“What is your emergency?” responded a voice, captured on video footage from a camera in the cell. It was a deputy about 50 feet away, in the control room of the women’s mental health unit where Upton, 21, was being held.

“It’s not an emergency, but —” she began, then the deputy cut off the call before she could finish. Charged with a misdemeanor, Upton was awaiting a court-ordered evaluation to determine whether she was competent to stand trial.

She took a few more listless steps, the video shows. She paused beneath a buzzing fluorescent light, then picked up a white bedsheet and said, “It’s time to hang myself.”

She was found, limp, 20 minutes later. In the interim, the camera recorded the young woman preparing to end her life. But no guards, who were tasked with monitoring the video feed, noticed until it was too late.

Upton was the first of 19 detainees at Riverside County jails to die in 2022. That total, the highest the department had reported in at least three decades, ranked the jail system among the most lethal in the nation that year.

The deaths, attributed to homicide, overdose, natural causes or suicide, reflected troubling patterns: neglect by jail employees, access to illicit drugs, and cell assignments that put detainees at increased risk of violence or did not allow for close oversight.

The suicides — at least three of the deaths, but most likely four — offer particular insight into some of those institutional problems and lapses, an investigation by The New York Times and The Desert Sun found.

The county Sheriff’s Department failed at times to adequately monitor detainees and intervene when they attempted suicide. Guards did not always enforce rules prohibiting detainees with mental illnesses from blocking cell windows and cameras, which hinders the required safety monitoring. The department has often isolated detainees with severe mental illness, which can exacerbate suicidal intentions.

And, the investigation found, the department has omitted pertinent facts about the deaths in communications to the families of the dead and to the public.

The department has assumed no responsibility for these deaths. California’s attorney general last year opened an ongoing civil rights investigation into the increase in deaths in custody, and Riverside County agreed to pay more than $12 million to settle lawsuits linked to detainee deaths going back to 2020. At least a dozen cases are still pending.

The county sheriff, Chad Bianco, did not respond to interview requests or comment on detailed questions about the news organizations’ findings. But on an episode of his podcast this summer devoted to inmate deaths, he said that it can be extremely difficult at times to prevent suicides, and falsely claimed that there had never been any allegation that the department had “somehow done something wrong, or mishandled inmates, or mistreated inmates, or caused their death.”

The president of the deputies union declined to comment.

To understand how the suicides occurred, The New York Times and The Desert Sun interviewed dozens of people including current and former jail employees, relatives of the dead, independent medical examiners and civil rights lawyers. The news organizations also reviewed court documents, including arrest records, detainee medical and mental health records, and department notes on jail housing decisions.

Many of the details in this article have never been publicly reported, including the jail security camera footage reviewed by a reporter — material that is rarely seen by outsiders. The department has not released that footage or a dozen other videos requested by the news organizations under the California Public Records Act.

The suicides strongly suggest that, despite a federal class-action suit a decade ago that exposed deficiencies in mental health treatment in Riverside County jails and resulted in new court-ordered requirements, problems persist.

One detainee in 2022, who told guards that he was suicidal, was cleared after a medical check to return to his cell without any suicide-watch protocol. He was found dead about an hour later. He had been in custody for one day.

Another man, who suffered from schizoaffective disorder, had been mostly segregated from other detainees for two years when he was found hanging, and later died. To conceal his actions, he had covered his cell window and camera without any intervention from guards.

There were 14 deaths in Riverside County jails in 2023. No suicides were reported, though the cause of death in five of those cases is still “pending investigation,” according to the California Department of Justice. Earlier this year, a man hanged himself while another detainee tried to alert jail guards but couldn’t get their attention.

That suicide and a separate drug overdose prompted Capt. Alyssa Vernal, then the head of the jail, to warn staff members that they were failing to maintain basic jail operating standards — including some of the same lapses identified years ago by the federal court.

Vernal, who did not respond to requests for comment for this article, wrote in an internal email reviewed by the news organizations, “It has become obvious we are not keeping house or following the rules we should be.”

‘Kept saying she was fine’

When she was 19, Alicia Upton hit the road and left everything behind. She piled into a friend’s car in West Virginia and embarked on what would become a cross-country trip.

