On a Saturday in the summer of 2002, Ramon Gavira was pulled over for drunk driving and taken to Los Angeles County Jail.
Five days after his arrest, the 43-year-old father of five was dead.
Guards say they found Gavira dangling from the bars of a one-man cell with a torn bedsheet tightly knotted around his neck. Los Angeles County sheriff's detectives and the coroner concluded that he had killed himself.
But when Gavira's brothers saw his bruised and battered body at the funeral home a few days later, they began to suspect there was more to the story.
Gavira's body had six broken ribs, a broken collarbone and bruises that would be hard for any man to inflict upon himself. Most curious was a snapped neck bone that medical experts say is more often seen when someone has been strangled by a pair of hands.
Since then, Gavira's family has been pressing a wrongful-death lawsuit that is set for trial early next year. A spokesman for Sheriff Lee Baca was adamant that Gavira committed suicide, and cast his death as an unavoidable tragedy in an understaffed and overcrowded jail system -- the nation's largest.
Regardless of how he died, testimony and other evidence suggest that Gavira -- mentally frail and withdrawing from alcohol from the moment he entered custody -- was deprived of medical care, mocked and beaten during his brief stint behind bars.
In addition, records and interviews show that sheriff's officials did little to determine how Gavira sustained such severe injuries, brushing aside allegations that a female deputy -- who trains as a boxer -- might have been responsible.
Attorney Michael Gennaco, who serves as an independent watchdog over the Sheriff's Department, said he could not comment on specifics because of the litigation. But he said he was convinced that Gavira was not slain.
Still, he acknowledged, "there are a lot of unanswered questions."
Searching for a Muffler
Gavira, an auto mechanic, spent the late morning and early afternoon of July 6, 2002, scouring a junkyard in Wilmington for a part he needed to fix up an old Chevy Blazer for one of his sons. It was typical; he was a protective father who often went out of his way for his children, taking them for barbecues at Magic Johnson Park in South L.A. and to the beach at Marina del Rey.
But as he also often did on weekends, he was drinking heavily.
Gavira's wife, who accompanied him to the Pick Your Part salvage yard, doesn't know how many beers he had consumed before he found the muffler he needed. After leaving the junkyard, they stopped at a liquor store, where Gavira bought her a soda and himself more beer, which he drank while parked outside.
They were headed home to Compton when a deputy noticed the car swerving from lane to lane and pulled them over.
Gavira was slurring his words and reeked of alcohol. He failed several roadside sobriety tests and was arrested.
At the Carson sheriff's station, he was given a Breathalyzer test. It showed he had a blood-alcohol level of 0.27 -- more than three times the legal limit for driving. Authorities also discovered that his license had been suspended because he had failed to appear in court on a drunk-driving charge years earlier.
Gavira was booked and placed in a holding cell. Two days later, he was bused to the sheriff's Inmate Reception Center in downtown Los Angeles.
There, jailers determine where to send those who enter the county system, which on an average day houses nearly 18,000 inmates in eight facilities. A medical check is a key part of the routine. Gavira spent most of July 9 being processed.
He was examined by a nurse and a doctor, records show. He was diagnosed as depressed, diabetic and suffering from alcohol withdrawal. A jail employee indicated on a form that Gavira, in responding to a standard series of questions, said he was hearing voices, had contemplated suicide in the past and was now thinking about it again.
During a separate interview hours later with Carmen Lima, a jail social worker, Gavira cried and expressed concern for his family.
"He was blaming himself for being in jail for drinking," Lima recalled during a court deposition.
Gavira told Lima that years before, he had twice tried suicide by wrecking his car. But he said he did not recall having told anyone that he was currently suicidal.
A psychiatric social worker, Lima deemed Gavira a low suicide risk who would not be a threat to himself or need special monitoring, although she did sign him up to be seen by a jail psychiatrist.
Lima recommended that Gavira be housed with a group of inmates who also had medical conditions. In a so-called pill module, he could receive treatment for his diabetes and alcohol withdrawal and have his blood sugar checked each morning.
Then Gavira was put in a line of other inmates and escorted through the long underground tunnel that connects the reception center with Men's Central Jail across Bauchet Street. A 5-foot-2, 143-pound man whose gray hair made him look older than his 43 years, Gavira emerged from the tunnel just after 8 p.m., records show.
