Keith Galen Bach had been dead for several hours. When an investigator from the medical examiner’s office arrived at the Men’s Central Jail after his death last September, the alarm on his insulin pump was still sounding.
According to autopsy findings obtained by the San Diego Union-Tribune and released this week by the medical examiner’s office, the pump likely beeped continuously for about 24 hours, letting Bach, who suffered from Type 1 diabetes, know it was out of insulin.
It beeped at mealtime, when Bach passed his food to fellow detainees because eating without insulin could raise his blood sugar level to dangerous levels. It also beeped when Bach and others in his module repeatedly alerted deputies that the insulin pump was empty.
The response to Bach’s health emergency by San Diego County sheriff’s deputies was so poor that the medical examiner’s office took the unusual step of declaring his death a homicide, citing “negligence.”
“Due to inadequate insulin administration while in custody, Mr. Bach developed diabetic ketoacidosis and died,” the medical examiner’s report said.
“This occurred despite medical records not detailing his medical condition, his need for insulin, when his pump ran out of insulin, and no response to multiple requests for insulin by Mr. Bach and fellow inmates,” it states.
The San Diego County Sheriff’s Office said in a statement that it could not comment on the findings.
“This is an ongoing investigation and it is imperative that we protect the integrity of the investigation,” the statement said. “We offer our condolences to Mr. Bach’s family and those affected by his passing.”
The district attorney’s office said the case is still “under review.” Tanya Sierra, a spokeswoman for District Attorney Summer Stephan, said there was no timetable for filing charges.
But inmate advocates and correctional health experts were shocked by the findings. They said Sheriff Kelly A. Martinez needs to do more to protect those in his department’s custody.
“The description of this death in custody as a result of inaction by prison staff is intolerable,” said Aaron Fisher, one of a group of lawyers. Suing the County Because of the lack of proper healthcare access for people in San Diego County jails.
“No one with diabetes should be denied the insulin or diabetes management tools they need to survive,” Fisher said. “When you deny someone oxygen, they suffocate.”
When it comes to jail deaths, San Diego County has a questionable record.
A State Audit The report, released in early 2022, showed San Diego had the highest death rate among California’s largest jail systems. It documented 185 in-custody deaths between 2006 and 2020.
The report said San Diego County jails are so dangerous that new legislation is needed to bring about reform.
Taxpayers have also suffered losses of millions of dollars due to these deaths.
For example, the county agreed to a settlement earlier this year. $15 million legal settlement With the family of Elisa Serna, who died in 2019 from inadequate medical care inside Las Colinas women’s prison.
Bach, 63, was working as a heating and air technician when he was arrested by Chula Vista police on suspicion of vandalism and making criminal threats on Sept. 25, 2023. Prosecutors never charged him.
He was too sick at the time of his arrest to be held in jail, so Chula Vista police took him to Sharp Mercy Hospital. His glucose levels were high, and hospital staff said his insulin pump was beeping and needed a refill.
Nevertheless, Bach was medically bailed out within 40 minutes and taken to the city’s central prison.
But Bach fainted 90 minutes later while the case was being filed against him. He was taken to the emergency room, where he was treated for diabetes and returned to prison on the morning of September 26.
“Orders were given to continue using an insulin pump, confirm metformin dosage, and continue monitoring blood sugar,” the autopsy findings show.
The autopsy report said Bach cooperated with prison medical staff and allowed nurses to check his glucose level at least six times, and was given 10 units of insulin on the afternoon of Sept. 26.
Just after 1 a.m. on Sept. 27, Bach’s blood sugar level reached a dangerously low 322 mg/dL. According to sheriff’s medical records, Bach declined an offer of 10 units of insulin because he felt the dose was too low.
The autopsy findings stated, “Mr. Bach was finally given 10 units of insulin at 0151, and this was the last documented insulin administration.”
The medical examiner said the nurse had requested a new insulin order with an increased dose, but approval was “pending review.”
Bach was not seen by any medical staff for the next 19 hours, the report said. The records did not make it clear who was responsible for approving the additional insulin recommended by the nurse.
He was found unconscious and not breathing in his cell on the morning of September 28. He was declared dead shortly after 4 a.m.
“Death was caused by complications of a natural disease,” the medical examiner wrote. “However, given the inaction (i.e., neglect) that characterized the events leading up to the incident, resulting in inadequate care … the manner of death is classified as homicide.”
Determinations of homicide due to medical negligence are rare.
Only once in the past two decades has the medical examiner’s office ruled the death of a man in sheriff’s custody a homicide when he was not killed by another inmate or police officers.
In 2022, Lonnie Rupard died in the same prison as Bach.
In that case, the medical examiner said that even though Rupard suffered from schizophrenia and other disorders, his death was a murder Because “the deceased was dependent on others for his or her care.”
Rupard was found in a closet with food smeared on the walls and feces on the floor.
The unit was littered with rubbish and the toilets were filled with faeces and urine. Rupard had lost a third of his weight due to malnutrition in the months before he died.
A wrongful death lawsuit was filed last year by the Rupard family against San Diego County, and has yet to go to trial.
Davis and MacDonald write for the San Diego Union Tribune,
