People are dying in custody at record rates across California. They’re dying in big jails and small jails, in red counties and blue counties, in rural holding cells and downtown mega-complexes. They’re dying from suicide, drug overdoses and the catch-all term natural causes.

The number of jail deaths is up even though the number of people in jail is down.

The state is aware. Reams of reports from oversight agencies have repeatedly pointed to problems in individual jails and the state board that oversees them.

Gov. Gavin Newsom pledged almost five years ago that the state would take a stronger hand to prevent deaths in the 57 jail systems run by California county sheriffs.

In every year since, more people have died in California jails than when Newsom made that pledge — hitting a high of 215 in 2022. Tulare, San Diego, Kern, Riverside and San Bernardino counties’ jails set records.

Nor was the pandemic the driving factor: California in 2022 had the smallest share of deaths due to natural causes in the past four decades. A surge in overdoses drove the trend of increasing deaths. And almost every person who died was waiting to be tried. A previous CalMatters investigation found that three-quarters of those held in county jails had not been convicted or sentenced, with many awaiting trial more than three years.

A state board was supposed to put in place measures that would keep inmates safer. Newsom committed to working through that board when he said in 2020, “I’ve got a board that’s responsibility is oversight. I want to see them step things up.”

But since then, Newsom and the Board of State and Community Corrections have been unable to slow the deaths. Until recently, the board was not even notified about deaths inside the county-run lockups, and a 2021 State Auditor’s report criticized the board for failing to enforce its own rules and standards on mental health checks and in-cell wellness checks of inmates.

The state has begun to take a somewhat stronger role.

The governor appointed a formerly incarcerated person to the Board of State and Community Corrections, and also signed a bill last year that added to it a licensed health care provider and a licensed mental or behavioral health care provider.

Following through on his 2021 budget proposal to increase the frequency of jail inspections and allow the board to perform them unannounced, Newsom directed an additional $3.1 million each year to the oversight board. The board reported that last year it conducted 31 unannounced jail inspections, a change from past practice when it would visit jails just once every two years, and told jail authorities in advance when inspectors were coming.

And a new law in July will add a staff position to review in-custody deaths, a position to be appointed by Newsom and confirmed by the Senate.

But critics say those steps have been insufficient. For instance, the original bill would have put jail death monitors in every county.

From right, Gov. Gavin Newsom, along with Senate President Pro Tem Toni Atkins, and Attorney General Rob Bonta, speaks in support of Prop. 1 during a press conference at the United Domestic Workers of America building in San Diego on Feb. 29, 2024. Photo by Kristian Carreon for CalMatters

CalMatters sent nine questions to the governor about jail deaths, the effectiveness of the state board, and his own 2021 pledge to strengthen jail oversight.

Newsom’s office did not answer the questions, instead sending a list of accomplishments to reflect “the Governor’s extensive record in this space.” Those mostly applied to his policies for state prisons, such as a death penalty moratorium.

When CalMatters asked him about high statewide jail deaths at a March 1 press conference in the Inland Empire, Newsom responded by saying:

“The governor,” Newsom said, “just signed legislation to actually be able to create a point person specifically responsible for overseeing what’s happening in county jails, working with (Attorney General Rob Bonta), who’s also been advancing investigations. One very close to home here in Riverside County, related to 18 in-custody deaths in 2022 with the current sheriff.”

The officials with the greatest influence over what happens in jails — the state’s elected county sheriffs — say additional state oversight is unnecessary. California State Sheriffs’ Association president Mike Boudreaux, who is also the sheriff of Tulare County, said he already answers to a state oversight board, the state Justice Department, county grand juries, federal courts, state courts and the media.

“What we see is that people criticize jails, they criticize sheriffs’ offices,” Boudreaux said. “And the reality of it is, they’ve never been inside a jail. They’ve never worked side-by-side with the sheriffs’ offices. They’ve never sat in meetings that we sit in to make sure that not only are we doing things right, we’re doing things that are for the safety and security of those inmates.”

In 2011 California — as it thinned severely overcrowded state prisons by sending tens of thousands of recently convicted offenders to county-run jails — created an oversight board for prisons and jails. This 13-member Board of State and Community Corrections is composed mostly of people with law enforcement and probation experience. The governor appoints eight, with one each appointed by the Judicial Council of California, Speaker of the Assembly and Senate Rules Committee.

The other two current board members are the state prison system’s chief and its director of parole operations.

The board’s initial mission was to lend independent expertise to jails and prisons and act as a “data and information clearinghouse.” The board gives out $400 million each year to jails, prisons, tribes and community organizations. It also sets standards for correctional facilities, from the hourly checks performed on inmates to the time set aside for recreation.

