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When people who rely on psychiatric medication are booked into a San Diego County jail, they are forbidden to bring their prescriptions with them, leaving them to decompensate as they go days or weeks without treatment.
When a person in jail expresses a desire to self-harm, they are stripped naked, put in a safety cell and forced to defecate and urinate into a metal grate. The conditions in these cells are so harsh that people lie about being suicidal to avoid them.
In San Diego jails, decisions that affect mentally ill people are regularly made by command staff rather than healthcare professionals — a practice that can jeopardize the well-being of people behind bars.
These and other findings are the conclusions of Dr. Pablo Stewart, a correctional healthcare expert, who spent three days early last year touring San Diego County jails and interviewing staff and those in custody in preparing a report for attorneys suing to force reforms.
Stewart’s conclusions echo those from a number of outside experts in recent years, including experts hired by the Sheriff’s Office, who recommended a series of reforms to improve the treatment of people in county jails.
Several of the studies, audits and court filings reference reporting in “Dying Behind Bars,” a six-month investigation published by The San Diego Union-Tribune in 2019.
“On the matter of imposing discipline for people with mental health needs and/ or intellectual disabilities, San Diego County jail is far behind other jail and prison systems in California,” Stewart wrote in the 165-page analysis, dated last August but only recently released publicly.
The San Diego County jail system — where more than 240 people have died since 2006 — is an outlier among other California counties, Stewart found.
“In my more than 35 years evaluating and working in detention facilities, I have come across very few, if any, mental health care systems so lacking in effective systems and levels of care,” he wrote.
The failed practices have led to dozens of lawsuits and cost taxpayers tens of millions of dollars in recent years.
More troubling, Stewart said, is that Sheriff Kelly Martinez and her predecessor, former Sheriff Bill Gore, have known about the deficiencies but have resisted adopting recommended reforms, including those made by their own consultants.
“A well-functioning jail mental health care system requires effective coordination across all staff and health care disciplines,” he wrote. “San Diego County jail is, in several respects, uniquely dysfunctional in this regard.”
The San Diego Sheriff’s Office declined to comment on Stewart’s findings.
Two dozen times, department spokesperson Lt. David Collins cited the lawsuit in explaining why he could not respond to questions from the Union-Tribune.
“As the matter involves active and ongoing litigation, the Sheriff’s Office declines to directly respond to the opinions that Dr. Stewart provided as part of the litigation,” Collins said by email again and again.
Since she was sworn in more than two years ago, Martinez has said that improving mental health care in jails is a priority. Just over 40 percent of people in San Diego jails are on a psychotropic medication.
In an interview with the Union-Tribune last October, Martinez described new booking protocols intended to flag people in need of psychiatric care and said the department had implemented periodic wellness checks by deputies and clinicians to make sure people with mental illness don’t fall through the cracks.
But Stewart, who reviewed patient files and testimony from mental health professionals and spoke with staff and people in custody, found such efforts were falling short.
For nearly a decade, the Sheriff’s Office has been seeking accreditation by the National Commission on Correctional Health Care, which promotes best practices for taking care of people behind bars.
In 2017, the county paid $100,000 for NCCHC consultants to tour its four largest jails and flag any deficiencies that would keep the sheriff from earning accreditation.
Stewart notes throughout his report that many of the issues raised then remain.
“Multiple NCCHC recommendations — dating back to 2017 — regarding how to fix deficiencies in the jail’s mental health care system have still not been implemented,” he wrote. “This fact, to be sure, raises concern as to the adequacy of this jail’s mental health care system.”
His testimony is only a fraction of the evidence presented by plaintiffs in what has become a class-action lawsuit against the Sheriff’s Office and probation department.
At least 12 outside experts submitted testimony in what’s called the Dunsmore case, finding that San Diego jails are filthy and that workers regularly fail to follow best practices or department policies.
Lawyers for the county are fighting to shield much of the expert testimony from a jury if the case goes to trial.
Lack of coordination
Darryl Dunsmore first sued the county in 2020, accusing the Sheriff’s Office of failing to run its jails in a way that ensured his well-being. More plaintiffs joined, and in 2023, the litigation was certified as a class action.
Last year,the county agreed to settle one part of the broad legal complaint — the sheriff’s compliance with rules under the federal Americans With Disabilities Act.
