On a Tuesday in October 2003, Ki Hong entered Men's Central Jail in downtown Los Angeles to serve a five-day sentence for soliciting a prostitute.
He didn't survive two hours.
Three members of a Korean gang instantly spotted Hong, 34, who authorities allege was a member of a rival gang. The trio had broad freedom to roam the jail because sheriff's deputies had given them jobs as inmate workers -- jobs for which they, awaiting trial on murder charges, should have been ineligible.
They let themselves into Hong's dormitory using a guard's control button. Then they stabbed Hong repeatedly, strangled him with bed linen and hid his body in a trash bin.
Since 2000, 14 inmates have been slain in jails run by the Los Angeles County Sheriff's Department, including four this year. Hundreds more have been injured in jail violence.
Taxpayers, who pay more than $500 million a year to operate the jails, paid an additional $6 million since 2004 to compensate inmates and their survivors for errors, negligence and brutality. In addition, a tentative $2.8-million settlement is awaiting county approval.
A Times review found that:
* The Sheriff's Department has failed to protect vulnerable inmates from predators, despite repeated calls for action by jail experts. Last year, deputies placed Chadwick Cochran, a low-level offender with a long history of mental illness, in an unsupervised holding cell with violent gang members. They punched and stomped him to death.
* The department has had increasing difficulty maintaining order at its eight jail facilities. More than 30 major disturbances involving large numbers of inmates erupted this year. Riots left two dead and at least 100 injured. After widespread rioting in 2000, the violence subsided briefly. But the number of disturbances has risen from 47 in 2001 to 112 this year, records show.
* Disciplinary action against sheriff's employees whose lapses contributed to inmate deaths or injuries is often softened or rescinded on appeal. In one case in 2003, a deputy was suspended five days for failing to notice that two inmates, drunk on jail-brewed alcohol, had beaten their mentally ill cellmate to death. A supervisor overturned the suspension over the objections of the department's internal affairs monitor.
The Hong case cost the county $800,000 in legal claims and prompted sanctions against a dozen jail employees. Yet similar failures played a role in at least seven inmate deaths over the next two years.
In the most notorious case, an inmate wandered unescorted through Men's Central Jail for several hours, finally finding a witness who had testified against him in a murder case and strangling him in his cell.
Sheriff Lee Baca says his department has done its best to contain an ever-more-explosive inmate population.
"It's remarkable there's not more violence in the context of the county jail demographics," he said in an interview. "It could be 10 to 100 times worse if it wasn't for the managers and deputies in the Los Angeles County Jail. We'll never be singled out for the murders we have prevented."
Baca said his department has taken steps to reduce jail violence in recent months. A centralized team now screens arriving inmates to separate the vulnerable from the violent. Many Latino gang members are held apart from the general population to avoid clashes with outnumbered black inmates.
The sheriff also said his department has inadequate resources to staff the jails properly and renovate unsafe facilities.
Civil rights attorney Hermez Moreno, who represented the family of the slain witness, 20-year-old Raul Tinajero, said the department's shortcomings came down to management, not money.
Tinajero's killer was allowed out of his cell by pretending to have a court appearance. The deputy responsible for checking his ID number against the list of inmates with court appearances apparently did not do so.
The $1.25 million paid earlier this year to settle a lawsuit filed by Tinajero's relatives was the second-largest payout for an inmate death in county history.
"How much money would it have taken for one guy to look at the wristband of the guy who killed Tinajero?" Moreno said. "The answer is no amount of money. The answer is accountability and appropriate training."
In the Los Angeles County Jail system -- the nation's largest -- about 3,300 uniformed employees watch over an inmate population that averages more than 18,000.
The New York City Department of Correction, which oversees about 5,000 fewer inmates, has three times as many uniformed guards.
At least one in five Los Angeles County inmates is a gang member. Nearly 90% are awaiting trial on felony charges.
Almost two-thirds of the jail killings since 2000 have taken place in Men's Central Jail, an aging 4,800-bed behemoth just north of Union Station.
Dilapidated, understaffed and chronically overcrowded, the cellblocks at "CJ" are a nightmare of poor sightlines and dark corners. During an internal affairs review, sheriff's personnel conceded that they rarely entered the bunk-lined dormitory where Hong was murdered. Instead, they monitored inmates by peeking through its sole small window.
Inmates routinely walk CJ's halls unaccompanied by staffers. Pairs of deputies guard lines of 100 inmates or more as they shuffle through the jail.
