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Family sues, alleging widespread failings, cover-up in 2013 prison pepper-spray death

The parents of a suicidal, mentally ill inmate who died at Mule Creek State Prison after being pepper-sprayed a year ago filed suit Thursday against dozens of defendants, including the guard who sprayed him and others they charge with trying to cover up the circumstances of his death.

The wrongful death suit, filed in federal court in Sacramento for Steven and Elaine Duran by attorney Stewart Katz, alleges widespread failings and subsequent cover-up attempts in the events that led to the Sept. 7, 2013, death of Joseph Duran.

Duran, who was serving a seven-year sentence for robbery and would have turned 36 on Wednesday, breathed through a tube in his throat and was blasted with pepper spray while standing alone in his cell at the prison outside Ione.

He was sprayed after refusing to remove his hands from the food port opening in his cell door, then left inside the cell despite repeated efforts by medical staff to get guards to remove him and decontaminate him and the cell, according to the suit, as well as internal corrections documents obtained by The Sacramento Bee last year.

Duran was found dead in his cell the next morning, and the Amador County coroner labeled his death a suicide, ruling that he stuffed spaghetti and feces into the hole in his throat after he yanked out his breathing tube. The corrections department later called it an accidental death, and a psychologist reviewing the case for the department concluded Duran used the pasta to soothe his throat from the pepper spray.

Word of his death did not seep out of the California Department of Corrections and Rehabilitation for four months, until The Bee notified the Durans that their son was dead. The circumstances of his death ultimately sparked a series of internal investigations and the reopening of a hearing in federal court on the use of force against mentally ill inmates.

The incident also contributed to the department revising its policy and procedures on when pepper spray may be deployed and the efforts that must be made to notify relatives when an inmate dies in custody.

The use of pepper spray is now strictly limited inside mental health units, and disputes between guards and medical staff over how to proceed with troublesome inmates must be taken up the chain of command.

The Durans’ lawsuit names 13 correctional officers and officials, including Mule Creek Warden William W. Knipp, as well as Amador County Sheriff Martin Ryan and the funeral home that cremated Duran’s body and had his ashes scattered at sea before his parents learned of his death. It also holds out the possibility of adding up to 20 other officials whose names are not yet known.

The first defendant named is guard Roy C. Chavez, who is identified in the suit and internal corrections documents as the officer who sprayed Duran in the face with a blast of pepper spray after receiving approval from Sgt. Mark Shepard.

“After receiving Sergeant Shepard’s non-verbal approval (a nod), but without giving Duran any warning, Officer Chavez inexplicably unloaded his oversized MK-9 can of Oleoresin Capsicum pepper spray (OC pepper spray) by spraying it directly at Duran’s face and neck, which were pressed up against the open food port on his cell door,” the lawsuit states.

The canister holds 16.9 ounces and is effective from 12 feet, the lawsuit states, and “a significant amount of OC pepper spray went directly into Duran’s throat through his tracheostomy tube.”

The suit contends the spray “creates an immediate known health risk” and that there was no training on whether it was appropriate to spray someone who breathed through a tube in their throat.

“There were no discussions about alternate or lesser uses of force or whether there was even any need to use force prior to Officer Chavez deploying the pepper spray,” the lawsuit states.

Chavez, Shepard and others involved the incident have not responded to previous requests for comment. JeVaughn Baker, a spokesman for their union, the California Correctional Peace Officers Association, said Thursday it would not be appropriate to comment on a matter under investigation.

The corrections department will not discuss matters involving individual officers, but corrections Secretary Jeffrey Beard has previously told The Bee he is “very concerned” about the Duran case and that any inkling of an attempted cover-up would “become the subject of an investigation.”

Transcripts of internal affairs interviews conducted after a Bee article on Duran’s death, which were provided to the newspaper earlier this year, suggested some officials felt unusual interference and oversight from their superiors as they investigated the death.

“This one was a very unusual report,” psychologist Corey Scheidegger told investigators, adding that at one point she was told to remove a mention of pepper spray from one report.

The lawsuit goes further, alleging that “several individuals deliberately gave false or incomplete statements” after Duran died “to avert or deny responsibility.”

The suit claims prison officials were “acutely aware that the incident had the potential to directly affect” federal court hearings being held at the time on whether guards were using inordinate amounts of force and pepper spray against mentally ill inmates statewide.

“(I)t would have been troublesome for the details of Duran’s death to break at this particular time, and there was a fear that Duran would become the face associated with its tragically systemic failures in regard to the treatment of mentally ill inmates,” the suit states.

Katz, the attorney who filed the suit, contends that officials deliberately avoided locating Duran’s parents to tell them he had died, despite the fact that their contact information “was easily obtainable online or using the telephone book.”

Duran’s body was cremated 17 days after his death, and the lawsuit notes that the cremation denied the Durans, who are Catholic, the chance to provide a proper Mass and burial.

It also prevented them from seeking a second autopsy on his body, which the lawsuit says would have provided an “important opportunity to obtain forensic evidence” that could be used in their wrongful death suit.

Duran’s death contributed to an overhaul of regulations on how and when next of kin are to be notified of an inmate’s death.

Corrections officials revamped their notification policies in April to require much more diligent efforts to contact relatives when an inmate dies.

The changes include a requirement that an inmate be interviewed about next of kin by staffers when the prisoner arrives at a facility, and that the inmate sign a notification form so that it can be entered into the corrections department’s computer system.

The new policy adds language requiring officials to “notify the contact listed as soon as possible” after a death, and adds that staffers making notification verify the mailing address of the next of kin.

The department also added a requirement that letters from the warden to next of kin “shall be done by return-receipt mail.”

Corrections officials say a phone call was made to a contact number for Duran’s next of kin that had been disconnected, and subsequently a telegram was sent to a Pico Rivera address where Duran had lived as a boy. The Bee located the family’s current address in less than half an hour using online records.

The new policy adopted in the wake of Duran’s death requires the warden or underlings to “use all reasonable means to make contact with family members,” including using investigative services, searching the inmate’s personal property, reviewing who had visited the inmate, contacting parole agents, the local coroner or the original arresting agency.

If those measure fail, officials are to review social media for clues, contact consulate offices if the inmate is a foreigner and document all efforts made to locate relatives.

The department also revised its rules on the disposal of unclaimed dead bodies, adding language requiring that “reasonable efforts” be made to locate relatives for at least 10 days before releasing the body for cremation or burial.

Related material:

•  Judge finds treatment of California’s mentally ill inmates ‘horrific’

•  Another inmate death raises questions about California prison practices

•  Was it suicide? Questions abound in death of pepper-sprayed inmate

•  Federal judge orders hearing into Mule Creek inmate death

•  Editorial: State prisons should not be a modern Bedlam

•  Judge reopens use-of-force hearings for California prisons after details emerge of inmate's death

•  The Public Eye: Confidential documents cite interference in prison death review

•  Judge orders new evidence in Mule Creek inmate death

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