The OCDA found that the SAPD breached their duty of care when an inmate hangedhimself

The Orange County District Attorney’s Office’s has concluded their investigation concerning the November 4, 2020, custodial death of 47-year-old inmate Jason Ray Jones.

The investigation revealed evidence that the Santa Ana Police Department {SAPD) breached its duty of care to Jones, however the OCDA cannot prove that the breach caused Jones’ death.

Consequently, there is an insufficient basis upon which to find criminal culpability for Jones’ death on the part of any SAPD personnel or those under the supervision of the SAPD.

On November 4, 2020, OCDA Special Assignments Unit (OCDASAU) Investigators responded to Orange County Global Medical Center (OCGMC) where Jones died after receiving medical aid.

Jones had been in custody at the Santa Ana Police Department Detention Facility and was found in his cell suspended above the floor by a ligature around his neck. The ligature had been formed with a bed sheet.

During the course of this investigation, the OCDASAU interviewed 19 witnesses, and obtained and reviewed reports from SAPD and the Orange County Crime Laboratory (OCCL), as well as incident scene photographs, and other relevant materials.

FACTS:

Jason Ray Jones was booked into the Santa Ana Police Department Detention Facility on July 3, 2020. From that time and until his death, Jones was moved to several different cells because of disciplinary issues. Jones was on Floor 3, Module D, Cell 24 when he died in custody.

During his incarceration, Jones experienced the death of his mother and brother; he suffered from substance abuse; and was in an unstable relationship with his girlfriend. Jones received both medical and mental health care while in custody and was prescribed medication for anxiety, hypertension, and addiction cessation. There was no known history of suicide attempts.

On November 3, 2020, at approximately 9:01 a.m., Jones was administered Acetaminophen (500 mg tablet), Lisinopril (2.5 mg tablet), and Hydroxyzine Pamoate (25 mg tablet) by a Licensed Vocational Nurse (LVN). Later at approximately 6:41 p.m., Jones spoke with his girlfriend over the phone and the two discussed a variety of topics including their finances, their relationship, their future living arrangements, and their substance abuse problems. That night at approximately 7:42 p.m., Jones was again administered Acetaminophen (500mg tablet), Trazodone HCL (100 mg tablet), and Hydroxyzine Pamoate (25 mg tablet) by an LVN.

On November 3, 2020, at approximately 9:30 p.m., SAPD Correctional Officer Celeste Fernandez (C.O. Fernandez) was assigned to oversee Floor 3, Modules C and D until her shift ended at 6:30 a.m. the next morning. As part of her job duties, C.O. Fernandez was required to conduct two welfare checks every hour on all inmates in her assigned area. At approximately 9:50 p.m., 10:28 p.m., 10:57 p.m., and 11:47 p.m., C.O. Fernandez logged welfare checks of Floor 3 Modules C and D using a department computer and reported no issues with any of the inmates. At approximately 11:45 p.m., SAPD Detention Facility video surveillance recorded C.O. Fernandez conducting a welfare check of Jones’ cell. Video surveillance then showed SAPD C.O. Mary Valenzuela (C.O. Valenzuela) arriving at 11:59 p.m. to relieve C.O. Fernandez for her break.

On November 4, 2020, at 1:04 a.m., C.O. Valenzuela logged a welfare check of Floor 3 Modules C and D via computer and reported no issues with any of the inmates. SAPD Detention Facility video surveillance system recordings showed, however, that C.O. Valenzuela remained at the module’s officer podium for the entire period of time she covered for C.O. Fernandez, which lasted until 1:14 a.m. C.O. Valenzuela subsequently declined to give a statement to investigators to explain the discrepancy between her computer log entry and the surveillance video recording.

At approximately 1:04 a.m., C.O. Fernandez returned from her lunch break and can be seen on surveillance conversing with C.O. Valenzuela for a few minutes before C.O. Valenzuela left. At 1:10 a.m., 1:15 a.m. and 1:16 a.m., video surveillance recorded Jones moving freely near the front entrance door of his cell. Due to the angle and distance of the surveillance camera, it cannot be determined what Jones was specifically doing inside his cell.

