John Horton was held in solitary confinement in the Los Angeles County Men‘s Central Jail following his arrest for drug possession. He committed suicide.

In the days leading up to his death in March 2009, jail staff noted that Mr. Horton was despondent. His cell was a dimly-lit, windowless, solid-front box the size of a closet. His body was already stiff by the time security staff discovered him hanging from a noose in his cell, with his hands bound – one of eight successful apparent suicides in the L.A. County jails in the past calendar year.

Shortly after the suicide, the ACLU received a letter from an inmate in an adjacent cell describing Horton’s obviously disturbed behavior and repeated suicidal gestures, which deputies had witnessed in the days before his death. The ACLU demanded that the County investigate.

The Office of Independent Review (OIR) for Los Angeles County conducted an independent investigation into the 22-year-old’s death, and recently released its explosive and damning findings. These findings underscore the urgency of the ACLU’s efforts to address the horrific conditions and abuses in Men’s Central Jail, where as many as 50 percent of the detainees are mentally ill.

The OIR’s July 19, 2010, report confirmed that the sheriff’s deputies knew Horton was despondent. Deputies were tasked with checking on him at frequent intervals, but during the hours leading up to his death, the requisite checks were not made. The deputy in charge of supervising Horton had been largely absent from his post: He went to the staff gym to work out, he took a shower, he even went to a nearby restaurant for a “chow run” with his supervisor’s approval. The OIR report noted that the subsequent autopsy on Horton showed internal bruising from injuries incurred before the hanging.

In a cover-up after the suicide, at least 10 deputies engaged in a deliberate, systematic faking of surveillance logs. According to the report, the deputies created fake bar codes to circumvent a jail policy requiring deputies to document their periodic “welfare checks” on inmates, by scanning bar code plaques mounted at each end of every cell row. Ironically, the scanning system had been implemented to deter “’after the fact’ efforts to doctor welfare check logs after something ‘bad’ such as suicide had occurred”, according to the report.

The deputies’ actions “were overt and premeditated and demonstrated a wholesale failure” to carry out their duty “to diligently watch over and provide safety and security for the inmates under his or her supervision” – a failure, the report noted, which might have facilitated Horton’s suicide. The OIR report concluded that during its nine years of oversight of L.A. County Jails, it had found evidence of a “sub environment in which outlier cultures can fester and cause deputies to lose their way and sense of mission.”

The OIR report substantiates similar findings in an annual report on conditions in the jails released in May 2010 by the ACLU of Southern California and the ACLU National Prison Project, which serve as official monitors of the L.A. County jails.