Fifteen recent deaths in the Orange County jails may have been prevented if jailers had properly recognized mental or physical illness, the Orange County grand jury reported Monday.
The report estimated that 44 percent of in-custody deaths in Orange County’s jails could have been avoided if not for delays in treatment as well as failures to identify health risks, diagnose serious mental illness or referral to doctors.
“Modest changes in procedures at a relatively low cost could improve survival rates,” the grand jury reported.
But the sheriff fired back, and said grand jury’s report fails “to take into account the security requirements of a custody facility that do not conform with procedures that may be common in other medical settings.
“A jail is not a hospital,” the department said in its statement.
The grand jury is a group of volunteers empanelled to examine government procedures, under California law. Their findings are never binding, but under the law are recommendations.
The Orange County grand jury began looking at deaths in the county jail system a year ago, when a convicted car thief, Danny Pham, was allegedly killed inside the jail system by Marvin Magallanes. Magallanes had been jailed awaiting trial for killing two homeless persons in Anaheim, and the placement of a car thief with an accused murderer prompted the grand jury investigation.
The grand jury investigated 34 in-custody deaths of jail inmates or detainees from 2014 through 2017. Of those, 14 deaths were due to natural causes such as cancer, liver or heath disease or stroke, the grand jury reported.
One inmate committed suicide, and Pham was killed, the grand jury reported.
In three cases the cause of death was undetermined. The grand jury considered 15 deaths “preventable.”
The grand jury concluded that jail officials failed to “observe and record obvious health issues” in 24 cases. In 21 cases there was a failure to diagnose communicable diseases, and in 19 instances inmates were assigned to cells with violent offenders or someone with a contagious disease.
In their response, sheriff’s officials also argued that the report does not “adequately take into account the high-risk health conditions often seen in inmates entering our jail.”
Since realignment in 2011 the jails have seen an uptick in inmates with “chronic health problems,” sheriff’s officials said.
Drug smuggling into the jails has also increased, officials say.
“Each death is tragic, but the long-term health consequences of drug abuse are difficult to remedy with even the best medical care,” Sheriff Sandra Hutchens said in the statement. “The lesson from this report is that efforts to combat drug addiction, drug trafficking and the root causes of drug dependency must continue.”
The grand jury said the Intake Release Center is too “noisy” for nurses to get a better medical history for incoming inmates. Also, some inmates may be reluctant to share more detailed information because it is done out in the open and other inmates may overhear, the grand jury said.
The grand jury also criticized the medical questionnaire inmates receive, as having a typeface that’s too small to read. It also noted “there is no section for a medical care plan of action initiated by a doctor or nurse practitioner to define an inmate’s course of medical treatment.”
The grand jury also recommended urine drug screening tests be done regularly.
“Six of the 34 inmates died within 72 hours of arrival at (the jail), in some cases due to undiagnosed drug intoxication or delayed treatment,” the grand jury wrote. “Urine tests done at intake could have been useful in averting these outcomes.”
Blood is not drawn or tested at intake either, the grand jury reported. Those tests could be used to detect HIV or hepatitis.
“A review of the 34 custodial death cases found that 32 had no documentation on the health intake form of any test performed to detect if the inmate was positive” for communicable diseases such as HIV or hepatitis, the grand jury reported.
At autopsy, two inmates were found to be HIV positive, one was hepatitis B positive and 16 had hepatitis C, the grand jury reported.
The grand jury also recommended chest X-rays. Two of the inmates had lung and heart issues that could have been diagnosed with an X-ray that looked for something other than tuberculosis.
The grand jury also recommended that inmates disrobe at intake for a more complete health review. In one case, jail officials overlooked an inmate’s need for blood-thinning medication because he was fully clothed and they did not see a long incision in his chest wall.
“Within a few days of arrival, he was sent to the hospital, immediately diagnosed as having had a stroke, and later died,” the grand jury reported. “Had a visual exam been performed at (intake), the obvious chest scar would have alerted the health care professionals, and appropriate care could have followed.”
In another case, an inmate complained of pain from a wound, but it wasn’t visible under his clothes and the nurse did not view it, the grand jury reported. An abscess developed and a few days later he became septic, the grand jury said.
Jail officials asked if the man wanted to go to a hospital, but since he was about to be released he declined and went to the hospital on his own, the grand jury said.
“He was admitted to surgery upon arriving at the hospital, but he died due to complications of his infection,” the grand jury reported.
The grand jury also identified a problem with a delay in accessing available medical information for incoming inmates.
“Hours or even days can go by while (officials) track down important medical information, delaying treatment,” the grand jury reported.
The grand jury also identified problems with getting medical care in a timely manner for inmates who request it. Some inmates may be illiterate or too incapacitated to fill out a request form, the grand jury said.
Some inmates may miss an appointment if they are in court, and care may be delayed if needed during a weekend or holiday when there isn’t a doctor or nurse on site, the grand jury reported.
The grand jury identified two cases where errors in diagnoses contributed to the death of inmates. In one of those cases, an inmate had a tear in the aorta, which caused “massive internal bleeding,” but was given a pain killer when checked in on a Friday night before a doctor’s appointment was scheduled for the following morning, the grand jury reported.
The grand jury also reported problems with administering CPR. Nine of 20 inmates who received CPR suffered three or more broken ribs, a broken sternum or damaged internal organs, according to the grand jury.
In one case, an inmate suffered 17 fractured ribs during CPR as well as a perforation of one of the heart chambers, the grand jury reported.
The grand jury also recommended a forensic pathologist review autopsies in Orange County, which is done in Los Angeles and Riverside counties. That would lead to more specific investigations identifying a cause of death more accurately.
The grand jury also recommended that the department’s Correctional Health Services obtain accreditation from the National Commission on Correctional Health Care.
“Membership in this peer review organization has the potential to improve efficiency, inmate care and inmate survival,” the grand jury reported.
Don Barnes, said the report “highlights the recurring issues within the sheriff’s department.
“There is a leadership culture that is unwilling to take responsibility and make changes,” Nguyen said. “This is not a few rogue deputies, this is a failure of management and supervision.
“The grand jury findings are not the first time we are hearing about improper management in our jails. We need accountability in the sheriff’s department, or this will continue to happen.”