Four inmates have died in a San Diego jail in less than six weeks. The deaths have reignited long-running concerns about medical and mental health care inside the jails of California’s second most populous county, and the ways the system puts vulnerable prisoners at risk, The Guardian reports. The jail system’s inmate death toll stands at 135 over the last decade. 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 increased. A majority of the 135 deaths involve inmates with serious mental illness. Some prisoners died of a lack of medical care. Many took their own lives.

San Diego County jails struggle with preventing inmate suicides, said a 2018 report by Disability Rights California, a watchdog organization. During the three-year span of the investigation, more inmates killed themselves in San Diego’s jail system than in Los Angeles County jails, despite L.A.’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. The recent wave of deaths started on February 7, when inmates at the Vista Detention facility alerted deputies that 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, 56, had stopped breathing and was “was turning blue”. He died an hour later at a hospital. The autopsy concluded a baggie of meth had burst open in his stomach. Department policy recommends inmates who are combative be placed on their side to prevent suffocation.