Justice Delayed Questions about recent deaths of inmates at Monterey County Jail remain unanswered; coroner blames backlog

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By Royal Calkins

Reformers concerned about how law enforcement agencies handle in-custody deaths might want to examine the work of the Monterey County Coroner’s Office. As an example of the wrong way to do things.

Actually, and this is part of the problem, it’s not a freestanding coroner’s office. It’s a division of the Monterey County Sheriff’s Office.  A coroner’s office is supposed to be an impartial investigator with allegiance to public health and the public itself, not an accomplice to official misbehavior. That’s why the California Legislature is currently considering legislation to ban arrangements like Monterey County’s under-one-roof approach.

Voices of Monterey Bay first had cause to question the coroner’s operation two years ago when the coroner’s staff ignored the Sheriff’s Office role in the death of a mentally disturbed woman from Marina, Rania Ishak. The Sheriff’s Office almost certainly helped cause the death but the final coroner’s report simply ignored the department’s role.

Now, Voices returns to another coroner’s case, the April 20 death of Monterey County Jail inmate Juan Carlos Chavez. The Sheriff’s Office and its coroner’s division decided right away that it was a suicide, a rare incidence of someone suffocating after stuffing toilet paper down his throat and up his nose. That could be so, but Sgt. Nick Kennedy, a supervisor in the coroner’s division, says it likely will take more than seven more months before the official coroner’s report, the pathologist’s official findings, will be available. See jail nurse’s account of Chavez’s death.

That’s a year after Chavez’s death, a delay longer than what occurred almost anywhere in the United States during the height of the COVID pandemic, when bodies were stacked in rail cars.

Why so slow?

Kennedy said last week that Chavez’s death clearly wasn’t a homicide and therefore “is not a high priority.” On top of that, he said, the county only has one pathologist available, Dr. Venus Azar, and is advertising for another on the county’s help-wanted website. That appears not to be the case, however.

A clearly defensive Kennedy referred additional questions to the Sheriff’s Office public information officer, Cmdr. Derrel Simpson. Simpson said that based on what Kennedy told him, there’s a tremendous backlog of coroner’s cases, more than 200, mostly because of the unexpected departure of a county-employed transcriptionist. Simpson said the office is catching up but the backlog already equals about six months of work.

During autopsies, usually performed on crime and accident victims or others who die without benefit of medical attention, pathologists record their observations and findings, which are later written up by transcriptionists. Until the findings are put into print and verified by the pathologist, the final coroner’s report remains a draft not ready for public inspection.

Sheriff Steve Bernal’s predecessor in office, Scott Miller, says his policy was to have any in-custody deaths investigated by the District Attorney’s Office instead of the sheriff’s staff.

Having the Sheriff’s Office investigate in-custody deaths “is an obvious conflict of interest,” Miller said last week. “That’s all there is to it.”

According to Miller and others in law enforcement, a coroner’s report is supposed to focus on more than the cause of death. It should also cover the circumstances surrounding the death — what was happening before the death, where the death occurred, who was involved, what factors may have contributed to the death. In Chavez’s case, as well as Ishak’s, the coroner’s staff seemingly determined how they died but not why.

If sheriff’s officials examined the circumstances surrounding Chavez’s death alone in an isolation cell, if they questioned why he wasn’t more closely monitored and why he was in isolation, if department policies weren’t followed, that information could be included in internal reports that will never be made public, according to sources in the jail and elsewhere in the department. And who made the decision to make his death a low-priority coroner’s case will likely never be known.

Anabel Chavez, who suspects her husband was the victim of foul play, said she was shocked to learn how long it will be before she can see the coroner’s report.

“It’s bullshit,” she said before saying it again, louder. “How in the world could it take so long? This makes no sense. If they think this is going to make me go away, they’re crazy.”

Anabel Chavez, who has retained a Bay Area lawyer, said she is convinced that her husband was murdered, possibly by the jail staff, possibly by other inmates. And even if he wasn’t, she said she believes he would be alive today if jail officials hadn’t ignored their own rules on monitoring inmates.

She said sheriff’s officials have refused to answer her questions, to state for the record whether her husband was on a suicide watch and why his death wasn’t discovered for hours even though he was in an isolation or observation cell. She said he was in custody only for a brief probation hold and had no reason to be suicidal.

Cmdr. Simpson said investigation by detective James Day failed to support the widow’s allegations but he was unable to provide details of Day’s findings.

Anabel Chavez said Day’s conclusion, suicide by toilet paper,  doesn’t sound plausible and doesn’t explain the bruising she said she saw on her husband’s neck at his funeral, purple lines that looked to her like ligature marks.

Sheriff’s Office sources told Voices in May that they understood rigor mortis had started to set in by the time Chavez, 39, the father of six, was found dead in an isolation cell. If so, that would indicate he probably had been dead at least two hours, according to pathology reference works.

Other than brief comments from Sgt. Kennedy and Cmdr. Simpson, sheriff’s officials have had nothing to say about the matter.