At approximately 1:30 a.m., C.O. Fernandez began her first set of welfare checks after returning from her break. At approximately 1:35 a.m., surveillance shows C.O. Fernandez approach Jones’ cell, immediately reach for her handheld radio, request emergency assistance, and attempt to enter the cell. When interviewed by investigators, C.O. Fernandez stated that it was at this time that she saw Jones unresponsive and hanging by a bedsheet from the top bunk inside his cell. Specifically, she stated that Jones was in a seated position between the bunk and toilet with bedding wrapped around his neck, and his head was slumped downward and his arms were hanging at his sides.

Immediately upon entering the cell, C.O. Fernandez tried to free Jones’ neck from the bedding. Her initial efforts were unsuccessful, and she yelled for responding personnel to bring scissors. Within seconds, Correctional Officer James Elizondo (C.O. Elizondo) and an LVN arrived to assist. C.O. Fernandez and the LVN were able to lift Jones’ body while C.O. Elizondo loosened all three knots in the bedding. Together, they were able to free Jones.

At approximately 1:36 a.m., a Registered Nurse (RN) arrived on scene to also provide aid. In a subsequent interview with investigators, the RN stated that immediately upon her arrival, Jones was unresponsive to verbal and tactile stimuli; his face and hands were mild-moderately cyanotic; and his skin was warm and dry, but pallid in color. At approximately 1:37 a.m., personnel moved Jones to a common area outside his cell where medical staff determined Jones had no pulse or respirations. A pulse oximeter reading indicated Jones had a blood oxygen level of 48%, consistent with a deceased person.

Medical staff began cardiopulmonary resuscitation (CPR), and a bag-valve mask was utilized to provide oxygen to Jones. At approximately 1:44 a.m., an LVN administered one dose of Narcan to Jones. At approximately 1:46 a.m., personnel removed Jones’ shirt, and an Automatic External Defibrillator (AED) was attached to his upper torso. After analyzing his condition, the AED audibly stated, “No treatment advised.” CPR and oxygen delivery continued, although medical staff still did not detect any pulse, any measurable blood pressure, or any pupillary response.

At approximately 1:47 a.m., a second pulse oximeter reading indicated Jones had a blood oxygen level of 50%. At approximately 1:48 a.m., Orange County Fire Authority (OCFA) personnel from Engine #71 arrived and took over patient care. They examined Jones and confirmed that he had no pulse, was not breathing, and had no blood pressure. Jones’ Glasgow Coma Scale score was measured as a three, the lowest score possible and also consistent with a deceased person.

At 1:50 a.m., Jones was intubated, an intraosseous infusion line was established in his lower right leg, and a Lucas Chest Compression System was attached to his chest. At 1:58 a.m., Jones was administered 1 mg of epinephrine. At approximately 1:59 a.m., Jones was transported Code-3 (lights and siren) via ambulance to OCGMC. During his transportation to the hospital, Jones received another dose of epinephrine. The ambulance arrived at the hospital at approximately 2:09 a.m., and OCFA relinquished responsibility of Jones’ care to OCGMC Emergency Room staff.

Following arrival at the emergency room, Jones’ was observed to have an asystolic heart rhythm (having no electrical cardiac activity), his skin was cyanotic, and his pupils were fixed and dilated. Emergency room staff continued advanced life-saving measures, including administering medications and providing mechanical ventilation. These efforts did not revive Jones. At approximately 2:14 a.m., Jones was observed to have a pulseless electrical activity heart rhythm followed by asystole, while his pupils remained fixed and dilated. At 2:15 a.m., Jones was pronounced dead by an OCGMC attending emergency room physician.

