Nancy E. O?Malley Office of the District Attorney Kevin E. Dunleavy Ala mada CCU Chief Assistant District Attorney alcoda.org June 17, 2020 Sheriff Gregory Ahern Alameda County Sheriff 5 Department 1401 Lakeside Drive, 12'] Floor Oakland, CA 94612 Dear Sheriff Ahern: Enclosed is the District Attorney?s Report on the in-custody death of Christian Eduardo Madrigal which occurred on June 10, 2019 I have reviewed the?report and agree with the conclusion that the evidence does not justify criminal charges against any law enforcement agency. AS indicated in the report, no further action will be taken in this case. A copy of the report will be available to the public no earlier than ?ve calendar days a?er June 17, 2020. Very truly yours, (C Nancy E. alley Dist?ctA mey Enclosure Ren? C. Davidson Courthouse, 1225 Fallon St., Suite 900, Oakland, Ca. 94612 Phone: (510) 272-6222 0 Nancy E. O’Malley Office of the District Attorney Alameda County District Attorney Kevin E. Dunleavy Chief Assistant District Attorney alcoda.org Date: June 17, 2020 Enclosed is the District Attorney’s Final Report on the in-custody death of Christian Eduardo Madrigal which occurred on June 10, 2019. I have thoroughly reviewed the Report. I concur in the conclusions that the evidence does not support criminal charges being filed against any law enforcement official related to this incident. When there is a death of a person in law enforcement custody, there are serious impacts on the community, on the family and friends of the person, and on the law enforcement officials involved. The Alameda County District Attorney’s Office, and I as the District Attorney, take seriously the need for accountability. As such, it is our legal and ethical obligation to conduct a separate, independent, thorough and impartial investigation into the case. The District Attorney does not take over the investigation. The police agency in whose jurisdiction the in-custody death occurred has that primary responsibility. The police agency’s investigation is reviewed by the District Attorney’s Critical Incident Team, as is all evidence in order for the District Attorney’s Office to render its final decision. After a comprehensive review of all of the evidence gathered by and presented to the Critical Incident Team, there is one question that we, as prosecutors, must answer in the criminal law context: Can we prove beyond a reasonable doubt that any law enforcement official acted unlawfully and in violation of the law? As in every criminal case filed, my prosecutors also consider whether or not a jury of 12 people would convict the person of the potential charges alleged. The suspect’s potential defenses must be considered in that analysis. This legal axiom protects all of our rights against unfair accusations of a crime. There can be confusion about the District Attorney’s role if the law enforcement agency finds that a law enforcement official acted outside of agency policy or used improper tactics. Acting out of policy or using improper tactics are not crimes. Those issues are sometimes determined by a civil action. The standard of proof in a civil trial is much lower than in a criminal trial. The District Attorney’s Office is not making determinations about civil liability. We know that when a person dies in the custody of law enforcement, families are devastated. Family and friends are grieving and the community is in pain. That is why the District Attorney’s Office must adhere to all ethical and legal standards under criminal law as we do in all cases. By doing so, we are upholding our commitment and our sworn duty to protect all members of our community. René C. Davidson Courthouse, 1225 Fallon St., Suite 900, Oakland, Ca. 94612 Phone: (510) 272-6222  askrcd-da@acgov.org DISTRICT REPORT IN CUSTODY DEATH OF CHRISTIAN EDUARDO MADRIGAL NANCY E. District Attorney Critical Incident Team June 17, 2020 INVESTIGATION OF THE IN CUSTODY DEATH OF CHRISTIAN EDUARDO MADRIGAL INTRODUCTION: The Alameda County District Attomey?s Of?ce has assembled a Critical Incident Team. The CI Team consists of experienced Assistant, Senior and/or Deputy District Attorneys as well as experienced District Attorney Inspectors, who are sworn peace of?cers. The CI Team conducts an investigation involving any death of a person in police custody in Alameda County. The CI Team is authorized by agreement with each local law enforcement agency serving Alameda County to conduct a separate, but parallel, investigation into the circumstances leading to the in custody death. The CI Team focuses exclusively on the question of Whether (1) there is evidence that a crime was committed, and (2) there is suf?cient evidence to prove beyond a reasonable doubt that a law enforcement of?cial committed a crime in connection with the in custody death. The CI Team does not examine collateral issues such as whether law enforcement of?cials complied with internal policies, used appropriate tactics, or any issues that may give rise to civil liability. This report should not be interpreted as expressing any opinions on non-criminal matters. The CI Team prepares a report documenting the investigation, factual background, and legal conclusions. The prosecutor