Waiting there was Deputy Adrian Dominguez. Having been told by reception center deputies that Gavira was having trouble with other inmates, Dominguez said, he pulled him aside. Gavira confided that he was afraid of being assaulted and wanted to know if he could have his own cell, Dominguez testified in a deposition.
Dominguez said he felt sorry for Gavira and told him he would put him in a single-occupant cell in the jail's disciplinary area, called the "hole." Gavira agreed to the move, the guard said.
The "hole" is usually where incorrigible inmates are housed in rows of dingy 8-by-4-foot cells. It is dark, dank and loud. Gavira was placed in Cell 26. It had an open metal toilet and a narrow bunk covered by a white sheet.
During his two days there, jail records show, Gavira never got the daily diabetes and alcohol withdrawal medications he was supposed to receive. Sheriff's officials say records indicate that the only time nurses tried to deliver his meds, Gavira was in court. So his elevated blood sugar -- a concern raised by the reception center medical staff -- went unchecked.
Experts say high blood sugar can affect a person's mental state when combined with depression and alcohol withdrawal. Whether that happened to Gavira is unknown, but the inmate quickly showed signs that he could not adjust to life behind bars. Deputies and inmates said he appeared scared and confused. He reacted slowly when given orders and cried at night, muttering that he wanted to go home. Such behavior, veteran inmates and guards say, can attract unwanted attention.
Jailer Denies Abuse
That's what happened the day Gavira was confronted by a female guard identified in court papers as Deputy Anel Manriquez, 32, according to three inmates who were also on his row.
Two of the inmates testified under oath that they saw Manriquez assault and humiliate Gavira. The third testified that he heard Gavira being taunted and crying out in pain, and later saw him walk past his cell as if he had been beaten.
Manriquez, called "J-Lo" by the inmates because of her resemblance to actress Jennifer Lopez, was what jail officials call a "prowler," roaming the complex and helping other deputies. The 5-foot-4, 130-pound deputy also fought on the sheriff's boxing team and had a reputation among prisoners as a tough-talking, take-no-guff officer.
Manriquez declined to comment for this article, but testified in her deposition that she barely remembered Gavira and firmly denied abusing him. On the night Gavira died, his body had been discovered before she arrived for her 10 p.m. shift, she testified.
But one inmate said Manriquez was on the row shortly before Gavira's death, and another said she was there right after. Sheriff's officials have dismissed the inmates' accounts as not credible.
Because there are no windows in that section of the jail, it is difficult to distinguish morning from night. And any sense of day or date can be quickly lost. In their depositions for the lawsuit, the inmates varied on the precise time of the alleged assault and other details. But they were consistent in describing a scenario in which Manriquez taunted and abused Gavira. All three said that she referred to the inmate's huevos.
Inmate Gregory William Franciskovich testified that he was standing in a corridor lined up with others waiting to go to court when he saw Manriquez approach Gavira.
He said the guard slammed Gavira head first into a wall and slapped him around. She then struck him between the legs and mocked him.
"Where's your huevos?" Franciskovich quoted the deputy as saying.
Gavira seemed frightened and started to cry.
Franciskovich, jailed on a car theft charge, said Manriquez then knocked the inmate to the concrete floor and continued to mock him until he urinated in his pants.
Gavira was ordered to change into a jumpsuit that turned out to be too small. The deputies standing nearby thought it was "real funny," Franciskovich said.
"So I made a comment to her, told her, 'Why don't you leave him alone?' " Franciskovich testified.
"Do you want to be next?" Manriquez replied, according to the inmate.
"She's a lady with an evil heart. If you look at her, she'll get in your face, trying to intimidate you. So everybody is pretty much afraid of her."
Farther down the row, another inmate said he was also out of his cell and saw Manriquez rough up Gavira. Like Franciskovich, he said he saw the deputy slam Gavira into a wall, grab his genitals and throw him to the ground. He said a male deputy, whom he could not identify, also joined in the assault.
"It was wrong," the inmate said during his deposition in the Gavira family's lawsuit. "You could see him crying, confused, lost."
Because the inmate was also an informant whom deputies relied on for tips, such as when another prisoner had a weapon, his name is being withheld by The Times.
A third inmate, Christopher Coleman, was in Cell 24, two down from Gavira's. He said he was resting in his bunk when he heard the voice of a female deputy teasing Gavira. Moments later, he said, Gavira walked past his cell "kind of hunched like somebody took some kidney shots or whatever to his stomach and stuff."
