Newly released records detail horrific health care failures at Monterey County Jail Death rate twice the national average as for-profit Wellpath ‘defies’ court-ordered obligations


By Royal Calkins

The medical and correctional staff at the Monterey County Jail had seen young David Sand before, which might explain why they ignored him and his obvious need for psychiatric care.

Born into a prominent Carmel Valley family, he fared well while growing up but fell into a hole of schizophrenia and other issues in his teens. His moods were ruled by demons and  methamphetamine. His family did everything and more but eventually keeping him housed and safe became impossible.

He had the comprehension of a 4-year-old, said his father, Eric. David was repeatedly arrested and sometimes got help for what ailed him. He was once held for a year in Santa Clara County before being ruled competent to be prosecuted.

His final stay in the Monterey County Jail, a place that sometimes seems as troubled as David, started on April 30, 2022. He had been arrested for throwing a rock at a fire truck. When he was booked, the medical staff employed by a contracted company called Wellpath didn’t bother to perform any significant mental or physical health screenings, even though his pulse was elevated.

During his seven-month stay, he received no psychiatric care. Not a little bit. Not any.

Nearly six months later he suffered a minor abdominal stab wound in an altercation with another inmate. A Wellpath nurse didn’t check him for internal bleeding and didn’t check his vital signs.

David died three weeks later, apparently at his own hands. It took his jailers several hours to discover his naked body on the floor of his cell.  He had cut himself on the legs and had used blood to write things on his body. The jail staff figured that’s what killed him: the blood loss. Deputies said there was also red writing on the walls.

But next to David’s body, there was also a pool of water. One of two autopsies later determined that he had died of water intoxication, a suicide method often used by mental patients. Drinking way too much water unbalances the body’s electrolytes, sometimes fatally.

Dr. Bruce D. Barnett, one of several court-appointed monitors who have been studying the Monterey County Jail for the past eight years, wrote in a report newly available to the public that Wellpath fell dangerously short of properly caring for Sand.

“The medical record does not document psychiatric evaluation of DJS (the monitors’ reports generally refer to inmates by their initials) and/or treatment of his diagnosed schizophrenia from his intake in April 2022, or in prior intakes, and even until his death,” Barnett wrote in one of numerous case studies contained in his reports.

The doctor concluded, “Medical services deployed in coordination with Mental Health would have reduced the risk of his demise.”

Barnett’s report is one of more than 30 monitor reports that were opened to public review on Friday, the result of a motion filed by attorneys for past and present Monterey County Jail inmates. It’s all part of what is known as the Hernandez settlement, a civil rights case that turned into formal monitoring of the jail by the federal court.

Related: Read previous Voices coverage of Wellpath’s troubles

It is a troubling collection of documents, more than 2,000 pages, that demonstrates what happens when a profit-driven company like Wellpath is contracted to provide medical and mental health services to an understaffed jail that has been inundated by serious criminals formerly housed in state prisons and a growing percentage of inmates afflicted by mental illness and/or addiction.

A crew of court-appointed specialists in medical and mental health, safety procedures, accessibility and other areas documented case after case of Wellpath nurses and others failing to perform proper intake examinations, failing to refer ailing inmates to physicians, weeks or months of waiting for medical care obviously needed earlier, conditions obviously requiring speedier attention, failing to provide walkers or wheelchairs to disabled inmates, and failing to provide inmates with critical prescription medications.

Failure to perform a rape test for an inmate who said she had been raped right before her arrest. Failure to provide prenatal care to pregnant inmates. Failure to provide any accommodation to elderly inmates with cognitive decline.

Monitors’ reports such as these have long been considered public records in other areas under federal monitoring. Since the local monitoring began in 2015, however, the reports have been deemed confidential under an agreement reached early on by the Monterey County Counsel’s Office and Wellpath, a Tennessee-based company that has contracts with most California jails.

The County Counsel’s Office argued, among other things, that making the reports public could prompt additional litigation against the county when inmates or their family see the findings, some of which contain information the families have not previously been provided. U.S. District Judge Beth Labson Freeman set aside the objections from the county and Wellpath and ordered the documents unsealed after redaction of some personal information. In some cases. Wellpath succeeded in having the names of its staff members excised from the record.

For some reason, the Sheriff’s Office, which runs the jail, and the County Counsel’s Office have never supplied the county Board of Supervisors with the reports, though the supervisors are responsible for all the financial and contracting decisions made by the Sheriff’s Office. County Counsel Les Girard, the lead lawyer for the county government, said attorney-client privilege prevents him from explaining.

The federal monitoring period largely overlaps the term of the previous sheriff, Steve Bernal, whose eight years in office were marked by sexual scandals, inmate escapes, financial improprieties and what appeared to be general indifference to conditions in the jail. Lori Rifkin, an Oakland attorney who successfully sued the jail over five inmate deaths, told Voices she had seen no change in the callous attitude of the Sheriff’s Office in the nine-year span from her first case in 2013 to her most recent case, which settled in late 2022. She said she believes nothing at the jail will change, despite the tragic human consequences and high financial costs to the county, unless public pressure forces it to.

In the last several years, the county and Wellpath have paid out about $8.5 in wrongful death judgments and settlements.

The current sheriff, Tina Nieto, arrived in office in January with a mission to improve jail conditions to the extent that the county could get out from under the Hernandez settlement mandates. Most significantly, the court sets staffing levels that the jail has been unable to meet without whopping amounts of overtime, as much as 300 hours per day. The Bernal administration, incidentally, used other methods such as having deputies assigned to special events falsely fill out timecards saying they had been working in the jail.

