The Most Dangerous Place in Alameda County 

A "barbaric" litany of horrors from Santa Rita, "the best big jail in the nation."

click to enlarge There have been at least 35 deaths at Alameda County jails since 2014.

Photo by Scott Morris

There have been at least 35 deaths at Alameda County jails since 2014.

Barbara Doss was preparing dinner on a Sunday evening when she got the call. Her son Dujuan Armstrong, who had been sentenced to jail for a 2014 residential burglary, was scheduled to be released from Santa Rita Jail that evening. His girlfriend, who had recently discovered she was pregnant, had gone to pick him up at the jail with her father. But when he didn't come out, she called Doss.

Then her father got on the phone. "Juan gone," a crying Doss recalled him telling her. "Juan dead."

Armstrong had only reported to the jail two nights earlier, since his 120-day sentence allowed him to serve his time solely on weekends. According to the wrongful death claim his mother eventually filed against the county, when Armstrong entered jail on June 22, he told deputies that he felt sick because he'd ingested narcotics. Jailers first placed him into a cell alone but later moved him into the jail's clinic. At some point, he was injured in a confrontation with jail deputies. Eventually, he collapsed and stopped breathing and was taken to Valley Care Medical Center in Pleasanton, where his death certificate says he died the following evening, at 7:24 p.m.

Doss has been trying to find out what happened to her son ever since, but few details have been released. In a letter to the county's Board of Supervisors, Sheriff Gregory Ahern, who runs the jail, wrote that Armstrong's death was "believed to be the result of a drug overdose."

But the sheriff's office has acknowledged that deputies used restraints on Armstrong during their struggle. And when Doss examined her son's body, she said his lip was swollen, there were three bruises on his cheek, a bump on his forehead, staples in his skull, and welts on his chest. This evidence made her believe that her son was Tased. The Alameda County District Attorney's Office is investigating. Pending the completion of that investigation, the sheriff's office has declined to release the coroner's report, body camera video, or any other information about the incident, even to Armstrong's family.

Armstrong had been working various jobs, including for a tow truck company in downtown Oakland. He had his first child when he was 16, and had an 8-year-old son, a 7-year-old daughter, and a newborn son, Doss said in an interview. "He took good care of his kids from the time that they were little," she said. "He was a good dad."

At times families of people killed in law enforcement use of force incidents have been permitted to screen video of the incident or receive the coroner's report during the investigation. But Armstrong's family has been waiting for nearly a year. Sheriff's spokesperson Sgt. Ray Kelly did not respond to questions about the reason for the secrecy surrounding Armstrong's death, except to say that the incident remains under investigation.

Armstrong's mother filed a claim with the county in December, the first step before filing a lawsuit. In January, she confronted the sheriff publicly and on video at the Lottery Commission building in Sacramento with members of the Ella Baker Center for Human Rights, which has been calling for an audit of the sheriff's office, and particularly Santa Rita.

"I don't have any answers," Doss said to Ahern. "I need answers. I need to ease my mind. I need to know what you guys are covering up. I want to know where his belongings are, I want to know where the footage is."

Ahern told Doss, "His property, the body-worn camera, was sent to the district attorney's office as part of the investigation. These all take time. These answers don't come from me." Asked by Doss if the deputies were put on leave during the investigation into Armstrong's death, the sheriff replied, "I don't know if they did or not."

According to state records, Armstrong was just one of the 35 people who have died in jail at Alameda County's Santa Rita Jail since 2014. Among the 17 California counties housing more than 1,000 inmates over the last five years, Alameda County had the fourth-highest rate of inmate deaths. Ten people died in 2014, eight in 2015, six each in 2016 and 2017, and four in 2018, with one so far this year. And while the number of deaths in the jails has gone down, so too has the jail's population. There were 3,301 inmates in Alameda County jails in 2014, compared to just 2,581 in 2018.

