ADMINISTRATIVE INVESTIGATION
CONFIDENTIAL
#19-038
Subject:

Craig Cedergren, Lieutenant, ACSO (

)

Representative:

Mike Rains, Rains Lucia Stern St. Phalle & Silver, PC

Witness:

Chris Comfort, Deputy Sheriff, ACSO

Witness:

Chris McMann, Deputy Sheriff, ACSO (

)

Witness:

Nikki Rhoades, Deputy Sheriff, ACSO

)

Witness:

Tiffiny Ross, Deputy Sheriff, ACSO (

Witness:

Anastasia Salazar, Deputy Sheriff, ACSO (

Witness:

Johnnie Graham, Sergeant, ACSO (

Witness:

Kevin Estep, Sergeant, ACSO

Witness:

Justin McComas, Lieutenant, ACSO (

Witness:

Derrick Hesselein, Captain, ACSO (

Witness:

Donald Mattison, Captain, ACSO (

Complainant:

Internal

Investigator:

Mark Pickett, Sergeant, ACSO (

Date:

June 30, 2019

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 SUMMARY OF COMPLAINT
On Monday, July 15, 2019, I was assigned this Internal Affairs investigation by Captain
Emmanuel Christy. The complaint was regarding an attempted suicide at the Santa Rita Jail
(SRJ), in which an inmate later died as a result. The complaint packet consisted of the following:
a memorandum from Lieutenant Jeremy Hamman to Commander Thomas Madigan (dated June
11, 2019), a timeline of events regarding Chrisan Madrigal’s custody at SRJ, along with
miscellaneous booking sheets and in-custody paperwork.
Assistant Sheriff Dennis Houghtelling reviewed this memorandum and requested an internal
affairs investigation, regarding the circumstances surrounding this incident.
Summary of Memorandum by Lieutenant Jeremy Hamman
Lieutenant Hamman advised that on June 10, 2019, the Fremont Police Department (Fremont
PD) arrived at SRJ to process arrestee Mr. Madrigal into custody. Mr. Madrigal had been placed
under arrest for 11550(a) HS – Under Influence of a Controlled Substance. He was secured in the
WRAP device and he was also wearing a spit mask. Mr. Madrigal was cleared for incarceration
by Wellpath healthcare services.
Shortly after Mr. Madrigal’s arrival to Intake Transfer and Release (ITR), he was removed from
the WRAP device by SRJ staff, and he was subsequently handcuffed to the rear. One end of a
pair of ankle restraints was applied to the handcuffs, which were behind Mr. Madrigal’s back,
and the other end of the ankle restraints were secured to the door of cell R-1. A restraint log was
initiated and placed on the cell door.
Welfare checks were made by staff periodically and notated on the restraint log. Mr. Madrigal
was later found in the cell unresponsive. It appeared Mr. Madrigal had maneuvered his handcuffs
from the rear of his body to the front of his body and had wrapped the chain of the ankle
restraints around his neck, causing him to lose consciousness. About 1723 hours, Deputy Tiffiny
Ross contacted CP-1 and requested a Code 3 medical response for Mr. Madrigal.
Mr. Madrigal received immediate care from staff with Wellpath healthcare services, until the
Alameda County Fire Department (ACFD) and Paramedics Plus arrived. About 1752 hours, Mr.
Madrigal was transported to the ValleyCare Medical Center in Pleasanton, CA. He was later
transferred to the Eden Medical Center in Castro Valley, CA, where he remained in the Intensive
Care Unit (ICU).
On June 11, 2019, about 0835 hours, Mr. Madrigal was released from Sheriff’s Office custody,
pursuant to CA Penal Code section 4011.7.

Page 1 of 117

 Per Eden Township Substation (ETS) Investigations’ Lieutenant Timothy Schellenberg, Mr.
Madrigal’s family would be contacted by investigators and advised of Mr. Madrigal’s release
from our custody.
Based on the above, this investigation will focus on whether ITR Supervisor Lieutenant
Craig Cedergren violated any of the Agency’s written directives during the intake and
transfer of custody of Mr. Madrigal into our care.
Based on the information discovered during this investigation, the following allegations will be
addressed:
•

On June 10, 2019, was Lieutenant Cedergren negligent in his duties as the ITR
supervisor?

•

On June 10, 2019, did Lieutenant Cedergren handcuff Mr. Madrigal to a cell door
and then leave him there as punishment for not cooperating with the deputies
during the booking process?

•

On June 10, 2019, did Lieutenant Cedergren fail to activate his Body Worn Camera
(BWC) as required by Alameda County Sheriff’s Office General Order 8.17?

Page 2 of 117

 SUMMARY OF INVESTIGATION
ALL INTERVIEWS WERE DIGITALLY RECORDED UNLESS OTHERWISE INDICATED.
THE RECORDINGS WERE LATER TRANSFERRED TO COMPACT DISC AND
RETAINED AT THE INTERNAL AFFAIRS OFFICE FOR REVIEW. ALL TRANSCRIBED
QUOTES ARE VERBATIM, INCLUDING SPELLING, GRAMMER AND PUNCTUATION,
OR LACK THEREOF.
SUMMARY OF ACSO INCIDENT REPORT# 19-009845
On Monday, June 10, 2019, about 1723 hours, Deputy Bump was working in ITR, when he
responded to cell R-1 for a Code 3 medical call, for Mr. Madrigal, who was unresponsive.
Deputy Bump later learned the following had taken place, prior to his arrival:
On June 10, 2019, about 1410 hours, Mr. Madrigal was brought into SRJ as an “express” (a term
given to non-cooperative and combative arrestees who are brought to the jail for booking). Mr.
Madrigal had been arrested by Fremont PD for 11550(a) HS – Being under the influence of a
controlled substance. Mr. Madrigal was brought into ITR in the WRAP restraint device, and he
was wearing a spit mask on his head.
Fremont PD officers told Deputies Nikki Rhoades, David Sides, and Chris McMann that Mr.
Madrigal was placed in the WRAP because he had been combative with the jail staff at the
Fremont PD. Fremont PD officers also relayed, Mr. Madrigal was under the influence of
psilocybin mushrooms (a hallucinogen). Wellpath Registered Nurse (RN) Gid Divinagracia
cleared Mr. Madrigal for incarceration.
About 1415 hours, ITR Sergeant Johnnie Graham decided to move Mr. Madrigal from the ITR
lobby to cell R-1.
Note: At the time of this incident – per an internal policy at SRJ, once an inmate had been
accepted into custody, the WRAP restraint device was no longer permitted to be used inside the
jail.
Sergeant Graham sent Deputy Chris Comfort to retrieve the Pro-Straint restraint chair, for Mr.
Madrigal, once he had been removed from the WRAP. Lieutenant Cedergren was also notified of
the request for the restraint chair.
About 1425 hours, Lieutenants Craig Cedergren and Justin McComas arrived in ITR and went to
cell R-1. Lieutenant Cedergren ordered deputies to remove Mr. Madrigal from the WRAP. Mr.
Madrigal was stood up and Lieutenant Cedergren attached the cuff of one end of a pair of ankle
restraints between Mr. Madrigal’s handcuffs. The chain of the ankle restraint was fed through the
Page 3 of 117

 cuffing port of cell R-1’s door. Deputy Justin Johnston was instructed by Lieutenant Cedergren
to further secure the ankle restraint by wrapping it around the hinge of the handcuffing port. The
other cuff of the ankle restraints was attached to the outside door handle of cell R-1.
While Mr. Madrigal continued to actively resist, a pat search was conducted, and the WRAP was
removed.
Deputies removed the ankle restraint cuff that had been attached to the exterior door handle and
positioned Mr. Madrigal inside the cell. Deputies attempted to pull Mr. Madrigal’s hands through
the cuffing port by pulling on the chain of the ankle restraint to uncuff him. However, Mr.
Madrigal continued to resist their efforts to uncuff him.
Deputy Marco Torres translated the commands from English to Spanish for Mr. Madrigal, in an
attempt to gain Mr. Madrigal’s cooperation, but this also met with negative results.
Ultimately, deputies were unsuccessful in gaining Mr. Madrigal’s cooperation, and Lieutenant
Cedergren instructed deputies to stop any further attempts to remove Mr. Madrigal’s handcuffs.
Lieutenant Cedergren attached one end of a pair of handcuffs to the ankle restraint cuff and the
other end of the pair of handcuffs to the outside doorknob of cell R-1. A restraint log was
initiated by Deputy Rhoades.
About 1457 hours, Deputy Torres saw Mr. Madrigal had maneuvered the handcuffs to the front
of his body, and he notified Sergeant Graham. Deputy Torres continued to try and gain Mr.
Madrigal’s compliance to remove his handcuffs, but he was unsuccessful.
During the next few hours, deputies made several attempts to gain Mr. Madrigal’s cooperation to
remove his handcuffs, but to no avail.
About 1720 hours, Deputy Ross and Lieutenant Cedergren found Mr. Madrigal unresponsive. It
was apparent Mr. Madrigal had manipulated the ankle restraints around his neck and asphyxiated
himself. The ankle restraints and handcuffs were removed, and Mr. Madrigal was laid onto his
back in front of cell R-1. Lieutenant Cedergren started Cardiopulmonary Resuscitation (CPR) on
Mr. Madrigal until he was relieved by medical personnel.

Page 4 of 117

 SUMMARY OF LIEUTENANT CEDERGREN’S SUPPLEMENTAL REPORT
On Monday, June 10, 2019, Lieutenant Cedergren was assigned to ITR. Lieutenant Cedergren
was wearing his Class D utility uniform and had his Axon BWC attached to the front of his
uniform, which was in buffering mode.
Note: In buffering mode, the camera captures the prior 30 seconds of video but no audio, and
the video will not record to permanent memory unless the record button is pressed.
About 1413 hours, Lieutenant Cedergren passed through the law enforcement lobby, when he
saw Mr. Madrigal seated on the floor, in the WRAP restraint device, attended to by Fremont PD
officers, ACSO Sworn and Professional Staff, and Sergeant Graham.
About 1416 hours, Sergeant Graham asked Lieutenant Cedergren to meet him by cell R-1, and
Lieutenant Cedergren acknowledged the request.
About 1421 hours, Sergeant Graham summoned Lieutenant Cedergren again on the radio and
requested approval to use the Pro-Straint restraint chair. Lieutenant Cedergren told Sergeant
Graham he was enroute.
About 1423 hours, Lieutenant Cedergren arrived in ITR. Sergeant Graham told him,
“Mushrooms, mushrooms, and he’s, he’s gonna fight us, he’s already tensing his body, we can’t
unrestrain him, so.”
As Lieutenant Cedergren walked toward Mr. Madrigal, he saw Deputies Anastasia Salazar,
Comfort, Ross, Johnston, McMann, Rhoades, and Sides present. Lieutenant Cedergren asked,
“We can’t get him out of there?” (in reference to the WRAP) Sergeant Graham replied, “Not
without fighting him.”
While Lieutenant Cedergren observed Mr. Madrigal’s demeanor, he asked why Fremont PD
officers restrained Mr. Madrigal in the WRAP. Deputy Comfort told him, “I heard he was down
at the jail, he fought with the, the jail deputies.”
Based on Lieutenant Cedergren’ s observations, and the information provided by those present
during the incident, Lieutenant Cedergren believed the use of the Pro-Straint restraint chair,
which was present, was inappropriate, given the circumstances known to him at the time.
Note: The Pro-Straint restraint chair is a chair with equipment designed to restrain, control, and
limit the movements of someone who displays hazardous behavior.

Page 5 of 117

 Lieutenant Cedergren noted, Mr. Madrigal, although restrained in the WRAP, had not displayed
the type of behavior which could have resulted in the destruction of property, nor had Mr.
Madrigal revealed intent to cause physical harm to himself or others.
Lieutenant Cedergren also recognized the need to remove Mr. Madrigal from Fremont PD’s
WRAP, to release Fremont PD officers back into service and to allow medical staff to further
evaluate Mr. Madrigal.
About 1424 hours, Lieutenant Cedergren directed Deputies McMann, Rhoades, and Sides to
stand Mr. Madrigal on his feet and remove him from the WRAP.
About 1425 hours, Lieutenant Cedergren asked Mr. Madrigal if he spoke English, and someone
told him no. Lieutenant Cedergren attempted to ease the tension of the tether strap on the WRAP,
while Mr. Madrigal was standing. Lieutenant Cedergren was unable to do so, so he told Deputies
McMann and Rhoades to return Mr. Madrigal to a seated position on the floor, which they did.
Deputies McMann, Rhoades, and Sides attempted to ease the tension of the tether strap but were
unable to do so, due to the texture of the WRAP material, as Mr. Madrigal leaned back and slid
forward on the floor.
About 1426 hours, Lieutenant Cedergren asked someone to tell Mr. Madrigal in Spanish to sit
up. With Deputies Sides and Rhoades assisting in ensuring Mr. Madrigal was seated fully
upright, Lieutenant Cedergren was able to ease the tension of the tether strap, and Deputies Sides
and Rhoades returned Mr. Madrigal to his feet.
Prior to removing the WRAP, ankle restraints were attached to Mr. Madrigal’s handcuffs, as
Lieutenant Cedergren recognized Mr. Madrigal’s behavior, volatility, and intentions were
unpredictable, and subject to change. By utilizing the restraints in this manner, through the open
cuffing port of the open cell door, this facilitated the removal of the WRAP. This technique
minimized Mr. Madrigal’s movements by utilizing the cell door as a barrier and limited his
ability to kick, resist, or assault anyone while being secured within cell R-1.
Note: Lieutenant Cedergren stated in his report that it was also his understanding that the use of
ankle restraints in this manner had been presented in the Core course curriculum for entry-level
staff and had also been used in other incidents at SRJ.
About 1428 hours, Deputies Sides and McMann searched Mr. Madrigal, while Lieutenant
Cedergren instructed Deputy Rhoades to maintain physical contact between Mr. Madrigal’s body
and the cell door, to limit Mr. Madrigal’s movements.
About 1430 hours, per Lieutenant Cedergren’s request, Deputy Torres directed Mr. Madrigal to
walk into cell R-1, which he did, and the cell door was closed.
Page 6 of 117

 About 1431 hours, Deputy Rhoades attempted to guide Mr. Madrigal’s hands through the open
cuffing port of the cell door, to remove his restraints, while Lieutenant Cedergren and Deputies
Sides and Ross assisted her. However, Mr. Madrigal did not cooperate, and he continued to pull
away from the cell door. In addition, Mr. Madrigal also refused to kneel and place his hands
through the cuffing port. While ACSO staff maintained control of Mr. Madrigal’s ankle
restraints, Deputy Torres directed Mr. Madrigal to place his hands through the cuffing port,
several times, without success.
To prevent physical injury to Mr. Madrigal and/or any other involved personnel, as well as to
maintain control of Mr. Madrigal and gain his compliance, the ankle restraints were secured to
the outside doorknob of cell R-1, with a pair of handcuffs (the circumference of the ankle
restraint cuff, when closed, was greater than the diameter of the doorknob). Without the use of
the handcuffs, Mr. Madrigal could have reached through the cuffing port and simply removed the
ankle restraint cuff from the doorknob, and then he would have had a weapon of opportunity.
It was Lieutenant Cedergren’s observation, based on Mr. Madrigal’s refusal to cooperate, that
even the removal of the ankle restraints from the handcuffs around Mr. Madrigal’s wrists (and
allowing Mr. Madrigal to remain in handcuffs within cell R-1), was not likely to occur without
employing force to overcome Mr. Madrigal’s resistance and/or lack of cooperation offered.
Lieutenant Cedergren also knew, based on his training and experience, an inmate can defeat a
pair of handcuffs even when properly applied and double-locked. This would allow the inmate to
have access to a means to cause physical harm to oneself or others.
About 1433 hours, while RN Divinagracia asked Mr. Madrigal questions to complete the intake
screening, Lieutenant Cedergren noted Mr. Madrigal appeared oriented and he responded to the
questions, but he continued to refuse to allow his restraints to be removed.
About 1435 hours, Deputy Torres contacted Mr. Madrigal again and attempted to get him to
cooperate with efforts to remove his handcuffs, to no avail.
About 1440 hours, Deputy Rhoades started a Restraint Observation Log (ROL) on Mr. Madrigal.
Given the assigned ITR personnel, Lieutenant Cedergren believed the required observations of
Mr. Madrigal to be manageable. He also believed Mr. Madrigal would ultimately cooperate in a
timely manner.
About 1650 hours, Lieutenant Cedergren returned to cell R-1 and observed Mr. Madrigal
standing at the cell door. Mr. Madrigal placed his hands on the inner edge of the open cuffing
port, and Lieutenant Cedergren saw he had maneuvered his handcuffs to the front of his body. As
Lieutenant Cedergren prepared to remove Mr. Madrigal’s handcuffs, Mr. Madrigal pulled his
hands back and prevented him from doing so. Lieutenant Cedergren left the area.
Page 7 of 117

 About 1720 hours, Lieutenant Cedergren returned to the ITR lobby and he walked to cell R-1 to
check on Mr. Madrigal. As he looked into the window of Mr. Madrigal’s cell, he did not see Mr.
Madrigal standing as he had on previous occasions. Lieutenant Cedergren looked closer and saw
Mr. Madrigal seated, with his upper body against the cell door and his hands on the right side of
his chest, as if they were resting on a knee. Lieutenant Cedergren attempted to communicate with
Mr. Madrigal, but he did not respond.
About 1721 hours, Lieutenant Cedergren asked Deputy Ross to standby, while he further
assessed Mr. Madrigal. As Lieutenant Cedergren opened the cell door, he saw Mr. Madrigal had
placed a single loop of the chain around his neck, formed with the piece of chain connecting the
ankle restraints, and he was now unresponsive. Lieutenant Cedergren immediately began
working to free Mr. Madrigal, by lifting his body up from the seated position, while removing
the loop of chain from around his neck.
About 1722 hours, Deputy Rhoades responded for assistance.
After Lieutenant Cedergren removed Mr. Madrigal’s left wrist from the handcuffs, he carefully
placed him in a supine position on the floor and started CPR.
Note: At this point, Lieutenant Cedergren inadvertently knocked his BWC off his uniform, which
fell onto floor. Lieutenant Cedergren also requested an Automated External Defibrillator (AED),
which Deputy Rhoades attached to Mr. Madrigal’s chest and activated.
About 1724 hours, medical staff from Wellpath healthcare services relieved Lieutenant
Cedergren and took over medical care for Mr. Madrigal.
Lieutenant Cedergren confirmed medical personnel were enroute to SRJ, Code 3.
About 1725 hours, Lieutenant Cedergren retrieved the ROL and updated it to reflect the time for
the Code 3 medical response. Lieutenant Cedergren contacted Commander Madigan and advised
him of the incident.
About 1734 hours, the ACFD arrived and assumed all lifesaving measures for Mr. Madrigal.

Page 8 of 117

 SUMMARY OF DEPUTY COMFORT’S SUPPLEMENTAL REPORT
On Monday, June 10, 2019, Deputy Comfort was working in ITR. Deputy Comfort was wearing
his BWC, which he activated during this incident.
About 1414 hours, the Fremont PD arrived at SRJ with Mr. Madrigal, a violent suspect, who was
in the WRAP restraint device and was also wearing a spit mask.
Officers with the Fremont PD advised Deputy Comfort that Mr. Madrigal had fought with their
jail staff, and he was currently under the influence of psilocybin mushrooms. Deputy Comfort
assisted Deputy Ross and Fremont PD officers removing Mr. Madrigal from the police vehicle
and brought him into the lobby.
Mr. Madrigal was resistant in the front lobby, and he refused to allow staff to remove him from
the WRAP. After several failed attempts, Mr. Madrigal was transferred from the lobby to cell R1 in ITR. Mr. Madrigal was placed on the floor in cell R-1, and he was rolled over onto his side.
Several more attempts were made to remove Mr. Madrigal from the WRAP, but they were also
unsuccessful.
Because of Mr. Madrigal’s violent history and his refusal to submit to jail staff demands, the
decision was made to place Mr. Madrigal in the Pro-Straint restraint chair. The restraint chair
was set up, and Sergeant Graham and Lieutenant Cedergren were on scene to monitor the
transition.
Lieutenant Cedergren decided to leave Mr. Madrigal in cell R-1 using the ankle restraints and
handcuffs to restrain Mr. Madrigal from injuring himself or any other staff members and a ROL
was initiated.

Page 9 of 117

 SUMMARY OF SERGEANT GRAHAM’S SUPPLEMENTAL REPORT
On Monday, June 10, 2019, Sergeant Graham was working in ITR. Sergeant Graham was
wearing his BWC, which he activated during this incident.
About 1409 hours, Sergeant Graham heard radio traffic asking for additional deputies for “an
express,” in the ITR lobby. Sergeant Graham responded to the ITR lobby, and he saw ITR
deputies speaking to two Fremont PD officers. He also saw a nurse speaking to Mr. Madrigal,
while he was seated in the rear seat of a patrol vehicle in the ITR parking lot.
Sergeant Graham saw Mr. Madrigal restrained in the WRAP, and he was wearing a spit mask.
Sergeant Graham briefly spoke with the Fremont PD officers, who advised him Mr. Madrigal
was on “mushrooms” and was combative. Once nursing staff cleared Mr. Madrigal for
incarceration, deputies assisted the Fremont PD officers in carrying Mr. Madrigal into the ITR
lobby, where he was placed on the floor. During the initial contact with Mr. Madrigal, he was
advised several times in English and Spanish to cooperate, to no avail.
Once Mr. Madrigal was inside the jail, Sergeant Graham made the decision to move Mr.
Madrigal into cell R-1, where he was placed on the floor. Sergeant Graham told deputies to
remove Mr. Madrigal from the WRAP, so they could transition him into waist restraints.
As the WRAP was being removed, Mr. Madrigal immediately began to stiffen his body, in an
attempt to overpower deputies. Sergeant Graham was asked if he thought the Pro-Straint restraint
chair should be used, to prevent an assault and/or a use of force with Mr. Madrigal. Sergeant
Graham agreed with the decision to use the restraint chair, and he directed Deputy Comfort to
retrieve it. Sergeant Graham radioed Lieutenant Cedergren, who advised he would respond to the
area. As they waited for Lieutenant Cedergren to respond, Sergeant Graham and the deputies
formed a plan to get Mr. Madrigal secured in the restraint chair. Deputy Torres was also
identified as the safety officer to monitor the application of the restraint chair.
After a few minutes, Sergeant Graham again radioed Lieutenant Cedergren and requested
authorization to use the restraint chair. A short time later, Lieutenants Cedergren and McComas
arrived on scene in ITR. Sergeant Graham advised them of the nature of the incident and told
them he believed the utilization of the restraint chair would prevent an assault.
Lieutenant Cedergren looked into cell R-1 and stated he did not want to use the restraint chair.
Lieutenant Cedergren directed the deputies to stand Mr. Madrigal up as the WRAP was removed
and Mr. Madrigal was handcuffed, with his hands behind his back.
Once Mr. Madrigal was standing, the cuff of a pair of ankle restraints was secured to Mr.
Madrigal’s handcuffs and the other cuff was passed through the cuffing port of the cell door.
Page 10 of 117

 Deputies held onto the ankle restraints from the other side of the door, to prevent Mr. Madrigal
from pulling away from them.
Deputies then exited the cell and Mr. Madrigal was held against the cell door. Several
commands, in English and Spanish, were given to Mr. Madrigal for him to bend down so the
handcuffs could be removed. However, Mr. Madrigal did not comply.
Lieutenant Cedergren decided to leave Mr. Madrigal in the restraints and to start a ROL. The
other end of the ankle restraints was secured to another set of handcuffs and those handcuffs
were secured to the outside doorknob of cell R-1.
Over the next hours, Sergeant Graham made several attempts to convince Mr. Madrigal to
cooperate and allow himself to be unhandcuffed, to no avail.
About 1445 hours, Sergeant Graham checked on Mr. Madrigal and saw he had maneuvered his
handcuffs to the front of his body. Sergeant Graham decided a ROL had already been initiated,
and there was no ongoing danger to staff, so no attempts should be made to relocate Mr.
Madrigal’s handcuffs to the rear of his body again. Sergeant Graham signed the ROL and relayed
this information to Sergeant Kevin Estep, prior to him leaving at the conclusion of his shift at
1600 hours.

Page 11 of 117

 SUMMARY OF DEPUTY JOHNSTON’S SUPPLEMENTAL REPORT
On Monday, June 10, 2019, Deputy Johnston was working in ITR. Deputy Johnston was wearing
his BWC, which he activated during this incident.
About 1420 hours, Deputy Johnston responded to Sergeant Graham’s radio call, requesting
additional deputies for a priority booking in the lobby. Deputy Johnston arrived and saw Mr.
Madrigal restrained in the WRAP, with a spit mask over his head. Deputy Johnston learned Mr.
Madrigal had been arrested for being under the influence of a controlled substance; Mr. Madrigal
was being uncooperative and refusing to answer basic questions.
Deputies Sides, Rhoades, and McMann carried Mr. Madrigal to cell R-1, to be searched and to
have him removed from the WRAP. Due to Mr. Madrigal’s behavior and his refusal to
cooperate, it was decided Mr. Madrigal should be transitioned out of the WRAP and into the ProStraint restraint chair, for his safety and the safety of other deputies.
Deputies assisted Mr. Madrigal to his feet and stood him up outside of cell R-1. Lieutenant
Cedergren attached one side of a set of ankle restraints to the handcuffs Mr. Madrigal was
wearing and put the other end of the ankle restraints through the cuffing port of the cell door of
R-1. The end of the ankle restraints was attached to the outside doorknob of the cell door.
Lieutenant Cedergren directed Deputy Johnston to double lock the ankle restraints, and he did.
Deputy Johnston saw that the diameter of the closed cuff of the ankle restraints was larger than
the doorknob and could be slipped off the handle. Lieutenant Cedergren directed him to secure
the restraint by wrapping it around the hinge of the cuffing port, which he did.
While Mr. Madrigal was secured to the cell door and his back was against the inside of the cell
door, Deputies Sides and McMann were able to remove the WRAP and search Mr. Madrigal.
Deputies were then able to get Mr. Madrigal back into cell R-1 and close the door.
The ankle restraints were still secured between the hinge of the cuffing port and the handcuffs
Mr. Madrigal was wearing. Deputies unwrapped the ankle restraints from the hinge of the
cuffing port and held onto them to control Mr. Madrigal. Deputy Torres spoke to Mr. Madrigal
in Spanish and told him to put his hands through the cuffing port so the handcuffs could be
removed, but Mr. Madrigal refused to cooperate.
After multiple failed attempts to remove Mr. Madrigal’s handcuffs, Lieutenant Cedergren
attached one cuff of a pair of handcuffs to one end of the ankle restraints and the other cuff of the
handcuffs to the outer doorknob on cell R-1.
Once Mr. Madrigal was restrained in this manner and secured inside the cell, Deputy Johnston
left the area.
Page 12 of 117

 SUMMARY OF DEPUTY McMANN’S SUPPLEMENTAL REPORT
On Monday, June 10, 2019, Deputy McMann was working at SRJ and assigned to Housing Unit
9, when he took his lunch break. Deputy McMann was wearing his BWC, which he activated
during this incident.
About 1410 hours, Deputy McMann heard a radio call for assistance in ITR, so he responded.
Upon arrival, Deputy McMann learned Fremont PD officers had brought Mr. Madrigal to the jail
for being under the influence of “mushrooms.” Deputy McMann saw Mr. Madrigal had been
restrained in the WRAP and he was wearing a spit mask, due to his erratic behavior.
Mr. Madrigal was conscious and breathing normally, and he did not appear to be in any type of
medical distress. However, Deputy McMann saw Mr. Madrigal was not compliant with any of
the orders from jail or medical staff. RN Divinagracia tried to take Mr. Madrigal’s vital signs,
but he was unable to do so, because Mr. Madrigal constantly tensed his body and clenched his
fists.
Sergeant Graham made the decision to escort Mr. Madrigal to cell R-1, to assist the deputies in
removing Mr. Madrigal from the WRAP and completing a custodial search of his person.
Deputies Rhoades, Sides, and McMann picked up Mr. Madrigal while he was still in the WRAP
and carried him to cell R-1. Deputy McMann noted, Mr. Madrigal appeared to be confused, as he
looked around the cell with a dazed look in his eyes.
While they were in cell R-1, Mr. Madrigal continued to tense his body, so Deputy McMann
utilized his bodyweight to apply pressure to Mr. Madrigal’s right hip.
Sergeant Graham made the decision to remove Mr. Madrigal from the WRAP and place him into
the Pro-Straint restraint chair, pending approval from Lieutenant Cedergren. While waiting for
Lieutenant Cedergren to arrive on scene, Deputy Rhoades and Deputy McMann removed
Fremont PD’s handcuffs, which were on Mr. Madrigal and secured him with a pair of ACSO
handcuffs.
About 1425 hours, Lieutenant Cedergren made the decision not to approve the placement of Mr.
Madrigal into the restraint chair. Lieutenant Cedergren instructed the deputies to loosen the
tether strap of the WRAP, so Mr. Madrigal could stand. However, Mr. Madrigal did not comply
with their orders to stop tensing his body.
Deputy McMann had to apply his bodyweight onto Mr. Madrigal’s upper back, while pushing
his body towards Mr. Madrigal’s feet, so that the tether strap could be loosened and then he and
Deputy Rhoades stood Mr. Madrigal up.
Page 13 of 117

 Mr. Madrigal was backed up to the cell door of R-1, where Deputy Rhoades assisted other
deputies in removing Mr. Madrigal from the WRAP. Deputy McMann conducted a custodial
search of Mr. Madrigal’s person.
After the search of Mr. Madrigal was complete, the cell door was closed. Deputy McMann left
and returned to Housing Unit 9 and allowed the ITR deputies to take over the duties of care and
custody of Mr. Madrigal.