Almost immediately after its formation, the board was confronted with the limits of its powers: It lacked authority to mandate that all California sheriffs report their data – including in-custody deaths.

That will change when the state board’s new reviewer of in-custody death starts this summer.

When asked by CalMatters why more people are dying in California jails, despite a declining jail population, Board of State and Community Corrections representative Adam A. Lwin responded, “The BSCC is not in a position to comment on this question with respect to deaths in jails.”

“Until the passage of (the new law adding a detention monitor), the BSCC did not have specific responsibilities related to deaths in custody, beyond inspecting for the local agency’s policy and procedures related to reporting on any death in custody,” Lwin wrote in response to CalMatters’ questions.

So why are so many dying in California jails?

The reasons people are dying at record rates in California jails are a matter of circumstance, although in interviews with more than 70 people involved in California jails systems, from sheriffs and prosecutors to inmates and nurses, some patterns emerged.

Natural causes have long accounted for the biggest share of jail deaths, followed by suicides.

Suicide prevention should be a higher priority for jail staff, said University of Texas School of Law professor Michele Deitch, among the nation’s foremost authorities on deaths in prisons and jails.

“The vast majority of these deaths are preventable,” she said.

The causes of a significant number of deaths for recent years are still pending – meaning that the sheriff’s office hasn’t yet identified the cause or the Justice Department hasn’t updated the cause in its data collection.

But the recent increase in deaths came from the third largest cause overall, accidental deaths including fentanyl overdoses. Overdoses accounted for 43 deaths in 2022.

Fentanyl overdoses present a far deadlier challenge now than the previous dominant drug in jails, methamphetamine. Other factors are the same ones Newsom cited a few years ago: suicide; failures in health care or psychiatric evaluations; and less commonly, violence among inmates or by jail guards.

Protestors hold signs outside the John F. Tavaglione Executive Annex building in protest of jail deaths in Riverside County, on Oct. 31, 2023. Photo by Jules Hotz for CalMatters

First: A row of cells in an inmate housing unit at the Tulare County Adult Pre-Trial Facility on Sept. 18, 2023. Photo by Larry Valenzuela, CalMatters/CatchLight Local. Last: Sabrina Weddle protests in front of the San Diego Central Jail in San Diego on Oct. 24, 2023. Waddle’s brother, Saxon Rodriguez, died while in custody at the jail after overdosing on fentanyl in 2021. Photo by Adriana Heldiz, CalMatters

Shannon Dicus, San Bernardino County’s Sheriff and a member of the Board of State and Community Corrections, said the rise in deaths in part reflects trends that are unfolding outside of jails, including an overstretched mental health system and widespread use of potentially deadly opiates.

For his deputies, a persistent issue is people who know they are in violation of their probation terms hiding drugs in their bodies before they’re returned to jail.

“So a lot of these folks are secreting opiates in their rectum,” Dicus said. “We run dogs through. We do a number of things. We’re spending $250,000 on body scanners. And what happens is some of these people, they’ll have it in their bodies where we can’t detect it.

“They go into the jail, they get housed in their general housing assignment, and then all of a sudden I have seven fentanyl overdoses. And that’s the truth.”

Dicus said jails also find letters sent to inmates in the mail that were dipped in diluted fentanyl or methamphetamine.

But sometimes the jail-keepers themselves are responsible. During the pandemic, when jails were closed to visitors, drugs still found a way in. Jail deputies in Riverside and Fresno counties have been charged with drug smuggling, and an Alameda County civil grand jury found that a private jail contractor fired the medical director of the county’s jails for writing fake prescriptions to obtain opioids for herself.

Sheriffs have sometimes resisted outside pressure to more closely monitor their employees. In San Diego County jails, where according to Justice Department statistics 47 people died between 2021 and 2023, Sheriff Kelly Martinez and her predecessor have repeatedly refused requests from the local civilian law enforcement review board to put her deputies through scanners before they start their shifts. Two jail deputies pleaded guilty to drug-related charges last year, one for burglary of medication from a jail prescription medication drop-off box and the other for possession of cocaine on jail property.

Burned out jail medical staff

Jails could do a better job beginning at intake and reception, said Corene Kendrick, deputy director of the American Civil Liberties Union National Prison Project. She noted that people who have been arrested often are asked deeply personal questions about their substance use and history of self-harm, within earshot of jail deputies and other inmates.

If they don’t disclose that they have drug or alcohol dependency – perhaps fearing that will lead to more charges – Kendrick said the immediate cutoff can pose an enormous health risk.

And for people who are on psychiatric medication but don’t like the side-effects or don’t want to disclose their condition, the cessation of their medication can send their mental health into a tailspin.

The pandemic also badly dented jails’ ability to provide quality health care, critics contend.