A mere three days after Armstrong died, another inmate died in Santa Rita: Jesus Dickey, a homeless man arrested for two sexual batteries in Berkeley. An autopsy revealed that Dickey died from water intoxication. He suffered from schizophrenia, which made him compulsively drink water. He had been prescribed medication but wasn't taking it; pills were found stuffed in his sock during an autopsy. A subsequent class-action lawsuit alleging systemic failures in mental-health treatment at the jail cited Dickey's death as an example.

Another death was linked to the jail last July. Jessica St. Louis was found dead of a drug overdose at the Dublin/Pleasanton BART station shortly after her release from jail at 1:30 a.m. Experts in opioid addiction say that people released from jail are at high risk of a drug overdose, but there is no data available for how many people die just after being released from the jail.

The jail's troubling track record has led to a litany of costly civil-rights lawsuits. From 2013-2017, Alameda County paid out $15.5 million in civil-rights settlements and judgments — which the East Bay Express has found was greater than the amount paid by any other agency in the region — including nearly $5.4 million relating to conditions in the jail. And the payouts continue to mount. In 2018, the Alameda County Board of Supervisors approved more than $2.5 million in such settlements, including $200,000 to the family of Michael Brown, who died by suicide in the jail in 2015.

Last year, three class-action lawsuits were filed on behalf of jail inmates. One alleges systemic negligence in providing proper medical care to female inmates, particularly pregnant women. That suit notes that one woman was forced to give birth in a jail cell, which the sheriff's office has admitted, and other inmates say they were encouraged to get abortions. Another lawsuit alleges that the sheriff's office has failed to provide adequate mental-health care to inmates, exacerbating disorders by routinely using isolation on inmates suffering from psychiatric disabilities. A third lawsuit alleges that guards are effectively torturing inmates with sleep deprivation, and a federal judge recently ordered the sheriff's office to adjust its schedule for medication and breakfast so guards are not continually waking inmates throughout the night.

The allegations in the lawsuits, many of which the sheriff's office has denied, describe horrific conditions in the jail, with filthy cells, kitchens, and medical facilities. They describe inattentive medical staff and abusive deputies. Some allegations regarding conditions at the jail have been impossible to deny. One inmate suffering from mental illness described being tortured while held in isolation by guards who allowed another inmate to spray him with urine and feces. Four guards are facing criminal charges for the alleged abuse, which at times resembles the horrors that occurred at Iraq's notorious Abu Ghraib prison complex.

Jail populations are difficult to manage. People who are sent to jail often have issues with honesty, anger, addictions, poor health, suicidal tendencies, or other mental-health issues. Well-run jails have protocols for dealing with such challenges. But a review of the fatalities that have occurred at or outside Santa Rita Jail in recent years suggests that Alameda County's systems and oversight are far-too-frequently inadequate.

In January, citing reporting by the East Bay Express as well as the numerous allegations found in some of the lawsuits described in this story, State Sen. Nancy Skinner wrote a letter to the Board of Supervisors expressing support for an independent financial and performance audit. "A strong performance audit will generate crucial evaluative data that can thoroughly assess all current practices and policies [and] provide lifesaving recommendations for implementation," Skinner wrote.

Skinner called the jail's track record troubling during a recent interview. "Thirty-four in-custody deaths in a five-year period is pretty significant and additionally having 29 women file suit in four years around allegations of mistreatment," she said. "We know a number of those allegations are actually accurate — I can't verify all of them — certainly a woman giving birth in her cell alone, that's not normal, it's not what you would expect in a well-run facility."

However, Alameda County's Sheriff has given Santa Rita an A grade. While addressing complaints about the conditions at the jail in an interview with KTVU reporter Candace Nguyen in November, Ahern said, "I think we're the best big jail in the nation."


Deputy Matthew Ahlf was alone when he opened Martin Harrison's cell door. Harrison, in the throes of delirium tremens, had broken his food tray, blocked his toilet and flooded his cell with water. Harrison had his mattress over his head. "They're coming to get me," Alhf recalled Harrison screaming. "They're going to kill me."

But when Ahlf spoke to Harrison, he said Harrison calmed down. Concluding that the inmate was no longer a threat, the deputy decided to open the cell door and handcuff him. But Ahlf still had his Taser drawn. Ahlf would later recall in a deposition that Harrison turned toward him and gave him an unsettling blank stare, so Ahlf pushed him back into the cell and then walked in himself. When Harrison stepped toward him, Ahlf Tased him, he recalled.

