A law-enforcement oversight board has found that San Diego County Sheriff's deputies lied and omitted information in the investigation of the death of a 28-year-old African-American man who'd swallowed a baggie of meth before being booked into custody.
In a series of eight findings pending approval at the Citizens' Law Enforcement Review Board's (CLERB) Sept. 9 meeting, the agency lays out how negligence and a failure to follow policies by deputies and medical staff resulted in Bernard Victorianne's death on Sept. 19, 2012.
According to CLERB, jail staff knew that Victorianne had swallowed the drugs; his jail medical records, excerpted in the report, document a man in distress, screaming and telling staff that his insides were "on fire." Despite obvious signs of overdose, CLERB says Victorianne's condition was left "largely untreated." Rather than being placed in the jail's medical-observation unit—where he would've been closely monitored—Victorianne was sent to solitary confinement, where officers twice failed to properly check on his well-being, even when he was found face-down and naked on the floor.
The strange circumstances behind Victorianne's death led off "60 Dead Inmates," CityBeat's investigative series on the high rate of deaths in San Diego County jails, and, in many ways, was the impetus for the overall project.
According to a Medical Examiner's report that CityBeat obtained in 2012, Victorianne was on probation for drug violations when he was arrested on Sept. 12 in City Heights for driving under the influence. Observed swallowing a baggie of drugs during the arrest, he was first taken to Alvarado Hospital but was released and booked into San Diego's Central Jail the following afternoon. The Medical Examiner's report says Victorianne was scheduled for another hospital visit, but the Sheriff's Department was unable to say whether they'd taken him to it.
CLERB's report confirms that medical staff were aware that Victorianne had swallowed the baggie of drugs, which should have triggered immediate medical attention and, at the least, close observation. But instead, he was first placed with the jail's general population and then moved to administrative segregation due to behavior described as "bizarre." He was also prescribed Benadryl, the sedative Ativan and Haldol, a powerful antipsychotic.
During the course of a week, Victorianne increasingly showed signs of a possible methamphetamine overdose. According to CLERB: "On three separate occasions, medical staff noted that the decedent appeared to be 'responding to internal stimuli,'" culminating in Victorianne "screaming during an examination, telling staff that he was 'on fire'; that 'something was burning his insides.'"
Victorianne's symptoms of drug toxicity "were clearly evident," CLERB's report says, "but went largely untreated by medical staff."
The night before his death, during what's referred to as a "hard count'—when deputies are required to scan each inmate's wristband—Victorianne's cell was skipped. A deputy told CLERB that he checked on Victorianne, though when CLERB investigators reviewed surveillance video, it showed the deputy walking by the cell at a pace "insufficient to verify Victorianne's information and well-being."
On the morning of his death, when Victorianne didn't retrieve breakfast from the flap in his cell door, two deputies entered the cell. Victorianne was naked and face down on the floor, the Medical Examiner's report says. Policy requires that deputies receive verbal or physical acknowledgement from an inmate who might be in medical distress, but Victorianne provided neither. One of the deputies told CLERB that Victorianne "appeared" to be breathing. Surveillance video shows the officers entering the cell and exiting 41 seconds later, never alerting medical staff.
By the time of the next check, three hours later, after a shift change, Victorianne was found dead in his cell, "cold to the touch," according to CLERB. Rigor mortis had already set in. During the autopsy, a small plastic baggie, knotted on one end and broken open on the other, was found in Victorianne's stomach. The Medical Examiner listed the cause of death as methamphetamine toxicity.
Before CityBeat published its initial story in March 2013, we asked the Sheriff's Department about Victorianne's death, based on what we'd read in the Medical Examiner's report. The department declined to address the case specifically but did claim that the jail system provides "excellent medical screening and care" and conducts thorough reviews of inmate deaths.
"The Sheriff's Department takes each inmate death very seriously since we are responsible for their safety and well-being," spokesperson Jan Caldwell said via email." Providing good, quality medical services to all inmates is paramount to our mission."
In addition to the lapse in medical attention, CLERB also found problems with how the Sheriff's homicide unit handled Victorianne's death. The deputy heading the homicide investigation failed to interview or get reports from the last two deputies to see Victorianne alive, a violation of policy. The deputy had been told by her supervisor not to expect reports from the two officers and, according to CLERB, the deputy didn't push back, "but instead acquiesced without resistance or minimal discussion."
CLERB also found that the deputy who didn't check on Victorianne the evening before his death "failed to truthfully answer" questions in the investigation.
In a written response to questions from CityBeat, Sheriff's Commander John Ingrassia emphasized that the department "is constantly reviewing policy and procedure" and that changes to the inmate-count procedure—additional counts and clarity on what's expected to happen during those counts—were made as a result of Victorianne's death.
As for why Victorianne was placed in a segregated cell and not in the medical-observation unit, Ingrassia said the decision was made by medical staff, and he wasn't at liberty to discuss the reasons for the placement, but he said that medical staff is now "taking a more liberal approach" in deciding who's placed in the medical-observation unit.
Victorianne's family, unaware of staff misconduct until contacted by CityBeat, have obtained legal counsel from Julia Yoo and Stan Morris, two attorneys who represented the family of Tommy Tucker, an inmate who was killed by deputies during an altercation in 2009. Last year, Tucker's family agreed to a $225,000 settlement with the county.
Margaret Dooley-Sammuli, policy director for the ACLU of San Diego and Imperial Counties, describes CLERB's findings as "disturbing."
"These in-custody deaths are tragic and senseless," she says. "The Sheriff's Department has a duty to provide a basic standard of care. Deputies and medical staff need to be prepared to address life-threatening situations to avoid future preventable deaths."
Dooley-Sammuli's been monitoring the county's response to prison realignment—diverting low-level offenders to jails to reduce prison overcrowding—and says that the county has more responsibility for care than ever before.
"It is in the interest of the county [Board of Supervisors] to really be paying to attention to how our criminal-justice system and agencies adapt and prepare to handle a very different population, a much more medically needy population," she says. "That could very well include different kinds of policies and procedures within jails to make sure vulnerable populations are kept safe while in custody."