If the inmates were telling the truth, the most likely time frame of such an assault would have been either July 10 or 11, jail records show. Gavira lined up to go to court the morning of July 10 and arrived at the Compton Courthouse. However, for some reason he did not appear before a judge.
Instead, his case was continued to the following day, when he again lined up, was taken to court and did appear. He pleaded no contest to reckless driving, driving drunk and driving with a suspended license. A judge sentenced him to 11 days in jail.
Gavira was then sent back to Men's Central. His release order would be coming in a matter of hours, although it is unclear if anyone told him that. Records don't say why he was to be released shy of the full 11 days; jail officials, who have wide latitude to reduce overcrowding, may have just decided he had served enough.
That evening, shortly after Gavira's return to the jail, Deputy Victor Montes said he saw the inmate wandering around a hallway, acting "disoriented to a point, almost intoxicated." He said the prisoner was insistent that he was "going home."
Montes checked a jail computer, which indicated that Gavira still belonged in the jail's disciplinary area, and escorted him there. An inmate trusty led Gavira the final steps down Row A to Cell 26. Montes watched as Gavira stepped in and the door slid shut behind him. The time, Montes estimated, was 8:15 p.m.
Inmate Franciskovich said he was lying on his bunk nearby that night when he heard Manriquez's voice. He said that he could not see down the row but that it sounded like the jailer had stopped by Gavira's cell and was again taunting him.
"I heard her say, 'You're never going home,' " the inmate testified. "She kept telling him that, and she walked away laughing. 'You're never going home, you're never going home.' "
Minutes later, Franciskovich said, "I heard a thump, like something fell.
"I didn't have no idea what it was. I asked the black guy a couple doors down, 'Is that you?' And he said, 'No,' " Franciskovich said. "We called out 'Pop, Pop,' and [Gavira] didn't answer."
At 9:26 p.m., Gavira was found dead. His release order arrived a short time later.
Two hours after Gavira's death, Sheriff's Department homicide Dets. Philip Guzman and Joseph Purcell were rousted from their homes and sent to investigate.
By the time they arrived, Gavira's body had been taken to a hospital morgue. Guzman and Purcell surveyed the contents of Cell 26, finding a tightly wound strip of white sheet still attached to one of the bars.
Guards told them Gavira had been found as if he had stood with the noose around his neck and then attempted to squat. His legs were splayed in front of him and his buttocks hung just above the floor. Deputies said they untied the noose, but Gavira's skin was pale, his lips were almost purple, he had no pulse and was not breathing. They tried to administer CPR, but to no avail.
As the detectives started to leave the cellblock, the informant inmate handed them a note. It accused a female deputy of harassing and assaulting Gavira. "She slap[ped] him around like a puppet," the inmate wrote, referring to Manriquez.
The detectives moved to a nearby room to question deputies and other inmates on the row. When they got to inmate Coleman, he volunteered that he had seen Gavira that morning show "a lady officer" and another deputy "wounds where they had messed with him and beat him up." The detectives did not ask any follow-up questions, according to transcripts of their interviews. Franciskovich refused to talk to them that night.
Finally, they called in the inmate informant and questioned him for half an hour.
When they were interviewing witnesses, Guzman and Purcell didn't know Gavira had sustained other injuries. But at the autopsy three days later, the coroner found the bruises, broken bones and internal bleeding.
Deputy Medical Examiner Jeffrey P. Gutstadt, who conducted the autopsy, said the red, purple and greenish marks on Gavira's torso, arms, legs and feet came from "blunt force trauma" inflicted 12 to 72 hours before he died. The rib fractures, he said, could have occurred any time "from minutes to about a day or two" before death. He also noted hemorrhaging on Gavira's scalp and in his small intestine. He estimated that those injuries occurred within "minutes to hours" of his death.
"This man had injuries from head to toe, didn't he?" the doctor was asked during a subsequent deposition.
"Yes," Gutstadt replied.
The coroner deemed the death a suicide. But, noting the unexplained injuries in his report, he added a caveat: "This is based on the information known at this time, and it is possible that subsequent information might lead to alteration of these conclusions."
The detectives, in a 28-page report on the incident, said Gutstadt had told them that Gavira "had sustained a recent beating." Yet, because none of the injuries was considered fatal, the detectives made no attempt to determine how Gavira received them, other than to speculate that the broken ribs may have been caused during attempts to resuscitate him.
They closed the case as a suicide.
