A federal judge in Sacramento on Wednesday ordered a hearing in the case of a mentally ill inmate who died after being pepper-sprayed inside his cell at the Mule Creek State Prison in Ione, and directed California prison officials to ensure that none of the documents concerning the death are destroyed.
The order by U.S. District Judge Lawrence K. Karlton follows a Sacramento Bee report this week that raised questions about the circumstances that led to the death of 35-year-old Joseph Duran.
Duran, who breathed through a tube in his throat, died Sept. 7, seven hours after he was doused in the face with pepper spray. Agitated and coated in spray, Duran yanked out his breathing tube and began coughing up blood and stuffing food into the hole in his throat, according to internal corrections department documents obtained by The Bee. In the hours that followed, guards left him alone in his cell, rejecting orders from medical officials that Duran be extracted, decontaminated of the pepper spray and have his breathing tube reinserted.
Karlton ordered a Jan. 30 status hearing “to address issues arising from the death” and told corrections officials “to assure that all documents and information” on the case be saved.
Duran, a career criminal who suffered from a range of mental disorders, was serving a seven-year sentence for robbery. He was pepper-sprayed at about 10 p.m. on Sept. 6 after refusing orders from guards to remove his hand from the food port opening in his cell door. Seven hours after he was sprayed, he was found unresponsive in his cell and was pronounced dead shortly thereafter.
The Amador County coroner concluded in November that the case was a suicide and that Duran died of asphyxia after removing his breathing tube and stuffing spaghetti into the hole in his throat.
A psychiatrist brought in as part of a corrections system death review team disputed that finding, saying she believed Duran was using the pasta to soothe irritation from the pepper spray and that his death likely was preventable.
The California Department of Corrections and Rehabilitation said Wednesday it is investigating the case and that prison officials had classified Duran’s death as “accidental,” not a suicide. The department also denied claims by attorneys representing mentally ill inmates in a class-action lawsuit against the state, who contend corrections officials purposely delayed reporting Duran’s death to them and a court-appointed special master who oversees inmate mental health care.
“While we dispute the allegation that this report was delayed or improperly edited, we take this inmate’s death very seriously,” Deborah Hoffman, the department’s assistant secretary for communications, said in an email. “An investigation was launched immediately and is ongoing.
“Based on the information we have right now, it appears mistakes may have been made. If it is determined any employee violated policy we will take appropriate action.”
Details of Duran’s death were not provided to inmate attorneys until this month, after The Bee began making inquiries. The state also failed to track down Duran’s parents and notify them of his death – they learned their son had died when The Bee called with questions about the case. The omission prompted an apology from a top state official on Tuesday evening.
Steven Duran, Joseph’s father, said Martin Hoshino, undersecretary of operations for the California Department of Corrections and Rehabilitation, called to apologize to him and Joseph's mother, Elaine, for failing to get word to them about what had happened. Duran’s body was cremated 17 days after his death and the ashes scattered at sea.
“He just wanted to let me know that he’s very sorry about the way that I found out about Joseph’s death and he said they’re looking into it,” Steven Duran said. “They’re investigating where the failures are and how they can get better in the future.
“That’s all fine and dandy, but it doesn’t do any good for me I just wish I had a box of ashes that I could pick up and take home.”
Duran’s parents have retained Sacramento attorney Stewart Katz to represent them in possible legal action against the state.
The corrections department said officials tried to reach the Durans the day of their son’s death but that a telephone number for them had been disconnected. Four days later, a telegram was sent to the address officials had on file for the father, but that was a home in Pico Rivera where the family had not lived for years.
The department also attempted to locate relatives through the Internet and left phone messages with several people, but none of the calls was returned, officials said.
Katz, who has handled dozens of lawsuits over alleged abuse of power by law enforcement officers, confirmed Wednesday that he has been hired by the Durans.
“It appears at least possible that this was a total breakdown of protections and upgrades of treatment that have been crafted over the years by Judge Karlton, his special master, and the parties in the class action on behalf of seriously mentally ill prisoners,” Katz said in a prepared statement.
“It also appears that, rather than acknowledge the mistakes, corrections officials may have attempted to make everything about Joey’s death disappear into a black hole.”
The controversy over Duran’s death comes as the state is fighting a federal class-action lawsuit that alleges California prison guards routinely use excessive force, including pepper spray, against mentally ill inmates. Karlton, who is hearing that case, has not yet ruled. The lawyers on Friday filed an “urgent petition” seeking an investigation into Duran’s death.
The court filing by Michael Bien, lead counsel for the inmates, contends that the state delayed for two months before submitting a report on Duran’s death to a court-appointed special master who oversees mental health care in California’s prisons. The submission was made Jan. 7, and Bien maintains the department, under court-ordered requirements, should have submitted the report by Nov. 6.
Bien also questioned the omission of information in that report that was included in an earlier version of the internal review documents obtained by The Bee.
“The Jan. 7, 2014, Suicide Report does not include specific findings regarding the custodial failings and the impact of the use of pepper spray on the behavior and ultimate death” of Duran that were included in the earlier report, he said.
For instance, the earlier death review report listed “five concerns related to custody,” but the January version submitted to the special master was changed to read “three concerns related to custody.” Bien also noted that the earlier report said documentation about what led to the pepper-spraying was incomplete, a finding not included in the January report.
The corrections department disputes Bien’s contention that there was a delay in reporting Duran’s death or that information was withheld. While inmate suicides must be reported to the special master within 60 days, the department said Wednesday it had concluded on Oct. 31 that the death was “accidental.”
After the department received a Nov. 27 report from the Amador County coroner labeling the death a suicide, corrections “determined that it would issue a report, even though it disagreed with the coroner’s conclusion,” Hoffman wrote in an email. That report was submitted on Jan. 7 to the special master and inmate attorneys as a possible suicide, “within 60 days of the coroner’s conclusion,” she added.
On Wednesday, state Senate Pro Tem Darrell Steinberg called the case “a terrible tragedy.”
Steinberg said the Duran death was “an absolutely shocking story and it speaks to how much work is left to be done to fix our criminal justice system and invest in desperately needed mental health resources
“This issue of mental health care is the under-attended-to issue of our time,” said Steinberg, who has fought for additional funding and services for the mentally ill.