supervising the CI Team reviews materials from the investigation and the CI Team report. The case is reviewed by multiple veteran prosecutors, including the Chief Assistant District Attorney and the District Attorney. When the report has been completed and approved, it is delivered to the Chief of Police or Sheriff of the involved law enforcement agency. Thereafter, the report is made available to the public. SCOPE OF THE INVESTIGATION: On June 10, 2019, Christian Madrigal was an inmate at the Alameda County Santa Rita Jail (SRJ). Alameda County Sheriff 3 Of?ce personnel discovered Mr. Madrigal hanging in a cell, with an ankle restraint chain around his neck. ACSO personnel initiated CPR. Mr. Madrigal was transported to a hospital and later died on June 15, 2019. The CI Team was noti?ed of the incident and conducted a parallel investigation. The CI Team reviewed, among other things, ACSO reports, Fremont Police Department reports, San Jose Police Department reports, and Mr. Madrigal?s medical and court records. The CI Team also reviewed the Coroner Investigator?s Report, autopsy protocol, and toxicology report relating to Mr. Madrigal. The CI Team requested and received body worn camera footage captured by FPD of?cers during their various interactions with Mr. Madrigal beginning on June 9, 2019, until the transfer of Mr. Madrigal?s custody to ACSO personnel at on June 10, 2019. Extensive body worn camera footage captured by ACSO personnel of their interactions with Mr. Madrigal at SRJ was also reviewed. In addition, footage from the stationary surveillance camera outside Mr. Madrigal?s cell was reviewed. Lastly, the ACSO ?Restraint Observation Log? pertaining to Mr. Madrigal?s con?nement at SRJ on June 10, 2019 was reviewed. FACTUAL Mr. Madrigal was arrested on June 6, 2019, by SJ PD of?cers after he became disruptive and physically combative with Transportation Security Administration agents assigned to the Norman Y. Mineta San Jose International Airport. This incident is documented in SJ PD report number 191570176. Mr. Madrigal had been brought to the San Jose Airport by family members to put him on a ?ight to Mexico to reunite with other family members. When Mr. Madrigal tried to bypass security without a boarding pass, a violent struggle ensued with TSA, SJ PD, and nearby travelers coming together in an effort to subdue Mr. Madrigal. One of the SJPD of?cers deployed a Taser during the confrontation after Mr. Madrigal attempted to remove another of?cer? 3 ?rearm from its holster. Once Mr. Madrigal? resistance was overcome, he was placed in a WRAP restraint device, strapped to a gurney, and transported by ambulance to Santa Clara Valley Medical Center Emergency Room Mr. Madrigal continued to be combative with medical staff at Eventually Mr. Madrigal was medically cleared for incarceration and transported to the Santa Clara County Jail After booking at SCCJ on multiple felony and misdemeanor charges, Mr. Madrigal was returned to ER for Emergency Services pursuant to Welfare and Institutions Code section 5150. This section permits a person to be held for up to 72 hours for mental health evaluation when the person is a danger to himself or others as a result of a mental health disorder. During the assessment, Mr. Madrigal denied having suicidal thoughts. He was discharged on June 8, 2019, and returned to his family?s residence in Fremont. On June 9, 2019, at 2142 hours, FPD of?cers arrived at the Fremont residence in response to a 911 call by Mr. Madrigal?s stepfather, Witness 1. The incident is documented in FPD report number 190610004. Of?cers met Witness 1 outside the family?s apartment. Witness I explained to of?cers that he called 911 because Mr. Madrigal was acting ?really aggressive, screaming, and throwing things away.? Witness 1 acknowledged that Mr. Madrigal had not made any speci?c threats toward family members and had not stated an intention to harm himself. Nevertheless, Witness 1 requested that of?cers evaluate Mr. Madrigal and place him on a 5150 hold. Before of?cers made contact with Mr. Madrigal inside the apartment, Witness 1 con?rmed to them that Mr. Madrigal had no history of suicide attempts or threats. Witness 1 stated the opinion that Mr. Madrigal?s recent aggressive behavior was attributable to drug use. Of?cers contacted Mr. Madrigal inside the apartment. Mr. Madrigal appeared confused but complied with instructions to exit the apartment and walk down a ?ight of exterior stairs to speak with of?cers. Mr. Madrigal denied engaging in aggressive behavior toward family members and appeared unaware that his behavior was negatively affecting his family. Mr. Madrigal denied any desire to harm himself or others. Mr. Madrigal also denied any past mental illness diagnosis. Mr. Madrigal did admit that he smoked marijuana and ingested mushrooms (psilocybin) within the past week. After an evaluation of Mr. Madrigal, of?cers concluded that he did not meet the criteria for a 5150 hold. Of?cers left the scene after facilitating a family meeting. During that meeting Mr. Madrigal assured of?cers that he would remain calm. On June 10, 2019, at approximately 0543 hours, FPD of?cers were dispatched back to the Fremont residence. Mr. Madrigal