Six Deaths in Custody: What Can Be Done?

Once again, the Santa Barbara County supervisors found themselves collectively squinting to figure out how to improve health care in the county jail, this time with the focus on the six inmate deaths that occurred there between December 2022 and December 2023. 

Of the six, five died within three days of being booked. Two were overdoses. Two were suicides, one by an inmate who had repeatedly threatened to kill himself yet somehow managed to throw himself off a second-story railing to the ground below. 

The grand jury concluded most deaths took place because of insufficient observation, a failure to communicate in a timely or effective manner, and ongoing staffing shortages — both among custodial staff and the private health-care contract workers. To many of the grand jury findings, the sheriff’s response was that protocols had been in place at the time of the deaths but had not been followed by health-care workers with Wellpath, the private company with whom the sheriff contracts out such care. 

The county supervisors also heard how many of the solutions proposed by the grand jury were either already being implemented or would be soon. The supervisors, for example, had authorized the hiring of 16 additional Wellpath workers earlier this year. They’d also eliminated the long waiting list for inmates seeking methadone treatment for opiate addiction. 

Two weeks ago, the supervisors raked Wellpath over the coals for failing to provide the number of medical staff called for in the contract. The county reportedly paid about half a million dollars for health-care staffing it did not receive; the sheriff was called on the carpet for poor contract oversight. 

In response, the supervisors called on the Public Health Department to assign one senior-level medical professional and one registered nurse to the county jail to monitor the quality of health care provided and provide greater oversight. To date, the supervisors heard, those positions have yet to be filled, though the RN position is slated to be filled September 30 and the medical director sometime later this fall. 

One longtime mental-health advocate noted that many of the inmates who died might still be alive had they been diverted to other treatment options — like the ER — prior to booking. One of the decedents died of complications arising from alcohol withdrawal. He’d complained of pains in his chest. Failure to pass on information gleaned by arresting officers to the nurses on jail intake contributed as well; naturally staffing shortages exacerbated all of this. 

Supervisor Joan Hartmann especially wanted to know why more use was not being made of the eight new lockdown beds now offered by the nearby Crisis Stabilization Unit or the equally nearby Sobering Center. She was told a judge would first have to sign off on any such releases from the county jail. Even so, she wanted to get a fresh report on the utilization of the facilities — still relatively new — within four months.

Mostly the supervisors heard how much collaboration was now taking place between all the many government agencies — and Wellpath, as well — that make up the criminal justice system. 

Supervisor Das Williams pointedly noted that Wellpath’s most recent annual report was a year late. A lot of problems could happen in a year, he added. 

The grand jury report was accepted, but not before multiple supervisors praised the work and its ongoing sustained focus on the county jail.