A Tale of Training, Leadership, and Another Death

Reading reports today in the Mercury News and other local media, deputies in the know are stunned. The failure to release relevant information to make this look like an isolated medical incident is potentially untrue. Incidents that remain unmentioned by the sheriff have a very good possibility of playing a role in what happened on Monday.

The sheriff is trying to follow the same initial line of bull that started with Micheal Tyree. A story that was unsustainable when deputies decided it was important to go public… found unconscious, unresponsive, CPR… etc. For a moment I was unsure if I was reading a recap of Tyree’s death or the current incident. Because the two incidents are nothing alike according to sources. The echo of that first attempted effort at spin control should have perked up the ears of the more curious.

Again there is a concern the truth will not come out and people are reaching out again to ensure that it does. Let me be clear here, the autopsy report will be the final say what happened here, but there are a lot of questions. Will the sheriff manage to put out such a palatable story for the media, that no one will go seeking the autopsy report when it finally comes out? Because that appears to be her agenda here.

The media really needs to develop better sources than the Sheriff’s PIO. The deputies are working in an environment that has reached critical mass and every day they work in that situation without training, leadership, and effective support, they are all at risk of being involved in something like the series of incidents over the past week that have resulted in yet another death. Yes, I said week.

While the timeline I’m getting is still slightly unclear, this “found unresponsive” inmate was possibly another mentally ill person. He was initially being held in Maximum Security on alleged domestic violence warrants out of another city. Within the first 48 hours he was in an incident where he was pepper sprayed, sprayed with tear gas, and hit with a less lethal rifle from an unrecommended close distance, less than 15 feet.

For some reason, deputies were attempting to cuff and move the inmate who was refusing to leave the cell according to sources. At that point, a series of events occurred to attempt to make the inmate comply. From my understanding talking to someone who has experience in training in the jails environment, it was a series of events that, in part, shouldn’t have happened in an environment that supported training and policy and a staff that understood their tools.

I have been told that this event occurred under the direct supervision of a lieutenant, the same lieutenant that was on duty the night of Michael Tyree’s death. But because of circumstances, trying to extract an inmate from a cell, he was supposedly present and approving each action taken in this latest incident.

My sources tell me the video of this particular extraction does exist.

From what is being told to me, this death, if caused by the process of extraction, wasn’t in any way intentional and it wasn’t a case of abuse, but a lack of detail and training to rely on during the events. However, given the lack of training in the tools used, the lack of understanding of best practices by the lieutenant in charge, and the apparently limited medical intervention, the fact this incident resulted in serious injury, even death, sadly isn’t surprising.

During the series of events, force used included a combination of chemical weapons at varying levels of severity. How closely was the inmate being monitored during and after? Was a medical entity present in the event the inmate wasn’t complying because of medical distress? What medical applications were used after the incident beyond just being moved to a medical floor?

The sheriff ran to make a public spectacle of herself after the Tyree death — look what I’m doing! I care so much! Cadets in the mental health court, big statements in interviews by the newly graduated, appearances by judges, and open and early public condemnations all with apropos tears…everything for appearances. Where was the substance? There has been none, not before and not after, and we see further results of that here.

What people don’t understand is that in the month of hearing about Dave Cortese’s and Cindy Chavez’s “blue ribbon commission” the sheriff has done nothing. A responsible leader would realize that this commission would in no way restrain them from beginning a top to bottom review of policy and training, as well as begin to address obvious factors that contribute to problems. She doesn’t have to wait for the commission in order to act in her own jails to improve things now. At the very least you would think she would call for a full review of training practices, current records, and current minimum training needs to get everyone up to date.

The sheriff believes and works on the concept that a lawsuit is cheaper than the training. But looking back at the Baltimore in custody death, their family just received $6.5 MILLION in settlement money. Is this where the county taxpayers feel this is the best place to spend their dollars? Two in custody deaths, that could be $13M or more if Baltimore becomes the standard settlement of the times. And keep in mind, Santa Clara county is at least perceived as far richer than Baltimore, the families may go for even more.

The sheriff added a lot of public window dressing, but what was really done? Jail training improved? Leadership issues addressed? Was there a policy regarding escalation practices in cell extractions? Was the lieutenant aware of it? Were the deputies aware of it? Had they been trained and certified by a certified trainer in the use of the various tools they used? It’s my understanding some deputies haven’t received training on some of the tools used in possibly years. All which resulted in at least one tool being used incorrectly according to my sources. Where’s the media in seeking a FOIA for training records of these officers? I can tell you they will likely not find any training records, because there are no records. Fortunately for the sheriff there seems to be little interest on the part of the media to dig to deeply for information like this.

My understanding of events was that an uncompliant, possibly mentally ill inmate refused to be cuffed and removed from the cell. Deputies proceeded to use OC (pepper spray) on the inmate who remained uncompliant. They escalated the chemical to Clear Out, a blend of OC and CS (more commonly known as tear gas). The inmate again remained uncompliant. They then escalated to the use of a less lethal rifle to shoot through the door. The problem is, according to the training materials and policies from other agencies, this rifle is not supposed to be shot from less than 15 feet away, yet the cell was less than 2/3 that length.

At that point, they then sent deputies in to get the inmate out of the cell. At that point my sources don’t have a lot of detail. What the level of medical distress was is unclear right now, however, he was moved to the 8th floor mental health unit after the incident, something the sheriff’s press release makes sound as if he was there from the beginning. It doesn’t appear after having been exposed to two chemical irritants and shot with a less lethal rifle that he received any extended medical attention, was removed to a medical facility to be examined, or other specialized medical attention was provided beyond being moved to that floor.

We don’t know for sure, but it may well be that the inmate either had some kind of lung damage or other internal injury, possibly from the less lethal rifle rounds. It appears there was some poor decisions made. A possible lack of medical intervention at an appropriate level, and a lack of knowledge from the deputies all the way up to the lieutenant regarding, at the least, the use of a less lethal weapon.

To date, despite all the information available to the public at this point regarding how poorly the sheriff has run her entire office, and the tragedies in the jails, issues inside the jails have not even begun to be examined by the sheriff on any level that could be considered serious.

The media appears to have fallen hook, line and sinker for this “we were watching him, he was on a medical floor… there were even attorneys present” line of half truths. Why do we hesitate to question this woman when so many times she’s been found telling us redesigned fairy tales that benefit her?

When will we recognize her less than stellar record of honesty and transparency? When will the Supervisors, SV De/bug and other local oversight mechanisms stop congratulating the sheriff over the bodies of dead people and start holding her responsible for the lack of training, leadership and structure throughout her department that continues to lead to tragedy?


One thought on “A Tale of Training, Leadership, and Another Death

  1. Maybe she’s waiting for the deceased to get a lawyer so she can hold another press conference, just so the lawyer can say how great she is for acting quickly. Oh yeah, with the entire administration behind her…..For what?!

    What a mess this politician Laurie is…..I hope she gets pressured to resign, this department will slowly get better when she leaves.

    I agree casey….another no confidence vote might do it.


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