Ahlf said that Harrison had charged at him. He slipped on the wet cell floor, and slid out, grabbing Ahlf's leg and pulling him to the floor as well. They wrestled and Ahlf punched Harrison multiple times. More deputies arrived. They joined the struggle, restrained Harrison, and placed a spit mask on his head. They continued to hit and Tase him until he stopped moving. A nurse checked his vitals and found he had a staggered pulse, Ahlf testified. Two days later, at Valley Care Medical Center, Harrison died.

His death highlights the troubling allegations linked to the jail's series of private health-care providers. The 50-year-old prisoner had been booked into Santa Rita Jail on Aug. 13, 2010, for a failure-to-appear ticket after he missed a court appearance for driving under the influence. According to the lawsuit later filed by his family, he told the jail's nursing staff that he drank alcohol every day and had a history of problems with alcohol withdrawal.

While the nursing staff noted his condition, according to the lawsuit, no one followed through with any blood tests or other screenings to determine the extent of his risk for alcohol withdrawal. Nor did they provide him with any medication to treat or prevent the symptoms of alcohol withdrawal. Two days after his arrest, the lawsuit says, Harrison requested medical care, but did not receive any.

By Aug. 16, the suit alleged, Harrison had symptoms of severe alcohol withdrawal, including hallucinations, disorientation, incoherent mumbling, and other bizarre behavior. Ahlf recalled in his deposition that Harrison — in a jail surrounded by 28 other men — asked him why there was a bunch of women in his house. His behavior had alarmed the other inmates, and Ahlf said he placed Harrison in an isolation cell at about 3 or 4 a.m. His shift ended shortly after that and he went home.

When he returned for his next shift 12 hours later, medical staff still had not seen Harrison. Ahlf said he called Megan Hast, an associate clinical social worker at the jail who was employed by the county, at about 4 p.m.

"We're talking over 12 hours of someone sitting in one cell and him being monitored by several other deputies," Ahlf said in his deposition. "At some point I would have expected that a mental-health worker would have been called out."

According to the lawsuit, sheriff's office policy requires correctional staff to respond to health-related situations within four minutes. But, according to her notes from that day, Hast did not go to the housing unit for an hour. When she arrived, deputies were in the middle of a shift change and could not assist her. Hast looked into the cell, saw Harrison standing at the toilet, and did not speak with him, she wrote.

By the time she came back, the deputies had Tased Harrison, and he'd been taken to the infirmary, Hast wrote.

In 2011, Harrison's family sued Alameda County and the jail's private healthcare provider at the time, Corizon Health Inc. The company had been established that year through a merger of Correctional Medical Services Inc. and Prison Health Services Inc., the latter of which had served as Santa Rita's healthcare provider since 1988. According to its website, the Tennessee-based Corizon now provides correctional healthcare services to more than 400 prisons, jails and other correctional facilities.

Harrison's family's lawsuit accused Corizon and its predecessor of a pattern of neglecting inmates struggling with addiction or mental illness. It's not the first time these companies had been accused of neglecting patients. A 2005 New York Times investigation found a nationwide pattern of poor medical care that suggested Prison Health Services had provided inadequate services to cut costs. Civil-rights advocates have argued that placing prison healthcare in the hands of for-profit companies will necessarily lead to such outcomes.

In a May 2011 letter recommending that the Board of Supervisors extend the Prison Health Services contract, Ahern said the company "has demonstrated a commitment to maintain and exceed the quality of their correctional health care services and programs."

Two months later, the newly-renamed Corizon donated $20,000 to Ahern's reelection campaign. A KTVU investigation found that Corizon and Prison Health Services had donated $110,000 to Ahern's campaign between 2006 and 2013. In 2013, the supervisors again renewed Corizon's contract for three years.

Harrison's family reached an $8.3 million settlement in February 2015, which split the cost between the county and Corizon. The family's attorneys said at the time that it was the largest wrongful-death settlement in California history.

