DEATH B-140 FRESNO COUNTY SHERIFF'S OFFICE
JAIL DIVISION POLICIES AND PROCEDURES
TITLE: INMATE DEATH NO: B-140
FILE: DEATH
EFFECTIVE DATE: 12-18-89 REVISED: 12-25-94, 05-05-96, 02-01-98, 09-01-98
09-01-99, 10-01-00, 03-01-07, 10-21-19,
10-01-20
AUTHORITY: Sheriff M. Mims APPROVED BY: Assistant Sheriff T. Gattie
REFERENCE: California Code of Regulations, Title 15, Section 1046; Government
Code Sections 12525, 26643, 27491.2 and 27491.3; Health and Safety Code
Section 7201; Vienna Convention on Consular Relations, Article 37; "Consular
Notification and Access Manual" (United States Department of State, 2018);
Public Law 106-297: Death in Custody Reporting Act of 2000 (and DICRA 2013.
Public Law 113-242); and Hall v. County of Fresno, E.D. Cal. No. 2:08-CV-
01196-TLN-EFB (2015).
PURPOSE:
The purpose of this policy is to establish a process to ensure timely notification is given
to the appropriate agencies whenever there is an inmate death, and that proper
procedures surrounding an inmate death are followed.
POLICY:
It is the policy of the Fresno County Sheriffs Office Jail Division that the death of any
inmate in custody shall be classified as a questionable death and will be investigated by
the Sheriffs Office Detective Bureau. The procedures to be followed after death shall
comply with the requirements of all applicable laws.
It is the policy of the Fresno County Sheriffs Office Jail Division that an autopsy will be
performed on all inmate deaths.
PROCEDURES:
I. HOSPITAL DEATH
A. When a death occurs at the hospital as a result of an illness or injury not
sustained while in custody, a Jail incident report (1008/Inmate Death)
shall be written.
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FRESNO COUNTY SHERIFF'S OFFICE
JAIL DIVISION POLICIES AND PROCEDURES
TITLE: INMATE DEATH NO: B-140
FILE: DEATH
1. The Detective Bureau should be notified when death is imminent.
2. The Detective Bureau shall again be notified when death occurs.
3. All notifications shall be made through the Patrol Watch Commander.
B. Written notification shall be made to the Attorney General's Office as
required by law. [Refer to Section VII(D).]
II. POSSIBLE DEATH
A. An employee discovering a possible inmate death shall immediately
summon medical assistance. The staff member shall:
1. Immediately notify Main Jail Central Control and advise them of the
situation and the location.
2. Call for a Code 33 (emergency - clear the radio channel) and Code
Blue (medical emergency).
B. Pending arrival of medical assistance, the employee shall make every
effort to preserve life utilizing normal first aid and CPR procedures.
Exceptions apply only if immediate intervention would jeopardize the
safety of staff or facility security, or the inmate shows obvious signs of
irreversible death. Signs of irreversible death include:
1. Decapitation
2. Decomposition
3. Postmortem lividity (hypostasis, livor mortis)
4. Postmortem rigidity (rigor mortis)
5. Burned beyond recognition (incineration)
C. Preservation of life shall take priority over preservation of a crime scene.
III. IMMEDIATE NOTIFICATIONS
A. Main Jail Central Control will be responsible to notify the following and
advise them of the situation and location:
1. Medical staff. Both Main Jail Central Control and the affected
facility's Central Control shall notify Medical staff by announcing
"Code Blue" followed by the location of the incident via the "All
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FRESNO COUNTY SHERIFF'S OFFICE
JAIL DIVISION POLICIES AND PROCEDURES
TITLE: INMATE DEATH NO: B-140
FILE: DEATH
Page" system. Staff should be aware that visitors and inmates will
also hear the transmission. The page shall be followed by a
telephone call to Medical Services, providing details about the type of
medical emergency so that Medical staff can respond with the
appropriate supplies.
2. Outside emergency medical personnel (i.e., ambulance and
paramedics) as requested by Medical or Jail staff.