In an interview, her mother, Nichole Thompson, recalled believing that she was going on a fleeting adventure before settling back home. “She was resolute when she fixed her mind on something,” said Thompson, a librarian who raised Alicia and her older sister in the Appalachian town of Lost Creek.

From a young age, Alicia was an animal lover who would bring home rabbits and raccoons she hoped to keep as pets. At 14, she sold the Xbox she had gotten for Christmas to buy a horse, which she trained herself. To raise money for the road trip, she sold her four-wheeler and some goats, but not the horse, which she left in the care of a friend.

Upton had shown no signs of mental health problems when she left home, her mother said. She had gone to counseling years earlier after the suicide of a close friend, and her mother felt that she was resilient.

The road trip took Upton to Florida, Texas, and across the country through New Mexico and Arizona. Finally, she called home from Hemet, a former farming town now sprouting strip malls and tract houses. It is near the western end of Riverside, one of the state’s fastest-growing counties, which extends from the Arizona border almost to Los Angeles.

She sounded happy, her mother recalled. She said California was beautiful. As the weeks wore on, though, she mentioned that the car needed costly repairs and that she was often looking for places to sleep.

“I walked a fine line, trying to coax her to come back, but also let her have her freedom,” Thompson said. While some companions left for new destinations, Upton stayed put.

As the months turned into a year, it became clear to Thompson that her daughter was living on the streets. “She always knew coming home was an option,” Thompson said. “If I pushed her, I felt she would disconnect. She just kept saying she was fine.”

Soon, Thompson became concerned that her daughter might be struggling with drugs. She recalled Upton saying irrational things on the phone, like describing seeing relatives who were thousands of miles away.

Eventually, Upton was arrested twice for minor offenses — shoplifting and trespassing. Both times, she was released. But a third arrest was different.

On April 19, 2022, a woman found Upton on her land in San Jacinto. She later told deputies the young woman appeared to be looking for something. When the landowner found a knife on the ground, the two had a confrontation. Upton left and no one was injured. But she was arrested nearby and charged with possession of drug paraphernalia and making criminal threats, both misdemeanors.

The paper trail of Upton’s incarceration describes her as distraught and combative on arrival at the Robert

Detention Center in the city of Riverside. Of the five jails in the county, it is the facility where detainees who need mental health care are most often sent. Reports from the booking note that she did not sign several required documents. One jailer wrote on the signature line that she could not be trusted with a pen.

She was given a mental health rating of “severe” and placed in the women’s mental health housing unit, where each cell was monitored by camera. She was not prescribed any medication. When asked if she had ever attempted suicide, she would not answer.

But, deputies wrote in her file, she said she had “multiple personality disorder” and “stated that she ‘always kinda wanted to die.’”

A surge in jail deaths

Long before Upton was sent to the jail, the Sheriff’s Department had struggled to treat mental illnesses among the nearly 3,700 detainees it housed on any given day.

In jail and prison systems across the country, the population of people with mental health needs has surged in recent decades. More than half the detainees in California’s jails have such problems, a 2023 study found. As Riverside County’s jails began to operate as de facto mental health facilities, some detainees who claimed mistreatment took action.

Four sued the county in federal court in 2013, in what would become a class action, claiming the department was not providing adequate care.

When a judge ordered experts to inspect the claims, Dr. Bruce Gage, then chief of psychiatry for the Washington State Department of Corrections, found multiple problems. Some detainees were not receiving prescribed medications. Others were being medicated indefinitely on mere suppositions of mental illness. It was unclear whether the call buttons in the cells even worked.

Gage reported that the jails didn’t monitor suicidal detainees who were awaiting transfer to psychiatric facilities. The jails had no protocol in place to transition someone who was no longer considered suicidal into less-restrictive living conditions. Detainees either were in a general population and could be outside their cells for hours a day, or confined for all but 15 to 45 minutes.

“Riverside County jail system is amongst the most restrictive correctional settings I have visited,” Gage wrote. Those struggling with mental illness, he added, are “placed at greater risk of harming themselves under these conditions.”

Based on the reports, in 2016 a judge ordered a remedial plan that included ongoing inspections of the facilities and the threat of court intervention. Gage noted that the department had faced a staffing shortage since the 2009 recession, but emphasized that basic standards of care were required by law.