Page 14 of 117

 SUMMARY OF DEPUTY RHOADES’ SUPPLEMENTAL REPORT
On Monday, June 10, 2019, Deputy Rhoades was working in ITR. Deputy Rhoades was wearing
her BWC, which she activated during this incident.
About 1410 hours, Deputy Rhoades heard Sergeant Graham broadcast, via radio, for additional
deputies to respond to the ITR lobby for a priority booking inmate. Deputy Rhoades understood
this to mean, the inmate had been in a physical altercation with officers and had been placed in a
restraint device or was being actively combatant, while in transport.
Deputy Rhoades responded to the lobby and learned Mr. Madrigal had ingested hallucinogenic
mushrooms and had been arrested by Fremont PD officers. Deputy Rhoades saw Mr. Madrigal
had been placed in the WRAP with a spit mask over his head and he was lying on the floor near
the intake counter.
RN Divinagracia examined Mr. Madrigal and attempted to check his vital signs to clear him for
incarceration. RN Divinagracia was able to obtain Mr. Madrigal’s blood pressure reading.
However, when RN Divinagracia attempted to place an oxygen monitor on Mr. Madrigal’s
finger to ascertain his oxygen level and pulse, Mr. Madrigal clenched his right hand into a fist
and refused to allow him to do so.
Deputy Rhoades tried to help, by prying Mr. Madrigal’s hand open. RN Divinagracia was able to
get Mr. Madrigal’s pulse manually, but he could not ascertain his oxygen levels. Mr. Madrigal’s
pulse was in the normal range, so he cleared Mr. Madrigal for incarceration.
Due to Mr. Madrigal’s uncooperative behavior and his history of assaulting law enforcement
staff, he was left in the WRAP. Deputies Rhoades, McMann, and Sides carried Mr. Madrigal to
cell R-1.
Once inside the cell, Mr. Madrigal was laid on his side and a pat search for contraband was
conducted. However, Mr. Madrigal actively resisted this search, by rolling onto his back and
tensing his body, in an effort to prevent deputies from searching him.
Due to Mr. Madrigal’s combative behavior at the Fremont jail, coupled with his active resistance
with ACSO staff and his refusal to follow orders, deputies on scene requested authorization to
remove Mr. Madrigal from the WRAP and place him in the Pro-Straint restraint chair. It was
determined that once Mr. Madrigal was in the restraint chair, he would be placed near the nurse’s
station. Deputy Torres would be designated as the assigned safety officer, who would be able to
maintain a direct visual observation of Mr. Madrigal.
In preparation of Mr. Madrigal’s placement into the restraint chair, Deputy Rhoades removed
Fremont PD’s handcuffs from Mr. Madrigal and replaced them with her own pair of handcuffs.
Page 15 of 117

 During the handcuff transition, Mr. Madrigal repeatedly tensed his arms and clenched his fists, in
an apparent attempt to prevent Deputy Rhoades from removing Fremont PD’s handcuffs and
replacing them with her own.
Sergeant Graham notified Lieutenant Cedergren of the request for authorization to use the
restraint chair, and Deputy Comfort retrieved the restraint chair and positioned it outside of cell
R-1.
About 1425 hours, Lieutenants Cedergren and McComas arrived on scene. Sergeant Graham
informed Lieutenant Cedergren that due to Mr. Madrigal’s pre-assaultive indicators, deputies
would not be able to remove Mr. Madrigal from the WRAP without using force.
Lieutenant Cedergren ordered Deputies Sides, McMann, and Rhoades to remove Mr. Madrigal
from the WRAP. Deputy Sides pushed Mr. Madrigal forward by his shoulders, while Deputy
Ross held his feet, preventing Mr. Madrigal from sliding forward so deputies had enough slack
to remove the center tether strap of the WRAP. However, Mr. Madrigal used his bodyweight to
push against Deputy Ross, which prevented the removal of the tether strap. Multiple efforts were
made to remove the center strap, with negative results.
Lieutenant Cedergren entered the cell and ordered Mr. Madrigal to sit up. Lieutenant Cedergren
was able to eventually pull Mr. Madrigal forward far enough, using the strap, to allow deputies
to undo the tether strap.
Lieutenant Cedergren ordered the deputies to stand Mr. Madrigal to his feet and Mr. Madrigal
was escorted just outside of cell R-1. Deputies McMann and Rhoades turned Mr. Madrigal, so he
was facing inside of the cell. Lieutenant Cedergren placed one cuff of the ankle restraints around
the chain of Mr. Madrigal’s handcuffs. The deputies turned Mr. Madrigal, so his back was
against the open cell door and the chain of the ankle restraints and remaining cuff were passed
through the open cuffing port of cell R-1.
The cell door was used to prevent Mr. Madrigal from falling, while Deputies McMann and
Rhoades removed Mr. Madrigal from the upper portion of the WRAP, even though Mr. Madrigal
continued to resist by pushing his body forward. Deputy Rhoades used her right arm and
bodyweight to hold Mr. Madrigal against the cell door and to keep him from falling forward.
Deputies Sides and McMann removed the lower portion of the WRAP from Mr. Madrigal, and a
search for contraband of his person was conducted.
Once the WRAP was completely removed, Mr. Madrigal was told to walk forward, into his cell.
Deputy Rhoades grabbed the chain of the ankle restraints and attempted to pull Mr. Madrigal’s
hands through the cuffing port, so deputies could remove the ankle restraints and Mr. Madrigal’s
handcuffs. However, Mr. Madrigal refused to cooperate, and he pulled away from the closed
Page 16 of 117

 door. Deputies Ross and Rhoades grabbed the other end of the ankle restraints by pulling
backwards on the ankle cuff, in an attempt to force Mr. Madrigal’s hands through the open
cuffing port, but they were unsuccessful.
Lieutenant Cedergren instructed Deputies Ross and Rhoades to stop pulling on the chain of the
ankle restraints. Lieutenant Cedergren took an additional set of handcuffs and secured one
handcuff to the remaining cuff of the ankle restraints and the other handcuff around the outside
doorknob of cell R-1.
Deputy Rhoades initiated a ROL.
Over the next few hours, multiple attempts were made by various staff members to remove Mr.
Madrigal’s handcuffs, but this met with negative results.
About 1721 hours, Deputy Rhoades returned to the intake area of ITR. As she neared cell R-1,
she saw Lieutenant Cedergren and Deputy Ross standing outside the cell door. She heard
Lieutenant Cedergren tell Mr. Madrigal, “Hey, wake up.” Deputy Rhoades saw Lieutenant
Cedergren open the cell door of R-1, and she saw Mr. Madrigal sitting against the cell door. Mr.
Madrigal was slumped down, the chain of the ankle restraints was around his neck, and his hands
were still in the handcuffs near the right side of his head.
Deputy Rhoades ran to the ITR nurse station and requested medical assistance.
Deputy Rhoades returned to cell R-1 and assisted Deputy Ross and Lieutenant Cedergren in
removing the chain of the ankle restraints from around Mr. Madrigal’s neck.
Mr. Madrigal was laid on the floor, and Lieutenant Cedergren immediately began CPR, until he
was relieved by medical staff.

Page 17 of 117

 SUMMARY OF DEPUTY ROSS’ SUPPLEMENTAL REPORT
On Monday, June 10, 2019, Deputy Ross was working in ITR. Deputy Ross was wearing her
BWC, which she activated during this incident.
About 1410 hours, Deputy Ross was notified by Sheriff’s Technicians that Fremont PD had a
priority booking.
Deputy Ross arrived in the ITR lobby and learned Fremont PD had transported Mr. Madrigal to
SRJ for booking. Deputy Ross saw Mr. Madrigal was in the WRAP and wearing a spit mask.
Fremont PD officers told her, Mr. Madrigal had been combative with the Fremont PD jail staff
earlier in the day and he had also ingested psilocybin mushrooms.
Sergeant Graham arrived on scene. Deputies Comfort and Ross, along with a Fremont PD
officer, carried Mr. Madrigal from the patrol car into the ITR lobby.
RN Divinagracia medically evaluated Mr. Madrigal, but Mr. Madrigal refused to answer his
questions. Mr. Madrigal also prevented RN Divinagracia from placing the oxygen monitor on his
finger, as he continuously tensed his hand and clenched it into a fist. After RN Divinagracia
obtained Mr. Madrigal’s blood pressure, he cleared Mr. Madrigal for incarceration.
Deputies Rhoades, McMann, and Sides carried Mr. Madrigal to cell R-1, where they attempted
to remove the WRAP and search Mr. Madrigal for contraband. However, Mr. Madrigal tensed
his body and prohibited the deputies from releasing the tension straps on the WRAP.
Due to Mr. Madrigal’s combative behavior at the Fremont Jail, the tensing of his body, and his
refusal to cooperate with deputies and nursing staff, it was believed Mr. Madrigal would
continue to cause physical harm to staff members. Deputies requested Mr. Madrigal be placed in
the Pro-Straint restraint chair.
Sergeant Graham notified Lieutenant Cedergren and requested approval for Mr. Madrigal to be
transitioned from the WRAP to the restraint chair. It was determined that once Mr. Madrigal had
been placed in the restraint chair, he would be placed in the sobering cell near the nurse’s station,
and Deputy Torres would be the designated safety officer, who would be responsible for
observation of Mr. Madrigal.
About 1425 hours, Lieutenants Cedergren and McComas arrived on scene. Sergeant Graham
explained to Lieutenant Cedergren that, due to Mr. Madrigal’s pre-assaultive indicators, ACSO
staff would be unable to remove Mr. Madrigal from the WRAP without using force.
Lieutenant Cedergren ordered Deputies Rhoades, Sides, and McMann to remove Mr. Madrigal
from the WRAP. However, Mr. Madrigal continued to tense his body and push his bodyweight
Page 18 of 117

 against the deputies, preventing them from doing so. Deputy Ross held Mr. Madrigal’s ankles
while Lieutenant Cedergren pulled Mr. Madrigal’s torso towards his feet, which allowed the
tension to release, and the straps of the WRAP were loosened.
Lieutenant Cedergren asked for ankle restraints and ordered Deputies Rhoades, Sides, and
McMann to stand Mr. Madrigal on his feet. After doing so, Lieutenant Cedergren attached ankle
restraints to the handcuffs Mr. Madrigal was wearing. Lieutenant Cedergren then put the other
end of the ankle restraints through the cell door’s cuffing port and hooked the cuff around the
cuffing port door.
Mr. Madrigal’s back was to the open cell door. Lieutenant Cedergren ordered deputies to remove
the WRAP while Mr. Madrigal was standing. Mr. Madrigal continued to resist, using his
bodyweight to push against Deputy Rhoades while Deputy Sides removed the WRAP. However,
once the WRAP was removed, Mr. Madrigal refused to walk into the cell.
Deputy Rhoades continued to close the cell door, while Deputies McMann and Sides pushed Mr.
Madrigal into the cell.
Mr. Madrigal refused to put his hand through the open cuffing port so deputies could remove his
handcuffs. Deputies Rhoades and Ross attempted to pull Mr. Madrigal’s hands through the open
cuffing port, with the ankle restraints that were attached to Mr. Madrigal’s handcuffs, but this
met with negative results.
Lieutenant Cedergren decided to hook the ankle restraint to the exterior doorknob until Mr.
Madrigal calmed down and was willing to allow the handcuffs to be removed. Deputy Torres
tried to talk Mr. Madrigal into putting his hands through the open cuffing port, but this met with
negative results. Deputy Rhoades initiated a ROL.
At an unknown time, Mr. Madrigal was able to manipulate his handcuffs from behind his back,
to the front of his body, while he was chained to the door. Typically, when an inmate is
combative and poses a threat to the safety of deputies, if that inmates slips his handcuffs from the
back to the front of his body, deputies will not re-engage the inmate to reposition the handcuffs
to the back of an inmate’s body again. This reduces the risk of injury to both, the deputies and
the inmate, and avoids a potential use of force.
About 1648 hours, Deputy Ross saw Mr. Madrigal standing at the cell door.
About 1700 hours, Deputy Ross responded to the transfer side of ITR to assist in unloading
several buses of inmates. Once the buses were unloaded, Deputy Ross went back to the intake
side of ITR. Soon thereafter, she heard Lieutenant Cedergren tell Mr. Madrigal, “Hey, wake up.”
About 1720 hours, Lieutenant Cedergren asked her to standby, as he opened R-1’s cell door.
Page 19 of 117

 Deputy Ross looked inside cell R-1 and saw Mr. Madrigal sitting, with his back to the cell door.
Deputy Ross saw there was tension on the handcuffs, and she asked Lieutenant Cedergren if Mr.
Madrigal was strangling himself. Lieutenant Cedergren opened the cell door slightly and tapped
Mr. Madrigal on the shoulder, as he told him to wake up. As Lieutenant Cedergren stepped back,
Deputy Ross saw Mr. Madrigal had the chain of the ankle restraints wrapped around his neck,
with his hands up near the side of his face. Deputy Ross said, “He’s got the chains. He’s got the
chains around it LT.”
Lieutenant Cedergren opened the cell door and she grabbed Mr. Madrigal’s right arm and
attempted to lift it over his head to free the chain from around his neck. Deputy Rhoades saw
what was happening and ran to get help from medical staff.
Lieutenant Cedergren and Deputy Ross were unable to get Mr. Madrigal’s right arm over his
head, with him sitting on the ground. Deputy Ross told Lieutenant Cedergren to pick up Mr.
Madrigal by his left shoulder as she picked up Mr. Madrigal by his right shoulder. Deputy
Rhoades unlocked the ankle restraints from the cell door, which freed Mr. Madrigal’s arm and
allowed enough slack for her to push Mr. Madrigal’s arm over his head and to free the chain
from around his neck.
Mr. Madrigal was laid on his back, on the floor, and Lieutenant Cedergren started CPR, while
Deputy Ross removed his handcuffs and the ankle restraints that were attached to his handcuffs.
About 1723 hours, Deputy Ross requested a Code 3 medical response for Mr. Madrigal.

Page 20 of 117

 SUMMARY OF DEPUTY SIDES’ SUPPLEMENTAL REPORT
On Monday, June 10, 2019, Deputy Sides was working in ITR. Deputy Sides was wearing his
BWC, which he activated during this incident.
About 1410 hours, Deputy Sides was advised that Fremont PD had arrived at SRJ with a priority
booking. Deputy Sides entered the lobby and saw Mr. Madrigal being carried into the law
enforcement lobby. He saw Mr. Madrigal had a spit mask over his head, and he was in the
WRAP.
Several attempts to communicate with Mr. Madrigal in English and Spanish were made, to no
avail. Fremont PD officers stated they believed Mr. Madrigal was under the influence of
psilocybin mushrooms and they also said he had been combative with them, prior to him being
placed in the WRAP.
Wellpath nursing staff evaluated Mr. Madrigal in the lobby, but he was resistant towards them.
Mr. Madrigal clenched his fists, tensed his body, and would not answer questions or allow
medical staff to place an oximeter on his finger. However, he was ultimately cleared for
incarceration.
About 1415 hours, while Mr. Madrigal was still in the WRAP, he was accepted into SRJ.
Deputies McMann, Rhoades, and Sides carried Mr. Madrigal to cell R-1 to determine if the
WRAP could be removed. Mr. Madrigal continued to resist, as he was laid on his side in a
recovery position. Mr. Madrigal tensed his body by pushing against the restraints and flailing his
body, in what appeared to be an attempt to sit up. Deputy Sides placed his left knee on Mr.
Madrigal’s right leg to prevent him from injuring himself.
Sergeant Graham requested approval from Lieutenant Cedergren for the restraint chair, and the
restraint chair was retrieved and made ready to use with Mr. Madrigal.
About 1425 hours, Lieutenant Cedergren arrived on scene. Lieutenant Cedergren did not approve
the use of the restraint chair, and he told the deputies he wanted Mr. Madrigal standing.
Deputies attempted to loosen the strap to allow Mr. Madrigal to stand, but Mr. Madrigal pushed
with his legs, which created tension between the top and bottom portions of the WRAP.
Eventually, Mr. Madrigal’s upper body was pushed forward far enough to free the strap.
Deputy Sides assisted Mr. Madrigal in standing and he was escorted outside the cell. Ankle
restraints were attached to the chain of Mr. Madrigal’s handcuffs and then fed through the
cuffing port of the cell door. Deputy Sides assisted in removing the top and bottom portions of
the WRAP, as Mr. Madrigal stood against the cell door. Deputies Sides and McMann performed
a pat search of Mr. Madrigal’s person, which did not yield anything of evidentiary value.
Page 21 of 117

 Deputy Sides removed the lower portion of the WRAP, and he assisted in closing the cell door,
securing Mr. Madrigal inside the cell.
Deputy Torres ordered Mr. Madrigal to place his hands outside the cell through the open cuffing
port of the door so they could remove his handcuffs, but Mr. Madrigal refused. In an attempt to
free Mr. Madrigal from the restraints, attempts were made to pull the ankle restraints (which
were attached to Mr. Madrigal’s handcuffs) through the cuffing port, but this was also
unsuccessful.
Rather than risk possible injuries to Mr. Madrigal by forcing his hands through the cuffing port,
the ankle restraints were attached to the exterior doorknob of the cell door, with an additional
pair of handcuffs.
A restraint log was initiated, and several attempts were made to convince Mr. Madrigal to
cooperate with the removal of his handcuffs over the next several hours, but this also met with
negative results.

Page 22 of 117

 Summary of Interview with Deputy Anastasia Salazar
On Thursday, December 5, 2019, Deputy Kevan Woods and I interviewed Deputy Salazar in the
administrative conference room at SRJ. In summary, Deputy Salazar told me the following:
On June 10, 2019, Deputy Salazar was working in ITR at SRJ, when Mr. Madrigal was brought
into the jail by Fremont PD. Deputy Comfort told her Mr. Madrigal was going to be transitioned
out of the WRAP and into the restraint chair, so she got the restraint chair.
I asked Deputy Salazar what her opinion of Sergeant Graham was, and she told me he was a
good sergeant, who was level-headed and made good decisions. Deputy Salazar stated she never
had any issues with him. I asked her if Sergeant Graham seemed to have the respect of the
deputies he supervised, and she told me, “somewhat.” Deputy Salazar elaborated on her answer
by telling me she believed Sergeant Graham was approaching the end of his career, and he was
known for not liking to do anything that would require him to work past his normal workday.
However, she added he was a reasonable supervisor.
I asked Deputy Salazar what her opinion of Lieutenant Cedergren was, and she told me she had
always liked him, as he used to be her supervisor on the security side of the jail. She stated she
also viewed him as level-headed supervisor who made good decisions. She told me from what
she could remember, she thought he also had the respect of the deputies and sergeants he
supervised. However, she told me that since he became a lieutenant, she did not really know him
that well anymore and she had limited interactions with him.
I asked Deputy Salazar what her understanding of an “express” was and she told me it was a
combative arrestee, who needed to be assessed by deputies once they arrived at the jail. When
Deputy Salazar heard Mr. Madrigal was in the WRAP and he was an “express,” she confirmed
she understood this to mean that Mr. Madrigal was non-cooperative and/or combative. Deputy
Salazar added, once she saw Mr. Madrigal in the WRAP and wearing a spit mask, this further
bolstered her belief.
I asked Deputy Salazar if it would be reasonable to conclude, based on these facts, that the
restraint chair would have been a reasonable choice to use for Mr. Madrigal, and she told me yes.
Deputy Salazar stated, she thought that was the best option available to them at the time.
I asked Deputy Salazar if she had ever seen anyone attach ankle restraints to the handcuffs an
inmate had been wearing to hold them against the door before and she told me no, not in that
manner.
Deputy Salazar added, she has seen deputies use ankle restraints or another pair of handcuffs to
help with leverage when pulling an inmate’s hands through the cuffing port of a cell door before.
Page 23 of 117

 However, Deputy Salazar confirmed she never saw a deputy use restraints to restrain an inmate
to a fixed object before, like Lieutenant Cedergren did.
I asked Deputy Salazar if she had ever tethered an inmate to the door before, and she told me no.
I asked Deputy Salazar if she was surprised when she saw Lieutenant Cedergren tether Mr.
Madrigal to the door, and she told me yes. Deputy Salazar stated she had never seen a deputy
tether an inmate to the door before. Deputy Salazar added, she did not really understand what
was happening at the time, so she thought Lieutenant Cedergren may have been using a
technique that she had never learned. However, she told me that it did not make sense to her,
when Lieutenant Cedergren had done that.
I asked Deputy Salazar if she ever heard Lieutenant Cedergren discuss a plan on how to deal
with Mr. Madrigal, and she told me no.
I asked Deputy Salazar if she was surprised when Lieutenant Cedergren arrived on scene and
went “hands on” with Mr. Madrigal. She told me she was not surprised because she had known
Lieutenant Cedergren to be more involved than most lieutenants. However, she stated in the
same regard, most lieutenants do not go “hands on,” so that was a surprise.
I asked Deputy Salazar if she ever thought the deputies were in danger or needed Lieutenant
Cedergren to step in, and she told me no.
I asked Deputy Salazar if she was surprised when the restraint chair was not used, and she told
me yes. Deputy Salazar told me, from her understanding she believed all the deputies on scene
thought the restraint chair should have been used with Mr. Madrigal and from what she
remembered, Sergeant Graham was also upset the restraint chair was not utilized.
I asked Deputy Salazar if she had recently been trained on the use of the restraint chair, and she
told me yes.
I asked Deputy Salazar if she thought this would have been an ideal situation to use the restraint
chair, and she told me yes. Deputy Salazar added that the ITR deputies were so upset that
Lieutenant Cedergren did not approve the use of the restraint chair, they decided to leave the
restraint chair next to Mr. Madrigal’s cell. She told me the purpose of doing so, was just so every
time Lieutenant Cedergren walked by Mr. Madrigal’s cell, he would have to look at the empty
restraint chair.

Page 24 of 117

 Summary of Interview with Deputy Chris McMann
On Tuesday, December 17, 2019, Deputy Woods and I interviewed Deputy McMann in the
administrative conference room at SRJ. In summary, Deputy McMann told me the following:
On June 10, 2019, while Deputy McMann was at lunch, he heard ITR requesting assistance for
an “express.” Deputy McMann ran to ITR, and upon his arrival, he learned Mr. Madrigal had
been brought to the jail in the WRAP by Fremont PD. When Deputy McMann saw Mr.
Madrigal, he could tell Mr. Madrigal was intoxicated and/or under the influence of an unknown
substance.
There was no real effective communication between Mr. Madrigal and staff, so the decision was
made to bring Mr. Madrigal to one of the “R” tanks in ITR and remove the WRAP. However, the
deputies had difficulty removing Mr. Madrigal from the WRAP because he pushed against them
as they exerted their effort to remove it.
One of the deputies suggested they use the restraint chair to restrain Mr. Madrigal, and the chair
was positioned next to Mr. Madrigal’s cell door. Sergeant Graham asked permission from
Lieutenant Cedergren to use the chair, but when Lieutenant Cedergren responded, the decision to
use the chair was not chosen. Lieutenant Cedergren told the deputies to take Mr. Madrigal out of
the WRAP and they were directed, step-by-step, on how to do it. Later, Deputy McMann saw a
deputy attaching ankle restraints to Mr. Madrigal’s handcuffs and he thought that was to hold the
inmate against the door. At this point, Deputy McMann backed away and left the care and
custody of Mr. Madrigal to the ITR deputies.
I asked Deputy McMann what his opinion of Sergeant Graham was, but he told me he did not
really know him. I asked him if Sergeant Graham seemed to have the respect of the deputies that
were on scene in ITR, and he told me yes. I asked him if he thought Sergeant Graham was a
competent ITR supervisor, and he told me yes. I asked him if he believed Sergeant Graham
wanted to use the restraint chair, and he told me yes. Deputy McMann told me everyone who
was on scene, prior to Lieutenant Cedergren’s arrival, wanted to use the restraint chair to restrain
Mr. Madrigal.
I asked Deputy McMann if he knew Lieutenant Cedergren, and he told me no, he had never
worked with him.
I asked Deputy McMann what his understanding of an “express” was. Deputy McMann told me
he believed it was someone who was extremely resistive, combative, or “high,” who needed to
forego the normal booking process, so they could be placed in a cell to sober up as safely as
possible.

Page 25 of 117

 When Deputy McMann heard Mr. Madrigal was in the WRAP and he was an “express,” he
confirmed he understood this to mean Mr. Madrigal was non-cooperative and/or combative. He
added, once he saw Mr. Madrigal was in the WRAP and wearing a spit mask, this further
bolstered this same belief.
I asked Deputy McMann if it would be rational to conclude, based on these facts, that the
restraint chair would have been a reasonable choice to use for Mr. Madrigal, and he told me yes.
Deputy McMann later admitted he was shocked when Lieutenant Cedergren did not approve the
use of the restraint chair.
I asked Deputy McMann if he thought the restraint chair was the best option available to them at
the time. Deputy McMann told me he did believe the restraint chair was a viable option, but he
also told me if they could have gotten the handcuffs off Mr. Madrigal and allowed him to roam
around in the cell, that would also have been another viable option. In addition, Deputy McMann
stated, another option would have been to leave Mr. Madrigal in handcuffs and allow him to
remain in the cell, with only the handcuffs restraining him.
I asked Deputy McMann if he had ever attached ankle restraints to the handcuffs an inmate had
been wearing, and he told me no. However, Deputy McMann did tell me he had witnessed
deputies attach ankle restraints to an inmate’s handcuffs before, as a temporary means to assist in
removing an assaultive inmate’s clothes. I asked Deputy McMann if he had ever been taught to
attach ankle restraints to an inmate’s handcuffs before, and he told me no.
I asked Deputy McMann if he had ever tethered an inmate to the door before, and he told me no.
I asked Deputy McMann if he had ever seen another deputy tether an inmate to the door before,
and he told me no.
I asked Deputy McMann if he was aware of Lieutenant Cedergren discussing the option of using
the restraint chair with anyone, and he told me no.
I asked Deputy McMann if he was surprised when Lieutenant Cedergren arrived on scene and
did not discuss a plan, nor did he discuss using the restraint chair with anyone. Deputy McMann
told me yes, saying this made him feel like there was a lack of direction and, other than
Lieutenant Cedergren telling people what to do, there was no real plan in place.

Page 26 of 117

 Summary of Interview with Deputy Chris Comfort
On Monday, December 30, 2019, Deputy Woods and I interviewed Deputy Comfort in the
administrative conference room at SRJ. In summary, Deputy Comfort told me the following:
On June 10, 2019, Deputy Comfort was working in ITR at SRJ, when Mr. Madrigal was brought
into the jail. It was apparent Mr. Madrigal was under the influence of a hallucinogen and he was
determined to be an “express.”
I asked Deputy Comfort what his opinion of Sergeant Graham was. Deputy Comfort told me
both Sergeant Graham and Lieutenant Cedergren had leadership skills he liked. He went on to
say Sergeant Graham was a good supervisor to work under – as he was true to his word, he
would take care of his troops, and he would keep everyone current on changing policies. I asked
Deputy Comfort if Sergeant Graham had good judgment and if people seemed to respect his
opinion and he told me yes. Deputy Comfort told me he believed Sergeant Graham was a
competent ITR supervisor, with a lot of street smarts.
I asked Deputy Comfort what his opinion of Lieutenant Cedergren was. He told me Lieutenant
Cedergren was very “book smart” and he had a lot of administrative skills. When I asked Deputy
Comfort if he thought Lieutenant Cedergren was a competent ITR Watch Commander, he told
me yes; however, he stated while Lieutenant Cedergren had experience in ITR, it was “older”
experience. Deputy Comfort added Lieutenant Cedergren’s style was more “hands on” and he
chose to get involved physically – as if he were another deputy, as opposed to more of a watch
commander / supervisory role.
I asked Deputy Comfort if he believed the restraint chair was a reasonable option to use with Mr.
Madrigal, based on the facts known to him at the time and he told me yes. Deputy Comfort also
confirmed, at the time, he thought the restraint chair was the best option available to them,
adding everyone had just been trained on how to use the restraint chair.
I asked Deputy Comfort to tell me what Lieutenant Cedergren did when he arrived on scene.
Deputy Comfort told me he did not remember Lieutenant Cedergren discussing the benefits or
drawbacks of using the restraint chair with anyone. Rather, once Lieutenant Cedergren arrived
on scene, he just took over Sergeant Graham’s position, basically pushing him aside and
“bullying him” down into a deputy role.
I asked Deputy Comfort if he had ever attached ankle restraints to an inmates’ handcuffs before
and he told me yes. I asked Deputy Comfort if an inmate had ever resisted being pulled back
towards the door for deputies to remove the ankle chains, and he told me yes. I asked Deputy
Comfort what was done in that scenario and he told me the deputies simply stopped pulling on
the ankle restraint chains and just opened up the door and remedied the situation. I asked Deputy
Comfort if he remembered if deputies had to use force against the inmate, in any of those
Page 27 of 117

 situations. Deputy Comfort told me no, saying when the deputies opened the cell door, the
inmate was somewhat pinned against the door and because of this, the inmate was pulled out of
the room with the outswing of the door.
I asked Deputy Comfort if he ever heard of a situation where an inmate refused to put their hands
out through the cuffing port of the door and a deputy left the inmate in the cell with the ankle
restraints attached to the inmates’ handcuffs and he told me no.
I asked Deputy Comfort if he had ever left an inmate tethered to the door or if he had ever seen
another deputy sheriff leave an inmate tethered to the door before and he told me no.
I asked Deputy Comfort if he was surprised when he saw Lieutenant Cedergren go “hands on”
with the other deputies and he told me no. However, Deputy Comfort did say he thought
Lieutenant Cedergren’s role as a lieutenant, should have been in more of a support role for
Sergeant Graham. Furthermore, he thought Lieutenant Cedergren’s actions of getting involved,
were inappropriate.
I told Deputy Comfort in watching the videos, it appeared one or more of the deputies were
uncomfortable and/or surprised by what Lieutenant Cedergren was telling them and/or directing
them to do. I asked Deputy Comfort if he had any of those same feelings and he told me yes.
Deputy Comfort said the team was already “battle tested” and was anticipating using the restraint
chair. However, Lieutenant Cedergren took the team in a new direction, which only confused
everyone.
I asked Deputy Comfort if he knew why Lieutenant Cedergren left Mr. Madrigal tethered to the
door with the ankle restraints, instead of going back inside the cell to remove them, and he told
me no. He added, if he had to guess, he thought Lieutenant Cedergren did not want to backtrack
and change his plan, as he had already decided on that course of action. I asked him if he thought
Lieutenant Cedergren left Mr. Madrigal tethered to the door to teach him a lesson for not
cooperating and he told me no, saying he thought it was more likely Lieutenant Cedergren did
that out of frustration.
I asked Deputy Comfort if there was a reason why they could not have opened up the door to Mr.
Madrigal’s cell and gone inside, to remove the ankle restraints and then simply laid Mr. Madrigal
on the ground and exited the cell. Deputy Comfort told me no, saying Mr. Madrigal was only
being passive resistant and going back inside the cell to remedy the situation, was the only
solution.
I asked Deputy Comfort if he knew Lieutenant Cedergren to do things that would be considered
questionable or reckless and he told me no.

Page 28 of 117

 I asked Deputy Comfort if he was aware of Lieutenant Cedergren approving or denying the use
of the restraint chair before and he told me no.
I told Deputy Comfort, in watching his BWC video, I saw Lieutenant Cedergren walk over to
him, after Mr. Madrigal had been secured in the cell and tethered to the door and make a
comment about the restraint chair. I asked Deputy Comfort to tell me what Lieutenant Cedergren
said to him. Deputy Comfort told me Lieutenant Cedergren something to the effect of not
wanting to use the restraint chair. I asked Deputy Comfort if Lieutenant Cedergren said why he
did not want to use the restraint chair. Deputy Comfort told me he could only guess, and he told
me he thought Lieutenant Cedergren’s lack of familiarity with the chair was a factor. Deputy
Comfort elaborated on this point, by explaining because Lieutenant Cedergren was acting like he
was the “tip of the spear,” he was not going to bring in a device he did not know how to operate
while he was in charge.

