A life that might have been saved Deputy and coroner dropped the ball

Rania Ishak’s photo hangs on the dining room wall at her parents’ home in Marina |


By Royal Calkins

Twice in 2019, the staff at the Monterey County jail in Salinas sent inmate Rania Ishak to the hospital out of concern she might kill herself. Then, as she was being booked after another arrest later in the year, on Aug. 30, jail personnel turned her away, saying she needed to go to the hospital again because she was suicidal and obviously high on drugs.

But instead of taking the homeless woman to the mental-health facility at the county’s Natividad Medical Center nearby, the deputy who had arrested her simply let her go.

Within a couple of hours, the 42-year-old mental patient and addict was struck by a train while she walked along the Union Pacific tracks in the Chinatown district where she spent much of her time. She was killed instantly.

The official coroner’s report from the Sheriff’s Department lays out the extent of her injuries in great detail. It’s clear how she died. But why she died may never be known because the report fails to delve into Ishak’s past or her encounters with a sheriff’s deputy and the jail staff in the hours before her death.

The coroner’s report concludes that it was an accident and not a suicide, partly on the basis that Ishak didn’t leave a suicide note.  But the report fails to mention that she had been arrested earlier that day and that the deputy had ignored the jail staff’s recommendation. The report does show that she had a toxic level of methamphetamine in her system, along with a lesser level of morphine, but it does not address how that would have affected her behavior.

Dr. David Hadden, a pathologist who served as coroner in Fresno County for 32 years, said the information about the arrest and Ishak’s activities “absolutely” should have been in the report. That information points to a suicide and or a finding that the cause was undetermined, Hadden said.

“At best, it was sloppy work,” he continued. “At worst, well, I’m not sure what it was.”

“The question was whether it was suicide or an accident,” Hadden went on. “It always is in cases like this and it is important to answer that question. You have to determine her mental state and to do that you have to know what was happening in her life. Especially what was going on right before she died.”

“There is no good reason not to gather as much information as you can before you make a finding,” Hadden said.

Why critical information was left out, and why the Sheriff’s Department never told Ishak’s family about the arrest or the jail’s referral, may never be known. The coroner’s investigator who prepared the report, Detective Jeffrey Squires, who carries the title of deputy coroner, told a relative of Ishak’s last week that he had never heard about the arrest or the aftermath. He told Voices this week that he could not comment and suggested a call to the administration.

Emails to Deputy Chief John Thornburg, who is the department’s public information office, and Assistant Sheriff John Mineau, were not returned. Sheriff Steve Bernal instructed his staff earlier this year not to communicate with me, apparently because of recent articles critical of the department.

After I provided Ishak’s family with details not included in the coroner’s report, one of Rania Ishak’s sisters, Ammie, called Squires last week to ask why the arrest and other information had been left out of the report, which is dated Jan. 10, more than four months after the death.

“He was quiet for a long time and then said he didn’t know anything about it,” Ammie Ishak said.

Six months after Ishak’s death, the deputy who arrested her that day remains on paid administrative leave while under investigation for releasing the woman and for allegedly telling his supervisor that the jail’s only concern had been that Ishak was dehydrated. He reportedly told his sergeant that he gave her water before letting her go.

The deputy’s name is known but is not being used here because he has not been given an opportunity to comment. Efforts to reach him have proved unsuccessful.

While the report contains nothing about Ishak’s arrest or mental state the day she died, it does quote Squires’s supervisor, Detective Sgt. Nick Kennedy, as saying he had become familiar with Ishak when he was previously assigned to the jail.

The report says that Kennedy recalled that  “Ishak would not respond when she was addressed by her name. She would continue in the activity she was currently engaged in…”

Ishak grew up in Southern California and moved with her family to Marina when she was 18. She earned a degree in liberal studies from  CSU-Monterey Bay and worked as a substitute teacher in Peninsula schools. She wanted to be a special ed teacher.

That was before things spun out of control.

Over the past decade, her life had been a pinball of rehab, jail, home with family, homeless camps, psychiatric care, more jail, more family, more treatment and then back to the tents and cardboard shelters of Chinatown.

An index of her court record fills three computer screens. It starts with numerous traffic tickets and moves into multiple arrests for minor violations: trespassing, shoplifting, drug use, resisting arrest and probation violations — mostly probation violations. That’s why she had spent most of the first half of 2019 in the county jail.

The coroner’s report barely mentions anything that happened before the train hit her. It doesn’t mention her history of suicidal thoughts and behavior. It doesn’t mention that deputies had actually dealt with her three times the day she was killed.

Each of the Sheriff’s Department encounters with Ishak that day was at Moss Landing Harbor. No one seems to know why she was there. Deputies were dispatched to the harbor twice that morning because Harbor District staff reported that Ishak was walking in the middle of the road and otherwise acting oddly. The third time they reported that she had been trying to open boat doors and had sneaked into the district’s maintenance area. That’s when she was arrested, sometime in the late morning.

If the deputy followed standard release procedure after deciding not to take her to the hospital, he likely drove her to the transit center in downtown Salinas. It’s a short walk from there to the tracks where, at 1:30 that sunny afternoon, Ishak was hit from behind by the train. Engineer Don Chakerian later told the Sheriff’s Department the train was traveling below 40 mph. Conductor Elizabeth Heller told the Salinas Police Department it was going about 20 mph.

Witnesses told the coroner’s office that she was walking west on the wood ties outside the rails but still directly in the train’s path. Chakerian, the engineer, said he honked the horn a couple of times but Ishak paid it no attention.

