Report 2020-102 Recommendation 7 Responses

Report 2020-102: Public Safety Realignment: Weak State and County Oversight Does Not Ensure That Funds Are Spent Effectively (Release Date: March 2021)

Recommendation #7 To: Alameda County

To ensure that it appropriately follows up on inmate deaths and works to prevent similar deaths from occurring in the future, Alameda should implement its updated inmate death follow-up process by June 2021.

1-Year Agency Response

AFBH continues to meet monthly with ACSO and Wellpath to identify high-risk clients and create plans to improve safety and care coordination for these clients. AFBH also continues to participate in the death review panel process facilitated by ACSO with a goal of identifying areas for improvement for AFBH's clinical services.

California State Auditor's Assessment of 1-Year Status: Partially Implemented

As we noted in our evaluation of Alameda's previous response, although Alameda conducted meetings with its Inmate Death Investigation Review Board (Review Board) after each inmate death since it revised its process in March 2020, Alameda did not demonstrate that its Review Board conducts its meetings within 30 days of the inmate death as its policy requires. Alameda did not provide any further documentation during this response to support its assertion of full implementation. Until Alameda provides such documentation, we will continue to evaluate this recommendation as partially implemented.

6-Month Agency Response

In March of 2020, ACSO revised our Inmate Death policy to ensure thorough, consistent, and objective criminal and administrative investigations are conducted. AFBH meets monthly with ACSO/Wellpath for a Suicide Prevention Program, the policy includes improvements to our administrative in-custody death review panel process, and ACSO coordinates a retrospective sentinel event review or "death review" which includes AFBH, Wellpath, and other pertinent parties relative to inmate care and coordination. County Public Health completes an annual review of all deaths at SRJ and AFBH reports incidents and coordinates with ACBH Quality Assurance unit to complete a separate review. ACSO created a Special Investigations Unit and a Jail Litigation Unit within SRJ to ensure critical incidents within the jail are investigated timely and comprehensively. To ensure transparency, the Alameda County Sheriff's Office Eden Township Substation (ETS) Crime's Against Persons Unit parallels the initial death investigation to quickly address potential criminal behavior, any deviations from policy, and addresses safety and security concerns identified by staff. The panel is convened by the Jail Litigation Unit and includes members of ACSO Command Staff, the Special Investigations Unit, Classification Unit, and representatives from our medical and mental health provider. The panel reviews the entirety of the incident and the personal, mental, medical and criminal history of the decedent. Deficiencies in staff response to the incident, feedback and direction to investigators, policy concerns, and recommendations to mitigate future incidents are included in the panel report. Further refinements to the policy are ongoing.

California State Auditor's Assessment of 6-Month Status: Partially Implemented

Although Alameda conducted meetings with its Inmate Death Investigation Review Board (Review Board) after each inmate death since it revised its process in March 2020, the Review Board did not conduct its meetings within 30 days of the inmate death as its policy requires. Specifically, in one instance the Review Board held its meeting nearly 5 months after the inmate's death. As a result, Alameda is hindered in its ability to quickly identify and implement corrective actions to prevent similar deaths from occurring in the future. We look forward to reviewing Alameda's progress in complying with its inmate death follow-up process during its 1-year response.

60-Day Agency Response

In March of 2020, ACSO revised our Inmate Death policy to ensure thorough, consistent, and objective criminal and administrative investigations are conducted. AFBH meets monthly with ACSO/Wellpath for a Suicide Prevention Program, the policy includes improvements to our administrative in-custody death review panel process, and ACSO coordinates a retrospective sentinel event review or "death review" which includes AFBH, Wellpath, and other pertinent parties relative to inmate care and coordination. County Public Health completes an annual review of all deaths at SRJ and AFBH reports incidents and coordinates with ACBH Quality Assurance unit to complete a separate review. ACSO created a Special Investigations Unit and a Jail Litigation Unit within SRJ to ensure critical incidents within the jail are investigated timely and comprehensively. To ensure transparency, the Alameda County Sheriff's Office Eden Township Substation (ETS) Crime's Against Persons Unit parallels the initial death investigation to quickly address potential criminal behavior, any deviations from policy, and addresses safety and security concerns identified by staff. The panel is convened by the Jail Litigation Unit and includes members of ACSO Command Staff, the Special Investigations Unit, Classification Unit, and representatives from our medical and mental health provider. The panel reviews the entirety of the incident and the personal, mental, medical and criminal history of the decedent. Deficiencies in staff response to the incident, feedback and direction to investigators, policy concerns, and recommendations to mitigate future incidents are included in the panel report. Further refinements to the policy are ongoing.

California State Auditor's Assessment of 60-Day Status: Partially Implemented

Although Alameda conducted meetings with its Inmate Death Investigation Review Board (Review Board) after each inmate death since it revised its process in March 2020, the Review Board did not conduct its meetings within 30 days of the inmate death as its policy requires. Specifically, in one instance the Review Board held its meeting nearly 5 months after the inmate's death. As a result, Alameda is hindered in its ability to quickly identify and implement corrective actions to prevent similar deaths from occurring in the future. We look forward to reviewing Alameda's progress in complying with its inmate death follow-up process during its 6-month response.

All Recommendations in 2020-102

Agency responses received are posted verbatim.