When San Diego sheriff’s deputies saw Matthew Godfrey lying unresponsive on the floor of his jail cell last November, they didn’t immediately unlock the door to see what was wrong.

Instead, according to an autopsy report released last week, deputies continued their rounds, checking on other inmates housed on the sixth floor of the San Diego Central Jail.

A Sheriff’s department spokesman said that the process took about 15 seconds.

When they returned to Godfrey’s cell, it was clear the inmate needed life-saving care. Deputies and medical staff started CPR and tried a defibrillator, to no avail. At 11:54 a.m., 11 minutes after deputies saw Godfrey on the floor, they called 911, the report states.


Help arrived quickly. The report states that deputies placed Godfrey in a waist chain, handcuffs and leg cuffs before paramedics began advanced life support procedures — a practice the Sheriff’s Department said was needed to transport Godfrey to a hospital.

The medical team was unable to save him. A Scripps Mercy Hospital emergency room physician reached by radio declared Godfrey dead at 12:15 p.m. on Nov. 27, the day after Thanksgiving.

Sheriff’s Department spokesman Lt. Ricardo Lopez said only a few seconds had passed between the time Godfrey was first seen “unresponsive” and when deputies completed their rounds and started tending to the inmate.

“For safety reasons, while the deputy was waiting for his cover partner to enter the cell, they completed their checks, which took a total of about 15 seconds,” Lopez said by email. “Both deputies then returned to Mr. Godfrey’s cell, opened the cell door, found him unresponsive and immediately began rendering aid and called for medical assistance.”


Godfrey’s criminal record consists of a string of misdemeanor arrests in the months prior to his death. He was booked into jail Nov. 3 and spent his last days in solitary confinement in a housing unit reserved for mentally ill inmates, records show.

He was the 16th inmate to die in San Diego County custody last year.

The San Diego Union-Tribune initially reported Godfrey’s death early in December from a document obtained under the California Public Records Act, because Sheriff Bill Gore no longer announces in-custody deaths until internal investigations are completed, which often takes months.

Based on information provided by two sources familiar with Godfrey’s case, the Dec. 4 story and a second article the following week called the death a suicide.


The Sheriff’s Department declined to comment at the time.

The Union-Tribune is examining the just released autopsy findings in closer detail to help explain why medical professionals inside the jail considered Godfrey’s death a suicide. The sources, who work with inmates in the county jail system, said they are troubled by the recent report, and one said that coroners tend to err on the side of caution in ruling on the causes and manners of inmate deaths.

The newly released autopsy lists Godfrey’s cause of death as hypertensive and atherosclerotic cardiovascular disease, a serious heart condition. The manner of death was ruled natural.

But the report’s own language is ambiguous about what killed Godfrey, saying, that nursing staff and paramedics had to clear “whole food particles” from his airway before rendering first aid and a folded food wrapper was found in his stomach.


“It (is) most likely the decedent succumbed to his coronary artery disease and the gastric contents in the airway are an effect of the terminal stages of dying,” the autopsy said.

Investigators also noted that Godfrey “had a torn section of a t-shirt rolled up and loosely secured around his neck when he was initially discovered in his cell.” While loose, paramedics cut the fabric from around Godfrey’s neck, the report said.

“The decedent also had a rope fabricated from various cloths concealed in his pants” and a “shirt and blanket pieces with multiple knots” were discovered, the autopsy said.

Some advocates said they were concerned with Godfrey’s condition and treatment in the cell.


Godfrey was found with “thin strands of sheet/ shirt material partially placed in (his) rectum,” the report said. His cell was “dirty and unkempt with paper waste and food debris strewn along the walls and floor,” the medical examiner’s investigator said.

The decision by deputies to restrict Godfrey to solitary confinement over his final days may have exacerbated his condition, one expert said.

Aaron Fischer, litigation counsel for Disability Rights California, a San Francisco-based organization that has federal authority to inspect detention facilities, said isolation can worsen existing symptoms of mental illness and deprive people of essential human contact.

“Putting a person with mental illness in solitary confinement conditions as harsh as those in San Diego County’s jails is extremely dangerous,” he said. “A deadly outcome like this one should surprise no one.”


Under the Sheriff’s Department policy, inmates assigned to solitary confinement are allowed one hour a day outside their cells but are still separated from other inmates.

The mortality rate in San Diego County jails is higher than every other large California county, according to a Union-Tribune investigation published in September.

Suicides have become a more significant problem, the “Dying Behind Bars” series showed. In each of the past 10 years ending in 2018, San Diego County experienced an average of 3.9 suicides a year, a rate two to five times that of other large California counties.

The Sheriff’s Department has said it hired additional therapists and imposed additional training to reduce the number of inmates killing themselves.


In the hours after Godfrey’s death, word spread among the jail staff that an inmate had died in custody. A source alerted the Union-Tribune that evening.

“Suicide today in 6E,” the source wrote in a Nov. 27 email. “That is solitary at Central Jail for psych folks. Tragic.”

The medical examiner’s report concludes with a referral of Godfrey’s case to the public administrator, which is a county agency that processes property owned by people who die without heirs or a will, because investigators could not locate his next of kin.

A relative recently contacted the Union-Tribune after reading about Godfrey’s death.


“We have located his remains. We thank you,” Godfrey family member Joanie DeVore-Gutierrez said by email. “Without your story, we may never have had some closure.”

According to DeVore-Gutierrez, Godfrey had been arrested repeatedly for returning to a rented room he shared with his mother before the pair was served with a notice of unlawful detainer last March, indicating a pending eviction.

Godfrey had a long history of mental-health issues but never indicated he was suicidal, she said.

“We do note the gaps in the timeline. And have deep concerns,” DeVore-Gutierrez said of the autopsy report. “Some are angry. But we also do not know if the outcome would have been different either. I personally feel they ignored him and brazenly noted it in the report.”


Even so, “at this time, no one wishes to pursue any further inquiry.”

There were 16 deaths in San Diego County jails last year, making it the second-highest number of fatalities per year over the prior two decades. Seventeen jail deaths were recorded in 2014.

So far this year, one inmate has died in custody.