Inmate died at hands of deputies, coroner rules
The San Francisco Chronicle, September 24, 2010
The San Francisco medical examiner has concluded that a San Francisco jail inmate died at the hands of sheriff’s deputies who twice forcibly restrained him in the minutes before his death last year.
Issiah Downes, 31, was in handcuffs when he went limp and died on Sept. 7, 2009, while being subdued by sheriff’s deputies inside a padded safety cell.
He died of positional asphyxia after the second of two struggles with deputies, the medical examiner’s office found.
The first occurred after Downes became agitated when he was going to be moved to an isolation cell after he grumbled about the television being shut off.
The second happened inside a padded “safety cell” where he had been moved. Deputies reported that other inmates felt threatened by Downes, who was 6 foot 1 and weighed 307 pounds.
Chief Medical Examiner Dr. Amy Hart said Thursday in a statement that Downes’ cause of death “was determined to be probable respiratory arrest during prone restraint, with morbid obesity.”
Hart’s office ruled that the manner of death was homicide but said that the ruling “does not relate to, or make any inference, as to any criminal activity or wrongdoing. It is an indication that, absent the actions of others, Mr. Downes would not have died at the time.”
The incident is under investigation by the San Francisco District Attorney’s office and San Francisco police. No one has been arrested or charged.
It is unclear how many deputies were involved – although the coroner’s report names seven – or whether any charges will be filed against them.
Geri Green, the lawyer for Downes’ family, welcomed the medical examiner’s finding.
“It was ugly,” Green said of the incident. “The medical examiner did a great job. The candor of the office is welcome.”
Eileen Hirst, spokeswoman for Sheriff Mike Hennessey, said the office is “very sorry this death has occurred. We believe all department procedures were followed properly.”
Downes suffered injuries to his neck and back that suggested deputies forced his head down at one point and that deputies had pressed on his back and neck during a struggle with such force that it caused hemorrhaging, the autopsy findings indicate.
None of the deputies interviewed, however, admitted that they ever put pressure on Downes’ back or neck, according to the notes in the case filed by assistant medical examiner, Dr. Judy Melinek.
Witnesses – several inmates and one jail nurse- reported, however, that they saw deputies either “hovering” over Downes or using their knees and their bodies to restrain him during a previous struggle.
Several inmates also told investigators that Downes complained that he was unable to breathe when his head was being held down by a deputy during the fist struggle. They reported that the deputies also kneed him to hold him down during the first struggle.
Among the questions in the case was why a nurse who had heard moaning and murmuring for “quite some time” inside a padded cell and also saw deputies “hovering” over Downes, was not summoned to check on Downes until after he stopped breathing.
Another issue was the lack of a digital record of Downes’ heart rhythm – apparently the machine used by the fire department to revive him was malfunctioning and did not record any data about his heart.
A key witness in the case is a jail nurse, Paula Avery, who said in an interview with Melinek months after the incident that she was concerned because of how long Downes was left moaning inside the safety cell.
It was “quite some time,” she said.
She was not called into the cell until after he stopped breathing, however, and did not intervene earlier. Downes had been in jail at the Hall of Justice since being arrested in March 2009 on allegations of assault and resisting arrest.
He had also been in the jail’s psychiatric ward before his death, authorities said. His mental problems had begun at age 17, and he reportedly had to tried to put his eye out in the past.
Police originally said Downes was causing a disturbance in the jail psychiatric ward and posed a risk to other inmates on the night of his death. Four deputies forcibly moved him to the padded cell – a specially designed space used for inmates deemed to be a danger to themselves or others. At that point, they said, Downes attacked the deputies.
When they removed the restraints, he was comatose. Downes was still handcuffed at the time of his death.
Dennis Damato, who was being held at the time, said he witnessed the first struggle.
“I heard him say, ‘I can’t breathe,’ ” Damato recalled, noting that one deputy “had him in a head lock.” The deputy wrestled the inmate to the ground then other deputies converged on top and held Downes’ legs and arms, according to the inmate’s account. He was then taken to the safety cell, where he died.