S1: Welcome in San Diego. It's Jade Hindman on today's show. What happens when an autopsy report doesn't align with how a person died in custody ? Local reporting and a new book. Explore just that. This is KPBS Midday Edition. Connecting our communities through conversation. Before we get to autopsies , we are going to start with some of the dangerous conditions in San Diego County jails. Yesterday , county supervisors approved a $3.5 million increase to the sheriff's budget to phase out one of those dangers , which are triple bunk beds. State regulators say they're a safety hazard. Aside from overcrowding inmates , they can and have fallen from those high bunks. Just last month , the sheriff's office announced a 10th person died in custody , surpassing last year's total. The sheriff's office recently started phasing out the use of triple bunk beds amid an ongoing class action lawsuit alleging unsafe jail conditions. Kelli Davis , investigative reporter at the San Diego Union Tribune who has covered all this extensively , joins me now. Kelly , welcome back to the show.
S2: Hi , Jade. Thanks for having me.
S1: Glad to have you here. So we have a general idea of what it is , but explain triple bunking and why it's so dangerous. Yeah.
S2: Yeah. So so San Diego jails and I think , um , probably all jails in California. Um , they were the they were designed to hold cells were designed to hold maximum two people. Um , triple bunks are not allowed. And so , um , during periods of overcrowding , um , here in San Diego , the sheriff's office added a third bunk to to many jail cells. About 300 something jail cells. And then there's these dorm style units that would have double bunks. And so they added a third bunk to those as well. And you know in state regulators come in and they do jail inspections. And for years they have flagged , um , San Diego as being , uh , out of compliance with , with state regulations and has have told the , the sheriff's office , um , and this is going back probably a decade. Um , you got to remove those triple bunks. Um , big issue for the sheriff's department is , is how do you fit people in if you have to remove a bunk from from a jail cell ? And so , as they've described to me , it's kind of been this , like this puzzle of sorting out , um , where to put people as they go through and do these , these , these removals. So they received a 3.5 million from the Board of Supervisors last week to to remove the bunks. And they're able to do that now because they have done some repairs , rehabs , fixes on a couple of , uh , jails that had um , uh , modules that weren't ready for people , but now they are. And so over the next year , they'll move people into those other jails , remove the triple bunks , and then put , put people back , um , to the , the cells. No more than two. Yeah.
S3: Yeah.
S2: Well the and we're talking uh , these , these cells are about 75ft². So we're talking about a very , very small space for three people. And , um , you know , very , very dangerous for folks with with mental health issues. It's just not a good situation. Yeah.
S3: Yeah.
S1: Well , the decision to continue this practice , which has been around since the late 80s , has cost taxpayers millions of dollars in legal settlements. Talk a bit more about that.
S2: Yeah , there's a gentleman named Frank Greer who who felt he had a seizure disorder and for , for some reason , was placed on the the assigned to the top bunk. He tried to tell deputies like , no , no , I please put me on the lower bunk. Was told to take the trip to the top bunk. He had a seizure. He fell. Um , serious brain damage. He's now in a assisted care facility , and so he was awarded , uh , $8 million in a lawsuit. Um , another young man with. With serious mental illness , Lyle Woodward. He was put in a three person cell. It just created a really bad environment. Um , kind of triggered his. His , um , he suffered from. I think it was bipolar disorder and schizophrenia. Um , he ended up being killed by one of his Is soulmates. And then there's a and his family received $400,000. There's another lawsuit right now. Um , the family of a man named Erich Von Tine. He was placed in a triple cell , and , um , got into a fight with his. One of his cell mates. And , um , both of the men had , um , serious psychiatric issues , and. And one of his cellmates , uh , killed him. And his family has filed a lawsuit. So those are , um. Yeah , three , three cases we know about , you know ? So we've got about more than $8 million just for the the Frank Greer and Lyle Woodard cases. And , um , you know , we're , uh , the Erich Von Stein's family's lawsuit is working its way through the process right now.
S1: Well , this push to now remove triple bunking is part of a broader plan to make jail upgrades across San Diego. Can you break down some of the changes the sheriff is pushing for ? Yeah.