Page 29 of 117

 Summary of Interview with Deputy Tiffiny Ross
On Monday, December 23, 2019, Deputy Woods and I interviewed Deputy Ross in the
administrative conference room at SRJ. In summary, Deputy Ross told me the following:
On June 10, 2019, Deputy Ross was working in ITR at SRJ, when she was notified Mr. Madrigal
had been deemed an “express” and was brought into the jail by Fremont PD. Deputy Ross went
outside and saw Mr. Madrigal in the WRAP, in the back of the patrol car. Deputy Ross assisted
in carrying Mr. Madrigal into the jail for booking, but he refused to answer the medical
questions. Medical staff approved his transfer into jail custody, and Mr. Madrigal was moved
into ITR; however, the deputies were unable to get Mr. Madrigal transitioned out of the WRAP,
as he resisted their efforts. Deputies requested to use the restraint chair and notified Sergeant
Graham, who requested permission from Lieutenant Cedergren.
Lieutenant Cedergren came to ITR and told the deputies to take Mr. Madrigal out of the WRAP,
as he assisted them in doing so. After partially removing the WRAP from Mr. Madrigal, ankle
restraints were attached to Mr. Madrigal’s handcuffs and then fed through the cuffing port and
then the remainder of the WRAP was removed. Mr. Madrigal was pushed into the cell and the
cell door was closed. However, deputies were unable to pull Mr. Madrigal’s hands back out of
the cuffing port. Lieutenant Cedergren used a second pair of handcuffs and attached them to the
other end of the ankle restraints and then attached the handcuffs to the door.
Deputies started a restraint log and checked on Mr. Madrigal on a regular basis. At some point,
Mr. Madrigal maneuvered his handcuffs to the front of his body. After a period of time, Deputy
Ross saw Lieutenant Cedergren go check on Mr. Madrigal and he asked Deputy Ross to standby
while he opened the door. Deputy Ross asked Lieutenant Cedergren if Mr. Madrigal had
strangled himself and he told her no, he did not think so. However, after Lieutenant Cedergren
opened the door and stepped back, she could see the chain of the ankle restraints was wrapped
around Mr. Madrigal’s neck. Deputy Rhoades came over and assisted Deputy Ross and
Lieutenant Cedergren in removing the chain from around Mr. Madrigal’s neck.
I asked Deputy Ross what her opinion of Sergeant Graham was, and she told me he was a good
supervisor. However, she stated sometimes it seemed like he had “one foot out the door” and as a
result, he did not provide the level of leadership they desired.
I asked Deputy Ross what her opinion of Lieutenant Cedergren was and she told me she had not
really worked with him. She stated she thought he was always very approachable, and she did
not have any issues with him. However, she told me that when Lieutenant Cedergren came to
ITR, about 2-3 weeks prior to this incident, he did not try to understand why the deputies did
certain things. Instead, Lieutenant Cedergren just tried to change everything – which frustrated
and annoyed her and many of the other deputies in ITR. Deputy Ross elaborated on her point and
Page 30 of 117

 said Lieutenant Cedergren would oftentimes make changes, but he would never take the time to
explain why he wanted to make the changes, leaving the deputies to guess his reasoning.
I asked Deputy Ross if anyone ever voiced any concerns over this to Lieutenant Cedergren.
Deputy Ross told me she and the other deputies talked to Sergeant Graham about it, but because
he was not fully involved at work anymore, she did not know if he ever made Lieutenant
Cedergren aware of their concerns. Deputy Ross added she personally never talked to Lieutenant
Cedergren about this, as she would never question a lieutenant directly.
I asked Deputy Ross if she thought Lieutenant Cedergren had the respect of the deputies in ITR.
Deputy Ross told me she respected him when he worked on the security side of the jail.
However, Deputy Ross stated the way Lieutenant Cedergren handled this situation and other
things when he first came to ITR – like telling her and the other deputies how to do their job,
made it difficult to say if she respected him or not. Deputy Ross confirmed she thought
Lieutenant Cedergren would try and tell them what to do, when he did not have the requisite
knowledge to legitimize this.
I asked Deputy Ross to estimate how competent Lieutenant Cedergren was as an ITR supervisor.
Deputy Ross told me on a 1-10 scale (1 – being totally incompetent and 10 – being extremely
competent), she would rate him at a 3 or a 4.
I asked Deputy Ross what her understanding of an “express” was. She told me this was typically
someone that was combative, non-compliant, or uncooperative. When Deputy Ross heard Mr.
Madrigal was an “express” and she saw he was in the WRAP, she confirmed she suspected Mr.
Madrigal was non-cooperative and/or combative. However, Deputy Ross added she would
generally make that final determination after the inmate was brought into the lobby.
I asked Deputy Ross if it would be rational to conclude, based on these facts, the restraint chair
would have been a reasonable choice to use to restrain Mr. Madrigal and she told me yes, saying
she thought the restraint chair was the best option available to them at the time. Deputy Ross
confirmed she and all the other deputies on scene wanted to use the restraint chair and Sergeant
Graham was made aware of this.
I asked Deputy Ross if she had ever attached ankle restraints to the handcuffs an inmate had been
wearing and she told me yes. Deputy Ross stated ITR deputies had used this technique many
times in the past, to remove a combative inmates’ handcuffs and avoid injury. Deputy Ross told
me this technique was successful about 90% of the time. However, she stated when the technique
was not successful, the deputies would always go back inside the cell to remove the ankle
restraints from the handcuffs.
I asked Deputy Ross if she had ever tethered an inmate to the door before or if she had ever seen
another deputy sheriff tether an inmate to the door before and she told me no. I asked Deputy
Page 31 of 117

 Ross if she was surprised when she saw Lieutenant Cedergren arrive on scene and then go
“hands on” with her and the other deputies. Deputy Ross told me yes, saying she did not think
Lieutenant Cedergren took the time he needed to, to understand what they were doing.
I asked Deputy Ross if she knew why Lieutenant Cedergren left Mr. Madrigal tethered to the
door with the ankle restraints, instead of going back inside the cell to remove them. Deputy Ross
told me she thought he may have done so to avoid a use of force and to let Mr. Madrigal “cool
off.” Deputy Ross told me she did not know if Lieutenant Cedergren’s intent was to teach Mr.
Madrigal a lesson, but she stated it was possibly more likely Lieutenant Cedergren just did not
know what else to do.
I asked Deputy Ross if Lieutenant Cedergren was known to do things that were questionable or
reckless. She told me yes, but only in this particular incident involving Mr. Madrigal.
I asked Deputy Ross if she ever heard Lieutenant Cedergren discuss using the restraint chair with
anyone, after he arrived on scene, and she told me no. I asked her if she was aware of Lieutenant
Cedergren ever approving or denying the use of the restraint chair and she told me no.
I asked Deputy Ross if she had recently been trained on the restraint chair and she told me yes,
saying she and the other deputies had just been trained at the June range. Also, Deputy Ross
added her, and the other deputies had recently received additional familiarization/training on the
restraint chair in ITR. She explained this was done in preparation for inmates who refuse to go to
court.
I asked Deputy Ross if Lieutenant Cedergren ever told them what the plan was, once the inmate
had been taken out of the WRAP and she told me no, saying Lieutenant Cedergren only directed
them on what to do. I asked Deputy Ross if Lieutenant Cedergren ever discussed a plan with
anyone, and she told me no. I asked her if she thought that was odd and she told me yes. I asked
Deputy Ross if she would have expected her supervisor to tell her a plan and not to just “jump
in” and she told me yes.
I asked Deputy Ross if there was ever a reason to be concerned if an inmate maneuvered his
handcuffs to the front of his body. Deputy Ross told me yes, saying the inmate would then have
access to a weapon and could wrap their arms around someone and/or choke someone.
I asked Deputy Ross what made her consider the possibility Mr. Madrigal was strangling himself
and she told me she saw the tension on the ankle restraints and her intuition told her there was a
problem.
After the incident was over, I asked Deputy Ross if she remembered anyone being upset and/or
making comments about why the restraint chair was not utilized. Deputy Ross told me yes,
saying she remembered everyone was pretty upset about it. Deputy Ross also confirmed Sergeant
Page 32 of 117

 Graham was baffled and appeared to have been confused as to why Lieutenant Cedergren had
not approved the use of the restraint chair.
I asked Deputy Ross if, based on the totality of the circumstances, this was the ideal situation to
have used the restraint chair and she told me, “absolutely.” Deputy Ross added she thought it
was a poor decision to not use the restraint chair for this incident.

Page 33 of 117

 Summary of Interview with Sergeant Johnnie Graham
On Saturday, January 11, 2020, Captain Christy and I interviewed Sergeant Graham in the
commander’s meeting room at Dublin Police Services (DPS). In summary, Sergeant Graham told
me the following:
On June 10, 2019, Sergeant Graham was working in ITR at SRJ, when he was summoned to the
law enforcement lobby for an “express.” Sergeant Graham responded and saw several ACSO
deputies outside at Fremont PD’s patrol vehicle. Sergeant Graham spoke with Fremont PD and
they told him they had already dealt with Mr. Madrigal several times that day and he had been
combative, and they believed he was also under the influence of mushrooms. Mr. Madrigal was
wearing a spit mask and he had already been restrained in the WRAP. Sergeant Graham saw that
once Mr. Madrigal was removed from the patrol vehicle he was agitated and uncooperative and
he did not seem to understand their directions.
All attempts to calm Mr. Madrigal down were unsuccessful. Sergeant Graham decided to bring
Mr. Madrigal into ITR, under the established procedures for an “express.” Jail staff brought Mr.
Madrigal into ITR and placed him inside a cell.
Sergeant Graham told me an “express” is the term given to an arrestee who is generally agitated,
intoxicated, non-cooperative, or difficult, which also necessitated additional deputies respond
and standby for assistance.
I asked Sergeant Graham if he thought the restraint chair was a good option to use with Mr.
Madrigal. Sergeant Graham told me he thought the possibility of transitioning Mr. Madrigal out
of Fremont PD’s WRAP and into an ACSO WRAP was a possibility, but he stated his
understanding was the department wanted to move away from the WRAP toward the
implementation of the restraint chair. To bolster this belief, Sergeant Graham added this was why
they were sent to training for the restraint chair, why they had trained on the restraint chair at the
range, why they watched videos on how to use the restraint chair in muster, and why he and his
deputies in ITR practiced the application of the restraint chair. Sergeant Graham confirmed he
believed, at that time, the restraint chair was the best option with Mr. Madrigal.
Captain Christy asked Sergeant Graham if he had used the restraint chair before and he told us
yes, saying he was present when the restraint chair had been used on a prior application and he
was comfortable in using it. Sergeant Graham also confirmed he understood how the restraint
chair worked and he was familiar with the polices surrounding the use of the restraint chair.
I asked Sergeant Graham if he had significant experience working in ITR as a supervisor and he
told me yes. Sergeant Graham told me he was the most senior supervisor in ITR, and he had
worked in ITR as a supervisor for about three and a half (3.5) years.
Page 34 of 117

 Sergeant Graham told me he felt confident in dealing with Mr. Madrigal, based on his past
experience, as he had dealt with hundreds of non-cooperative arrestees that needed to be booked
into ITR. He stated on a historical average, there were 3 to 5 “express” inmates brought to SRJ
each week, week after week, year after year, with some type of mental impairment.
I asked Sergeant Graham if he had ever attached ankle restraints to an inmate’s handcuffs before
and he told me yes. Sergeant Graham said he would do this to pull an inmate against the door to
remove the inmate’s handcuffs. Sergeant Graham also stated he saw deputies attach ankle
restraints to an inmate’s handcuffs, feed the ankle restraints through the cuffing port, and attach
the other end of the ankle restraints to the exterior door handle, but only as a temporary means to
prevent the inmate from overpowering the deputy and pulling their hands into the cell through
the cuffing port. Sergeant Graham confirmed this technique was shown to Defensive Tactics
instructors who approved the use of it, for a temporary measure to prevent deputies from getting
hurt.
I asked Sergeant Graham if he had ever tethered an inmate to the door or saw another deputy
sheriff tether an inmate to the door before and he told me no.
I asked Sergeant Graham if, once Lieutenant Cedergren arrived on scene, Lieutenant Cedergren
ever discussed Mr. Madrigal’s history with him and the options available to restrain Mr.
Madrigal. Sergeant Graham told me yes, but he stated this was only a very brief conversation, as
Lieutenant Cedergren was walking while Sergeant Graham was talking to him.
I asked Sergeant Graham if he was surprised when Lieutenant Cedergren just walked past him
and went over to the other deputies. Sergeant Graham stated he had worked extensively with
Lieutenant Cedergren in the past, from when they worked together as deputies and sergeants and
he thought he had a good grasp of Lieutenant Cedergren’s working style. In answer to my
question, Sergeant Graham told me he no, he was not surprised when Lieutenant Cedergren
arrived on scene and took over, as he knew Lieutenant Cedergren to be “hands on.”
I asked Sergeant Graham if he thought Lieutenant Cedergren acted in a dismissive manner
towards him, when he arrived on scene. Sergeant Graham told me he was not surprised that
Lieutenant Cedergren treated him that way. Sergeant Graham told me he had received several
complaints from his staff and the other ITR sergeants, on some of the other teams, about
Lieutenant Cedergren over the last month. Sergeant Graham said he met with Lieutenant
Cedergren to go over his concerns and he left that meeting feeling like Lieutenant Cedergren was
not receptive to what he was talking about. Sergeant Graham elaborated on this point by saying
over the 4-6 weeks that Lieutenant Cedergren had been working in ITR, they had significant
staffing issues as it pertained to the ITR lieutenant and he informally brought those concerns up
to Lieutenant Jared Hattaway and Captain Derek Hesselein. Furthermore, Sergeant Graham told
them Lieutenant Cedergren was doing things in front of the ITR deputies he did not want them
Page 35 of 117

 seeing, as he believed Lieutenant Cedergren was not doing things properly and he did not want
his deputies learning the wrong way to do things.
Sergeant Graham clarified his response and said he never directly confronted Lieutenant
Cedergren over the things Lieutenant Cedergren was doing he did not agree with. Sergeant
Graham said he just tried to manage the best he could without being confrontational, as Sergeant
Graham was afraid of what he would say to Lieutenant Cedergren. However, this also meant
several times he and Lieutenant Cedergren would work an entire shift together and they would
not even speak to each other.
I asked Sergeant Graham how he felt when Lieutenant Cedergren did not respond to ITR after
the first time he contacted him on the radio, and he told me he felt like Lieutenant Cedergren was
“second guessing” him. Sergeant Graham added, he was expecting Lieutenant Cedergren to grant
him permission to use the restraint chair over the air and then respond to monitor the event.
When Lieutenant Cedergren did not respond over the radio granting verbal approval, Sergeant
Graham became frustrated with the delay and then as time progressed, he felt disrespected.
Sergeant Graham added that time delay for Lieutenant Cedergren’s response was significant, as
they were dealing with Mr. Madrigal and everyone was just waiting for Lieutenant Cedergren to
show up.
As an ITR supervisor, Sergeant Graham estimated in the past, he has requested permission to use
the WRAP about twenty times and every time he would get a verbal approval on the radio. Then,
depending on what was going on at the jail, the approving lieutenant would sometimes respond
to ITR, to monitor the event. Sergeant Graham said this was the first time he had to ask
Lieutenant Cedergren for approval for a restraint device, as he had always gone through the
watch commander for SRJ, in the past.
I asked Sergeant Graham how it made him feel when Lieutenant Cedergren arrived in ITR, but
did not even stop walking, to get his opinion on how they should handle Mr. Madrigal. Sergeant
Graham said he was not surprised Lieutenant Cedergren was not fully interested in listening to
his plan or his observations of Mr. Madrigal. At this point, Sergeant Graham stated he allowed
Lieutenant Cedergren to take over, as he recognized the need to follow the chain of command
and he did not challenge Lieutenant Cedergren, as he did not want to get in a confrontation with
him.
Sergeant Graham stated he later regretted this decision to not speak up and he wished he had
voiced his objection and “stood up” more, for his plan on how he thought Mr. Madrigal should
have been handled.
Sergeant Graham tried to provide Lieutenant Cedergren with as much detail, as fast as he could,
by saying Mr. Madrigal was “high,” officers from Fremont PD thought Mr. Madrigal was under
the influence of mushrooms, Mr. Madrigal had been uncooperative with ACSO staff and he
Page 36 of 117

 thought if they took Mr. Madrigal out of the WRAP he was going to fight with them, and he
wanted to use the restraint chair.
Sergeant Graham stated he thought he made a good assessment of what was going on and he had
a plan in place and he admitted he was upset when Lieutenant Cedergren did not grant him the
approval to place Mr. Madrigal in the WRAP.
Sergeant Graham told us Lieutenant Cedergren had accused him of being weak, as Lieutenant
Cedergren told him he was not as “hands on” as Lieutenant Cedergren would have liked him to
have been. Sergeant Graham explained he preferred not to get directly involved in events, but
rather to stand back and watch more in a supervisory / manager role, so he could prevent getting
so involved, his judgement would become clouded by his personal feelings.
I asked Sergeant Graham if he thought Lieutenant Cedergren had the respect of the ITR deputies.
Sergeant Graham told me Lieutenant Cedergren did not have a good working relationship with
the ITR deputies, which was evident to him by the statements several ITR deputies made to him
about Lieutenant Cedergren doing things that made their jobs harder. Sergeant Graham told me
Lieutenant Cedergren’s knowledge of certain polices was not current and he was doing things
improperly.
In regard to the event with Mr. Madrigal, Sergeant Graham said he could tell several of the
deputies were not happy with the directions Lieutenant Cedergren was giving them, as they
would roll their eyes after Lieutenant Cedergren told them what to do or they would look at
Sergeant Graham. Sergeant Graham admitted this was the point where he felt like he was weak
and he should have done something, but instead he just allowed Lieutenant Cedergren to control
the event, as Lieutenant Cedergren outranked him.
I asked Sergeant Graham if he knew why Lieutenant Cedergren left Mr. Madrigal tethered to the
cell door and he told me no, but he guessed that Lieutenant Cedergren did that planning to “wait
him (Mr. Madrigal) out.” I asked Sergeant Graham if it would have been reasonable to go back
inside the cell to remove the ankle restraints from Mr. Madrigal’s handcuffs and he told me yes.
Sergeant Graham stated, that in his opinion, he saw that as the only option once they were unable
to remove the ankle restraints from Mr. Madrigal’s handcuffs.
I asked Sergeant Graham if he thought it was reasonable for Lieutenant Cedergren to tether Mr.
Madrigal to the door and he told me he thought Lieutenant Cedergren must have thought it was
reasonable. I asked Sergeant Graham if he would have allowed a deputy to tether an inmate to
the door with ankle chains and he told me no, saying he would never tether an inmate to the door
with ankle chains, either.
Sergeant Graham told me he had approached Lieutenant Cedergren right after Mr. Madrigal had
been secured in the cell and then tethered to the door, because he was frustrated the restraint
Page 37 of 117

 chair was not used. Sergeant Graham said he told Lieutenant Cedergren he understood
Lieutenant Cedergren did not want to use the restraint chair, but he asked him why he did not
grant the approval to use it. Lieutenant Cedergren told him command staff did not want him
using the chair, because staff was not familiar enough with it and staff did not understand the
purpose of it.
Sergeant Graham clarified his statement by saying Lieutenant Cedergren told him the reason he
did not grant permission for Sergeant Graham to use the restraint chair was because “the
Captain” did not want them using the chair in ITR. Lieutenant Cedergren told him there was an
incident with the restraint chair the previous night, the restraint chair was not fully implemented,
and policy regarding the restraint chair was still being worked on.
Within a couple days of Lieutenant Cedergren telling Sergeant Graham this, Sergeant Graham
contacted Captain Hesselein, because he knew Captain Hesselein was responsible for obtaining
the restraint chair. Sergeant Graham asked Captain Hesselein if he gave explicit directions not to
use the chair and he said, “What are you talking about? I’m the one that got the chair.” Captain
Hesselein confirmed to Sergeant Graham, he had no knowledge of any orders or policies
prohibiting the use of the restraint chair.
Sergeant Graham added he did not believe there ever was any orders from management,
prohibiting the use of the restraint chair. Rather, he thought Lieutenant Cedergren was simply not
familiar enough with how the chair worked and did not want to use the restraint chair for that
reason.
I asked Sergeant Graham if he thought Lieutenant Cedergren left Mr. Madrigal tethered to the
door as a form of punishment for not cooperating. Sergeant Graham told me no, saying he never
heard Lieutenant Cedergren say anything that would have led him to believe that.
I asked Sergeant Graham if he knew Mr. Madrigal had maneuvered his handcuffs to the front of
his body and he told me yes. I asked Sergeant Graham if this concerned him and he told me no.
Sergeant Graham stated he was most concerned with trying to get Mr. Madrigal to comply and
allow the handcuffs to be removed.

Page 38 of 117

 Summary of Interview with Sergeant Kevin Estep
On Friday, February 14, 2020, Deputy Lonnell Goodall and I interviewed Sergeant Estep in an
interview room inside the Special Victim’s Unit (SVU), out of the Eden Township Substation
(ETS), located at 15001 Foothill Blvd, San Leandro. In summary, Sergeant Estep told me the
following:
On June 10, 2019, about 1630 hours, Sergeant Estep reported to SRJ to work an overtime shift in
ITR as the ITR Sergeant. Sergeant Estep spoke with Sergeant Graham, who told him how Mr.
Madrigal had been placed in a cell, tethered to the door. Sergeant Estep remembered Sergeant
Graham was very upset, as Sergeant Graham told him he got into a disagreement with Lieutenant
Cedergren about how Mr. Madrigal should have been restrained and dealt with in ITR. Sergeant
Graham stated he thought Mr. Madrigal should have been restrained in the restraint chair, but
Lieutenant Cedergren did not agree with him.
Sergeant Estep went and checked on Mr. Madrigal in the cell and then he went to the 1700-hour
muster. Sergeant Estep contacted one of his ITR deputies and told him after muster had
concluded, Sergeant Estep wanted the deputy to go contact Mr. Madrigal and talk to him, so he
could get him out of the restraints and properly booked. However, about one minute later, the
call went out for medical assistance and he learned Mr. Madrigal needed immediate medical
attention.
I asked Sergeant Estep if he knew why Lieutenant Cedergren did not approve Mr. Madrigal to be
placed in the restraint chair and he told me no. However, he stated when he had a conversation
with Lieutenant Cedergren, he made a reference to the restraint chair and Lieutenant Cedergren
told him how in the “old days,” he (Lieutenant Cedergren) used to always handcuff people in
that manner and he did not think the restraint chair was necessary and/or he did not want to use
the restraint chair.
Sergeant Estep confirmed Lieutenant Cedergren told him Mr. Madrigal had been handcuffed
behind his back and then an ankle chain was attached to the handcuffs and the other end of the
ankle restraints were attached to the door. I asked Sergeant Estep if Lieutenant Cedergren
appeared concerned at all, when Lieutenant Cedergren explained how he had restrained Mr.
Madrigal, and he told me no.
I asked Sergeant Estep if he was aware of any problems with the restraint chair or any issues that
would have prohibited using the restraint chair at the time of this incident and he told me no.
I asked Sergeant Estep if he had ever tethered an inmate to the door with ankle restraints before
or if he had ever seen anyone else tether an inmate to the door before and he told me no.

Page 39 of 117

 I asked Sergeant Estep if it was his understanding Lieutenant Cedergren would have the final say
as to how they handled Mr. Madrigal, based on the fact Lieutenant Cedergren was the ITR
Watch Commander and he told me yes.
I asked Sergeant Estep if he saw any reason why the deputies could not have gone back into the
cell to retrieve the ankle chains, once Mr. Madrigal refused to cooperate and allow himself to be
uncuffed. Sergeant Estep told me he thought there was a hesitancy for deputies to go back inside
a cell with an inmate that may be hostile and supposed that may have been a factor; however, he
added if that was a concern, a Resistive Inmate Management (RIM) team could have been
assembled to enter Mr. Madrigal’s cell to limit the chance of injury.
I asked Sergeant Estep if Mr. Madrigal was only being passively resistant, if there would still be
any concerns and he told me no. Sergeant Estep stated in that scenario, several deputies could
enter the cell and place Mr. Madrigal face down on the ground and then remove the restraints,
before backing out of the cell.
I asked Sergeant Estep what his opinion of Sergeant Graham was, and he told me he thought
Sergeant Graham was a hard worker and a competent ITR supervisor.
I asked Sergeant Estep what his opinion of Lieutenant Cedergren was and he told me he did not
know him well enough to offer an opinion of him. However, Sergeant Estep did state he heard
several deputies complaining about how Lieutenant Cedergren was doing things that were out of
policy, by moving multiple maximum-security inmates and administrative segregation inmates
by himself.
I provided Sergeant Estep with the details surrounding Mr. Madrigal being brought into custody
at SRJ. I asked Sergeant Estep if, based on these facts, he thought the restraint chair was a
reasonable option to use and he told me yes. I asked Sergeant Estep if he could think of a better
option and he told me no. Sergeant Estep added this scenario was what the restraint chair was
designed for and everyone had just been trained on it.

Page 40 of 117

 Summary of Interview with Deputy Nikki Rhoades
On Tuesday, February 11, 2020, Deputy Luis Martinez and I interviewed Deputy Rhoades in the
conference room at YFSB, out of ETS. In summary, Deputy Rhoades told me the following:
On June 10, 2019, Deputy Rhoades was working in ITR at SRJ, when Mr. Madrigal was brought
into the jail by Fremont PD. Fremont PD officers told her Mr. Madrigal was possibly under the
influence of a hallucinogen and he had assaulted their staff; she saw Mr. Madrigal had already
been restrained in the WRAP.
Deputy Rhoades and several other ACSO deputies brought Mr. Madrigal into ITR to transition
him out of the WRAP and into the restraint chair. Deputies advised Sergeant Graham of their
intention to use the restraint chair and he notified Lieutenant Cedergren to get Watch
Commander approval. However, when Lieutenant Cedergren arrived, he advised them he was
not going to allow them to use the restraint chair and he instructed them to remove Mr. Madrigal
from the WRAP. Deputy Rhoades and several other deputies began to do so. Lieutenant
Cedergren placed ankle restraints around Mr. Madrigal’s handcuffs and pulled the chains
through the cell door’s cuffing port. Deputies finished removing the WRAP off Mr. Madrigal
and then searched him. Once Mr. Madrigal was inside the cell, deputies closed the door and
attempted to pull Mr. Madrigal’s hands to the cuffing port, by pulling on the ankle restraints that
were attached to his handcuffs. However, Mr. Madrigal refused to comply with their instructions,
and this attempt to remove the ankle chains from Mr. Madrigal’s handcuffs was unsuccessful.
Lieutenant Cedergren took another pair of handcuffs and attached them to the other end of the
ankle restraints and attached them to the door. Lieutenant Cedergren told the deputies to start a
restraint log, which they did. Deputies monitored Mr. Madrigal and continued to make attempts
to gain Mr. Madrigal’s cooperation, but these attempts were also unsuccessful.
I asked Deputy Rhoades what her opinion of Sergeant Graham was, and she told me he was a
good sergeant, who took care of his staff, and was willing to help when deputies needed him.
However, she did say Sergeant Graham was a little “checked out,” and not fully involved at
work. Deputy Rhoades provided me an example of this, by telling me Sergeant Graham would
neglect to fill unfilled positions in ITR, even when deputies would call in to offer to work the
vacant positions on overtime.
I asked Deputy Rhoades if Sergeant Graham was a competent ITR supervisor, who knew what
the proper ITR procedures were and how to handle significant incidents. Deputy Rhoades told
me, “absolutely.”
I asked Deputy Rhoades what her opinion of Lieutenant Cedergren was and she told me there
was a lot of tension as soon as Lieutenant Cedergren started working in ITR. She stated her and
many of the other deputies thought Lieutenant Cedergren was “too involved” as a lieutenant,
saying when he first got to ITR he never took the time to “step back” and understand how things
worked.
Page 41 of 117

 Deputy Rhoades added Lieutenant Cedergren would also “do things,” without letting the
deputies in ITR know – as if he was trying to be more of a line deputy, than a supervisor. Deputy
Rhoades elaborated on her point, by telling me Lieutenant Cedergren would often just go out and
move inmates out of the holding tanks and then to the back of ITR or even out of ITR
completely, to various housing units. Deputy Rhoades stated Lieutenant Cedergren probably
thought he was helping them, but when he did not check with the ITR deputies or even let them
know what he was doing, it would throw them off.
Deputy Rhoades explained when Lieutenant Cedergren came to ITR, he would just jump in and
try and make changes, when many of the deputies thought he did not even understand what was
happening. Lastly, Lieutenant Cedergren had told them he planned on making a bunch of
changes in the next few weeks, which Deputy Rhoades suspected was not going to be helpful.
Deputy Rhoades said the general consensus among her and several of the other ITR deputies was
that if Lieutenant Cedergren remained in ITR, they were going to transfer out of ITR and back to
the security side of SRJ.
I asked Deputy Rhoades if she thought Lieutenant Cedergren had the respect of the deputies in
ITR and she told me no. Deputy Rhoades confirmed she thought Lieutenant Cedergren wanted to
be proactive, but he failed to take the necessary time to understand how ITR ran, before he acted.
I asked Deputy Rhoades what her understanding of an “express” was and she told me this was
typically someone that was non-cooperative and actively combative (kicking, spitting, etc...) or
already in a WRAP. Deputy Rhoades explained the ITR deputies would generally process that
arrestee into custody and then place him in a holding cell, as quickly as possible.
When Deputy Rhoades heard Mr. Madrigal was an “express” and she saw he was in the WRAP,
she confirmed she suspected Mr. Madrigal was non-cooperative and/or combative.
I asked Deputy Rhoades if it would have been sensible to conclude, based on these facts, the
restraint chair would have been a reasonable choice to use to restrain Mr. Madrigal and she told
me yes, saying she thought that was the best option available to them at the time.
I asked Deputy Rhoades if she had ever attached ankle restraints to the handcuffs an inmate had
been wearing before and she told me no. However, Deputy Rhoades stated she had seen deputies
use this technique, to remove handcuffs from a semi-combative inmate, to avoid injury.
I asked Deputy Rhoades if she had ever tethered an inmate to the door before or if she had ever
seen another deputy sheriff tether an inmate to the door before and she told me no. I asked
Deputy Rhoades if she was surprised when she saw Lieutenant Cedergren arrive on scene and
then go “hands on” with her and the other deputies. Deputy Rhoades told me no, saying she
knew his reputation of wanting to be involved.
Page 42 of 117

 I showed Deputy Rhoades an approximate ten second clip (18:40 mark) of Sergeant Graham’s
BWC video, that captured her facial expression – when Lieutenant Cedergren was telling her and
the other deputies what to do. I told Deputy Rhoades it appeared to me, she was skeptical of
Lieutenant Cedergren’s instructions and I asked her if this was an accurate assessment. After
Deputy Rhoades viewed the video, she told me they had pre-staged the restraint chair, the
deputies and Sergeant Graham had devised an entire plan on how to transition Mr. Madrigal
from the WRAP into the restraint chair, and they had already designated a safety officer, when
Lieutenant Cedergren arrived on scene and told them they could not use the restraint chair.
Deputy Rhoades told me she was in disbelief, as she was thinking to herself, they had all just
been trained on the restraint chair and it was readily available, so she could not understand how
they were not going to use it.
Deputy Rhoades told me at the moment her facial expression changed, Lieutenant Cedergren had
just attached the ankle restraints to Mr. Madrigal’s handcuffs and she thought to herself, “Okay,
now what are we doing?” Deputy Rhoades told me my suspicion, that she was incredulous about
what Lieutenant Cedergren was doing and telling them to do, was correct.
I asked Deputy Rhoades if there was a reason she did not speak up and she told me yes, saying
she understood her role as a deputy in the chain of command, and she added she also did not
fully understand where the situation was going.
Deputy Rhoades told me Sergeant Graham had explained to them the reason they were not given
authorization to use the restraint chair, was because Lieutenant Cedergren told him there had
been issues with the restraint chair the last time it was used, as it had been used improperly and
there were numerous administrative issues with the chair.
I asked Deputy Rhoades if she knew why Lieutenant Cedergren left Mr. Madrigal tethered to the
door with the ankle restraints, instead of going back inside the cell to remove them. Deputy
Rhoades told me she actually talked to a couple of the deputies, who also had that same question.
She stated there were six to seven deputies and even if Mr. Madrigal became combative and
attempted to assault them, they would have been able to gain control over him and remove the
ankle restraints. Deputy Rhoades even went so far as to say she remembered when they removed
Mr. Madrigal from the WRAP, he was not trying to kick them, as he was just being passively
non-compliant.
I asked Deputy Rhoades why she thought Lieutenant Cedergren left Mr. Madrigal tethered to the
door and she told me she was unsure, but stated she remembered Lieutenant Cedergren saying,
“He can just stay like that.” I asked Deputy Rhoades if she thought he left Mr. Madrigal tethered
to the door to teach him a lesson. Deputy Rhoades told me maybe, but she also told me she
thought it might just have been an “old school way” of how Lieutenant Cedergren used to do it,
or it could have just been what he thought was the best solution at the time – in hopes of not
risking an injury to the ITR deputies.
Page 43 of 117

 I asked Deputy Rhoades if she thought Lieutenant Cedergren was known to do things that were
questionable or reckless. She told me yes, in this particular incident. However, Deputy Rhoades
also told me she heard about him still being involved, as a lieutenant, in “use of force” incidents
with inmates and actively participating in shakedowns, which she thought showed questionable
judgment.
I asked Deputy Rhoades if she ever heard Lieutenant Cedergren discuss using the restraint chair
with anyone, after he arrived on scene, and she told me no. I asked her if she was surprised when
Lieutenant Cedergren did not approve the restraint chair and she told me yes. I asked her if all
the deputies seemed surprised when Lieutenant Cedergren did not approve the restraint chair and
she told me yes.
I asked Deputy Rhoades if she was aware of Lieutenant Cedergren ever approving or denying the
use of the restraint chair and she told me no.
I asked Deputy Rhoades if she had recently been trained on the restraint chair and she told me
yes, saying she and the other deputies had just been trained at the June range.
I told Deputy Rhoades I wanted to talk to her about when she went over to Mr. Madrigal’s cell,
when Lieutenant Cedergren and Deputy Ross discovered Mr. Madrigal unresponsive. I asked
Deputy Rhoades what Lieutenant Cedergren’s demeanor was, when he opened the cell door and
discovered Mr. Madrigal had wrapped the ankle restraint chain around his neck and appeared to
have strangled himself. Deputy Rhoades told me Lieutenant Cedergren appeared to be in a panic,
as he exclaimed the word “fuck.” Deputy Rhoades told me everyone attempted to remove the
chain from around Mr. Madrigal’s neck and after doing so, they laid Mr. Madrigal down on the
ground, when Lieutenant Cedergren let loose with a plethora of “fucks.” Deputy Rhoades told
me she understood Lieutenant Cedergren’s panicked response to mean he realized he had made
an extreme error, which resulted in the worst-case scenario.
I asked Deputy Rhoades if Lieutenant Cedergren ever talked to the ITR deputies about a plan.
Deputy Rhoades told me no, saying Lieutenant Cedergren just walked over and “jumped right
in” and started dictating what he wanted the deputies to do.
Deputy Rhoades told me at some point, Mr. Madrigal had maneuvered his handcuffs from
behind his back to the front of his body, which now created a significant amount of slack in the
ankle restraints. She told me she knew Lieutenant Cedergren had been advised of this, because of
the possible risks of what Mr. Madrigal could do now that there was slack in the chains.
Deputy Rhoades told me she was unable to remember who told Lieutenant Cedergren about this
updated information.

