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HomeMy WebLinkAboutOCDA Investigative Report_pdf.REDACTEDNAMEONLY.TBCa a r ""= = = -- a I INVESTIGATIVE REPORT S.A 20-027 CUSTODIALRELATED DEATH ' SANTA ANA POLICE DEPARTMENT i 4,,,..ll.,.'P.lal"s"; &l..}iXl77"("'n:Z-J-.,.i I II.. ,," )" "'-Ya__a#;',i,, * (i -" " ,," L c Nl ':li. " ,- Il+t '- 0 TIp ,Q '7 4,G@,:: i:, , _ %,O<ta (5_Nc0J%4; a iN OFFICE OF THE DISTRICT ATTORNEY ORANGE COUNTY, CALIFORNIA TODD SPITZER February 16, 2023 Chief of Police David Valentin Santa Ana Police Department 20 Civic Center Plaza Santa Ana, CA 92701 Re: Custodial Death on 1 1/04/2020 Death of Inmate: District Attorney Investigations Case # 20-027 Santa Ana Police Department Case # 20-23197 Orange County Crime Laboratory Case # 20-53528 Chief Vafentin, Please acceptthis letterdetailing the Orange County DistrictAttorney's (OCDA) Office's investigation and legal conclusions concerning the November 4, 2020, custodial death of 47-year-old inmate In sum, the investigation revealed evidence that the Santa Ana Police Department (SAPD) breached its duty of care to however the OCDA cannot prove that the breach caused death. Consequently, there is an insufficient basis upon which to find criminal culpability for death on the part of any SAPD personnel or those under the supervision of the SAPD. OVERVIEW This letter contains a description of the scope of OCDA's investigation of the custodial death of a summary of the subsequent legal analysis, and the resulting legal conclusions concerning any potential criminal liability. In this letter; the OCDA describes the criminal investigative methodology employed, evidence examined, witnesses interviewed, facts discovered, and the legal principles applied to review the conduct of all SAPD personnel involved with this custodial death incident as well as any other individuals under the supervision of the SAPD. On November 4, 2020, OCDA Special Assignments Unit (OCDASAU) Investigators responded to Orange County Global Medical Center (OCGMC) where died after receiving medical aid. had been in custody at the Santa Ana Police Department Detention Facility and was found in his cell suspended above the floor by a ligature around his neck, The ligature had been formed with a bed sheet. During the course of this investigation, the OCDASAU interviewed 19 witnesses, and obtained and reviewed reports from SAPD and the Orange County Crime Laboratory (OCCL), as well as incident scene photographs, and other relevant materials. The OCDA conducted an independent and thorough investigation of the facts and circumstances of this event and impartially reviewed all evidence and appfied all relevant legal standards. The scope and findings of this review are expressly limited to determining whetherany criminal conduct occurred on the part of SAPD personnel or anyothers acting under the supervision of the SAPD. The OCDA will not be addressing any possible issues related to policy, training, REPLY TO: ORANGE COllNTf DISTRICT ATTORNEY'S OFFICE WEB PAGE: http:noran(lecoumvda,oif [X iaiuomce € NORTH OFFICE 3o@ N. FLI)WER 8ET Pl:l.BaX8 8AhffA AHA, aA W702 (7M) 834-3mO 1275 N. 8ERKEljY AVE FUlLERTON, CA 92832 1714) 77>4]80 € WESTOFFICE 8141 13"18TREET WESTMIN!)TER, OA 92(183 (7111) 896-7261 € HARBOROFFICE 4601 JAMBORE! RD. N5WF'ORT BEACH, CA g2u0 (940) 476-4850 € JUVENILEOFFICE 341 CITY DRIVE SOIITH ORANGE. CA g28fl8 (714) 935-7624 € CENTRALOFFICE 40t CMC CENTER DR. W p.o. aox aoa SANTA ANA, CA 92701 i7%)834-3952 tactics, or civil liability. INVESTIGATIVE METHODOLOGY Among other duties, the OCDASAU is responsible for investigating the deaths of individuals that occur while an individual is in custody within Orange County. An OCDASAU Investigator is assigned as a case agent and is supported by other OCDASAU tnvestigators, as well as investigators from other OCDA units. Six investigators are assigned to the OCDASAU on a full-time basis. There are additional OCDA Investigators assigned to other units in the Office trained to assist when needed. On average, eight investigators respond to an incident within an hour of being called. The investigators assigned to respond to an incident perform a variety of investigative functions that