3. The Facility or Administrative Sergeant. If unable to immediately
contact a Sergeant, the Watch Commander shall be notified.
B. The Sergeant will notify the Watch Commander.
C. The Watch Commander will be responsible to notify the following (refer
to Section VI for additional subsequent notifications):
1. The Jail Operations Bureau Commander or in his/her absence the
Medical & Services Bureau Commander.
2. The Patrol Watch Commander—who will contact the Persons Crimes
Unit Commander, Crime Scene Investigations Unit, District Attorney,
Coroner's Unit, and Internal Affairs.
3. The SERT Commander — to assess the need for a full or partial-team
call-out to assist with scene management.
4. The Peer Support Coordinator.
IV. PRIORITIES
The following protocols should be followed for any in-custody death (or likely
death), including suicides, natural causes, drug overdoses, and homicides.
A. All inmates in the area shall be locked down or moved to a secure area.
If the death occurs in a dayroom area, cover the cell windows to obstruct
the inmates' view (as time permits).
B. An officer that is not involved in the death investigation shall be assigned
to start a scene log documenting the names and times of all persons
who enter and exit the scene. This information shall be documented in a
Jail incident report (1008/Inmate Death). This officer is to remain on
scene until relieved by detectives.
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FRESNO COUNTY SHERIFF'S OFFICE
JAIL DIVISION POLICIES AND PROCEDURES
TITLE: INMATE DEATH NO: B-140
FILE: DEATH
C. Secure the scene from contamination and loss of evidence. Once the
area has been secured, all non-essential personnel need to vacate the
scene, so as not to corrupt the area or interfere with the ensuing
investigation.
1. The area is not to be cleaned prior to the arrival of investigators.
2. The inmate's body shall not be disturbed, covered or moved from the
position or place of death without permission from the Coroner's Unit.
3. Evidence should not be disturbed, unless necessary for safety or
security reasons. All evidence is to be included in a chain of custody.
D. Identify all potential inmate witnesses, suspects, and informants.
Separate them from each other and keep them isolated for subsequent
interviews. Where evidence points specifically to the involvement of
certain persons in the death, they should be separated without delay
from everyone else and placed in an area that prevents them from
washing themselves or clothing.
E. Create a list of all involved personnel, including Medical staff who were
involved in providing lifesaving procedures on the inmate. All involved
personnel will need to remain on-site until interviewed by investigators.
F. The Facility Sergeant (or a Compliance Sergeant) will be responsible to
download any facility video surveillance footage related to the incident.
Any handheld video recording shall be uploaded prior to going off-duty in
accordance with policy D-215/Recording Planned Emergency
Responses (FILE: VIDEO RECORDINGS).
G. If photographs have been taken by Jail staff, advise investigators of
such.
H. The inmate's Offendertrak screens shall not be completed without the
approval of the Watch Commander. (Refer to Section X.)
V. WRITTEN DOCUMENTATION
No reports will be written until the detectives from the Detective Bureau
arrive on scene. Detectives will coordinate with the Watch Commander to
determine which correctional staff and Jail Medical staff need to be
interviewed by detectives, and which staff members should write a Jail
incident report.
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FRESNO COUNTY SHERIFF'S OFFICE
JAIL DIVISION POLICIES AND PROCEDURES
TITLE: INMATE DEATH NO: B-140
FILE: DEATH
VI. RECORDS ASSEMBLED FOR INVESTIGATORY PURPOSES
A. The Watch Commander will be responsible to assemble the following
documents considered critical to the incident. The data shall be
forwarded to the Medical & Services Bureau Commander, who will
forward to Internal Affairs. These items may be digitally transferred
(hard copies may be provided upon request).
1. Lieutenant Summary (brief summary of the incident in memorandum
form, to include the scene log/timeline).
2. Safety Check log (specific to the housing unit or incident area).
3. Inmate's Classification forms and a Population Management review
memo.