Page 44 of 117

 Deputy Rhoades stated this slack in the chain of the ankle restraints now created more of a
danger to her and the other deputies, because Mr. Madrigal had more freedom to move around.
Deputy Rhoades stated there was additional talk amongst the deputies about the possibility of
going back inside Mr. Madrigal’s cell, because of this newfound risk; however, this did not
happen.

Page 45 of 117

 Summary of Interview with Lieutenant Justin McComas
On Wednesday, March 11, 2020, Captain Christy and I interviewed Lieutenant McComas in a
makeshift office at his personal residence in Tracy, CA. In summary, Lieutenant McComas told
me the following:
On June 10, 2019, Lieutenant McComas was working as the Watch Commander at SRJ, when he
responded to ITR for an “express.” Lieutenant McComas stated he heard Sergeant Graham ask
Lieutenant Cedergren for permission to use the restraint chair, which everyone had just recently
been trained on. Lieutenant McComas told me he responded to ITR to watch the application of
the restraint chair.
Upon Lieutenant McComas’ arrival, he heard a discussion between Lieutenant Cedergren and
Sergeant Graham about the decision of using the restraint chair or an alternate restraint option.
Lieutenant McComas remembered there were concerns, because Mr. Madrigal was under the
influence of a hallucinogen and they were unsure how violent he was going to be, and they
needed to keep Mr. Madrigal safe and prevent him from assaulting staff.
I asked Lieutenant McComas what his understanding of an “express” was. Lieutenant McComas
told me this was someone who was non-cooperative, assaultive and/or combative, or under the
influence of drugs, necessitating additional deputies to assist in booking the arrestee.
I asked Lieutenant McComas if he suspected Mr. Madrigal was non-cooperative and possibly
combative, when he heard he was an “express,” and he told me yes.
I asked Lieutenant McComas if Lieutenant Cedergren was with him when he heard Sergeant
Graham ask Lieutenant Cedergren for approval to use the restraint chair on the radio. Lieutenant
McComas stated he remembered Lieutenant Cedergren walking past his office, when he
responded to ITR, but he could not remember if they responded to ITR together. I asked
Lieutenant McComas if he and Lieutenant Cedergren talked about this incident. Lieutenant
McComas told me he did not specifically remember them speaking about this incident, before
they arrived in ITR.
After Lieutenant McComas arrived in ITR, he saw Mr. Madrigal wearing a spit mask and
restrained in the WRAP device, which further emphasized his belief Mr. Madrigal was noncooperative and possibly combative. I asked Lieutenant McComas if it would be realistic to
assume, based on these facts, the restraint chair would have been a reasonable choice to use to
restrain Mr. Madrigal and he told me yes.
After deputies began to remove Mr. Madrigal from the WRAP and the ankle restraints had been
applied to Mr. Madrigal’s handcuffs, they were fed through the cuffing port. At this point,
Page 46 of 117

 Lieutenant McComas told me he was surprised when Lieutenant Cedergren did not grant
approval for Mr. Madrigal to be restrained in the restraint chair.
Lieutenant McComas told me he talked to Lieutenant Cedergren about the change in restraints
Lieutenant Cedergren chose to use. Lieutenant Cedergren justified his decision to not use the
restraint chair, by telling him something to the effect of, “We’re not using it now, because
someone used it incorrectly and management doesn’t want us using it until everyone can get
retrained.” Lieutenant McComas confirmed he was never told this information by anyone in
management.
Lieutenant McComas told me his understanding of the situation was Sergeant Graham had
already made the decision to restrain Mr. Madrigal in the restraint chair and he was just asking
Lieutenant Cedergren for his approval, as it was a required formality.
Lieutenant McComas confirmed based on the facts known to him at the time, the restraint chair
was not only the best option available to them, but this was the ideal situation for the restraint
chair.
I asked Lieutenant McComas if he had ever attached ankle restraints to the handcuffs an inmate
had been wearing before, to pull the inmate against the door to search him and he told me no.
However, Lieutenant McComas did say he had seen it done before, but only for that specific
purpose – as a temporary restraint. Lieutenant McComas told me it was his understanding this
was a technique that had been used, but not one that had been taught in any type of formalized
training.
I asked Lieutenant McComas if he had ever tethered an inmate to the door before or if he had
ever seen anyone else do that before and he told me no, not that he could recall.
Lieutenant McComas told me, from what he remembered, he saw several of the deputies had a
look of confusion on their faces. The deputies appeared to have been very hesitant to cooperate
with Lieutenant Cedergren’s direction of what he was telling them to do and the strange method
of restraint he had chosen.
After Lieutenant Cedergren tethered Mr. Madrigal to the door and walked away from the cell,
Lieutenant McComas told me he followed Lieutenant Cedergren down the hall and stopped him.
Lieutenant McComas spoke to Lieutenant Cedergren and confirmed he was going to initiate a
restraint log and he asked Lieutenant Cedergren how long he was going to have Mr. Madrigal in
the cell. Lieutenant McComas stated he reiterated to Lieutenant Cedergren the restraint chair was
not only right next to Mr. Madrigal’s cell, but it was ready to be used. In addition, Lieutenant
McComas also told Lieutenant Cedergren the restraint chair was the better option to use to
restrain Mr. Madrigal. Lieutenant Cedergren told him, “I’ve done this a hundred times before.
It’s not a problem. I’ll take, I’ll take responsibility for it.” Lieutenant McComas told him okay
Page 47 of 117

 and added he was not comfortable with not using the restraint chair, as they had just received
training on it.
Lieutenant McComas confirmed this conversation was significant, which caused it to stand out in
his mind.
I asked Lieutenant McComas if he ever saw Mr. Madrigal acting combative or assaultive or if
Mr. Madrigal was being more non-cooperative, in a passive resistant manner. Lieutenant
McComas told me he never saw Mr. Madrigal being assaultive or aggressive and that Mr.
Madrigal seemed to be more passively resistant. I asked Lieutenant McComas, if this was the
case, if Mr. Madrigal was only being passive resistant, then why not go back into the cell to
remove the ankle chains. Lieutenant McComas told me he would agree, there was no reason not
to have gone back inside Mr. Madrigal’s cell.
I asked Lieutenant McComas if he and Lieutenant Cedergren ever discussed any other options to
restrain Mr. Madrigal, besides the restraint chair and tethering Mr. Madrigal to the door and he
told me no.
I asked Lieutenant McComas if he remembered Lieutenant Cedergren and Sergeant Graham
discussing the situation. Lieutenant McComas told me he recalled their initial conversation and
he remembered Sergeant Graham appeared clearly upset over Lieutenant Cedergren not
approving the use of the restraint chair.
Lieutenant McComas confirmed that based on the brief conversation he saw between Sergeant
Graham and Lieutenant Cedergren, and Sergeant Graham’s demeanor afterwards, it did appear
Lieutenant Cedergren was somewhat dismissive of Sergeant Graham’s opinion of how they
should proceed in restraining Mr. Madrigal. Lieutenant McComas confirmed he could
understand how Sergeant Graham may have felt disrespected by Lieutenant Cedergren in this
situation.
I asked Lieutenant McComas if he knew why Lieutenant Cedergren was so opposed to using the
restraint chair and he told me no. I asked Lieutenant McComas if he was surprised when
Lieutenant Cedergren just walked over to Mr. Madrigal and the other deputies and immersed
himself in the incident by going “hands on” and he told me yes, saying he would not have done
the same. Lieutenant McComas elaborated on his response by saying when there is enough staff
and your staff is competent, it is better to stand back – as you are better able to manage a
situation overall, if you are watching it, versus being involved in it.
I asked Lieutenant McComas what his opinion was of Sergeant Graham. Lieutenant McComas
told me he thought Sergeant Graham was competent, had significant experience as an ITR
supervisor, and he made good decisions. Lieutenant McComas added he would feel comfortable
in following Sergeant Grahams’ recommendations, which is something he has done in the past.
Page 48 of 117

 I asked Lieutenant McComas what his opinion was of Lieutenant Cedergren and he told me had
had not worked with Lieutenant Cedergren very much, so he did not have an opinion of him.
I asked Lieutenant McComas if he knew why Lieutenant Cedergren left Mr. Madrigal tethered to
the door with the ankle restraints, instead of going back inside the cell to remove them from Mr.
Madrigal’s handcuffs and he told me no.
Lieutenant McComas told me he never heard Lieutenant Cedergren say anything that would lead
him to suspect Lieutenant Cedergren left him tethered to the door for punitive reasons, nor did he
see Lieutenant Cedergren do anything that would lead him to believe this was punitive; rather,
Lieutenant McComas told me it appeared to be more of a restraint technique Lieutenant
Cedergren was comfortable with. I asked Lieutenant McComas if he saw anything wrong with
going back inside Mr. Madrigal’s cell to retrieve the ankle restraints and he told me no.
Lieutenant McComas reiterated he would have preferred Mr. Madrigal had been placed in the
restraint chair.
Captain Christy asked Lieutenant McComas if he considered stepping in to override Lieutenant
Cedergren’s decision not to use the restraint chair, since he was the Watch Commander for the
jail and Lieutenant Cedergren was the Watch Commander for ITR. Lieutenant McComas said
yes, but stated that Captain Hesselein had spoken to him a week or two prior to this incident and
told him ITR was Lieutenant Cedergren’s area of responsibility and Lieutenant McComas was
supposed to monitor the operation of the housing units and the rest of the jail. In addition,
Lieutenant McComas confirmed Lieutenant Cedergren’s statement that management did not
want them to use the restraint chair was a contributing factor as to why he did not override
Lieutenant Cedergren, as he had no way to refute that and had no choice, but to accept
Lieutenant Cedergren’s statement as true.
Lieutenant McComas told me he tried to follow up with Lieutenant Cedergren’s statement with
his sergeants, to see if anyone else had been told that same information, regarding management
directing ITR staff not to use the restraint chair. However, none of his sergeants had heard
anything similar and he found no evidence Lieutenant Cedergren’s statement was true. In
addition, Lieutenant McComas had extensive conversations with Commander Madigan and
Captain Hesselein and learned this information that Lieutenant Cedergren claimed was true was
not factual.
I asked Lieutenant McComas if he was ever made aware Mr. Madrigal had maneuvered his
handcuffs to the front of his body while he was tethered to the door and he told me yes but told
me he only learned of this several days after the incident. I asked Lieutenant McComas if he had
heard this information that day, would it have concerned him, and he told me he was unsure if he
would have thought this would have been a significant development.
Page 49 of 117

 Lieutenant McComas told me he spoke to Sergeant Graham the next day, about the incident. He
remembered Sergeant Graham saying he was frustrated, disappointed, and sick to his stomach
about the way things turned out and he was very upset that his decision to use the restraint chair
had been overruled by Lieutenant Cedergren.

Page 50 of 117

 Summary of Interview with Captain Donald Mattison
On Wednesday, January 22, 2020, I interviewed Captain Mattison, via telephone. In summary,
Captain Mattison told me the following:
Captain Mattison was assigned to SRJ as the D&C Captain and he confirmed he was familiar
with Mr. Madrigal’s death at SRJ on June 10, 2019. Captain Mattison told me his understanding
was Mr. Madrigal had been restrained by chains in an unorthodox manner, involving Lieutenant
Cedergren – who had only been assigned to SRJ as the ITR lieutenant for a few weeks.
Captain Mattison told me prior to this incident, he and Lieutenant Cedergren never spoke about
the use of the restraint chair. I asked Captain Mattison if he ever told Lieutenant Cedergren he
did not want him to use the restraint chair and he told me no.
I asked Captain Mattison if he was aware of any other Captain making statements about not
wanting the restraint chair to be used at SRJ, because of prior issues or policies that still needed
to be worked out and he told me no.
I asked Captain Mattison if he was surprised when he learned Lieutenant Cedergren had denied
approval for the use of the restraint chair and he told me yes. Captain Mattison added that given
Lieutenant Cedergren’s job history of working in Internal Affairs and his base of administrative
skills, he knew Lieutenant Cedergren to be a rule follower, who abided by policy.
Captain Mattison told me on the day of this incident, he was out of town on vacation. I asked
Captain Mattison if Lieutenant Cedergren ever discussed this incident with him after it occurred,
and he told me yes. Captain Mattison stated Lieutenant Cedergren called him within an hour
after this incident occurred and told him something bad happened, an inmate was going to die,
and Lieutenant Cedergren thought it was his fault.
I asked Captain Mattison if he was familiar with who Sergeant Graham was and he told me yes. I
asked Captain Mattison if he was comfortable with Sergeant Grahams’ competence as an ITR
supervisor and he told me yes.
I asked Captain Mattison if he ever asked Lieutenant Cedergren why he did not use the restraint
chair and he told me yes, saying Lieutenant Cedergren told him he was not comfortable using it.

Page 51 of 117

 Summary of Interview with Captain Derrick Hesselein
On Wednesday, January 22, 2020, I interviewed Captain Hesselein, via telephone. In summary,
Captain Hesselein told me the following:
Captain Hesselein was assigned to SRJ as the Commanding Officer and confirmed he was
familiar with Mr. Madrigal’s death at SRJ, on June 10, 2019. Captain Hesselein told me his
understanding was Mr. Madrigal had been arrested by the Fremont PD and he was brought into
the jail in the WRAP. Once Mr. Madrigal had been accepted into custody, Sergeant Graham
arranged for Mr. Madrigal to be removed from the WRAP and then restrained in the restraint
chair. However, per policy, Sergeant Graham was required to get approval from the on-duty
watch commander, for permission to use the restraint chair and the on-duty watch commander
was also required to be present during the application of the restraint chair. There was a delay in
Lieutenant Cedergren arriving, but once he did, he elected not to use the restraint chair – which
was situated just outside the cell door. Instead, Lieutenant Cedergren used ankle restraints and
attached them to the handcuffs Mr. Madrigal was wearing and then he pulled the chain of the
ankle restraints through the cuffing port and attached the other end of the ankle restraints to the
outside of the cell door.
Captain Hesselein added after reviewing the video, he thought Sergeant Graham was very
thoughtful and had put a lot of effort into using the restraint chair. He stated Sergeant Graham
had briefed his staff, and everyone knew what their job was going to be in restraining Mr.
Madrigal in the restraint chair.
I asked Captain Hesselein if he ever told Lieutenant Cedergren he did not want him to use the
restraint chair and he told me no.
I asked Captain Hesselein if he was aware of any other captain or anyone else in management
ever saying anything to Lieutenant Cedergren about not using the restraint chair and he told me
no.
I asked Captain Hesselein if he was surprised when he learned Lieutenant Cedergren had denied
approval for the use of the restraint chair. Captain Hesselein told me yes, saying he was shocked,
based on the facts and his review of the video.
Captain Hesselein told me he did not remember Lieutenant Cedergren ever discussing this
incident with him.
I asked Captain Hesselein if he had any idea why Lieutenant Cedergren did not use the restraint
chair and he told me no. Captain Hesselein also went on to say he had never known anyone to
use the ankle chains in a similar application as to the way Lieutenant Cedergren used them, other
than on a very temporary basis, to gain immediate control of an inmate.
Page 52 of 117

 Summary of Interview with Lieutenant Craig Cedergren
On Monday, March 23, 2020, Captain Christy and I interview Lieutenant Cedergren in the
Internal Affairs interview room, located at 1401 Lakeside Dr, Oakland. Lieutenant Cedergren
was accompanied by his legal representative, Mike Rains. In summary, Lieutenant Cedergren
told me the following:
On June 10, 2019, Lieutenant Cedergren was the ITR Watch Commander, while he was working
at SRJ. About 1413 hours, Lieutenant Cedergren walked through the law enforcement lobby on
his way to the front of the jail, to drop off paperwork. Lieutenant Cedergren saw Mr. Madrigal
sitting on the floor in the WRAP, surrounded by deputies from our agency, Sergeant Graham and
officers from Fremont PD. A few minutes later, Sergeant Graham radioed Lieutenant Cedergren
and asked him to meet him at cell R-1 in ITR. Lieutenant Cedergren told Sergeant Graham he
was enroute and he dropped off the paperwork he had. As Lieutenant Cedergren started walking
back to ITR, Sergeant Graham told him he was requesting approval for the use of the restraint
chair.
Lieutenant Cedergren arrived on scene in ITR and he saw numerous ACSO deputies and the
restraint chair in the hallway. Lieutenant Cedergren saw Mr. Madrigal seated on the floor in the
WRAP. Lieutenant Cedergren asked what the circumstances were, surrounding Mr. Madrigal’s
intake into custody and Sergeant Graham told him, “Shrooms, he’s on shrooms – he’s gonna
fight us.”
Lieutenant Cedergren asked where Fremont PD was and why they were not removing Mr.
Madrigal from the WRAP and he also asked why Mr. Madrigal was in the WRAP. Lieutenant
Cedergren was told Mr. Madrigal had fought with Fremont PD earlier in the day. Lieutenant
Cedergren directed the deputies to stand Mr. Madrigal up and get him out of the WRAP.
Lieutenant Cedergren tried to undo one of the tether straps on the WRAP, but he could not get it
to reduce tension, so he had a deputy push Mr. Madrigal forward to get the tension off the strap.
Lieutenant Cedergren did not hear Mr. Madrigal grunting or screaming, nor was Mr. Madrigal
acting like he was seeing things. Lieutenant Cedergren also noted he did not see any indicators
Mr. Madrigal was going to jump out of the WRAP and attack anyone.
Lieutenant Cedergren and the deputies stood Mr. Madrigal up and Lieutenant Cedergren decided
he wanted to remove Mr. Madrigal from the WRAP and place him in the cell, without any use of
force. Lieutenant Cedergren stated he did this to prevent any injury to Mr. Madrigal and the
deputies. Lieutenant Cedergren had deputies attach the chain of the ankle restraints around Mr.
Madrigal’s handcuffs and then feed the chain through the cuffing port and pull him back to the
door, using the door as a shield. Lieutenant Cedergren and deputies were able to close the door
with Mr. Madrigal pulled against it, effectively pulling Mr. Madrigal inside the cell as they shut
the door. Lieutenant Cedergren stated he told Mr. Madrigal to put his hands out the cuffing port
door, so he could remove the chain of the ankle restraints from his handcuffs, but Mr. Madrigal
Page 53 of 117

 did not comply. Lieutenant Cedergren instructed a Spanish speaking deputy to give Mr. Madrigal
commands to comply in Spanish, but Mr. Madrigal continued to ignore their requests for him to
put his hands out the cuffing port of the door. Lieutenant Cedergren decided to give Mr.
Madrigal time to calm down and he determined he should “wait him out,” rather than having his
deputies fight Mr. Madrigal. Lieutenant Cedergren stated he chose not to restrain Mr. Madrigal
in waist chains, because Mr. Madrigal had a skinny build and he suspected Mr. Madrigal could
have easily slipped the waist chains off, from around his waist.
Lieutenant Cedergren had the Spanish speaking deputy ask Mr. Madrigal if he was under the
influence of drugs and Mr. Madrigal told him no. Lieutenant Cedergren also told the Spanish
speaking deputy to ask Mr. Madrigal if he was “mental” and Mr. Madrigal told him no.
Lieutenant Cedergren did not know Mr. Madrigal’s history, so he was inclined to believe Mr.
Madrigal. Lieutenant Cedergren asked Mr. Madrigal if he would comply and Mr. Madrigal just
told him he wanted to go home. Lieutenant Cedergren told deputies to start a restraint log on Mr.
Madrigal and told deputies to watch him and allow Mr. Madrigal to calm down, until he wanted
to surrender for processing. Lieutenant Cedergren left the area.
About 1650 hours, Lieutenant Cedergren returned to Mr. Madrigal’s cell and he saw Mr.
Madrigal had maneuvered his cuffs to the front of his body. Lieutenant Cedergren asked Mr.
Madrigal if he was ready to comply.
At this point, Lieutenant Cedergren told me he remembered an earlier conversation he had with
ITR Sergeant Anthony Moschetti, who relayed the difficulties he had with a previous restraint
chair placement, involving a female inmate. Sergeant Moschetti told Lieutenant Cedergren the
restraint chair ordeal lasted sixteen hours, they were unable to fingerprint the female in the chair,
the ITR staff had to fight her, and the female inmate got marks on her from the restraint chair.
Lieutenant Cedergren reiterated his goal was to use the most least intrusive means possible and
reduce the likelihood of injury to Mr. Madrigal and staff and to not go “hands on” with Mr.
Madrigal.
Note: After Lieutenant Cedergren’s interview, I contacted Sergeant Moschetti, who
confirmed he had an earlier conversation with Lieutenant Cedergren about the restraint
chair. Sergeant Moschetti advised me he remembered telling Lieutenant Cedergren about
an issue he had in using the restraint chair, where he struggled to get the resistant inmate
into the restraint chair and then had difficulty in securing the inmates’ legs and feet in
the chair. Sergeant Moschetti also stated it was likely he had talked to Lieutenant
Cedergren about a previous incident the security side of SRJ had, in which a female
inmate needed to be moved from a housing unit to ITR, and the inmate was combative
and staff was unable to fingerprint her. However, Sergeant Moschetti told me he did not
remember how long the inmate would have been left in the restraint chair.

Page 54 of 117

 In addition, Lieutenant Cedergren stated he talked to Sergeant Scott Sylvester regarding this
incident and Lieutenant Cedergren told him about the technique he had used to restrain Mr.
Madrigal. Lieutenant Cedergren told us Sergeant Sylvester confirmed this technique was still
being taught. Captain Christy asked Lieutenant Cedergren to explain exactly what the technique
was, he was referring to. Lieutenant Cedergren stated the technique of using ankle restraints to
hold a problematic inmate to the door, so they cannot pull away. However, Sergeant Sylvester
told Lieutenant Cedergren about a previous incident that occurred about a week prior to
Lieutenant Cedergren contacting him, where the inmate refused to cooperate and allow the
deputies to remove his ankle restraints through the cuffing port, which necessitated the deputies
going back inside the cell and ultimately fighting the inmate, to get the ankle restraints back.
In response to Lieutenant Cedergren’s question asking Mr. Madrigal if he was ready to comply
with his request to bring his hands over to the cuffing port, so he could remove the restraints, Mr.
Madrigal moved his wrists closer to the cuffing port, but then suddenly, he pulled them back, as
he laughed.
At this time, Lieutenant Cedergren decided as soon as he got deputies on the floor, he was going
to remove Mr. Madrigal from the cell and remove the restraints and if they had to write a report
as a result, they would do so. Lieutenant Cedergren decided he would wait for deputies to get out
of muster and he left Mr. Madrigal’s cell.
Later, while Lieutenant Cedergren was near Mr. Madrigal’s cell, he saw Mr. Madrigal was now
sitting down, so he returned to Mr. Madrigal’s cell to check on him. Lieutenant Cedergren saw
the chain of the ankle restraints was now looped around Mr. Madrigal’s neck, so he opened the
door and had another deputy help him free the chain from around Mr. Madrigal’s neck and then
he started CPR and called for medical to respond.
Lieutenant Cedergren stated he called Captain Mattison to advise him of what just happened, and
he also called Commander Madigan, who responded to the jail.
I asked Lieutenant Cedergren what his opinion was of Sergeant Graham. Lieutenant Cedergren
told me he had worked with Sergeant Graham on patrol together at Dublin Police Services (DPS)
and he was polar opposites with Sergeant Graham, in regard to work ethic, productivity, and in
showing up to work for the full 84-hour pay period. Lieutenant Cedergren described how he
consistently worked more hours than Sergeant Graham did each pay period and he went so far as
to elaborate on how he heard Sergeant Graham was hanging out at his personal residence, instead
of working and responding to calls he was assigned, during his shift.
Lieutenant Cedergren admitted he did not know if this disparaging information he was telling me
regarding Sergeant Graham being home when he should have been at work was true, as it was
just a rumor he had heard. However, he thought it was significant enough to tell me this
information during his Internal Affairs interview.
Page 55 of 117

 Immediately after telling me this, Lieutenant Cedergren told me he did not dislike Sergeant
Graham and he stated he got along with him. However, Lieutenant Cedergren told me he
considered himself to be a very “hands on” supervisor and he told me Sergeant Graham appeared
to be very “hands off-ish,” who he thought was very willing to just follow along. Lieutenant
Cedergren stated in one of the last arrests he made with Sergeant Graham he offered to give
Sergeant Graham the arrest for statistical purposes, but Sergeant Graham told him no. Lieutenant
Cedergren believed Sergeant Graham did not want anything to do with the arrest, rather he just
wanted to be present on scene. In addition, Lieutenant Cedergren told me he was amused when
he learned Sergeant Graham went to the Alameda County Narcotics Task Force (ACNTF), as he
did not think Sergeant Graham had ever made a narcotic related arrest in his life. Lieutenant
Cedergren reiterated he did not dislike Sergeant Graham, rather they just had a different work
ethic.
I asked Lieutenant Cedergren if Sergeant Graham seemed to have the respect of the deputies he
supervised. Lieutenant Cedergren told me he could not answer that question as he had only been
in ITR a short time, but he added the deputies worked hard for Sergeant Graham and they did
what he wanted them to do. Lieutenant Cedergren added, most of the staff that came from GDJ
did not have the respect of the ITR deputies, as they were not originally from SRJ. In addition,
Lieutenant Cedergren received feedback from different people, the ITR deputies were already
saying they were not going to change the way they did things or run the operation the way
Lieutenant Cedergren wanted them to.
I asked Lieutenant Cedergren if he thought he had the respect of the ITR deputies. Lieutenant
Cedergren told me he had been told he was a micromanager, but he stated that was not true, he
just liked to see what people were doing.
I asked Lieutenant Cedergren if Lieutenant McComas was the acting watch commander at SRJ
that day. Lieutenant Cedergren told me yes, saying he believed Lieutenant McComas showed up
for the incident and then disappeared shortly thereafter.
I asked Lieutenant Cedergren what his opinion of Lieutenant McComas was. Lieutenant
Cedergren told me he thought Lieutenant McComas was fine; however Lieutenant Cedergren
added he knew Lieutenant McComas was not happy about being at SRJ and he also knew
Lieutenant McComas was upset about losing his work vehicle because of the discontinuance of
Urban Shield. Lieutenant Cedergren added he did not talk a lot to Lieutenant McComas.
I asked Lieutenant Cedergren if he thought Lieutenant McComas was a competent watch
commander who knew what he was doing. Lieutenant Cedergren told me, “He should know what
he’s doing. He’s a watch commander. Yeah. He’s – He was there before me. But, again – he’s
not the same type of watch commander I am, either though. So.”
Page 56 of 117

