State auditor to investigate deaths at San Diego County jails

An empty jail hallway.
The county jail in downtown San Diego.
(San Diego Union-Tribune)

The audit follows a Union-Tribune investigation finding that San Diego County’s jail mortality rate was the highest among California’s large counties.


The California state auditor will investigate inmate deaths in San Diego County jails over the past 15 years after approval of a proposal from local lawmakers.

A 2019 investigation by the Union-Tribune found that the county’s jail mortality rate was the highest among large counties in the state. At least 140 people died in county custody over a 10-year span beginning in 2009, the year Bill Gore became sheriff.

State Auditor Elaine Howle will lead an inquiry into those deaths, as well as examine how the county Sheriff’s Department trains jail personnel, maintains facilities and provides healthcare for thousands of inmates at its seven jails.

Assemblymember Akilah Weber, who represents the 79th District, said at a hearing of the Joint Legislative Audit Committee on Wednesday that the findings will help improve conditions in county jails. Weber was among a group of San Diego-area Democrats who requested the audit.


“This is a systemic issue that requires an independent, objective review so that we can completely understand how a jail sentence became a de facto death sentence for members of our community,” Weber said.

Assistant Sheriff Erica Frierson, who heads the department’s detention services, said at Wednesday’s hearing that the department has done “rigorous review” and made “extensive improvements” to how it provides healthcare for inmates over the past five years, but remains open to the audit and its findings.

“If there is information offered through an external audit that brings improved care for the individuals in our custody, we welcome it,” Frierson said.

The audit will also examine wrongful-death lawsuits filed against the Sheriff’s Department, the settlements of those lawsuits and whether recommendations — made either by the county Grand Jury or the Citizens’ Law Enforcement Review Board — were implemented in practice, Howle said.

Among other witnesses who testified in support of the audit were the mothers of two inmates — Elisa Serna and Michael Wilson — who died in county custody in 2019.

Paloma Serna said the audit would bring accountability in cases in which people died in county custody like her daughter. Elisa Serna, 24, died in Las Colinas Detention and Reentry Facility in Santee in November 2019.

Paloma Serna, along with her husband and her son-in-law, has filed a lawsuit against the department alleging the department was indifferent to Elisa Serna’s welfare while she was in custody.

“No criminal charges have been brought against any of the people responsible for Elisa’s death… These deaths continue because no one is held accountable for these deaths,” the mother said.

On Nov. 11, 2019, Elisa Serna was found “unresponsive” in a jail medical isolation unit. An autopsy later determined she died from complications of chronic polysubstance abuse with a contributing factor of early intrauterine pregnancy. She was suffering from heroin withdrawal, dehydration and pneumonia at the time of her death. The manner of death was ruled natural.

Over a year later, an independent review board found that Serna had been left alone in her cell after a deputy and jail nurse saw her hit her head on a wall and collapse from a seizure. The deputy and nurse tried to assess her condition, but walked away after Serna failed to respond. An hour later, she was found dead.

Michael Wilson, 32, died after being transferred to a hospital from the Central Jail in downtown San Diego on Feb. 14, 2019. His mother, Phyllis Jackson, said at the hearing that he was denied medication he relied on to treat a congenital heart condition over the 10 days he was in county custody.

Jackson said she told sheriff staff that Wilson’s life depended on the medication, but she was ignored.

“My son died because the San Diego County Sheriff did not provide medical assistance to him after being told several times, not only by his family but by Michael himself,” Jackson said.

Wilson died at UCSD Medical Center on the same day he was found unresponsive in his cell. An autopsy report revealed that his lungs weighed twice the normal amount because they were so full of fluid.

Liberty Sanchez, from the Service Employees International Union in California, said at the hearing that health workers in San Diego County jails are overworked and frustrated with poor care standards in county jails.

Sanchez said the Sheriff’s Department has failed to follow proper protocols within the jails and defer to medical professionals when necessary, and that has put health workers — as well as the inmates — at risk.

“This is deeply personal for my members, who have dedicated their lives to the provision of healthcare for a population most of society chooses to ignore,” Sanchez said.

None of the Assembly members or witnesses at the meeting spoke against the audit.

The state auditor estimated that the investigation would take about seven months.