Assessing the conditions in February as part of ongoing civil rights litigation, former Virginia prison Warden Toni V. Bair wrote that "in every instance where there was a mass inmate movement I did not observe anything close to adequate supervision.... Inmates, frequently numbering 100 or more, could have created a disturbance, rioted and taken hostages."
Jail management experts such as Bair acknowledge the sheriff's challenges but say his agency has not done enough to safeguard the most likely targets of violence.
The Sheriff's Department is well aware of who the most vulnerable are: informants, child molesters, the mentally ill, the elderly and African Americans, who are outnumbered by Latino inmates. Yet time and again, these inmates have been victimized.
In May 2003, sheriff's deputies placed a defendant in a courthouse holding cell with Martin Davis, a witness in his criminal trial, even though the men's security classifications mandated that they be kept apart.
Spotting Davis sleeping on the floor, the defendant, Joseph Allen, kicked him repeatedly until a deputy intervened. Davis emerged from a coma after more than a week and sued the county, receiving a $375,000 settlement.
Seven months after the Davis assault, Jose Beas, an accused child molester, was placed with 80 other inmates in a dorm at Men's Central Jail even though a special order had been entered into the jail system's computer to segregate him for his protection. Beas, 41, was beaten severely.
The Board of Supervisors is scheduled to vote Tuesday on a settlement paying his family $2.8 million for his lifelong care.
In a November 2004 report to the supervisors, Merrick Bobb, who monitors the sheriff for the board, urged the Sheriff's Department not to house the most dangerous inmates -- given security ratings of 8 or 9 -- with lower-risk inmates. He based his recommendation on the circumstances surrounding five jail homicides between October 2003 and April 2004.
The department did not follow Bobb's advice until early this year. By then, there had been three more slayings. In two of them, assailants classified as higher-level risks killed lower-level offenders.
Sean Anthony Thompson, 38, was killed in his cell at Men's Central Jail in February, 2 1/2 months after Undersheriff Larry Waldie assured the supervisors that plans were underway to separate level 8 and 9 inmates from others. Thompson was a Level 6. Three of his four attackers were Level 8.
Marc Klugman, chief of the sheriff's correctional services division, said the agency moved as quickly as possible. "It was a pretty massive sea change. It was not something we could just do overnight," he said.
Within weeks of Thompson's slaying, the Sheriff's Department was putting all Level 9 inmates in one-man cells and segregating Level 8s from the rest of the jail population.
The department moved more swiftly on recommendations to tighten policies on inmate workers, who handle such tasks as distributing meals and cleaning cells and common areas.
Deputies used to choose the workers informally. One of Hong's attackers kept his job -- and, thus, access to Hong -- even after deputies received a tip that he was dealing drugs inside the jail.
After Hong's killing, the Sheriff's Department required supervisors to approve all inmate workers.
Yet in practice, the selection process has remained casual. Inmates sometimes pass deputies makeshift resumes through their cell bars, listing as "references" other officers for whom they have worked.
Baca rejected the notion that if his agency followed its own rules better, it could avert at least some attacks.
"The problems in the jails, in my opinion, are 100% bred by the prisoners," Baca said. "They're going to commit crimes in the jails. They just find a new victim population."
They did not have to look far to find Stephen Prendergast.
On Dec. 6, 2003, two of Prendergast's cellmates at Men's Central Jail attacked him, apparently angry that he was acting strangely and talking to himself.
Prendergast, 33, awaiting trial on an arson charge, had spent several months in a state mental hospital before being sent to the Los Angeles County jails.
He was transferred into the general population at Men's Central Jail after refusing to take medication for schizophrenia at Twin Towers' mental health unit.
Prendergast's cellmates started assaulting him at 6 p.m. and continued for several hours, a sheriff's investigation found.
Two hours into it, a deputy came around to check on the cell. He did not notice that Prendergast had been beaten or that his cellmates were drinking a homemade jail brew called pruno. The assault continued. When Prendergast cried out, other inmates on the row yelled to cover up the sound.
It wasn't until almost 8 a.m. the following day that another deputy realized Prendergast was injured. He was taken to the hospital, where he died from severe brain trauma. The county paid his family $262,500 to settle their wrongful death lawsuit.
