Report says staff and contracted medical providers did not follow procedures with Goleta man who committed suicide in custody
Blog note: Noozhawk, the reporting media, says about this article: “Noozhawk does not typically report on a suicide unless it takes place in public or involves a public figure, and coverage often omits details, including the method, due to responsible reporting guidelines. However, regarding the Grand Jury investigation into institutional failures, the details of Alexander Braid’s suicide in a jail cell are important to understanding the conclusions and recommendations in the report.”
A Goleta man killed himself in his jail cell last year, and Santa Barbara County Sheriff’s Department staff and contracted medical providers did not follow procedures and did not recognize that he was potentially suicidal.
That was the conclusion of the Santa Barbara County Civil Grand Jury in its last report of the 2018-19 session, which was released over the weekend.
The Grand Jury regularly investigates deaths in custody, and this report digs into the July 5, 2018, death of 45-year-old Alexander Ricardo Braid.
Braid was arrested that day for acting aggressively toward another resident in his home, according to the Grand Jury report.
He appeared to be under the influence of alcohol and was agitated in the patrol car; he struck his head against the vehicle’s interior, and called out to God for help, according to video reviewed by the Grand Jury.
The deputy told the jail over the radio that Braid was being “combative,” with no mention of the self-harming behavior, the report found.
At the jail, a registered nurse is supposed to evaluate arrestees to give them medical and mental health clearance, and jail staff are supposed to check prior arrest records.
Braid was arrested in December 2015 and “suicidal talk” triggered a 5150 mental-health hold, and transport to the Santa Barbara Cottage Hospital emergency room, the report found.
However, during his July 2018 arrest, no one appeared to examine records of Braid’s mental health or arrest history.
“Despite (Braid’s) prior arrest record, which included a 5150 hold, and despite his palpable agitation, his anger, his apparent state of intoxication, and his repeated self-harming behavior while seated in the patrol car, at his home, and in transit to the jail, none of the patrol or custody deputies, or the Wellpath nursing staff, recognized that (Braid) potentially was suicidal,” the report found.
Braid was arrested on suspicion of elder abuse and disrupting a wireless communication device, and it appeared likely that he would be cited and released, after being detained at the jail long enough to “sleep it off,” according to the Grand Jury investigation.
Braid was placed in a cell where the camera system could not view the entire space. He was only wearing board shorts when he was arrested, so jail staff gave him a white T-shirt and beltless blue pants.
About 15 minutes after entering the cell, Braid hanged himself with the shirt tied to the bars, out of view of the camera, the Grand Jury found. About 10 minutes later, a custody deputy walked by and discovered him, and called for a “man down” response.
Jail staff attempted live-saving measures, but Braid died of his injuries, and an autopsy named asphyxiation as the cause of death.
“In investigating further, the jury learned that when (Braid) was first discovered hanging in his cell, emergency resuscitation equipment could not be located, and when located, did not function properly.
“The Sheriff’s Department told the jury that the malfunctioning resuscitation equipment had not been retained as evidence, and more importantly, that there was no log or other documentation showing that required inspections of the jail’s life-saving equipment had occurred,” the report concluded.
The Grand Jury viewed video of the “man down” response, and saw what appeared to be a deputy removing a piece of evidence from the cell, what they think was the T-shirt ligature. The shirt was in a paper bag at the autopsy, according to photos, but was later thrown away and not preserved as evidence, the Sheriff’s Department told the Grand Jury.
The Grand Jury viewed video, conducted interviews, and reviewed documents and reports during the investigation into Braid’s death.
Members were frustrated at being delayed or refused documents requested from the Sheriff’s Office, including internal investigative reports, and said while they did not challenge all of the refusals, a future Grand Jury may do so.
The 2019-20 Grand Jury was sworn in Monday and includes three members from the former Grand Jury that worked on this report.
“The purpose of this report is not to speculate whether (Braid's) death could have been avoided had employees of the Sheriff’s Office and Wellpath done a better job,” the report concludes. “The jury’s role in this case is to investigate the circumstances of the death, determine the facts, and make recommendations with the goal of improving local government operations.
“The jury regrets that, for the most part, the Sheriff’s Office seemed more interested in obstructing than working cooperatively with the jury toward that goal,” it continues, in bold.
“Dealing with persons who are under the influence of drugs, alcohol, and/or mental illness is no easy task. Nevertheless, the sheriff is responsible for the physical safety of every person taken into custody.”
The Grand Jury report has multiple findings and recommendations for the Sheriff’s Office, and one for the county Board of Supervisors.