Simply monitoring Wellpath’s performance under its annual $15 million contract has been an expensive task, as have other Hernandez mandates.

Nieto says her staff is “laser focused” on fixing things but saw a record number of jail deaths — five in six months — since she took office, Attorneys for the Hernandez inmates say the jail’s death rate over the past several years has doubled the national average.

While Bernal had one deputy assigned part-time to managing the Hernandez mandates and reporting requirements, Nieto has set up a team of several deputies and managers to handle the same work. Part of the team is sheriff’s Capt. Joe Moses, who also was a senior manager in the jail under Bernal. In last year’s election, Moses lost out to Nieto in a bid to become sheriff.

About Wellpath’s staffing, Dr. Barnett wrote last year that “the overall access to medical care … is not sufficient.”

He found that the jail, with a population of around 900 men and women, had no director of nursing and only a part-time medical director and nurse practitioner.

Wellpath officials have said in court papers that they are doing everything possible to increase their staffing in Monterey County and elsewhere, but medical practitioners and others don’t like working in jails. Lawyers on the other side argue that it obviously would help if the company simply paid more.

Wellpath is owned by a large hedge fund, H.I.G. Capital. The county originally contracted with Wellpath’s predecessor, California Forensic Medical Group. That company, founded by Monterey psychiatrist Taylor Fithian, was later absorbed into Wellpath. One of Wellpath’s co-CEOs, Tony Tamer, recently bought a $25 million mansion in Miami. The South Florida Business Journal reported that he likely will tear it down and replace it with something larger.

The next step in the Hernandez matter is a plaintiffs’ motion to fine Wellpath what could amount to millions of dollars for failing to satisfy numerous conditions contained in a decade-old settlement agreement. After the plaintiffs’ lawyers sued on behalf of inmates past and present, the county, another firm that eventually was merged into Wellpath, and the courts reached a settlement committing Wellpath to making wholesale changes to its performance.

The plaintiffs’ legal team is headed by the San Francisco law firm of Rosen Bien Galvan & Grunfeld. In her latest motion, lawyer Cara Trapani of that firm wrote that Wellpath “has defied its court-ordered obligations and provided systemically inadequate care to people incarcerated at the Monterey County Jail.”

The result, Trapani continued, “is a death rate at the jail more than twice the national average and a suicide rate more than three times the average for California jails.

“Year after year, the court-appointed neutral monitors responsible for evaluating medical, mental health, and dental care find Wellpath noncompliant with the vast majority of the requirements of the settlement agreement and implementation plan.”

Dr. Barnett, a Harvard-trained physician with extensive jail and prison experience, wrote that conditions seemed to be deteriorating in 2022. Even so, the Bernal administration agreed to a new three-year contract with Wellpath, which is probably the nation’s largest provider of inmate care and probably the most criticized. (Here’s a recent San Francisco Chronicle package on its statewide performance.)

Trapani wrote that in Barnett’s most recent visit, he found several problems that he thought had been corrected following his previous inspection.

The mental health monitor, Dr. James Vess, found numerous areas of noncompliance in staffing, treatment plans, quality management and other areas, “the vast majority of which were the same findings made by the previous mental health monitor, Dr. Kerry Hughes,” Trapani wrote.

“For nearly all of October 2022 to January 2023, Wellpath provided no dental care at the jail because it lacked adequate dental staff,” Trapani told the court. “From June to September 2022, due to critical nursing staff shortages, Wellpath stopped conducting 14-day initial medical, mental health, and dental assessments for all incarcerated people. Staffing shortages are so dire that most of Wellpath’s current healthcare leadership are interim staff. The deficiencies in the medical, mental health, and dental care provided by Wellpath cause daily pain and suffering, including serious medical and dental complications, untreated chronic illnesses, suicide attempts, and deaths.”

Wellpath has declined to respond to requests for comment. The company’s lawyers are scheduled to appear August 24 in Freeman’s courtroom to explain why it should not be fined.

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About Royal Calkins

Contributing writer Royal Calkins has worked for newspapers in Santa Cruz, Monterey and Fresno. He can be reached at

5 thoughts on “Newly released records detail horrific health care failures at Monterey County Jail Death rate twice the national average as for-profit Wellpath ‘defies’ court-ordered obligations

  1. Unfortunately I have been there many times and have seeb ¹st hand horrible medical failures such as ladies miscarriage on bathrôm doors that are fight, another have a stoke abd was given Tylenol and an ice pack, I myself was given Xanax with only saying I was sad wich I wasn’t I only wanted to sleep .y time away. I no pregnant women on top bunks and M.S ladies on ²nd tiers, I have even seen seizures looked at by a nurse n put in cold rooms to be watched after hittingthiwr head and that’s only a start.

  2. Born and raised in Monterey County, I’m deeply troubled by the recent findings regarding our jail system. The secrecy by the Sheriff’s Department and the withholding of crucial reports by the County Counsel’s Office and Wellpath is unacceptable. We urgently need an Inspector General and an oversight committee for transparency and accountability. We must restore trust and ensure the safety and wellbeing of our residents. It’s time for reform.

  3. Excellent reporting. How can this happen? Where’s the accountability? Why are the Supes not doing more? An absolute shame.

  4. Thank you for this report. There are so many problems it will be difficult for those in charge to know where to start. But first we need the facts, and Voices is doing a great job uncovering and sharing them.

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