Just six months after that, another death raised new questions about Corizon's ability to properly handle medical care at the jail.

Mario Martinez, 29, had been charged with attempted murder and possession of a firearm in November 2014. In February 2015, while he was jailed awaiting trial, he was examined by a doctor for growths on his nasal passages that had become so large they almost hung out of his nostrils, according to medical records. The doctor referred him for possible surgery to remove these nasal polyps.

But at his next court appearance on March 23, Martinez still had not been seen by the jail's medical staff. A judge issued multiple orders for Martinez to be treated, but months went by and he was not. In court filings, his defense attorney, Timothy Rien, wrote that he visited Martinez on June 8, 2015. "It was obvious he was having trouble breathing," Rien stated. "A large, clearly visible polyp was ballooned and protruding from his nostril. He also reported an infected tooth. He said he still had not seen anyone."

On July 15, 2015, Martinez's cellmate heard him cry out, "I can't breathe!" according the lawsuit later filed by his family. Jail staff ordered Martinez's cellmate to take him to the kitchen. They then told Martinez to walk into the yard, where he collapsed, according to the lawsuit. He later died in the jail's clinic.

Martinez's family sued Corizon and Alameda County on Feb. 23, 2016, just weeks after the county's Board of Supervisors voted to launch a competitive bidding process for the jail's healthcare provider.

That summer, Corizon lost the contract to California Forensic Medical Group, a Monterey-based company that was founded in the early 1980s. California Forensic Medical Group, or CFMG, took over management of medical services at the jail in October 2016.

But the new provider faced its own controversies. The Sacramento Bee newspaper reported in 2015 that over a 10-year period, jails contracting with CFMG had a rate of suicide and drug overdoses 50 percent higher than in other county jails in California. At least three county grand juries had criticized its role in inmate deaths. A class-action lawsuit in the company's home county of Monterey alleging improper medical and mental-health care led to a 2015 settlement requiring sweeping improvements to the jail's healthcare.

Jose Bernal, an organizer with the Ella Baker Center who has been working on the campaign to audit the Alameda County Sheriff's Office, said that he has been following developments with the Santa Rita's medical providers closely over the last few years.

"There is no indication to me that CFMG is doing any better than the previous provider," Bernal said.


The deputies in Santa Rita's Housing Unit 2 called him "Preacher." William Epting, 51, had gone to prison in the 1990s for voluntary manslaughter and was back in jail on a domestic violence charge. Epting was given the nickname "Preacher" because, with the guards' assistance, he was "spreading the gospel" — meaning he was spraying other inmates with a mixture of feces and urine from a shampoo bottle, according to testimony at the deputies' preliminary hearing. The guards called the nauseating cocktail "crapuccinos."

Spraying urine and feces like this is common in jails and prisons, and is known as "gassing." Yet typically, such assaults are directed at the guards — not facilitated by them. Prosecutors say that in Santa Rita the guards used Preacher to assault inmates for months.

Four deputies — Justin Linn, Erik McDermott, Stephen Sarcos and Sarah Krause — were eventually arrested and criminally charged for the repeated assaults. McDermott and Linn faced more serious charges. All four have been ordered to stand trial and their criminal cases are ongoing.

The deputies were overseeing Housing Unit 2, F-pod, which is used for administrative segregation, also known as solitary confinement. A class-action lawsuit filed in December 2018 alleged systemic failures in mental-health treatment for inmates in Santa Rita Jail, including that solitary confinement is routinely used in lieu of treatment for people suffering from psychiatric disabilities. Inmates in administrative segregation spend 23 or 24 hours per day in their cells. They are only allowed 5 hours of structured out-of-cell time per week. The sheriff's office has said that administrative segregation is used for exceptionally violent offenders or to separate rival gangs.

