SAN DIEGO, CA -- On a sweltering April afternoon in 2017, James Leonard Acuna spent what may have been the last day of his life playing soccer with fellow inmates at the Richard J. Donovan Correctional Facility in Otay Mesa, a few miles north of the Mexican border. The 58-year-old Los Angeles resident was serving a 16-year sentence for assault with a deadly weapon, and was sharing a cell with a man convicted of murdering his father.

Decomposition was so advanced that forensic experts aren't sure how he died and officially listed his cause of death as "undetermined." But the autopsy concluded that while it was possible Acuna died of natural causes, "homicidal violence cannot be completely excluded," indicating his body showed "signs of minor blunt force injury of head and extremities."

It was a year ago this week Acuna died quietly in his cell, on April 21 or 22 – nobody knows for sure because his body wasn't discovered until April 24, hidden under a blanket on his bed and decayed to the point it caused an odor prison employees initially thought was a sewage problem.

The California Department of Corrections and Rehabilitation (CDCR), which was supposed to be watching Acuna, has been less than forthcoming with details. Other local and state authorities have refused to release information related to his death.

Yet a year after Acuna's remains were unceremoniously cremated and his ashes scattered at sea, the full circumstances surrounding his death remain a mystery.

Why Acuna's death went unnoticed despite required headcounts and the fact he was supposed to be administered daily medication in person by a licensed psychiatric technician are just two questions that remain unclear.

CDCR regulations require the physical counting of inmates at least "four times each calendar day" and further require that during evening headcounts inmates like Acuna — who occupied a cell — must stand at the cell door until counted.

Dan Vasquez —a former warden at two state prisons, including San Quentin, the state's oldest correctional facility — said he was taught, and in turn instructed his employees, to check for "living, breathing flesh" during inmate headcounts.

Vasquez found Acuna's death troubling from a procedural standpoint and said prison supervisors, including the warden, should be held accountable for failing to follow procedure. "In a modern prison like RJ Donovan, officers should not be able to make a serious mistake to the point a body is decomposing in a cell," he said.

"It was a rule drilled into my head," said Vasquez, who worked for the state corrections department for more than three decades. "You had to make sure you saw living, breathing flesh —that's when you knew the inmate was OK."

That view was supported by the California Office of Inspector General (OIG), the agency responsible for overseeing the corrections department, which described prison officials' response to the death as "not adequate," finding that corrections officers and licensed psychiatric technicians "should have discovered the inmate."

In a report released last August, the OIG said the CDCR "identified potential staff misconduct based on several officers' alleged failure to conduct proper inmate counts, licensed psychiatric technicians alleged failure to administer and monitor the inmate's medications, and alleged false reporting regarding contact with the inmate after his death."

The OIG report noted that the CDCR's own Office of Internal Affairs investigated "allegations against eight officers, two licensed psychiatric technicians, and one teacher" in connection with the death but failed to notify the Inspector General.

The OIG also reported that the Office of Internal Affairs for some reason "refused to investigate similar alleged misconduct by four additional officers and three additional license psychiatric technicians" even after evidence showed Acuna had been dead for several days.

Shaun Spillane, a spokesman for the OIG, said its monitoring of the Acuna case was closed last June but would not reveal whether any prison employees were dismissed as a result, saying "that investigation is still ongoing."

However, this week, Vicky Waters, a spokeswoman for CDCR, told Patch the investigation had finally concluded and "appropriate action is being taken against some employees," but she would not disclose the number of employees, their positions or what specific disciplinary action was being considered, citing employees' "due process" rights.

What Was the Cellmate's Story?

Another lingering question raised by Acuna's death is what his cellmate may have told investigators. Not only did this inmate kill his father and conceal the body under a mattress where it decomposed before being discovered, but according to a San Diego County Medical Examiner's report, the cellmate told a mental healthcare professional at the prison that he "had murdered his former cellmate to get a cell to himself" while he was incarcerated in Kern County.

Corrections officials have refused to identify the cellmate, citing personal privacy. However, Patch has learned that shortly after Acuna's death the cellmate was quickly transferred to another unidentified prison.

The San Diego County Sheriff's Department has also refused Patch's requests to release the report of its investigation, so it's impossible to determine how extensive the probe by homicide investigators was, or whether detectives corroborated the cellmate's claims.

Sheriff's Lt. Michael Blevins said investigators interviewed several prison officials and inmates, including Acuna's cellmate, who didn't make "much of a response at all."

The autopsy said officials were told that a day after Acuna was last seen alive another inmate attempted to enter his cell, but was told by the cellmate Acuna had the flu. The autopsy report further noted the cellmate also attempted to block prison staff from checking on Acuna's welfare.

One corrections expert told Patch any report of an inmate with the flu should have been immediately investigated. Many prisons will quarantine any inmate with flu to prevent outbreaks among other prisoners.

Vasquez said the cellmate's action should have been a "red flag," especially in view of the cellmate's history, saying a convicted murderer who allegedly killed another inmate after being sent to prison should have been kept away from other prisoners.

"To double-cell a man convicted of homicide is a failure," Vasquez said.

State regulations don't directly address the issue of cellmate selection and instead leave those decisions to a prison's designated custody supervisor, who has great leeway in determining an inmate's "appropriate housing assignment" after considering several factors that include a "history of in-cell assaults and/or violence."

What About The Meds?

Besides the issue of improper prisoner headcounts, another pressing question is why healthcare professionals who should have had daily face-to-face contact with Acuna didn't discover him dead in bed.

Acuna, who suffered from cirrhosis of the liver due to a chronic Hepatitis C viral infection, had been assigned to Yard C, the cellblock housing inmates requiring the most medical attention, sources said.