was located in the front room of the apartment surrounded by family members. Mr. Madrigal exhibited erratic behavior and was incoherent in his speech. Witness 1 informed of?cers that Mr. Madrigal had been up all night and repeatedly had demanded the keys to the family car so that he could leave. Witness 1 told of?cers that he refused Mr. Madrigal?s demand for the car keys and prevented him from leaving the apartment. Witness 1 repeatedly requested of?cers to return Mr. Madrigal to the hospital. FPD of?cers again concluded that Mr. Madrigal did not meet the criteria for a 5150 hold. Of?cers noted, however, that Mr. Madrigal had red and bloodshot eyes, delayed and lethargic speech, and appeared disoriented. Of?cers escorted Mr. Madrigal out of the apartment. Once 2 outside, Mr. Madrigal began shouting for his mother. Mr. Madrigal?s mother shut and locked the apartment door. Mr. Madrigal repeatedly shouted ?mom!? for several minutes. At one point Mr. Madrigal became silent and stared blankly and intently at a passing helicopter for several seconds before again calling out repeatedly for his mother. Based on Mr. Madrigal?s behavior, objective admission of prior use of hallucinogenic mushrooms, and the statements of Witness 1, the FPD of?cers concluded that Mr. Madrigal was under the in?uence of drugs, a violation of Health and Safety Code, section 11550. Mr. Madrigal was placed in handcuffs and transported to Detention Center in the rear of a patrol car. It was the initial intent of arresting of?cers to release Mr. Madrigal on a citation after booking. While at Detention Center, however, Mr. Madrigal became increasingly uncooperative with FPD jail staff. A jailer attempted to escort Mr. Madrigal to the ?ngerprinting station. Mr. Madrigal pulled away and a struggle ensued. Two jailers ended up on the ground with Mr. Madrigal. The jailers were able to move Mr. Madrigal into a vacant cell. Mr. Madrigal attempted to exit the cell, but the jailers were eventually able to close the cell door. Due to Mr. Madrigal?s inability to comply with the directives of jail staff, the decision was made to transfer Mr. Madrigal to the custody of ACSO at SRJ in Dublin. A group of FPD of?cers later entered the cell to remove Mr. Madrigal. The of?cers used a plastic shield to control Mr. Madrigal while of?cers handcuffed him. Mr. Madrigal was placed in a WRAP restraint device and transported to SRJ by FPD of?cers. The transport was uneventful. The interaction between Mr. Madrigal and FPD personnel while at the Fremont residence, Detention Center, and the transport to SRJ, was captured by multiple body worn camera recordings and surveillance cameras. The District Attomey?s CI Team reviewed these recordings. The FPD of?cers transporting Mr. Madrigal were met at SRJ ?s Intake and Release (ITR) section sally port by several ACSO deputies at approximately 1410 hours on June 10, 2019. Together the FPD of?cers and ACSO deputies removed Mr. Madrigal from the FPD patrol SUV and carried him inside the ITR lobby. The events that transpired at SRJ-ITR are documented in ACSO report number 19- 009845. In addition to a review of that report, the CI Team reviewed ?xed security camera footage from the ITR section and body worn camera footage from multiple ACSO deputies. Mr. Madrigal remained in the WRAP Restraint Device with a spit mask over his head as he was carried into the ITR lobby. The FPD of?cers informed ACSO deputies that Mr. Madrigal was placed into the WRAP Restraint Device due to his combativeness with FPD jail staff. The FPD of?cers also told deputies that Mr. Madrigal was believed to be under the in?uence of psilocybin mushrooms. Mr. Madrigal was cleared for further. incarceration by a Wellpath nurse. At 1415 hours, ACSO Sergeant J. Graham was on scene and directed deputies to move Mr. Madrigal from the ITR lobby to a more secure location. Deputies carried Mr. Madrigal into intake cell R-1 and placed him on the ?oor. From the time of his arrival at SRJ-ITR to the point at which he was placed on the ?oor of cell R-l, Mr. Madrigal was told several times in both English and Spanish to cooperate with deputies. Mr. Madrigal stiffened his body in an effort to resist deputies as they began to remove the WRAP Restraint Device to transition him to waist restraints. At this point one of the deputies suggested that Pro- Straint Restraint Chair be used. Sergeant Graham tasked one of the deputies to retrieve the restraint chair. At approximately 1416 hours, Sergeant Graham contacted Lieutenant C. Cedergren, via hand held radio and requested approval, pursuant to jail policy, for the use of the Pro-Straint Restraint Chair on Mr. 3 Madrigal. Lieutenant Cedergren responded to ITR and spoke to Sergeant Graham. Sergeant Graham expressed the opinion that removing Mr. Madrigal from the WRAP Restraint Device would pose a threat to jail staff. Lieutenant Cedergren proceeded to Mr. Madrigal? cell where he saw Mr. Madrigal on the ?oor in the WRAP Restraint Device. Lieutenant Cedergren asked Sergeant Grahamthere?? referring to the WRAP device. Sergeant Graham replied, ?Not without fighting with him.? Present inside Mr. Madrigal?s cell were Deputies T. Ross, J. Johnson, C. McMann, N. Rhoades, and