When jails reopened to their regular capacity, Kendrick said, the arrival of new inmates and the resignations of burned-out health care workers stressed the systems beyond their breaking points. “A lot of jails have said that they’re having problems with correctional and health care staff who quit during the pandemic,” she said.

“I was not able to offer the kind of medical care that I wanted to be able to offer and that contributed to burnout for me.”
— Dr. Lauren Wolchok

One of those was Dr. Lauren Wolchok, who worked in Los Angeles County jails from 2016 to 2021. Before and during the pandemic, she said, the number of opioid-dependent patients she saw skyrocketed. But those jails strictly restricted opioid treatment, she said, confining it to a small subset of the population that needed it.

“I was not able to offer the kind of medical care that I wanted to be able to offer and that contributed to burnout for me,” Wolchok said. “I had long struggled with the existential crisis of, am I doing more harm than good by working in this terrible setting or am I sort of fighting against the system and getting people care that they otherwise wouldn’t have?

“Especially as the quality of the care that I felt I was delivering declined, it became harder and harder for me personally to decide that I was fighting the good fight.”

Drug overdoses, insufficient medical treatment, suicides — all of those causes of jail deaths could be minimized by more stringent policies. Academics, inmates and their advocates suggest scanning jail workers for drugs, providing a ready supply of the opioid-blocking naloxone nasal spray, ensuring inmates go through intake in a more private area, performing more frequent checks of inmates, and instituting local oversight boards.

Those decisions fall to one person: The county sheriff.

An overdose? Or a heart attack?

Some of California’s deadliest jails are in Riverside County, where 45 people have died since Jan. 1, 2021. One of them was Richard Matus.

Matus knew he wasn’t feeling well days before he died.

In journals he kept during his incarceration, which his family provided to CalMatters along with his medical records, Matus complained of feeling ill and receiving no medical help in jail.

“Its hard to deal with being treated as a sick animal an feeling like im just waiting to die,” he wrote in one entry. “Iv put in medical slips to see a doctor because I felt sick, very dizzy, bad head ack, felt like I was running fever and completely lost my sense of smell witch was really weird. They never followed up I believe it was twice I put in medical slips an no response so I gave up.”

Matus, whose family said he hadn’t used drugs besides marijuana before his incarceration, was found dead in his cell on Aug. 10, 2022, of a fentanyl overdose.

The Riverside County Sheriff’s Department coroner’s death record for Richard Matus Jr. Illustration by Miguel Gutierrez Jr., CalMatters

In a lawsuit filed in March 2023, Matus’ family alleges that Matus was lucid and communicative on the phone with his mother, Lisa, hours before his death. They allege that his “dire need for emergency medical intervention went unnoticed by the (jail’s) custody staff.”

An autopsy conducted eight hours after Matus’ death found something else. His left anterior descending artery, which provides half the heart’s blood supply and is known colloquially as “the widowmaker,” was 80% to 90% blocked. A medical form filled out by Matus on Sept. 26, 2021, indicated that a doctor told him his cholesterol and blood pressure were far above normal.

“Every time he complained to that (jail medical) office, they gave him cholesterol pills and told him to lose weight,” Matus’ mother, Lisa, told CalMatters. “They never sent him to the hospital, even though his blood pressure and cholesterol was (above normal). The whole time, he needed medical care and they just ignored him.”

That contention became part of the family’s lawsuit.

“Due to the great delays in securing adequate emergency medical attention for Richard Matus, Jr., and the failures on behalf of the (jail’s) custody staff in performing the required safety and welfare checks,” Matus’ family wrote in the lawsuit, “Mr. Matus did not respond to medical intervention and died.”

The Riverside County Sheriff’s Office responded to the lawsuit by denying all liability and said that Matus’ death was his own doing.

The family of Richard Matus Jr. stands outside the John F. Tavaglione Executive Annex with memorial photos of Richard, who died in-custody of the Riverside Sheriff’s Department in Riverside County. Photo by Jules Hotz for CalMatters

“If Plaintiffs sustained any injury or damages,” they wrote, “such injury or damages were solely caused or contributed to by the wrongful conduct of other entities or persons other than the answer Defendants.”

Some sheriffs have changed their practices to avoid in-custody deaths. Others say they’re looking for solutions. But Riverside County Sheriff Chad Bianco has instead taken an adversarial approach.

Criticism of his policy and practices, Bianco told the Riverside Press-Enterprise, are a “political publicity stunt of the far left.” He did not answer questions from CalMatters.

After an inmate died in 2022, the Riverside Press-Enterprise posted an interview with Bianco. In the comments under the story, someone who identified himself as Bianco ­ interacted with commenters, referring to the demands of people whose family members had died in his jails.