Guzman and Purcell noted that the allegations against the deputy were turned over to a captain to pursue as an administrative matter, because they "had no significance" to their inquiry.
Discovery at the Mortuary
Enrique Gavira knew nothing about the autopsy when the funeral was held at Groman Mortuary. He'd been told that Ramon had hanged himself, but during the service noticed more bruising around the neck than he expected.
After speaking with the manager, he and his other brother Victor were eventually allowed to see Gavira's body, which by then had been undressed and covered with a sheet.
When the brothers peeled back the sheet, they began to cry.
"He was completely demolished," Enrique said. "All black and blue."
Enrique got a camera and began snapping photos. The next day he called a lawyer.
The Gaviras turned to Antonio Rodriguez, a veteran civil rights attorney in East Los Angeles. Rodriguez brought two other lawyers into the case -- Samuel Paz and Sonia Mercado -- and hired his own medical expert, Dr. Harry J. Bonnell, to review the autopsy.
Besides the bruises and broken bones on the torso, Bonnell saw that the medical examiner had made a passing reference to something else: There were injuries to the inmate's neck that, Bonnell said, were "inconsistent with being caused by a ligature" -- like hanging -- "but are frequently seen in manual strangulation."
Specifically, Gavira had a broken thyroid cartilage and broken hyoid, a U-shaped bone at the base of the tongue.
Bonnell also cited bleeding in Gavira's eyes, another phenomenon more commonly associated with manual strangulation than hanging.
He rejected the suggestion that Gavira's broken ribs were the result of CPR, noting that there was corresponding bruising a few inches from the ribs, as if skin had been crushed against bone while Gavira was alive.
"It is my opinion to a reasonable degree of medical certainty," Bonnell concluded, "that Ramon Gavira was murdered."
At the request of The Times, two nationally recognized forensic experts reviewed Bonnell's findings and Gavira's autopsy report.
Michael Baden, chief forensic pathologist for the New York State Police, agreed with Bonnell that the fractured hyoid was suspicious in a hanging death, but doubted there was sufficient evidence to deem the death a homicide.
"It's a possibility, if an awful lot of people were lying," Baden said.
Cyril H. Wecht, who served for 20 years as Pittsburgh's chief medical examiner, said he found Bonnell's declaration "right on target" regarding the neck injuries.
"To see one of those injuries with this kind of hanging would be highly atypical. To have both, I would not hesitate to say, is rare," Wecht said.
The Times also reviewed autopsy reports for all in-custody hanging deaths in Los Angeles County between Jan. 1, 2000, and last July. Of those 40 cases, only Gavira had a broken hyoid bone.
In addition to scrutinizing the medical evidence, lawyers for Gavira's family examined sheriff's reports and other documents about Gavira's incarceration, including his alleged encounter with Deputy Manriquez.
Among them was a report by Sheriff's Lt. Benjamin N. LaMothe, who conducted the administrative inquiry into whether Manriquez had been "taunting, insulting and assaulting" Gavira.
When LaMothe interviewed the inmate informant a few days after the allegation was made, he received the same account.
"He said that it was obvious that inmate [Gavira] was mentally ill and Deputy Manriquez just made fun of him," LaMothe's report stated.
When he then questioned Manriquez, LaMothe wrote, she "vehemently denied the accusation."
"She vaguely remembered inmate [Gavira] but said she doesn't behave in the manner described," LaMothe wrote. "Manriquez said that she is fair but firm with all inmates and is frequently the target of their complaints and accusations because of her professional demeanor and strict adherence to the established policy and rules."
Moreover, LaMothe wrote that Det. Purcell subsequently told him the inmate accusing Manriquez had retracted the allegations during an interview later on the night Gavira died.
"Based on the forgoing," LaMothe declared, the allegations against Manriquez are "unfounded."
Gavira's lawyers say they were incredulous two years later when Manriquez testified in a deposition that neither LaMothe nor anyone else ever asked about the assault allegations.
"Nobody in the entire Sheriff's Department ever asked you at any time prior to today to respond to [the inmate's] allegations?" one lawyer asked during the questioning.
"Correct," Manriquez replied.
Nor, it turned out, had the inmate retracted his allegations that night, according to transcripts of the detectives' interview with him. As he had all along, the inmate accused Manriquez of harassing Gavira and criticized other deputies for not coming to the suffering inmate's aid.
"This could have been avoided," said the informant. "That's all I'm saying."