D. Sides. Alameda County Sheriff Of?ce, Detentions and Corrections Policy and Procedure, Order 8.26, states in part as follows: ?Restraint devices shall only be used on inmates who display behavior which results in the destruction of property or reveal an intent to cause physical harm to self or restraints should be utilized only when it appears less restrictive alternatives would be ine?ective in controlling the disordered behavior. Application of restraint devices shall be approved by the Watch Commander.? In his Supplemental Narrative to ACSO 19-009845, Lieutenant Cedergren articulated the basis for his decision, pursuant to Order 8.26, not to transition Mr. Madrigal from the WRAP Restraint Device to a Pro-Straint Restraint Chair: ?Based upon my observations, and information provided by those present during the incident, I believed the'restraint device present, the Pro-Straint Restraint Chair, as de?ned by the ACSO, and its requested utilization, to be inappropriate given the circumstances known to me at the time. I noted Madrigal, although restrained in a WRAP Restraint Device, had not displayed behavior which could have resulted in the destruction of property, nor revealed intent to cause physical harm to self or others. By ACSO de?nitions, the Pro-Straint Restraint Chair is, ?a chair with equipment designed to restrain, control, and limit the movements of someone who displays hazardous behavior.? I also recognized the need to remove Madrigal from the WRAP Restraint Device to release the FPD of?cers back to service, and to have him further evaluated by California Forensic Medical Group (CFMG) staff.? Lieutenant Cedergren directed the deputies to move Mr. Madrigal to a standing position, to allow for the removal of the WRAP Restraint Device. Handcuffs were placed on Mr. Madrigal?s wrists, which were secured to the rear of his body. Lieutenant Cedergren then applied an ankle chain restraint to Mr. Madrigal?s handcuffs. The ankle chain, also known as a ?leg iron,? is a metal chain with ankle cuffs at each end. The chain was run through the open cuf?ng port and secured to the exterior door knob of the cell. As Deputy Sides began to-remove the WRAP Restraint Device, Mr. Madrigal twisted and tensed his upper body. Deputy Rhoades maintained control of Mr. Madrigal. Once Mr. Madrigal was removed from the WRAP Restraint Device, deputies exited the cell and shut the door. In a later report, Lieutenant Cedergren explained his use of the ankle chain as follows: Prior to removing the WRAP Restrain Device, a set of available Leg Irons were attached to Madrigal?s handcuffs, as I recognized Madrigal?s behavior, volatility, and intentions were unpredictable, and subject to change. By utilizing restraints in this manner, through the open Cell Door Cuf?ng Port, we minimized Madrigal?s movements by utilizing the cell door as a barrier/ shield and limited Madrigal?s ability to kick, resist, or assault us while being secured within Cell R1. This technique also 4 facilitated the removal of the WRAP Restraint Device. It is my understanding that the use of Leg Irons in this manner have been presented in the Core Course curricula for entry-level staff, and have been utilized in other incidents occurring within the After deputies left the cell and shut the door, several commands were given to Mr. Madrigal in both English and Spanish to bend down and extend his hands through the cuf?ng port so that the handcuffs could be removed. The cuf?ng port is an opening in the cell door that allows jail staff to apply or remove an inmate? handcuffs from outside the cell. Use of the cuf?ng port, especially with combative inmates, allows jail staff to more safely remove handcuffs. If an inmate becomes combative once the handcuffs are removed through the cuffing port, the jail staff and inmate are separated by the cell door. This process reduces the risk of injury to jail staff from an inmate, and the risk of injury to an inmate in the process of being restrained. Mr. Madrigal refused to comply with commands to place his hands through the cuffing port. At approximately 1431 hours, Deputy Rhoades attempted to guide Mr. Madrigal?s hands through the cuf?ng port to remove the remaining restraints. Lieutenant Cedergren, Deputy Sides, and Deputy Ross tried to help Deputy Rhoades, but Mr. Madrigal continued to pull away from the cell door. Deputy M. Torres arrived and again instructed Mr. Madrigal several times in Spanish to place his hands through the cuf?ng port. Mr. Madrigal refused to comply as he stared at Deputies Sides and Torres. At that point, Lieutenant Cedergren directed that Mr. Madrigal be left in restraints. Mr. Madrigal remained in the cell, with his hands handcuffed behind his back. One end of the ankle restraint chain was attached to the handcuff chain. The other end of the chain was secured to the exterior door knob of the cell through the cuf?ng port. At approximately 1433 hours, a nurse interviewed Mr. Madrigal to complete the ACSO Intake/Receiving Screening Form. With Deputy Torres providing Spanish translation, the nurse asked Mr. Madrigal several health related questions. Mr. Madrigal denied being under the in?uence of any drugs and denied any mental health or