include witness interviews, scene processing, evidence colJection, and hospital investigative responsibilities as needed. The OCDASAU audio records all interviews, and the OCCL processes all physical evidence related to the investigation. Deputy district attorneys from the Homicide, TARGET/Gangs, and Special Prosecutions Units review fatal and non-fatal officer-involved shootings and custodial death cases, and determine whethercriminal charges are appropriate. Thus, when the OCDASAU Investigator has concluded the investigation, the file is turned over to an experienced deputy district attorney for legal review. If necessaiy, the reviewing proseciitor will send the case back for further investigation. Throughout the review process, the assigned prosecutor will be in consultation with the Assistant District Attorney supervising the Special Prosecutions Unit or the OCDA, who will eventually review any legal conclusions and resulting documents. It is also common for the case to be reviewed by several experienced prosecutors and their supervisors. Ultimately, the District Attorney personally reviews and approves all officer involved shooting and custodial death letters. FACTS was booked into the Santa Ana Police Department Detention Facility on July 3, 2020. From that time and until his death, was moved to several different ce(Is because of disciplinary issues. was on Floor 3, Module D, Cell 24 when he died in custody. During his incarceration, experienced the death of his mother and brother; he suffered from substance abuse; and was in an unstable relationship with his girlfriend. received both medical and mental health care while in custody and was prescribed medication for anxiety, hypertension, and addiction cessation. There was no known history of suicide attempts. On November 3, 2020, at approximately 9:01 a.m., was administered Acetaminophen (500 mg tablet), Lisinopril (2.5 mg tablet), and Hydroxyzine Pamoate (25 mg tablet) by a Licensed Vocational Nurse (LVN). Later at approximately 6:41 p.m., pokewithhisgirlfriendoverthephoneandthetwodiscussedavarietyoftopicsincludingtheirfinances, their relationship, their future living arrangements, and their substance abuse problems. That night at approximately 7:42 p.m., was again administered Acetaminophen (500mg tablet), Trazodone HCL (100 mg tablet), and Hydroxyzine Pamoate (25 mg tablet) by an LVN. On November 3, 2020, at approximately 9:30 p.m., SAPD Correctional Officer Celeste Fernandez (c.o. Fernandez) was assignedtooverseeFloor3,ModulesCandDuntilhershiffendedat6:30a.m.thenextmorning. Aspartofhe2obduties, c.o. Fernandez was required to conduct two welfare checks every hour on all inmates in her assigned area. At approximately 9:50 p.m., 10:28 p.m., 10:57 p.m., and 11:47 p.m., c.o. Fernandez logged welfare checks of Floor 3 Modules C and D using a department computer and reported no issues with any of the inmates. At approximately lat:45 p.m., SAPD Detention Facility video surveillance recorded c.o. Fernandez conducting a welfare check of cell. Video surveillance then showed SAPD c.o. Mary Valenzuela (c.o. Valenzuela) arriving atl1:59 p.m. to relieve c.o. Fernandez for her break. 2 On November 4, 2020, at I :04 a.m., c.o. Valenzuela logged a welfare check of Floor 3 Modules C and D via computer and reported no issues with any of the inmates. SAPD Detention Facility video surveillance system recordings showed, however, that c.o. Valenzuela remained at the module's officer podium for the entire period of time she covered for C.0. Fernandez, which lasted until 1 :14 a.m. c,o.. Valenzuela subsequently declined to give a statement to investigators to explain the discrepancy between her computer log entry and the surveillance video recording. At approximatelyl:04 a.m., c.o. Fernandez returned from her lunch break and can be seen on surveillance conversing with c.o. Valenzuela for a few minutes before c.o. Valenzuela left. At 1:IO a.m., 1:15 a.m. and "1:16 a.m., video surveilfance recorded moving freely near the front entrance door of his cell. Due to the angle and distance of the surveillance camera, it cannot be determined what was specifically doing inside his cell. At approximately 1:30 a.m., c.o. Fernandez began her