In another case, deputies stood by for months as a man lost more than one-third of his body weight while repeatedly refusing meals, showers and day room visits, the Citizens' Law Enforcement Review Board concluded. He was later found unresponsive in his feces-covered cell.
"The evidence showed an egregious neglect of care and ultimate failure of the system," the outside investigators said in a new report.
The findings are the latest eye-popping conclusions from independent reviews of San Diego Sheriff's Department practices, which have come under growing scrutiny over the hundreds of deaths inside county jails over the past two decades.
The citizens' review board is scheduled to convene Tuesday night to debate the findings from its investigative staff, along with dozens of other policy violations or misconduct claims.
The civilian oversight board will consider five separate death investigations — and put forward five specific recommendations aimed at improving the Sheriff's Department handling of people in custody.
Sheriff Kelly Martinez is not required to adopt or implement recommendations issued by the oversight board.
Department officials said they continuously review jail incidents for violations of policy or the law.
"We do not wait for an outside review, and it is not accurate to state that the CLERB has discovered something that we have not already reviewed and handled in the appropriate fashion," the department said in a statement.
"We will continue to critically assess our performance, holding ourselves to the highest standards, and change and adjust processes and policy when it makes sense."
In all, the outside investigators sustained six separate violations of Sheriff's Department policies in the five death cases under review — meaning they found there was enough evidence to support the allegations.
Six other complaints were not sustained, meaning there was insufficient evidence to support or reject them. Two claims were ruled unfounded, two were summarily dismissed for lack of jurisdiction and one found the deputy's action was justified, investigators said.
While the Citizens' Law Enforcement Review Board also investigates shootings by law enforcement and complaints against sworn Sheriff's and Probation department officers, much of its work in recent years has focused on deaths in San Diego County jails.
San Diego County jail deaths have cost taxpayers millions of dollars in legal settlements and jury awards, and the Sheriff's Department is defending numerous other cases.
Dominique McCoy, for example, was a 38-year-old whose probation term ended in 2021. He was nonetheless arrested Dec. 22, 2021, for allegedly violating the terms of his probation. When he went to court a week later, a judge ordered him to be released that day.
But while processing his release, deputies placed McCoy in a cell with John Medina, an 18-year-old Chula Vista man who had been arrested on suspicion of felony child cruelty and assault with a deadly weapon.
Medina beat McCoy to death, the Sheriff's Department said in a news release. He is now facing trial for first-degree murder and other charges in April.
The review board investigation said deputies did not protect McCoy.
"Based on (incarcerated person) Medina's documented propensity towards violence, the department failed to implement reasonable measures to prevent him from doing harm to others, shortcomings that contributed to IP McCoy's death," the report said.
"The lack of protection to IP McCoy cannot be attributed (to) one individual, but as a department the SDSD failed to provide a safe environment for McCoy," investigators found.
McCoy's family is now pursuing a wrongful-death lawsuit against San Diego County.
Vianna Granillo also died in sheriff's custody when she should not have even been booked into jail, the review board investigation found.
Granillo, who was 25, was suspected of violating a criminal protective order and found in possession of a small amount of drugs when sheriff's deputies were executing a search warrant in Escondido in 2022.
The woman repeatedly told deputies she was not in violation of the order — a claim that was later confirmed by the District Attorney's Office, the review board said.
What's more, COVID-19 protocols in effect at the time called for Granillo to be issued a ticket on the drug charge rather than being taken to jail, the investigation found.
But deputies transported her to the Las Colinas women's jail. She died days later after deputies found her in medical distress inside her cell.
The Sheriff's Department said at the time that jail staff immediately began life-saving measures, but her health declined and she died.
The independent investigation said the sheriff's response to the medical emergency violated policy and noted that an intercom system was not functional. The civilian oversight board has reported for years that jail intercom systems are too often inoperable.
"There was a delay in additional medical support response due to intercom issues and/or direct supervision staff issues," the review board said. "While there was no one point of failure that led to Granillo's death, she should never have been booked into custody."
In the Granillo case, the oversight board summarily dismissed a complaint that the medical staff did not provide proper treatment, because it has no authority over doctors and nurses.
Executive Officer Paul Parker has been pushing to expand the review board's jurisdiction to include jail medical staff, to date without success.
One of the recommendations issued by the review panel calls for the Sheriff's Department to mandate the supervision of intercoms and doors during medical emergencies. Another calls for the department to enact a plan that allows for the safe placement of people due to be released.
"In addition to a policy that governs all release, it is recommended that (incarcerated persons) shall not be allowed to return to housing if released from or while at court," the recommendation said.
The review board also found policy violations in the death of Lonnie Rupard, a mentally ill man who was found dead in his trash- and feces-strewn cell in the San Diego Central Jail two years ago.
The Medical Examiner's Office ruled the death a homicide and listed the causes of death as pneumonia, malnutrition and dehydration.
The review board noted that Rupard had lost 60 pounds over three months in jail — more than one-third of his body weight — and said deputies and medical staff fundamentally failed in their duty to respond to a clear medical emergency.
"It is incumbent (on) the entire ( Sheriff's Department) to take responsibility to care for those in their custody and identify and facilitate a higher level of care when needed," they wrote. "While CLERB does not currently have jurisdiction (over) medical personnel, the evidence showed an egregious neglect of care and ultimate failure of the system."
The Rupard death prompted a protest against the Sheriff's Department and also sparked civil litigation.
Deaths of people in custody have haunted San Diego County jails for years.
The county reported 185 in-custody deaths between 2006 and 2020, according to a state audit released in 2022. The California State Auditor concluded that conditions in San Diego County jails were so dangerous that new legislation was needed to impose reforms.
The audit was requested by state lawmakers after The San Diego Union-Tribune reported that at least 140 people died in San Diego County jails between 2009 and 2019.
Two bills aimed at boosting oversight of county jails were signed into law last fall by Gov. Gavin Newsom.
Deaths in custody have continued despite what Sheriff's Department officials say has been a concerted effort to improve conditions and practices in their jails. Eighteen people died in San Diego County jails in 2021, 20 more the following year and 13 last year.
The department is on pace to record another deadly year in county jails. So far in 2024, two people have died in sheriff's custody.
©2024 The San Diego Union-Tribune. Distributed by Tribune Content Agency, LLC.