medical problems. In response to the question concerning medical problems Mr. Madrigal replied, only want to go home.? Deputy Torres continued to converse with Mr. Madrigal in Spanish at the cell door and repeatedly directed Mr. Madrigal to place his hands through the cuffing port to allow removal of the handcuffs. Deputy Torres explained to Mr. Madrigal that once he put his hands through the cuf?ng port, the restraints would be removed and he would be able to eat and lay down. Mr. Madrigal continued to refuse to comply with Deputy Torres? directions while repeatedly stating that he wanted to go home. At approximately 1440 hours, Deputy Rhoades began a Restraint Observation Log for Mr. Madrigal at the direction of Lieutenant Cedergren. The form is used to document the application of restraints and the subsequent visual observation of inmates in restraints. The ROL includes the instruction to deputies that ?Observation intervals shall not exceed 1 5 minutes. Observations shall be random.? Pursuant to policy, mental health staff at the jail were also noti?ed of the initiation of the ROL. At approximately 1457 hours, Deputy Torres observed Mr. Madrigal through the cell door window and noted that Mr. Madrigal had moved his handcuffed hands to the front of his body. Deputy Torres again pleaded with Mr. Madrigal to approach the cuf?ng port so the handcuffs could be removed. When Deputy Torres touched the ankle cuffs, Mr. Madrigal immediately took a step back and attempted to use his body weight to pull the ankle restraint chain towards him. Deputy Torres advised Sergeant 5 Graham that Mr. Madrigal had moved his handcuffs to the front and had attempted to pull Deputy Torres? hands into the cell. At approximately 1500 hours, Deputy Torres again observed Mr. Madrigal standing at the window of the cell. Deputy Torres requested that Mr. Madrigal place his hands out of the cuf?ng port. Mr. Madrigal did not comply. The ROL documented a series of visual observations of Mr. Madrigal at approximately 15-minutc intervals. The ROL entries indicated that Mr. Madrigal remained standing. The ROL documented a visual observation of Mr. Madrigal by Deputy Rhoades at 1640 hours. This was the last observation documented on the ROL before Mr. Madrigal was discovered unresponsive at approximately 1720 hours. In a later report, Deputy Rhoades explained that she relocated to another area of the jail for a period of time to assist with arriving inmates. Deputy Rhoades stated the following: About 1700 hours, Deputy Ross informed me there were four (4) transfer buses of inmates waiting to be unloaded on the transfer side. I responded to the transfer side and assisted Deputy Ross and Transportation Deputies with escorting inmates off the bus into their assigned holding cells. Each bus holds approximately 15-20 inmates of different classi?cations. Groups of eight (8) or more inmates of the same classi?cation, or inmates classi?ed as Administrative Separation, require two deputies for movement. Deputy Ross and I assisted in of?oading and escortng approximately 40-50 inmates of varying classi?cations in total. Despite the absence of an entry in the ROL between 1640 hours and when Mr. Madrigal was found nonresponsive at 1720 hours, Lieutenant Cedergren wrote in his report that he had contact with Mr. Madrigal at 1650 hours. In Lieutenant Cedergren?s Supplemental Report he states: approximately 1650 hours, after attending to other functions as required in ITR, I returned to Cell R1, and observed Madrigal standing at the cell door. Madrigal placed his hands, now positioned in front of his abdomen, although previously positioned behind his back, in the inner edge of the Open cuf?ng port. As I prepared to remove the restraints, believing Madrigal was cooperating in the removal of them, he pulled his hands back. I continued my walk-through and visual observations of the immediate The CI Team reviewed footage from the surveillance camera located outside of Cell R-l. The time stamp on the surveillance footage appears to be approximately 25 minutes ahead of the actual time. The footage shows a deputy checking on Mr. Madrigal and making an entry on the log at approximately 1736 hours. Approximately a minute later, another deputy checks on Mr. Madrigal and looks into the cell. Approximately ?ve minutes later, the footage shows Lieutenant Cedergren checking on Mr. Madrigal. For the next six minutes, at various times Mr. Madrigal can be seen through the cell window in a standing position. Thereafter, and for approximately four minutes, movement inside the cell can be seen through the open cuf?ng port. Beginning at approximately 1700 hours, no further movement is seen through the cuf?ng port. At approximately 1712 hours, the footage depicts a deputy brie?y in the area outside the cell, but the deputy does not appear to make any observations into Mr. Madrigal?s cell. 6 At approximately 1720 hours, Lieutenant Cedergren walked towards Cell R1 to observe Mr. Madrigal. As he looked into the cell through the window he saw Mr. Madrigal seated with his upper body against the cell door. Mr. Madrigal?s hands were on the right side of his chest. Lieutenant Cedergren attempted to communicate with Mr. Madrigal