first set of welfare checks after returning from her break. At approximately "1:35 a.m., surveillance shows c.o. Fernandez approach cell, immediately reach for her handheld radio, request emergency assistance, and attempt to enter the cell. When interviewed by investigators, c.o. Fernandez stated that it was at this time that she saw unresponsive and hanging by a bedsheet from the top bunk inside his cell. Specifically, she stated that was in a seated position between the bunk and toilet with bedding wrapped around his neck, and his head was slumped downward and his arms were hanging at his sides. Immediately upon entering the cell, c.o. Fernandez tried to free neck from the bedding. Her initial efforts were unsuccessful, and she yelled for responding personnel to bring scissors. Within seconds, Correctional Officer James Elizondo (c.o. Elizondo) and an LVN anived to assist. c.o. Fernandez and the LVN were able to lift body while c.o. Elizondo loosened all three knots in the bedding. Together, they were able to free At approximately 1:36 a.m., a Registered Nurse (RN) arrived on scene to also provide aid. In a subsequent interview with investigators, the RN stated that immediately upon her arrival, was unresponsive to verbal and tactile stimuli; his face and hands were mild-moderately cyanotic; and his skin was warm and dry, but pallid in color. At approximately 1 :37 a.m., personnel moved to a common area outside his cell where medical staff determined had no pulse or respirations. A pulse oximeter reading indicated had a b(ood oxygen level of 48%, consistent with a deceased person. Medical staff began cardiopulmonary resuscitation (CPR), and a bag-valve mask was utilized to provide oxygen to At approximately 1 :44 a.m., an LVN administered one dose of Narcan to At approximately "l :46 a.m., personnel removed shirt, and an Automatic External Defibrillator (AED) was attached to his upper torso. After analyzing his condition, the AED audibly stated, "No treatment advised." CPR and oxygen delivery continued, although medical staff still did not detect any pulse, any measurable blood pressure, or any pupillary response. At approximately 1:47 a.m., a second pulse oximeter reading indicated had a blood oxygen level of 50%. At approximately 1:48 a.m., Orange County Fire Authority (OCFA) personnel from Engine #71 arrived and took over patient care. They examined and confirmed that he had no pulse, was not breathing, and had no blood pressure. Glasgow Coma Scale score was measured as a three, the lowest score possible and also consistent with a deceased person. At 1:50 a.m., was intubated, an intraosseous infusion line was established in his lower right leg, and a Lucas Chest Compression System was attached to his chest. At I :58 a.m., was administered 1 mg of epinephrine. At approximately 1:59 a.m., was transported Code-3 (lights and siren) via ambulance to OCGMC. During his transportation to the hospital, received another dose of epinephrine. The ambulance arrived at the hospital at approximately 2:09 a.m., and OCFA relinquished responsibility of care to OCGMC Emergency Room staff. Following arrival at the emergency room, was observed to have an asystolic heart rhythm (having no e(ectrical cardiac activity), his skin was cyanotic, and his pupils were fixed and dilated. Emergency room staff continued advanced life-saving measures, including administering medications and providing mechanical ventilation. These efforts did not 3 revive At approximately 2:14 a.m., was observed to have a pulseless electrical activity heart rhythm followed by asystole, while his pupils remained fixed and dilated, At 2:15 a.m., was pronounced dead by an OCGMC attending emergency room physician. EVIDENCE COLLECTED The following items of evidence were collected and examined: * One white t-shirt cut open with apparent blood stains @ Onepairoftanjailpants * One pair of white boxers * Possibleligatureblanketwithsheettiedinknots(westendofjailcellbed) @ Tied sheet with apparent blood (east end of jail cell bed) @ Plastic baggie containing a white/brown substance @ Brown paper bag, removed fmm the right hand * Brown paper bag, removed from the left hand * Deep tissue standard @ Heart blood standard AUTOPSY On November 6, 2020, Forensic Pathologist of Orange County Coroner's Office conducted an autopsy on at the Orange County Sheriff-Coroner Forensic Science Center. t found no significant trauma to the body. had an enlarged heart, but no coronary heart disease. rt found no ligature marks and determined that had no neck fractures. determined cause of death to be ligature hanging in the mannerof suicide. EVIDENCE ANALYSIS Toxicoloqical Examination A sample of postmortem blood yielded the following results: j -TbrNC;'-"=" 'l-- - -m7- y W gakl-L-T!!ATmtafaRE'['ATM6 l. ..... .