One frequent target of the gassing attacks was Fernando Miguel Soria. He was jailed Aug. 25, 2016 for four misdemeanor counts of alleged battery on hospital workers at John George Psychiatric Pavilion in San Leandro, the county's public mental-health hospital. According to a lawsuit Soria filed last year, he had gone there to refill a prescription for depression. While there, according to the lawsuit, the hospital staff tried to sedate him with a shot, which Soria objected to, and there was a struggle. Soria was arrested. The charges were later dismissed and Soria's attorney, civil-rights attorney John Burris, has called the initial arrest unwarranted.

Soria was jailed at Santa Rita, where he was held in isolation for two days and then taken to administrative segregation, where he was held until November, according to his lawsuit. The guards let Preacher gas Soria several times while he was in jail, according to Soria's lawsuit and the district attorney's charging documents. They would open the handcuffing port on the cell door and make Preacher spray urine and feces inside. The lawsuit alleges there were at least five different incidents. After Soria was gassed, the deputies would refuse to return his clothes for two or three days and he would be forced to clean them in the toilet. The lawsuit also alleges that McDermott maced Soria in his cell and he wasn't allowed to wash that off either.

Left with his clothes covered in urine and feces, the lawsuit states, Soria would vomit and convulse in his cell. McDermott allegedly took Soria's clothes at one point but didn't give him any new clothes and made him sleep on the concrete floor with no mat or blanket. Another time, Soria tried to stop them from gassing him by reaching into the handcuff port after they opened it. The deputies allegedly slammed the port, breaking Soria's arm. His lawsuit alleges they didn't provide him with medical care for a week after that.

At a news conference announcing his lawsuit against the county in October, Soria lifted his shirt sleeve to show reporters the scar on his arm. It nearly runs from his elbow to his shoulder.

Linn and McDermott were ordered by Alameda County Superior Court Judge Morris Jacobson in April to stand trial for the assaults, including one count each of dissuading a witness. According to charging documents, Linn brought an inmate into a walk-in refrigerator, took off his body camera, and told the inmate to tell a rival gang that an inmate who had reported the assaults was a "snitch."


Candace Steel says she had no towel, blanket, or bed in the room where her daughter was born. It had a concrete floor, a toilet, a sink, and a locked solid metal door. She says she was alone, screaming in pain. Steel would later recount that the umbilical cord was wrapped around the baby's neck, but Steel managed to open her airways. As she cradled her crying baby in the cell in Santa Rita, she couldn't even dry off the fluids and afterbirth.

Steel's ordeal is just one of a series of incidents in which pregnant inmates accuse the jail system of subjecting them to what one lawsuit described as "barbaric" standards of medical care.

Three days earlier, Steel had been living with her boyfriend and 2-year-old daughter in an encampment on Caltrans property near Interstate 580 in Castro Valley. She was arrested by Alameda County Sheriff's Deputy Marcus Cox, who wrote in court filings that conditions at the camp were "deplorable," with piles of trash, decaying food, and a shallow hole filled with urine and feces.

Steel's daughter was "incredibly disheveled," Cox wrote, and "covered in grime and filth." Her hair was matted and her clothes were soiled, and he worried that the toddler might wander onto the nearby highway. The Alameda County District Attorney's Office eventually charged Steel with one misdemeanor count of child endangerment. The charge was later dismissed.

According to her lawsuit against the county and the jail's medical provider, California Forensic Medical Group, Steel was booked into Santa Rita shortly after midnight. When doctors at Valley Care Hospital examined her before she was booked, they determined that she was eight months pregnant.

She told the doctors that she'd smoked methamphetamine and drank alcohol during her pregnancy, that she had received no pre-natal care, and did not know her due date, according to her lawsuit. Her previous pregnancy had ended with her having seizures and spontaneously delivering the baby. Hospital staff diagnosed her with a urinary tract infection, which can lead to pre-term labor and delivery.

But despite her precarious medical state and the risks that it posed, she was transferred to Santa Rita. Two days later, she told jail staff she was in so much pain that she could not walk and was crawling on her hands and knees, according to the lawsuit. She was examined by a medical group nurse, who determined she only had a stomach ache, according to the lawsuit. When she was returned to the housing unit, deputies put her in an isolation cell as punishment, where she screamed in pain.