Sara Norman, one of the plaintiffs lawyers in the case, said that the jail had made progress in improving medical care, but less so with mental health care. “We have been concerned for years about the dearth of programming and group and individual therapy for people struggling with mental illness in the jails,” she said.

Meanwhile, the county system experienced an increase in jail deaths over the past decade. Among them was a man in 2020 who had been arrested for drug possession and was to be released with a citation for a later court appearance. Instead, he died after being violently extracted from his jail cell by guards while experiencing symptoms of psychosis. His relatives received $7.5 million this year to settle a lawsuit.

The surge of 19 deaths in 2022 made Riverside’s rate the second-highest in the state, behind Kern County, which had a much smaller jail population. Among the nation’s 15 largest jail systems, Riverside was the second-most deadly, with a rate more than twice that of Chicago, Philadelphia and Dallas.

While some people at the Riverside jails were serving criminal sentences, most — including those who died by suicide — were detainees awaiting trial or other resolution of their cases.

Robert Robinson, 41, was arrested in September 2022 for trying to cash a fraudulent check at a casino. Because he was a gang dropout, he was considered a likely target of violence and was housed alone.

He told jailers while being booked that he was having suicidal thoughts, according to a lawsuit filed by his relatives. He was placed in a cell without a camera and was not put on suicide watch, records show.

The next day, he told deputies he was suicidal, and he met with a medical provider and a mental health nurse, according to court documents. Both cleared him to return to his cell alone. About an hour later, a deputy discovered that he had hanged himself.

Riverside County settled the civil suit with his relatives this past August for $1.8 million, with no admission of wrongdoing. His family did not respond to requests for comment.

Aaron Aubrey, 28, had an extensive history of mental illness and violence. During his three-year incarceration awaiting trial on a murder charge, he was housed in a mental health unit. He spent significant time in isolation after he was charged with killing another detainee in 2020.

In December 2022 a guard saw that Aubrey had blocked his window and covered his camera, but took no action, according to the coroner’s report. During another security check 40 minutes later, the detainee was found hanging. He died six days later at a hospital.

And this year, Reynaldo Ramos, 55, hanged himself even as a cell neighbor twice tried to alert guards over the intercom, according to a complaint filed with the county by the man’s relatives. The guards didn’t respond, the complaint said.

The claim attributed that account to an anonymous letter sent to the family’s lawyer and separately to a reporter for The Times and The Desert Sun, containing those closely guarded details. A person who had reviewed jail surveillance video of the unit also described the failed alert efforts.

Ramos, who had been given a mental health rating of severe when admitted to the jail on drug charges, was discovered unresponsive during a routine safety check, according to an internal incident report provided to the Times.

‘Man down!’

In the days after Upton’s arrest, her mind continued to fray.

On April 28, 2022, a judge ordered her to undergo a mental competency evaluation. Her criminal case was suspended, and with it the possibility of bail, until the findings were reported. When she was admitted to the jail, she had briefly been placed in a safety cell, without access to items that could be used for self-harm. Soon after, she was placed in the mental health unit.

That evening, the surveillance video showed, she was restless. Her cellmate was asleep on the top bunk as Upton paced and looked out of the cell door’s window. Meal trays were stacked at the foot of the bed and clothes were scattered nearby.

At 8:13 p.m., she pressed the intercom button, but got only a few words out before the deputy hung up. Moments later, Upton can be heard in the video saying she intends to hang herself.

She looped the bedsheet around her neck and, for a few minutes, tried anchoring it. She smacked her head three times. She looked toward the camera. At one point, it sounded as if she was weeping.

Sitting on the bottom bunk, she tied the sheet above her and tightened it around her neck.

At 8:18 p.m., Upton raised a middle finger to the cell camera. Over the next few minutes, the video captured her final movements. By 8:22, she was still.

It all unfolded in view of the deputies who were supposed to monitor the feed from her cell. A guard at a workstation near the control room was responsible for constantly tracking the video footage of the unit, according to three former jail employees speaking on the condition of anonymity for fear of reprisals from the department.