 I asked Lieutenant Cedergren if he thought he would do a better job as a watch commander than
Lieutenant McComas and he told me not necessarily; however, he stated it would depend on the
situation.
I asked Lieutenant Cedergren if there was any truth to the statement that he would regularly
move inmates from the holding tanks in ITR to other areas of ITR and/or to various housing
units and he told me yes. Lieutenant Cedergren stated he was more comfortable taking small
groups of inmates on a constant basis, rather than waiting for large groups of inmates to be
moved at once, which he stated was the preference of the ITR deputies.
Lieutenant Cedergren added he also moved inmates from ITR out to the housing units, when he
was a sergeant. Lieutenant Cedergren confirmed sometimes the deputies in ITR would come
with him and other times they “would just sit there,” waiting for large groups to form, so they
could move the inmates all at once, while he did the work of moving the inmates. Lieutenant
Cedergren said he would not say anything to the deputies who did not help him and he told me
his logic behind moving the inmates out to the housing units was not to show the ITR deputies he
was better than they were, but to move the inmates before they got angry – as they would get
upset just sitting in ITR, waiting to be go back to their housing units.
I asked Lieutenant Cedergren if he would generally tell the ITR deputies or the ITR sergeant
when he was going to move the inmates or if he would just move them on his own, without
telling anyone else what he was doing. Lieutenant Cedergren stated he would just move the
inmates on his own.
I asked Lieutenant Cedergren if he heard Sergeant Graham request for additional deputies to
respond to ITR for an “express,” over the radio and he told me no. I asked Lieutenant Cedergren
what his definition of an “express” was and he told me this was usually someone who was
combative, kicking out the windows, or spitting on the deputy. I asked Lieutenant Cedergren if
he agreed with defining an express as an arrestee who has shown risky or dangerous behavior
and he told me yes.
Note: According to our Agency Policy & Procedure 8.26 – the Pro-Straint Restraint Chair is a
chair with equipment designed to restrain, control, and limit the movements of someone who
displays hazardous (risky and/or dangerous) behavior.
I asked Lieutenant Cedergren why he thought Sergeant Graham asked him to meet at cell R-1 in
ITR. Lieutenant Cedergren he told me he assumed it was regarding Mr. Madrigal, who he saw
earlier restrained in the WRAP. I told Lieutenant Cedergren about six minutes passed since
Sergeant Graham requested he meet him, and he still had not responded to ITR. I asked
Lieutenant Cedergren what he had been doing, which prevented him from responding to
Sergeant Graham’s location. Lieutenant Cedergren told me he did not remember exactly, but he
Page 57 of 117

 knew he had gone to the front of the jail to drop off paperwork and he told me he was possibly in
the alcove or the administrative area of the jail.
I asked Lieutenant Cedergren if there was ever a sense of urgency on his part, to respond to
Sergeant Graham’s location. Lieutenant Cedergren told me no, saying he did not know Sergeant
Graham needed approval for the chair until the second time Sergeant Graham raised him on the
radio. However, Lieutenant Cedergren stated he did not do anything that would have delayed his
response to ITR.
I asked Lieutenant Cedergren if there was a reason why he did not respond to Sergeant Graham
over the radio, when Sergeant Graham told him he was asking for his authorization to use the
restraint chair. Lieutenant Cedergren told me he did not see the need to respond again over the
radio, as he had already told Sergeant Graham he was enroute and he would evaluate the need for
the restraint chair once he arrived on scene.
I asked Lieutenant Cedergren if he was aware a significant number of staff (six or seven ACSO
deputies, an ACSO sergeant, two Fremont PD officers, and nursing staff) were just standing
there, dealing with Mr. Madrigal, while everyone waited for him to respond. Lieutenant
Cedergren told me he was only aware of the staff that were assigned to ITR. Lieutenant
Cedergren added in no way was he trying to delay his response to ITR.
I asked Lieutenant Cedergren what he thought everyone would have been doing, while they
waited for him to respond. Lieutenant Cedergren told me at the time he last saw Mr. Madrigal, he
did not hear anyone say anything about Mr. Madrigal fighting.
Lieutenant Cedergren went on to say the following day, when he talked to Sergeant Graham, he
asked Sergeant Graham if there was anything else of interest about Mr. Madrigal and Sergeant
Graham told him at some point, before Mr. Madrigal came into SRJ, there was a previous
incident at the San Jose airport. In this event, Mr. Madrigal charged the TSA, breached their
security line, and subsequently got into a physical altercation with the TSA agents, where he
tried to take someone’s weapon before he was subdued. As a result of that occurrence, Mr.
Madrigal was placed on
, before going home the following day, when he got into
the known physical altercation with Fremont PD.
I asked Lieutenant Cedergren what he saw, when he arrived in ITR, after Sergeant Graham
requested his approval for the restraint chair. Lieutenant Cedergren told me he saw the deputies
standing there, the restraint chair, and Mr. Madrigal in the WRAP, sitting on the floor in the
doorway of cell R-1. At this point, Lieutenant Cedergren referred to his ACSO supplemental
report and he began to read from it. Lieutenant Cedergren told me he arrived in ITR and Sergeant
Graham told him, “Mushrooms, mushrooms, he’s gonna fight us, he’s already tensing his body,
we can’t unrestrain him, so” as Lieutenant Cedergren walked towards cell R-1.
Page 58 of 117

 Lieutenant Cedergren saw the eight ACSO deputies and asked if they could not get Mr. Madrigal
out of the WRAP and Sergeant Graham told him, “not without fighting him.”
Lieutenant Cedergren asked Sergeant Graham why Fremont PD put Mr. Madrigal in the WRAP,
and Deputy Comfort told him he heard Mr. Madrigal was at Fremont PD’s jail, when he fought
with the Fremont PD officers.
I asked Lieutenant Cedergren if he could provide me with a few examples of why an arrestee
would be placed in the WRAP. Lieutenant Cedergren told me an arrestee could be placed in the
WRAP if they were combative and fighting, having “an episode” of acting out or harming
themselves, or if the arrestee had the potential to harm others.
I asked Lieutenant Cedergren if Mr. Madrigal was wearing a spit mask when he arrived at SRJ
and he told me yes. I asked Lieutenant Cedergren if he could provide me with a few examples of
why an arrestee would be wearing a spit mask. Lieutenant Cedergren told me if the arrestee was
attempting to spit or if it was believed the arrestee was going to bite or spit, then they could be
outfitted with a spit mask.
I asked Lieutenant Cedergren if Sergeant Graham or anyone else told him Mr. Madrigal had
ingested mushrooms and/or was under the influence of mushrooms and he told me yes. I asked
Lieutenant Cedergren if he understood mushrooms to be a hallucinogen and he told me yes,
saying he knew people under the influence of mushrooms could “see things.” Furthermore,
Lieutenant Cedergren told me that based on this, he also assumed Mr. Madrigal had been
arrested for 11550(a) HS – Under the Influence of a Controlled Substance.
I asked Lieutenant Cedergren if, at this time, he had a good understanding of the Pro-Straint
restraint chair and he told me yes. I told Lieutenant Cedergren the definition of the restraint
chair, according to our agency P&P, was a chair with equipment designed to restrain, control,
and limit the movements of someone who displays hazardous behavior and is equipped with a
wheeled transport carriage for easy movement after the inmate has been secured in it. I asked
Lieutenant Cedergren if he agreed with that definition of the restraint chair and he told me yes.
I asked Lieutenant Cedergren what reason Sergeant Graham gave him for wanting to use the
restraint chair. Lieutenant Cedergren told me the only non-specific comments Sergeant Graham
made, was Mr. Madrigal was on mushrooms, Sergeant Graham believed Mr. Madrigal was going
to fight with them, and Mr. Madrigal was tensing his body. I repeated my question to Lieutenant
Cedergren, and I asked him again, what reasons Sergeant Graham gave him for wanting to use
the restraint chair. Lieutenant Cedergren just stated Sergeant Graham made a reference to
mushrooms and the fact Mr. Madrigal was going to fight with them.
I asked Lieutenant Cedergren if at that time, he agreed with Sergeant Graham’s recommendation
to place Mr. Madrigal in the restraint chair. Lieutenant Cedergren did not directly answer my
Page 59 of 117

 question but said not until he could see Mr. Madrigal getting aggressive, for himself. Lieutenant
Cedergren stated he wanted to get Mr. Madrigal out of the WRAP, so he could see what Mr.
Madrigal did once he was no longer restrained.
I asked Lieutenant Cedergren if I was correct in my understanding, that he was saying at that
time he did not agree with Sergeant Graham’s recommendation to place Mr. Madrigal in the
restraint chair. Lieutenant Cedergren told me he did not say he did not agree with Sergeant
Graham’s recommendation, but Lieutenant Cedergren told me he was not going to start off with
restraining Mr. Madrigal in the restraint chair. Lieutenant Cedergren added he understood
anytime you took an inmate in and out of restraints, that inmate would want to fight, because
they were not going to be happy. Lieutenant Cedergren added the only time this was not the case,
when an inmate did not want to immediately fight after being removed from restraints, was when
the inmate was at John George Psychiatric Pavilion (JGPP) and the inmate was immediate given
a sedative injection prior to being restrained in five-point restraints.
Lieutenant Cedergren reiterated he did not want to start with the restraint chair to restrain Mr.
Madrigal; rather, he wanted to start with the least intrusive means and the least use of force
option.
Captain Christy told Lieutenant Cedergren he had just told us he understood he might have had
to fight Mr. Madrigal, just to get him out of the WRAP. Lieutenant Cedergren said he still could
have put Mr. Madrigal into the restraint chair at that time, and then said he wanted to talk about
the WRAP training he received.
Lieutenant Cedergren stated he attended the summer range training program on May 29, 2019,
which was taught by Sergeant Smitherman. Lieutenant Cedergren remembered practicing the
Carotid Restraint Hold, he remembered going over the WRAP, and he remembered Sergeant
Smitherman demonstrating how the restraint chair worked. However, Lieutenant Cedergren
added, no one was physically placed in the chair, although he admitted people in the class were
taught how to connect the belts of the restraint chair and the policy on the chair was read to the
class. In addition, Lieutenant Cedergren expressed displeasure that the training class was allotted
four hours for this training, but the time of instruction provided was less than four hours.
In response to Captain Christy’s question about him acknowledging he may have had to fight
Mr. Madrigal once he was taken out of the WRAP, Lieutenant Cedergren stated he knew how the
restraint chair operated, but he did not see the need to take Mr. Madrigal out of the WRAP and
then move him into the restraint chair.
Lieutenant Cedergren spoke about how inmates would often be problematic for the arresting
officers, but then they would be compliant with the booking deputies, since ACSO was not the
same law enforcement agency who arrested them.
Page 60 of 117

 I asked Lieutenant Cedergren how much consideration he gave Sergeant Graham about his
opinion on how he thought Mr. Madrigal should be handled. Lieutenant Cedergren told me he
heard what Sergeant Graham said, but he admitted that was the extent of his conversation with
Sergeant Graham. Captain Christy asked Lieutenant Cedergren if he asked Sergeant Graham any
clarifying questions to get more detail or any additional information to assist him in making his
decision. Lieutenant Cedergren stated,
No, cuz at this time, by the – when I – by the, by this time – point right here, when
he – I uh, came past the lobby and we had medical out there. I had a pretty good
understanding that medical – they believed if this guy needed to be cleared at the
hospital, he would have been sent out or he had already been cleared and since
we made it to this side – and the doctor I think is Jed, a large Asian guy, he was
fine with him, everything – he was ours, we were good to go. So that was my
assumption that, he would have never been that far, had he not been fit to come
in. So, we are gonna deal with what we have, and keep going.
I told Lieutenant Cedergren I did not believe he sufficiently answered my question or Captain
Christy’s question. I told Lieutenant Cedergren, Sergeant Graham told him, his recommendation
was to restrain Mr. Madrigal in the restraint chair, but Lieutenant Cedergren disagreed with that
idea. I explained to Lieutenant Cedergren both Captain Christy and I were trying to find out how
much thought he gave Sergeant Graham’s opinion. I also repeated Captain Christy’s question to
Lieutenant Cedergren, and asked Lieutenant Cedergren if he ever asked Sergeant Graham any
clarifying questions to get a better understanding of the situation or if he just ignored him.
Lieutenant Cedergren stated he did not ignore Sergeant Graham, because he did not recall
Sergeant Graham telling him his recommendation was to use the restraint chair.
I asked Lieutenant Cedergren if he was saying he did not recall Sergeant Graham asking him for
permission to use the restraint chair. Lieutenant Cedergren told me, “You said, he told me his
recommendation was to use the chair and that, I don’t recall.”
I told Lieutenant Cedergren, Sergeant Graham had asked him for authorization to use the
restraint chair. Lieutenant Cedergren told me Sergeant Graham had only stated he needed a chair
placement, one time.
I asked Lieutenant Cedergren if he was now telling me he did not think Sergeant Graham wanted
to use the restraint chair. Lieutenant Cedergren told me,
No, no – I knew he did. I – I just need approval for the chair is what he asked me
when I was enroute. That’s the only comment that I remember him making to the
chair. Had he told me – I believe we should do the chair then I would have gave it
more consideration, yeah – but I don’t recall him specifically telling me no, we
need to use the chair.
Page 61 of 117

 I told Lieutenant Cedergren I wanted to make sure I was understanding him correctly. I asked
Lieutenant Cedergren if was saying he heard Sergeant Graham ask for approval for the restraint
chair and he told me yes. I asked him if he was now saying he did not understand Sergeant
Graham wanted to use the restraint chair. Lieutenant Cedergren told me no, saying he understood
Sergeant Graham wanted to use the restraint chair.
Lieutenant Cedergren stated he thought I was making it sound like Sergeant Graham had
explicitly told him he wanted to use the restraint chair and Lieutenant Cedergren told me he did
not specifically remember Sergeant Graham telling him that. Lieutenant Cedergren added that he
did not specifically recall anyone telling him his plan was not a good idea, nor did he specifically
recall anyone asking him a second time if they could use the restraint chair.
Captain Christy asked Lieutenant Cedergren what he thought Sergeant Graham wanted, when
Sergeant Graham asked him for his approval to use the restraint chair. Lieutenant Cedergren told
us he thought Sergeant Graham was saying ITR staff wanted to use the chair for Mr. Madrigal,
which is why he responded to ITR, so he could be on scene in case Mr. Madrigal fought when
they removed him from the WRAP. Captain Christy asked Lieutenant Cedergren if he thought
Sergeant Graham wanted to use the chair and he told us yes.
I asked Lieutenant Cedergren how much time he took to talk to Sergeant Graham, to ensure he
had a good understanding of the situation with Mr. Madrigal, after he arrived on scene.
Lieutenant Cedergren told me a few minutes.
At this point, I pulled up Sergeant Graham’s BWC video (14:05 into his first BWC video
segment) and I played the portion of video that began as Lieutenant Cedergren arrived on scene
in ITR and was contacted by Sergeant Graham. The video showed Lieutenant Cedergren only
glance towards Sergeant Graham as Sergeant Graham told Lieutenant Cedergren that Mr.
Madrigal was on mushrooms, Mr. Madrigal was going to fight them, and they were unable to
restrain Mr. Madrigal, as he walked right past him and over to Mr. Madrigal.
After watching the video, I asked Lieutenant Cedergren if it was more accurate to say he had
talked to Sergeant Graham for closer to three to five seconds – and not the three to four minutes
he told me he had spent talking to Sergeant Graham, to get a good understanding of the situation.
Lieutenant Cedergren admitted three to five seconds was a more accurate time frame.
I asked Lieutenant Cedergren if he thought Sergeant Graham’s opinion to use the restraint chair
was unimportant and he told me no. I asked Lieutenant Cedergren if there was a reason he did
not trust Sergeant Graham’s judgment. Lieutenant Cedergren told me he never said he did not
trust Sergeant Graham’s judgment, rather he wanted to see what Mr. Madrigal was going to do
once he was removed from the WRAP. Lieutenant Cedergren confirmed he did not agree with
Page 62 of 117

 Sergeant Graham’s decision to transition Mr. Madrigal into the restraint chair from the WRAP,
rather he wanted to remove Mr. Madrigal from the WRAP and investigate further.
I told Lieutenant Cedergren, if I was understanding the situation correctly, when he arrived on
scene he was aware Mr. Madrigal had already categorized as an “express,” Mr. Madrigal was
reportedly under the influence of a hallucinogen, Mr. Madrigal had recently fought with Fremont
PD officers, Mr. Madrigal was wearing a spit mask, Mr. Madrigal was currently restrained in the
WRAP, Mr. Madrigal was currently resisting and being uncooperative with the ITR deputies, the
ITR Sergeant advised Lieutenant Cedergren they believed Mr. Madrigal was going to fight with
the deputies, and the ITR Sergeant recommended Mr. Madrigal be placed in the restraint chair. I
asked him if this was all correct and he told me it was. However, Lieutenant Cedergren stated he
was not aware of exactly how recently Mr. Madrigal had fought with the Fremont PD officers.
In addition, I told Lieutenant Cedergren it was my understanding the restraint chair had already
been obtained, there was plenty of ACSO staff present, a safety officer had already been
designated, and the restraint chair was setup right next to cell R-1, ready to be utilized. I asked
Lieutenant Cedergren if this information was also correct and he told me yes.
I told Lieutenant Cedergren, in my opinion, this sounded like an ideal situation to use the
restraint chair. I asked Lieutenant Cedergren if he agreed with me and he told me, “It was an
option.” I confirmed Lieutenant Cedergren was telling me it was not ideal, in his opinion, but it
was an option and he repeated, “An option.”
I told Lieutenant Cedergren he wrote in his report, based upon his observations, and the
information provided by those present during the incident, he believed the restraint device
present, the Pro-Straint Restraint Chair, and its requested utilization, to be inappropriate given
the circumstances known to him at that time. I asked Lieutenant Cedergren exactly what
circumstances made the restraint chair an inappropriate option to use with Mr. Madrigal. After a
long drawn out pause, Lieutenant Cedergren told me,
The fact – that he’s, in the wrap – and I know what they’re saying he had done –
allegedly. I hadn’t witnessed it, but I also knew that as he came out of the WRAP,
if he had a propensity, he would show it, or he could choose to comply. So, I, at
some point, I made the decision to act on what he was going to do, based on what
I know. But again, he wasn’t spitting, he wasn’t grunting, he wasn’t yelling – I
didn’t know exactly when. Could I have asked – when he fought – exactly? Yeah, I
could have. But, I – I didn’t. I just know that’s what they said – so.”
Based on Lieutenant Cedergren’s disjointed answer, I attempted to clarify his answer. I asked
Lieutenant Cedergren if he was saying the circumstances that made the restraint chair an
inappropriate option, in his opinion, were because he had not personally witnessed any of the
information that was told to him. Lieutenant Cedergren told me he had not seen Mr. Madrigal be
aggressive or display an intent for harm.
I asked Lieutenant Cedergren if he was saying, at the time, this information he was told did not
carry significant weight. Lieutenant Cedergren told me he kept the information in mind – as he
did not tell anyone to remove the restraint chair, but he wanted to see how the unfolding of the
incident progressed.
Page 63 of 117

 I began to explain to Lieutenant Cedergren why I believed all the facts he had been told about
Mr. Madrigal were significant, when he interrupted me and told me he had noted the details, but
at that moment he decided not to use the restraint chair. Lieutenant Cedergren added, if Mr.
Madrigal had become aggressive, he would have restrained Mr. Madrigal in the restraint chair.
I asked Lieutenant Cedergren if he ever talked to Sergeant Graham or the deputies on scene, to
find out if they had recently been trained on the use of the restraint chair, and he told me no.
I asked Lieutenant Cedergren if concerns regarding staff being trained on the use of the restraint
chair were ever a factor in his decision to use the chair or not, and he told me no, saying he
assumed everyone had recently been trained on the use of the restraint chair within the last
month.
I asked Lieutenant Cedergren if he discussed the benefits or drawbacks of using the restraint
chair versus other options with Sergeant Graham, once he arrived on scene, and he told me he
did not.
I asked Lieutenant Cedergren who he did discuss the benefits or drawbacks of using the restraint
chair with that day, before he decided not to use it. Lieutenant Cedergren told me, “no one.”
I asked Lieutenant Cedergren how long he had been an ITR supervisor at SRJ, at the time of the
incident and he replied, “In this current role? Uhh – probably, the pay period.”
I asked Lieutenant Cedergren how many “express” inmates he would have dealt with in his role
as the ITR supervisor at SRJ and he told me “several.” I asked Lieutenant Cedergren to give me
an estimate of how many several meant, and he told me it was hard to “put a number” on it. I
told him to give me his best guess and he told me he estimated he oversaw between one and ten
“express” inmates get booked into SRJ, while he was the ITR Watch Commander.
I asked Lieutenant Cedergren if it was important for him to know the experience level of the staff
that worked for him in key leadership positions and he told me yes. I asked Lieutenant Cedergren
how many years Sergeant Graham worked in ITR as an ITR supervisor and he told me,
I’d say probably, at least a – a year before that, but before – I – he was there
when I came, so I don’t know exactly his starting time. But as a deputy I don’t
remember him having been assigned to ITR. I never crossed paths with him.
I reminded Lieutenant Cedergren he had just agreed it was important for him to know the
experience of staff members that worked for him in key leadership positions. I asked Lieutenant
Cedergren again, how long Sergeant Graham worked in ITR as an ITR supervisor and he told
me, “I have no idea.”
I asked Lieutenant Cedergren if it would surprise him to know Sergeant Graham was the most
senior ITR supervisor working at SRJ and he told me no. I asked Lieutenant Cedergren if it
would surprise him to know Sergeant Graham had worked as the ITR supervisor for over three
and a half years and he had supervised the booking of several hundred “express” inmates in that
time and he told me, “Yes, those numbers are larger than I would believe.”
I asked Lieutenant Cedergren if he was aware of whether or not nursing staff had been able to
take Mr. Madrigal’s vital signs and complete his medical assessment. Lieutenant Cedergren told
Page 64 of 117

 me he did not ask, but he assumed the medical staff had, because Mr. Madrigal had “made it to
this point,” and the nurse was standing by. Lieutenant Cedergren added in his experience, the
nurses would go out to the front lobby first and if the inmate had high blood sugar or another
medical condition, it would be documented, and the inmate would be turned away.
I told Lieutenant Cedergren, in his report, he recognized the need to remove Mr. Madrigal from
the WRAP, to have him further evaluated by the CFMG staff. I asked Lieutenant Cedergren if
Mr. Madrigal had been placed in the restraint chair, if the nurses would have been able to do a
better medical screening of him than if Mr. Madrigal was handcuffed and locked in a cell.
Lieutenant Cedergren told me yes.
I asked Lieutenant Cedergren what exactly he considered, before he decided he did not agree
with Sergeant Graham and he chose to deny his request to restrain Mr. Madrigal in the restraint
chair. Lieutenant Cedergren stated if he could get Mr. Madrigal out of the WRAP and into a cell
with the door closed, without a “use of force,” Mr. Madrigal would be free to walk about the cell
and they could come back to him later. Lieutenant Cedergren added this was the least intrusive
option “harm wise.”
I told Lieutenant Cedergren he stated in his report Mr. Madrigal had not displayed behavior
which would have resulted in the destruction of property, nor had he revealed the intent to cause
physical harm to himself or others. I reminded Lieutenant Cedergren Mr. Madrigal was currently
wearing a spit mask and restrained in the WRAP device. I asked Lieutenant Cedergren if this
was correct and he told me yes. I also asked Lieutenant Cedergren if he had been advised that
Mr. Madrigal had previously fought with Fremont PD officers at the jail and he told me yes. I
asked Lieutenant Cedergren for some examples of things Mr. Madrigal could have been doing,
while he was restrained in the WRAP and wearing a spit mask, to indicate he was going to be
combative, assaultive, or destructive. Lieutenant Cedergren replied,
Yelling, actively trying to spit, uhh – showing signs that he was seeing things that
weren’t there, being vocal. He was sitting there, rather mundane – as I mean, cuz
when you’re in the WRAP, there’s not a lot you can do. You – in it. Okay, but he
wasn’t talking to people, hearing voices, or giving me indications that he was
having auditory – or seeing things that weren’t there, either.
I confirmed with Lieutenant Cedergren he was saying Mr. Madrigal could have been voicing his
intent to be assaultive or he could have been spitting and he told me yes.
I asked Lieutenant Cedergren if he and Lieutenant McComas discussed the use of the restraint
chair and he told me, “I do not – believe so.”
I asked Lieutenant Cedergren if Lieutenant McComas told him he should use the restraint chair
and he told me he did not recall Lieutenant McComas saying that.
I asked Lieutenant Cedergren if he ever told Lieutenant McComas anything similar to, “We’re
not using it now, because someone used it incorrectly and management doesn’t want us using it
until everyone can get retrained.” Lieutenant Cedergren told me no.
I asked Lieutenant Cedergren if Lieutenant McComas would have been lying if he told us
Lieutenant Cedergren had made that statement to him. Lieutenant Cedergren told us he did not
recall saying that to Lieutenant McComas. I asked Lieutenant Cedergren to clarify if he was
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 saying he believed Lieutenant McComas was lying to us when Lieutenant McComas told us he
made that statement or if he was just saying he did not remember saying that to Lieutenant
McComas. Lieutenant Cedergren told us he just did not remember saying that.
I asked Lieutenant Cedergren if he told Lieutenant McComas his idea, on how he planned to
restrain Mr. Madrigal in handcuffs, while tethered to the door, instead of utilizing the restraint
chair and he told me no.
I asked Lieutenant Cedergren if Lieutenant McComas told him it was not a good idea to tether
Mr. Madrigal to the door after he did so, saying he thought the restraint chair should have been
used, as it was already set up right next to Mr. Madrigal’s cell. Lieutenant Cedergren told me he
did not recall Lieutenant McComas saying that.
I asked Lieutenant Cedergren if he recalled any conversation, at all, with Lieutenant McComas
about the restraint chair and he told me no. I asked Lieutenant Cedergren to clarify his answer by
telling me if that was because he just possibly did not remember that happening or if this was
because Lieutenant McComas was lying to us when he told us this information. Lieutenant
Cedergren just repeated he did not recall Lieutenant McComas saying that to him.
Captain Christy asked Lieutenant Cedergren if he recalled anything in talking to Lieutenant
McComas and he told us no.
At this point, I played a portion of the audio recording from Lieutenant McComas’ interview
(11:31 into the interview). I explained to Lieutenant Cedergren the portion of the interview I
wanted him to listen to, was where Captain Christy asked Lieutenant McComas a question and
he answered it. I played the recorded audio interview, where Captain Christy asked Lieutenant
McComas if he asked Lieutenant Cedergren about tethering Mr. Madrigal to the door or if they
had any discussion regarding this. Lieutenant McComas told us after Lieutenant Cedergren
tethered Mr. Madrigal to the door, he began walking down the hall to the nurse’s office.
Lieutenant McComas followed Lieutenant Cedergren down the hall and he stopped him and
confirmed Lieutenant Cedergren was going to start a restraint log. Lieutenant McComas asked
Lieutenant Cedergren how long he planned on having Mr. Madrigal tethered to the door and he
reiterated the restraint chair was right next to Mr. Madrigal’s cell, ready to be used, and he
thought it was the better option. Lieutenant Cedergren told Lieutenant McComas he had done
this a hundred times before, it was not a problem, and he would take responsibility for it.
I asked Lieutenant Cedergren if this audio clip refreshed his recollection of the conversation he
had with Lieutenant McComas and he told us he did not recall the conversation. I asked
Lieutenant Cedergren if he thought Lieutenant McComas was being untruthful when he told us
the details of this conversation. Lieutenant Cedergren told us he had no reason to believe
Lieutenant McComas made this conversation up, but he just did not recall this specific
conversation.
I asked Lieutenant Cedergren if he viewed Lieutenant McComas as his peer or his supervisor
that day. Lieutenant Cedergren told me they were both lieutenants, so he viewed him as his peer.
Page 66 of 117

 I told Lieutenant Cedergren I wanted to talk about his involvement with Mr. Madrigal and when
he assisted in removing him from the WRAP. I asked Lieutenant Cedergren if there was a reason
why he was trying to adjust the tension strap of the WRAP, instead of directing a deputy to do
this. Lieutenant Cedergren told me no, saying he just stepped in and did it.
I told Lieutenant Cedergren, in watching the video from Deputy Ross’ BWC, it seemed that after
Mr. Madrigal had been stood up, deputies still thought the plan was to put Mr. Madrigal in the
restraint chair. I told Lieutenant Cedergren it appeared the deputies started to turn and walk Mr.
Madrigal to the restraint chair, when Lieutenant Cedergren told them not to put him in the
restraint chair, but to bring Mr. Madrigal over to him.
I asked Lieutenant Cedergren if he had discussed using the restraint chair with anyone at this
point and he told me no. I asked Lieutenant Cedergren if he told the deputies what his plan was,
before he started telling the deputies what to do and went “hands on” himself and he told me at
this point, he never told anyone what the plan was regarding Mr. Madrigal.
I told Lieutenant Cedergren in his report he stated, prior to removing Mr. Madrigal from the
WRAP, the ankle restraints were attached to Mr. Madrigal’s handcuffs, as he recognized Mr.
Madrigal’s behavior, volatility, and intentions were unpredictable and subject to change. I told
Lieutenant Cedergren this statement sounded like he was trying to justify why he decided to
attach the ankle restraints to Mr. Madrigal’s handcuffs. I asked Lieutenant Cedergren if this
assumption was correct and he told me yes. I asked Lieutenant Cedergren if this same logic
would have also applied to justification for placing Mr. Madrigal in the restraint chair and he told
me yes, saying “you could.”
I told Lieutenant Cedergren, just a few paragraphs earlier in his report, he argued he did not
believe the restraint chair was appropriate, given his observations of Mr. Madrigal. However,
now he claimed he recognized Mr. Madrigal’s behavior, volatility, and intentions were
unpredictable and subject to change. I asked Lieutenant Cedergren what, if anything, happened
to drastically change his stance on Mr. Madrigal. I explained, in reading his report, it sounded
like the only thing that changed during this time, was that he had stood Mr. Madrigal up, placed
Mr. Madrigal back on the ground, and eased the tension strap on the WRAP. Lieutenant
Cedergren told me, “Just the – that he was unpredictable. He had made no – actions that showed
anything different.”
I told Lieutenant Cedergren I was questioning what happened that we did not know about, that
caused him to drastically change his stance on the level of risk Mr. Madrigal now presented.
Lieutenant Cedergren stated when he responded to Mr. Madrigal’s cell in ITR, he decided he
was not going to initially use the restraint chair, based on his earlier observations of Mr.
Madrigal in the lobby, coupled with the fact Mr. Madrigal was not spitting. Lieutenant
Cedergren also considered Mr. Madrigal may have been under the influence of mushrooms, but
since he had no report with Mr. Madrigal, he could not confirm this.
When Lieutenant Cedergren removed Mr. Madrigal from the WRAP, he utilized the cell door
and cuffing port to remove Mr. Madrigal’s handcuffs, by using the ankle restraints attached to
the handcuffs, which allowed him to keep Mr. Madrigal held tight against the door, preventing
him from turning or swinging toward a deputy. Lieutenant Cedergren stated this was his thought,
Page 67 of 117

 to maintain control of Mr. Madrigal, when he was referring to Mr. Madrigal’s unpredictability.
Lieutenant Cedergren added, if he needed to use the restraint chair, depending on how Mr.
Madrigal reacted when he was removed from the WRAP, he would have, as he had never
dismissed the option of using the restraint chair.
I asked Lieutenant Cedergren how he came up with the decision to attach the ankle restraints
between Mr. Madrigal’s handcuffs. Lieutenant Cedergren stated he had used this technique
numerous times before, as it was a method that was taught. Lieutenant Cedergren stated he used
this technique to limit Mr. Madrigal’s movement, by holding him against the door to complete a
search.
I asked Lieutenant Cedergren if using the chains in this manner, to pull Mr. Madrigal against the
door, was enough to hold Mr. Madrigal against the door, or if a deputy had to also push Mr.
Madrigal back against the door, to hold him against the door. Lieutenant Cedergren told me he
did not know if a deputy had to physically push or hold Mr. Madrigal against the door. I asked
Lieutenant Cedergren if it would surprise him to know Deputy Rhoades had to exert significant
effort to hold Mr. Madrigal’s upper body against the door, while she also told Mr. Madrigal to
stop resisting. I offered to show Lieutenant Cedergren the video from Deputy Rhoades’ BWC,
but he declined. Lieutenant Cedergren told me he believed Deputy Rhoades had to exert
significant effort to hold Mr. Madrigal against the cell door.
I asked Lieutenant Cedergren if, at this point, it would have been appropriate to place Mr.
Madrigal in the restraint chair and he told me yes. I asked Lieutenant Cedergren if he was ever
concerned with Mr. Madrigal doing something to injure himself and he told me no.
I asked Lieutenant Cedergren if he secured the ankle restraints between Mr. Madrigal’s
handcuffs or if he directed someone else to do it. Lieutenant Cedergren told me he would assume
he did it, but he did not know. I told him after watching Deputy Johnston’s BWC video, it was
evident he had done it and he said okay.
I asked Lieutenant Cedergren if he had been taught to secure ankle restraints around an inmate
that had been handcuffed behind the back, and then pull that inmate against the door through the
cuffing port while using the door as a shield. Lieutenant Cedergren told me he had done it on
different extractions, it had been taught, and he talked about this technique as a Jail Training
Officer (JTO) Sergeant in 2005.
I asked Lieutenant Cedergren if this technique was taught in a class or if it was passed along as
jail techniques and he told me it was passed along as institutional knowledge. I asked Lieutenant
Cedergren if this technique was taught in the police academy and he told me no. I asked
Lieutenant Cedergren if any defensive tactics instructors taught this technique. Lieutenant
Cedergren stated it was his understanding this was taught in classes by the defensive tactics
instructors, based on a brief conversation he had with Sergeant Sylvester.
Captain Christy asked Lieutenant Cedergren what kind of class Sergeant Sylvester would instruct
that would teach this technique. Lieutenant Cedergren stated “Use of force” classes with trainees
in the JTO program. Lieutenant Cedergren also confirmed Sergeant Sylvester presented this
technique in the Core Course curriculum and he had assisted in teaching this technique as a JTO
Sergeant.
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 I asked Lieutenant Cedergren what the purpose of technique was, and he told me he would use
this technique to control an aggressive inmate or an inmate who was prone to violence.
Lieutenant Cedergren stated he would use this practice to search an inmate before the inmate
went into the cell and he also stated he could also use this technique to hold the inmate against
the door, so when the cell door was shut, the inmate was pulled into the cell with the closing of
the door. I asked Lieutenant Cedergren if there were any other situations where it would be
beneficial to use this technique and he told me these were the only two reasons he was aware of.
I asked Lieutenant Cedergren what was taught in the instance, when an inmate resisted or refused
to cooperate when the inmate was inside the cell, but the deputies were unable to pull the inmate
against the door to remove the inmates ankle restraint from around the handcuffs. Lieutenant
Cedergren told me he did not know what was taught in this instance.
I told Lieutenant Cedergren, if I was understanding him correctly, he was saying he showed this
technique to new deputies, telling them this was a technique they could use. I asked Lieutenant
Cedergren what he taught them to do when this technique did not work, and the inmate refused
to allow the deputies to remove the ankle restraints from their handcuffs. When Lieutenant
Cedergren did not immediately answer me, I asked him if this technique was effective one
hundred percent of the time. Lieutenant Cedergren told me no.
I asked Lieutenant Cedergren again, what he taught the deputies to do to resolve the issue, when
the technique he taught them was not effective. Lieutenant Cedergren stated if the inmate did
not want to be compliant, he would advise them to give the inmate time to change their minds
and become compliant. Lieutenant Cedergren went onto explain he believed that was the purpose
of the restraint log, to watch the inmate and wait for them to comply.
I told Lieutenant Cedergren I only was talking about leaving the inmate secured with the ankle
restraints around their handcuffs. Lieutenant Cedergren told me he understood, and he reiterated
his response, saying if the inmate did not comply, he would leave the inmate secured with the
understanding that over time, the inmate would become compliant. Lieutenant Cedergren added
when it got to a certain point and the inmate still had not complied, he would switch to another
plan and go into the cell and remove the ankle restraints, regardless of whether or not they need
to use force to accomplish this.
I told Lieutenant Cedergren he had just said when it reached a “certain point,” he or the deputies
would go back inside and remove the ankle restraints. I asked Lieutenant Cedergren what was
the “certain point.” Lieutenant Cedergren told me this was generally less than four hours. I told
Lieutenant Cedergren if I was understanding him correctly, he was saying in the instances when
he applied ankle restraints to an inmates handcuffs and the inmate refused to surrender the ankle
restraints, he would give that inmate four hours to change his mind and comply. In the instance
the inmate did not comply within the four hours, he would open up the door and go back inside
the cell and remove them. Lieutenant Cedergren replied, “Not – not four hours, in a hard, fast
rule.” I asked Lieutenant Cedergren what the hard, fast rule was, and he told me, in this specific
case, it was the end of the shift, as he did not want to leave it for the next shift.
I asked Lieutenant Cedergren what he taught the deputies to do, when this technique did not
work and he told me, “They’re never – that was never taught. I – I have no idea what Scott
taught, at that point, either. I wasn’t.”
Page 69 of 117

