Sheriff Bill Gore said: "If you have a prior conviction for 800 classifications of crime, a serious or violent offense, we can share that information with ICE, when they are in our jails."
Sheriff Bill Gore, whose last day on the job was Thursday, has pushed back against jail critics in the past. Photo by Ken Stone

On Sheriff Bill Gore’s last day in office, a state auditor released a damning report Thursday that calls on state lawmakers to make “meaningful changes” to reduce his agency’s high rate of jail deaths.

State audit of San Diego County Sheriff's Department jail deaths. (PDF)
State audit of San Diego County Sheriff’s Department jail deaths. (PDF)

“In light of the ongoing risk to inmate safety, the Sheriff’s Department’s inadequate response to deaths, and the lack of effective independent oversight, we believe that the Legislature must take action,” said Michael Tilden, acting California state auditor.

His 126-page study, released Thursday morning, notes that from 2006 through 2020, 185 people died in San Diego County jails, confirming San Diego Union-Tribune reports that this is one of the highest in the state.

“The high rate of deaths in San Diego County’s jails compared to other counties raises concerns about underlying systemic issues with the Sheriff’s Department’s policies and practices,” the audit says.

“In fact, our review identified deficiencies with how the Sheriff’s Department provides care for and protects incarcerated individuals, which likely contributed to in‑custody deaths.”

Tilden also faulted the Citizens’ Law Enforcement Review Board, a panel approved by San Diego County voters to restore public confidence in county law enforcement.

The board, he said, “has failed to provide effective, independent oversight of in‑custody deaths. CLERB also failed to investigate nearly one‑third of the deaths of incarcerated individuals in the past 15 years, which means that dozens of deaths have not been subject to a key form of review outside of the Sheriff’s Department.”

Senate President pro tem Toni Atkins and Assemblywoman Akilah Weber, both San Diego Democrats, called the findings “deeply disturbing and shine a light on a situation that clearly needs to be changed.”

Manner of jail deaths in four counties.
Manner of jail deaths in four counties. Image via state audit.

“We, along with our Legislative and San Diego delegation colleagues, remain committed to accountability and to ensuring that the recommendations laid out by the State Auditor are implemented — including independent civilian oversight and robust safety checks and health screenings — so that the constitutional rights of those in the Sheriff Department’s custody are secured, and they are treated humanely, and with dignity and respect,” they said in a statement.

The Sheriff’s Department, anticipating the audit’s release, responded with a statement, which said in part:

State auditors conducted their review of the Sheriff’s Department from July 2021 to December 2021. The audit was extensive and included every aspect of Sheriff’s Department’s record of in-custody deaths, policies, procedures, facility maintenance and staff records.  The department was open and transparent during the audit.  We participated and cooperated throughout the entire process.  We take the findings of the audit seriously and are taking action to implement the recommendations. 

Many of JLAC’s recommendations are ones that we provided and completely support. They also align with our existing practices, current and future plans, as well as proactive efforts to continuously improve health care services and the safety of our jails. 

These recommendations will require substantial investment in the existing jail system. They include, but are not limited to, hiring more personnel and renovations at our detention facilities. The County Board of Supervisors has already approved funding for more healthcare staff and we are actively working to fill these positions. Infrastructure and technology investments to the existing jails are planned and moving forward. The addition of programs such as medication-assisted treatment and mental health evaluations at intake are already in process or in place.  …

Sheriff’s Department jail staff and medical personnel are some of the finest, most dedicated, compassionate and committed county employees. We support change and know the recommendations will improve our jail system for the people in our custody and employees. 

Undersheriff Kelly Martinez, who is becoming acting sheriff, was being made available for interviews on the report over the next two days, the statement concluded.

15-year death comparison of four counties.
15-year death comparison of four counties. Image via state audit

Other key findings of the audit:

  • The Sheriff’s Department “alarmingly” saw a total of 52 suicides in jail over the past 15 years, “which is more than twice the number in each of the comparable counties.”
  • Based on Sheriff’s Department data, in 2018 through 2020 the percentage of deaths of Black inmates was disproportionately higher than their overall composition of the jail population.
  • But “White individuals died at proportionally higher rates in 2007, 2009 through 2014, 2016, 2017, and 2020. In 2006, 2008, and 2015, the percentage of deaths among Hispanic individuals exceeded their population percentage,” the audit said.
  • Sheriff’s departments statewide may be underreporting the number of deaths occurring from incidents in the jails, with some deaths occurring outside of county lockups.
  • “Our case review found that Sheriff’s Department staff did not always follow up after individuals previously received or requested medical or mental health services, even though these individuals often had serious needs that, when unmet, may have contributed to their deaths.”
  • Based on video surveillance footage, “we observed multiple instances of sworn staff who spent no more than one second glancing into an individual’s cell, sometimes without breaking stride as they walked through the housing module. … Staff later discovered individuals unresponsive in their cells, some with signs of having died several hours earlier, as detention staff described some of these individuals as stiff and cold to the touch.”

The U-T noted Thursday how its six-month investigation in 2019 showed San Diego County had the highest jail death rate among California’s largest counties.

“The ‘Dying Behind Bars’ report showed the suicide rate in San Diego was almost five times higher than in Orange County and almost three times the Los Angeles County rate over the 10 years ending in 2018,” wrote Jeff McDonald, who teamed with freelancer Kelly Davis on the series.

“Many of the deaths have resulted in civil lawsuits that have cost San Diego County taxpayers millions of dollars in legal settlements and jury awards,” said the former San Diego SPJ Journalist of the Year.

In fact, the audit said 22 lawsuits filed between 2006 and 2020 were related to jail deaths.

“San Diego County has settled 11 of these, for a total cost of $9.2 million,” the audit said. “Payments for these cases ranged from $10,000 to $3.5 million for an average of $838,000 per settlement.”

Union-Tribune editor and publisher Jeff Light hailed his paper’s series as “important, meticulous reporting by a sophisticated, well-sourced team.”

He told Times of San Diego: “If you wonder whether there is a problem in the jails, all you have to do is watch Kelly’s presentation of this awful video, which shows Paul Silva being crushed in his cell by deputies. These are formidable journalists. They do important work. We are fortunate to have them in town.”

Kelly Davis, who has followed the story for nine years, including some with Dave Maas at San Diego CityBeat, said via email: “The audit confirms our reporting, which the sheriff has challenged repeatedly, including trying to subpoena all my notes and interviews in 2017. The audit identifies issues that are fixable and I hope the Sheriff’s Department makes the necessary changes. Reporting on these deaths has been heartbreaking.”

On Feb. 2, 2018, federal magistrate Judge Andrew Schopler ruled in favor of Davis, defeating the subpoena.

Davis also credited racial justice groups with driving calls for an audit. She cited Showing Up for Racial Justice North County, the Racial Justice Coalition and the North County Equity & Justice Coalition.

“Up until those groups took an interest in jail deaths, particularly Elisa Serna’s death [in 2019], the public rarely attended CLERB meetings,” Davis said via email. “I was often the only person in the audience. For oversight to work, the public needs to be engaged.”

Updated at 4:40 p.m. Feb. 3, 2022