S2: Um , so. So , um , I recently was able to tour both the the Vista jail and , uh , George Bailey detention facility. Um , two of the seven jails in San Diego County and , uh , Vista jail. It's it's it's pretty bad. It was built. It's the oldest jail in San Diego. It was built in the late 1970s. Um , it looks like a jail built in the late 1970s. Um. It's cold , it's dark , it's bleak. Um , pipes are failing. You know , there's been , uh , leaks of sewage , um , through falling through roofs. Um , you know , onto , um , office areas. Little to no space for classes , little to no space for private mental health visits. Um , it's got outdated security systems. Um , so the goal is to replace the facility with a new jail. That's more in line with with what we know about how and why people end up in the criminal justice system. So so a jail that has more of a focus on services that will help people pull their lives together and stay out of jail. Um , but there's a big price tag. Um , if if construction started today , it would cost nearly $1 billion to build a new jail. Uh , that number goes up the longer the project is delayed. Um , so right now , the county is in talks about how to approach funding this. Maybe they'll issue a bond to fund construction , but what they've decided to do hasn't been nailed down yet. And then there's these , uh , the only jail that's newer is the Las Colinas Women's Jail , and that's about a decade old. Um , all the other jails , like , really are really in need of of anything from , um , uh , you know , security upgrades , new cameras. Um , but really , the sheriff's office really wants to , to provide a more rehabilitative space for folks and , and really focus on kind of rethinking , um , jail space. So.
S1: What's the status on that lawsuit ? Yes.
S2: So in , um , I just checked this , um , because it's kind of been a in flux ever evolving , but , um , there will be a pretrial conference in late February , and that's where they will set dates for the trial. And , um , the earliest the trial could begin is March. And this is a huge case. There are multiple causes of action. Mental health care , medical care. Who ends up in jail. How people are classified once they end up in jail. It's it's it's a really big case. And if it does go to trial , this trial could last for 2 or 3 months. Hmm.
S3: Hmm.
S1: Well , you know , I want to switch gears here a little because you've been reporting on jail deaths for more than a dozen years and have read many autopsy reports during that time. What are the biggest challenges to obtaining those records and getting a more accurate picture of what really happened ? Yeah.
S2: To the to the credit of the Senegal Medical Examiner's office , they are really good at turning over reports when I've requested them. Um , very responsive. I can put in requests. Um , as soon as I learned that someone has died. And even if it takes months or a year for that report to be finished , they will get it to me as soon as it's finished. Um , but just a quick overview of what goes into a medical examiner's report , you know , and when someone dies in jail , that triggers an automatic investigation under state law. So an investigator goes into the jail , goes into the scene , takes notes and takes , makes photos , looks at the person's medical history , talks to next of kin , passes that information along to the pathologist who conducts the autopsy and arrives at a cause of death. And I've read probably easily more than 250 autopsy reports. And what you see , sometimes the pathologist does a really deep dive and puts together a 2 to 3 page narrative , and you get a really good picture of what happened to this person. Were there lapses in care ? Um , you know , the medical examiner's office has ruled in two two death case , jail death cases that they ruled the deaths a homicide due to neglect. So sometimes we'll see this this really careful look. But in other cases there's just been this brief summary that , um , to me , I , you know , raises a lot of questions. And I kind of left thinking like , what ? What are we not being told or couldn't you have , um , you know , while there are strict privacy rules on what information can be released , um , I feel like there's there's more the medical examiner can do in cases where somebody dies in a jail , um , you know , a psychiatric facility , you know , where there's there's a government agency involved. Um , and , and kind of more oversight is needed. And that could be the role should be the role of the medical examiner's office.
S1: You know , you recently wrote about 82 year old Karim Taleb , who died earlier this year. Can you tell us about his case and what you found from reading his autopsy report ? Yeah.