A Salinas Police Department incident report says a nursing student at the scene told officers a witness had told her that Ishak had jumped in front of the train. The officers weren’t able to find that unidentified witness.

At the bottom of three pages of the five-page report, someone at the Police Department checked boxes indicating that the report should be forwarded to the coroner.

Ishak was hit by the train on the south end of the railroad bridge that crosses North Main Street, essentially linking two homeless camps.

Along the tracks earlier this week, residents of the closest tent camp debated exactly where Ishak was when she was killed. A couple people pointed to a flowery memorial on a cement slab 50 yards from the bridge but others said it marked the spot where another woman had been hit by a train a few years ago.

Woody, a longtime resident who didn’t want his full name used, said he had witnessed Ishak’s death but his description was improbable. Still, he demonstrated how easy it would be for someone to be killed while walking along the tracks rather than on them.

“I don’t see how more people don’t get killed,” said Woody.

The coroner’s division seems to have assigned little or no significance to the potentially toxic level of methamphatine in Ishak’s system, her history of depression and schizophrenia, her talk of suicide, or the jail staff’s recommendation that she be hospitalized.

The death presents several questions. What was on her mind? What had she been doing earlier? Why might she have wanted to kill herself? Why didn’t the Sheriff’s Department do more to protect her?

And those questions lead logically to more. The failure to include information about her arrest and the deputy’s decision to let her go suggest the department might have kept that part quiet in an attempt to avoid liability.

Ishak’s family didn’t know about any of that until this writer told them about it earlier this month after being alerted by law enforcement officials outside the department. The coroner’s report doesn’t mention any effort to talk to Ishak’s family even though her Marina address listed on the document is that of her loving family, The report describes her as Mexican/Chicano though she actually was of Egyptian descent. Her parents teach Arabic at the Defense Language Institute in Monterey.

The day I told Rania’s mother, Mary, about the arrest and other details, she looked and acted as though she was reliving the terrible days last summer after her oldest daughter’s death. She told the painfully familiar story of a family trying to help a child through mental health issues, through addiction, through little successes and larger setbacks. Through arrests and promises and broken promises and all the guilt that such a roller coaster ride creates.

“We did everything,” Mary Ishak said softly in her Marina living room. “We did everything until we could not. She would call us for a ride in the middle of the night and then she would not be there. Then we did everything again.”

Having a coroner’s office operate as a unit within county sheriff’s departments has been the subject of continuing controversy, with many arguing that coroners should be independent of any law enforcement agencies to prevent conflicts of interest.

Hadden, the pathologist, ran the Fresno County Coroner’s Office while it was independent. He retired after Fresno County officials folded the operation into the Sheriff’s Office there, mostly to save money. He opposed the consolidation on grounds that it would erode professionalism and create conflicts of interests, especially when someone died in custody or when autopsy results were critical to a criminal case.

The state of California periodically considers legislation mandating independent coroners’ offices in each county, but the idea dies, largely for financial reasons and sometimes because sheriffs don’t want to give up the function for reasons financial and political.

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Royal Calkins

About Royal Calkins

Contributing writer Royal Calkins has worked for newspapers in Santa Cruz, Monterey and Fresno. For the past couple of years, he has produced a local news and commentary blog, the Monterey Bay Partisan. He can be reached at calkinsroyal@gmail.com.

4 thoughts on “A life that might have been saved Deputy and coroner dropped the ball

  1. The FIRST job of law enforcement is to protect the people. It would seem there are reasonable questions about whether that happened in this case. Trying to ignore the situation—or worse, hiding it—undercuts the very premise of our governmental institutions.

  2. In this case it seems that one too many things were neglected by the Sheriff’s Department, resulting in a death, that then was not properly reported to the coroner. It also seems that by neglect or deceit the Sheriff’s Department kept the family from having the full story.

  3. This tragedy accentuates the lack of accountability in both leadership and morality in the Sheriff’s Department. How many more stories like this have been covered up?

  4. One compelling question arising from this article concerns the Sheriff’s duty under the facts presented. Did the Sheriff owe a duty of care to the late Rania Ishak and the rest of us? That to keep Ms. Ishak and the rest of us safe from the potential results of her mental condition, the Sheriff’s duty required getting Ms. Ishak into a custodial arrangement? Those questions might have been answered by the Sheriff’s staff statement that Ms. Ishak was suicidal and obviously high on drugs, because someone high on drugs might pose a threat to herself and public safety. However, the Sheriff is a law enforcement agency, not a guarantor of public safety.
    The compelling question then becomes whether the Sheriff breached his duty to faithfully and fairly enforce the law. How could the Sheriff’s jail staff unilaterally decide that it could refuse to incarcerate an arrested and booked individual? In the main jail or in a special medico-legal unit in a hospital? And, as a result, fail to enforce the law to which it had taken an oath?
    Somewhere between law enforcement and public safety, sheriffs and police chiefs have realized what’s required for both. And many have taken great efforts to address them. Royal’s article describes an opportunity to address the situation in Monterey County.
    As to the cost issue, the County Coroner or Medical Examiner likely remains the only program within the county health care system that continues to be supported entirely by County funding. Funding is a nationwide problem and the need for professionally trained death investigators continues, regardless of whether a County is served by an elected Coroner or an appointed board-certified Medical Examiner. Both systems require a Medical Examiner to provide the medical reason the person died, and both need skilled investigators working in the field to determine the manner and cause of death.
    Perhaps it’s time to discuss a better way to enforce the law, investigate deaths, and reduce avoidable loss of life?

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