4. Review of the inmate's Offendertrak files (including grievances,
discipline, etc.).
B. Information contained within the inmate's Jail records will be made
available to authorized investigative personnel.
C. Access to medical and mental health records may be gained only by
permission of the Health Services Administrator of Jail Medical Services,
or their designee. Access to health records may require a court order.
D. All documents and records related to the deceased inmate and the
relevant incident must be preserved in anticipation of litigation.
Preservation of video footage is critical.
VI I. ADDITIONAL NOTIFICATIONS
A. The Watch Commander shall ensure that all affected agencies are
notified. Notification to the following agencies should take place as soon
as reasonably possible (or as soon as personnel are on duty), as
applicable:
1. The agency of arrestor jurisdiction
2. Any institution that may have a detainer on the inmate (e.g., CDCR)
3. Parole/probation
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FRESNO COUNTY SHERIFF'S OFFICE
JAIL DIVISION POLICIES AND PROCEDURES
TITLE: INMATE DEATH NO: B-140
FILE: DEATH
B. If the decedent is a foreign national, the nearest consulate of his or her
country needs to be notified immediately (or as soon as reasonably
possible).
1. Notification should be made by fax or email if possible, and by
telephone, if not. The notification shall be documented via Offender-
trak (Person--+Demographics--+Add/Tele/CDC/Consul) and a copy of
the fax and fax confirmation shall be scanned into the inmate's file.
[Refer to Addendum A for fax template.]
2. If notification is made via telephone, the Notes section shall be
modified to document the location and telephone number of the
consulate contacted, the name of the official to whom the information
was given (or message left), and the date and time of notification.
C. If the decedent is a federal inmate, the United States Marshal's Office
needs to be notified immediately (or as soon as reasonably possible) at
(559) 487-5600. If the federal inmate is sentenced and committed to
serve their term in the Fresno County Detention Facility, the Federal
Bureau of Prisons must be notified, as well.
1. The Federal Bureau's Community Corrections Office shall be
contacted and notified at (916) 930-2007 during their normal working
hours (7.30 a.m. to 4.00 p.m.).
2. After normal business hours, the Community Corrections Manager
can be contacted at (916) 203-3313.
D. All in-custody deaths are to be reported within 10 days of the death to
the California Attorney General's Office, in accordance with Government
Code section 12525. A Department of Justice "Death in Custody
Reporting Form" (BCIA 713 - Addendum B) shall be completed and
forwarded to the Criminal Justice Statistics Center by the Jail Division's
Administrative Assistant. A copy of the form shall be retained in the Jail
Division's "Inmate Deaths" file.
E. The Deaths in Custody Reporting Act requires each state to report the
death of any person who is detained, arrested, or incarcerated to the
U.S. Department of Justice (DOJ) on a quarterly basis. The Board of
State and Community Corrections (BSCC) serves as the designated
centralized state reporter, and all federal reports shall be submitted to
the BSCC Justice Assistance Grant (JAG) contact by the Jail Division's
Administrative Assistant.
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FRESNO COUNTY SHERIFF'S OFFICE
JAIL DIVISION POLICIES AND PROCEDURES
TITLE: INMATE DEATH NO: B-140
FILE: DEATH
1. The DOJ Death in Custody Reporting Act Form DCR-1A Incident
Report (Addendum C) requires an official cause of death and should
be completed after receipt of the Coroner's report.
2. A Death in Custody Reporting Act Form DCR-1 Quarterly Summary
report (Addendum D) is completed and submitted within 30 days of
the end of each quarter (ending March 31, June 30, September 30
and December 31).
Vill. NOTIFICATION OF NEXT OF KIN
A. Dependent upon the circumstances, either the detectives or the
Coroner's Unit will be responsible to notify the relatives or friends of the
inmate's death. Notification shall be made within twelve (12) hours of
death, absent extenuating circumstances (e.g., no next of kin on file).
B. Custody staff shall not attempt to provide information regarding the
inmate's death, but shall refer any person inquiring to the detectives
assigned to the case.
