The Santa Barbara County Grand Jury found potential perceived conflicts of interest in how the Sheriff/Coroner's Office conducts death-in-custody investigations, according to the report released Monday.
From 2021 to 2023, the California State Attorney General's office reported 10 deaths in custody (DIC) in Santa Barbara County. According to the California Department of Justice, the total number of DICs from 2006 to 2020 was 24.
California is one of three states by law that does not mandate the separation of the Sheriff and Coroner offices, according to the Grand Jury report. The other two states are Montana
and Nevada.
Santa Barbara County is one of the 47 counties in California that have a Sheriff/Coroner system. There are five counties with a Coroner system separate from the Sheriff and six, including Ventura County, with Medical Examiner departments.
As part of the investigation, the Grand Jury compared and contrasted how San Luis Obispo, Santa Barbara and Ventura Counties Sheriff Offices conduct their DIC investigations.
Only one death in custody was reported in San Luis Obispo County from 2021 to 2023. There were seven deaths reported in Ventura County within the same time frame, according to the California State Attorney General's office.
Similar to Santa Babara County, San Luis Obispo County has a Sheriff/Coroner system, according to the report. However, San Luis Obispo County outsources the pathology work to NAAG Forensic, a firm based in San Diego.
Ventura County has a separate Medical Examiner Department and employs its own certified pathologists and forensic investigators.
The Grand Jury reports that autopsies were performed for all the DICs in the three counties unless an inmate died of known natural causes.
In San Luis Obispo and Ventura Counties, the medical staff decides if an autopsy should be performed. However, in Santa Barbara County, both a member of the Coroner's Detective Staff and a pathologist make the decision and not solely on the direction of the pathologist.
The report also pointed out that neither the medical staff nor the facilities of the Santa Barbara County Coroner's Bureau are certified to the standards of the American Board of Medicolegal Death Investigators (ABMDI) and the National Association of Medical Examiners (NAME). According to the report, those standards are recommended by the U.S. Department of Justice but are not mandatory.
While the Santa Barbara County Sheriff's Office has a specific protocol that requires members of the Custody, Criminal, and Coroner investigator departments to take part in every DIC investigation, the report said that there has been reluctance from the Criminal Investigation Department to participate in some of the reviews.
For example, when an inmate committed suicide at the County Main Jail in December, 2023, the Sheriff specifically ordered that all departments comply with this policy with no exceptions.
The Grand Jury reports that the reluctance exacerbates the "inherent risk and potential liability" to the County especially when DIC numbers are rising.
To avoid a potential conflict of interest, the Grand Jury recommends the Sheriff/Coroner's office to request another Santa Barbara County agency to conduct either an "independent or parallel investigation for all deaths in custody events" and hire an independent medical examination team for all deaths in custody pathology investigations.
The Sheriff/Coroner's office was also recommended to develop and implement a succession plan for pathology technicians following current California Department of Health standards.
KSBY reached out to the Sheriff/Coroner's office for comment. The office's spokesperson said they have received the Grand Jury report and will respond to the findings in 60 days, per the requirement of the grand jury report.
Click here to read the Grand Jury report.