Anthony Fernandez lives in the garage of his mother's Pico Rivera home. He struggles with his balance. His speech is halting and sometimes slurred. In April 2004, while Fernandez was serving a six-month sentence for carrying a concealed weapon, four inmates who thought he stole from them dragged him to the back of his dormitory at Pitchess Detention Center's North Facility and beat him senseless.
Fernandez, 21, suffered extensive neurological damage and may never be able to live independently. His assailants had 20 minutes to attack him undetected because the deputy assigned to watch his dorm left her post unattended, assuming her replacement was on his way.
It was a costly error. The county agreed to pay $750,000 to settle a lawsuit by Fernandez's family.
The Sheriff's Department handed down a stiff penalty too, demoting the deputy to custody assistant, a lower-paying civilian position. But after the deputy objected, she was reinstated and given a 30-day suspension instead.
The agency has followed a similar pattern in dozens of other instances in which employees' lapses played a role in inmate deaths and injuries, records show. Department officials initially took disciplinary action against eight deputies, two custody assistants and two sergeants for mistakes and inattention in the Tinajero killing, doling out a combined 72 days of suspensions.
But their supervisors reduced the punishments imposed on nine of the 12, dropping suspensions to written reprimands in three cases. A five-day suspension for the deputy who apparently failed to check the ID of Tinajero's killer was dropped entirely after he appealed.
Department executives slashed the discipline imposed in the Hong case by two-thirds. Just one employee served a suspension longer than five days.
Correctional Services Chief Klugman said punishments are often eased after deputies promise to learn from their mistakes.
Jail experts and attorneys said the department lacks the will to hold employees accountable. The pattern of imposing, then rescinding, punishments sends a message that negligent or abusive officers have little to fear, they contend.
"They know nothing is going to happen," said Moreno, the civil rights attorney.
Michael Gennaco, chief attorney for the sheriff's Office of Independent Review, acknowledged that disciplinary action is sometimes watered down without justification. But he said misconduct by deputies is investigated more thoroughly and punished more harshly than under previous sheriffs.
Jail employees' use of significant force rose 60% between 2000 and 2005, department records show. Incidents resulting in hospitalization or verifiable injury to inmates almost doubled in that time, from 186 to 339.
Gennaco said many uses of force are appropriate reactions to inmate behavior. Still, he acknowledged, the Sheriff's Department has a reputation for parking problem officers in the jails. Some incidents stem not from problem deputies but from questionable practices passed down over the years.
On Nov. 16, 2005, Chadwick Cochran was placed in an unmonitored television room in Men's Central Jail with about 30 other offenders.
Two gang members apparently mistook him for a police informant and pummeled him with their hands and feet as well as plastic dinner trays. As Cochran lay motionless on the floor, the pair took turns jumping off steel benches and stomping on his head.
The officers who left Cochran unsupervised were not disciplined. What they had done was so common at the jail that internal investigators decided it wouldn't be fair to punish them.
"The informal practice of placing inmates in television rooms was well-established, if misguided," a report released by Gennaco's office concluded. "This made it difficult to hold people accountable for following it."
Despite strides made by the Sheriff's Department this year, violence is commonplace in the L.A. County jails. In the last six weeks, two more inmates have been slain. A 51-year-old mentally ill man was killed in his cell by a younger, stronger cellmate, and an inmate was beaten to death by gang members.
Baca said his department continues searching for ways to bring the violence under control.
"I'm certainly of the belief that we can always do better," he said. "I don't think any death in the jail is acceptable."
(BEGIN TEXT OF INFOBOX)
Inmate disturbances in jails run by the Los Angeles County Sheriff's Department since 2000.
Money Los Angeles County has spent to compensate inmates and their survivors for negligence, errors and violence since 2004.
Average number of inmates held daily in jails operated by the Los Angeles County Sheriff's Department.
(BEGIN TEXT OF INFOBOX)
Inmate disturbances in Los Angeles County jails are up sharply this year. Major disturbances are described as involving a majority of inmates in affected areas and may lead to serious injuries; minor disturbances involve smaller groups and may result in minor or no injuries; riots are classified as violent disruptions that put the safety of the staff and inmates in serious jeopardy.
*--* Incident type 2000 2001 2002 2003 2004 2005 2006* Riot 1 0 0 0 0 0 3 Major 78 19 26 31 26 28 34 Minor 35 28 48 28 31 39 75 Total 114 47 74 59 57 67 112
*Through Dec. 6.
Source: Los Angeles County Sheriff's Department