Sources within CDCR, who asked to remain anonymous because they were not authorized to discuss the matter, told Patch that Acuna was prescribed medication that should have been administered daily in person by a healthcare professional.

It is uncertain whether Acuna was receiving medication through his cell door or from the "pill window" – a location where inmates line up to have medications administered. Once medications are dispensed from the prison pharmacy they're transported to individual cell blocks, where a healthcare professional takes possession and actually administers the medicine to an inmate.

Patch has been told prison pharmacy records show the medication was dispensed to a licensed psychiatric technician who "marked off" that Acuna had received his daily medication during the time he lay dead in his cell.

What those medications were is unknown, although Acuna's post-mortem toxicology tests reported traces of antidepressants Venlafaxine and Amitriptyline as well as Nortriptyline, a drug prescribed for headaches and sleep issues. There was no indication of any medication being prescribed to treat Hepatitis C.

Dr. David Bernstein, an internal medicine and gastroenterology specialist and Hepatitis B and C researcher at Northwell Health in New York, reviewed the autopsy report and doesn't believe Acuna died as the result of Hepatitis C, a condition that is typically treated orally with one or two pills a day for 12 weeks.

"If someone is not treated for eight to 12 weeks, they're not going to die because they didn't receive the medication," said Bernstein, who said he's worked with thousands of patients over a 30-year career. He said people can die from complications of cirrhosis but there will be bleeding and other symptoms, none of which Acuna's autopsy indicated he had.

"My guess is that Hepatitis C had nothing to do with his demise," Bernstein said.

State and federal laws guarantee some form of medical care for inmates and California regulations require CDCR to provide medical services for inmates based on medical necessity, although no inmate can be forced to take medication if they are competent and object except in an emergency.

Acuna's Hepatitis C infection was not unusual for an inmate. According to CDCR, more than 18,000 inmates in the state's prison system have been diagnosed with chronic Hepatitis C.

In February, civil rights lawyers Marek Merin and Fred Hiestand filed a class-action lawsuit on behalf of 18 inmates – five of whom had spent various stints at Donovan – alleging CDCR and its Correctional Health Care Services division were denying more effective treatment to infected inmates by refusing to administer new drugs — medications the CDCR claims are too expensive for general use. That case is pending in Sacramento federal court.

Correctional Carelessness 'Shocking'

The California Correctional Peace Officers Association, the union representing prison guards, declined to comment citing an ongoing investigation, while the California Association of Psychiatric Technicians, the union representing psychiatric technicians, did not respond to requests for comment.

Several members of the state Senate Public Safety Committee, which has jurisdiction over CDCR, told Patch they were "too busy" to comment and referred inquiries to committee chairwoman Sen. Nancy Skinner (D-Berkeley), whose press secretary also said her schedule prevented her from commenting. The office of Sen. Ben Hueso, who represents Otay Mesa, home of the prison, also did not comment.

But prisoner rights advocates have criticized CDCR employees for failing to find Acuna's body sooner.

Bardis Vakili, senior staff attorney with the ACLU of San Diego and Imperial Counties, describes the incident as "shocking."

"Whenever the government takes someone into custody, it bears the responsibility for that individual's safety," Vakili said. "However harsh the conditions in prison may be, for a dead body to go unnoticed in a cell for so long that the cause of death can no longer be determined requires a shocking level of carelessness. In this case, something clearly went wrong, and a transparent investigation and public account of corrective measures to be taken are necessary."

Sara Leslie, a volunteer for the nonprofit inmates' rights group California Prison Focus, said a Donovan prison inmate wrote to the group to express his dismay over the late discovery of Acuna's body. Although the nonprofit declined to identify the inmate who authored the letter, she said it's just one of many disturbing incidents that have occurred at the Otay Mesa prison.

"Clearly CDCR and the COs [corrections officers] who oversee his housing unit are at fault," Leslie said. "The fact that he was not seen or counted for two to three days shows they were not doing their job. If this inmate had a job, appointments etc., they should have investigated his absence."

A 'Two-Strike' Career Criminal

Sketchy court records spanning more than three decades portray Acuna as a career criminal who spent much of his life in courtrooms and cellblocks, beginning in 1984 when he was sentenced to six years in prison after his conviction for robbery with a firearm.

Following a string of convictions for relatively minor offenses that included convictions in 1992 for vandalism and DUI, were a 1997 conviction for brandishing a weapon resulting in a 49-day jail sentence and two 1998 convictions, one on a weapons charge, the other for assault and battery resulting in a combined total of 50 days in jail.

In December 1999, Acuna was charged with first degree residential burglary and received an eight-year prison sentence. Public records do not indicate whether Acuna served the entire sentence or was paroled. However, in 2012, Acuna received a 10-day jail sentence after he was convicted for being drunk in public.



Acuna's final trip to prison, as a "second-striker," came in 2014 when he was sent to Donovan correctional to serve 16 years for assault with a deadly weapon. That sentence was never completed.

Patch was unable to obtain details of Acuna's early life or locate any relatives. His death certificate indicated family members were "unknown" and the autopsy report listed the Donovan correctional facility as Acuna's next of kin. CDCR considers a body unclaimed if "all reasonable efforts have been exhausted" to locate the loved ones of the deceased.



Former prosecutors and public defenders in Acuna's criminal cases who could be located did not return calls and emails seeking comment.

Dying neglected and unnoticed in a prison cell surrounded by hundreds of other inmates is distressing to prisoners' rights advocates.

"The fact [Acuna] made bad choices and was paying his debt to society doesn't mean he should have been neglected," said Prison Focus's Leslie. "We as a society should care because we are a civilized country and it's expected that we treat all people in a humane manner."



Patch reporter Emily Holland contributed to this report.

Photo composite via Shutterstock and CDCR booking photo

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