but he did not respond. Lieutenant Cedergren opened the cell door to ?lrther assess Mr. Madrigal as Deputies Ross and Rhoades stood by. As stated by Deputy Rhoades in her Supplemental Report: ?About 1721 hours, I was walking from the transfer side of ITR towards the intake side. As I turned the corner, I saw Lieutenant Cedergren and Deputy Ross standing outside the door of cell R-l. As I approached, I heard Lieutenant Cedergren attempting to talk to MADRIGAL, saying, ?Hey, wake up.? Lieutenant Cedergren opened the cell door of R-1 and I saw MADRIGAL sitting against the cell door. MADRIGAL was slumped down and I immediately saw the chain of the ankle restraints wrapped around his neck. hands were stillin handcuffs and up near the right side of his head.? Lieutenant Cedergren lifted Mr. Madrigal from the seated position and removed the loop of chain from around his neck. Deputies Ross and Rhoades assisted removing the handcuffs from Mr. Madrigal and placing him in a supine position on the ?oor. Lieutenant Cedergren requested a Code 3 Medical Response to ITR and started CPR. Deputy Rhoades retrieved an Automated External De?brillator attached it to Mr. Madrigal, and activated it. Lieutenant Cedergren continued CPR on Mr. Madrigal until relieved by nursing staff. At approximately 1734 hours, Alameda County Fire Department personnel arrived and continued resuscitation efforts. Mr. Madrigal was intubated and transported by ambulance to Stanford Valley Care Hospital in Pleasanton. Mr. Madrigal was seen in the Emergency Department of Valley Care where he presented with a chief complaint of strangulation. The ED doctor noted a liver laceration on his work-up. Mr. Madrigal was referred to Eden Medical Center the nearest regional trauma center. Mr. Madrigal arrived by ambulance at EMC on June 10, 2019, at approximately 2107 hours. He was admitted to the Intensive Care Unit The ICU trauma surgeon on duty performed emergency assessment, trauma evaluation, and critical care management of Mr. Madrigal. The trauma surgeon found Mr. Madrigal?s airway compromised. Mr. Madrigal. was re-intubated by the trauma anesthesiologist to ensure a secure airway. Thereafter, Mr. Madrigal was found to be breathing spontaneously, without paradoxical chest wall motion. During a physical examination, multiple bruises were noted to Mr. Madrigal?s right arm, left hip, legs, back and shoulder. A contusion and abrasions were observed across Mr. Madrigal?s anterior neck. Computerized tomography scans detected mild left hepatic liver lacerations with mild perihepatic hemorrhage and trace pneumoperitoneum. Also detected was a mild splenic laceration with a small volume of perisplenic hemorrhage. Probable pulmonary contusions in the left lower lobe and lingual were also noted. Mr. Madrigal was admitted to EMC for ongoing acute care with a primary diagnosis of strangulation, with evidence of assault. Despite supportive therapy, Mr. Madrigal progressed to brain death from anoxic brain, acute respiratory failure. AUTOPSY PROTOCOL: An autopsy was performed on the body of Mr. Madrigal at the Coroner?s Bureau on June 18, 2019, by Dr. Angellee Chen. Dr. Chen made ?ndings of hanging based on a patterned ligature mark around Mr. 7 Madrigal?s neck, small focus of hemorrhage within the soft tissues of the lower anterior neck, and a history of anoxic encephalopathy. Other injuries noted by Dr. Chen were abrasions on Mr. Madrigal?s wrists consistent with handcuff marks, multiple small contusions of bilateral upper and lower extremities, and a small capsular tear of the spleen. During the internal examination Dr. Chen noted possible remote fractures of the anterior aspects of the right and left 5th ribs. A small amount of bloody ?uid was observed in the peritoneal cavity. At the time of autopsy several organs had been harvested previously by Donor Network West with Dr. Chen?s permission. These organs were the heart, lungs, trachea, liver, gallbladder, spleen, both kidneys, pancreas, and both adrenal glands. Dr. Chen determined the cause of death as anoxic encephalopathy due to hanging. CORONER NARRATIVE SUMMARY: ACSO Coroner?s Deputy Jeff Hovda was assigned to complete a report on Mr. Madrigal?s death. Deputy Hovda accompanied Dr. Chen to EMC on June 15, 2019, to view and photograph Mr. Madrigal?s body before any organ donation procurement. During the examination Deputy Hovda and Dr. Chen saw ligature indenture marks around Mr. Madrigal?s neck and other various scrapes and bruises present on his body. According to Deputy Hovda?s report, the scrapes and bruises did not appear to have any contributory factor in his death as most appeared to be old and in the healing process. Thereafter, Dr. Chen was summoned by Donor Network West to attend Mr. Madrigal?s organ procurement. Prior to the procedure, Dr. Chen stated that when she examined and photographed Mr. Madrigal?s liver she did not see any injuries to the liver that would have caused Mr. Madrigal?s death. Dr. Chen authorized the donation of Mr. Madrigal?s liver along with other organs. At the conclusion of his investigation, Deputy Hovda determined the manner of Mr. Madrigal?s death to be suicide. Deputy Hovda?s ?ndings were based on his