‘When someone dies by suicide in a system’s highest level of care, there is enormous cause for concern,’ says an attorney from Disability Rights California

On 18 March, Maria Palacios Escalera got a call from a doctor at the UC San Diego hospital in southern California. Her son, Ivan Ortiz, an inmate at San Diego’s Central jail, had tried to kill himself, he said. Doctors had been able to revive him, but he had a weak pulse and his brain had been deprived of oxygen. She should make her way over to the hospital as soon as possible.

Escalera and her daughter Priscilla rushed to the hospital, but when they got there, a deputy with the San Diego sheriff’s department told them they’d need to get a permit to see Ivan – visitors must obtain a permit from the jail’s watch commander to visit an inmate who’s been hospitalized, even if the inmate is “in grave condition”, department policy says.

So they headed to the Central jail. Once there, they waited 40 minutes before a man – Escalera was too frantic to ask his name – came out and told her the hospital had just called to say Ivan had died.

Ortiz, 26, was the fourth person to die in a San Diego jail in less than six weeks.

The recent deaths have reignited long-running concerns about medical and mental healthcare inside the jails of California’s second most populous county, and the ways the system puts at risk some of the most vulnerable prisoners.

The jail system’s inmate death toll stands at 135 dead over the last decade, according to public records. Between 2000 and 2007, San Diego had the second highest death rate of inmates among the state’s large jail systems, according to the Bureau of Justice Statistics. Since then, those numbers have only increased. A majority of the 135 deaths involve inmates who struggled with serious mental illness. Some prisoners died of a lack of medical care. And many took their own lives.

San Diego county jails particularly struggle with preventing inmate suicides, a 2018 report by Disability Rights California, a watchdog organization, found. During the three-year span of the investigation, more inmates killed themselves in San Diego’s jail system than in LA county jails, despite LA’s inmate population being three times the size. The report found the San Diego jails struggled with an over-incarceration of people with mental health-related disabilities, failed to provide adequate mental health treatment to inmates, did not have in place appropriate suicide prevention practices and lacked oversight.

‘He died because the San Diego Central jail failed’

The recent wave of deaths started on 7 February, when inmates at the Vista Detention facility alerted deputies that 56-year-old Joseph Castiglione was behaving erratically. To subdue him, deputies shackled Castiglione’s wrists and ankles and placed him face-down on a gurney. Several minutes later, the autopsy report said, a deputy noticed Castiglione had stopped breathing and was “was turning blue”. He died an hour later at a local hospital. The autopsy concluded a baggie of meth had burst open in his stomach. Department policy recommends inmates who are intoxicated and combative be placed on their side to prevent suffocation.

A week later, Michael Wilson succumbed in San Diego’s Central jail. Wilson, who was 32, died of heart failure on Valentine’s Day. His sister, Shanel Wilson, told the Guardian he was born with a congenital heart defect and had recently had a defibrillator placed in his chest.

The San Diego jails struggled with an over-incarceration of people with mental health-related disabilities and failed to provide treatment

Wilson had been booked on a probation violation and had called his mom from jail to tell her he was having trouble breathing and wasn’t being given his prescription heart medication, according to Shanel. Over the 10 days Wilson was incarcerated, his mother repeatedly called the jail to ask staff to move her son to the facility’s medical unit, Shanel said. Wilson, however, remained in the jail’s general population.

Wilson had a history of mental illness. Court records show he’d been found incompetent to stand trial on assault charges in 2016.

Shortly after his death, Shanel saw a TV report saying her brother died of “unknown causes”. “He didn’t die of ‘unknown causes’,” she wrote on Facebook in response. “He died because the San Diego Central jail failed to provide him with his prescription heart medications.”

Derek King, 45, died two days after Wilson. He passed away as a result of colon cancer that had spread to other parts of his body, an autopsy report concluded. King had recently returned to jail from a state psychiatric hospital after being found incompetent to stand trial on attempted murder charges, according to court records.

‘Enormous cause for concern’

Four deaths in six weeks is troubling, Aaron Fischer, an attorney with Disability Rights California who co-wrote last year’s report, told the Guardian in response to the latest incidents.

Fischer was especially troubled by Ivan Ortiz’s death, given that the young man had been placed in the jail’s psychiatric observation unit.

“When someone dies by suicide in a system’s highest level of care, there is enormous cause for concern about whether the system is capable of keeping people safe,” Fischer said.

Ortiz had been an inmate at the Central jail since June, and had long suffered from schizophrenia, his mother said.

Our jail system provides excellent medical screening and care San Diego sheriff's spokeswoman

He had been arrested after attacking two young men with his skateboard outside a downtown San Diego restaurant and was charged with attempted murder. A hearing scheduled for 19 March was supposed to determine whether he was legally insane at the time of the assault.

While incarcerated, Ortiz had broken his own jaw, and had been housed in the jail’s psychiatric observation unit for the last two months in an effort to prevent him from further harming himself. Maria said she’d told jail staff many times that her son shouldn’t be left alone. Still, he was placed in a single cell.

“They didn’t listen,” she said.

‘Here we go again’

Deaths in San Diego county jails have prompted at least a dozen lawsuits since 2008 and more than $7m in settlements – yet critics say there have been few reforms.

Attorneys such as Julia Yoo, whose firm Iredale & Yoo has represented families in several lawsuits, wonders if the sheriff’s department is learning from previous incidents.

Yoo’s law firm is currently handling two such cases. In one, a man diagnosed with schizophrenia, whose illness caused him to drink water uncontrollably, died of water intoxication after the jail ignored warnings to monitor his water intake. In another case, a schizophrenic man was Tasered four times and suffered cardiac arrest after deputies pinned him to the ground.

“It seems like there are ways for the sheriff’s department to fix the problem,” Yoo said, “but they don’t, and here we go again.”

A San Diego sheriff’s spokeswoman told the Guardian via email that she couldn’t comment on individual deaths but that, “our jail system provides excellent medical screening and care.”

The statement showed just how little has changed over the past few years. It was exactly the same line a different sheriff’s spokeswoman gave in response to a series of stories on deaths in San Diego jails for a local newspaper. That series ran six years ago.