Home All Articles News NewsAn interview with the sheriffs chief medical officer
July 16 2014 10:38 AM

Dr. Alfred Joshua talks about reducing deaths in San Diego County jails

Dr. Alfred Joshua has been on the job since last November.
Photo by Kelly Davis

On July 3, 36-year-old Hector Lleras hanged himself in San Diego Countys Central Jail, the fifth inmate to commit suicide this year. With his death, 2014 tied 2013s five inmate suicides—itself a high number for a jail system that, since 2007, has seen three suicides a year, on average. Last year, 12 inmates died in custody, a number thats nearly been matched by this years 11 deaths.

Last November, Dr. Alfred Joshua became the chief medical officer for the Sheriffs Departments Detentions Services Bureau, replacing Dr. Earl Goldstein, who retired in 2013 after more than a decade in the position. Joshua, who declined to give his age, attended medical school at State University of New York, Syracuse, and earned an MBA from UC Irvine. Prior to joining the Sheriffs Department, he was the senior medical officer in charge of healthcare reform at Tri-City Hospital and served as medical director for Volunteers of America. Hes board certified in emergency medicine and, to maintain his skills, picks up four to six shifts a month at a local emergency room (he declined to say which one).

Joshua came in not only amid an increasing number of in-custody deaths, but also facing the challenges of AB 109, the state law aimed at reducing prison over crowding by sentencing certain offenders to county jails instead of state custody. Prior to AB 109, the average stay for a San Diego County jail inmate was two months, the maximum stay one year; now, some inmates are serving sentences of three to four years or longer.

Last week, Joshua sat down with CityBeat to talk about policy changes hes made and strategies hed like to implement to not only reduce the number of inmate deaths, but also improve inmate welfare overall. Shortly after being hired, Joshua undertook a review of all clinical policies, clinical programs, disease management, hospitalizations and mortality data, he said. His review of inmate deaths had him pulling files going as far back as January 2004. He wouldnt say whether the number of suicides—or number of deaths overall—indicate a problem, only that each case gets a thorough review with procedural changes in mind.

Every death is taken very, very seriously, he said. We have a very stringent process of reviewing how these events occurred and what we can do to prevent anything going into the future.

Since March 2013, CityBeats run a series of stories on deaths in San Diego County jails. A 2012 report by the Bureau of Justice Statistics (BJS)—the research and analysis arm of the U.S. Department of Justice—revealed that the county had the second-highest inmate death rate among Californias large jail systems. Using the same formula as the BJS, which allows for comparisons with other populations (the annual number of deaths divided by a jail systems average daily population and expressed as per 100,000 inmates), CityBeat found that between 2007 and 2012, the countys inmate death rate had only increased.

There are two ways to measure a jail systems inmate-death rate: using the average daily population or using total annual bookings. This chart shows how San Diego County fares among Californias seven largest counties using both formulas for the year 2013. Counties for which there is only one bar had no suicides.
Graphic by Lindsey Voltoline


In our initial story, the Sheriffs Department took issue with our use of the BJS formula, arguing that we should have used annual bookings and not the average daily population because, theoretically, each person who enters the jail is at risk of dying. Using this metric, San Diego County fares much better, because, for various reasons, the jails here book a disproportionately high number of inmates—annual bookings are close to 90,000. By comparison, Los Angeles County booked roughly 137,000 inmates last year but had an average daily population (ADP) three times the size of San Diegos. Orange Countys 2013 ADP was 6,690, compared with San Diegos 5,556, but O.C. booked 61,801 inmates, compared with San Diegos 89,577.

The more people who are booked and released, we wrote, the better the [mortality] rate looks.

And, as Lindsey Hayes, an expert on jail suicides, has noted, jail systems tend not to complain about the BJS formula until their mortality rate comes under scrutiny.

Joshua took issue with CityBeats use of the BJS methodology for the same reason as the department did last year: Its not just whos in jail on any given day, but whom the jails are going to see that year that needs to be considered. And, its a group of people who, largely, havent taken care of themselves.

So, youre looking at that many people that are cycling through our system every given year with a whole myriad of past medical problems, past psychiatric problems and then all the other issues, he said.

This week, the county Medical Examiners office released its annual report, showing that suicides are up countywide. Since 1988, only twice has the suicide rate been higher. Joshua said this could explain the uptick in suicides in county jails. Jails are a microcosm of society, he said, and folks who suffer from the things that might lead to suicide—mental illness, addiction—are more likely to end up in jail.

San Diego, though, isnt the only county to see a recent increase in general-population suicides. There were no suicides in Orange County jails in 2013 and only one each in 2011 and 2012, despite that county seeing an increase in its overall suicide rate. Trends are similar in Riverside County, which also had no suicides in its jails last year.