 I challenged Lieutenant Cedergren and said he told me he had taught a technique and he
interrupted me and told me he never taught this technique, rather he had only seen the technique.
I confronted Lieutenant Cedergren and told him I believed he had told me earlier, he did teach
this technique, when he was the JTO Sergeant. However, Lieutenant Cedergren adamantly
denied this, telling me no, saying Sergeant Sylvester was the instructor in the Core Course and he
had only witnessed the technique and utilized it, but he had never actually been the instructor
who taught it. I asked Lieutenant Cedergren if this meant he never showed anyone else how to do
it and he told me he had applied it, but he had never instructed anyone else how to do it in a
formalized setting.
I asked Lieutenant Cedergren if he was saying his understanding was this technique was taught,
but when it failed to work as designed, he did not know what to do. Lieutenant Cedergren
replied,
Well, in that – one case, not that it’s a hard, fast rule, but the one that Scott
shared with me, when I’d asked him, he said they ultimately ended up going in
and fighting the guy and having a bigger use of force to get him out.
Lieutenant Cedergren confirmed he was telling us about a previous incident Sergeant Sylvester
relayed to him, when the inmate refused to cooperate and surrender the ankle restraints and
handcuffs by backing up to cuffing port of the cell door, so the deputies had to open the door and
enter the inmates’ cell to forcibly remove the restraints.
I told Lieutenant Cedergren I had talked to Sergeant Sylvester, who told me this technique was
taught, but only for the purposes of searching an inmate – as a temporary means to restrain an
inmate. However, I told Lieutenant Cedergren, Sergeant Sylvester was adamant that it was never
taught under any circumstances, that it was okay to walk away from an inmate, leaving that
inmate tethered to the door with ankle restraints. Lieutenant Cedergren told me he thought this
was a fair statement and he would believe this.
I asked Lieutenant Cedergren if it was fair to say the act of attaching the ankle restraints to the
inmate’s handcuffs was a technique he was taught, but the resolution he came up with, leaving
the inmate tethered to the door, he was not taught. Lieutenant Cedergren told me yes, saying he
thought it was a reasonable solution at that time.
I asked Lieutenant Cedergren if he could understand how the act of leaving an inmate chained to
the door, could be considered cruel and unusual, and he told me yes.
I asked Lieutenant Cedergren if he discussed this technique with any other supervisors before
this incident and he told me he did not specifically remember doing so. I asked Lieutenant
Cedergren if he remembered talking about the technique he used with Lieutenant McComas,
Sergeant Graham, or any of the ITR deputies on the day of the incident, and he told me no.
I told Lieutenant Cedergren he stated earlier in the interview he used this technique before at
SRJ. I Lieutenant Cedergren how many times he had used this technique before and he said,
“less than five, myself.” I asked Lieutenant Cedergren how many of these times did he have to
leave the inmate tethered to the door, before the inmate became compliant. Lieutenant Cedergren
replied, “Generally – within a few minutes. Maybe – maybe walking out of the pod and watching
from the dayroom and then having them motion ‘go back in,’ and they’re compliant.”
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 I asked Lieutenant Cedergren if he had any prior BWC video of him using this technique and he
told me no. Captain Christy explained to Lieutenant Cedergren that if he had used this technique
in the past, it would have necessitated a “Use of Force” report and Captain Christy asked
Lieutenant Cedergren again, if he could remember recording anything from his prior applications
of this technique. Lieutenant Cedergren stated he was unsure when he last used this technique
and he thought it was possible BWC’s were not issued then.
I asked Lieutenant Cedergren if any memorandums, training bulletins, or training videos had
been circulated at SRJ discussing the technique of applying ankle restraints in-between a pair of
an inmate’s handcuffs and he told me no.
I asked Lieutenant Cedergren if he ever conducted any training or wrote any memorandums or
training bulletins, or put together training videos on what he perceived to be the benefits of using
this technique to be, and he told me no.
I asked Lieutenant Cedergren he ever taught anyone else this technique in a classroom setting
and he told me no.
I asked Lieutenant Cedergren if he remembered assisting Deputies Ross and Rhoades in pulling
on the chain of the ankle restraints after Mr. Madrigal was inside his cell with the door closed
through the open cuffing port door, in an attempt to pull Mr. Madrigal to get him to come back to
the door to remove the restraints and handcuffs and he told me yes. I asked Lieutenant Cedergren
if he told the deputies to stop pulling on the chain, when he realized this was not going to be
successful and he told me yes, saying he did not want the deputies to get injured.
I asked Lieutenant Cedergren if, at this time, he stopped and considered removing Mr. Madrigal
from the cell and placing him in the restraint chair. Lieutenant Cedergren told me, “I don’t know
if I actually thought about it or not. So, I’ll say – no, but I don’t ever remember making a
conscious decision either way.”
I asked Lieutenant Cedergren what he did next and he told me he took a pair of handcuffs and
attached one end of the handcuffs to the cuff of the ankle restraints that were attached to Mr.
Madrigal’s handcuffs and then he attached the other end of the handcuffs to the outside doorknob
of Mr. Madrigal’s cell door.
I asked Lieutenant Cedergren why he did not just open Mr. Madrigal’s cell door and lay Mr.
Madrigal on the ground, facedown, and then remove the ankle restraints. Lieutenant Cedergren
replied, “Couldn’t tell you.”
I told Lieutenant Cedergren I had spoken to multiple deputies, who told me Mr. Madrigal was
only being passively resistant and there was no apparent reason why they could not have simply
gone back inside Mr. Madrigal’s cell to remove the ankle restraints. I asked Lieutenant
Cedergren why he did not want to go back inside Mr. Madrigal’s cell, after he was unable to
remove the ankle restraints from Mr. Madrigal’s handcuffs. Lieutenant Cedergren told me,
I thought – given the fact we had closed the door, he would become compliant –
and he would take them out without having to re-open the door and go back in.
cuz – not to justify anything but putting him on the floor – if he had chose to be
fine, that would have been great. But it – I , having – all my experience, had you
gone in and then you had to fight him or somebody punched him or kneed him in
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 the back or figure-four, then you’ve got the ‘use of force’ and – not saying it
would happen in this case, but that’s the kind of case where somebody says, ‘well
if you had him there, why didn’t you simply wait him and leave him in the cell.’
You – there, it’s almost like a no-win scenario.
I told Lieutenant Cedergren the problem with his decision was our agency just did not teach staff
to tether inmates to the door and “wait them out.”
I asked Lieutenant Cedergren if he ever considered assembling a Resistive Inmate Management
(RIM) team to deal with Mr. Madrigal, once he could not get Mr. Madrigal to surrender the ankle
restraints and handcuffs. Lieutenant Cedergren told me no, saying he had the personnel
necessary for a RIM team already there and he stated it was never a matter of extricating Mr.
Madrigal from the cell. I explained to Lieutenant Cedergren a RIM team is equipped with a
shield, which could lessen the likelihood of injury to deputies if they had to go back inside the
cell to physically retrieve his restraints, and he told me okay.
I asked Lieutenant Cedergren why, at this point, he did not use the restraint chair, as it had
already been set up and was right next to Mr. Madrigal’s cell. Lieutenant Cedergren told me,
I don’t think there was a conscious reason not to – or to. Simply to see what he
would do. Cuz we were, even at this time, we’re talking to this guy and he wants
to go home. Says he’s not mental, he said that he’s not high – not that I believe
him, but he’s not giving – he’s not giving me any signs that he’s got any other
intention other than that. And again, I don’t know when he ingested shrooms or
how many or when, so – I don’t know. I could have erred – I guess on the side of
caution, yeah.
I asked Lieutenant Cedergren if he was aware Lieutenant McComas, Sergeant Graham, and
every deputy present on scene in ITR were all surprised when he chose not to use the restraint
chair, and he told me, “I could see they would be surprised, now – yeah.” Lieutenant Cedergren
went on to say he did not see any visual signs of their disagreement, he did not see anyone
shaking their heads in a “no” motion, nor did he remember anyone telling him to stop or re-think
his actions. I asked Lieutenant Cedergren to clarify he was saying he did not see anyone
disagreeing with what he was doing, and he told me, “Not that I – openly saw – no.”
I asked Lieutenant Cedergren if he thought Sergeant Graham was okay with his decision not to
approve the use of the restraint chair. Lieutenant Cedergren told me, “Yeah, cuz he didn’t voice
any different opinion or say anything else, he – stood there.”
I asked Lieutenant Cedergren if he had ever handcuffed an inmate to the door before, just using a
pair of handcuffs, and he told me no. I asked Lieutenant Cedergren if he had ever utilized any
unorthodox handcuffing techniques in the past when dealing with an uncooperative inmate to
secure him to a door, and he told me no.
I told Lieutenant Cedergren I was going to pull up the video of a BWC and I asked him if he was
sure he had never done this before, or if it was possible he had done this, and he just was not
remembering it. Lieutenant Cedergren told me it was possible he had done this before, and he
just was not remembering it.
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 I told Lieutenant Cedergren that I was going to play Deputy Matt Ahlf’s Body Worn Camera
video, which was about ninety seconds long. Lieutenant Cedergren interrupted me and told me
he was now familiar with the incident I was referring to, but I advised him we were still going to
watch it.
Note: The video covered an incident that occurred on July 23, 2017, in Housing Unit 2, on the
east side of the housing unit, in F-Pod. Lieutenant Cedergren explained that it was concerning
an inmate who refused to lock down and he advised he had used some profanity, when he
secured the inmate to the cuffing port of the door, until the nurse arrived, and he removed the
inmate from the door.
The BWC video showed an inmate who was refusing to lock down in his cell, while deputies and
Sergeant Tony Aniasco talked to the inmate through the open cuffing port of the F-Pod door.
Lieutenant Cedergren arrived on scene and approached the inmate and asked him what his name
was. As the inmate extended his wrist so Lieutenant Cedergren could read his wristband,
Lieutenant Cedergren reached through the open cuffing port and grabbed the inmate’s wrist and
pulled it out of the door and ordered deputies to open the door. Once deputies did so, Lieutenant
Cedergren assisted deputies in pulling one of his arms around the door, before he handcuffed the
inmate’s wrists together, effectively handcuffing the inmate to the door. While the inmate was
straddling the edge of the door on his knees, Lieutenant Cedergren told the inmate, “Chill
motherfucker!” and walked away.
I asked Lieutenant Cedergren if the video refreshed his recollection, and he told me yes. I asked
Lieutenant Cedergren if earlier, when I asked him if he had ever handcuffed an inmate to the
door in an unorthodox manner, he just did not remember this incident, and he told me yes.
However, Lieutenant Cedergren added that in his mind, he thought I was just talking about
handcuffing an inmate to the doorknob or handle of a door.
I asked Lieutenant Cedergren if he was reprimanded over this incident and he told me no.
Lieutenant Cedergren told me he spoke to Captain Darren Skoldqvist and told him what
happened, and Captain Skoldqvist responded by saying, “Madigan is gonna shit,” because of the
way the inmate was secured around the door.
However, Lieutenant Cedergren never heard anything or received any discipline regarding this
incident. Lieutenant Cedergren stated he would have understood if he was reprimanded over this
incident, which is why he notified Captain Skoldqvist right after this incident occurred.
I asked Lieutenant Cedergren how long he left the inmate on his knees, handcuffed to the door.
Lieutenant Cedergren told me he left the inmate that way until medical staff arrived, but he was
unsure how long that was. I asked Lieutenant Cedergren if it would surprise him to know he left
the inmate on his knees, handcuffed to the door, for over ten minutes. Lieutenant Cedergren
agreed that it could have been ten minutes that he left the inmate there.
I asked Lieutenant Cedergren what his justification was, to leave the inmate handcuffed in that
manner for that long of a time, and he told me he did this, so he would only have to move the
inmate one time, which would be after the nurse examined him.
I told Lieutenant Cedergren that his statement, “Chill motherfucker!” sounded like it may have
been punitive, as if he left the inmate in that manner for not cooperating. Lieutenant Cedergren
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 told me he had no punitive intentions when he said and did this, rather he was frustrated, and his
emotions got the better of him.
I told Lieutenant Cedergren that I wanted to talk about Mr. Madrigal again and I asked him if he
left Mr. Madrigal tethered to the door for over two hours, as a form of punishment for not
cooperating with him. Lieutenant Cedergren told me no, and stated he would have been able to
remove Mr. Madrigal from being tethered to the door at any time, whenever Mr. Madrigal
became compliant.
I asked Lieutenant Cedergren if he remembered asking anyone else if they thought his idea of
tethering Mr. Madrigal to the door with ankle chains was a good idea. Lieutenant Cedergren told
me he did not specifically remember asking anyone this.
I told Lieutenant Cedergren that he stated in his report the following: based on Mr. Madrigal’s
refusal to cooperate, even the removal of the ankle restraints from the handcuffs around Mr.
Madrigal’s wrists, was not likely to occur, without employing force to overcome Mr. Madrigal’s
resistance and/or lack of communication offered. I asked Lieutenant Cedergren what he meant
by that statement.
Lieutenant Cedergren referred to his supplemental report to refresh his recollection and told me
he had stated this to explain why they stopped pulling on the ankle restraint chains attached to
Mr. Madrigal’s handcuffs through the open cuffing port.
I asked Lieutenant Cedergren if he thought it was possible to go back inside the cell while Mr.
Madrigal was tethered to the door with his hands behind his back, to gain control of Mr.
Madrigal without using force. Lieutenant Cedergren admitted that option would have been
possible, but he did not recall if he consciously considered doing that at the time.
I told Lieutenant Cedergren that in watching the video from the various BWC’s, I only saw Mr.
Madrigal being passively resistant. I asked Lieutenant Cedergren if Mr. Madrigal was doing
anything different, that I could not see, which would have shown he was being actively
assaultive, and he told me no, not that he could recall.
I told Lieutenant Cedergren he also stated in his report that an inmate can defeat a pair of
handcuffs, even when properly applied and double-locked, and have access to a means to cause
physical harm to oneself or others. I asked Lieutenant Cedergren what he meant by that
statement.
Lieutenant Cedergren told me he needed to refresh his recollection, and he referred to his report
before telling me he stated this to explain why he attached a pair of handcuffs to the cuff of the
ankle restraints, because the inmate could have slipped the large cuff of the ankle restraints off
the doorknob due to the diameter of the ankle restraint cuff.
I asked Lieutenant Cedergren if he was ever concerned Mr. Madrigal may hurt himself or others,
and he told me no. Lieutenant Cedergren stated Mr. Madrigal had not done anything to lead him
to believe this. I asked Lieutenant Cedergren if he ever considered placing Mr. Madrigal in a
safety cell, and he told me no.
I asked Lieutenant Cedergren why, at this point, he did not choose to place Mr. Madrigal in the
restraint chair with a safety officer to watch over him. I reminded Lieutenant Cedergren that he
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 had just said he planned on waiting Mr. Madrigal out and he was going to periodically check on
him, so why not place Mr. Madrigal in the restraint chair, since there is also a designated safety
officer who would be assigned to watch him. Lieutenant Cedergren replied, “To me, it was more
restrictive, then – what was going on there – at the time, given the time. In hindsight? Yeah –
wouldn’t be sitting here today.”
I told Lieutenant Cedergren that in watching video from several of the deputies’ BWC’s, as well
as Sergeant Graham’s BWC, it was apparent to me, that no one else had any idea of what to do,
in regard to how Lieutenant Cedergren wanted them to restrain Mr. Madrigal in the handcuffs
and ankle restraints. I told Lieutenant Cedergren it seemed like he was constantly talking to the
deputies, directing deputies, and having to explain what he wanted them to do, as he showed
them what he was talking about. I asked Lieutenant Cedergren if that was a fair assessment, and
he told me that was a fair statement.
I asked Lieutenant Cedergren if it was likely that none of the deputies present had ever restrained
an inmate in a similar manner, and he told me yes. I asked Lieutenant Cedergren if he believed
Sergeant Graham or Lieutenant McComas had ever restrained an inmate in the same manner as
he restrained Mr. Madrigal, and he told me no.
I asked Lieutenant Cedergren if his understanding of the purpose of the restraint log was for the
inmate’s safety, and he told me yes. Lieutenant Cedergren stated it necessitated checking on the
inmate every fifteen minutes.
I asked Lieutenant Cedergren if he was familiar with our BWC policy, and he told me yes. I
asked him if he was aware of the specific section of our policy that covered D&C, and he told me
yes. I asked Lieutenant Cedergren if he could provide me with examples of when he would be
required to activate his BWC in the jail. Lieutenant Cedergren told me a placement like Mr.
Madrigal, cell searches, entering a housing unit, and for evidentiary purposes.
I provided Lieutenant Cedergren with a copy of our agency’s BWC policy, as outlined in
General Order 8.17, and I instructed him to turn to page 4, where I had him read several sections
under D&C that I had previously highlighted. I asked him to read aloud the sections that mandate
an activation of the BWC. Lieutenant Cedergren read the section that stated activation is required
any time an inmate is removed from their holding area, when entering a cell occupied by an
inmate, during count, during meals, during window checks, during observation checks, while
conducting general observation checks, while completing IOL’s, during other regular checks,
when contacting inmates inside their cell, including conversations through the window, during
medical emergencies, during any other inmate contact when recordings are not prohibited, and
during the processing of new arrestees (except for medical screenings).
I provided Lieutenant Cedergren with the most recent training bulletin covering the BWC policy.
Lieutenant Cedergren confirmed the language in the bulletin was consistent with the G.O. and
appeared to have been incorporated into the G.O.
I told Lieutenant Cedergren that the G.O. clearly outlined how this incident with Mr. Madrigal
required him to activate his BWC multiple times during his encounter with Mr. Madrigal. I told
Lieutenant Cedergren that once he went “hands on” with Mr. Madrigal, I would have expected
this to further emphasize the fact that he needed to use his BWC.
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 Note: Lieutenant Cedergren only activated his BWC after discovering Mr. Madrigal had
strangled himself and was no longer responsive.
Since Lieutenant Cedergren only activated his BWC after he found Mr. Madrigal unresponsive, I
asked him if that meant he did not know he should have activated his BWC at any other time
during this incident. Lieutenant Cedergren told me, “No, it does not mean – that I did not know
so – I had it in the buffering I – somewhere I thought – either I hit it, or I didn’t or I – it wasn’t
on. I admit it – it wasn’t on.”
I asked Lieutenant Cedergren if he had received training on BWC, and he told me yes. I asked
Lieutenant Cedergren if both he and his sergeants talked in briefings about the importance of
everyone activating their BWC’s, and he told me yes.
I asked Lieutenant Cedergren if, when he decided to go “hands on” with Mr. Madrigal, that
heightened his awareness that he was required to activate his BWC. Lieutenant Cedergren stated
if he would have remembered it, he would have turned it on.
I asked Lieutenant Cedergren if there was a reason why he did not follow the agency policy and
activate his BWC, when he assisted loosening the straps of the WRAP, and he told me there was
no reason it was not on.
I asked Lieutenant Cedergren if there was a reason why he did not follow the agency policy and
activate his BWC when he assisted removing Mr. Madrigal from the WRAP, and he told me no.
I asked Lieutenant Cedergren if there was a reason why he did not follow our agency policy and
activate his BWC, when he assisted with pushing and pulling on Mr. Madrigal’s body, and he
told me no.
I asked Lieutenant Cedergren if there was a reason why he did not follow the agency policy and
activate his BWC, when he assisted with pulling on the ankle restraint chain that was attached to
Mr. Madrigal’s handcuffs, and he told me no.
I asked Lieutenant Cedergren if there was a reason why he did not follow the agency policy and
activate his BWC when he conducted a general observation check of Mr. Madrigal, and he told
me no.
I asked Lieutenant Cedergren if there was a reason why he did not follow the agency policy and
activate his BWC, when he conversated with Mr. Madrigal, as he tried to get him to cooperate so
Lieutenant Cedergren could remove his handcuffs, and he told me no.
I told Lieutenant Cedergren that in watching all the video from the BWC’s and ITR, it appeared
he failed to activate his BWC at any time during his encounter with Mr. Madrigal, while Mr.
Madrigal was still alive. I told Lieutenant Cedergren that after the incident, I saw video showing
him checking with a group of deputies, ensuring they had turned off their BWC’s. I explained to
Lieutenant Cedergren that the logical conclusion would be that he did not want this incident
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 recorded and I asked him if this conclusion was accurate. Lieutenant Cedergren stated he could
not remember why he may have said something like that, but he explained that he was upset, he
had a lot of thoughts going through his head at the time, and everything that could have gone
wrong went wrong; however, Lieutenant Cedergren stated he never had any intent to prevent this
incident from being recorded.
Captain Christy told Lieutenant Cedergren that, as a lieutenant, he would have expected
Lieutenant Cedergren to have taken more of a supervisory role and not go “hands on,” but rather
manage the situation and take a more outside approach.
Note: At his point, Lieutenant Cedergren nodded his head in an up and down motion and said,
“Yes, yes” (as if he was in complete agreement with what Captain Christy was saying).
Captain Christy asked Lieutenant Cedergren if there was a reason he felt it was necessary to do
the work himself. Lieutenant Cedergren stated, “That’s just how I am. I – like to be involved and
– I thought that was the least minimal, invasive way, and that’s – at that moment – the best way
to address it. So – shame on me for being involved and thinking I had a better way.”
Captain Christy told Lieutenant Cedergren that even if he wanted to do this his own way, he
could have done more directing, so he could have gotten a more comprehensive feeling for what
was happening. Lieutenant Cedergren replied, “True. In hindsight – yeah.”
I told Lieutenant Cedergren almost everyone I talked to, described him as very “hands on.” I
asked Lieutenant Cedergren if this was accurate and he told me, “Yeah. I mean – it – it’s been
since day one, so – you can go back and pull – freakin’ stat sheets and – there aint – there’s – to a
fault. Let’s just say it’s to a fault.”
I asked Lieutenant Cedergren if this meant that even though he was a lieutenant, he still went
“hands on” on a regular basis, and he told me yes.
I asked Lieutenant Cedergren if, in his opinion, supervisors that tended to stand back and watch
and observe, were not effective as those supervisors who chose to actively participate in what
was happening and he told me, “Not necessarily.” I asked Lieutenant Cedergren if he thought
Sergeant Graham’s style of supervising was more likely to stand back and watch and observe,
and he told me this was more so Sergeant Graham’s style than his. I asked Lieutenant Cedergren
if he thought this made him a more effective supervisor than Sergeant Graham, and he told me
no. Lieutenant Cedergren stated it just meant they had different styles.
I told Lieutenant Cedergren I wanted to ask him about when he would move inmates from ITR to
other sections of ITR or out to various housing units. I asked Lieutenant Cedergren if it was
common for him to move inmates on a regular basis and if it was common for him to move
inmates by himself. Lieutenant Cedergren told me, “Depending on the inmates’ classification –
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 yeah, you can move inmates by yourself, common, I like to stay busy – I average fifteen to
twenty thousand steps – not that steps mean you are any busier than anybody else.”
I asked Lieutenant Cedergren if he would regularly move multiple inmates, administrative
segregation inmates, or inmates of different classes to housing units. Lieutenant Cedergren told
me he would regularly take administrative segregation inmates out to the housing units, but he
would not do this while he was also escorting inmates of other classifications. I asked Lieutenant
Cedergren if, to the best of his knowledge, he was abiding by the Agency policy and procedures
when he did this, and he told me yes. I asked Lieutenant Cedergren to confirm he was saying that
if he ever moved inmates out of ITR, outside of the Agency’s policy and procedures, it would
have been unintentional. Lieutenant Cedergren told me, “At the moment, we’re getting bodies
cleared out of ITR.”
I told Lieutenant Cedergren that, in watching the video from everyone’s BWC’s for this incident,
I noticed he did not have latex gloves on. I told Lieutenant Cedergren that it was apparent that
everyone else on scene was wearing gloves, except him. I asked Lieutenant Cedergren if he ever
stopped to think about putting on gloves. When Lieutenant Cedergren did not immediately
answer me, I asked him if he normally used gloves for protection, and he told me, “Nope.” I
asked Lieutenant Cedergren, “You normally don’t?” and he told me, “Pat-search people on the
street when I arrested them – don’t wear gloves. I don’t wear gloves at Raider game.”
I asked Lieutenant Cedergren if he ever checked the restraint log or followed up with Sergeant
Graham or the ITR deputies to ensure Mr. Madrigal was being checked on. Lieutenant Cedergren
told me he may have looked at the log, but he did not specifically remember doing so, other than
when he talked to Mr. Madrigal at the door.
I told Lieutenant Cedergren, according to his report, he left Mr. Madrigal in his cell about 1437
hours, and the next time he returned to Mr. Madrigal’s cell to check on him was 1650 hours.
Lieutenant Cedergren checked his report and told me yes, those times were correct.
I asked Lieutenant Cedergren if it ever caused him concern that over two hours had elapsed and
there was still no resolution regarding getting Mr. Madrigal out of the restraints. Lieutenant
Cedergren told me yes, saying he was going to resolve it. I confronted Lieutenant Cedergren and
asked him why then, he did not do anything to resolve it. When Lieutenant Cedergren did not
immediately answer me, I asked him what time the next shift started in ITR, and he told me 1700
hours.
In response to my previous question as to why Lieutenant Cedergren did not do anything to
resolve the situation with Mr. Madrigal after more than two hours had elapsed since he tethered
Mr. Madrigal to the door with ankle restraints, and no resolution had been reached, he stated:

