California agency tasked with scrutinizing jail deaths hasn’t completed a single review

A state office created in 2024 to scrutinize local investigations into jail deaths has yet to complete a single review of the more than 150 people who have died in custody in California’s county jails over the past year-and-a-half.

That’s because it hasn’t received the records needed to fully analyze the deaths, according to the Board of State and Community Corrections, a regulatory body appointed by the governor to oversee the state’s jails and juvenile halls.

SB 519, signed into law in October 2023, established the In-Custody Death Review Division within the BSCC following a series of deadly years in San Diego, Riverside and Los Angeles county jails.

But the new law’s limitations quickly became apparent once the division began collecting data on deaths that occurred after its formation in July 2024. The initial information submitted by counties lacked sufficient detail, with the majority of the means and manners of death listed as “pending investigation.”

Such internal investigations can take months — sometimes even years — to complete.

In early discussions, the counties made it “clear they would not send nonpublic information,” such as medical records or investigatory materials, according to Jana Sanford-Miller, a spokesperson for the BSCC.

“Some agencies did not send records, and others sent redacted records,” Sanford-Miller said. “We have yet to receive a completed investigation for an in-custody death in a local detention facility.”

As a result, it hasn’t completed any review, though there is hope that will change soon.

Late last year, the BSCC worked with the governor’s office, the Legislature and the Department of Finance to add language to a trailer bill hitched to the 2025-26 budget that clarified that ICDR’s director and employees can have full, unredacted access to investigative records, including medical information that would otherwise be protected under federal privacy laws.

Allison Ganter, appointed by Gov. Gavin Newsom to a six-year term as the division’s director in October 2024, stressed in a statement that her office is “committed to conducting meaningful and transparent reviews of deaths that occur in local detention facilities.”

“Families experience unimaginable pain when their loved ones die in custody, and that pain is magnified when questions about their death go unanswered,” she stated. “Our goal is to understand why people die in custody, make recommendations to prevent future deaths, and share our findings to drive systematic change in local detention facilities.”

A spokesperson for Newsom’s office declined to comment.

Original bill touted

Newsom, in response to questions in early 2024 from CalMatters about high statewide jail deaths, touted signing the legislation, saying it would create “a point person specifically responsible for overseeing what’s happening in county jails” who would work with California Attorney General Rob Bonta’s Office to advance Department of Justice investigations into the deaths. Bonta had sued Riverside County in 2023 and later would sue Los Angeles County in 2025 over “inhumane” jail conditions.

The ICDR, however, is “not currently working with the Attorney General’s office on in-custody deaths,” according to Sanford-Miller.

Advocates and the families of the deceased have called for independent review of in-custody deaths for years. Official autopsy reports — one of the few publicly accessible records prior to SB 519’s passage — typically do not factor in the quality of medical care or how conditions within the jails may have contributed to an inmate’s death.

Last year, the Southern California News Group analyzed more than a thousand pages of lawsuits, audits, coroner reports and investigative reviews. The review found that someone died in custody in the jails of Los Angeles, Orange, San Bernardino and Riverside counties every five days on average and detailed instances of institutional neglect and failed supervision.

In one example, a 61-year-old man was listed as dying of “multiple organ failure” and heart disease in March 2023 by the Los Angeles County Medical Examiner’s Office, yet a review by an oversight agency found that he had presented with hypothermia and a body temperature of 87.6 degrees after heating systems failed in Los Angeles’ downtown jails.

In Riverside County, the cause of death for an inmate who died in 2020 was listed as acute methamphetamine intoxication even though he had been violently subdued by a team of correctional deputies inside a cell at the Larry D. Smith Correctional Facility in Banning two days before he died.

The four counties had nearly 500 deaths from January 2020 to the end of 2025. Two-thirds of those who died had not been convicted of anything.

Some families are forced to turn to lawsuits and even commission independent autopsies to try to get answers.

“So many of the families that are impacted by these jail deaths have to spend their whole lives, have to spend every waking moment, doing their own investigations,” said Nick Shapiro, a UCLA assistant professor who studies Los Angeles County’s jails.

Law is ‘clawless’

There was “cautious excitement” when SB 519 was introduced, but the law, as written, is “clawless” when it comes to holding counties accountable, Shapiro said. An early version would have given county supervisors the authority to strip control of jails away from sheriff’s departments that failed to address problems by instead creating a separate county Department of Corrections and Rehabilitation.

That language never made it out of the Senate.

Under the final version, the ICDR Division can review investigations into deaths — rather than investigating a death itself — to evaluate a law enforcement agency’s performance and can consider “the circumstances prior to, during and after the in-custody death incident” as part of that evaluation, according to a September 2025 fact sheet. It can then make recommendations to the agency for improvements, report its findings publicly, use that information to find jails “out of compliance” with the state’s Welfare and Institutions Code and even call police chiefs and sheriffs to answer before the Board of State and Community Corrections.

But it can’t force sheriff’s departments to adhere to those recommendations and there is no enforcement mechanism described if an agency refuses to turn over the records the ICDR relies upon.

If the state wants actual oversight and accountability, the ICDR needs subpoena power and the authority to conduct its own investigations by interviewing witnesses, reconstructing timelines and commissioning independent autopsies, Shapiro said.

“I hope Sacramento can get it to together to make this use of taxpayer money meaningful,” he said.

Oversight without enforcement

California has a long history of creating oversight bodies without sufficient powers to carry out their mandates, said Marcella Rosen, a media coordinator for the Care First California Coalition, a group of community organizations that, among other reforms, is pushing for the closure of Men’s Central Jail in Los Angeles County.

“I think it was set up to fail, from our perspective of actually saving lives,” Rosen said of the ICDR. “Oversight bodies that aren’t given enforcement powers are extremely limited.”

Some, such as oversight commissions in Los Angeles County, even have subpoena powers, yet still have to fight to get records from county departments.

But even without subpoena power, the ICDR could do more to shine light on jail deaths, Rosen said. The California Department of Justice has decades of data on in-custody deaths that could be analyzed to identify trends. The records that sheriff’s departments and medical examiners must release publicly, while limited, could still provide fodder for analysis, Rosen said.

First reports coming

Following the changes to state law and a budget increase, ICDR now hopes to publish its first public reports in the second quarter of 2026.

California doubled the ICDR’s funding to nearly $5.4 million and authorized up to 25 positions in the current fiscal year. The additional money will allow it to hire staff with medical and behavioral health backgrounds to review deaths from those perspectives.

After the trailer bill passed, ICDR immediately began requesting new information from the county agencies that will allow it to “conduct initial facility operational reviews of in-custody deaths, analyze the updated data, build publicly available data dashboards, and begin trend analysis,” according to Sanford-Miller, the BSCC spokesperson.

While there has still been “some hesitancy to share sensitive information” during conversations with local agencies, the ICDR hasn’t experienced actual “resistance” yet, Sanford-Miller said.

It is still in the process of completing the new records requests to California’s 58 counties.

“Incomplete records will impact the timing of our reviews, especially in complicated cases,” she said. “When we have a complete picture of the records we’ll be receiving and reviewing and better understand when those records will be submitted after a death, we will create a process in which initial reviews in these complicated cases can be completed and perhaps inform initial recommendations before the investigation is fully complete.”