But other causes of action persist, and the plaintiffs’ attorneys are still pushing to impose reforms that the Sheriff’s Office and Probation Department have yet to implement.
Among other things, they want the county to provide regular and confidential mental health evaluations, offer group therapy and individualized treatment for the most serious cases, reduce wait times for psychiatric appointments, improve safety checks by deputies, streamline the way psychotropic drugs are prescribed and dispensed and ensure that staff coordinates with contracted health providers when deciding patient care.
While they prepare for trial, the plaintiffs’ lawyers have filed scores of sworn declarations from employees and detainees describing filthy and dangerous conditions inside the county’s seven jails.
“My patients were subjected to terrible conditions and put at risk of great harm every day, and I felt powerless to give them the care they need and deserve,” wrote Jennifer Alonso, who was a mental health clinician inside county jail before resigning in frustration three years ago.
The only drug prescribers are contractors, Stewart noted — something he called a major lapse that other counties do not experience.
“Jail mental health staff shared with me during my jail site visits that psychiatric prescribers have little to no interaction with county-employed clinicians,” Stewart wrote. “This lack of coordination is an enormous problem.”
San Diego County contracts with the national correctional healthcare provider NaphCare for its physicians and physician assistants.
Records produced in the Dunsmore case show that the Sheriff’s Office issued multiple corrective-action notices to NaphCare in 2023 because the company repeatedly failed to meet terms of its contract, citing a large backlog of psychiatric appointments and the lack of a clear process to identify areas of care that need improvement.
When people do see a prescriber, they often don’t receive coordinated care, Stewart noted. He singled out the case of a woman who was never properly treated despite a history of self-harm.
“Mental health records show that she had seven different psychiatric providers across eight psychiatry encounters,” he wrote. But “there is no evidence that she ever received consistent therapy tailored to addressing her specific mental health needs.”
Stewart also said NaphCare workers had dodged his questions each time he visited jail.
“Every time, the psychiatric prescribers refused to speak with me,” he wrote. “County staff and legal counsel explained to me that because the psychiatric prescribers were employed by a private health care contractor, the county had no authority to have them speak with me.”
‘Unacceptable delay’
The failures inside San Diego County have real-world consequences for vulnerable people.
One of them was Jonathan McDowell, a 47-year-old Ramona man who was found hanging in his cell July 19, 2023. He died at a hospital 10 days later.
McDowell had been arrested five months earlier on suspicion of assault. Before his arrest, he was being treated for a mood disorder and told staff during booking that he was experiencing a mental breakdown.
Three weeks passed before McDowell was assessed; by then he was hearing voices. He was referred to a psychiatric provider in March but not scheduled to be seen until April, Stewart said.
He missed the appointment for reasons that are not clear.
“Mr. McDowell did not see the provider at that time, however, and did not get any psychiatric evaluation at the jail until June 2, 2023 — three and a half months after he came into custody,” Stewart reported. “This is an unacceptable delay in psychiatric care for this sort of patient.”
Stewart also noted that mental health evaluations are too often conducted through cell-door food flaps — preventing confidentiality, and potentially making a patient less willing to discuss their needs.
Collins, the sheriff’s spokesperson, declined to respond to that assertion but said in a written reply that mental health assessments are conducted throughout the detention period for any person in custody.
“Patients who could benefit from psychiatric care are scheduled for an initial full psychiatric evaluation and any additional mental health needs identified by the provider,” he said.
Stewart noted another anomaly in San Diego County jail practices: a position the sheriff calls a “gatekeeper.”
When someone who has been arrested acknowledges suicidal thoughts during booking, the jail appoints a gatekeeper to conduct a risk assessment. But that evaluation is limited to instituting suicide-prevention measures — not for mental health treatment.
“I am not aware of this sort of extremely limited ‘gatekeeper’ role in any other detention system, and based on my review of this system, I find that its design leads to failures in mental health care delivery,” Stewart wrote.
The consequences of delayed behavioral healthcare can be deadly, he added. He noted that a state audit released in 2022 cited eight San Diego County jail deaths of people who needed but never received help, including one whose urgent request for treatment was denied because a referral already was in process.
“Two days later, the person died by suicide having never seen a mental health professional,” he said.
Levels of care
Even when people are placed into special housing due to mental illness, they do not always receive reasonable treatment, Stewart found. He cited the case of Lonnie Rupard, whose 2022 death was so brutal it was ruled a homicide.