-. o ' "'....-....... ' a '..'.y.-... ' - r..- Amphetamine Pos!;o;e-m Blood--"0.0632-+ a.(Xj4-7'mg/L-- - 108 +- 0.'08 mg/L -'Methamphetamine i Hydroxyzine Postmortem Blood - Postmoffem Blood 0.152 t O.019 mg/L T Morphine (free)Postmortem Blood 0.122 + 0.0'l3 mg/L 7 Acetaminophen (free) 1-(4-chlorobenzhydryl)-piperazine Postmortem Blood 1.85 = 0.18 mg/L DetectedPostmortem Blood Cetrizine Postmortem Blood Detected Noscapine Postmortem Blood ---- Detected - Papaverine Postmortem nlo-od -Detected Trazoa-Postmortem Blood Postmortem Blood -'-'-'-Detected "" Caffeine BACKGROUND INFORMATION had a State of California Criminal History record that revealed arrests for the following violations: 4 * * * * * THE LAW Homicide is the killing of one human being by another. Murder, voluntary manslaughter, and involuntary manslaughter are types of homicide. To prove that a person is guilty of murder, the following must be proven: a. Thepersoncommittedanactthatcausedthedeathofanotherperson; b. When the person acted he/she had a state of mind called malice aforethought; and c. He/she killed without lawful excuse or justification. There are two kinds of malice aforethought, express malice and implied malice. Express malice is when the person unlawfully intended to kill. Implied malice requires that a person intentionally committed an act, the natural and probable consequences of the act were dangerous to human life, at the time he acted he knew his act was dangerous to human life, and he/she deliberately acted with conscious disregard for human life. A person can also commir murder by his/her failure to perform a legal duty, if the following conditions exist: The killing is unlawful (i.e., without lawful excuse or justification); The death is caused by an intentional failure to act in a situation where a person is under a duty to act; The failure to act is dangerous to human life; and The failure to act is deliberately performed with knowledge of the danger to, and with conscious disregard for, human life. A person can also commit involuntaty manslaughter by failing to perform a legal duty, if the following conditions exist: The person had a legal duty to the decedent; The person failed to perform that legal duty; The person's failure was criminally negligent; and The person's failure caused the death ofthe decedent. In Giraldo v. California Dept. of Corrections and Rehabilitation (2008) 168 Cal.App.4th 231, 250-251, the court held that there is a "special relationship" between jailer and prisoner: "[T}he most important consideration 'in establishing duty is foreseeability.' [citationl It is manifestly foreseeable than an ii'imate may be at risk of harm.... Prisoners are vulnerable. And dependent. Moreover, the relationship between them is protective by nature, such that the jailer has control over the prisoner, who is deprived of the normal opportunity to protect himself from harm inflicted by others. This, we conclude, is the epitome of a special relationship, imposing a duty of care on a jailer owed to a prisoner, and we today add California to the list of jurisdictions recognizing a special relationship between jailer and prisoner." California Government Code 845.6 codifies that the special relationship that exists in a custodial setting gives rise to a legal duty, as follows: "[A] public employee, and the public entity where the employee is acting within the scope of his employment, is liable if the employee knows or has reason to know that the prisoner is in need of immediate medical care and he fails to take reasonable action to summon such medical care." 5 Criminal negligence involves more than ordinary