Observers have for years expressed concern about death rates in the seven adult facilities the San Diego County Sheriff’s Office supervises.
A new report delves into 179 of those deaths over the course of a dozen years, but zeroes in on one facility – the downtown San Diego Central Jail.
The report, from a Seattle firm, Mountain-Whisper-Light: Statistics & Data Science, describes the central jail as a “universe of its own,” with the county’s jail deaths concentrated disproportionately behind its bars.
From Dec. 27, 2011 through April 2, 2024, 91 inmates died at the Front Street facility, accounting for half of all the local jail deaths, the firm found.
The county Citizens’ Law Enforcement Review Board commissioned the independent report, and will hear from the team of researchers at Thursday’s CLERB meeting.
One key goal for the panel is finding when incarcerated people are most vulnerable to in-custody death, whether natural, by accident, suicide or another’s hand.
Central jail is particularly violent. It had nearly all in-custody homicides and the highest rate of assaults on staff “by a significant margin.”
“SDCJ has by far the highest rate of assaults on staff, 63% higher than the next facility,” the report reads.
Twelve of the county system’s 15 total homicides were at SDCJ. Every other facility had one homicide at most in the 12-year study period.
The North County booking facility, Vista Detention Facility, primarily for males, was half as deadly as the central jail. The female booking and male non-booking detention centers had even lower death rates.
One possible factor is crowded conditions. Central Jail books 69,000 male inmates per year in a facility opened in 1998 that can accommodate 945 inmates at a time. In a 2018 report, a county grand jury found that during a visit in August 2017, the facility housed 1,080 inmates; its average daily population at the time, 944, was just under capacity.
The Sheriff’s Office noted other factors that make operating Central Jail more challenging. Over 50% of total bookings across the county occur there. It’s the only detention center in a metropolitan area, so it sees more homeless individuals and those with mental and behavioral health issues. Plus, it’s the closest booking facility to the border, so it draws inmates arrested for international drug smuggling who may try to bring contraband inside.
“These factors introduce unique operational complexities,” the Sheriff’s Office said in a statement responding to the CLERB report.
For the researchers, the more inmates at Central Jail, the more dangerous the conditions became for everyone. “Simply by having more incarcerated people present (in SDCJ), everyone’s chances of dying worsened,” according to their report.
On the other hand, the more staff at the jail, the lower the death rate. That was particularly true when it came to having supervisors and leadership on site to oversee deputies and other personnel. This was not universally the case at all facilities, but a major factor downtown.
The deaths are, of course, tragedies, but they have funding and policy ramifications as well. The county has spent millions in settlements with loved ones of the deceased, while state officials conducted an audit of the jail system and elected officials passed laws to increase transparency. Journalists followed the developments closely, even before the release of the 2022 audit.
Former Senate President Pro Tem Toni Atkins, for instance, authored a bill, passed by the legislature in 2023, to evaluate inadequate healthcare provisions for inmates and provide more transparency to the public around jail death investigations.
But in the case of the report prepared for CLERB, researchers could not access all the information they sought in the 14-month study period. The county did not provide all the requested public records in time for a true look at deaths labeled as “natural” in the jails, among other issues. Without those records, the April report could not verify if any deaths ruled as natural might have been preventable with better medical care.
But the report does provide an analytical look at what makes San Diego’s jails so lethal – along with the timing of when they are most dangerous.
Yet the deaths can’t solely be blamed on the raw number of inmates or overcrowding. George Bailey Detention Facility, with a capacity of 1,380 people, can accommodate nearly 50% more inmates than the central jail. And pre-Covid, the South Bay facility, on average, housed hundreds more inmates than that.
Still, it accounted for just 25 deaths in the same 12-year period when SDCJ had nearly 100.
A chart showing average jail occupancy pre and post-Covid. (Photo courtesy of the San Diego Sheriff’s Office)Researchers also factored in the amount of days inmates were incarcerated when looking at the facility death rates.
“SDCJ clearly stands out,” researchers wrote.
Some of the danger comes from the timing. Suicides are more likely to occur within the first two days of booking. Plus, booking facilities are more prone to ‘accidental’ deaths, a category that in almost all cases means deaths from overdoses and withdrawals. Those types of fatalities also usually occur within the first two days of being booked, according to the analysis.
The researchers recommended that the sheriff institute new booking procedures that screen better for intoxicated individuals so those at risk of dangerous withdrawals may be sent to detox and medical facilities, rather than suffering symptoms in jail without medical supervision.
The Sheriff’s Office responded to the findings by stating that some of those changes have been implemented since the study period ended. Medical doctors were added to booking facilities in 2025 to enhance screening. The office said overdose deaths decreased by 65% between 2024 and 2025.
Overall though, researchers urged officials to focus death prevention efforts on SDCJ, and to a lesser degree, Vista Detention Facility, the second-deadliest jail.
“These findings suggest that the problems of deaths in custody and violence are not systemwide issues, but rather problems concentrated in two specific facilities,” the report reads. “The implication is that the (Sheriff’s Office) should focus its prevention efforts most urgently in SDCJ and secondarily in VDF.”
The report will be presented in a meeting starting at 5:30 p.m. Thursday in room 310 at the County Administration Center at 1600 Pacific Highway. For more details about monthly meetings, visit the CLERB website.
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