Nurse recounts futile life-saving effort Was suicide watch called off too early in Monterey County Jail?


By Royal Calkins

In her four days working in the Monterey County Jail, registered nurse Michelle Nattrass was struck by three things — the dingy, dirty cells, the overwhelming workload caused by the endless stream of incoming inmates and how icy cold one inmate felt when she tried to take his pulse.

The inmate was Carlos Chavez, an apparent suicide victim who died in circumstances that add to longstanding questions about the ability of the Monterey County Sheriff’s Office to monitor prisoners in crisis and about the quality of medical care in the jail.

His death in the jail on April 20 came to light only after his widow, Anabel, took to social media to allege the Sheriff’s Office was responsible for his death and to post videos of herself going from one county office to another in a fruitless search for additional information.

It turns out that the Sheriff’s Office does not routinely issue public alerts about in-custody deaths, contrary to public expectations. Reporters working on articles about Chavez’s death essentially stumbled on a recent civil rights lawsuit regarding another previously unpublicized suicide in the jail. In that case, from March 2021, a patient with a history of mental health issues, Carlos Regalado, hanged himself after being taken off of a suicide watch for unexplained reasons. 

Anabel Chavez says she’s shopping for a lawyer at the moment.

Nattrass said she can’t be certain but believed Chavez had been taken off suicide watch the night before she first saw him. And she said she understood that inmates where he was housed were not being checked at least every 15 minutes, as protocol dictated. She said she understood it was common for deputies not to awaken sleeping inmates, even those thought to be in jeopardy.

Sheriff’s officials presumably have video footage from the inside of Chavez’s cell but they haven’t disclosed what it reveals.

'The place is very chaotic'

Nattrass is a former Veterans Administration nurse with decades of experience. She began work at the jail on April 18 as an employee of Wellpath, based in Nashville, Ky., which provides medical and psychiatric care at jails across the country. It replaced Monterey County’s previous provider, Forensic Medical Group, but that firm’s longtime chief executive, Dr. Fithian Taylor, remains involved in Wellpath’s current operations here. Past lawsuits challenging jail conditions have also lobbed serious accusations against Wellpath and Fithian, allegations that they have repeatedly denied.

Nattrass said she was surprised by the volume and pace of work at the jail, where she was primarily responsible for performing quick medical reviews on incoming inmates. While a small crew of licensed vocational nurses distributed medications and performed other tasks in the housing units, Nattrass worked 12-hour shifts to handle daytime admissions as another RN handled nighttime duties. The jail, recently expanded, has a capacity of 1,401 inmates.

“It was my third day working there,” Nattrass told Voices of Monterey Bay. “The place is very chaotic. Honestly I was just doing my best to complete my orientation. I thought this job is just not going to work for me. I couldn’t take the chaos, and nurses are expected to do the work of two or three nurses.”

She had started work at 7 a.m. on April 20. Minutes after 8 a.m., she recalled, “a deputy came into intake and said there’s an unresponsive, there’s an unresponsive inmate.”

“I said OK, OK, oh shit, oh shit, because I had just started working there. When I got to the cell, two deputies — a man and a woman — were doing CPR on the gentleman, chest compressions.”

She said it was a terrible scene. “He had been there all by himself in a tiny, horrible, depressing cell. There is, like, nothing in there. He had been sleeping on the floor, a blanket wrapped around him.”

She went on, “They said, I think they said, he had been taken off suicide watch the night before.”

She said someone was trying to start oxygen. She yelled out for someone to call 911 and ran to the intake office to retrieve an oxygen canister. When she returned, her supervisor and Wellpath’s local nursing director were trying to move Chavez out of the cell to create more room to maneuver.

Nattrass said the nursing director said he needed forceps to remove something from Chavez’s throat. She said she rushed back to the medical supply area in the intake area but there were no forceps. She returned and the nursing director was using his hand to take wads of white toilet paper from Chavez’s mouth and nostrils.

Though autopsy results are incomplete pending toxicology tests, the death certificate issued by the county on May 4 says Chavez died of asphyxia after stuffing tissue into his nose and throat. 

With county officials refusing to disclose any information about Chavez’s death or the circumstances leading up to it, Voices hasn’t been able to determine exactly where he had been housed in the jail. By one anonymous insider account, he started in general population but was moved to a “safety cell” after expressing suicidal thoughts. 

Safety cells are empty rooms without beds, bedding or toilets other than a drain in the floor. Inmates in safety cells generally are dressed only in heavy gowns that can’t be torn into pieces for use in suicide attempts.