Meanwhile, a deputy in the control room reminded a trainee to occasionally scan the images. They looked up at the feeds from the roughly 40 cameras, two of the former employees said. Spotting Upton, the deputy shouted over the radio, “Man down!”

She had been hanging by the bedsheet for 16 minutes before guards flashed lights signaling an emergency, video footage shows. Two deputies and a jail nurse entered her cell and began resuscitation efforts, but it was futile.

The next morning, back in West Virginia, Upton’s mother woke to pounding on her door, she recalled in an interview. It was a local deputy, who told her to call the Riverside County Sheriff’s Department.

She remembers asking, “Does this mean she’s dead?”

Yes.

“I thought my heart would stop,” she said.

The sheriff is the coroner

In Riverside County, the final accounting of how people die depends to a large extent on Sheriff Bianco.

A veteran of the department, Bianco was first elected sheriff in 2018. He has cast himself as a right-wing firebrand at odds with the state’s left-leaning legislature and governor. He has also criticized Atty. Gen. Rob Bonta’s investigation of jail deaths as a “political stunt.”

California is one of just three states that allow elected law enforcement officials to oversee coroners’ offices. Until recently in Riverside County, that meant the Sheriff’s Department typically investigated deaths at its jails while also supervising the pathologists conducting the autopsies. (This year, the department began outsourcing those autopsies.) The final report about the cause of death is signed by the sheriff, who also serves as the coroner.

The state Legislature has considered bills to separate the offices but none have passed. The California Medical Assn. has long advocated a separation, saying that the consolidation of the responsibilities of sheriff and coroner is an “immense conflict of interest.”

The New York Times and The Desert Sun found discrepancies when comparing the department’s public death summaries of the 2022 suicides against jail records turned over in civil suits, the video of Upton’s death and information provided by current and former employees.

Mario Solis, who had a history of mental illness, was jailed after a scuffle with a grocery store security guard over a stolen bag of Skittles, according to court records. In September 2022, his mother, Sara Solis, was told that he had died alone in a cell — but not much else. About six months later, she received the department’s summary report.

It included findings from an autopsy conducted days after Solis, 31, died in the mental health unit of the jail in Murrieta. Inside his mouth and throat were two pencils, a toothbrush, a plastic cap and bars of soap, the report said. It also noted cut marks on his arms.

A deputy coroner wrote that Solis had “an unspecified mental health history” and had been prescribed two psychiatric medications.

Sheriff Bianco attributed Solis’s death to suffocation and blood loss after his jugular vein was punctured. He certified the death as an accident.

More than a year later, a lawyer representing the Solis family in a suit against the county received a trove of information the Sheriff’s Department had not previously disclosed. Jail medical staff had treated Solis for schizophrenia, including with antipsychotic medication. On three occasions, he said he was suicidal and talked about stabbing himself with a pencil.

During a chaotic five-month incarceration, he was transferred 10 times among four county jails and did two stints in intensive psychiatric treatment.

From the start, Solis had pleaded for help and medication, his scribbled notes show: “I am not well. Please help me before things worsen,” one read. In another, he requested a psychiatric visit, which was arranged but later canceled.

On Sept. 2, 2022, Solis was ruled incompetent to stand trial and ordered to a hospital for treatment. The next day, he was found unconscious in his cell. He had lacerations on his wrist and neck, a nurse wrote. His neck was red and bruised. His mouth and nose were bloody.

Photos of the cell show flooding from the toilet that soaked books and trash. One wall was filled with erratic writing.

The department’s reports do not explain why Sheriff Bianco determined that the death was accidental.

Bianco has accused media outlets and advocacy groups of misrepresenting the jail deaths to the public, including on his podcast episode on the topic, which was promoted on the department’s social media channels. Without naming names, the sheriff said that a detainee who had died after swallowing objects, including a pencil, had a “propensity to eat things.”

“They suffocated themselves, basically,” Mr. Bianco said. “But we don’t believe it was a suicide.”

In 1,600 pages of jail medical notes, there is no mention of Solis habitually swallowing harmful objects, as the sheriff claimed.

“This is not someone who accidentally died,” Hugo Solis, one of Solis’s brothers, said in an interview. “He killed himself in despair. And the sheriff knows that.”