Rupard died from pneumonia, malnutrition and dehydration, the medical examiner found. But records show he had lost 60 pounds over his three months in custody. When he was found dead, his cell was smeared with feces and strewn with trash, indicating he lacked proper care over days.
“This patient had a long history of a psychotic-level mental disorder which had a documented response to medications in the past,” Stewart wrote. “The patient did not receive any psychiatric medications for the three months he spent at the jail leading up to his death.”
Rupard refused psychiatric care, so healthcare professionals simply pushed back his evaluations.
“This does not meet the standard of care for this sort of patient,” Stewart said. “The psychiatric provider is still obligated to evaluate the patient whether the patient is cooperative or not.”
San Diego County is now defending a civil lawsuit filed by Rupard’s family.
Another serious problem in San Diego County jails is the lack of contact mental health patients have with healthcare providers or even with other incarcerated people. By and large, people housed in safety cells, enhanced observation units or even psychiatric units are left alone, Stewart wrote.
“They are essentially on 24/7 lockdown,” he said of the most acutely ill people in the Central Jail’s psychiatric unit. “I observed four patients in these observation cells, and they were all extremely decompensated. The area reeked of urine and feces.”
Other jails manage to treat seriously mentally ill patients every day, Stewart said.
“In the Sacramento County Jail acute psychiatric unit, policy requires that all patients are provided a daily out-of-cell contact with a clinician and a daily out-of-cell contact with an attending psychiatric prescriber,” he found.
At the George Bailey Detention Facility in Otay Mesa — the county’s maximum-security jail — Stewart found administrative segregation units “filled with people with serious mental illness.”
Men housed in a unit Stewart visited are allowed out of their cells for no more than an hour every other day. That time is spent in a small 12-by-12-foot cage that’s connected to a shower and another cell.
Stewart described this level of isolation as “outside the norm.”
“Individuals have no normal human contact with any other person, even when they are allowed out of their cell,” he wrote.
Once or twice a week, men in administrative segregation are offered a visit to the jail’s recreation yard. But this also involves being locked in a metal cage — an environment one man described as worse than “even the most restrictive settings in the California state prison system.”
One mental health clinician told Stewart that rec yard cages were the only way she could hold group therapy sessions.
“The clinician must use a microphone so that patients can hear her from inside their individual cages,” Stewart wrote.
Recommendations ignored
One former clinician at the George Bailey Detention Facility put forward a formal recommendation to provide her patients at least two hours of structured treatment every day.
“At the time she left her job at the jail in late 2023, the proposal had gone nowhere,” Stewart wrote. “There remains almost no structured mental health programming in the administrative separation units.”
San Diego County jail workers and medical staff and contractors also do not collaborate on treatment goals for people in these units, he said.
Sworn commanders are allowed to overrule healthcare professionals in the interest of safety, and medical records are not shared between the sheriff, NaphCare and the county Health and Human Services Agency, which employs nurses and other providers, Stewart noted.
The Sheriff’s Office acknowledged the discrepancy when it responded to the state audit in 2022.
“Unlike many other counties, San Diego does not have a coordinated county health system or shared electronic healthcare records system,” the sheriff told the state auditor.
Aaron Fischer, an attorney representing plaintiffs in the Dunsmore lawsuit, said he hoped sheriff’s leadership will take seriously the examples Stewart gave of other jail systems that do a better job of treating the most vulnerable people in their custody.
“Dr. Stewart’s report makes clear that there are solutions to address San Diego’s deficient jail mental health care system,” he told the Union-Tribune. “But it will require a willingness to make real changes to conditions. Other jail systems are doing it. Why can’t San Diego?”
Fischer said it was significant that jail mental health staff cited in Stewart’s report were flagging deficiencies and recommending changes. “That is an alarm bell to which we must respond,” he said.
The class-action lawsuit, which legally affects every former, current and future person locked up in San Diego County jails, appears headed to trial later this year.
Defendants have filed a motion for summary judgment — a request that the court rule in their favor based on the evidence that has been submitted to date.
They did not ask the judge to rule on the plaintiffs’ claim that San Diego jails fail to provide adequate mental health treatment.
The litigants will next appear in San Diego federal court July 24, when they argue in favor and against allowing specific evidence to be presented to the jury.