EVIDENCE COLLECTED

The following items of evidence were collected and examined:

• One white t-shirt cut open with apparent blood stains
• One pair of tan jail pants
• One pair of white boxers
• Possible ligature blanket with sheet tied in knots (west end of jail cell bed)
• Tied sheet with apparent blood (east end of jail cell bed)
• Plastic baggie containing a white/brown substance
• Brown paper bag, removed from the right hand
• Brown paper bag, removed from the left hand
• Deep tissue standard
• Heart blood standard

AUTOPSY

On November 6, 2020, Forensic Pathologist Dr. Etoi Davenport of Orange County Coroner’s Office conducted an autopsy on Jones at the Orange County Sheriff-Coroner Forensic Science Center. Dr. Davenport found no significant trauma to the body. Jones had an enlarged heart, but no coronary heart disease. Dr. Davenport found no ligature marks and determined that Jones had no neck fractures. Dr. Davenport determined cause of death to be ligature hanging in the manner of suicide.

EVIDENCE ANALYSIS

Toxicological Examination

A sample of Jason Ray Jones’ postmortem blood yielded the following results:

BACKGROUND INFORMATION

Jason Ray Jones had a State of California Criminal History record that revealed arrests for the following violations:

• Domestic Battery
• Willful Cruelty to a Child
• Violation of Protective Order
• Violation of Probation
• Under the Influence of a Controlled Substance

LEGAL ANALYSIS

There is no evidence of express or implied malice on the part of any SAPD personnel, inmates, or other individuals under the supervision of the SAPD. Therefore, the only possible type of homicide in this situation is murder or manslaughter under the theory of failure to perform a legal duty.

Without question, the SAPD and its custodial personnel owed Jones a duty of care to protect him from foreseeable harm. This included any harm he intended to bring upon himself. Based on this investigation, there is no evidence that C.O. Fernandez, C.O. Elizondo, or SAPD medical personnel breached this duty of care. By contrast, there is evidence that C.O. Valenzuela failed to follow SAPD protocols and in so doing breached her duty of care. However, there is insufficient evidence of a causal connection between C.O. Valenzuela’s breach and Jones’ death to establish criminal liability.

The two SAPD Correctional Officers assigned to monitor Jones’ cell leading up to the time of his death were C.O. Fernandez and C.O. Valenzuela. These correctional officers were responsible for conducting welfare checks twice per hour on inmates housed on Floor 3, Modules C and D, which included Jones.

On November 3, 2020, at 9:30 p.m., C.O. Fernandez began her shift and performed three welfare checks at approximately 10:28 p.m., 10:57 p.m., and 11:47 p.m. before going on her lunch break at 11:59 p.m. SAPD Detention Facility video surveillance confirmed that C.O. Fernandez conducted her last welfare check of Jones’ cell at approximately 11:45 p.m., approximately 14 minutes before her lunch break. According to computer entries made by C.O. Fernandez, there were no issues with any of the inmates at this time. Thereafter at 11:59 p.m., surveillance showed C.O. Valenzuela arriving at the module’s officer podium to assume shift duties for C.O. Fernandez.

On November 4, 2020, at 1:04 a.m. (approximately 1 hour and 5 minutes into C.O. Valenzuela’s shift duties), C.O. Valenzuela made a computer entry indicating that she had conducted a welfare check on Floor 3 Modules C and D and reported no issues with any of the inmates. Contrary to this record, however, SAPD Detention Facility video surveillance showed that C.O. Valenzuela never left the module’s officer podium until her shift ended at 1:14 a.m. No other evidence was provided to account for this inconsistency, and C.O. Valenzuela declined to provide any statement to investigators. Based on this contradiction, it is fair to conclude that C.O. Valenzuela did not actually perform a welfare check on Jones’ cell during the approximate 1 hour and 15 minutes she was on duty, and that two welfare checks were missed between the hours of 12:00 a.m. and 1:00 a.m. on November 4, 2020.

Despite the two missed welfare checks leading up to the final hour of Jones’ death, SAPD Detention Facility video surveillance recorded Jones moving about near the entrance door of his cell at 1:10 a.m., 1:15 a.m. and 1:16 a.m. As a result, Mr. Jones must have committed suicide between 1:16 a.m. and 1:35 a.m.