S2: So. So , um , the class for the class action lawsuit. Um , as soon as soon as Mr. Kelly died , um , an attorney in that case went to the central jail and interviewed several men who were in the same unit as Mr. Talib. Um , it was an administrative separation unit , which is kind of akin to to solitary confinement , single person cells. You don't get much out of cell time. Um , but men in nearby cells , they they described , um , they were when Mr. Taleb came in , he was he was incontinent. He was wearing a diaper. They could smell him. They could smell , um , the smell of feces coming from his cell. And then when they when these men , they , they get out of cell time , kind of one , one person at a time. And they would go , they would ask him if he was okay , they could see into his cell. They described him as as laying in his own waist , barely able to move. Did not respond when when spoken to. They described his diaper as being just really , really gruesome. Details. His diaper was filled with fecal matter. It was sliding down his legs , one man said. Mr. Talib looked like he was dead. Um , so. So , uh , you know , when I got his autopsy report , I was I was hoping that the , um , pathologist or investigator kind of dug into these claims a little bit more , but it was it was very. The report was the narrative was very , very brief. Um , and it found that he he died from heart disease , but heart disease , complicated by a bacterial infection that had spread to his kidneys. And I checked with some folks I know who are medical experts. And they said that kind of bacterial infection is caused , can be caused by by someone like in his situation where they're not being , um , kept clean. Um , they're exposed to to feces. That's the way the , the infection spreads. So I think that raises a lot of questions about the care he received. Um , in the days leading up to his death. Yeah.
S3: Yeah.
S1: Well , it definitely shows the need for more transparency and clarity in these reports. Um , you know , in the last minute we have here , we mentioned that the number of jail deaths this year has gone up compared to last year.
S2: Yeah. 110 people have died so far this year compared to nine last year. Um , Mr. Talib death stands out. Um , weeks , a few weeks before his death. Um , another man named Corey Dean died in the Vista jail under very similar conditions. Uh , the the attorneys , um , in the class action lawsuit also sent someone to get depositions or declarations from from men in Cary Dean's cell. The similarities are jarring and upsetting and raise a lot of questions about conditions and administrative separation. Um , there there are some other cases where we're still waiting to find out more information. You know , some families , families are able to request medical records. And so we're just kind of waiting , waiting to see what we're able to find out.
S1: A lot to follow up on with you , I've been speaking with San Diego Union-Tribune investigative reporter Kelly Davis. Of course , we'll include links to her reporting on KPBS. Kelly , thank you so much.
S4: Thank you. Jade.
S1: Still to come , a new book highlights systemic failures in forensic science and how some death investigators allegedly cover up violent in custody deaths. Hear more when KPBS Midday Edition returns. Welcome back. You're listening to KPBS Midday Edition. I'm Jade Hindman. We just heard the latest on jail conditions and in custody deaths across San Diego County. Now we look at the system more broadly through the lens of a new book. It explores the role coroners , death investigators and state institutions have played in covering up the circumstances around in custody deaths. The book is called The Coroner. silence , death records and the hidden victims of police violence. I'm joined now by the book's author , Terence Kiehl. He is a professor of Human Biology society and African-American studies at UCLA. He's also the founding director of the Bio Critical Studies Lab. Professor Kiehl , welcome to the show.
S5: Thank you for having me.
S1: So glad to have you on. You know the coroner. Silence. It started with the countless hours you've spent looking at autopsy reports , spending time with the victims and their loved ones.
S5: And if you remember when the George Floyd protests began , It was his autopsy. The Hennepin County Medical examiner said that George died of a homicide. But when you look at the record , there was an effort to say that his heart , his biology , something was wrong with his body and that it ultimately contributed to why he died. And there's a big discrepancy there that I caught and many others. And so I wanted to know how many George Floyd's were there. And as I began to ask that question , I realized just how broken our system really was. Hmm.
S3: Hmm.
S1: Well , you share an alarming statistic. Three people in the United States lose their lives to police violence every day , who are often the victims of this violence.