“Did they demand their family members not commit suicide or consume drugs while they were in custody?” he wrote. “Did they ever demand that their family members not commit crimes in the first place? Did their parents ever demand that they take responsibility for their own actions?”

The ACLU sent a letter in September 2021 demanding that the state investigate Riverside County jails. In 2022, another 19 people died, including Matus. After the ACLU wrote again demanding an inquiry by the state’s jail oversight board in early 2023, Attorney General Rob Bonta launched an investigation.

The Justice Department refused to answer any questions about its investigation. Bianco did.

“This announcement comes as a shock but at the same time should have been expected from our California DOJ and the attorney general who cares more about politics than he does about transparency and the truth,” Bianco said in a video the day the investigation was announced.

“This investigation is based on nothing but false and misleading statements and straight out lies from activists, including their attorneys. This will prove to be a complete waste of time and resources.”

‘All we’re doing is making recommendations to sheriffs’

The attorney general has two open investigations into jails, one in Riverside County and one in Santa Clara County. But the organization charged with overseeing day-to-day operations of California’s jails is the Board of State and Community Corrections.

The board can wield significant power.

When it repeatedly found the Los Angeles juvenile hall were unsuitable for housing last year, it shut down the system and directed the county probation department to find new housing for about 300 young people.

But that was an exception.

A Feb. 9, 2023 board meeting turned contentious when it came to the Riverside County jail system, the 15th-largest in the U.S.

Avalon Edwards, a policy associate of Riverside-based social justice organization Starting Over Inc., said the board was not enforcing its own standards of inmate care.

“If (Riverside County) can kill 20 people in 13 months and fail to provide any information to the families impacted, fail to report those deaths to the DOJ within the 10-day mandated reporting period, continue to lie to the public about the cause of death for all these people,” he said, “what are those minimum standards accomplishing?”

Edwards urged the board to withhold funding from noncompliant departments or, if they wouldn’t, he asked every board member to resign.

Critics argue that the board lacks the ability to effectively regulate jails.

“It is not set up with the kind of enforcement power, or teeth, to be able to meaningfully hold accountable agencies that are failing to comply with standards,” recently recalled San Francisco District Attorney Chesa Boudin told CalMatters. “So that’s one problem. And I don’t say that as a criticism of the organization or the people there so much as of the structure.

“I mean, it doesn’t have the ability to actually impose remedies even when it is aware of violations,” he said.

Two independent state oversight agencies also have found fault with the board and the jail system. The Legislative Analyst’s Office found in 2021 that the board’s effectiveness is hard to judge because it’s unclear what the board’s mission is. It said this “undermines the Legislature’s ability to assess whether the program is operating effectively and is consistent with Legislative priorities.”

The State Auditor’s Office, meanwhile, zeroed in on San Diego County jails in February 2022. It found that the San Diego Sheriff’s Department failed to prevent deaths in its jails and that its practices “likely contributed to in‑custody deaths.” The auditor’s office also found fault with the state corrections board, saying its jail regulations are inconsistent and its answers to the audit were “deficient or misleading.”

Even one member of the state corrections board feels the board’s hands are tied.

“All we’re doing is making recommendations to sheriffs,” said board member Norma Cumpian. “You’re like, hey, 20 people have died in your jails. We recommend that you, you know, report it quicker. Like, that’s not a lot.”

A Tulare County Sheriff stands guard at an inmate housing unit at the Tulare County Adult Pre-Trial Facility on Sept. 18, 2023. Photo by Larry Valenzuela, CalMatters/CatchLight Local

Cumpian, a former inmate who served nearly 20 years in prison for killing her abusive partner, said she often senses indifference or complacency from her colleagues.

As for plans to add a detention monitor, a dubious Cumpian said “I don’t know, this bill is supposed to release reports to the public. Like, what is that gonna do?”

Dicus, the San Bernardino sheriff who operates the seventh-largest jail system in the U.S., doesn’t see a problem with the way the oversight board operates. He said the oversight board is doing its job in accordance with its mission: assessing the policies and procedures of the jails it oversees while ensuring facilities are up to code.

He said the blame for in-custody deaths extends beyond the jails.

“Locally, try getting some help,” Dicus said. “Our local department of behavioral health, and this is not me throwing stones at them, but they’re 9 to 5. We live in a 24/7 environment where people are in crisis. And the crisis that we’re experiencing, the cops are there 24/7, but we need some of these other service providers to have the same level of response.”

He said the state has to rethink how it operates the social safety net at the county level, especially for mental health and substance abuse.

“It’s just typically this is the way we’ve handled everything, and we need to break out of that,” he said. “I think we need kind of a statewide revisit of what’s working and what’s not.”

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CalMatters.org is a nonprofit, nonpartisan media venture explaining California policies and politics.