investigation which included the cause of death given by Coroner?s Pathologist Dr. Chen, video footage showing Mr. Madrigal as the sole occupant of a jail cell with a chain ligature around his neck, ACSO reports, and statements made by Mr. Madrigal?s stepfather concerning Mr. Madrigal?s mental health prior to his death. Deputy Hovda further observed that Mr. Madrigal had no other contributory injuries to his person, excluding the ligature marks on his neck. As such, according to Deputy Hovda, it did not appear Mr. Madrigal was the Victim of an assault. TOXICOLOGY REPORT Blood samples collected from Mr. Madrigal were submitted to Alere Forensics at Redwood Toxicology Laboratory for drug screen classi?cation and analysis. Marijuana metabolite was detected during the initial screen and con?rmed. No other common drugs were detected. According to Alere Forensic?s toxicology report, testing for psilocybin/psilocin (mushrooms) is a separate test and was not covered in the service request submitted for Mr. Madrigal?s blood samples. Scienti?c literature reviewed by the CI Team revealed that the detection window for psilocybin through a blood test requires that the blood draw occur within hours after use. LEGAL ANALYSIS: To prove the crime of involuntary manslaughter in violation of Penal Code Section 192(b), the People must prove beyond a reasonable doubt that: A person had a legal duty to the decedent; (2) The 8 person failed to perform that legal duty; (3) The person?s failure was criminally negligent; and (4) The person?s failure caused the death of the decedent. Penal Code Section 192(b); CALCRIM No. 582. A legal duty to render aid is imposed when a special relationship exists between the decedent and the defendant. People v. Montecino (1944) 66 Cal.App.2d 85. Such a special relationship exists, and a duty is imposed, when a jailer takes custody of a suspect. Lum v. County of San Joaquin (2010) 765 F.Supp.2d 1243; Girardo v. California Department of Corrections and Rehabilitation (2008) 168 Cal.App.4th 231. This duty is codified in California Government Code Section 845.6. Criminal negligence involves more than ordinary carelessness, inattention, or mistake in judgment. A person acts with criminal negligence when: (1) He or she acts in a reckless way that creates a high risk of death or great bodily injury; and (2) A reasonable person would have known that acting in that way would create such a risk. CALCRIM No. 581. A person acts with criminal negligence when the way he or she acts is so different from the way an ordinarily careful person would act in the same situation that his or her act amounts to disregard for human life or indifference to the consequences of that act. Id. The California Supreme Court, in initially de?ning criminal negligence, explained how criminal negligence differs from civil negligence: ?[T]here must be a higher degree of negligence than is required to establish negligent default on a mere civil issue. The negligence must be aggravated, culpable, gross, or reckless, that is, the conduct of the accused must be such a departure from what would be the conduct of an ordinary prudent or careful [person] under the same circumstances as to be incompatible with a proper regard for human life, or, in other words, a disregard of human life or an indifference to the consequences.? People v. Penny (1955) 44 Cal.2d 861, 879. An act causes death if the death is the direct, natural, and probable consequence of the act and the death would not have happened without the act. CALCRIM No. 582. In this case, there is no dispute that ACSO had a legal duty to use reasonable care in caring for Mr. Madrigal. The evidence indicates shortcomings in the care provided by ACSO personnel. The use of the ankle restraint chain to help control Mr. Madrigal while deputies removed the WRAP device does not appear unreasonable. The decision to leave Mr. Madrigal secured to the restraint chain, unattended, is concerning. CI Team members familiar with custodial practices indicated that, leaving a handcuffed inmate chained to a ?xed object is not a regular occurrence and does not represent best practices. Leaving an inmate unattended in this manner creates a risk that the inmate could become entangled in the chain or use the chain to attempt suicide. In this instance, ACSO personnel did not leave Mr. Madrigal restrained as any kind of punitive measure. Rather, ACSO personnel repeatedly attempted to persuade Mr. Madrigal to put his hands through the cuf?ng port so that the restraints could be removed. Mr. Madrigal had been combative with jail staff at FPD. And during the removal of the WRAP device at SRJ, Mr. Madrigal twisted and tensed his body, indicating that he could again become combative with jail staff. It was not unreasonable for ACSO personnel to utilize the cuf?ng port to remove the restraints, rather than re- entering the cell to remove them. The latter approach risked injury to ACSO personnel and Mr. Madrigal if he became combative while being unhandcuffed. The evidence in this case does not indicate that ACSO personnel were indifferent to Mr. Madrigal?s well-being. After Mr. Madrigal refused requests to put his hands through the cuf?ng port, ACSO facilitated