Hours later, the other inmates heard Steel stop screaming. According to the lawsuit, her cries were replaced by those of her newborn daughter.

The Alameda County Sheriff's Office has acknowledged that Steel gave birth in an isolation cell on July 23, 2017 after a "series of incidents," but says that staff discovered her in the process and helped her deliver the baby. Steel has said that's not true.

Her lawsuit was filed separately last year, but Steel's ordeal was first disclosed in a class-action lawsuit alleging systemic failures in providing proper healthcare to incarcerated women by the Alameda County Sheriff's Office and the medical group. Steel was not included in that lawsuit only because the attorneys were unable to find her at the time. The two cases are now related as they make their way through federal court.

The sheriff's office called a press conference just after the class-action lawsuit was filed in January 2018. While Sgt. Ray Kelly acknowledged that a woman had given birth in the jail, he said she had gone to the hospital but been misdiagnosed and taken back to the jail. "That child was born healthy as far as we know and there were no lasting effects from that incident," Kelly said.

The suit also alleges that two women suffered miscarriages after being encouraged by medical staff to have an abortion. In one case, it alleges that guards may have caused the miscarriage.

Christina Zepeda, who was 37 years old at the time, was booked into jail on Aug. 13, 2017, for a felony burglary conviction. She was pregnant when she entered the jail and told medical staff that she wasn't feeling well, according to the lawsuit. But the suit alleges she never received any medical care; instead the medical staff told her she could have an abortion anytime, and the guards encouraged her to do so. Four days later, she suffered a miscarriage. The lawsuit alleges that she received no counseling or support as she was grieving.

The lead plaintiff in the lawsuit, Jaclyn Mohrbacher, says she also had a miscarriage in custody. Mohrbacher alleges that guards and medical staff tried to force her to get an abortion, and repeatedly strip-searched her before her miscarriage. The staff even falsely told her that her baby was dead, the suit alleges. Mohrbacher refused to have an abortion, but the medical staff scheduled one anyway. Two male deputies tried to force her from her housing unit to have an abortion, the lawsuit alleges, yet she resisted. Deputies Debra Farmanian and Tania Pope told her she "needed to get" an abortion, the suit alleges, and they accused her of being on drugs.

At last year's press conference, Kelly from the sheriff's office said those allegations are false. "[Deputies] would never engage in that kind of egregious behavior to influence women to terminate a pregnancy," he said.

The suit also alleges that jail guards strip-searched Mohrbacher three times in less than a week. During the third search, she started bleeding from her vagina, and eventually suffered a miscarriage. The lawsuit alleges that she never received medical care for her miscarriage.

That same month, a California Forensic Medical Group staffer quit in protest over the company's treatment of pregnant inmates, specifically those suffering from opioid dependency. Savannah O'Neill was the jail's opioid treatment program coordinator from February 2017 until her Dec. 6, 2017 resignation. She is a certified addiction treatment counselor and associate clinical social worker who had worked with the county since 2016 on overdose prevention and distributing naxalone, an overdose-reversal drug that many drug users keep on hand in case of an accidental overdose. Police officers are increasingly carrying the drug and have credited it with saving lives.

After O'Neill was hired at Santa Rita, she worked only four hours a week providing counseling for people in methadone treatment. When she arrived there, the medical group did not yet have a license to dispense methadone, a pain reliever commonly used to treat opioid addiction, and so a contractor, HAART, was dispensing methadone in the jail. HAART's policy was to provide pregnant women with methadone treatment and maintain the treatment for anyone who was already on it. Everyone else went through medically supervised withdrawal, also known as detox.

O'Neill was troubled by this approach. "Detoxing people off that is not based in evidence," she said in an interview. "There's a lot of evidence if you sustain people in treatment there is lower recidivism, people are healthier. The practice of detoxing people was always incredibly counter to what I saw work in the community."

In her resignation letter, O'Neill would note that the American College of Obstetricians and Gynecologists "recommends methadone maintenance for pregnant women and advises against medically supervised withdrawal because relapse rates are so high and can cause negative maternal and fetal health outcomes, as well as miscarriage."

