Visalia Dobie-Johnson was finishing work on April 5 when she saw two missed phone calls from the Sacramento County Main Jail.
Worried her fiancé may be there, she rushed to the downtown jail from her Pocket-Greenhaven condo. She had believed that he was out with friends for the night, but learned when she arrived at the jail around 2 p.m. that Delion Johnson had been in a holding cell for more than 11 hours. She was told that she could not see him.
“I wanted to let him know I was there for him,” Dobie-Johnson, 35, said in a recent interview. She wore a necklace and a gold locket with Johnson’s picture.
“I went home and kept checking the website to see if they’d housed him so I could visit him. (His mother) called me at midnight and told me he was gone. I couldn’t believe it. All I could think about was his kids.”
Johnson had an 11-year-old boy and a 6-year-old daughter. He and Dobie-Johnson were expecting to have Dobie-Johnson’s baby, due in September.
Johnson was one of three inmates who have died at the jail so far this year of suspected drug overdoses — deaths that could have been prevented with adequate monitoring and detoxification, according to a new report by two medical professionals tasked with independently monitoring medical care of Sacramento inmates under a federal settlement.
Unlike homicides and suicides, medical deaths at the jail, including overdoses, typically lack any independent oversight. When a death occurs, the Sheriff’s Office does not request Inspector General Francine Tournour or internal affairs personnel to respond to the jail to launch their own investigations unless there appears to be policy violations by deputies. For the seven deaths that have occurred since Tournour started her position September 2022, that has not happened.
Sheriff’s Office spokesman Sgt. Amar Gandhi declined to answer a list of questions for this story.
“The county reviews the circumstances of every death that occurs in the jails … to determine if the quality of care was a factor in the death and develop a plan to improve performance if it was a factor,” said county spokeswoman Kim Nava. The county did not provide those reports to The Bee, citing privacy laws.
In 2018, the County Board of Supervisors removed jail medical care from under the Sheriff’s Office. As a result the county division responsible for medical care does not fall under the oversight of the inspector general, Sheriff’s Office internal affairs, or the District Attorney’s office. The jail currently has vacancies for six mental health workers and 25 registered nurses.
A civil grand jury this year found the vacancies — which nurses said was the reason they couldn’t properly monitor at least one of the deceased inmates — violate a federal settlement in a 2019 class action lawsuit called the Mays Consent Decree. That decree outlines a list of requirements for the jail to improve medical and mental health care for inmates.
The Board of Supervisors earlier this month approved nearly $1 billion for a new mental health and intake annex to the jail, which county officials say will make it compliant with the decree, but it won’t open until 2028. In the meantime, the lack of compliance could result in the county jail being placed into receivership. That would mean a judge would appoint a third party to take control of things like the jail budget, contracts, and staff, instead of the Board of Supervisors.
Drugs getting into jail
Although the coroner’s office has not yet determined Johnson’s official cause of death, he can be seen on surveillance footage ingesting a white substance from a plastic bag and giving it to cellmates. Therefore, his cause of death is a suspected overdose, the report states.
“At the time of the response, (his) pupils were fixed and dilated suggesting (he) had been without a pulse for several minutes before (he) was responded to,” the report stated. “Nurses appropriately administered Narcan to the patient. However, there was a 9-minute delay in applying AED pads and use of the AED.”
Dobie-Johnson thinks he would be alive today if they had strip-searched him more quickly, to find the pills, or if they had watched him more closely in the holding cell.
“I just hate that they didn’t do their job,” Dobie-Johnson said. “They could’ve very well (strip) searched him, clearly they didn’t. I wonder how long he was sitting there before they even realized he was unresponsive.”
Tournour, a former deputy in the jail, said inmates sometimes are able to ingest drugs while waiting hours to be strip-searched and booked.
“There are drugs that can be easily hidden and there is a period of time from arrest to intake that can allow for ingestion of these drugs,” Tournour said.
Drugs in the jail are not a new issue. Last year, three inmate deaths included meth as one of multiple causes, according to coroner reports.
“The availability in drugs in prisons has been a pervasive persistent problem,” said Mark Merin, longtime civil rights attorney representing the Johnson family in a lawsuit against the county. “There’s no excuse for letting people overdose on drugs in jail that should never have been allowed in the institution in the first place.”
An advocacy organization, the plaintiff in the consent decree, demanded earlier this month the jail start searching employees when they enter both facilities, the way prisons do.
