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Sheriff’s review board reverses course, finds deputy violated policies in inmate death

Undated photo of Elisa Serna
(Family photo)
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The independent board that provides oversight of the San Diego Sheriff’s Department has reversed a finding that a deputy did nothing improper when she and a jail nurse watched an inmate strike her head and slump to the floor before leaving her alone to die.

In a rare decision, the Citizens’ Law Enforcement Review Board changed a “not sustained” finding to “sustained” and added a second finding of misconduct against a deputy who left Elisa Serna unconscious an hour before she died at the Las Colinas women’s jail in November 2019.

The two determinations said the unidentified deputy failed to meet department standards in recognizing and responding to Serna’s medical needs and failed to properly treat a person in sheriff’s custody.

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“Serna’s condition was one that deserved attention,” the review board wrote in an amended report that was released after numerous speakers complained during the monthly public meeting Tuesday night.

“According to (sheriff’s policies) employees shall be responsible for their own acts, and they shall not shift to others the burden, or responsibility, for executing or failing to execute a lawful order or duty,” the updated report said. “Deputy 1 had a responsibility to respond to Serna’s emergency medical needs. This did not occur and, therefore, Deputy 1 mistreated Serna.”

Before the review board meeting, board staff concluded that the two complaints were “not sustained” because there was no evidence the deputy violated department policies when Serna died.

But a host of speakers attending the online board meeting complained that the department should not have left Serna alone to die in her cell.

“There were two human beings who saw another human being have a seizure, hit her head and slump to the ground,” said Andrea St. Julian, a co-chair of the San Diegans for Justice advocacy group. “And their response was to leave her there to die?

“A 10-year-old has a higher moral compass than that,” St. Julian added.

Sheriff’s spokesman Lt. Ricardo Lopez said the department respects the review board’s authority.

“We take their recommendations seriously,” he said Thursday. “We review CLERB’s findings and take any recommendations into consideration.”

The board recommendations for policy changes and employee discipline are non-binding, so Sheriff Bill Gore is free to resist suggestions from the independent oversight body.

Also, even when deputies are disciplined for actions they take on the job, the punishments are almost never made public.

Nonetheless, the Citizens’ Law Enforcement Review Board’s reversal was welcome news to the Serna family, which last year filed a wrongful-death lawsuit against the Sheriff’s Department.

“I hope that the sheriff will take these recommendations seriously,” said attorney Julia Yoo, who represents the Serna family. “And I hope they will investigate the medical staff who steadfastly refused to render even the most basic care as a young woman was pleading for her life for days and dying of dehydration.”

Serna was 24 when she was arrested on theft and drug charges on Nov. 6, 2019.

When she was being booked into custody, she told sheriff’s employees that she had used heroin, Xanax and alcohol less than two hours before her arrest — an admission that calls for the department to implement drug-withdrawal protocols.

But medical records released to Serna’s family show the young woman was not treated according to those protocols over the five days she spent in custody. Instead she was given Zofran to treat her nausea and told to drink plenty of fluids.

When Serna’s parents were informed of their daughter’s death on Nov. 11, a sheriff’s official said she had been fainting and vomiting over the days before she died, implying that the death was due to some general sickness.

“She made it seem like Elisa was put in a cell and she had snuck in drugs,” her mother, Paloma Serna, told The San Diego Union-Tribune days after her daughter died. “She made it sound like it was an overdose.”

An autopsy later determined that Serna was suffering from heroin withdrawal, pneumonia and dehydration. She died from complications of chronic polysubstance abuse, with a contributing factor of early intrauterine pregnancy. Her manner of death was ruled to be natural.

Speakers at the review board meeting this week complained that a sworn deputy is obliged to help an inmate in obvious need of medical care.

“I can assure you that, based on the information presented, medical protocols were not followed,” said Lisa Vincent, an activist with Standing Up for Racial Justice North County. “The fact that this woman was left unattended for any amount of time displays negligence.”

Vincent said the oversight panel should investigate why a deputy assigned to the jail medical unit lacked training in advanced life support. Vincent acknowledged that some inmates lie about medical conditions but said that’s no excuse for failing to act.

“The default should always be to err on the side of caution,” she said.

Jail medical records indicate that a nurse believed Serna was faking her symptoms.

“Will attempt to recheck vitals when (patient) more cooperative,” the nurse wrote, referring to the seizure that preceded Serna’s death.

In their initial findings, review board investigators stated that deputies are required to defer to medical professionals when it comes to determining a course of treatment. The report also noted that the review board has no jurisdiction over the jail medical staff or its contractors.

Robin Sales, another member of Standing Up for Racial Justice North County, said that needs to change.

“I implore the CLERB and county of San Diego to institute oversight of medical personnel as well as law enforcement,” she said. “The Sheriff’s Department must recognize and act upon inhumane treatment of inmates now.”

Paul Parker, the review board executive officer, said expanding the role of the volunteer panel would improve the oversight process.

“Without jurisdiction over medical staff, it will continue to be difficult for CLERB to thoroughly investigate deaths and transparently report on deaths occurring in the jails, as sometimes that critical information must be redacted, if even known,” he told the Union-Tribune.

Yoo, the lawyer suing the county on behalf of Paloma Serna and other relatives, said her clients hope the turnaround by the review board helps change department practices.

“The Serna family has seen CLERB’s findings, and they are greatly relieved and grateful that there is a step towards justice for their daughter,” Yoo said.

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