After returning from her break, C.O. Fernandez performed a welfare check on Jones’ cell and discovered him at approximately 1:35 a.m. unresponsive and hanging from a bedsheet tied around his neck and attached to the top bunk of his cell. At this moment, C.O. Fernandez was under the legal duty to render immediate medical care to Jones, which she did.

C.O. Fernandez acted in accordance with her legal responsibilities by immediately requesting emergency medical aid and attempting to free Jones from the ligature wrapped around his neck. SAPD medical staff arrived within seconds and assisted C.O. Fernandez in freeing Jones. They then began to render emergency medical services to him, including performing CPR, artificially inducing breathing through an oxygen bag-valve mask, and using an AED device to try and revive his heart. Despite these efforts, SAPD personnel were unable to revive Jones.

Based on the evidence collected and statements made by responding medical personnel, it appears likely that Jones had died prior to C.O. Fernandez discovering him unconscious hanging inside his cell. In support of this conclusion, one of the first nurses to respond to Jones’ cell at 1:36 a.m. described to investigators that Jones was unresponsive to verbal and tactile stimuli, his face and hands were mild-moderately cyanotic, his skin was pale in color and was warm and dry to the touch. Next at 1:37 a.m., additional SAPD medical staff arrived on scene and determined that Jones had no pulse or respirations and had a blood oxygen level of 48%. At 1:48 a.m., OCFA paramedics arrived and confirmed that Jones was not breathing, and had no pulse or blood pressure. Thereafter, Jones was transported to the OCGMC emergency room and continued to receive medical treatment. Such treatment was unsuccessful, and Jones was officially pronounced dead at 2:15 a.m.

Based on the foregoing, it is clear that C.O. Fernandez acted within the scope of her legal duties under the circumstances.

C.O. Fernandez conducted her last welfare check in accordance with set policy based on the information she knew to be true at that time. Upon finding Jones’ unresponsive in his cell, she promptly called for assistance and immediately began to render emergency aid to him. Therefore, C.O. Fernandez is not legally culpable for Jones’ death.

With respect to C.O. Valenzuela, while there is evidence that she breached her legal duty of care to Jones, there is insufficient evidence that this breach contributed to his death. To establish criminal liability under a theory of murder or manslaughter, evidence must show beyond a reasonable doubt that C.O. Valenzuela’s failure to act “caused” the death of Jones.

C.O. Valenzuela apparently failed to conduct welfare checks between 12:00 a.m. and 1:14 a.m. in accordance with SAPD protocol. Had Jones attempted suicide during this timeframe, criminal responsibility would potentially lie with her. However based on the surveillance video recordings and Jones’ observed movements thereon, it is clear that Jones committed suicide after C.O. Fernandez relieved C.O. Valenzuela and sometime between 1:16 a.m. and 1:35 a.m.

It is possible that welfare checks conducted prior to 1:14 a.m. would have revealed evidence that Jones was preparing to commit suicide. It is equally possible that Jones’ made no preparations until after he was observed on surveillance video at 1:16 a.m. Ultimately, both theories are speculative, and lack evidentiary support.

Consequently, evidence of a causal connection between the absence of earlier welfare checks and Jones’ suicide sufficient to prove criminal responsibility beyond a reasonable doubt is lacking. This determination is not a referendum on potential civil or administrative liability. Again, such evaluations are beyond the scope of this investigation. Rather solely for criminal liability purposes, there is insufficient evidence to establish that had C.O. Valenzuela conducted welfare checks in accordance with protocol, it would have prevented Jones’ suicide.

CONCLUSION

Based on all the evidence provided to and reviewed by the OCDA, the evidence shows that Jason Ray Jones died by suicide as a result of a ligature hanging. Pursuant to applicable legal principles, it is our conclusion that there is insufficient evidence to support a finding of criminal culpability for Jones’ death on the part of any SAPD personnel or any individual under the supervision of the SAPD.

Accordingly, the OCDA is closing its inquiry into this incident.