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 And at this point – you have – 1650, is right before count. So, I didn’t have the
same seven people. I don’t recall exactly how many, but people count, people
move bodies. I do know, when I came back at 1720 – which was in thirty minutes,
the only person I had was Ross and Pete Mineo, Mineo was fingerprint – finger
printing three people at a time. So, whatever had been there, had gone – or,
eaten, or whatever. Cuz usually at count time – people do what they gotta do – so.
I don’t have a specific number. So, I wasn’t going to move him by – if I uncuffed
him by myself – fine. But when he pulled back, I wasn’t going to open the door by
myself, and I wasn’t gonna take – Mineo was still fingerprinting – so I said okay,
I’ll come back as soon as muster breaks. Which was 5:20 – around there, I don’t
know if it broke or not. Musters vary in length.
I asked Lieutenant Cedergren if he also saw Mr. Madrigal had maneuvered his handcuffs
from behind his back to the front of his body, and he told me yes. I asked Lieutenant
Cedergren if this caused him more concern now that Mr. Madrigal was no longer
handcuffed behind his back, but instead he was handcuffed in front of his body, and he
told me yes. I asked Lieutenant Cedergren why this increased his level of concern.
Lieutenant Cedergren told me, “Because now that they’re to the front – most – he has
some flexibility and that he has a longer reach on that chain – to get to where he needs to
be.” I asked Lieutenant Cedergren what Mr. Madrigal could do, now that he had that
slack in the chain. Lieutenant Cedergren told me, “Eventually what he did.”
I asked Lieutenant Cedergren that, with that information in mind, if there was a reason
why he did not just stay there and radio for deputies to respond and assist him in solving
the problem. Lieutenant Cedergren told me, “No there’s not – cuz he – in looking at the
log, he’d been – copesetic to that point, so.”
After providing me with his last answer, Lieutenant Cedergren stated he wanted to point
out that while writing his supplemental report, he reviewed other people’s BWC video,
which showed Deputy Sides notify Sergeant Graham that Mr. Madrigal had maneuvered
his handcuffs to the front of his body, within thirty minutes of Mr. Madrigal being placed
in the cell. Lieutenant Cedergren told me he was disappointed he was not notified of this
information when it was first discovered, because if he had been, he would have
addressed it then.
I asked Lieutenant Cedergren to clarify he was saying, had he been told earlier, that Mr.
Madrigal had maneuvered his handcuffs to the front of his body, he would have
recognized it as a significant concern and with ample staff present, he would have
immediately addressed it, and he told me yes. I asked Lieutenant Cedergren if, when he
later saw this himself, if he still recognized it as an immediate concern, and he told me
yes. I asked Lieutenant Cedergren if he was saying the reason he did not immediately
address this was because he did not have the necessary staff to assist him, and he told me
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 yes. Lieutenant Cedergren told me he was not going to address this by himself, and
Deputy Mineo was fingerprinting inmates, so he had to wait for Deputy Mineo to finish
before he would have been able to assist him.
I asked Lieutenant Cedergren if he ever realized that because Mr. Madrigal had
maneuvered his handcuffs to the front of his body, he could have taken off his spit mask
and used the straps of the spit mask to strangle himself. Lieutenant Cedergren told me, “I
hadn’t thought about that.”
I told Lieutenant Cedergren his report indicated he found Mr. Madrigal unresponsive
about 1720 hours. I asked Lieutenant Cedergren what caused him to check on Mr.
Madrigal at that time, and he told me, when he was near Deputy Mineo, he looked toward
Mr. Madrigal, and he could see Mr. Madrigal was sitting against the door.
I told Lieutenant Cedergren, that in reviewing Deputy Ross’ BWC video and reading his
report, I learned the following had occurred: When Lieutenant Cedergren was at Mr.
Madrigal’s cell door, he told Deputy Ross that Mr. Madrigal was not answering him.
With a look of alarm on Deputy Ross’ face, she asked Lieutenant Cedergren if he thought
Mr. Madrigal was strangling himself. Very unconcerned, Lieutenant Cedergren told
Deputy Ross, “No, he couldn’t have – not unless he got the fucking mask around his
neck.” I asked Lieutenant Cedergren what he meant by that statement. Lieutenant
Cedergren told me he did not remember making that comment, but he added, he did not
expect to find Mr. Madrigal in that condition.
Note: At this point, I played the video from Deputy Ross’ BWC (1:22 mark) for
Lieutenant Cedergren, to refresh his recollection of the incident. The video showed
Lieutenant Cedergren outside Mr. Madrigal’s cell door, when he saw Deputy Ross and
asked her to come over and assist him. Lieutenant Cedergren had the handcuffing port of
the door open and he was trying unsuccessfully to unlock the handcuff that was attached
to the chain of Mr. Madrigal’s restraints and remove it from the exterior door handle.
When Deputy Ross came over, Lieutenant Cedergren told her Mr. Madrigal was not
answering him. Deputy Ross asked Lieutenant Cedergren if he thought Mr. Madrigal was
strangling himself, to which Lieutenant Cedergren told her no, saying Mr. Madrigal
could not have done so, “not unless he got the fucking mask around his neck.” Lieutenant
Cedergren opened the door and tried to rouse Mr. Madrigal from what he appeared to
think was a slumber, before Deputy Ross pointed out that Mr. Madrigal had the chain of
the ankle restraints around his neck and Lieutenant Cedergren realized that Mr.
Madrigal was in need of assistance.
After we watched the video, I asked Lieutenant Cedergren if, when Deputy Ross asked
him if he thought Mr. Madrigal was strangling himself, and he replied, “Not unless he got
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 the fucking mask around his neck,” if he would have been referring to the spit mask, and
he told me yes.
I told Lieutenant Cedergren, it was obvious Deputy Ross thought it was possible Mr.
Madrigal used the chain of the ankle restraints to strangle himself. I asked Lieutenant
Cedergren if he failed to realize that was possible. Lieutenant Cedergren told me, “I
realized it was possible then, but originally – no – when his hands to the back, no. It – it
takes – I’d never even dreamed he would slip to the front, cuz most people – don’t.” I
told Lieutenant Cedergren I was asking him if he thought it was possible for Mr.
Madrigal to use the chain of the ankle restraints to strangle himself, after he realized Mr.
Madrigal maneuvered his handcuffs to the front of his body, and there was now slack in
the chain. Lieutenant Cedergren told me, “Yeah, now it was a possibility – cuz that’s why
I wanted to take him out of there. Yes.”
I told Lieutenant Cedergren that, in knowing Mr. Madrigal had maneuvered his handcuffs
to the front of his body and there was a possibility Mr. Madrigal could now use the chain
of the ankle restraints to strangle himself, I had to ask him the same question I asked him
before. I asked Lieutenant Cedergren again, why he failed to immediately do something
to resolve the issue. When Lieutenant Cedergren did not instantly answer me, I asked him
if he was afraid no one would have responded if he had radioed for additional deputies.
Lieutenant Cedergren told me, “I don’t know – I didn’t ask, but I know – …”
I interrupted Lieutenant Cedergren and asked him about his answer.
Right after I interrupted Lieutenant Cedergren, he told me, “I don’t know why I didn’t – I
– deputies come when you ask, yes – yes. Even on what you have on staff, and all that –
yes... but see, I – not to justify it – again, you look at the log – standing, standing,
standing, so I had no idea when he slipped. I should have stayed there, but had I known
earlier.”
I told Lieutenant Cedergren, after he discovered Mr. Madrigal had strangled himself with
the chain of the ankle restraints, he appeared flustered and overwhelmed. I told
Lieutenant Cedergren he repeatedly and excessively exclaimed the word, “fuck.” I asked
Lieutenant Cedergren if it was at that point, he realized he made a serious error, tethering
Mr. Madrigal to the door, and he told me yes. Lieutenant Cedergren stated it was an
“epic” mistake, and he was clearly panicked and overwhelmed with the whole situation.
I asked Lieutenant Cedergren if, in hindsight, he believed it would have been a better
option to have used the restraint chair, versus the restraint option he chose, tethering Mr.
Madrigal to the door with ankle restraints, and he told me, “It would have been a better
option to do something different, which might have included the restraint chair. Could
have been simple, as you said, open the door and make him lay on the floor.”
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 I told Lieutenant Cedergren, right after that happened, he grabbed the restraint log and
forcefully exhaled, as he looked at the log. I asked Lieutenant Cedergren what was
upsetting to him and he told me he was upset because he had to enter the “Code 3” entry
and he realized this was “the ultimate ‘oh fuck’ moment, where you own it – nothing
good is going to come of it – you’re fucked.”
I asked Lieutenant Cedergren if he was speaking candidly in our interview; if he was
admitting responsibility for what happened, saying, “I own this moment, like – I fucked
up. I own it.” Lieutenant Cedergren told me, “Oh, it’s – owned. It’s gonna – I know it’s
gonna come back to me – I – I have, I’ve had – we’ll get into that part about – different
conversations. I’ll let you finish up what you had – cuz.”
I asked Lieutenant Cedergren what his understanding was of the word negligent.
Lieutenant Cedergren told me, it was doing something wrong with malice, on purpose or
blind indifference. I told Lieutenant Cedergren it was failing to take proper care of
something.
I asked Lieutenant Cedergren what his understanding was of the phrase, deliberate
indifference. Lieutenant Cedergren told me it was doing something wrong with the intent
to not do it right or to cause someone harm. I told Lieutenant Cedergren it was a
conscious and reckless disregard of the consequences of one’s acts or omissions.
I asked Lieutenant Cedergren if he believed he was negligent in his actions as a
supervisor, when he chose to tether Mr. Madrigal to the cell door with ankle restraints.
Note: When Lieutenant Cedergren did not initially respond, Mr. Rains interjected and
stated he believed it was my responsibility to establish whether Lieutenant Cedergren’s
actions were negligent or not. However, Mr. Rains asked if I was going to insist
Lieutenant Cedergren answer the question and I told him I was. Mr. Rains asked
Lieutenant Cedergren if he clearly understood the definition of negligence and the
definition of deliberate indifference as I had explained those definitions to him, and he
told Mr. Rains yes.
Captain Christy asked Lieutenant Cedergren if, at the time, Lieutenant Cedergren thought
his actions were negligent, and Lieutenant Cedergren stated no. Lieutenant Cedergren
stated, at the time he thought he was doing the right thing. However, Lieutenant
Cedergren stated, in hindsight, he recognized and agreed his actions were negligent.
I asked Lieutenant Cedergren if he thought his actions rose to the level of deliberate
indifference, and he told me no.

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 I told Lieutenant Cedergren that after he tethered Mr. Madrigal to the door and secured
him in the cell, he walked over to Deputy Comfort and told him he did not want to use
the restraint chair. I asked Lieutenant Cedergren what it was about the restraint chair that
made him not want to use it. Lieutenant Cedergren stated it was because he had only been
briefly trained on the restraint chair, he had never seen the restraint chair used, he wasn’t
familiar with the restraint chair, Sergeant Moschetti told him about problems he had in
using the restraint chair in a past incident, and at the time, he did not think it was the best
option to use.
I summed up Lieutenant Cedergren’s response and told him, by saying it sounded like his
overall reason for not using the restraint chair was a lack of familiarity with it. Lieutenant
Cedergren responded:
I think more of the fact you don’t – it’s familiarity – it is what it is. It’s got
belts and you put people in it, okay. So that’s not so much a familiarity –
it’s – you don’t know how people will react. Cuz, like when I went in the
wrap, my first thing is I got claustrophobic. I sucked it up, I toughed it up,
but – what if you put in the chair and someone has an episode and then
you’re – you’re – you don’t know what you’re gonna cause. So, I – it is
what it is. You can believe in it or not believe in it. I just don’t believe in it.
So – sorry.
I told Lieutenant Cedergren that in speaking to almost everyone else involved, I thought
the most reasonable answer I was told, as to why other people thought he did not use the
restraint chair, was because he was “running the show” and he wasn’t going to bring in a
device he did not know how to operate. I asked Lieutenant Cedergren if it was fair to say
that his lack of familiarity with the restraint chair was a significant factor in his decision
not to use it, and he said yes.
I asked Lieutenant Cedergren if he ever asked Sergeant Graham if he was confident in
knowing how the restraint chair worked or if he was comfortable in using the restraint
chair, and he told me no.
I confirmed with Lieutenant Cedergren that he was present on May 29, 2019, at the range
for the 2019 June Weapons Proficiency Program, in which Sergeant Smitherman taught
the portion of training that covered the Carotid Restraint Hold, the Use of the WRAP, and
the use of the Pro-Straint restraint chair, and he told me yes. I told Lieutenant Cedergren,
according to the training records, the training occurred less than two weeks before the
incident with Mr. Madrigal. Also, I told Lieutenant Cedergren that Sergeant Smitherman
remembered him attending the class and confirmed he did not have any questions,
concerns, or complaints about the restraint chair, that she could remember. I asked
Lieutenant Cedergren if there was anything he could remember, that would contradict her
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 statement, and he told me no, saying that he never raised any concerns to her either inside
or outside of the classroom.
Note: On November 7, 2019, I spoke to Sergeant Smitherman and she confirmed she
taught the Weapons Proficiency Program at the range on May 29, 2019. Sergeant
Smitherman advised me she was confident Lieutenant Cedergren had been thoroughly
trained on the restraint chair and she remembered covering the material with him in
class that day. Furthermore, this information was corroborated by Lieutenant
Cedergren’s Individual Training Activity log.
I asked Lieutenant Cedergren if he needed to understand every detail of how something
worked, before he could authorize someone else to use it. When Lieutenant Cedergren
did not answer me, I provided an example of my work computer malfunctioning and me
not knowing the intricacies of how to fix it. I explained that in this instance, I would call
someone from IT (Information Technology) and have them fix it. I asked Lieutenant
Cedergren if I needed to understand exactly what they were doing to fix my computer or
if it would be acceptable to trust in the process that has been put in place and allow the IT
staff to fix my computer, while overseeing the repair. Lieutenant Cedergren told me in
that instance, it would be permissible. However, he stated if the scenario involved
liability like teaching someone how to fire a gun that did not know how to fire a gun, then
no.
I told Lieutenant Cedergren that in specifically talking about the restraint chair, I asked
him if he needed to know exactly how the restraint chair functioned, such as which button
to push, which belt to pull, or which clip went where, to supervise the use of the restraint
chair, but he did not answer me.
I asked Lieutenant Cedergren again, if he needed to know exactly what everything on the
restraint chair did, to supervise it’s use. Lieutenant Cedergren told me, “It would be nice
to – but I don’t – before I put my faith in somebody else – yes.” I told Lieutenant
Cedergren that it may be nice to know everything about the restraint chair, but I asked
him again, as a lieutenant, if he needed to know exactly how everything on the restraint
chair worked, before he could authorize its use. Lieutenant Cedergren stated, “As a
lieutenant in general – no, for me – I would want to know.”
Captain Christy asked Lieutenant Cedergren to clarify that was one of the main reasons
he did not authorize the use of the restraint chair. Lieutenant Cedergren stated he just did
not like how someone was placed in the chair, and he also reiterated his concerns about
what Sergeant Moschetti told him, in which an inmate remained in the restraint chair for
about sixteen hours. Captain Christy asked Lieutenant Cedergren if it was fair to say
every restraint incident could be different, depending on the details of each case, and
Lieutenant Cedergren told him yes. Captain Christy asked Lieutenant Cedergren if
Page 84 of 117

 placing Mr. Madrigal in the restraint chair could have gone perfectly well, and Lieutenant
Cedergren told him yes.
Lieutenant Cedergren stated part of the goal was to avoid a “Use of force.” Captain
Christy asked Lieutenant Cedergren if the option he chose, tethering Mr. Madrigal to the
door, was not still a “Use of force,” and Lieutenant Cedergren admitted that it was, and
stated, “You could say that.”
Lieutenant Cedergren went on to elaborate at times handcuffing would be considered a
“Use of force.” I reminded Lieutenant Cedergren that our Use of Force policy was clear,
and in that instance, it would only be considered a “Use of force” if the deputy applying
handcuffs was overcoming an arrestee’s resistance when he was handcuffing the person,
and Lieutenant Cedergren acknowledged I was correct.
I asked Lieutenant Cedergren if, prior to this incident, anyone had ever requested his
approval to use the restraint chair, and he told me no.
I asked Lieutenant Cedergren if he called his supervisor and talked to him right after this
incident occurred. Lieutenant Cedergren stated, he called Captain Mattison and told him
Mr. Madrigal had been restrained to the door and he had hung himself. I asked Lieutenant
Cedergren if he told Captain Mattison something had happened, it was his fault, and an
inmate was likely to die as a result. Lieutenant Cedergren told me he did not specifically
remember saying that, but he admitted he could have said that. I asked Lieutenant
Cedergren if he remembered telling Captain Mattison the reason he chose not to use the
restraint chair, and he told me no. I told Lieutenant Cedergren that Captain Mattison told
me he stated he had not used the restraint chair because he was uncomfortable using it.
Lieutenant Cedergren told me, he did not recall saying that, but he admitted it was
possible he had said that or something similar.
I asked Lieutenant Cedergren if Captain Mattison ever gave him an order or told him not
to use the restraint chair, and he told me no.
I asked Lieutenant Cedergren if Captain Hesselein ever told him not to use the restraint
chair, and he told me no.
I asked Lieutenant Cedergren if Captain Tara Russell ever told him not to use the
restraint chair, and he told me no, Lieutenant Cedergren told me Captain Russell was not
at SRJ when he was assigned there.
I asked Lieutenant Cedergren if anyone in a management position ever told him not to
use the restraint chair, and he told me no.
Page 85 of 117

 I asked Lieutenant Cedergren if anyone on the entire department ever tried to discourage
him from using the restraint chair, and he told me no.
I asked Lieutenant Cedergren if he and Sergeant Graham ever got into a disagreement
with how Mr. Madrigal was ultimately restrained, and he told me no, not that he recalled.
I asked Lieutenant Cedergren if Sergeant Graham ever asked him why he did not approve
the use of the restraint chair, and he told me no, not specifically. I asked Lieutenant
Cedergren if he was saying he did not remember Sergeant Graham ever asking him why
he did not approve the restraint chair. Lieutenant Cedergren admitted Sergeant Graham
may have asked him, but he stated he did not specifically recall this happening.
I told Lieutenant Cedergren that Sergeant Graham notified him and specifically asked for
approval to use the restraint chair. Lieutenant Cedergren arrived on scene and decided
against using the restraint chair. I explained to Lieutenant Cedergren that it would only be
logical, Sergeant Graham would follow-up and ask him why he denied his request to use
the restraint chair. Lieutenant Cedergren replied, “He could have – I don’t specifically
recall.”
I asked Lieutenant Cedergren if Sergeant Graham was truthful, when he told us that he
had confronted Lieutenant Cedergren about not using the restraint chair, saying
Lieutenant Cedergren’s response was, “The captain didn’t want deputies using the
restraint chair – as they had problems with it the other night and policy still needed to be
worked out on it.” Lieutenant Cedergren answered by saying he had no idea which
captain it would have been that he would have been referring to. Lieutenant Cedergren
also added that the policy on the restraint chair had been revised several times before it
was finalized. However, Lieutenant Cedergren denied telling us that Sergeant Graham
was being untruthful when he told us this and he said that statement might have been
Sergeant Graham’s understanding of their conversation.
Captain Christy asked Lieutenant Cedergren if he was saying he did not tell Sergeant
Graham someone in management told him not to use the chair until they got additional
training. Lieutenant Cedergren said he did not even know who this person in management
would have been, but he also stated it was possible that he did tell Sergeant Graham this
and he just did not remember that occurring.
I asked Lieutenant Cedergren if he ever told Lieutenant McComas that management did
not want deputies using the restraint chair because there were problems with it the last
time it was used, and the policy still needed to be worked out. Lieutenant Cedergren
stated, he could have mentioned the story Sergeant Moschetti had told him to Lieutenant
McComas, but he did not specifically recall anyone in management ever saying yes or no
to using the restraint chair.
Page 86 of 117

 I asked Lieutenant Cedergren if he remembered talking to Lieutenant McComas about
management not wanting deputies to use the restraint chair, and he told me no, saying he
could have said it in passing, but he did not specifically remember saying that.
I asked Lieutenant Cedergren if he ever asked any of the ITR deputies or sergeants any
questions about Sergeant Graham’s supervisory style. Lieutenant Cedergren told me he
may have asked deputies how Sergeant Graham was to work for or what his management
style was, but nothing more specific than that.
I asked Lieutenant Cedergren if he ever asked one of the ITR deputies if it was normal
for Sergeant Graham not to be involved in an incident, and he told me, “I might have.”
I asked Lieutenant Cedergren if he ever made any comments about Sergeant Graham
being weak as a supervisor or if he ever asked any questions about Sergeant Graham not
being more “hands on,” during the incident with Mr. Madrigal. Lieutenant Cedergren told
me he did not specifically remember doing so, but he admitted he could have.
I asked Lieutenant Cedergren if Sergeant Graham ever talked to him about concerns his
staff and other ITR sergeants had with him, and he told me, “No – more had, more
(unintelligible) was more – and nobody, nobody specifically – it was everybody word of
mouth, coming over, in general and I guess – I was part of that, but nobody ever directly
to me or whatever and asked me what my thought was or whatever – they had just
decided that they were gonna do the things the way they were – change wasn’t gonna
happen. So.”
I asked Lieutenant Cedergren if he ever talked to Sergeant Estep when he arrived at work to
relieve Sergeant Graham about the incident with Mr. Madrigal. Lieutenant Cedergren told me he
may have, briefly – in passing, but not about anything specific.
I asked Lieutenant Cedergren what reasoning or justification he provided to Sergeant Estep, as to
why he did not authorize the use of the restraint chair. Lieutenant Cedergren told me he did not
know.
I asked Lieutenant Cedergren if he ever told Sergeant Estep the way he had restrained Mr.
Madrigal was the same way he had restrained inmates in the past, and he did not think it was
necessary to use the chair. Lieutenant Cedergren told me, “It’s possible.” I asked Lieutenant
Cedergren if that sounded like something he would have said, and he told me, “It could be –
yeah.”
I asked Lieutenant Cedergren if he told Sergeant Estep something like, “In the old days we used
to cuff people in this manner. It’s not necessary to use a chair, I’ve done it this way before, and it
was fine.” Lieutenant Cedergren stated, while he did not remember using those specific words,
Page 87 of 117

 he assumed he did have a similar conversation with Sergeant Estep, when he would have
checked in with him around 1630 hours, that day.
I asked Lieutenant Cedergren if he ever told Sergeant Graham or any of the ITR deputies he
planned to make “a bunch” of changes to ITR, once he started working there, and he told me
“No.”
I asked Lieutenant Cedergren to confirm he was saying he never told people he was going to
make a “bunch of changes.” Lieutenant Cedergren answered, “I may have said some changes
might be coming, to other people, but not specifically to Sergeant Graham. First, because I was
going in to watch and wait and evaluate and see what’s what – and if you’re hanging out and
hiding, you’re gonna be gone.”
I asked Lieutenant Cedergren who he told this information to, and he told me different people
“just in passing.” Lieutenant Cedergren also stated he may have told Sergeant Graham as well,
but it would also have been, just “in passing,” and not with the intention of threatening or scaring
him.

Page 88 of 117

 SUMMARY OF FACTS:
On June 10, 2019, about 1410 hours, Mr. Madrigal was brought into SRJ as an “express.” Mr.
Madrigal had been arrested by Fremont PD for 11550(a) HS – Being under the influence of a
controlled substance. Mr. Madrigal was brought into ITR in the WRAP restraint device and he
was also wearing a spit mask.
Fremont PD officers reported Mr. Madrigal was placed in the WRAP because he had been
combative with the jail staff. In addition, Fremont PD officers advised the ITR staff that Mr.
Madrigal was under the influence of psilocybin mushrooms, a hallucinogen.
ITR Sergeant Graham moved Mr. Madrigal from the ITR lobby to cell R-1 and determined the
Pro-Straint restraint chair was the best option to restrain Mr. Madrigal once he had been removed
from the WRAP. Sergeant Graham requested approval from Lieutenant Cedergren to place Mr.
Madrigal in the restraint chair, and he waited for him to respond.
Sergeant Graham had recently conducted muster training on the use of the restraint chair with his
ITR deputies, and he knew his ITR deputies had all recently received formalized training for the
restraint chair, at the recent Range program. Sergeant Graham sent Deputy Comfort to retrieve
the restraint chair, and he pre-designated Deputy Torres to be the safety officer, during the
placement of Mr. Madrigal in the restraint chair.
About 1425 hours, Lieutenant Cedergren arrived on scene in ITR. Once Lieutenant Cedergren
entered ITR, he walked past Sergeant Graham and went over to Mr. Madrigal. Sergeant Graham
followed Lieutenant Cedergren as he tried to brief him about the risk factors concerning Mr.
Madrigal and why he wanted to restrain him in the restraint chair. Sergeant Graham told
Lieutenant Cedergren Mr. Madrigal was under the influence of a hallucinogen and he was
already resisting and tensing his body when the deputies were trying to get him out of the
WRAP.
As Lieutenant Cedergren walked over to Mr. Madrigal’s cell, he saw numerous deputies present.
Lieutenant Cedergren saw Mr. Madrigal had been restrained in the WRAP and was wearing a
spit mask. Lieutenant Cedergren asked if the deputies were unable to get Mr. Madrigal out of the
WRAP, and Sergeant Graham told him they were unable to get Mr. Madrigal out of the WRAP
without fighting him.
While Lieutenant Cedergren briefly observed Mr. Madrigal and his demeanor, he asked why the
Fremont PD officers had restrained Mr. Madrigal in the WRAP. Deputy Comfort told Lieutenant
Cedergren that Mr. Madrigal had previously fought with the Fremont PD jail deputies.
As Lieutenant Cedergren was on scene, the restraint chair was readily available and had been set
up for use, and it had already been positioned next to Mr. Madrigal’s cell. However, Lieutenant
Page 89 of 117

 Cedergren made the determination that the restraint chair was not an appropriate option to use to
restrain Mr. Madrigal, at the time.
Lieutenant Cedergren ordered deputies to remove Mr. Madrigal from the WRAP. Lieutenant
Cedergren instructed the deputies to loosen the tether strap of the WRAP so Mr. Madrigal could
stand. Mr. Madrigal did not comply with their orders to stop tensing his body, which prevented
deputies from removing Mr. Madrigal from the WRAP by loosening the tether.
Deputy McMann applied his bodyweight onto Mr. Madrigal’s upper back while pushing his
body towards Mr. Madrigal’s feet. Lieutenant Cedergren then loosened the tether strap of the
WRAP and Mr. Madrigal was stood up.
Lieutenant Cedergren attached the cuff of a pair of ankle restraints between Mr. Madrigal’s
handcuffs. The chain of the ankle restraints was fed through the cuffing port of cell R-1’s door
and the other cuff of the ankle restraints was attached to the outside door handle of cell R-1.
While Mr. Madrigal continued to resist, Deputy Rhoades held him against the door and a pat
search was conducted, as the WRAP was removed.
Deputies removed the ankle restraint cuff that had been attached to the exterior door handle,
pushed Mr. Madrigal back inside the cell, and closed the door. Lieutenant Cedergren and two
deputies attempted to pull Mr. Madrigal’s hands through the cuffing port, by pulling on the chain
of the ankle restraints to uncuff him, to remove his restraints. Mr. Madrigal however continued to
resist their efforts, and he refused to cooperate and allow his restraints to be removed.
Lieutenant Cedergren instructed the deputies to stop any further attempts to remove Mr.
Madrigal’s handcuffs and ankle restraints from around his handcuffs. Lieutenant Cedergren took
an additional pair of handcuffs and attached one handcuff to the ankle restraint cuff and the other
handcuff to the outside doorknob of the cell door, tethering Mr. Madrigal to the door.
Lieutenant Cedergren chose to leave Mr. Madrigal handcuffed and tethered to the door with the
ankle restraints until he calmed down and decided to cooperate. A deputy initiated a restraint
observation log, and the deputies continued to check on Mr. Madrigal over the next several
hours, as they tried to convince him to cooperate and surrender his restraints, to no avail.
About 1650 hours, Lieutenant Cedergren returned to Mr. Madrigal’s cell, and he saw Mr.
Madrigal had maneuvered his handcuffs from behind his back to the front of his body.
Lieutenant Cedergren asked Mr. Madrigal if he was ready to comply. Mr. Madrigal moved his
wrists closer to the cuffing port, but then he quickly pulled them back, and laughed.

Page 90 of 117

 At this time, Lieutenant Cedergren decided to wait for the 1700 hours muster to conclude, so he
would have additional deputies to help him get Mr. Madrigal out of the cell and remove his
restraints. Lieutenant Cedergren left Mr. Madrigal’s cell.
About 1720 hours, Lieutenant Cedergren returned to Mr. Madrigal’s cell to check on him, but he
found him unresponsive. Lieutenant Cedergren and Deputy Ross opened Mr. Madrigal’s cell
door to investigate further and they discovered Mr. Madrigal had wrapped the chain of the ankle
restraints around his neck and asphyxiated himself.

Page 91 of 117

 OPINIONS AND CONCLUSIONS:
As to the allegation that on June 10, 2019, Lieutenant Cedergren was negligent in his duties
as the ITR supervisor, I conclude the following: SUSTAINED.
Concerning the above allegation, I conclude the following violations occurred:
•

Civil Service Law and Rules Section 2104 (c) - Inefficiency

•

Civil Service Law and Rules Section 2104 (d) – Neglect of duty

•

Sheriff’s Office Rules and Regulation – 2.1.13 –Performance of Duty

The following is the basis for my findings.
During the interview with Lieutenant Cedergren, he told me he did not agree with Sergeant
Graham’s initial assessment of using the restraint chair. Lieutenant Cedergren stated he wanted
to get Mr. Madrigal out of the WRAP first, so he could see what Mr. Madrigal did, once he was
no longer restrained. Lieutenant Cedergren confirmed he did not want to use the restraint chair,
until he saw if Mr. Madrigal was going to get aggressive.
However, Lieutenant Cedergren also explained he understood anytime an inmate is taken out of
restraints, that inmate is not going to be happy, and they are going to want to fight. Lieutenant
Cedergren added the only time this was not the case, was when that inmate was at John George
Psychiatric Pavilion (JGPP) and the inmate was immediately given a sedative injection, prior to
being restrained in five-point restraints.
Lieutenant Cedergren’s statement, based on his experience, that anytime you take an inmate out
of restraints that inmate is going to want to fight, contradicts his logic and reasoning for what he
did that day. Early in the interview, Lieutenant Cedergren stated he wanted to remove Mr.
Madrigal from the WRAP to see what Mr. Madrigal was going to do, before he authorized the
use of the restraint chair. However, based on Lieutenant Cedergren’s declaration that he knew
inmates being taken out of restraints would want to fight, after removing Mr. Madrigal from the
WRAP, Lieutenant Cedergren should have immediately planned on transitioning Mr. Madrigal
into another restraint device, like the restraint chair. Had Lieutenant Cedergren exercised sound
judgment and done this, he could have utilized the readily accessible restraint chair, which would
have been the safest and most appropriate option to prevent injury and/or the loss of life to Mr.
Madrigal and/or the ITR staff. Having a plan in place like this, or something similar, would have
been prudent if safety was Lieutenant Cedergren’s top priority.
In Lieutenant Cedergren’s report, he stated he made this determination not to use the restraint
chair based on the circumstances known to him at the time. Lieutenant Cedergren specified these
circumstances were that Mr. Madrigal was not displaying the type of behavior which could have
resulted in the destruction of property or intent to cause harm to himself or others.
Page 92 of 117

 During Lieutenant Cedergren’s interview, he acknowledged he had already been told Mr.
Madrigal had recently ingested mushrooms, a hallucinogen, was arrested for being under the
influence of a controlled substance, and previously fought with Fremont PD jail officers. In
addition, Sergeant Graham told him Mr. Madrigal was already tensing his body and had not been
cooperating with them when they tried to get him out of the WRAP, and he believed Mr.
Madrigal intended on fighting them, once he was removed from the WRAP.
During Lieutenant Cedergren’s interview, when I confronted him about why he chose not to use
the restraint chair after being aware of all this information, he attempted to justify his reasoning
by stating while he knew Mr. Madrigal had fought with the Fremont PD officers, he did not
know exactly how recently this had occurred.
Lieutenant Cedergren also told me he asked Mr. Madrigal if he was “mental” or if he was
hearing voices. Mr. Madrigal told him no. Lieutenant Cedergren told me he thought he had no
choice but to believe Mr. Madrigal, when he told him this. Lieutenant Cedergren also stated he
was not ready to restrain Mr. Madrigal in the restraint chair because he wanted to start with the
least intrusive means and the least use of force option.
I considered the explanation Lieutenant Cedergren provided to me as an attempt to justify why
he chose to disregard Sergeant Graham’s recommendation to place Mr. Madrigal in the restraint
chair. The numerous circumstances known to Lieutenant Cedergren at the time easily justified
this restraint option. I believe this lapse of judgement on Lieutenant Cedergren’s part shows a
lack of competence. The Pro-Straint restraint chair is defined as a chair with equipment designed
to restrain, control, and limit the movements of someone who displays hazardous behavior.
During Lieutenant Cedergren’s interview, he agreed that an “express” is an inmate who has
shown risky or dangerous behavior, otherwise known as hazardous behavior.
Furthermore, if Lieutenant Cedergren’s statement that he was unsure how long ago Mr. Madrigal
fought with law enforcement was a factor in his decision not to use the restraint chair, he should
have clarified this and/or asked additional questions to gain a better understanding of the
situation, before he disregarded Sergeant Graham’s recommendation. However, Lieutenant
Cedergren neglected to stop and take the requisite time to speak to Sergeant Graham to gain a
decent understanding of the details surrounding why Mr. Madrigal had been deemed an
“express.” Lieutenant Cedergren also should have asked if there were any additional reasons why
Sergeant Graham believed the use of the restraint chair was appropriate.
I found it to be incorrect when Lieutenant Cedergren told me he had no choice but to accept Mr.
Madrigal at his word, when Mr. Madrigal told him he was not “mental” or hearing voices. I
cannot understand why a law enforcement officer with over nineteen years of experience would
trust a combative and resistant inmate’s response that he was not mental or hearing voices and
then prioritize that information over details that had been provided to him by other sworn
Page 93 of 117

 officers, merely because he had not personally seen the inmate be aggressive or combative for
himself.
In Lieutenant Cedergren’s interview, I asked him how much consideration he gave Sergeant
Graham’s opinion on how he thought Mr. Madrigal should be handled. Lieutenant Cedergren
told me he heard what Sergeant Graham said, but he admitted that was the extent of his
conversation with Sergeant Graham. Captain Christy asked Lieutenant Cedergren if he asked
Sergeant Graham any clarifying questions to get more detail or any additional information to
assist him in making his decision. Lieutenant Cedergren stated,
No, cuz at this time, by the – when I – by the, by this time – point right here, when
he – I uh, came past the lobby and we had medical out there. I had a pretty good
understanding that medical – they believed if this guy needed to be cleared at the
hospital, he would have been sent out or he had already been cleared and since
we made it to this side – and the doctor I think is Jed, a large Asian guy, he was
fine with him, everything – he was ours, we were good to go. So that was my
assumption that, he would have never been that far, had he not been fit to come
in. So, we are gonna deal with what we have, and keep going.
After Lieutenant Cedergren answered this question, it was obvious to me he did not give
Sergeant Graham’s recommendation to use the restraint chair any significant consideration.
Based on Lieutenant Cedergren’s rambling response, I believe it was apparent Lieutenant
Cedergren was struggling to come up with a valid reason as to why he did not adequately discuss
the situation with Sergeant Graham, or ask him any further questions, to gain a better
understanding of Mr. Madrigal’s hazardous behavior prior to him moving forward with his own
idea on how he could handle Mr. Madrigal.
In Lieutenant Cedergren’s interview, he stated he did not recall anyone objecting to him not
approving the use of the restraint chair. Lieutenant Cedergren even went so far as to say he was
not aware Sergeant Graham wanted to use the restraint chair.
Only after Captain Christy and I repeatedly asked Lieutenant Cedergren if he was saying he was
not aware Sergeant Graham wanted to use the restraint chair, even though Sergeant Graham was
the sergeant who asked him for approval to use the restraint chair, did he finally admit he knew
Sergeant Graham wanted to use the restraint chair. Lieutenant Cedergren stated he did not ignore
Sergeant Graham’s recommendation to use the chair, but he told us, had Sergeant Graham
specifically told him he wanted to use the chair, he would have given the option more
consideration.
I found Lieutenant Cedergren’s initial statement that he was unaware Sergeant Graham wanted
to use the restraint chair to be ridiculous. Lieutenant Cedergren later admitted he knew Sergeant
Graham wanted to use the restraint chair, however Lieutenant Cedergren added that had Sergeant
Page 94 of 117