further assessment of Mr. Madrigal by a nurse. Deputy Torres assisted by providing Spanish 9 translation. During the assessment, Mr. Madrigal did not express any suicidal indications. Deputy Torres explained to Mr. Madrigal that if he put his hands through the cuf?ng port, the restraints would be removed and Mr. Madrigal would be able to eat and lay down. ACSO personnel properly initiated a ROL and followed policy by notifying mental health staff at the jail. ACSO personnel neglected to make timely observations of Mr. Madrigal pursuant to the ROL after Lieutenant Cedergren last'checked on Mr. Madrigal at approximately 1655 hours. Prior to this lapse in observation, ACSO personnel were diligent about making timely observations. From the video footage, it appears that Mr. Madrigal ended up strangled by the restraint chain within an approximate ?ve to 10 minute period after Lieutenant Cedergren last checked on him. It is unknown whether a more timely discovery of Mr. Madrigal would have changed the outcome. Accordingly, it cannot be proven beyond a reasonable doubt that lapse in timely observations legally caused Mr. Madrigal?s death. The lapse in timely observation does not appear to have been motivated by any deliberate disregard or indifference to Mr. Madrigal?s well-being. Deputy Rhoades explained that she temporarily left the area where Mr. Madrigal was housed in order to assist with the arrival of numerous inmates at the jail. Moreover, although ACSO personnel initiated a ROL, there was no information provided to ACSO to indicate that Mr. Madrigal was suicidal. The evidence is insuf?cient to prove beyond a reasonable doubt that Mr. Madrigal?s death was reasonably foreseeable under the circumstances. Under the speci?c facts of this case, there was never a time when either Mr. Madrigal?s family, medical providers, FPD of?cers, FPD jail staff, or members of ACSO at SRJ had notice that Mr. Madrigal was in any way contemplating doing harm to himself. Indeed, records of recent treatment of Mr. Madrigal established that Mr. Madrigal adamantly denied current thoughts of suicidal or homicidal ideations or past suicide attempts. As part of this investigation, the CI Team examined evidence in an attempt to determine how Mr. Madrigal received internal injuries to his spleen and liver. The pathologist determined that these injuries did not contribute to Mr. Madrigal?s death. Nevertheless, any evidence of excessive force by law enforcement is relevant in determining whether other acts or omissions by law enforcement rose to the level of criminal negligence or malice. Medical records described Mr. Madrigal?s internal injuries as ?mild.? Indeed, the lacerations were not signi?cant enough for the spleen and liver to be rejected by Donor Network West for organ procurement. There was a violent struggle between Mr. Madrigal, SJPD of?cers, TSA agents, and civilian passengers at the San Jose Airport on June 6, 2019. Mr. Madrigal was then in the custody of SCCJ personnel for a period of time. It is unknown whether Mr. Madrigal was involved in any physical altercations after his release from the 5150 hold until his arrest by FPD of?cers on June 10th. FPD jail staff used force to restrain Mr. Madrigal and move him into a vacant cell. Other FPD personnel later used force to remove Mr. Madrigal from the cell and apply the WRAP restraint device. A review of the PD surveillance footage, as well as body camera footage, does not reveal any unreasonable use of force. ACSO personnel at SRJ also used force to restrain Mr. Madrigal while they removed the WRAP device and transitioned him to handcuffs tethered by the ankle restraint chain. Again, a review of the SRJ surveillance footage, as well as body camera footage, does not reveal any unreasonable use of force. 10 It appears there were multiple occasions over a period of several days when Mr. Madrigal?s internal injuries may have occurred. However, the evidence does not indicate that FPD or ACSO personnel applied unreasonable force or were criminally negligent in the application of force. Mr. Madrigal?s death is tragic and admittedly concerning. ACSO personnel left Mr. Madrigal unattended and tethered with an ankle restraint chain. Thereafter, in certain instances, ACSO personnel neglected to check on Mr. Madrigal as required by the ROL. However, criminal liability for involuntary manslaughter requires more than mere negligence. To establish the crime of involuntary manslaughter, the evidence would need to prove beyond a reasonable doubt that the acts or omissions evidenced a disregard of human life or an indifference to the consequences of the acts or omissions. In this matter, the evidence is insufficient to prove criminal negligence beyond a reasonable doubt. CONCLUSION: A prosecutorial decision must rest squarely on the ability to establish the elements of a crime beyond a reasonable doubt in a dispassionate manner, even in the face of an unintended tragedy such as this one. Applying the high charging standards by which the District Attorney?s Office is ethically bound, we can only conclude that the ACSO personnel involved in this incident are not criminally liable. We will take no further action in this matter. 11