S5: Um , what we're learning is that many of the victims of police violence. People who lose their lives in custody during arrest or in jail are often people who have already been failed many times over by our democracy and our , you know , evaporating social safety net. So these are people who are often unhoused or sometimes people who are suffering with substance abuse issues or mental illness. There are also people who can't afford bail and find themselves confined in carceral spaces that are violent , that make us ill and , quite frankly , tragically , take our lives. You know , dying in custody is something that , um , should not happen in a robust , functioning criminal justice system. It should be a rare occurrence. And instead , what we're finding is that actually , around five people will die every day in police custody. But we will only know the names of three of those people. Hmm.
S3: Hmm.
S1: You know , autopsy reports can be dense. So how do you read between the lines and find what ? A medical examiner is leaving out.
S5: You know , I'm trained as a historian of science and medicine , and I've written a great deal about genetics and biology and evolution and a whole host of other things. I can read an autopsy. But the issue is not one's ability just to read the record. To really understand an autopsy , you need to see it from the perspective of the people who have been failed by a criminal justice system , people who have lived or living in the wake of the violence of police. And this is something that I was I had the benefit and fortune of learning from Helen Jones , who was an impacted , um , community organizer here in Los Angeles , working with Dignity and Power Now , which is a social justice organization committed to social change and criminal justice reform. Helen lost her son , John Horton died on March 30th , 2009 , and she went about the business of trying to read his record with the perspectives of many other families and impacted communities. Who knew that these records really weren't being written for the public. They were being written to provide cover for police and provide cover for local officials. Unfortunately , Helen , with her wisdom and expertise , was able to help me see these records from this perspective. And then from there , um , we designed a really sophisticated protocol that allows any death record in the United States to be analyzed by researchers in my lab , and for us to turn a death record into data points where we can identify patterns of discrimination and patterns of abuse and injustice.
S1: Can you talk about that more ? Because what I'm hearing is that there really isn't a lot of independence within the death investigation system. Uh , talk a bit about the relationship between coroners , medical examiners and the law enforcement agencies they're working with. Absolutely.
S5: Absolutely. You know , most of the conversation about criminal justice reform has been focused on police and law enforcement. And that makes sense , right ? Law enforcement are the ones who are inflicting the violence. They are , tragically , the ones ending people's lives. But what we have not been focused on or look carefully at are how death investigators and coroners play a role in these tragedies. You know , the coroner system is probably one of the oldest institutions in American history. When America was a colony. Uh , the very first death investigators were called crooners because they worked for the Crown of England , and their job was to figure out if someone lost their life , if money or debts had to be returned back on the other side of the Atlantic. As America became an independent nation and a democracy. Uh , the coroner became a position that was an appointed position. It was not a position where people run for office. And that continues to be the case today. If you look across the 50 states , you'll find that in most jurisdictions , the medical examiner or coroner is either directly appointed by a local official or some other state authority , or they sit underneath the sheriff's department. So if you look at , let's say , Alameda County , here in California , the sheriff's office is in charge and oversees administratively the death investigation work there. And so there's a conflict of interest between death investigators when they're investigating violence and deaths of people who lost their lives and law enforcement custody. And you can see this in the way the records are written. And you can certainly see this in the effort to kind of prevent public access to these documents. If you look across the country , there are certain states where one can't even get a public record. One can't see an autopsy , like in New York , for example , death records are not part of the public record. So this is a situation and a system that's been developed carefully over time. But it's not one that , quite frankly , works in favor of the people.
S1: And , you know , you said the coroner system is an old institution. How else has the death investigation process changed over time ? Um , yes. Did it use.
S5: In those 12 , jurors would have a conversation with themselves and try to figure out what happened to this individual before , during , and after they died. And then those 12 members of our democracy would then inform the coroner and the sheriff who to be arrested and what the charges were. The coroners system was a system of direct democracy after emancipation in 1865. And you get the sort of the franchise of democracy opens up to black people , formerly enslaved folks and other racial minorities. These systems become much more limited. The states begin to change the laws that do two things one. They require a corner to be a physician. Now , on the one hand , that's a good thing. You would want someone doing death investigation who knows a bit about science and evidence and forensics and other sorts of details. But on the other hand , they turned the institution into something that was less public. It was more sort of tied to institutions of law enforcement , policing control and public health , which are further and further removed. So we have a system that is rooted in direct democracy , but its current iteration is something that actually can be quite anti-democratic , especially when medical examiners write records that blame the victims Bodies for why they're perishing in police custody. Rather than telling us narratives that allow us to see clearly the connection between police violence and the death of members of our community.