The agencies have 60 and 90 days to respond, respectively, and the responses will show whether more action is required, whether by the governmental agencies or the Grand Jury itself, the report concludes.
“The Sheriff’s Office received the Grand Jury’s report and is in the process of carefully reviewing its findings and recommendations,” spokeswoman Kelly Hoover said in a statement Monday. “The Sheriff’s Office takes the report seriously, and will issue a detailed response well within the time frame requested, including correcting several inaccuracies.
“Suicide is a sad reality throughout our society, and the jail is not immune to these tragedies,” she said.
“Our staff has intervened in suicide attempts at the jail and has saved lives. Whether people commit suicide inside or outside of the jail, all of us here at the Sheriff’s Office are deeply saddened by such loss of life,” Hoover said.
About 17,000 inmates are booked into the Main Jail every year, and there have been four in-custody deaths due to suicide since 2001, she said.
That includes an inmate death by apparent suicide that the Sheriff’s Office disclosed on Monday.
Joseph Frederick Rose, 47, was transported to a local hospital after an apparent suicide attempt June 25, and died of his injuries on Sunday, Hoover said in a statement.
He had been held in custody since April 10, 2018, on suspicion of burglary, battery, and violating probation.
The Grand Jury report on Braid's suicide in custody recommends the Board of Supervisors examine the contract with Wellpath (formerly called California Forensic Medical Group, CFMG), which provides medical and mental health services to Main Jail inmates.
The Main Jail continues to operate its medical and mental health services without accreditation from the National Commission on Correctional Health Care, and that accreditation was supposed to be obtained by 2017, the Grand Jury found.
“While the Jury understands that the certification process can be lengthy, the lack of accreditation constitutes a continuing violation of the contract and is a matter of real concern. Especially considering that the North Branch Jail is scheduled to open later this year, this issue should be addressed promptly by the Board of Supervisors.”
The Northern Branch Jail, which is still under construction near Santa Maria, has 32 designated medical and mental health beds.
County staff members are currently reviewing the Grand Jury report, said Fifth District Supervisor Steve Lavagnino, chairman of the Board of Supervisors.
“Obviously, any death in custody concerns me,” he said in emailed comments on the report.
“That is one of the reasons why the board has devoted so many resources to upgrading our facilities, including building a new Northern Branch Jail. We approved the current five year contract with CFMG in 2017, which specifically addressed the accreditation issue by the NCCHC which was to occur by April 1, 2019.
“CFMG provided an update at the July 31, 2018, BOS meeting and as part of the board’s response to this Grand Jury report, I expect to receive another update about that status later this year,” Lavagnino said.
The Grand Jury report’s findings and recommendations for the Sheriff’s Office include:
» Review and improve training for patrol deputies responding to people who appear to be under the influence of drugs or alcohol, or exhibit symptoms of mental illness, including questioning people at the scene who may have relevant information about the person’s condition. One witness at the scene of Braid’s arrest had information that the Grand Jury “believes might have helped avoid AB’s death if sheriff’s deputies or medical personnel had obtained it; however, sheriff’s deputies did not interview this witness.”
» Review and improve training for deputies “in recognizing and accurately communicating to jail staff any self-harming behavior by detainees.”
» Have the Sheriff’s Office require that Wellpath, the health care provider in the Main Jail, assure its staff adhere to policies to assess arrestees. The registered nurse “failed to follow established procedure requiring that a medical/mental health evaluation be conducted in a private interview room where the arrestee’s computerized records are available for immediate reference.”
» Have the Sheriff’s Office require custody staff to adhere to booking policies, including examining prior arrest records during the booking process. “Custody deputies at booking failed to closely examine (Braid's) prior arrest records, which contained information that might have helped avoid AB’s death,” the Grand Jury found.
» Since Braid was placed in an observation cell with a video camera that did not show the portion of the cell where he committed suicide, the Grand Jury recommends the Sheriff’s Office stops using that cell, or improve the video equipment to give a complete view of the cell.
» Review and improve training for “man down” responses and require custody staff to properly handle and preserve evidence connected to incidents at the jail.
» Require Wellpath to inspect, repair and replace emergency life-saving equipment on a regular schedule, maintain a service log, and train custody staff on its location. “Wellpath medical staff and sheriff's custody staff responding to the 'man down' announcement was unaware of the location of life-saving resuscitation equipment and that it was not functional,” the Grand Jury report found.
July 1, 2019
Noozhawk Santa Barbara
By Giana Magnoli
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