Eyes around the country are on Los Angeles County after a series of revelations about conditions in its jails, and the outcome in the George Rosales case is not surprising, but it speaks volumes about the attitudes of people working within the system. Rosales was caught in a web of circumstances that ultimately led to his death, and following any one of a number of trails leads to equally grim conclusions: This is a death that could have, and should have, been prevented, but it wasn’t.

Five months after his death in a Los Angeles County jail facility, the autopsy results are back, and they declare the death was unconnected with the blow to the head Rosales sustained in an altercation with a deputy two days before his death. Instead, he apparently died of an acute pancreatic inflammation leading to hemorrhaging, which could have been caused by abdominal trauma or a drug reaction.

There are several ways to interpret the autopsy results. One is that the deputy who hit Rosales in this head didn’t cause the fatal injury, if, as stated, he only hit Rosales in the head. According to Robert Faturechi and Jack Leonard at the Los Angeles Times, the coroner’s report indicated that ‘no abdominal trauma’ occurred during the incident two days before his death. The information on this? From internal jail reports, which may not be the most reliable source when it comes to determining the nature and extent of the injuries that landed Rosales in the infirmary.

According to reports, Rosales was attempting to break for an elevator when a deputy used ‘excessive force’ to restrain him by hitting him on the head, causing a concussion severe enough to put him in the infirmary for several days. Before he had a chance to recover, he was found unresponsive by jail personnel, and death was pronounced shortly thereafter. This is one in a long line of excessive force cases in LA County jails, but it came to the attention of the public because of Rosales’ death, which changed the picture considerably; instead of being a ‘routine’ inmate assault, it ended in death. Officials assure the media that most deputies are not abusive with prisoners, and that incidents like this are the exception, not the rule, but even one prisoner beating is too much of an exception for my taste.

However, Rosales was also in treatment for mental illness, which complicates his case. The medications he was using are known to be damaging to the pancreas, and the jail is attempting to claim that he developed pancreatitis and secondary medical problems because of the medications. It’s an issue that has been known to happen, and because of concerns about this particular side effect, users of the medication are typically monitored carefully while on it for signs of pancreatic inflammation. One small problem with the jail’s attempt to dodge responsibility: The autopsy showed that the medication levels in his blood were way too high.

This suggests that while Rosales was in the ‘care’ of the jail, he was overmedicated, quite substantially. One might innocently assume that the overmedication simply wasn’t caught; his dosage was incorrectly recorded, perhaps, and no one bothered to run serum tests to check on the blood concentration. However, dosing on psychiatric medication is tight, and it’s unlikely a mistake this significant would be made entirely accidentally; more likely, he was overmedicated on purpose as a means of control, a common practice in institutions. And no one cared enough to make sure the dose wasn’t high enough to damage his pancreas.

According to both jail reports and his family, Rosales was agitated in the weeks preceding his death, which is indicative that something was wrong, and his medications would have been a natural first thing to check. He was beating the walls, acting confused, falling, and displaying other symptoms of psychiatric side effects. These should have been caught by prison medical staff, and should have led to an evaluation to find out what was going on and how to resolve it, which would have included a blood panel to check on serum levels and pancreatic health.

The fact that no measures were taken despite the fact that he was obviously distressed, and Rosales was allowed to die in the jail infirmary, says a lot about the penal system. In California, large numbers of inmates and prisoners are mentally ill and do not receive adequate care and treatment; until very recently, the prison system was actually in a receivership on the grounds that the health care it provided was so inadequate that it was posing a threat to the health and safety of prisoners. Inmates often do not access mental health services at all, and don’t necessarily receive appropriate care when they do connect with mental health professionals.

This is a reflection of the state at large, where cuts to mental health funding are occurring across numerous counties, making it extremely difficult to provide services. At the same time, the number of people needing access to these services is on the rise as a result of loss of insurance, stress related to the economy, and other factors. For mentally ill youth, like Rosales, the resources are even more limited. Some parents are even being told to effectively surrender their children to the prison system because community-based resources are so limited; youth with severe mental illness cannot get resources outside of institutions.

This young man was drinking water out of the toilet on the day he died, indicating that something was severely medically wrong. Either he was experiencing acute psychosis or acute thirst, and in either case, he needed emergency medical attention. Instead, he was left alone to die in his cell. This is what ‘justice’ looks like for mentally ill prisoners in California, who are overwhelmingly young men of colour like Rosales was. This is not a coincidence.

If nothing else, this case reinforces the critical need for a total overhaul of health services in LA County jails, including a clear protocol for identifying mental health complications and treating them quickly, and training for infirmary staff so that they know to take action when prisoners are developing severe medical conditions. It’s also yet another reminder that the LA County jail system is hopelessly, dangerously broken and cannot be left in its current state. Whether Rosales’ death will lead to reform is doubtful, however; he’s just another young man of colour broken by the justice system.