Grand Jury Blisters Santa Barbara County Jail

Warning Signs There but Not Seen in Three Deaths, Reports Say

Santa Barbara County Main Jail | Credit: Daniel Dreifuss File Photo

In a fiercely detailed report, the Santa Barbara County Grand Jury excoriated the medical care provided in the county jails, blaming the failure to follow established medical protocol combined with repeated failures of communication for the deaths of three jail inmates this past year. One of the deaths involved the suicide by an openly suicidal 41-year-old woman with a history of psychotic disorders who had been placed in an observation cell within eyeshot of the inmate reception desk and managed to hang herself with a 12-inch telephone cord.

Another of the deaths involved a 40-year-old Spanish-speaking man with a history of homelessness and alcoholism who fell on his head while having an alcohol-withdrawal-related seizure while in custody.

And the other involved a 57-year-old Lompoc woman — identified in the report only as CF, also with a history of mental illness — who died after screaming in pain repeatedly for nearly two days while in the Northern Branch Jail because of what would later be revealed to be an infection of her stomach lining that burned a hole through her stomach. In her case, medical professionals in the jail incorrectly believed the woman to be experiencing opioid withdrawals because she regularly took painkillers to deal with chronic lower back pain. Had any of the jail medical professionals evaluated the woman for her pain, the grand jury concluded, they might have saved her.

At the time of the woman’s death, Sheriff Bill Brown issued a press statement, describing the inmate’s death as “unavoidable.” In a bluntly outspoken tone, the Grand Jury begged to differ. “The Jury concludes that there were opportunities to prevent this death.”

In this case, the inmate — arrested for possession of firearms and ammunition when she was barred from doing so — was never seen by a physician during her time in jail; her requests for an emergency room transfer were likewise not acted upon.

“Had CF’s complaints been evaluated, she would have received treatment for her perforated ulcer,” the Grand Jury concluded, “and her death could have been prevented.”

Of the three deaths, the one that got most attention at the time it occurred was the suicide by hanging by a woman identified in the Grand Jury report only as CC, but at the time, November 13, was known to the public at large as Cecilia Michelle Covarrubias, a mother and Santa Ynez resident. Covarrubias was placed in the Main Jail on Calle Real after getting arrested on November 8 for resisting arrest and assault with a deadly weapon after crashing her car into that of a sheriff’s deputy in an attempt to evade arrest. Deputies on the scene, believing Covarrubias to be under the influence of fentanyl, administered Narcan.

“In the days preceding CC’s death on November 13, 2024, she made several suicidal statements to mental health providers, who then assigned her to a safety cell on suicide watch,” the report stated. “Five days into her incarceration, CC was moved into a holding cell, where she committed suicide by hanging.”

Two weeks prior to her death, Covarrubias had been the subject of a welfare check by a county sheriff’s deputy; given the high degree of agitation she displayed at the time, an ambulance was called, and Covarrubias was taken to Santa Ynez Valley Cottage Hospital. There, she would be diagnosed with psychosis. During her treatment there, Covarrubias’s alter ego, Patricia, was manifesting. Typically, Patricia was more agitated and ruder than Covarrubias. A member of the county’s Mobile Crisis Team was called; Covarrubias did not meet the definition of a 5150 — an imminent threat to self or others — so she was not placed on a protective hold for 72 hours but was instead released.

After being arrested the night of November 8, Covarrubias was taken to the Santa Ynez Valley Emergency Room, where she informed medical staff there that she thought she was “the devil and had to kill herself to protect her children.” She also reported trying to choke herself when visiting deceased relatives at a nearby cemetery. She told mental health workers there she was suicidal. One staff member wrote in a report she needed psychiatric hospitalization. But later, in an interview with a staff psychiatrist, she denied having suicidal thoughts and was discharged to the Sheriff’s Office and was taken to the Main Jail.

Cecilia Michelle Covarrubias | Credit: Courtesy

During her jail intake interview, Covarrubias identified herself as bipolar and said she tried to choke herself the day before. But, she added, she was no longer suicidal. As a result, she was assigned a cell in the general population. As the Grand Jury noted, “A psychiatric consultation was not sought.”

The next day, jail medical staff was called. Covarrubias was speaking gibberish. She stated she deserved to die. Accordingly, she was transferred to a safety cell. There, she stated she wanted a pregnancy test and sought to choke herself. The next day, she cried and worried that the devil would harm her children. She was anxious and angry and refused to engage in a Cooperative Safety Plan. The attending jail mental health worker recommended she be moved to a non-safety cell. Pursuant to this, she was placed in an observational isolation cell equipped with a wall-mounted telephone that had a 12-inch phone cord. The following day, November 12, she announced she wanted to hang herself. She was placed back in a safety cell. The following day, she spoke with jail mental health workers for five minutes. She said her children gave her a reason to live. She was placed back in a room with a telephone and a cord. During her time in custody, she never saw a psychiatrist, and she refused to be evaluated. The psychiatrist prescribed her a sedative and scheduled a follow-up visit for a week later but never researched her prior history or noted that she’d been in safety cells two of the three prior days.

Jail correctional staff checked on her every 15 minutes, as protocol dictated. At 4:48 p.m. on November 13, they found Covarrubias hanging with the phone cord around her neck.

A prior grand jury in 2019-2020 dealt with a similar case: death by suicide with a telephone cord by an inmate in an observation room. The Grand Jury recommended that inmates with mental health histories not be placed in rooms with telephone cords and that the Sheriff’s Office not house inmates in cells with telephone cords. In his response to the Grand Jury, Sheriff Bill Brown declined, arguing it was inconvenient for other inmates, adding that the telephone cords had all been reduced from their original length of 18 inches to 12. The 12-inch cord, Brown said, “does not allow for the ligature point and still provides inmates with normalized telephone.” He added that the recommendation to house mentally ill inmates in cells designed to meet their needs “has been implemented.”

Once again, the Grand Jury begged to differ. “Unfortunately for CC [Covarrubias], the SBSO’s [Santa Barbara Sheriff’s Office’s] failure to provide a suitable holding cell resulted in her untimely death.”

Raquel Zick, spokesperson for the Sheriff’s Office, declined to comment; the report, she noted, had only just been released. By law, Brown has 60 days in which to respond to the Grand Jury.

The Grand Jury found the shortage of jail cells to be at the root of the problem and praised the county supervisors for voting this April to expand the number of jail cells in the Northern Branch Jail by 325.

If you or someone you know is at risk of suicide, please call or text 988 for the Suicide and Crisis Lifeline or call the local 24/7 Access Line at (888) 868-1649.