IX. PERSONAL PROPERTY DISPOSITION
The Coroner's Unit may take charge of any and all personal effects,
valuables, and property and hold or safeguard them until lawful disposition
can be made.
A. All property on the inmate's body shall be the responsibility of the
Coroner's Unit. The Detectives will be responsible to document/
photograph the evidence. This includes, but is not limited to, booking
the inmate's personal effects on their body into evidence, and/or
releasing to an authorized individual (i.e., family member).
B. The Watch Commander shall ensure that all personal property belonging
to the deceased inmate is immediately collected. When feasible,
property that is immediately available (e.g., property in the inmate's cell)
should be turned over to the Coroner's Unit at the time the body is
picked up. The property should be itemized on a receipt.
1. Property in storage (i.e., the inmate's property envelope, personal
clothing, and bulk property) shall be collected and inventoried and
turned over to the Coroner's Unit. Money belonging to the deceased
shall remain on the inmate's account until authorized for withdrawal
or release.
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FRESNO COUNTY SHERIFF'S OFFICE
JAIL DIVISION POLICIES AND PROCEDURES
TITLE: INMATE DEATH NO: B-140
FILE: DEATH
2. Any property or evidence related to an investigation or prosecution of
a known or suspected criminal death may instead be delivered to the
investigating detectives or District Attorney (with the knowledge of the
Coroner's Unit).
3. If the Coroner's Unit does not take possession of the property and if
the property it is not needed as evidence, the Watch Commander
shall designate a staff member to facilitate the return of the inmate's
property and money to the inmate's next of kin.
4. A report shall be written documenting the items and the identification
of the receiving party (i.e., detective, member of the Coroner's Unit,
or next of kin).
X. CUSTODY STATUS
A. After the inmate's next of kin has been informed, the Watch Commander
will notify Jail Records to update the inmate's Offendertrak records. Jail
Records will be responsible to:
1. Modify the inmate's custody status and remove the inmate from the
count. (Refer to Addendum E for procedures.)
2. Notify the court of jurisdiction. The court will be responsible to send a
Minute Order, releasing the charge(s).
B. Once the Minute Order is received and all charges and holds are
released, the inmate's records can be dispositioned and completed.
(Refer to Addendum E.)
XI. IN-CUSTODY DEATH REVIEWS
A. Jail staff will meet with the investigating detectives to go over the
circumstances surrounding the death within 30 days (prior to the
mortality review).
B. A mortality review shall be conducted within 30 days. This initial review
will assess the appropriateness of clinical care; whether changes to
policies, procedures, or practices are warranted; and to identify issues
that require further study. The multi-disciplinary review team minimally
shall include:
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FRESNO COUNTY SHERIFF'S OFFICE
JAIL DIVISION POLICIES AND PROCEDURES
TITLE: INMATE DEATH NO: B-140
FILE: DEATH
1. The Medical & Services Bureau Commander and/or the Jail
Operations Bureau Commander
2. Sheriff's Health Services Manager (or designee)
3. Health Services Administrator for jail health services
4. The Site Medical Director for jail health services
5. Director of Mental Health for jail health services, if relevant
6. Other health care and supervision staff who are relevant to the
incident
C. The mortality review team shall prepare a written report that includes
identification of problems for which corrective action is undertaken. The
report is to be forwarded to the Continuous Quality Improvement (CQI)
committee.
D. The CQI committee will conduct a multi-disciplinary review upon receipt
of the final Coroner's report. All information relative to the death
gathered by medical and custody staff is reviewed collectively by the
CQI committee to determine the adequacy of the actions taken and
procedures followed. The CQI committee should include the principal or
a representative for each of the following:
1. Fresno County Director of Public Health
2. Fresno County Director of Behavioral Health
3. Sheriff's Health Services Manager
4. Health Services Administrator for jail health services
5. Director of Nursing for jail health services
6. Director of Mental Health for jail health services
7. Medical & Services Bureau Commander
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