It's likely no one will ever know for sure what happened to Jerry Cochran the night before he died. On the evening of Sept. 15, 2014, his girlfriend, Vella Rhinehart, called an ambulance to take Cochran to the emergency room—she was concerned about some swollen spider bites on his neck. They were homeless, and Cochran had trouble walking without assistance.
The last time Rhinehart saw Cochran, he was in the back of the ambulance, his walker folded up next to him. He was wearing his medical-ID necklace that let folks know he was diabetic, she says. The EMT told her Cochran didn't need his wallet or medication; she told the EMT to tell the hospital to call her when Cochran was discharged—she'd find a way to come get him.
"Nobody ever called," she says. "I called and called and called, and walked and walked"—up and down Fourth and Fifth avenues the next day, the path Cochran might have taken on his way back to their camp. Wednesday night, after two days of searching, Rhinehart got a phone call from her sister telling her Cochran had been arrested and died in jail.
Since March 2013, CityBeat's been reporting on deaths in San Diego County jails, a series prompted by our finding that the county had the highest inmate mortality rate of California's 10 largest jail systems between 2007 and 2012. During that period, the county averaged 10 deaths a year, with a high of 12 in 2009 and a low of eight in both 2007 and 2012. Twelve people died in 2013. This year, as of Dec. 19, 16 county-jail inmates have died.
"Sixteen deaths in a one year period is a concern to us," wrote Sheriff's Cmdr. John Ingrassia in an email to CityBeat. He noted that several of those inmates were terminally ill—CityBeat counted four based on medical examiner's reports. He also noted that the Sheriff's Department books more people into jail than similarly sized counties due to different booking acceptance criteria—a point the Sheriff's Department's has made to us in the past to challenge our reporting. But, Ingrassia added, "we don't hide behind this figure as an excuse or justification for the number of jail deaths."
"Our goal is to have zero inmate deaths," he wrote, "and we take each and every case very seriously."
Cochran didn't make it beyond a Central Jail holding cell. On the morning of Sept. 16, he was arrested for trespassing only a few blocks from Scripps Mercy hospital, where Rinehart says he was taken (CityBeat wasn't able to confirm this due to patient-privacy rules). He was wandering in and out of a chiropractor's office, "mumbling gibberish" about having lost his wallet, according to the medical examiner's report. At the jail's sally port, he refused to get out of the police car and had to be carried inside.
Rhinehart believes his behavior was the result of him being without his medication and food for possibly a dozen hours.
"He would have been like a 2-year-old," she says.
Rhinehart doesn't know if Cochran was coherent enough to let the jail's medical staff know during intake that he was diabetic. She doesn't know if he was still wearing his medical-ID necklace—it wasn't among the items inventoried by the medical examiner. At around 12:30 p.m., less than two hours after he'd arrived at the jail, he fell face-forward off a bench. Paramedics were called, and he was taken to UCSD Medical Center, where he was pronounced dead at 2:15. The cause of death was diabetic ketoacidosis, a condition caused by an insulin shortage that's rarely fatal if treated immediately.
Rhinehart says a sheriff's homicide detective told her that deputies "did nothing wrong." Ingrassia told CityBeat that a review of Cochran's death is scheduled for next month.
Rhinehart's back in North Carolina, where she and Cochran are from, living with her sister. "I don't go out of my bedroom," she says. "I don't leave my bed. He was my life."
During the six-year period CityBeat examined for its initial story, three lawsuits had been filed against the county over inmate deaths. By comparison, there have been three lawsuits filed in 2014 alone; last week, CityBeat confirmed that a claim's been filed in a fourth case, the precursor to a lawsuit. And, in November, a jury found the county liable in the death of Daniel Sisson, a 21-year-old who was found dead in his jail cell on June 25, 2011, from an acute asthma attack made worse by heroin withdrawal. The county is appealing the $3-million verdict.
One of the cases filed this year was by Anna Sandoval, whose husband, Ronnie Sandoval, died in the Central Jail on Feb. 23, the result of a drug overdose. He'd been arrested on Feb. 22 for methamphetamine possession. The medical examiner's report notes that during intake, Sandoval was observed to be sweating profusely. The lawsuit argues that despite obvious signs he was in distress, he was deprived of "life-saving medical attention."
A response filed by the county argues, among other points, that Sandoval alone was responsible for his death. According to the medical examiner's report, during the intake screening, he denied ingesting drugs.
"We don't know what Ronnie told the nurses, at least not yet," says Diana Adjadj, Anna Sandoval's attorney. Regardless, "there were objective signs" of possible overdose, Adjadj says. The limited records she's been able to get say that in addition to Sandoval's profuse sweating, he struggled to respond to questions during intake. At some point, he was removed from a general-population holding cell and put in a single cell, where he remained for nearly eight hours, a possible violation of California's Minimum Standards for Local Detention Facilities, which says that an inmate who's placed in a sobering cell isn't to be left there for longer than six hours without being evaluated.
"They knew something was wrong with him," Adjadj says, "but instead of monitoring him, they isolated him in a holding cell."
According to the medical examiner's report, at close to 1 a.m., a guard saw Sandoval slump over and fall to the ground in a seizure. Emergency personnel showed up 20 minutes later but were unable to transport him; he was declared dead at 2:15 a.m.
In his email to CityBeat, Ingrassia noted that while there have been five suicides this year, none have happened since July, "which I believe is a positive sign that changes implemented by our new medical director, Dr. [Alfred] Joshua, and mandatory training received by our deputies are working."
Joshua was hired in January, and CityBeatspoke with him in July about policy changes he'd made and strategies he planned to implement to reduce the number of inmate deaths. He was looking to implement a "step-down unit" for inmates who'd been taken off suicide watch. He also said staff would be trained to be more attentive to signs that might indicate mental distress, like the condition of an inmate's cell or whether someone was refusing meals.
The two last suicides of 2014 highlight the need for these new approaches.
Hector Lleras, 36, the fifth suicide of the year, twice told jail staff—first a nurse, then a deputy—that he was going to kill himself. On July 1, he was put in a safety cell and then released 24 hours later. Almost exactly 24 hours after that, he was found hanging in his Central Jail cell.
Christopher Carroll, a mentally ill homeless man, was arrested on June 14 for disorderly conduct. A chronic alcoholic who, according to his family, suffered from serious mental illness, Carroll was placed in administrative segregation because, during previous jail stays, he'd been unable to get along with other inmates. His segregated status meant he was allowed out of his cell for only one hour every 48 hours.
On June 18 at 11:45 a.m., Carroll inquired, via intercom, when he'd get his hour in the dayroom and was told it wasn't time yet. At 12:30, he was found with a noose around his neck, attached to the cell's top bunk.
According to the medical examiner's report, he'd smeared blood on the wall of his cell. He'd urinated on the floor and food and feces were stuck to the ceiling.
Carroll was only 5 feet tall and weighed 105 pounds. His family tried to help him, says his brother Ken, but he'd reject their offers. When he was lucid, he was funny and outgoing, "full of life," Ken says. "But mental illness just kept dragging him back in."
Ken says the family wasn't able to get much information about Christopher's death. They didn't know, for instance, that he'd scrawled a suicide note on his cell wall. When CityBeat told Ken that Christopher had been placed in solitary confinement, he wondered if that's what pushed his brother to kill himself.
"He just didn't like four walls," Ken said. "He couldn't stand four walls."