005. Shanley said his friend had a difficult life—he'd grown up in a foster home and later struggled with addiction—and had tried many times to pull his life together. But complicating matters was a 1985 charge for sexual assault—Bowman, then 22 and in prison for burglary, had taken part in the rape of an inmate who'd molested a child. That crime haunted him for the rest of his life. He was repeatedly arrested for failure to register as a sex offender; he was frequently homeless.

Though it's not clear from his court file when he was required to start wearing a GPS device, he was arrested in 2011 for removing it, as well as for failing to register.

"Mr. Bowman does not want to live life in and out of prison," his public defender wrote to a judge, hoping to get her client probation instead of jail time.

Bowman's last arrest was for a parole violation. He'd told his mom that he was going to stop attending his parole-mandated classes, Shanley said. The last time the two talked, Bowman described a psychological evaluation he was forced to undergo to determine if he was sexually attracted to children.

"He said, ‘I can't take it. This is crazy. Who do these people think I am?'" Shanley recalled. "He told his mom the night before he went back to jail, ‘I can't go back to this program. I can't do it.'" 

Sheriff's Commander John Ingrassia said Bowman had been in and out of jail several times in the past year for parole violations.

"Guys who are coming in a lot, I think they just say enough's enough. It's hard for the staff to recognize."

He said deputies who knew Bowman took his death pretty hard.

"They had been interacting with him a lot recently, and they didn't see that one coming."

If Bowman was intent on killing himself, Ingrassia questioned whether having access to the moveable chair that allowed him to reach the fire sprinkler made a difference—the majority of inmates who commit suicide tie a sheet or item of clothing to a bed post or door handle and lean forward, strangling themselves. Regardless, Ingrassia said he's been looking into having retractable fire sprinklers installed in the Central Jail, similar to what's been installed at the new Las Colinas women's jail in Santee.

Of the more than six-dozen autopsy reports CityBeat has reviewed, Bowman's is one of only three, and the only suicide, that doesn't include any information in the section that describes an inmate's medical and social history. In the case of a suicide, that information, which is based on jail records and interviews with family members, would usually include whether the person had expressed suicidal ideations to family or jail staff, had ever tried to commit suicide or had been prescribed psychotropic medication. For Bowman, the medical examiner's report says only, "The decedent's medical history was undetermined."

Neither was Bowman's case turned over to the Citizens Law Enforcement Review Board (CLERB)—an independent oversight body charged with investigating deaths in custody that aren't ruled natural by the Medical Examiner's office, or natural deaths for which there are extenuating circumstances—until CityBeat asked about it two weeks ago.

"Unfortunately, through an oversight on our part, CLERB was not notified," Sheriff's spokesperson Jan Caldwell said in an email. "This was not an intentional oversight. New parameters have been put into place to ensure this doesn't happen again."

As CityBeat reported last year, there were a number of deaths in 2009 and 2010 about which CLERB wasn't notified, prompting the board to send the Sheriff's Department a letter, demanding that a notification process be codified in the department's policies and procedures manual. The sheriff denied the request but assured that no more cases would slip through the cracks.

Bowman's was the fifth suicide in county jails in 2013. While experts caution that it's important to look at jail-death data over a number of years and not focus on deaths within any one year, those five deaths coupled with the fact that two people have committed suicide so far this year show an alarming trend. According to data we collected for our jail-deaths series, Orange County, which has a slightly larger jail population than San Diego County, averaged 1.3 suicides per year between 2007 and 2012. For that same six-year period, San Diego County's average was double that, or 2.6 suicides annually. To put that into perspective, Los Angeles County, with a jail population nearly four times the size of San Diego's, averaged only four suicides per year between 2007 and 2012.

Kristopher Nesmith
Photo via Facebook

On March 1 of this year, Kristopher Nesmith hanged himself in the Vista Detention Center. Three months earlier, the 21-year-old former Marine had stabbed a man and attacked another. He was being held for attempted murder.

The Medical Examiner's office told CityBeat that Nesmith's autopsy report isn't yet complete.

Dan Leib, an attorney hired by Nesmith's family to investigate his death, said jail staff knew he was suicidal.

"The question is, did they provide the appropriate level of safeguards and care?" Leib said. "If you're going to deprive somebody of their liberty and take them into custody, you're agreeing to certain obligations to keep them safe."

This isn't the first time the Vista Detention Center has been accused of not taking a suicidal inmate seriously. In January, the family of Robert Lubsen filed a lawsuit alleging that jail medical staff failed to note that the 26-year-old, who was struggling with drug addiction, had ligature marks around his neck when he was booked, the result of a suicide attempt in a holding cell at California State University, San Marcos, where he'd been arrested for trying to steal a computer. The lawsuit says that jail staff "received a tip" that Lubsen "was a risk to himself" but failed to act on it, despite a policy that says "all reports of suicidal behavior are to be taken seriously." Lubsen, who was initially placed in a lower-level cell when he was booked, was moved to a second-floor cell. The next morning, when cell doors opened to allow inmates access to a common area, Lubsen climbed onto a walkway railing, leaned over and fell, headfirst, to the concrete floor below.

Email kellyd@sdcitybeat.com or follow her on Twitter at @citybeatkelly.


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