A forensic pathologist and a medical anthropologist reviewed the coroner’s report for this article. Both said that, aside from the mention of Solis’s psychiatric history and prescriptions, it was unclear whether the coroner staff had reviewed his extensive mental health records or knew about his suicide threats. Both said that information was crucial for determining whether the death was a suicide.

Dr. Judy Melinek, a board-certified forensic pathologist, asked, “Why was he left alone and unsupervised after showing severe signs of mental health deterioration?”

‘It was their job’

Thompson, Alicia Upton’s mother, said she was stunned at how little information the Riverside County Sheriff’s Department would share about her daughter’s death.

For weeks, she said, she struggled to learn even basic details about the events leading up to the suicide. She asked to see any reports and obtain any surveillance video, though she wasn’t sure if she could bear to watch it. But the department declined to provide much of the material she requested.

Thompson sued the Sheriff’s Department last year, saying that it had failed to monitor and protect her daughter. In its response, the county denied that deputies had failed to monitor Upton at the time of her suicide. However, according to two former employees, two jail workers faced discipline for lapses.

When a reporter described to Thompson the footage from the jail cell, she said she had long suspected that her daughter had been desperate for help — but had been ignored.

“It was their job to keep her safe,” Thompson said. “It was their job to monitor her. They didn’t care to do it.”

Christopher Damien is a reporter with the Desert Sun, reporting about law enforcement in Southern California’s inland and desert communities. He is part of The New York Times’ Local Investigations Fellowship. This article is co-published with the Los Angeles Times. Justin Mayo and Ana Facio-Krajcer contributed reporting. Julie Tate contributed research. This article was reported in partnership with Big Local News at Stanford University.

If you are having thoughts of suicide, call or text 988 to reach the 988 Suicide and Crisis Lifeline or go to SpeakingOfSuicide.com/resources for a list of additional resources.

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That includes 216 deaths in custody in San Bernardino County and 226 deaths in Riverside County, according to Inland Empire Lives Lost, a report released in early October by Care First California. 

“Advocates across the state are demanding accountability for in-custody deaths as there is a tendency by law enforcement to downplay or outright deny their role in these deaths,” the report stated.

The authors analyzed public records from the Attorney General’s Office from January 2011 through December 2022.They counted at least 2,312 people who died while in custody in California. About 19% of those deaths occurred in Riverside and San Bernardino Counties, although the Inland Empire makes up about 12% of the state’s population.

Its disproportionate death rate is consistent with a CalMatters investigation by CalMatters reporters Nigel Duara and Jeremia Kimelman. They concluded some of the state’s deadliest jails are in Riverside County and counted 45 people who have died in lockup there since Jan. 1, 2021.

The most dangerous period for inmates is before they get through trial, Care First reported.  Statewide only 14% of deaths happened after sentencing. Nearly a quarter of deaths happened during arrests, and 40% took place during the first week in jail, the report found.

Why is that first week so deadly? 

“When you’re bringing someone in who has documented mental health concerns and they’re put in an isolated and not well monitored cell, the early days of incarceration are vulnerable,” said Marcella Rosen, media coordinator for the nonprofit. 

The Lives Lost report didn’t analyze causes of death because of disputes over how they’re recorded and categorized.

“A lot are listed as natural deaths, and we have problems with that terminology since most deaths are preventable if given proper care,” Rosen said. 

Broadly speaking, people often die in custody from suicide, overdose, disruption of medication or injuries sustained during arrest, she said. 

The organization recommends several ways to prevent those deaths, including ending the cash bail system, enforcing the right to an immediate trial, creating diversion programs for people with mental health or substance use conditions and oversight by coroners who are separate from sheriff’s departments, Rosen said.

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Their fight comes amid a headline-making spike in jail deaths in this sprawling county east of Los Angeles. In 2022, at least 19 people died while held in Riverside county detention facilities, according to California department of justice data. That’s a higher rate of jail deaths than in LA county that year, which had three times as many inmates. Last year, at least 14 people died in the Riverside county detention centers.

But the high number of deaths isn’t the only reason behind the families’ quest. In Riverside county, as in 48 of California’s 58 counties, the coroner’s office is run by the sheriff’s department – the same agency that runs the jails.

