Michelle Moriarty called the Vista jail 31 times, begging the staff to make sure her husband couldn’t harm himself.

Heron Moriarty, a 43-year-old father of three, was booked into jail in late May 2016 after suffering a psychotic breakdown. He’d already been hospitalized twice and had stopped taking his medication.

“I would sit on the phone for half an hour,” she said in an interview. “But they’re, like, ‘Don’t worry, we’re taking care of him.’ They said he’s in good hands.”

After six days in solitary confinement, Heron Moriarty strangled himself and died.


A new report on suicides in San Diego jails doesn’t mention Moriarty by name, but among the cases it highlights as preventable suicides is one Michelle Moriarty knows is her husband. Hours before he died, a nurse practitioner recommended Heron Moriarty be placed on suicide watch. But a jail sergeant ignored the nurse’s recommendation, the report says.

The report was published today by Disability Rights California, which has federal authority to investigate conditions in adult and juvenile detention facilities throughout the state.

It’s the result of a years-long investigation into San Diego County jails that included a review of policies and incident reports and interviews with inmates, jail staff and correctional experts.

The report criticizes the San Diego County Sheriff’s Department for not providing appropriate care for seriously mentally ill inmates, resulting in dozens of preventable suicides. Additional faults include poor supervision of at-risk inmates and lack of communication among staff.


Rebecca Cervenak, San Diego staff attorney for the group, said the number of suicides in San Diego jails is what prompted the investigation. Since 2010, more than 30 inmates have killed themselves in county lockups.

“We knew that those deaths were likely the tip of the iceberg and that they were evidence of systemic issues that required attention,” Cervenak said.

In an emailed statement, Sheriff’s Department spokeswoman Karen Stubkjaer said the department takes all suicides seriously. She noted the recent drop in suicides and attributed it to improved training to identify at-risk inmates and provide them with appropriate services.

Since Jan. 1, 2017, two inmates have killed themselves in San Diego county jails, a sharp reduction from previous years, when Moriarty and others died.


The improvement comes after the Sheriff’s Department brought on additional mental health clinicians and introduced “enhanced observation units” as an alternative to safety cells, where suicidal inmates could be closely monitored. The department also started doing “psychological autopsies” of inmates who committed suicide to see if warning signs were missed.

The Disability Rights report acknowledges these changes, but points out that suicide attempts haven’t seen a similar decline.

Eighty-two attempts were documented in 2015, 107 in 2016 and 73 between Jan. 1, 2017, and Sept. 11, 2017, according incident reports DRC reviewed. The 73 attempts, the report says, included overdoses, hangings, self-strangulation and jumps from the second tier of jail housing units.

“While we are convinced that the Sheriff’s Department has begun to take the issue of suicide prevention seriously, there remain many aspects of the system’s treatment of people at risk of suicide that require urgent action,” the report says.


For its investigation, the Sacramento-based Disability Rights group examined 17 inmate suicides between 2014 and 2016.

The report notes that during that same three-year period, Los Angeles County jails — which have an inmate population three times the size of San Diego’s — had eight suicides. Orange County, with a jail system similar in size to San Diego’s, had one suicide.

In one case the group reviewed, surveillance video showed an inmate standing naked on a desk in his cell for 14 minutes “praying and preparing to jump” before diving headfirst onto the floor, where he lay for four minutes before staff checked on him.

The man had been housed in the new enhanced observation unit where inmates are supposed to be checked on every 15 minutes.


In another case, after finding an inmate hanging in his cell, deputies waited seven minutes to summon help, “and then prevented nursing staff from evaluating the inmate’s condition,” the report says.

And in another case, surveillance video showed 11 deputies waiting several minutes before initiating lifesaving measures.

One inmate’s request for psychiatric services went ignored for two days. The man had been placed in solitary confinement, where he was allowed out of his cell for one hour every 48 hours. He hung himself 45 minutes after asking for some time out of his cell.

“Prior to hanging himself,” the report says, “he had urinated on the floor, stuck food and feces on the ceiling and scrawled a suicide note on the cell walls using his own blood.”


The report points out that at least a third of inmates who committed suicide had been placed in solitary confinement or some form of restrictive housing.

The report also argues the jails use safety cells to manage inmates who’d benefit more from treatment. Last year, the report notes, suicidal inmates were placed in safety cells 6,700 times, some for as long as four days. Lights in the cells remain on 24 hours a day, there’s no bed and a grate on the floor serves as a toilet.

In an 18-page response, the Sheriff’s Department thanked Disability Rights for its report, but argued that some of its conclusions were wrong, starting with the finding that San Diego has the highest suicide rate among California’s large jail systems.


Cervenak said the group calculated the suicide rate using average daily population — the number of inmates in a jail on any given day. It’s the same methodology used by the federal Bureau of Justice Statistics for its Deaths in Custody Reporting Program and by experts who study jail suicides.

“At the end of the day, the number of suicides in the jails is troubling,” she said.

A more accurate approach, the department said in its response, would be to look at the total number of people booked into jail annually — known as the “at-risk population” — and also take into account the fact that San Diego jails house more white inmates than other jails, a group statistically more likely to commit suicide.

The department hired San Diego State University statistics professor Colleen Kelly to re-do the numbers factoring in racial disparities. Doing this, Kelly found that the suicide rate in San Diego jails is similar to most large jail systems in California.


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