How Many Inmate Deaths Is Too Many?


Bernard Joseph Victorianne was a 28-year-old black male with a ticking time bomb in his stomach.

He was arrested on Sept. 12, 2012, less than two blocks from the San Diego Police Department's Mid-City station on suspicion of driving under the influence. A week later, he was found dead in his cell.

Victorianne, who was on probation for a number of narcotics offenses, was believed by police and medical staff at Alvarado Hospital—where he was first treated for alcohol intoxication—to have swallowed a bundle of drugs.

Victorianne was the 60th inmate to die in the custody of the San Diego County jail system since 2007—the latest casualty in a jail system with one of the highest mortality rates in California.

San Diego's record raises questions about whether better oversight can prevent such jail deaths, according to a series of investigative reports for San Diego's CityBeat.

In 2000, Congress passed the Deaths in Custody Reporting Act (DCRA) to help address increasing reports of neglect and abuse in U.S. jails and prisons.

“The analogy is between jail and an emergency room, and a prison is like a doctor's office,” Marc Stern, a correctional healthcare consultant and former Health Services Director for the Washington State Department of Corrections, told CityBeat.

“In jails, people are coming and going all the time; it's very difficult to operate a jail. It's hectic and it's high-risk.”

But, Stern added, San Diego's high mortality rate is a red flag.

“The best news—if I were writing your article, or if I were investigating this—would be talking to the jail and have them say, 'You know, we noticed the same thing you did; there's an unexpectedly high number of deaths and suicides compared to other places, and we are investigating it,” he told CityBeat.

“That would be kind of the good-news story—to find out that they really are addressing it.”

Dave Maass, a 2012 John Jay/Tow Juvenile Justice Reporting Fellow, and colleague Kelly Davis, a John Jay public welfare fellow, analyzed medical-examiner investigations for the 60 deaths in San Diego County jails between 2007 and 2012. Read the first of their reports HERE.

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