That structure, legal experts say, presents at least the perception of a conflict of interest when someone dies in jail, in police custody, or following police use of force.

Many families of people who have died in Riverside county jails agree. That’s because Chad Bianco – the Riverside county sheriff and a rabble-rouser who was once affiliated with the Oath Keepers and recently endorsed Trump by saying “I think it’s time to put a felon in the White House” – has deflected responsibility for the deaths on his watch. When the California attorney general in 2023 announced an investigation into Bianco’s department, he dismissed it as a political maneuver by his detractors in Sacramento. “Every single one of these inmate deaths was out of anyone’s control,” Bianco told Riverside’s Press-Enterprise. “The fact of the matter is that they just happened to be in our custody.”

In another instance, Bianco used his personal Facebook account to respond to an article posted by the Press-Enterprise about deaths in his jails, most of which were due to drug overdoses or suicide. “Did [inmates’ families] ever demand their family members not commit suicide or consume drugs while they were in custody?” he wrote. “Did they ever demand that their family members not commit crimes in the first place?”

And in an interview with the Guardian in March, Bianco doubled down. “It’s not my fault that someone is going [to] extraordinary lengths to smuggle fentanyl into the jail,” he said. “When are we going to say that it’s not the government’s fault or the government’s responsibility to take care of all this?”

Lisa Matus’s son Richard died of a fentanyl overdose at Riverside county’s Cois M Byrd detention center in 2022. The autopsy performed by Bianco’s office ruled Matus had died of a fentanyl overdose. But it also found that his left anterior descending artery, which provides half the heart’s blood, was 80-90% closed. Matus’s family alleges he was not given adequate medical attention while in jail, despite requesting care on multiple occasions.

Richard was awaiting trial with his brother Raymond for attempted murder and attempted robbery when he was found unresponsive in his cell, according to the coroner’s report. Matus said she called the sheriff’s department multiple times to locate Richard’s body but couldn’t get answers until she got an attorney involved.

“How do you trust somebody that’s bashing you [on] social media, but is also in charge of letting us know what happened inside the jail?” she said.

Matus has filed a civil suit against the department, which is ongoing.

When the Guardian asked Bianco about his social media remarks, he softened his stance. He said his comment was not meant to single out Matus or imply she was to blame for her son’s death. If given the opportunity to speak to Matus in person, he said: “I would make it perfectly clear to her that that’s not what I meant. And never would I think or accuse her of that.”

‘Not to satisfy law enforcement but to get to the truth’
If the idea of a law enforcement agency overseeing a coroner’s office sounds unusual, that’s because it is. California is one of just four states that uses a sheriff-coroner system, according to the US Centers for Disease Control and Prevention.

Generally speaking, a coroner is an administrative figure who oversees autopsies conducted by physicians who are also board-certified forensic pathologists. In California, anyone 21 or older with a high school diploma and no felony convictions meets the minimum requirements to become a coroner.

Several experts said allowing law enforcement officials to serve as coroners in their own jurisdictions, as is the case in Riverside, is problematic. “The job of the person doing an autopsy is not to satisfy law enforcement but to get to the truth,” said Thomas Mauriello, a former police officer and federal investigator who teaches at University of Maryland’s department of criminology and criminal justice. Law enforcement agencies and coroners, he said, “should be separate and distinct”.

Marcella Fierro spent 14 years as the chief medical examiner for the Commonwealth of Virginia, and has written extensively on death investigations for the National Academy of Sciences. “Death investigations and forensic science investigations need to be separate from law enforcement, unequivocally,” she said.

Over the years, there’ve been reports about the relationship between sheriff’s departments and coroners impacting investigations elsewhere in the state. In a high-profile California case, two forensic pathologists in San Joaquin county accused their boss, then sheriff-coroner Steve Moore, of meddling in a death investigation that might have implicated his deputies, and resigned. Moore denied the allegations. The San Joaquin county board of supervisors later stripped Moore of his duties, separated the sheriff- coroner office and implemented a new system.

And there’s been research into the topic. A 2023 study by researchers at University of Southern California found that California counties that use a sheriff-coroner system “grossly undercount” deaths involving officers.