Once the medical group was licensed to dispense methadone, the company implemented a new protocol to detox all inmates off opioids, regardless of their condition or history, O'Neill said. Although the protocol made an exception for pregnant women, O'Neill wrote in a sworn statement that she saw two pregnant women in withdrawal. One had symptoms of withdrawal including vomiting and diarrhea, O'Neill said, but the medical director said she was not actually opioid dependent, despite documented history. The other had been given methadone, but only 10 mg, when an initial dose is usually around 30 mg and an average dose is 80 mg.

While she was in the jail, O'Neill also advocated that inmates at risk of opioid overdose be given naxalone when they are released. She had pushed the sheriff's office to implement the policy since 2016 and gave seven presentations to medical staff and the sheriff's office over the next three years.

"Having someone in withdrawal and with no tolerance, when they get out has a huge risk of overdose," O'Neill said. "Giving it to people who are leaving jails is a really effective intervention."

But the sheriff's office never implemented the policy until after a woman recently released from the jail was found dead of an overdose at the nearby BART station. Her death would spur a call for statewide reform on the late-night release of prisoners.

While not technically an in-custody death because it happened after she was released, the death of 26-year-old Jessica St. Louis in July alarmed observers at the jail. St. Louis was found at the passenger pickup area of the Dublin/Pleasanton BART station when it opened at 5:30 a.m. on July 28. She had reached a plea agreement and was sentenced a day prior to five days in jail, which she had already served while awaiting sentencing, and three years of probation. She was released from the jail at 1:30 a.m., well before BART started running. An autopsy determined that she had died from a fentanyl and heroin overdose.

The death of St. Louis appears to have spurred some policy changes, possibly at a statewide level. Beginning in September, a little more than a month after St. Louis's death, Santa Rita staff began providing some inmates at risk of an overdose with naxalone when they're released. It's the same policy that O'Neill had been advocating for years.

In December, state Sen. Nancy Skinner introduced legislation that would give people scheduled to be released in the middle of the night the option to either stay in the jail until daytime or get transport anywhere in the county, so people like St. Louis would not be released with no way to get home. The bill passed the Senate's Public Safety Committee in April.

"They're very vulnerable when they're released, regardless of their job, and vulnerable people are easy prey and predatory people are always seeking vulnerable people," Skinner said in an interview. Late night release is "a perfect recipe for a predatory person to take advantage of a vulnerable person," she said.


In late 2017 and early 2018, two inmates hanged themselves while held in isolation. On Nov. 28, 2017, according to a lawsuit alleging systemic failures in mental-health treatment at the jail, Edwin Villalta was found dead in his cell after hanging himself with his county-issued blanket. Villalta was not on intensive observation log, a jail protocol for people demonstrating behavioral problems or who could be suicidal. Logan Masterson was found dead on April 7, 2018, while held in administrative segregation in Housing Unit 2, the same unit where guards had allegedly subjected inmates to gassing attacks in 2016. A lawsuit filed over the latter incident highlights alleged deficiencies in the jail's treatment of inmates with suicidal tendencies.

Masterson had been arrested three days earlier, after leading Livermore police officers on a pursuit. He had allegedly stolen a car at gunpoint in downtown Livermore. According to a lawsuit filed by his family in March, Masterson was intoxicated and suicidal when he was booked into jail.

He was first placed on suicide watch in a "safety cell," rooms with no furnishings except for a door and a grate on the floor that's used as a toilet. According to Masterson's family's lawsuit, inmates in safety cells are stripped naked and dressed in a tear-proof smock. They are not given access to toilet paper and have no way to wash up, so they and the cell get progressively dirtier the longer they're in there.

"These conditions are traumatic for all prisoners, but especially for those who are already experiencing severe mental-health symptoms," the class-action lawsuit alleges. "Suicidal prisoners perceive the safety cells as a method of punishment which dissuades them from telling staff they are suicidal."

Masterson was moved to administrative segregation in Housing Unit 2 on April 6. While there, he asked for mental-health assistance, the lawsuit alleges, but no one responded.

