The Los Angeles County Department of the Medical Examiner and Coroner often overgeneralizes or misrepresents the reasons people are dying inside the county’s jails, according to a new report from Dignity and Power Now and UCLA’s BioCritical Studies Lab (BSL) scrutinizing autopsy results from in-custody deaths.
The report, which looks at the influence the LA County Sheriff’s Department has on the county’s death investigation system, is part of a larger body of research examining the “history and current practices of the United States medical examiner/coroner system.”
LA County, however, is free of a worse conflict because the LA County Sheriff doesn’t oversee the coroner’s office.** Yet, according to the new report, that the fact that sheriff’s personnel are present during the coroner’s autopsy process, may have influenced a longstanding pattern in which deaths in custody are misclassified as natural, undetermined, or suicide.
The March 1 report points to a string of cases in which medical examiners labeled deaths that show multiple signs of being caused by physical violence as due instead to “undetermined” factors, suicide, or natural causes.
For example there is the case of Markese Braxton, a 26-year-old Black man who died in Twin Towers in 2018. Braxton’s autopsy described blood between his brain and skull, as well as soft tissue hemorrhage on his hands, back, shoulders, and shins. The toxicology report showed there were non-fatal doses of antihistamine and antipsychotic medications in Braxton’s body. Yet, the coroner’s office reported an undetermined cause of death.
Seven years earlier, in 2011, an 18-year-old named Jorge Rosales was being held pretrial when he died in Twin Towers Correctional Facility. According to the UCLA/DPN report, Rosales’s body showed “significant physical trauma, including a black eye and scleral hemorrhage, scalp and facial contusions and abrasions, bruising and abrasions of the arms, and pancreatic hemorrhage” that could have been caused by blunt abdominal trauma. Yet, again, the medical examiner labeled the official cause of death as undetermined.
As mentioned above, in a large number of the state’s counties the conflict of interest is far more severe due to the fact that California is just one of three states that allows non-medically trained elected officials to run the coroner’s office.
While, in Los Angeles the coroner is not elected, but is appointed by the LA County Board of Supervisors, in the majority of the state’s other 57 counties, this elected official is the local sheriff. Efforts to forcibly separate the offices at the state level have failed.
The issue found itself in a spotlight in December 2017, when two medical examiners, including renowned forensic pathologist Dr. Bennet Omalu,resigned from their posts. Omalu accused then-San Joaquin County Sheriff Steve Moore — who also served as the county’s coroner — of “intentionally” withholding information “in order to mislead me” from determining cases to be homicides.
In response to the allegations, during the next legislative session, lawmakers passedSB 1303, a bill that would have required autopsies to be conducted by licensed physicians and surgeons.
Former Governor Jerry Brown vetoed the bill.
The decision of how to structure local coroners’ offices, Brown said in hisveto message, “is best left to the discretion of local elected officials who are in the best position to determine how their county offices are organized.”
In 2022, a similar bill, AB 1608, failed to pass out of the Senate.
The same week that DPN and UCLA released their report, the LASD’s Civilian Oversight Commission (COC) approved findings from an investigation led by Special Counsel Bert Deixler into deputy gangs operating within the LA County Sheriff’s Department, as well as a list of 27 recommendations for Sheriff Robert Luna to eradicate those gangs.
“The Department currently contains several active groups that have been, and still are, engaged in harmful, dangerous, and often illegal, behavior,” the members of Special Counsel wrote in their report to the Civilian Oversight Commission (COC). “Some of these groups have engaged in acts of violence, threatened acts of violence, placed fellow Deputies at risk of physical harm, engaged in acts celebrating officer involved shootings, and created a climate of physical fear and professional retribution to those who would speak publicly about the misconduct of such groups.”
At a rally outside the coroner’s office on March 1, Dignity and Power Now and the larger JusticeLA Coalition urged the COC to look more deeply at the connection between deputy gangs and the coroner’s office, suggesting that members of the toxic culture of LASD deputy gangs may be influencing the investigations of in-custody deaths and other deadly encounters with law enforcement.
“There are real lives at stake and the [COC] needs to investigate the impact that LASD gangs have on these coroner’s reports,” JusticeLA wrote on Twitter. The presence of LASD personnel during the coroner’s autopsy process alongside the unchecked violence and influence of Deputy gangs have resulted in a longstanding pattern where deaths in custody are misclassified as natural, undetermined, or suicide.”
The coroner’s office labeled the 2009 death of a 22-year-old Black man, John Horton III, a suicide, despite evidence of “fresh intra-abdominal and back muscle blunt force injury,” according to the report. Horton was being held pre-trial.
