Jailers’ Lapses Led to Slaying, Report Says

The killing of an inmate allegedly by the man he testified against could have been prevented had jailers taken basic precautions required by their own rules to safeguard him, according to a review of the incident obtained Wednesday by The Times.

Key conclusions have been presented to the Los Angeles County Board of Supervisors. One was that jailers violated six policies, some of which could have prevented the death of the witness, inmate Raul Tinajero, according to sources familiar with the review.

Twelve Sheriff’s Department jailers are facing discipline in the case.

The review found that Santiago Pineda, who is facing trial in Tinajero’s death, was moved to 10 cellblocks at the Men’s Central Jail in the five months before the slaying.

Pineda could have gained enough knowledge of shortcomings of the jail system to allow him to roam undetected for hours the day of the killing, according to the review. A source said Pineda “knew the jail as well as anyone who worked there.”

The report notes that Pineda was assigned as a trusty whose duties may have included helping with inmate head counts and checks of identification wristbands worn by every inmate. That is particularly troublesome because Pineda had been accused of threatening an inmate to obtain his wristband, sources said.

The most egregious lapse in the series of missteps by jailers came in December, five months before Tinajero’s slaying, according to sources familiar with the report, prepared by the Office of Independent Review. The agency, created by supervisors, is headed by former federal prosecutor Michael Gennaco.

Pineda took the wristband from a trusty and used it to take a sheriff’s bus to West Hollywood on Dec. 19, 2003, where he was discovered before he could escape.

Jailers are required to keep inmates who have tried to escape under constant guard when not in their cells, according to jail policy. But jailers failed to watch Pineda more closely, according to the report.

“The most critical failure was when the jailers had knowledge of his escape but did not follow protocols in requiring him to be followed wherever and whenever he moved,” one source familiar with the report said. “Had that occurred, he would not have the opportunity to kill the witness testifying against him.”

Other failings noted in the report:

Jailers failed to make hourly safety checks of cells. They did not discover Tinajero’s body for four hours, and then only after they were notified of the corpse.

Because wristband identifications were not checked, Pineda was allowed to roam undetected through the Men’s Central Jail from 5 a.m. to 3 p.m. the day of the killing.

No attempt was made to prosecute Pineda for three offenses he allegedly committed in jail before Tinajero’s slaying. Had those charges been pursued, Pineda would have been more securely guarded, sources said.

The report attributed to a “miscommunication” the fact that Tinajero was designated a “keepaway” -- meaning he was supposed to have been isolated from other inmates -- but was not. He was merely placed on a different floor from Pineda.

The report provides additional details about the day Pineda allegedly killed Tinajero.

About 5 a.m., Pineda entered a line of inmates heading for court appearances even though he didn’t belong there. He was discovered, but deputies failed to escort him back to his cell, allowing him to roam the jail for hours and eventually gain access to Tinajero’s cell.

Sheriff’s officials said inmates often are not punished for being caught where they are not supposed to be. In the last year, sheriff’s deputies have disciplined inmates 408 times, an average of once a day, for being at the wrong place at the wrong time.

Pineda entered Tinajero’s cell about 10:30 a.m. by shadowing an inmate who was returning from a parole hearing, the review found. Pineda then allegedly ordered Tinajero’s cellmates to turn around as he used a ligature to choke Tinajero. Then Pineda wrote down the names and booking numbers of the other inmates, threatening them if they reported the incident.

According to the review, Pineda allegedly made phone calls from the jail bragging about the killing. A sheriff’s deputy stopped at the cell to make a linen exchange but did not notice Tinajero’s corpse in his bed or Pineda, the review said.

At 3 p.m., Pineda left the cell and was caught by a deputy as he tried to sneak out of the cellblock, the review said. Pineda reportedly told deputies he was visiting a cousin, but he wasn’t written up for roaming.