Unreported suicide deaths in the Monterey County Jail raise continuing questions about safety procedures, staff shortages and training. Candidates for sheriff agree external investigations are necessary.
By Royal Calkins
The way Carlos Chavez’s widow sees it, her husband had no reason to kill himself even though he was in the Monterey County Jail. He liked his job, was close to his family and had been arrested only for a minor probation violation. He may have faced only another week or two in custody.
The widow, Anabel Chavez, also doesn’t buy the bits of information the Sheriff’s Office provided following her husband’s death on April 20. She says coroner’s investigator James Day told her Carlos had suffocated after stuffing toilet paper in his nostrils and throat. She says that doesn’t sound plausible and doesn’t explain the bruising she saw on his neck at his funeral, purple lines that look like ligature marks.
Today, shortly after this article was published, Anabel Chavez received a copy of the death certificate, signed by Day. It says her husband died of “Asphyxia: upper airway obstruction, foreign object.” It also says he “intentionally swallowed a large amount of toilet paper and it became lodged in his throat.” The death certificate is not the same thing as the coroner’s report, which likely won’t be completed for weeks.
If Carlos really was out to kill himself, Annabel wants to know, why wasn’t the jail staff able to stop him? He was in a safety cell where he was supposed to be checked regularly, either “every 15 minutes” or “constantly,” depending on which part of the sheriff’s policy manual you’re reading. Even within the Sheriff’s Office there seems to be confusion about what “suicide watch” means and what prompts a call for medical help.
Sheriff’s Office sources say they understand that rigor mortis had started to set in by the time Chavez, 39, the father of six, was found in an isolation cell. If so, that would indicate he probably had been dead at least two hours, according to pathology reference works. With jail and county management declining to comment, there is no way to confirm that at this point.
While waiting for more information from the county. Anabel Chavez says she’ll be talking to lawyers about a possible wrongful death suit.
“I think they killed him,” she offered, while acknowledging she has no way to prove that.
Anabel Chavez, 41, is from Watsonville but lives now in Red Bluff. She operates a thrift store there and is also a rather skillful researcher. She knows how to gather inmate information online, how to search court records and file public information requests. She’s had some scrapes with the law herself and knows how the system works, and how it’s supposed to work.
“I just kind of learned that stuff when I was on drugs,” she explains. “And I watched a lot of ‘Forensic Files’.”
She’s also persistent. She alerted the world to the death via social media and began an online petition seeking justice for her husband. When she went to the jail, the Sheriff’s Office and the courthouse in search of answers, she carried a video camera. She was not always well received.
Despite considerable effort, she has had almost no success prying information out of the Sheriff’s Office.
She is not the only one.
The sheriff’s official in charge of the jail is Capt. Joe Moses, a current candidate for sheriff. The focus of his campaign has been improving mental health services for inmates. It might therefore have been worthwhile for him to publicly point to Chavez’s death as additional evidence of the need for improvement. Instead, Moses has declined to say anything at all about Chavez’s death.
Voices of Monterey Bay requested basic information from Moses but was referred to the County Counsel’s Office. Attorney Susan Blitch there said no information would be made public because of privacy concerns and federal HIPAA rules. HIPAA imposes strict confidentiality over people’s medical conditions and treatments but is rarely used to withold information related to suicide attempts or acts of violence in U.S. jails. In fact, Monterey County sheriff’s officials publicly announced the suicide death of rapist Thomas Pollacci last August, and they have publicly reported basic details about previous suicides.
Other jails around the country routinely issue news releases about jailhouse hangings and other self-inflicted deaths. Google “inmate suicide” and you’ll see.
At some point, the county will be required to release some information on this death. In addition to the public-record status of the eventual coroner’s report, the county must file reports with the state Department of Justice on every in-custody death. Voices has requested access to recent reports filed by Monterey County but has not received a response.
At least one other Monterey County Jail suicide occurred in recent times and it also was not made public. It has led to a federal civil rights lawsuit.