Horton’s mother, Helen Jones, said her son “was murdered in Men’s Central Jail on March 30th, 2009 by the 3000 Boys deputy sheriff gang members,” who operated on the 3000 floor of the Men’s Central Jail — a “dangerous, deadly, toxic, outdated jail where Black and Brown men have been killed over a decade before and after John was killed and they will continue to die.”
In 2009, one of the jail system’s most deadly pre-pandemic years, thirty-eight people died in custody.
“Most of these deaths involved Black and Latino men and the majority happened before standing trial. This is unacceptable. No one should die while in jail,” said UCLA Professor Terence Keel, who founded the BioCritical Studies Lab and co-authored Monday’s report. “Our report shows that Los Angeles County Jails are some of the most lethal in the nation…Each day that Men’s Central Jail remains open is a day that someone is likely to die.”
While it is the most dangerously dilapidated facility, Men’s Central Jail is not the only county-run lockup where people are dying.
Shackled to benches for days
At the LASD’s Inmate Reception Center, the backlogged way station where people are processed into the jail system after arrest, people die after being chained to benches for days, or after going without necessary medication.
On June 19, 2015, a man died after being restrained for 32 hours after he ripped up his shirt, threatened to hurt himself, then head-butted a deputy, injuring her.
Deputies left the man for 32 hours with his hands both cuffed behind his back and attached to waist chains attached to a bench. During those 32 hours, he received no meals, only one cup of water, and no access to a toilet. In response to the man’s death, then-Sheriff Jim McDonnell fired ten department members.
LASD leaders did not resolve the longstanding problems at IRC with the 2015 firing spree, however.
Eight years later, conditions at the facility remain inhumane and dangerous, according to the ACLU of Southern California and the LA County Office of the Inspector General (OIG).
Staff from both offices have reported seeing garbage, feces, and urine on the floors of the facility.
The OIG reported to the LA County Board of Supervisors that some people with mental illness had been chained to IRC benches for “over sixty hours each.” One man diagnosed with schizophrenia was reportedly cuffed to the jail’s front bench for more than 99 hours.
In April 2022, a man died after waiting two days at the facility for an evaluation, according to the OIG.
A month later, a 72-year-old man collapsed and died after also being held for two days without an evaluation, the ACLU said in a court filing.
A federal court order issued last September dictated that the LASD could not hold people at the IRC for more than 24 hours, and could not chain people to benches or other objects for more than four hours. The department was also ordered to keep conditions at IRC sanitary, with clean water provided, working toilets, mattresses for people held overnight, and timely access to mental health care and medications.
On February 27, 2023, the ACLU filed a motion asking Judge Dean Pregerson to hold the LA County Supervisors and the new sheriff, Robert Luna, whose department still remains “massively out of compliance,” in contempt of court.
A hearing on the matter will be held in Judge Pregerson’s court on March 20, at 10 a.m.
“Contempt of court is the strongest sanction available to a judge, and rare because it is used only after all other efforts to enforce compliance have failed,” said Corene Kendrick, deputy director of the ACLU National Prison Project.
Kendrick brought the motion together with Peter Eliasberg, chief counsel at the ACLU SoCal, and David Fathi, director of the ACLU’s National Prison Project.)
“Make no mistake,” Kendrick said, “L.A. County has failed to comply with past orders about the jails, and the ACLU’s request for contempt is how the federal court can bring the county into line and protect the people locked in its jails.”
The ACLU’s filing notes describe how the sheriff’s department has been using Men’s Central Jail as overflow for IRC, chaining people to gurneys in hallways for hours instead of their former habit of chaining those waiting to be placed to the IRC benches.
The sheriff’s department has not included these people and conditions in “IRC overflow” in their reports required by a preliminary injunction.
The LA County Board of Supervisors have been in the process of closing the dungeon-like Men’s Central Jail for more than a decade, with a troubling lack of measurable progress. After vowing to close the jail by employing a robust system of community-based alternatives to incarceration, the supes are reconsidering the once-scrapped idea of building locked medical facilities for people in the county’s jail system who have the most severe forms of mental illness.
“For years, the county and board of supervisors have known about these inhumane conditions and that the only solution was to expand effective programs to move people with mental illness out of the jails into community treatment,” said Eliasberg.
“But they have failed to do what was necessary to solve the problem, and scores of vulnerable people are suffering every day because of their inaction.”
**Editor’s note and correction: Earlier WLA incorrectly wrote that the Los Angeles County Medical Examiner-Coroner is overseen by the Los Angeles County Sheriff’s Department. While that is true in 48 out of California’s 57 counties, in LA County the Board of Supervisors appoints the coroner.