County Grand Jury Examines Three Custody-Related Deaths at Local Jails

FATAL HEAD INJURY AT THE NORTHERN BRANCH JAIL

A Custody-related Death Investigation

An inmate, AAO, died at Marian Regional Medical Center 19 days after he fell from standing height and struck his head on the floor of Santa Barbara County’s Northern Branch Jail due to an apparent seizure. This seizure occurred approximately seven hours after he arrived at jail on August 29, 2024.

While the cause of his seizure is impossible to know for certain, the 2024-25 Santa Barbara County Grand Jury learned that AAO had a history of and was at risk for alcohol withdrawal—which, in some cases, can include seizures—when he arrived at jail. That risk was not properly recognized or shared among relevant staff during the intake process.

In case after case, previous Grand Juries have noted that the first 72 hours of an inmate’s arrival at jail is a time of particular sensitivity, requiring careful attention from custody and medical staff. In the course of this investigation, the current Grand Jury discovered several deficiencies in the medical receiving screening process, the electronic health record, and staff communication.

AAO had multiple prior arrests, and his health record at the jail included warnings related to prior alcohol withdrawal episodes as well as a previous head injury. On this occasion, however, AAO was not monitored for symptoms of alcohol withdrawal.

As a result, no medical warnings were ever communicated to custody staff on August 29th before AAO’s ultimately fatal fall occurred. The Grand Jury concludes that this and other related shortcomings placed AAO at greater risk for harm than should have been allowed to occur.

The Grand Jury recommends that the Santa Barbara County Sheriff’s Office, the Board of Supervisors, and County Health engage in increased oversight and enforcement of the Wellpath contract for health services in the jails. The Grand Jury also recognizes that steps toward this goal have recently been accomplished. This report underscores the critical need for strong and immediate action.

ANOTHER SUICIDE IN SANTA BARBARA COUNTY JAIL

Inmate’s Death Should Have Been Prevented

On November 13, 2024, a 41-year-old female with suicidal ideations who we identify as CC was incarcerated at the Santa Barbara County Main Jail.  CC hung herself using a wall-mounted telephone cord. The 2024-25 Santa Barbara County Grand Jury has investigated the matter and issued a report which finds that her death should have been prevented.

CC was arrested for felony assault with a deadly weapon and evading police officers on November 8, 2024. She was booked into the Main Jail on November 9^th. In the four days preceding CC’s death, she made several suicidal statements to Jail mental health providers. Accordingly, she was twice assigned to protective custody in a suicide-proof safety cell so that she could be closely monitored. On the fifth day of her incarceration, CC was moved from the safety cell to a holding cell that contained a 12-inch telephone cord. Later that day, CC committed suicide in that cell using the telephone cord.

Based upon its investigation, the Grand Jury finds that several systemic problems within the Main Jail limited the staff’s ability to safeguard CC, including insufficient numbers of properly equipped mental health observation cells. Additionally, the Grand Jury concluded that several policies and procedures were not followed at the Main Jail. These problems resulted in a series of breakdowns leading to CC’s placement in a holding cell with a telephone cord, which ultimately resulted in her death.

In the past seven years, six inmates, including CC, have committed suicide in the Santa Barbara County Main and Northern Branch Jails combined, mostly by hanging.

To avoid future deaths by suicide in the County’s jails, the Grand Jury recommends that the Santa Barbara County Sheriff and the Board of Supervisors initiate a number of specific improvements by January 1, 2026, as fully outlined in the Grand Jury’s report. Chief among those recommendations is that the Sheriff’s Office will not assign an inmate deemed to have been recently suicidal to an observation cell that contains a telephone cord.

PREVENTABLE DEATH AT THE NORTHERN BRANCH JAIL

A Death-in-Custody Investigation

On March 24, 2025, a 57-year-old female, CF, was found unresponsive in her cell by custody deputies in the Santa Barbara County Northern Branch Jail. Despite emergency medical efforts, she could not be revived and was pronounced deceased at the jail.

The 2024-25 Santa Barbara County Grand Jury has investigated this case and found that CF complained persistently of intense abdominal pain for two days prior to her death, claiming “her guts are all twisted up,” and asking to be sent to a hospital emergency department. Tragically, CF’s moaning and screaming in pain merely resulted in her placement in a mental health observation cell. She was never examined or treated for her pain complaints before she died, nor was she was ever evaluated with a standardized pain assessment form, though nursing staff were expected to use such a form.

When properly diagnosed and treated, ruptured gastric ulcers have a roughly 90 percent survival rate. When untreated, they consistently lead to death from peritonitis, or infection inside the body, as in CF’s case.

The Grand Jury concludes that CF did not receive proper medical treatment in the jail, and that her death might have been prevented if she had. The Grand Jury recommends that the Sheriff’s Office require jail medical staff to follow proper practices for evaluating pain complaints as outlined in existing policy, procedure, and protocol and in accordance with generally accepted standards.

On March 25, the Santa Barbara County Sheriff’s Office released a Notice of In-Custody Death to local media describing the circumstances, and on March 27, the Sheriff’s Office issued a public update on the case that stated the following:

The autopsy revealed that this was a tragic, but unavoidable death. The cause of death has been determined to be acute peritonitis due to a ruptured gastric ulcer. The manner of death is natural causes.

While the Sheriff’s Office released a statement that CF’s death was unavoidable, the Jury concludes that there were opportunities to prevent this death.

Read the full reports here.