In that case, Carlos Patino Regalado died in March 2021, six days after hanging himself in an isolation cell. According to a news release from his mother’s lawyer, Jamie Goldstein of Emeryville, Regalado had been in custody for about a month and had been on and off special suicide watches several times before then, sometimes for expressing suicidal thoughts, other times because of actual attempts.
Earlier on the day he hanged himself, Regalado had been on a suicide watch because he had just returned from the hospital following a “psychiatric emergency,” Goldstein said.
“However, the watch was discontinued and he was placed in an isolation cell (that) contained a number of hanging points,” the lawyer said.
According to the lawsuit, “On March 13, 2021, at approximately 2:30 p.m., Mr. Regalado was found hanging in cell G104 by cloth wrapped around his neck which had been attached to the air flow grate in the cell.”
Jail officials almost everywhere in the United States have been attempting to eliminate so-called hanging points — things like bed frames, grates, shelves or other objects that inmates can use to attach hand-made nooses made of bedding or other materials. Monterey County’s new jail was designed to eliminate as many of those spots as possible, but Regalado was in the old jail.
Defendants in the Regalado action include Sheriff Steve Bernal and several of his subordinates, but not Moses, who was not assigned to the jail at the time. Another defendant is Wellpath, the company that provides medical and mental health services at the jail. Wellpath and a related company that formerly held the jail company have been regular contributors to sheriffs’ political campaigns. Forensic psychiatrist and Wellpath principal Taylor Fithian contributed $4,500 to the current Moses campaign.
“The jail and Wellpath have been on notice for years regarding the dangers of putting someone like (Regalado) in an isolated cell with hanging points but they just keep doing it,” said the Regalado family attorney. “It is especially egregious knowing he just returned from the hospital … and should have been on suicide watch.”
Wellpath and the other defendants have filed court papers denying any wrongdoing.
Chavez, unlike Regalado, was on a suicide watch at the time of his death. Unfortunately, with county officials declining to comment, what path he took to a suicide watch cell isn’t clear — and it also isn’t totally clear what being on a watch means in the Monterey County Jail.
Anabel Chavez says Carlos had turned himself in to Watsonville police in hopes of clearing up an outstanding traffic warrant from Placer County. Carlos Chavez was from Watsonville but settled in Red Bluff following Anabel’s move there.
She said he had been faithfully reporting to a probation officer in Red Bluff and was trying to have his probationary responsibilities transferred there.
“He was working construction,” Anabel said. “He was happy because his family was proud of him.”
Anabel said she and her husband were surprised to learn that his name was also on a probation violation warrant in Monterey County. From court records, it appears he had been arrested in Red Bluff for public intoxication, which could impact his probation status. He was on probation after spending about 18 months in the Monterey County jail for auto theft.
Anabel Chavez said she and her husband had both been meth addicts but were clean in recent times.
Because of the probation violation warrant, Monterey County authorities had Chavez moved to the county jail in Salinas the day before his death. According to a Sheriff’s Office employee, Chavez was initially placed in the general population and reportedly said something about wanting to hurt himself. That landed him in a “Level 2” suicide watch cell, where he reportedly was supposed to be under constant video surveillance and checked by deputies at least every 15 minutes.
When he died, Chavez was wearing only a heavy jail-issued smock with no straps or anything else that could be used for a hanging. According to the department’s policy manual, deputies checking his cell were supposed to wake him at each visit, but that policy may have fallen by the wayside because of staffing shortages.
Since 2015, the jail and the Wellpath medical-psychiatric operation have been working under a federal settlement agreement, known as the Hernandez ruling, that resulted from a lawsuit filed by the Public Defender’s Office, American Civil Liberties Union and others alleging inhumane conditions in the jail. Since it went into effect, sheriff’s officials have complained that mandated staffing levels in the jail have made it financially difficult to hire an adequate number of patrol deputies.
Because of jailhouse staffing shortages, some U.S. jails have even started hiring inmates to perform suicide checks on other inmates.
