Riverside County jails face lawsuits and investigation over high death rate

Aside from staffing issues, the jails aren’t in compliance with other provisions in the consent decree affecting how correctional staff evaluate people with mental health diagnoses.

According to the decree, people housed in safety cells, which are designed for inmates who are a threat to themselves and others, should be evaluated daily by a clinical therapist or someone with more training.  Safety cells are padded rooms that have multiple cameras and a door window but no furniture, sinks, standard toilets or objects that people can use to harm themselves or others.

People who are booked and sent to a mental health cell or transferred from the general population to a safety cell should be evaluated by a clinical therapist within 48 hours. 

Supervisors are required to inspect safety cells and safety cell logs to ensure that policies are followed and that the cells are cleaned and sanitized. The agreement also requires the jails to develop plans to transition people from safety cells to mental health cells and back to general population cells, if appropriate. 

Norman said the new court-ordered mental health expert will present a preliminary report on treatment in the jails in December 2023.

Providing adequate mental health care for people in jails and prisons is a challenge across the country. 

Jails and prisons aren’t set up to treat people with mental illness, said Craig Haney, a distinguished professor in the psychology department at the University of California Santa Cruz who studies the effects of incarceration. Yet they’re often forced to provide mental health care without enough staff to safely and effectively manage treatment, he said.

“We don’t have a functioning, adequate public mental health system in the United States,” said Haney. “As a result, people suffering from mental health problems often end up in the criminal justice system.”

Suicides raise concerns about monitoring of incarcerated persons

The day before he died in a mental health cell after swallowing a toothbrush and other objects, Mario Solis refused to take his medication, according to a coroner’s report. 

Solis’ death was deemed an accident, though attorneys for the family believe he killed himself. 

“Typically on suicides they tell their cellmate or someone would say they were talking about killing themselves or they leave notes,” said Bianco, explaining why the death was labeled an accident. “For him, there was no indication that he was trying to commit suicide. He was just eating things.”

During a mental health evaluation when he was booked into jail, Solis denied having suicidal thoughts.  So he was placed in general population, according to a coroner’s report. When he began displaying erratic behavior, the report said, he was evaluated again and placed in a mental health cell for closer observation where he died. (The coroner’s report said he was in a safety cell.)

Denisse Gastélum, who is suing the county on behalf of the families of Solis and Alicia Upton, who also committed suicide in 2022, said the jails aren’t properly monitoring people with mental illness.  

When a person is booked into jail, they’re screened to determine if they have mental health issues and to decide where to house them. The consent decree requires a registered nurse to ask them a series of questions, including whether they have attempted suicide in the past or are thinking about it. If they answer yes to any of the questions, they’re referred to medical and mental health staff for further screening.

Safety cells, the most restrictive housing, are reserved for people at risk of hurting themselves and others. State guidelines require deputies to check on people in safety cells every 15 minutes. 

People with other “severe” mental health diagnoses are placed in mental health cells with cameras so they can be monitored. People with less critical diagnoses are placed in general population cells without cameras, where deputies check on them hourly as with all incarcerated people, said Riverside County Chief Deputy James Krachmer.

Upton, 21, was in a mental health cell at the Robert Presley Detention Center when she tied her bedsheet to the top bunk and hanged herself on April 28, 2022. According to a coroner’s report, deputies didn’t notice Upton’s body on camera or start life-saving measures for 20 minutes. 

Footage from a camera in the cell showed Upton looping the bed sheet around her neck, the coroner’s report states. Four minutes later, she tied the sheet to the upper bunk and hanged herself

When she was booked into jail on April 19, Upton told jail officials she “always kinda [sic] wanted to die” and said she had multiple personalities, the report said. Two days after being booked, she was put in a safety cell after kicking other inmates’ cell doors; later, she was moved back to the mental health cell, where she hanged herself.

“It’s very clear that their mental health staff doesn’t know what the hell they’re doing in those jails,” Gastélum said. “Because Ms. Upton and Mr. Solis committed suicide in such tragic and obvious ways, they missed every single sign that you had a suicidal [incarerated person] on your watch.”

Gastélum doesn’t represent the family of Robert Robinson, who killed himself on Sept. 7, 2022. Still, his death also raises concerns about how well deputies monitor people and the quality of mental health care in the county jails.

Robinson, 41, died less than 24 hours after arriving at the Robert Presley Detention Center, where he was in protective custody in a single cell, according to the coroner’s report. On the day of his death, he warned jail personnel that he would kill himself. But after consulting with a mental health professional, he was returned to his cell in general population housing. 

A video shows him hanging himself right after an hourly cell check, according to the coroner’s report. Deputies didn’t discover his body until more than an hour later. A toxicology report detected amphetamines and morphine in Robinson’s system.

Referring to the suicides, Bianco said there’s a limit to what jail personnel can do. 

“We do everything in our power to prevent suicides. The bottom line is if someone’s going to kill themselves, they’re going to find a way to kill themselves,” he said. “And usually, it’s not the first time they try. They keep trying until they’re successful.” 

Questions about accountability

But before the spike in jail deaths in 2022, the Sheriff’s Department had been under scrutiny for years for its treatment of people in custody and officer-involved shootings. 

 “These things have been happening in Riverside for a long time. The only difference is that the numbers have spiked to a ridiculous level,” said Luis Nolasco, senior community engagement and policy advocate at the ACLU of Southern California, which urged Attorney General Rob Bonta to investigate the Sheriff’s Department. 

Since 2014, several Riverside County grand juries have investigated the department, recommending a range of changes, some of which are relevant to issues surrounding the 2022 deaths. The department rejected most of the recommendations, according to grand jury records.

A grand jury suggested that medical or psychiatric staff conduct routine rounds in holding and sobering cells to ensure people are receiving timely mental health support.

On Aug. 26, 2022, Octavio Zarzueta Jr., 30, died at a local hospital after being held in a sobering cell for public intoxication. His family is suing the county alleging corrections officers failed to properly assess or monitor him.  

Another grand jury recommended that the department improve how it maintains incident logs, providing a more accurate, detailed description of what happened and identifying who wrote the report. The jury also proposed that the reports be screened for continuity and reviewed by a supervisor. Families suing the county have challenged the accuracy of jail records. 

Lisa Matus and other family members of people who died in custody in 2022 are waiting for answers from Bianco.  

“All we want you to say is, ‘Let me look into it. Let me see what happened.’ Because obviously, [the sheriff] wasn’t there,” she said. “So how can he say he knows that everything’s good across the board if he’s not in all the jails all the time watching what people do.”

Gail Fry contributed to this report. 

This project is a collaboration between the Investigative Editing Corps and Report for America and produced with support from inewsource, a nonprofit investigative newsroom in San Diego.