Capt. Joe Moses, who is in charge of the jail and who is running for sheriff in the November election, didn’t respond to emails from Voices in May and again last week.

Moses’ opponent in the sheriff’s race, Marina Police Chief Tina Nieto, said the deaths of Chavez and others in the jail, along with several escapes, “raise real questions about his (Moses’) abilities.”

Cmdr. Simpson scoffed at the idea the coroner’s report might be intentionally delayed so it doesn’t become a campaign issue.

Sheriff Steve Bernal, who has made few appearances at the Sheriff’s Office after announcing he wouldn’t seek re-election, didn’t respond to a request for comment. He hasn’t replied to Voices’ queries for more than a year.

(Bernal announced this week that Undersheriff John Mineau will retire in February and is being replaced immediately by Deputy Chief John Thornburg.)

The coroner’s division handled 465 autopsies in 2021, slightly fewer than the previous year. This February, Monterey County raised the per-autopsy fee from $1,100 to $1,170 for Azar. The pathologist previously worked for the San Francisco Medical Examiner’s Office and also performs autopsies on a contract basis for Solano County. She could not be reached to comment on the delay of Chavez’s report.

The previous fumbled case highlighted by Voices involved the possible suicide of Rania Ishak, a troubled methamphetamine addict from Marina. Ishak walked in front of a train in downtown Salinas a couple of hours after being set free by a sheriff’s deputy who was supposed to have taken her to the county’s Natividad Medical Center for psychiatric treatment.

The official coroner’s report concluded that Ishak’s death was an accident, not a suicide. However, it made no mention of Ishak’s arrest earlier that day, a deputy’s failure to take her to the hospital, the potentially toxic level of methamphetamine in her system, or her history of suicidal behavior or anything else. It simply started with her being dropped off near the tracks.

Retired Fresno County Coroner David Hadden told Voices earlier that the whole point of autopsies is to get it right, to determine the cause of death with as much precision as possible, for legal reasons, for medical reasons, for public health reasons, and for the survivors.

Ishak, 42, had been held in the county jail in Salinas for much of 2019, and twice that year she was sent to Natividad for fear she was suicidal. She was arrested again: Aug. 20, 2020, after being spotted trying to break into boats docked at Moss Landing. She was taken to the jail but staffers there told the deputy with her that she needed to be hospitalized instead because she was suicidal and high on drugs.

Instead, the deputy took her downtown and let her go. A couple of hours later she was hit by a train while walking along the Union Pacific tracks in Chinatown. The engineer said he sounded the horn twice but Ishak didn’t respond.

The deputy was suspended indefinitely, not for what he did, but for lying to his supervisor about it.

Largely because she didn’t leave a suicide note, the coroner’s report concluded that Ishak hadn’t killed herself.

“At best, it was sloppy work,” said the retired coroner, Dr. Hadden. “At worst, well, I’m not sure what it was.”

Months after her death, Ishak’s family learned about the Moss Landing arrest and other details from Voices rather than from officialdom. The family later sued the county, alleging negligence. Monterey County Weekly reported in June that the litigation had been settled for an undisclosed amount. The County Counsel’s Office says it was $150,000.

California is one of a handful of states in which counties are allowed to operate coroner’s divisions meshed into sheriff’s departments. Most California counties operate that way despite the obvious conflicts that arise, especially when sheriff’s departments are involved with the deaths under review.

Although critics are particularly bothered by sheriff’s offices managing coroner’s divisions in cases of officer-involved shootings, law enforcement agencies have successfully lobbied to keep arrangements such as Monterey County’s intact. Elected sheriffs in California’s 52 counties are a powerful political force.

Some county sheriffs have fought to keep coroner’s units under their direct supervision for cost reasons and because they say separating the operations would dilute their authority and cast doubt on their professional integrity.

Nonetheless, California legislators this month are expected to take up Assembly Bill 1608 sponsored primarily by Assemblymember Mike Gipson, D-Carson.

Supporters of Gipson’s bill point to early coroner’s findings in the infamous Minneapolis death of George Floyd, which focused on drugs in his system rather than the prolonged neck pressure that actually killed him. Gipson also draws attention to the 2017 resignation of San Joaquin County’s chief pathologist, who alleged the sheriff there interfered with death investigations to protect law enforcement officers.

When medical examiners determine a cause of death, Gipson has said, “It should be absolutely scientifically based, without any kind of biases, without any kind of intimidation.”

The bill passed through the Assembly by a vote of 44-20 in May with support from the California Medical Association, the ACLU, the Union of American Physicians and Dentists, and others. Opposing it, among others, are the California State Association of Counties, which fears the financial ramifications, and the California State Sheriffs Association.

Earlier this year, Riverside County Sheriff Chad Bianco told the Desert Sun newspaper that AB 1608 “is nothing more than a continuation of an agenda to eliminate the Office of Sheriff and paint law enforcement as corrupt.”

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