On the afternoon of April 7, Masterson was acting bizarrely. He clogged the toilet and flooded his cell and had partially covered the window in wet toilet paper, according to the lawsuit. Deputies who witnessed the behavior did not intervene or contact mental-health staff. A welfare check was conducted about an hour before he was found dead, but the suit alleges that Deputy Nicholas Lagorio's check was "dangerously cursory and superficial," since he had no clear view of Masterson.

While state records show there were four deaths in Santa Rita Jail in 2018, Masterson's was the only death disclosed in a press release. Two other inmates died in the jail within three days in June, but their deaths were only publicly reported a week later, after the East Bay Express received a tip. Even then, the sheriff's office did not release their names for months. And one death in March 2018, that of Gino Willie Dalbianco, is being publicly disclosed here for the first time. In fact, when confirming the deaths of Armstrong and Dickey last July, Sgt. Kelly said there had been three deaths in Santa Rita at that point in 2018. In fact, there had been four.

Dalbianco, 58, had been arrested earlier in the year and charged with failing to register as a sex offender after a felony conviction. He was assigned to Housing Unit 9, the behavioral health unit, according to the sheriff's office's incident report. Dalbianco was found unresponsive in his bunk at 7:52 a.m. on March 8, 2018, and was pronounced dead there. An autopsy revealed his cause of death to be acute pulmonary emboli; blood clots had entered the arteries in his lungs. Dalbianco had a long history of arrests and incarceration. A coroner's investigator was unable to locate his next of kin; his only family member listed in a law enforcement database had died in 1982.

Although Dujuan Armstrong died on the night of Saturday, June 23, his family wasn't notified until after he was scheduled to be released the following evening. Later that night, a sergeant went to Doss's Oakland home to tell her that her son was dead. Jesus Dickey was found dead in his cell two days after Armstrong was scheduled to be released, but not even his name was publicly disclosed until it was reported in the East Bay Express the following January.

Ceasar Pajuelo, 70, was found unresponsive in his cell on March 10, and thus appears to be the first death at Santa Rita in 2019. The sheriff's office said that Pajuelo had been beaten by his cellmate, 19-year-old Paul Stefano, who was charged with murder days later. Stefano was in custody for auto theft.

A second inmate died later in March, but according to the sheriff's office, his death doesn't count as an in-custody death. Michael Hermon, 47, was punched in the nose during a fight on March 13. His nose didn't stop bleeding and he was taken to the hospital. Eventually he was placed on life support and died.

Hermon's death wasn't disclosed publicly until his family alerted Berkeleyside, which reported the story on April 5. Hermon, a Gulf War veteran with a Ph.D. in philosophy, had been arrested in Berkeley in February after he had allegedly fired a gun into his own van, injuring no one. He was scheduled to be moved to a diversion program for veterans, but the transfer hadn't happened because of space constraints, according to Berkeleyside.

"There are a lot of unknowns as to how he ultimately died and until the medical reports are finalized we can not draw a conclusion," Kelly told the Express in an email. "A series of unforeseen medical events and issues unfolded that led to him being on life support and passing."

Kelly said the sheriff's office always complies with its requirements to report in-custody deaths to the state and the county Board of Supervisors. Yet he did not respond to follow up questions about why the deaths of four inmates this and last year were not disclosed via press release.

Meanwhile, the three-year contract for the jail's embattled health care provider, California Forensic Medical Group, is up this year. But the contract authorizes two one-year extensions, and Kelly said it is likely the county will use the extension this year.

And Barbara Doss, the grieving mother of Dujuan Armstrong, still is seeking answers as the one-year anniversary of his death approaches.

"They're doing whatever they want to do and Santa Rita needs to be stopped," she said. "And I'm going to stop them. They're going to wish they had never heard from me."

Doss and St. Louis's family appeared together in a small protest outside Santa Rita in August, where she asked jailers to "give me some answers to my questions. They couldn't answer me. I asked them what was their protocol; they couldn't give me that either."

Speaking through a megaphone to the group, she turned, faced the jail, and yelled. "I need you to give me answers, us answers, you hear?"

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