From Nattrass’s description, however, it sounds as though Chavez had been moved to a less secure “isolation cell,” meant for one inmate, next to the group drunk tank cells at the front of the jail. She said he had a blanket and she thinks he was wearing the standard jail-issued uniform “but I’m not super clear on that.”

By the time she returned from looking for forceps, she said Chavez was obviously dead.

'When I reached down to check his pulse and touched his left wrist, he was ice cold'

‘He had flatlined. The paramedics were there. When I reached down to check his pulse and touched his left wrist, he was ice cold.

“I’m not a forensic person but there was no point in doing CPR. He was already passed. He was really cold. I’ve been a nurse for 33 years. I know when somebody has passed.”

Others in the jail say they have heard that rigor mortis had set in by the time the death was discovered. That usually starts about two hours after death.

Nattrass said the paramedics from American Medical Response set up a defibrillator in hopes of restarting his heart but the machine flashed a “No Shock” code. That means it couldn’t detect any signs of life.

She said she was shocked by the amount of toilet paper in Chavez’s mouth and throat. “I racked my brain thinking how someone could do that. I just pray for the family and the county.”

Nattrass quit the job the next day but not entirely because of the death. “On the last day I told my preceptor, Melissa, that I couldn’t stay, not just because of Mr. Chavez, but I just don’t think I will be able to keep up the pace here.”

She said the orientation and staffing levels provided by Wellpath were inadequate. “The police departments are bringing guys in from Pacific Grove, Seaside, Monterey, Salinas and you’re supposed to do an assessment, check their vitals, make sure they don’t need to be in a hospital, make sure they’re stable. But most of them are coming off drugs and alcohol and I don’t think anyone coming off drugs and alcohol is stable.” 

“My supervisor said, ‘Wait till summer, when there are 25 of them coming in at a time.’”

Nattrass said the deputies she worked with were all professional and engaging.

“I really enjoyed working with them,” she said.

The Wellpath staff? Not so much. “They are excellent nurses but the job is so hard, I mean, they really don’t have time to be welcoming or helpful,” she said. “The place is overwhelming.”

An email seeking comment from Wellpath headquarters produced no response Friday.

Sheriff’s Capt. Joe Moses, who heads the jail, and other county officials have refused to provide any information about Chavez’s death, though Moses did release a statement this week suggesting that short-staffing played a role and congratulating himself for improving jail conditions overall.

The county did release the booking slip for Chavez late Thursday. Anabel Chavez has said her husband had turned himself in to Watsonville police on April 19 because of a failure to appear warrant in another county. She said that triggered a warrant check and discovery of another failure-to-appear warrant in Monterey County.

According to his wife, he was wanted only for a minor parole violation stemming from an auto theft conviction. In her view, Carlos Chavez was facing little additional jail time, not enough to spur him to suicide. 

The booking paperwork for Chavez says he was arrested on bench warrants for failure to appear on three counts of vehicle theft and one count of possessing burglar tools. Anabel Chavez said he had already spent about 18 months in jail on those cases.

Law enforcement agencies are often slow to release detailed information about in-custody deaths but quick to put out information about the victims’ criminal records.

PHOTO: Monterey County Jail exterior, by Carlos Castro

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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

2 thoughts on “Nurse recounts futile life-saving effort Was suicide watch called off too early in Monterey County Jail?

  1. Unfortunately, the tax payers of Monterey County will be responsible “again” to settle these in-custody deaths with the inmate’s families. Sheriff candidate Joe Moses claims he has improved the conditions in the jail which is totally false. To prove my point, the jail lawsuit has been extended indefinitely due to non-compliance issues, employee morale is low which contributes to employee burnout, employees leaving to other agencies, excessive overtime, and recruiting new employees has been problematic due to the continuous negative publicity of the way the Sheriff’s Office is currently being ran. Recently the Monterey County Grand Jury released a negative report of the jail contrary to Captain Moses claims. There also appears to be a conflict of interest between Well Path and the current Administration due to personal friendships and large financial contributions to the Bernal and Moses campaigns. The newly elected Sheriff should terminate the current Jail’s medical contract and go out to bid for a new competent medical provider with no conflict of interest issues. Someone needs to remind jail Chief Jim Bass and Captain Joe Moses what “deliberate indifference” means.

    1. Jose, you are so right. The Monterey County Taxpayer will again pay for the lawsuit that will surely follow. More importantly, the loss to the Chavez family is surely heartbreaking. It seems to me that Joe Moses should not be seeking a higher office at this juncture in his career. Personally, I put NO faith in his ability. How can our former Congressman, Sam Farr endorse him? Joe Moses is running as a Democrat in a non-partisan office. Sam Farr, and everyone who endorsed him might want to think about pulling their support.

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