carelessness, inattention, or mistake in judgment. A person acts with criminai negligence when he acts in a reckless way that creates a high risk of death orgreat bodily injury and a reasonable person would have known that acting in that way would create such a risk. In other words, a person acts with criminal negligence when the way he acts is so different from how an ordinarily careful person would act in the same situation that his or her act amounts to disregard for human life or indifference to the consequences of that act. An act causes death ifthe death is the direct, natural, and probable consequence ofthe act and the death would not have happened without the act. A natural and probable consequence is one that a reasonable person would know is likely to happen if nothing unusual intervenes. There may be more than one cause or death. An act causes death only if it is a substantial Factor in causing the death. A substantial factor is more than a trivial or remote factor; however, it does not need to be the only factor that causes the death. LEGAL ANALYSIS There is no evidence of express or implied malice on the part of any SAPD personnel, inmates, or other individuals under the supervision of the SAPD. Therefore, the only possible type of homicide in this situation is murder or manslaughter under the theory of failure to perform a legal duty. Without question, the SAPD and its custodial personnel owed a duty of care to protect him from foreseeable harm. This included any harm he intended to bring upon himself. Based on this investigation, there is no evidence that c.o. Fernandez, c.o. Elizondo, or SAPD medical personnel breached this duty of care. By contrast, there is evidence that c.o. Valenzuela failed to follow SAPD protocols and in so doing breached her duty of care. However, there is insufficient evidence of a causal connection between c.o. Valenzuela's breach and death to establish criminal liability. The two SAPD Correctional Officers assigned to monitor cell leading up to the time of his death were c.o. Fernandez and c.o. Va!enzuela. These correctional officers were responsible for conducting vvelfare checks twice per hour on inmates housed on Floor 3, Modules C and D, which included On November 3, 2020, at 9:30 p.m., c.o. Fernandez began her shift and performed three welfare checks at approximately 10:28 p.m., 10:57 p.m., and 11:47 p.m. be'tore going on her lunch break at 11:59 p.m. SAPD Detention Facility video surveillance confirmed that c.o. Fernandez conducted her last welfare check of cell at approximately 11:45 p.m., approximately'l4minutesbeforeherlunchbreak. AccordingtocomputerentriesmadebyC.O.Fernandez,therewereno issues with any of the inmates at this time. Thereaffer at 1l :59 p.m., surveillance showed c.o. Valenzuela arriving at the module's officer podium to assume shiff duties for c.o. Fernandez. On November 4, 2020, at 1:04 a.m. (approximately 1 hour and 5 minutes into c.o. Valenzuela's shift duties), c.o. Valenzuela made a computer entry indicating that she had conducted a welfare check on Floor 3 Modules C and D and reported no issues with any of the inmates. Contrary to this record, however, SAPD Detention Facility video surveillance showed that c.o. Valenzuela never left the module's officer podium until her shift ended at 1:14 a.m. No other evidence was provided to account for this inconsistency, and c.o. Valenzuela declined to provide any statement to investigators. Based on this contradiction, it is fair to conclude that c.o. Valenzuela did not actually perform a welfare check on cell during the approximate 5 hour and 15 minutes she was on duty, and that two welfare checks were missed between the hours of 12:00 a.m. and 1 :OO a.m. on November 4, 2020. Despite the two missed welfare checks leading up to the final hour of death, SAPD Detention Facility video surveillance recorded moving about near the entrance door of his cell at I :IO a.m., 1 :15 a.m. and 1 :16 a.m. As a result, Mr. must have committed suicide between 1:16 a.m. and 1 :35 a.m. After returning from her break, c.o. Fernandez performed a welfare check on cell and discovered him at 6 approximately 1:35 a.m. unresponsive and hanging from a bedsheet tied around his