Joshua emphasized that his focus is bigger than what happens to folks while theyre in custody. Incarceration is associated with an overall reduced life expectancy, and inmates, research has found, are at a higher risk of death—from suicide, drug overdose and chronic health conditions— shortly after theyre discharged.

Im, like, lets take a much more long-term view on these individuals, Joshua said. Lets look at a lot more integrative potential into the community. Lets try to make them as successful on the front end as the back end.

One area that Joshuas overhauled is when and how inmates are prescribed medication. Last November, 100,000 narcotic pills were dispensed in San Diego County jails. In June, that number was 42,000.

And that was with aggressive physician education; that was with a policy that basically said that theyre counseling the inmates, asking about substance-abuse history, all that stuff. That was about making sure that if [inmates] were caught trying to sell it to somebody else, those behaviors were stopped immediately.

Of the 72 inmate deaths CityBeat looked at between 2007 and 2013, 10 were the result of either intentional or accidental drug overdose. In many of those cases, prescription drugs were involved, either alone or in combination with illegal drugs. One example is Christopher Blenderman, a 40- year-old with a history of psychiatric issues who was found dead on Sept. 7, 2012, from a lethal combination of meth, heroin, antidepressants and anti-anxiety medication, some of which had been prescribed to him while some hadnt. His cellmate told a deputy that Blenderman had been hoarding medication. And in its September 2009 review of the death of James Phillips, the countys Citizens Law Enforcement Review Board, which investigates suspicious in-custody deaths, found that other inmates had helped Philips hoard the antidepressant Doxepin.

The jail has a zero-tolerance policy when it comes to hoarding and selling medications, Joshua said, and will discontinue a medication, or find another method of delivery—liquid form or crushed pills—if an inmates caught.

Its not that theyre completely going cold-turkey, he assured.

The revamped drug policy also takes into account what happens when inmates leave jail, especially those with mental illness who receive psychotropic medications in custody—more than one-third of the jail population—but then discontinue taking them after discharge.

Most of these individuals, when theyre off their medications, theyre likely to get into trouble, Joshua said. And then we see them, we stabilize them, they go right back out.

Making sure inmates get hooked up with community clinics so theres continuity in care is something Joshuas working on with the countys Probation Department.

For inmates, it should be simple regimens; they should have the least amount of side effects... and then cost is another thing, he said You put them on very expensive medications in here—great, we stabilize them and they cant afford them when they get out.

Joshua said that suicide-prevention policies are also being examined. Currently, when an inmate expresses the intent to commit suicide, hes put into a safety cell. The restricted environment and constant monitoring means that inmates often wont admit suicidal thoughts to jail staff, or will claim to be doing better when theyre really not. Since 2008, at least two inmates killed themselves shortly after being removed from suicide watch, CityBeat found Joshua said the Sheriffs Department is looking at whether there can be an intermediate step in that process—like a step-down unit, he said, between an inmate being placed in a normal cell and a safety cell.

In 2008, CLERBs investigation of the suicide of 21-year-old Adrian Correa—a schizophrenic whod threatened suicide in the past—identified significant gaps in how information regarding at-risk inmates was being communicated between guards and support staff. The board advised the Sheriffs Department to include briefings during shift changes and implement a checklist system so deputies could better keep track of suicidal inmates.

It took the Sheriffs Department nearly two years to respond to CLERBs recommendation. When it did, Goldstein, Joshuas predecessor, dismissed CLERBs findings and downplayed the problem of suicides, saying that during a two-year period—July 1, 2007, through June 30, 2009—only four inmates had killed themselves (his count was off by two).

It is not practical to add these systems to the current program, Goldstein wrote.

Joshua declined to comment on policies under Goldstein, but said that better communication among staff—not only deputies, but anyone who comes in contact with an inmate—is one of the suicide-prevention strategies hes focusing on.

One of the triggers for further evaluation by mental-health providers would be when an inmate deviates from what they normally do, he said. So, housekeeping, those who pass out meals, would be trained to recognize those behaviors.

Staff would also be trained to look for triggers— an inmate who seems troubled after a phone call, family visit or a bad day in court.

Joshua also wouldnt discuss specific cases with CityBeat but emphasized that the Sheriffs Department is examining all aspects of suicide prevention, down to the sheets that inmates fashion into nooses—hanging is the leading method of jail suicide. But I think the most important thing from a medical standpoint is: How do we get them away from the moment that they feel hopeless? he said.

In his review of inmate deaths, Joshua found that for every completed suicide, there were 11 attempted suicides.

So, in 11 cases, our deputies are successful, our medical staff are successful in stopping these individuals and identifying these individuals—and these 11 attempts dont go into how many people weve pre-identified and taken out of that whole equation, he said.

We always know we can get better. In every situation and every month Ive been here, thats what weve been driving towards.

Write to kellyd@sdcitybeat.com and editor@sdcitybeat.com.


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