S1: Powerful way to put that. You know , you talked about people who've been failed by the criminal justice system. It's also important to talk about how people end up in custody.
S5: You know what I learned writing this book and doing the research and talking to communities and families and organizers around the country. Our social safety net in this country has been slowly evaporating and eroding , really. You can document this from the Nixon administration down to the Reagan administration to our current moment. What does this mean ? It means that more and more Americans are living lives where they're working in jobs that can't compete with inflation. They are living in parts of the country where affordable housing is outside of reach. They don't have access to steady employment , which makes it difficult to get access to health care. You just take those three things alone housing , health care , wages you have en masse. A great number of Americans currently , right now , as our government is debating , you know , whether or not we're going to , you know , keep the premiums for health insurance low , which looks like it's not going to happen. People are living with precarity. They're living with uncertainty. They're making difficult decisions. Do I pay for groceries or do I pay for my medical bill ? And when you create a nation like that , you're creating a society where people are vulnerable to mental illness. They're vulnerable to substance abuse or vulnerable to chronic conditions and illness. And what we're doing is that we're using law enforcement to clean up the mess when those people are failed by these larger efforts to retract sort of institutions of care and investment into people in the communities. The way I like to think about it is when the military veteran comes home and that veteran has PTSD , and it might make that person difficult to sort of find a job or to live in affordable housing. And they're having a health crisis and family calls. The people that we need on the scene are not law enforcement. We need social workers , we need psychologists. We need people who can provide care and support. And you'll see in the book , that doesn't always happen. And so many of the victims , tragically , that end up in our nation's death letters are people who are struggling. They need support and safety in a nation state. That's sort of kind of pulling the rug from underneath them. Hmm.
S1: Hmm. You know , in terms of transparency , you know , an important focus of your book is solutions. So what are the solutions that you really want to bring awareness to what needs to be done here.
S5: There are a number of solutions that happen at multiple scales , quite frankly. This is a system despite it being broken and flawed. It's one that can be changed. And I think legislative change is one thing that certainly has a tremendous amount of power and upside. There are states like California and Illinois that have done simple things like make sure in the state of Illinois , for example , the state law makes it very clear anyone who dies during arrests or while in jail that a mandatory autopsy be done for that person. Why does this matter ? Well , if you look across the 50 states , there's only a handful of states that actually require an autopsy to be conducted. When someone dies in , say , custody , that's huge. It's important because we would want to know the real causes for why people are losing their lives. That needs to be a part of our state law. There also is a system where , you know , the communities I've been working with here in California and elsewhere , we have been doing something that is really vital , which is providing a peer review or a public review system. Death investigation records are written and there are not consulting physicians. There's not a secondary committee or review that sort of looks at these records. We've been trying to build systems that allow us to do that work so that we're , you know , investigating cases where people have died in police custody , writing reviews of those cases and trying to challenge some of the established narratives. There's a lot of traction that this sort of work has , has made. And then finally , you know , um , uh , Roger missile Jr and others. Yeah , yeah , have been arguing that , you know , we need to change the way death certificates are written right now. We don't even know when people die in police custody. And a simple adjustment to the death certificate boxes that say this person died in police custody would give us the record trail that we need for the kinds of transparency and social change that we all deserve.
S1: You know , in your book you write , I hope you lose a part of yourself and gain in return the ability to see the humanity of the people we are socialized to forget. A very powerful statement there. I've been speaking with Terrence Kiehl , UCLA professor and author of the book The Coroner Silence , Death Records , and the Hidden Victims of Police Violence. Professor Kiehl , thank you so much.
S6: Thank you.
S1: That's our show for today. I'm your host , Jade Hindman. Thanks for tuning in to Midday Edition. Be sure to have a great day on purpose , everyone.
