San Diego sheriff’s deputies failed to check on a Vista Detention Facility inmate for 20 hours before he was found unresponsive in his cell and declared dead, the Citizens Law Enforcement Review Board said in a report.
The independent oversight panel will meet Tuesday night to consider three misconduct findings related to the 2017 death of Michael Macabinlar, who was 34 when he died in the sheriff’s custody.
Despite the failure to check on the inmate, the review board investigation could not say if the lack of attention contributed to Macabinlar’s death by drug overdose six days after he was jailed.
“There was inadequate evidence to prove that the failure to conduct proper hard and soft (inmate) counts would have led to a sooner initiation of CPR or would have prevented this death,” investigators wrote.
Nonetheless, the report found that deputies who were responsible for checking on the inmate failed at least three times to follow department rules requiring a verbal or physical acknowledgement that the inmate is alive.
“Video surveillance showed Deputy 3 appeared to look in Macabinlar’s cell and checked the handle on the door,” it said. “He did not stop at the door. He continued walking after checking the door, towards the next cell and did not return to Macabinlar’s cell.”
Macabinlar may have been dead for hours by the time he was found unresponsive in his cell. At 4:23 a.m. on the day he died, a deputy delivered him breakfast, “but Macabinlar did not move,” the report said. Four and a half hours later another inmate reported his condition to jail officials.
Under soft-check procedures, deputies are supposed to get a verbal or physical acknowledgement from the inmate that he or she is OK. Hard-check protocols require deputies to use a bar-code reader or other tools to confirm the identity of an inmate.
The sheriff’s department issued a statement Monday declining to respond to the review board findings.
“It is premature for the department to comment at this time because CLERB has yet to formally vote on its findings,” the statement said. “Once it does … we will review the report thoroughly and address issues recommended by the board.”
Macabinlar was booked into the Vista jail after he was arrested Sept. 19, 2017, the review board said. Its report did not specify why he was arrested.
At the time, Macabinlar told jail deputies he did not use drugs. He reported that he had diabetes that he was not treating, investigators said.
The jail staff ordered five medications for him and placed him on a special diet.
The next day, September 20, Macabinlar refused a sick call. He was last seen alive in his cell four days later, at 1 p.m.
Once Macabinlar was reported unresponsive, about 9 a.m. on Sept. 25, staff began life-saving measures but were unable to revive him, the report said. Paramedics arrived by 9:26 a.m. and declared him dead.
An autopsy found the cause of death was an accidental overdose of methamphetamine, with contributing health factors related to heart disease.
Investigators could not say how Macabinlar acquired the drugs.
San Diego County has been plagued for years by deaths inside its jail system. Last Thursday, 56-year-old Joseph Castiglione was found in medical distress inside a Vista holding cell and later died.
Frederick Jefferson hanged himself in his cell at the George Bailey Detention Facility in September and, in October, Manuel Cruz committed suicide in his cell at the San Diego Central Jail.
The sheriff’s department has adopted several policy changes aimed at reducing jail suicides, but it has not eliminated the deaths. At least 136 people have died in San Diego County jail custody since 2007, according to department records and news releases.
In April, when The San Diego Union-Tribune reported that sheriff’s officials were not announcing jail deaths according to policy, 57 deaths were ruled the result of natural causes and 40 were suicides.
Twenty-two others were ruled accidental or overdoses, six were homicides and a handful were undetermined, the newspaper reported.
Several of the in-custody deaths have resulted in lawsuits against the county that have cost taxpayers millions of dollars in recent years.
The county paid $3.2 million to the family of Daniel Sisson, who died in 2011 from medical complications while in sheriff’s department custody. The county paid $2.3 million to relatives of Bernard Victorianne, who died in custody in 2012 after deputies failed to respond to symptoms of a drug overdose.
The Citizens Law Enforcement Review Board is a volunteer group organized to review in-custody deaths, officer-involved shootings and complaints against sheriff’s deputies. Its findings and recommendations may or may not be accepted by the sheriff’s department.
The panel meets at 5:30 p.m. Tuesday in downtown San Diego at the County Administration Center on Pacific Highway.