Lawyers at the San Quentin-based Prison Law Office suspect some of the drugs could be coming in from the staff, not the inmates. The organization sent a letter to Sheriff Jim Cooper Aug. 7 demanding the jail start screening employees for drugs. Currently, deputies do not walk through a scanner and are not searched when entering the jail, the letter stated.
“The Sacramento County Jail is in crisis,” the letter stated. “Drugs are widely available inside the facilities, and people are dying as a result. Despite the serious risk of harm to people in the jail, the Sacramento Sheriff’s Office is failing to make appropriate and sensible interdiction efforts to stop drugs from entering the jails.”
Supervising Deputy County Counsel Rick Heyer on Aug. 14 sent the organization an email to deny the request.
“The Sheriff agrees that drugs smuggled into the facility is a serious concern,” the email stated. “However, there is no evidence that such contraband is being brought into the facilities by (Sheriff’s Office) employees. (The Sheriff’s Office) has investigated the possible sources of these narcotics entering the facilities and has enacted heightened screening protocols in booking and inmate visitation.”
Two other suspected drug ODs
Two additional deaths suspected to be fentanyl overdoses occurred after Johnson, the report states.
Cody Catanzarite, 37, arrived back at the jail July 20 after having to go to the emergency room for a fentanyl overdose. The report found he was not seen by a nurse and had not started detoxification for more than five hours. During that time his opioid withdrawal level spiked, and he died within hours.
Two weeks later, Michael John Prince, 43, died after being in the jail for six days. The cause of death is not yet determined, but he was in a detoxification cell. the Prison Law Office said that raises the possibility that he also could have taken drugs brought to him by a staff member or another inmate.
His death left six children without a father, the youngest of whom is 12, his wife Sophia Costello said.
“He had a beautiful personality and he loved to talk about the Lord,” Costello said. “He was a great father. Now I’m lost without him. I don’t know how long I’m going to be able to keep my home.”
Another possible cause of overdoses within the prison relates to the practice of “cheeking” medication, which takes place when inmates don’t take their detoxification medications to stay high, or collect enough of the medications to get high again. The protocols around ensuring inmates ingest their medications as prescribed is one issue that Tournour wants to be able to investigate.
“Did the inmate cheek their medicine?” Tournour told the Community Review Commission, a Sheriff’s Office oversight body, during a meeting July 18. “I want to see if nurses are checking their mouths.”
Uptick in deaths
Of the 25 people who have died at the Sacramento jails since the start of 2021, none has been from homicide or suicide. While that means the jail has made positive improvements to prevent those types of deaths, it also means the public knows little about any of the inmates who have died there in the past two and a half years.
Not all medical jail deaths are overdoses.
Robert Lee Wood, 52, was arrested in September 2022. He was taking medications for seizures, but a jail doctor did not keep giving him the medication, the report found. In October the providers were only giving him half the antibiotics he was prescribed for his arm cellulitis. On Jan. 12, an outside doctor said Wood had a hernia the size of a grapefruit and needed immediate surgery. The jail doctor never ordered the surgery referral. He died Jan. 23.
The coroner death report states Wood’s cause of death is choking on a peanut butter sandwich.
There has been an uptick in the number of overall Sacramento jail deaths in recent years. In 2021 and 2022, there were 19 jail deaths — higher than any other two-year period dating back to 2005, according to the Department of Justice. All of the 19 were main jail inmates except for one Rio Consumnes Correctional Center inmate.
The average age for the six deaths so far this year is 41 — much lower than the U.S. Centers for Disease Control national average of 76.
Tournour said she plans to ask the Board of Supervisors in February, during her annual report, to be able to investigate medical jail deaths. As soon as a death occurs, she wants to be able to get a call and respond, the way she would if it were a homicide.
“There are things you need to see, or want to see, and you’re reliant on jail staff to do this cursory look and quite often they’re very busy,” Tournour said during the July 18 meeting.
Board of Supervisors Chairman Rich Desmond declined comment for this story.
Tournour said she plans to audit all jail deaths since she arrived in 2022, but she must wait for the District Attorney’s Office to review them for criminal misconduct first. The DA’s Office so far has not completed its reviews of any of the six deaths this year, and only three of the nine deaths from last year. In those deaths it has found no evidence that deputies engaged in criminal misconduct.
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