According to various sources in the Monterey County department, who fear reprisals if they were to be identified, the rule about waking inmates isn’t always followed and there is not full agreement on when a deputy should enter a suicide-watch cell for a close inspection. Some say deputies can move on to the next cell as long as there are signs of life, such as breathing. Others said some jail deputies understand that they are to intervene only if there are “signs of distress.” In other words, under that policy, Chavez could have been dead or otherwise motionless for a considerable amount of time without triggering a reaction from the jail staff.
Anabel Chavez said a timeline she computed has added to her suspicions. She tracked down police scanner traffic that shows the jail called for an ambulance at 8:05 a.m. on the day of Carlos’s death.
“He had court that morning at 8:30,” Anabel said. “He shouldn’t even have been in his cell. He should have been at the courthouse. Nobody woke him up for breakfast. Nobody woke him up to take him to court.
“So apparently they found him at 8:05, did CPR, pronouncing him dead. And then called the court and got his case dismissed, then got all his property together, and got him all checked out on the computer and the check for the money on his books was already printed out by 8:36 a.m. They did all that in 20 minutes.”
She said she was told the pathologist who performed an autopsy on behalf of the county removed toilet paper from her husband’s nose and throat. She said that makes her wonder whether anyone actually had performed CPR as she was told.
After he missed his scheduled court appearance, Anabel started checking on Carlos’s whereabouts, unaware of the reality. Mid-morning she was told by a jail staffer that he had been released. She didn’t learn the truth until the afternoon.
One of Moses’ opponents in the June 6 primary election, sheriff’s deputy Justin Patterson, said that based on the rumors he has heard about Chavez’s death, the Sheriff’s Department should call for an independent investigation.
“I know this much, Joe Moses is the captain of that facility and he touts his leadership skills as being the best to run the sheriff’s office,” Patterson said in an email. “The jail has experienced Mr. Chavez’s death, escapes of homicide suspects in the recent past, and roughly 100 hours of overtime daily, etc.”
Patterson said some deputies in the jail are working several 16-hour shifts in a row.
“If this administration truly cared about their deputies and the care of inmates, they would be working diligently to solve the fatigue issue as well as other problems that occur routinely,” said Patterson.
Moses would not respond to Voices’ questions about the death but he did respond to Patterson’s comments.
In an email, Moses said, “As the captain in charge of Custody Operations for the past two years, we have already made great strides in improving the professionalism and efficiency of the jail. This is evidenced by the progressively better reviews on our progress.”
He continued, “Staffing shortages is an issue that law enforcement in general is facing, but we continue to work with our staff to try new and innovative ways to increase our recruitment and appeal to our next generation of deputies. I welcome the input from anyone about how we can improve the operation.”
Moses went on to criticize Patterson for not making suggestions on solving the staffing issues and to point out that Patterson has worked 21 years as a deputy without receiving a promotion. (That actually makes Patterson more experienced than the current sheriff, Steve Bernal, when he was elected in 2014. He is not seeking re-election.)
The other two candidates opposing Moses also weighed in on the county’s failure to disclose Chavez’s death.
Marina Police Chief Tina Nieto said the Sheriff’s Office “needs to be transparent in disclosing in-custody deaths to our communities. The fact that our current Sheriff’s Office continues to not release this kind of information while at the same time making claims about the great work the executive team is doing creates an atmosphere of distrust.”
Nieto said county leadership needs to know “that when someone dies in the jail, notifying the public is a basic expectation. … Beyond the human toll on the families, each death is costing the taxpayers money for claims and cost of litigation.”
Nieto said the Chavez death is another indication of why the Sheriff’s Office needs independent oversight or an inspector general.
Del Rey Oaks Police Chief Jeff Hoyne agreed with the other candidates that it would be wise to have such cases investigated by an outside agency. He said that if he were sheriff, he would ask the District Attorney’s Office to help investigate in-custody deaths.
“Additionally,” he said, “formal press releases should always be made regarding these incidents so the community is better informed about their Sheriff’s Office.”
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FEATURED IMAGE | Monterey County Jail, Carlos Castro