A Sacramento man suffering from a drug overdose was neglected by a police officer, medical workers and sheriff’s deputies over the course of more than two hours before he died at a county jail last May, according to reports from court-appointed monitors.
That man, David Kent Barefield Sr., 55, was among seven detainees the Sacramento County Sheriff’s Office reported dying at its facilities last year — and one of three who died at its main jail in the span of about a month.
Jail staff members claimed he was faking illness, and the Sheriff’s Office told the California Department of Justice that his death was from natural causes. But an autopsy by the county Coroner’s Office found he had overdosed on methamphetamine and fentanyl.
Like many jails and prisons across the country, those in Sacramento County have been faulted for inadequate medical care in recent years. Details of Mr. Barefield’s last hours were captured on jail video footage, which has not been publicly released but was viewed by lawyers appointed to monitor conditions at the county jails as part of a 2020 consent decree in a federal lawsuit.
The lawyers’ report described a culture of neglect for detainees in the jail system. Two medical experts, also assigned to track compliance with court-ordered reforms, asserted that there was misconduct by police officers, sheriff’s deputies and jail medical personnel in handling Mr. Barefield and others who died.
“Review of these deaths showed serious system and individual performance issues, including inadequate emergency response, inadequate medical care prior to death, and in one case, callous deliberate indifference to a man who was so obviously gravely ill that even a lay person would see that the patient needed emergent care,” the medical experts wrote.
The footage — showing Mr. Barefield seemingly unable to sit, stand or lift his head, incoherent and at times passed out — was particularly troubling, according to the court-appointed monitors. The lawyers recounted the details in a letter to Sheriff Jim Cooper obtained by The New York Times and The Desert Sun. The medical experts described it in a report filed with the U.S. District Court for the Eastern District of California last week.
Officials from the three agencies that had contact with Mr. Barefield at the jail declined to respond to questions about the circumstances of his death and any lapses in his care.
The Sacramento Police Department requires officers to oversee arrestees until another agency takes custody, and to transport them to the hospital if needed. The Sheriff’s Office — which said it had done a full investigation of the matter but has not released any of its findings — asserted that Mr. Barefield was only its responsibility for 15 minutes, after his booking process was complete. Both the Sheriff’s Office and the health agency supervising the jail’s medical staff said they made changes to the intake process but did not provide details.
Mr. Barefield, who was homeless and had a history of drug abuse, was handcuffed, pulled from a police car and brought to Sacramento’s main jail around 1 a.m. on May 12, accounts from the lawyers and medical experts note. A police officer had dragged him about 100 feet over the concrete floor of the parking garage to get to the jail entrance, according to an attorney representing the dead man’s relatives in a lawsuit. The family did not respond to requests for comment for this article.
The police department said Mr. Barefield had been arrested on theft and trespassing charges, but would not provide more details.
Once Mr. Barefield was inside, a certified nursing assistant had difficulty checking his vital signs, and should have alerted a registered nurse to examine him but did not make that request, the medical experts wrote. As Mr. Barefield lay on the floor for several minutes, the nursing assistant and the arresting officer did not attend to him.
The officer “reportedly told health care staff that the patient had been able to walk at the time of arrest but was now ‘playing possum,’” wrote the medical experts — a nurse practitioner and a registered nurse who are both experienced in working in correctional institutions.
Mr. Barefield was soon placed in a cart that is normally used to restrain combative detainees. At around 2 a.m., the medical experts and lawyers said, a nurse cleared him to be held at the jail but failed to complete a medical screening and later falsified his intake papers.
The medical experts, who did not respond to requests for comment, noted in their report that the police should have taken Mr. Barefield directly to a hospital rather than to the jail. The report also said that nurses and sheriff’s deputies should have recognized that he was in dire need of medical care.
Deputies took him out of the cart at about 3:30 a.m., carrying and dragging him to be photographed and fingerprinted. “Stop playing games!” one of them yelled, according to the lawyers.
Two of the lawyers — who work with the Prison Law Office, a nonprofit legal group representing detainees in the federal court case — described Mr. Barefield’s condition in an interview.
“He was near death and completely incapable of engaging throughout the interaction,” said Margot Mendelson, one of the lawyers. “He was not treated like a person who needed care. This should have been the moment to help save his life.”
“He is not standing at any point,” said Patrick Booth, another of the lawyers. “They’re pulling him by the biceps about 30 or 40 feet. His pants had come down. He’s completely exposed.”
Mr. Booth said the footage showed the deputies lifting Mr. Barefield’s head up by the hair, his body on the floor, while taking booking photos from different angles
While he mumbled occasionally throughout the encounter, the lawyers said he made his only discernible comment while being photographed: “I am Jesus Christ.”
Minutes later, a Sheriff’s Office sergeant observed that the man appeared to be unconscious and asked the nurse to confirm he had been cleared medically for booking. All the accounts say the nurse claimed that the man’s vital signs had been normal, adding, “He’s just old and homeless.” The nurse then left the area.
Deputies began checking Mr. Barefield’s pulse, calling for backup and eventually starting chest compressions at 3:46 a.m. A nurse’s note in the family’s lawsuit says Mr. Barefield received overdose medication, though the other accounts do not include that detail.
Mr. Barefield was pronounced dead about 30 minutes later.
His relatives sued the county, the Sheriff’s Office, the City of Sacramento and its police department in December, claiming he was not provided medical treatment and seeking damages.
The two nursing experts warned of serious consequences elsewhere for such lapses.
“In similar cases across the country,” they wrote, “nurses who falsified medical records and jeopardized patient safety have lost their license, and in some cases, were charged and convicted of felonies for patient endangerment.”
They noted that the nurse who faked Mr. Barefield’s intake papers faced disciplinary action, was reported to the California Board of Registered Nursing and resigned.
While Mr. Barefield was technically in the custody of the arresting officer until the jail booking was complete, the Sacramento Police Department said there was no need to investigate further. “It would not be customary for our department to conduct an administrative review, as Mr. Barefield did not die in our custody.”
The federal consent decree requires the Sheriff’s Office to provide timely medical care and improve its investigations of in-custody deaths. The lawyers involved in monitoring the jail said they continued to have concerns.
“The Sheriff must take accountability for the apathy and callousness that pervades the jail and exercise leadership to make immediate changes,” they wrote in their letter to Sheriff Cooper. “Sacramento County should demand decency for the people it incarcerates.”