The Riverside county sheriff’s department, which oversees 4,000 people incarcerated across five detention facilities, recently faced scrutiny over one such death: Christopher Zumwalt died in 2020 after sheriff’s deputies raided his jail cell with pepper spray and shocked and restrained him, according to recent reporting by the New York Times. The sheriff’s department determined Zumwalt’s cause of death to be cardiac arrest, according to the Times, and the coroner ruled it a justified homicide.

Law enforcement agencies are required to report such incidents to the state. But the Guardian could not find a similar case in the California justice department’s use-of-force database, where the information would ordinarily be.

Bianco did not respond to a request for comment about whether his department reported the use-of-force to the state, or the accuracy of the Times’s reporting.

‘Tired old false argument’
Aided by the ACLU, Matus and other family members of people who died in Bianco’s jails have had some success putting the issue on the agenda of local leaders. In December 2023, Riverside county supervisors Kevin Jeffries and V Manuel Perez authored a proposal to study the separation of the coroner from the sheriff. “While there is no evidence of any improprieties in Riverside county regarding the operations of the coroner’s office under the sheriff,” they wrote, “the optics of a potential conflict of interest can lead to a loss of confidence in our institutions.”

The group that conducted the study ultimately advised against separating the sheriff from the coroner, citing costs.

But Jeffries, Perez and advocates scored a small victory. In March, the board voted in favor of a new arrangement: autopsies for people who die in the county’s detention facilities will be outsourced to neighboring agencies. Luis Nolasco of the ACLU said that’s a step in the right direction, but he worries that law enforcement employees look out for each other regardless of jurisdiction, and “there may be some influencing [between] neighboring counties”.

Bianco bristles at Nolasco’s suggestion. “That’s a tired old false argument,” he said. “There is no law enforcement officer that looks out for themselves.”

The argument over which county coroner examines a body is beside the point, experts say. The real problem is the fact that coroners exist at all. Fierro said coroners typically have limited training and juggle responsibilities with other duties. “This is not a part-time, do-it-on-the-weekend job,” she said. “Coroners should be done away with unless the coroner is an MD.”

Many states, like Virginia, Maryland and Massachusetts, use state-run systems made up of forensic pathologists overseen by medical examiners, who are either physicians, forensic pathologists or both; those systems are not associated with law enforcement agencies.

Some California counties, such as Los Angeles, San Joaquin and San Diego, have medical examiners’ departments that are also separate from law enforcement.

But replacing coroners with medical examiners, in California or anywhere else, is challenging. In the US, there are only about 700 forensic pathologists across roughly 2,400 death investigation systems, according to a 2022 study in the journal Missouri Medicine.

“It’s a very rare career choice,” said J Keith Pinckard, president of the National Association of Medical Examiners. “It is a lower-paying specialty compared to other branches of medical practice,” he said, “and salaries in government may not be comparable to the private sector”.

‘Less headache’
The ACLU of Southern California and the families say they’re not done fighting for the separation of the sheriff and the coroner.

There’s some attention on the issue at the state level, too. California assemblymember Mike Gipson, who in 2021 introduced a bill to separate coroners and sheriffs statewide that failed over budget concerns, says he plans to reintroduce his bill after the November elections, when the state legislature has new members.

The Riverside county sheriff, meanwhile, has his hands full. The California attorney general’s investigation into his department is ongoing. And the department has been under a federal consent decree due to poor jail conditions since 2016, prior to Bianco’s election. Bianco has been working with court-appointed attorneys to comply with the decree, which calls for improvements and better staffing of medical and mental health units, and improved conditions in mental health settings.

Two inmates have died in Bianco’s jails since the Riverside county supervisors’ decision earlier this year to outsource jail death autopsies to neighboring counties. The procedures were done by the San Bernardino county sheriff-coroner’s department; San Bernardino county has not fulfilled a request for autopsy reports.

Bianco said sending the bodies of people who die in his jails out of the county is fine by him. He even said he would be open to having someone else serve as coroner. “Would I be open to less responsibility? Would I be open to less scrutiny? Would I be open to less headache? Would I be open to less calls in the middle of the night? Absolutely,” he said. “Absolutely.”

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