OCDA Investigative Report_pdf.REDACTEDNAMEONLY.TBC

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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 which she did. c.o. Fernandez acted in accordance with her legal responsibilities by immediately requesting emergency medical aid and attempting to free from the ligature wrapped around his neck. SAPD medical staff arrived within seconds and assisted c.o. Fernandez in freeing 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 Based on the evidence collected and statements made by responding medical personnel, it appears likely that had died prior to c.o. Fernandez discovering him unconscious hanging inside his cell. In support ofthis conclusion, one of the first nurses to respond to cell at 1:36 a.m. described to investigators that 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 had no pulse or respirations and had a blood oxygen level of 48%. At 1:48 a.m., OCFA paramedics arrived and confirmed that was not breathing, and had no pulse or blood pressure. Thereafter, was transported to the OCGMC emergency room and continued to receive medical treatment. Such treatment was unsuccessful, and was officially pronounced dead at 215 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 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 culpabfe for death. With respect to c.o. Valenzuela, while there is evidence that she breached her legal duty of care to 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 reasonabie 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 "l :14 a.m.in accordance with SAPD protocol. Had attempted suicide during this timeframe, criminal responsibility would potentially lie with her. However based on the surveillance video recordings and 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 ") :35 a.m. lt is possible that welfare checks conducted prior tol:14 a.m. would have revealed evidence that was preparing to commit suicide. It is equally possible that made no preparations until after he was observed on surveillance video at 116 a.m. Ultimately, both theories are speculative, and lack evidentiary support. Consequently, evidence of a causal connection between the absence ofearlierwelfare checks and suicide sufficient to prove criminal responsibility beyond a reasonable doubt is lacking. This determination is not a referendum on potential civiloradministrativeliabi!ity. Again,suchevaluationsarebeyondthescopeofthisinvestigation. Rathersolelyforcriminal liability purposes, there is insufficient evidence to establish that had c.o. Valenzuela conducted welfare checks in accordance with protocol, it would have prevented suicide. CONCLUSION Based on all the evidence provided to and reviewed by the OCDA, the evidence shows that died by suicide as a result of aligature hanging. Pursuant to applicable legal principles, it is our conclusion that there is 7