County Called Negligent in Inmate’s Death

The Los Angeles County Sheriff’s Department negligently allowed a mentally ill man to die in its custody after deputies tried to subdue him, then performed an internal investigation so flawed that it undermined the agency’s credibility, according to a strongly worded report by the county supervisors’ special monitor of the agency.

Attorney Merrick Bobb compared the 1999 death of 33-year-old Kevin Evans to the case of Margaret Mitchell, a diminutive mentally ill homeless woman who was killed by Los Angeles police officers that same year when she charged one with a screwdriver. His 59-page report on the Evans case found that the Sheriff’s Department “acted in a negligent, perhaps reckless way.”

Bobb reported that Evans had never acted violently yet was placed in restraints, that sheriff’s deputies held him down for minutes even after he began gagging, and that after Evans stopped breathing, no one performed cardiopulmonary resuscitation for 15 minutes.

One nurse involved in the Evans case has been forced to leave the department. But even though Bobb cited a host of oversights and questionable actions, no deputy has been disciplined.

The department’s review of the incident found that its deputies acted appropriately. Bobb disagreed sharply.

He criticized the internal investigation as “careless to the point of slipshod, self-justifying and rationalizing to the point where their credibility vanished, and insensitive and defensive to the point where reason and good judgment flew out the window.”

While saying that he does not believe the deputies who restrained Evans intended to harm the inmate, Bobb recommended that some be disciplined and that the agency undertake wide-ranging reforms in its jail health care system, including immediately trying to contract with local medical schools for better service. He noted that for years he has urged improvements in health care in the nation’s largest jail system, which is also being monitored by the U.S. Department of Justice.

The report was requested by county supervisors after spending $600,000 to settle a wrongful-death lawsuit by Evans’ family. It is scheduled to be discussed Tuesday at their weekly meeting.

Bobb distributed the report to a number of officials late last week with the expectation that it not be publicly released until Tuesday morning. The Times separately obtained a copy of the report.

Chief Taylor Moorehead, the head of the sheriff’s custody division, said Saturday that he had not seen the report. He stressed that the department considers Evans’ death a “tragedy” and blamed the state’s failing mental health system. Cutbacks in that network have left mentally ill people with nowhere to go but jail, he said, and deputies are not trained to counsel some of the most disturbed inmates.

The Sheriff’s Department has asked the county’s Department of Mental Health to handle inmate restraints, but they have refused, Moorehead added.

“Nobody punched him, nobody kicked him, nobody was brutal to him,” Moorehead said of Evans. “They did the best they could to calm him down. . . . They did it exactly textbook, by policy. . . . The deputies did not have homicide in their minds. They feel awful. I mean, my god, a man died.”

Nonetheless, Moorehead said that subsequent attention to the case, including an article in The Times’ Sunday magazine, has sparked a new internal review of the incident and the department’s initial investigation.

Supervisor Gloria Molina, whose viewing of a videotape of the incident sparked Bobb’s probe, said she was not reassured by the agency’s promise of a new investigation. “I’m supposed to trust what they tell me?” she asked.

Comparing Evans’ death to the beating of Rodney G. King, Molina said she was especially concerned that top sheriff’s officials found that their deputies behaved properly. “When you have the top brass looking at this and saying there is not a problem,” she said, “you have to worry about the top brass.”

Evans was arrested while pushing a stolen shopping cart in Palmdale on the evening of Oct. 20, 1999. He was held in a minimum-security cell in the Sheriff’s Department’s Lancaster jail and classified as “aggressive” for no apparent reason, Bobb reported.

Evans spoke erratically in holding cells and during a court appearance the next day. One deputy, not identified in the report, filled out a “keep away” card after Evans made a gesture that she interpreted as threatening. Bobb found some of her justification for classifying Evans in that manner to be “exaggerations.”

When Evans was processed into Twin Towers Jail in downtown Los Angeles that night, that “keep away” card led him to be classified as “dangerous,” according to the report. Because the department did not have computerized records of inmates, deputies could not know that Evans had several prior stays in jails, during which he spoke erratically but was never violent.

A physician examined Evans, diagnosed him with cerebral palsy and ordered him into three-point restraints without writing his justification on his report. Bobb noted that there were several alternatives to restraining Evans, such as placing him in a padded cell.

Two hours later, Evans was still waiting to be restrained. As he sat handcuffed on a bench, a nurse noticed him mumbling and called a jail psychiatrist at home. Without coming to the jail to examine Evans, the psychiatrist upped the restraint order to four-point restraints--meaning all of Evans’ limbs would be tied to a bed.

An hour later, Evans was moved to a room in the jail’s Medical Services Building to be restrained. He was still calm, clutching a baloney sandwich. A sheriff’s videotape recorded his restraint by four deputies in a room in the jail medical building. Evans remained calm when laid down on the bed, but when a deputy, without explanation, grabbed the sandwich from his hand, Evans began kicking and struggling.

As the deputies shouted for him to calm down, other officers ran into the room to help hold Evans down. Although a sergeant was present, Bobb wrote, “no one coordinated the use of force. Instead, the officers improvised.”

One deputy leaned on Evans’ chest. Two pressed against his throat area with their hands and knees, Bobb reported. When Evans began gasping and groaning, the sergeant, believing Evans was about to spit on deputies, called for a mask to block his spittle. The coroner’s report later said that mask could have contributed to the inmate’s asphyxiation.

After more than six minutes, Evans was quiet. The sergeant ordered everyone but two deputies out. Bobb said the videotape showed that one deputy who had been leaning on Evans’ chest let his full weight come down on Evans while hopping off. A sheet had apparently been placed over Evans’ head.

Several seconds later, deputies checked for a pulse. “Someone want to get a nurse in here?” one deputy asked. “Kill the camera,” the sergeant ordered. The video ends at this point.

The staff at the sheriff’s medical ward called paramedics, and Bobb reported that it took 15 minutes before a jail doctor realized no one had attempted CPR and began doing so.

Jail records, though, were falsified to obscure Evans’ time of death, according to Bobb’s report. The supervising nurse that night, Eulalia Cristobal, was forced to resign for violating department policy by not ensuring a nurse was present at the restraint. She also pleaded no contest to a misdemeanor for falsifying a report.

The coroner’s office found Evans died from a combination of asphyxiation and the strain against his enlarged and scarred heart, according to Bobb’s report.

Bobb said that sheriff’s homicide and internal affairs investigators performed a poor follow-up investigation. He lists two pages of witnesses who were not interviewed, including the deputy who filled out Evans’ “keep away” card, the doctors who ordered Evans into restraints and one of the deputies who restrained Evans.

Bobb said sheriff’s officials had initially claimed to have interviewed that deputy but later conceded that no one did. He also noted that for the first time in his eight years monitoring the Sheriff’s Department, he had difficulty arranging interviews and getting access to records from the agency. Moorehead said Saturday that Bobb should have had full cooperation.

Internal investigators never questioned why deputies placed a sheet over Evans’ face, or held his neck or his diaphragm even after he was restrained. “Instead,” Bobb wrote, “the investigators sailed quickly through their interviews, spending roughly 10 minutes to question each officer.”

In his report, Bobb provides a transcript from the investigation, relaying an interview between an investigator and the sergeant.

During that interview, the investigator asked, “OK. Did you see anyone punch this inmate?”

“No,” the sergeant responded, “absolutely not.”

“Did you see anyone kick this inmate?”

“Absolutely not,” the sergeant replied.

“Did anyone do anything that was out of the ordinary as far as restraining is concerned?” the investigator asked.

The sergeant replied: “At . . . No.”