neck and attached to the top bunk of his cell. At this moment, c.o. Fernandez was under the legal duty to render immediate medical care to which she did. c.o. Fernandez acted in accordance with her legal responsibilities by immediately requesting emergency medical aid and attempting to free from the ligature wrapped around his neck. SAPD medical staff arrived within seconds and assisted c.o. Fernandez in freeing They then began to render emergency medical services to him, including performing CPR, artificially inducing breathing through an oxygen bag-valve mask, and using an AED device to try and revive his heart. Despite these efforts, SAPD personnel were unable to revive Based on the evidence collected and statements made by responding medical personnel, it appears likely that had died prior to c.o. Fernandez discovering him unconscious hanging inside his cell. In support ofthis conclusion, one of the first nurses to respond to cell at 1:36 a.m. described to investigators that was unresponsive to verbal and tactile stimuli, his face and hands were mild-moderately cyanotic, his skin was pale in color and was warm and dry to the touch. Next at '1:37 a.m., additional SAPD medical staff arrived on scene and determined that had no pulse or respirations and had a blood oxygen level of 48%. At 1:48 a.m., OCFA paramedics arrived and confirmed that was not breathing, and had no pulse or blood pressure. Thereafter, was transported to the OCGMC emergency room and continued to receive medical treatment. Such treatment was unsuccessful, and was officially pronounced dead at 215 a.m. Based on the foregoing, it is clear that c.o. Fernandez acted within the scope of her legal duties under the circumstances. c.o. Fernandez conducted her last welfare check in accordance with set policy based on the information she knew to be true at that time. Upon finding unresponsive in his cell, she promptly called for assistance and immediately began to render emergency aid to him. Therefore, c.o. Fernandez is not legally culpabfe for death. With respect to c.o. Valenzuela, while there is evidence that she breached her legal duty of care to there is insufficient evidence that this breach contributed to his death. To establish criminal liability under a theory of murder or manslaughter, evidence must show beyond a reasonabie doubt that c.o. Valenzuela's failure to act "caused" the death of Jones. c.o. Valenzuela apparently failed to conduct welFare checks between 12:00 a.m. and "l :14 a.m.in accordance with SAPD protocol. Had attempted suicide during this timeframe, criminal responsibility would potentially lie with her. However based on the surveillance video recordings and observed movements thereon, it is clear that Jones committed suicide after c.o. Fernandez relieved c.o. Valenzuela and sometime between 1:"16 a.m. and ") :35 a.m. lt is possible that welfare checks conducted prior tol:14 a.m. would have revealed evidence that was preparing to commit suicide. It is equally possible that made no preparations until after he was observed on surveillance video at 116 a.m. Ultimately, both theories are speculative, and lack evidentiary support. Consequently, evidence of a causal connection between the absence ofearlierwelfare checks and suicide sufficient to prove criminal responsibility beyond a reasonable doubt is lacking. This determination is not a referendum on potential civiloradministrativeliabi!ity. Again,suchevaluationsarebeyondthescopeofthisinvestigation. Rathersolelyforcriminal liability purposes, there is insufficient evidence to establish that had c.o. Valenzuela conducted welfare checks in accordance with protocol, it would have prevented suicide. CONCLUSION Based on all the evidence provided to and reviewed by the OCDA, the evidence shows that died by suicide as a result of aligature hanging. Pursuant to applicable legal principles, it is our conclusion that there is 7 insufflcientevidence to support a finding ofcriminal culpabilityfor death on the part ofanySAPD personnel orany individual underthe supervision ofthe SAPD. Amrdingly, the OCDA is closing its inquiry into this incident. STEVEN SCHRIVER Senior Deputy DistrictAttomey Special Famsecutions Unit READ AND APPROVED BY 8