 Graham told him he specifically wanted to use the restraint chair, he would have given this
option more consideration than he did. I found this insincere and I believed this statement to be
less than credible. I believe Lieutenant Cedergren knew Sergeant Graham thought the restraint
chair was the best option to use, as Sergeant Graham wanted to use it. Sergeant Graham asked
Lieutenant Cedergren for his approval to use the restraint chair, which was the sole reason
Sergeant Graham asked Lieutenant Cedergren to respond to ITR. Furthermore, Sergeant Graham
had already coordinated the retrieval of the restraint chair and it had been placed next to the cell
and was made ready for use.
During Lieutenant Cedergren’s interview, I asked him how much time he took to talk to Sergeant
Graham, to ensure he had a good understanding of the situation with Mr. Madrigal, after he
arrived on scene. Lieutenant Cedergren told me a few minutes. After this answer was provided, I
pulled up Sergeant Graham’s BWC video and I played the portion of video that began as
Lieutenant Cedergren arrived on scene in ITR and was contacted by Sergeant Graham. The video
showed Lieutenant Cedergren only glanced towards Sergeant Graham as Sergeant Graham told
Lieutenant Cedergren that Mr. Madrigal was on mushrooms, Mr. Madrigal was going to fight
them, and they were unable to restrain Mr. Madrigal. While Sergeant Graham was telling him
this, Lieutenant Cedergren walked right past him and over to Mr. Madrigal.
After watching the video, I asked Lieutenant Cedergren if it was more accurate to say he had
only talked to Sergeant Graham for closer to three to five seconds – and not the three to four
minutes he told me. Lieutenant Cedergren admitted three to five seconds was a more accurate
time frame.
It was apparent Lieutenant Cedergren did not value Sergeant Graham’s input or opinion on the
matter. Lieutenant Cedergren was very dismissive of Sergeant Graham and walked right past
him, as if he was not even there. In fact, Sergeant Graham was forced to turn and follow, almost
chasing behind Lieutenant Cedergren and talking to Lieutenant Cedergren’s back, as Sergeant
Graham continued to try and brief him about the details of the incident.
During Lieutenant Cedergren’s interview, I asked him if concerns regarding staff being trained
on the use of the restraint chair were ever a factor in his decision to use the chair or not, and he
told me no, saying he assumed everyone had recently been trained on the use of the restraint
chair within the last month.
I asked Lieutenant Cedergren if he ever talked to Sergeant Graham or the deputies on scene, to
find out if they had recently been trained on the use of the restraint chair, and he told me no.
I asked Lieutenant Cedergren if he discussed the benefits or drawbacks of using the restraint
chair, versus other options with Sergeant Graham, once he arrived on scene, and he told me he
did not.
I asked Lieutenant Cedergren who he did discuss the benefits and drawbacks of using the
restraint chair with, before he decided not to use it. Lieutenant Cedergren told me, “No one.”
Page 95 of 117

 I asked Lieutenant Cedergren how long he had been an ITR supervisor at SRJ, at the time of the
incident and he told me less than a month.
I asked Lieutenant Cedergren how many “express” inmates he would have dealt with as the ITR
supervisor at SRJ, and he told me more than one, but less than ten.
I asked Lieutenant Cedergren if it was important for him to know the experience level of the staff
who worked for him in key leadership positions, and he told me, yes. I asked Lieutenant
Cedergren how long Sergeant Graham worked in ITR as an ITR supervisor, and he told me he
had no idea.
It was surprising to hear Lieutenant Cedergren did not know how much experience Sergeant
Graham had at SRJ as the ITR supervisor or what Sergeant Graham’s level of experience was in
this position. With this in mind, I believe it is troubling that Lieutenant Cedergren overrode
Sergeant Graham’s plan on how to deal with Mr. Madrigal, when Sergeant Graham was the most
experienced ITR sergeant at SRJ and he had been an ITR supervisor for three and half years.
Lieutenant Cedergren had only been the ITR Watch Commander for less than a month. To put
the level of ITR supervisor experience in perspective, Lieutenant Cedergren told me he had
overseen the booking of one to ten “express” inmates at SRJ, while Sergeant Graham had
overseen the booking of hundreds of “express” inmates at SRJ.
During Lieutenant Cedergren’s interview, I asked him if he was aware whether nursing staff had
been able to take Mr. Madrigal’s vital signs and complete his medical assessment or not.
Lieutenant Cedergren told me he did not ask, but he assumed the medical staff had. Lieutenant
Cedergren was incorrect in this assumption. When Mr. Madrigal was first brought to SRJ and
still restrained in the WRAP, Wellpath RN Divinagracia attempted to take Mr. Madrigal’s vital
signs, however Mr. Madrigal was non-compliant. He tensed his body and clenched his hands into
fists and prevented RN Divinagracia from completing his medical assessment.
During Lieutenant Cedergren’s interview, I told him his report indicated he recognized the need
to remove Mr. Madrigal from the WRAP to have him further evaluated by the CFMG staff. I
asked Lieutenant Cedergren, had Mr. Madrigal been placed in the restraint chair, if the nurses
would have been able to do a better medical screening of him than if Mr. Madrigal was
handcuffed and locked in a cell. Lieutenant Cedergren told me yes.
Lieutenant Cedergren’s actions clearly contradicted his stated intentions in his report. If having
Mr. Madrigal further evaluated by medical staff was truly a priority for him, this could have
easily been accommodated by placing Mr. Madrigal in the restraint chair. However, Lieutenant
Cedergren’s decision to secure Mr. Madrigal in a cell would make a further evaluation of him by
medical staff a much harder task.
During Lieutenant Cedergren’s interview, I asked him if he and Lieutenant McComas discussed
the use of the restraint chair, and he told me, “I do not – believe so.” I asked Lieutenant
Cedergren if Lieutenant McComas told him he should use the restraint chair, and he told me he
did not recall Lieutenant McComas saying that.
I asked Lieutenant Cedergren if he ever told Lieutenant McComas anything like, “We’re not
using it now because someone used it incorrectly and management doesn’t want us using it until
everyone can get retrained.” Lieutenant Cedergren told me no.
Page 96 of 117

 I asked Lieutenant Cedergren if he told Lieutenant McComas his plan on restraining Mr.
Madrigal in handcuffs while tethered to the door, instead of utilizing the restraint chair, and he
told me no.
I asked Lieutenant Cedergren if Lieutenant McComas told him it was not a good idea to tether
Mr. Madrigal to the door, or if Lieutenant McComas told him he thought the restraint chair
should have been used, as it was already set up right next to Mr. Madrigal’s cell. Lieutenant
Cedergren told me he did not recall Lieutenant McComas saying that.
When Lieutenant Cedergren answered, saying he did not recall Lieutenant McComas telling him
it was not a good idea to tether Mr. Madrigal to the cell instead of using the restraint chair, his
response was meek and his voice lacked confidence, leading me to doubt his level of truthfulness.
I asked Lieutenant Cedergren if he recalled any conversation at all with Lieutenant McComas,
regarding the restraint chair, and he told me no. Captain Christy asked Lieutenant Cedergren if
he recalled anything at all, regarding talking to Lieutenant McComas, and he told us no.
During the interview with Lieutenant Cedergren, I played an audio portion of Lieutenant
McComas’ interview, in which Captain Christy asked Lieutenant McComas if he questioned
Lieutenant Cedergren about tethering Mr. Madrigal to the door or if they had any discussion
regarding this. Lieutenant McComas told us yes, saying that after Lieutenant Cedergren tethered
Mr. Madrigal to the door, Lieutenant Cedergren began walking down the hall to the nurse’s
office. Lieutenant McComas followed Lieutenant Cedergren, stopped him, and confirmed
Lieutenant Cedergren was going to start a restraint log. Lieutenant McComas asked Lieutenant
Cedergren how long he planned on having Mr. Madrigal tethered to the door and Lieutenant
McComas also reiterated the restraint chair was right next to Mr. Madrigal’s cell, ready to be
used, and Lieutenant McComas thought it was the better restraint option. Lieutenant Cedergren
told Lieutenant McComas he had done this a hundred times before, it was not a problem, and he
would take responsibility for it.
I asked Lieutenant Cedergren if this audio clip refreshed his recollection of the conversation he
had with Lieutenant McComas, but he told us no, saying he did not recall the conversation. I
asked Lieutenant Cedergren if he thought Lieutenant McComas was being untruthful when he
told us the details of this conversation. Lieutenant Cedergren told us he had no reason to believe
Lieutenant McComas made this conversation up, rather, he just did not recall this specific
conversation.
I found it interesting Lieutenant Cedergren did not remember the details of any of the
conversations he may have had with Lieutenant McComas that day, regarding the restraint chair.
I believed his answers were a little too convenient, with respect to how he did not recall
Lieutenant McComas confronting him about tethering Mr. Madrigal to the cell, or in Lieutenant
Cedergren choosing not to use the restraint chair. While Lieutenant Cedergren denied defending
his decision not to use the restraint chair by telling Lieutenant McComas “We’re not using it
now, because someone used it incorrectly and management doesn’t want us using it until
everyone can get retrained,” I thought Lieutenant Cedergren’s alleged statement that he had done
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 this a hundred times before, it was not a problem, and he would take responsibility for it was
particularly interesting, and I noted that Lieutenant Cedergren did not deny making this latter
statement or accuse Lieutenant McComas of lying, rather Lieutenant Cedergren just gave the
blanket defense answer that he did not recall saying that.
During Lieutenant Cedergren’s interview, I asked him if he would regularly move
multiple inmates, administrative segregation inmates, or inmates of different classes to
housing units. Lieutenant Cedergren told me he would regularly take administrative
segregation inmates out to the housing units, but he would not do this while he was also
escorting inmates of other classifications. I asked Lieutenant Cedergren if, to the best of
his knowledge, he was abiding by the Agency policy and procedures when he did this,
and he told me yes. I asked Lieutenant Cedergren to confirm he was saying that if he ever
moved inmates out of ITR, outside of the Agency’s policy and procedures, it would have
been unintentional. Lieutenant Cedergren told me, “At the moment, we’re getting bodies
cleared out of ITR.”
I did not notice Lieutenant Cedergren’s sidestep of this question at the time of the
interview, but when listening to the audio recording of the interview while writing this
report, I realized that when I asked Lieutenant Cedergren if his actions of moving inmates
out of policy were ever intentional, he deflected in answering my question. I believe
Lieutenant Cedergren’s statement of “getting bodies cleared out of ITR” was a selfjustification as to why he would have intentionally violated the Agency’s policies and
procedures, regarding the movement of inmates. This bears significant weight, as this
was a chief complaint amongst many of the ITR deputies, that Lieutenant Cedergren
would regularly fail to abide by the Agency’s policies and procedures by moving inmates
on his own, without telling anyone what he was doing.
During Lieutenant Cedergren’s interview, I told him I wanted to talk about his physical
involvement in removing Mr. Madrigal from the WRAP. I asked Lieutenant Cedergren if there
was a reason why he was trying to adjust the tension strap of the WRAP, instead of directing a
deputy to do this. Lieutenant Cedergren told me no, saying he just stepped in and did it.
I told Lieutenant Cedergren almost everyone I talked to described him as very “hands on.” I
asked Lieutenant Cedergren if this was accurate and he told me, “Yeah. I mean – it – it’s been
since day one, so – you can go back and pull – freakin’ stat sheets and – there aint – there’s – to a
fault. Let’s just say it’s to a fault.”
I thought Lieutenant Cedergren’s statement of admitting his desire be involved “to a fault,” very
candid. This showed Lieutenant Cedergren understood his choice to always be actively involved
may be detrimental.

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 I asked Lieutenant Cedergren what his opinion was of Sergeant Graham. Lieutenant Cedergren
told me he had worked with Sergeant Graham on patrol together at Dublin Police Services (DPS)
and he was the polar opposite of Sergeant Graham, in regard to work ethic, productivity, and in
showing up to work for the full 84-hour pay period. Lieutenant Cedergren described how he
consistently worked more hours than Sergeant Graham did each pay period, and he went so far
as to elaborate on how he heard Sergeant Graham was hanging out at his personal residence,
instead of working and responding to calls he was assigned, during his normal work shift.
Lieutenant Cedergren admitted he did not know if this information he was telling me regarding
Sergeant Graham being home when he should have been at work was true, as it was just a rumor
he had heard. However, he thought it was significant enough to tell me this information during
his Internal Affairs interview.
Immediately after telling me this, Lieutenant Cedergren told me he did not dislike Sergeant
Graham and he stated he got along with him. However, Lieutenant Cedergren told me he
considered himself to be a very “hands on” supervisor, and he told me Sergeant Graham
appeared to be very “hands off-ish,” who he thought was very willing to just follow along.
Lieutenant Cedergren stated in one of the last arrests he made with Sergeant Graham he offered
to give Sergeant Graham the arrest for statistical purposes, but Sergeant Graham told him no.
Lieutenant Cedergren believed Sergeant Graham did not want anything to do with the arrest,
rather he just wanted to be present on scene. In addition, Lieutenant Cedergren told me he was
amused when he learned Sergeant Graham went to the Alameda County Narcotics Task Force
(ACNTF), as he did not think Sergeant Graham had ever made a narcotic related arrest in his
life. Lieutenant Cedergren reiterated he did not dislike Sergeant Graham, rather they just had a
different work ethic.
I formed the impression that Lieutenant Cedergren wanted me to know he was much more
productive and a harder worker than Sergeant Graham, so I would possibly conclude he was a
better employee. Along the same vein, Lieutenant Cedergren appeared very proud and boastful,
lending credibility to the idea that any other supervisor who was not “hands on,” was not as good
as he was. I was skeptical of Lieutenant Cedergren’s constant reassurance he did not dislike
Sergeant Graham, given the constant barrage of criticism he had for Sergeant Graham’s character
and work ethic.
Captain Christy told Lieutenant Cedergren, as a lieutenant, he would have expected Lieutenant
Cedergren to have taken more of a supervisory role and not go “hands on,” but rather, manage
the situation and take a more outside approach. Lieutenant Cedergren responded by nodding his
head up and down and saying, “Yes, yes.”
Captain Christy asked Lieutenant Cedergren if there was a reason he felt it was necessary to do
the work himself. Lieutenant Cedergren stated, “That’s just how I am. I – like to be involved and
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 – I thought that was the least minimal, invasive way, and that’s – at that moment – the best way
to address it. So – shame on me for being involved and thinking I had a better way.”
Captain Christy told Lieutenant Cedergren that even if he wanted to do this his own way, he
could have done more directing, so he could have gotten a more comprehensive feeling for what
was happening. Lieutenant Cedergren replied, “True. In hindsight – yeah.”
I believe Lieutenant Cedergren’s decision to go “hands on” with Mr. Madrigal showed poor
judgment, and a lack of the most basic and fundamental leadership skills. There was no
justifiable reason for Lieutenant Cedergren to physically insert himself in removing Mr.
Madrigal from the WRAP. It is obvious he let his desire to get involved overpower his
responsibility to manage the incident, as he failed to even devise a plan or tell the other deputies,
who he was trying to assist, what his intentions were. By abandoning his role as a lieutenant and
adopting more of a deputy role, he lost sight of his most important responsibility, the need for
him to supervise. As the ITR Watch Commander, he should have gathered all the facts and
assessed the situation, and then he could have allowed his ITR Sergeant to manage the booking
of Mr. Madrigal, while he oversaw the event.
During Lieutenant Cedergren’s interview, I asked him how he came up with the decision to
attach the ankle restraints between Mr. Madrigal’s handcuffs. Lieutenant Cedergren stated he had
used this technique numerous times before, as it was a method that was taught. Lieutenant
Cedergren stated he used this technique to limit Mr. Madrigal’s movement, by holding him
against the door to complete a search.
I asked Lieutenant Cedergren if using the chains to pull Mr. Madrigal against the door was
enough to hold him against the door, or if a deputy had to also push Mr. Madrigal back against
the door. Lieutenant Cedergren told me he did not know if a deputy had to physically push or
hold Mr. Madrigal against the door. I asked Lieutenant Cedergren if it would surprise him to
know Deputy Rhoades had to exert significant effort to hold Mr. Madrigal’s upper body against
the door, while she also told Mr. Madrigal to stop resisting. I offered to show Lieutenant
Cedergren the video from Deputy Rhoades’ BWC, but he declined. Lieutenant Cedergren told
me he believed Deputy Rhoades had to exert significant effort to hold Mr. Madrigal against the
cell door.
Earlier, Lieutenant Cedergren stated he reserved his decision on deciding whether to utilize the
restraint chair, depending on how Mr. Madrigal reacted when he was being removed from the
WRAP. However, Lieutenant Cedergren failed to realize Mr. Madrigal was continuing to
struggle and resist, as he tried to push off the cell door, while deputies fought to control his
movement as they removed him from the WRAP. This awareness failure was directly attributed
to Lieutenant Cedergren’s decision to get involved and go “hands on” with the other deputies.
Had Lieutenant Cedergren maintained his supervisory role as the ITR Watch Commander, he
would have seen this, which would have assisted him in making a better determination as to
whether the restraint chair should have been used or not.
I asked Lieutenant Cedergren if he had been taught to secure ankle restraints around an inmate
that had been handcuffed behind the back, and then pull that inmate against the door through the
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 cuffing port, while using the door as a shield. Lieutenant Cedergren told me he had done it on
different extractions, it had been taught, and he talked about this technique as a Jail Training
Officer (JTO) Sergeant in 2005.
I asked Lieutenant Cedergren if the technique was taught in a class, or if it was passed along as a
jail technique, and he told me it was passed along as institutional knowledge. I asked Lieutenant
Cedergren if the technique was taught in the police academy, and he told me it was not. I asked
Lieutenant Cedergren if any defensive tactics instructors taught the technique. Lieutenant
Cedergren stated it was his understanding it was taught in classes by the defensive tactics’
instructors, based on a brief conversation he had with Sergeant Sylvester.
Captain Christy asked Lieutenant Cedergren what class Sergeant Sylvester instructed which
taught the technique. Lieutenant Cedergren stated “Use of force” classes with trainees in the JTO
program. Lieutenant Cedergren also confirmed Sergeant Sylvester presented the technique in the
Core Course curriculum, and he had assisted in teaching the technique as a JTO Sergeant.
I asked Lieutenant Cedergren what the purpose was for using the technique, and he told me he
would use the technique to control an aggressive inmate or an inmate who was prone to violence.
Lieutenant Cedergren stated he used the practice to search an inmate before the inmate went into
the cell. He also stated, he could use the technique to hold the inmate against the door, so when
the cell door was shut, the inmate was pulled into the cell with the closing of the door. I asked
Lieutenant Cedergren if there were any other situations where it would be beneficial to use the
technique, and he told me these were the only two reasons he was aware of.
I asked Lieutenant Cedergren what was taught when an inmate resisted or refused to cooperate
from inside the cell and the deputies were unable to pull the inmate against the door to remove
the ankle restraints from around the handcuffs. Lieutenant Cedergren told me he did not know
what was taught in that instance.
I told Lieutenant Cedergren, if I understood him correctly, he was saying he showed the
technique to new deputies, telling them it was a technique they could use. However, I asked
Lieutenant Cedergren what he taught them to do when the technique did not work, and the
inmate refused to allow the deputies to remove the ankle restraints from their handcuffs. When
Lieutenant Cedergren did not immediately answer me, I asked him if this technique was effective
one hundred percent of the time. Lieutenant Cedergren told me no.
I asked Lieutenant Cedergren again, what he taught the deputies to do to resolve the issue when
the technique he taught them was not effective. Lieutenant Cedergren stated, if the inmate did
not want to be compliant, he would advise them to give the inmate time to change their mind.
Lieutenant Cedergren went on to explain he believed that was the purpose of the restraint log, to
watch the inmate and wait for them to comply.
Lieutenant Cedergren added, when it got to a certain point, and the inmate still had not complied,
he would switch to another plan and go into the cell and remove the ankle restraints, regardless
of whether or not they needed to use force to accomplish this.
I told Lieutenant Cedergren, he had just said when it reached a “certain point” he would go back
inside and remove the ankle restraints. I asked Lieutenant Cedergren what was the “certain
point.” Lieutenant Cedergren told me it was generally less than four hours. I told Lieutenant
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 Cedergren, if I understood him correctly, he was saying in the instances when he applied ankle
restraints to an inmate’s handcuffs and the inmate refused to surrender the ankle restraints, he
would give that inmate up to four hours to change his mind and comply; in the instance the
inmate did not comply within four hours, he would open up the door and go back inside the cell
and remove them. Lieutenant Cedergren replied, “Not – not four hours, in a hard, fast rule.” I
asked Lieutenant Cedergren what the hard, fast rule was, and he told me, in this specific case, it
was the end of the shift, as he did not want to leave this for the next shift.
I again asked Lieutenant Cedergren what he taught the deputies to do when this technique did not
work. Lieutenant Cedergren told me, “They’re never – that was never taught. I – I have no idea
what Scott taught, at that point, either. I wasn’t.”
I told Lieutenant Cedergren I believed he told me he had taught this technique. He interrupted
me and told me he never taught this technique; rather, he had only seen the technique.
Lieutenant Cedergren stated he had only witnessed the technique and utilized it, but he had never
actually been the instructor who taught it. I asked Lieutenant Cedergren if that meant he never
showed anyone else how to do it. Lieutenant Cedergren told me he had applied it, but he had
never instructed anyone else how to do it in a formalized setting.
I asked Lieutenant Cedergren if he was saying his understanding was that the technique was
taught, but when it failed to work as designed, he did not know what to do. Lieutenant Cedergren
responded to this question by telling me about a previous incident Sergeant Sylvester had relayed
to him. In this incident, when the inmate refused to cooperate and surrender the ankle restraints
and handcuffs by backing up to cuffing port of the cell door, the deputies had to open the door
and enter the cell to forcibly remove the restraints.
I told Lieutenant Cedergren I had also talked to Sergeant Sylvester, who told me the technique
was taught, but only as a temporary means to restrain an inmate for the purposes of searching an
inmate. I told Lieutenant Cedergren that Sergeant Sylvester was adamant it was never taught,
under any circumstances, that it was okay to tether an inmate to the door and walk away from the
inmate. Lieutenant Cedergren told me he thought this was a fair statement and he would believe
this.
I asked Lieutenant Cedergren if it was fair to say the act of attaching the ankle restraints to the
inmate’s handcuffs was a technique he was taught, but leaving the inmate tethered to the door
was not taught. Lieutenant Cedergren told me yes, however he said he thought leaving the
inmate tethered to the door was a reasonable solution, at that time.
While Lieutenant Cedergren’s decision to attach ankle restraints to Mr. Madrigal’s handcuffs
was a technique that was taught and used in the jail, it was only taught as a temporary means to
maintain control of an uncooperative inmate. This information was confirmed by Sergeant
Sylvester, who taught it for the JTO program.
Lieutenant Cedergren was never taught to tether inmates to the door, nor was he taught to leave
an inmate tethered to the door, for any reason. Lieutenant Cedergren’s personal decision to do so
turned out to be a fatal one. After Lieutenant Cedergren secured Mr. Madrigal in the cell, and
then realized Mr. Madrigal was not going to cooperate and surrender his restraints, he should
have immediately stopped what he was doing and come up with an alternative solution.
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 Lieutenant Cedergren could have re-assessed and discussed his options with his ITR Sergeant,
the SRJ Watch Commander, and even the ITR deputies, all of whom were on scene and had
significantly more experience in dealing with uncooperative inmates than he did. However,
Lieutenant Cedergren neglected to seek out anyone else’s input or advice.
During Lieutenant Cedergren’s interview, I asked him why he did not just open Mr. Madrigal’s
cell door and lay Mr. Madrigal on the ground, facedown, and then remove the ankle restraints.
Lieutenant Cedergren replied, “Couldn’t tell you.”
I told Lieutenant Cedergren that I had spoken to multiple deputies, who told me Mr. Madrigal
was only being passively resistant, and there was no apparent reason why they could not have
simply gone back inside Mr. Madrigal’s cell to remove the ankle restraints. I asked Lieutenant
Cedergren why he did not want to go back inside Mr. Madrigal’s cell after he was unable to
remove the ankle restraints from Mr. Madrigal’s handcuffs. Lieutenant Cedergren told me he
thought Mr. Madrigal would become compliant, and they would be able to remove his restraints
without having to re-open Mr. Madrigal’s door and go back inside the cell. Lieutenant Cedergren
added, he thought somebody would second-guess him for going back inside the cell, instead of
just waiting for Mr. Madrigal to comply.
I told Lieutenant Cedergren the problem with his statement was that our agency did not teach
staff to tether inmates to the door and “wait them out.”
Once Lieutenant Cedergren realized his technique was not going to be successful to secure Mr.
Madrigal in the cell without restraints, he should have immediately gone back inside the cell and
retrieved the handcuffs and ankle restraints. According to statements from the sworn staff on
scene, Mr. Madrigal was only being passively resistant and there were no reason deputies could
not have re-entered the cell and retrieved the restraints, most likely with minimal to no force
used. Even if the retrieval of the restraints would have necessitated substantial force, this action
was necessary to prevent the risks associated with leaving Mr. Madrigal tethered to the door in
handcuffs with ankle restraints.
During Lieutenant Cedergren’s interview, I asked him why, at this point, he did not use the
restraint chair, as it had already been set up and was right next to Mr. Madrigal’s cell. Lieutenant
Cedergren told me he did not think there was a conscious reason why he decided not to use it,
but he supposed he should have erred on the side of caution and used it.
I asked Lieutenant Cedergren if he was aware that every deputy present on scene in ITR, as well
as Sergeant Graham and Lieutenant McComas, were all surprised when he chose not to use the
restraint chair, and he told me, “I could see they would be surprised, now – yeah.” However,
Lieutenant Cedergren went on to say that he did not see any visual signs of their disagreement,
he did not see anyone shaking their heads in a “no” motion, nor did he remember anyone telling
him to stop or to re-think his actions. I asked Lieutenant Cedergren to clarify he was saying that
he did not see anyone disagreeing with what he was doing, and he told me, “Not that I – openly
saw – no.”
Lieutenant Cedergren admitted he understood how everyone on scene was surprised, when did
not approve Mr. Madrigal’s placement in the restraint chair. It was interesting to me that once
Lieutenant Cedergren’s attempts to secure Mr. Madrigal in a cell unrestrained proved
unsuccessful, he failed to reassess and/or reconsider his decision not to use the restraint chair.
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 Lieutenant Cedergren’s statements that he did not see anyone openly disagreeing with him or
challenging him as justification for going forward with his decision to leave Mr. Madrigal
chained to the door came across as an attempt at self-justification for the improper decision he
made that day.
I asked Lieutenant Cedergren if he thought Sergeant Graham was okay with his decision not to
approve the use of the restraint chair. Lieutenant Cedergren told me, “Yeah, cuz he didn’t voice
any different opinion or say anything else, he – stood there.”
I thought Lieutenant Cedergren’s reasoning for why he thought Sergeant Graham was okay with
his decision not to approve the restraint chair, based solely on Sergeant Graham not objecting or
confronting him, did not have a strong foundation.
During Lieutenant Cedergren’s interview, I told him that, in watching video from several of the
deputies BWC’s, as well as Sergeant Graham’s BWC, it was apparent to me no one else had any
idea of what to do regarding how Lieutenant Cedergren wanted them to restrain Mr. Madrigal in
the handcuffs and ankle restraints. I told Lieutenant Cedergren it seemed like he was constantly
talking to the deputies, directing them, and having to explain what he wanted them to do, as he
showed them what he was talking about. I asked Lieutenant Cedergren if that was a fair
assessment, and he told me yes.
I asked Lieutenant Cedergren if it was likely none of the deputies present had ever restrained an
inmate in a similar manner, and he told me yes. I asked Lieutenant Cedergren if he believed
Sergeant Graham or Lieutenant McComas had ever restrained anyone else in the same manner as
Mr. Madrigal, and he told me no.
The apparent fact that no one else had any idea how to restrain Mr. Madrigal in the way
Lieutenant Cedergren wanted him restrained, coupled with Lieutenant Cedergren’s realization
that no one had ever restrained Mr. Madrigal in a similar manner, should have been enough to
have given him pause. It is of interest to me as to why he thought he knew better than anyone
else what to do in this situation, when he had so little ITR supervisor experience, and he was
surrounded by staff who practiced and understood exactly what the right thing was to do.
During Lieutenant Cedergren’s interview, I told him according to his report he left Mr. Madrigal
in his cell about 1437 hours and the next time he returned to Mr. Madrigal’s cell, to check on
him was 1650 hours. Lieutenant Cedergren confirmed this was correct.
I asked Lieutenant Cedergren if it ever concerned him that over two hours had elapsed and there
was still no resolution regarding getting Mr. Madrigal out of the restraints. Lieutenant Cedergren
told me yes, saying he was going to resolve it. I asked Lieutenant Cedergren why he failed to do
anything to resolve it. Lieutenant Cedergren told me he no longer had the same number of
deputies available to help him, and since he was not going to open the door to deal with Mr.
Madrigal by himself, he decided to wait until the 1700 hours muster let out and then he would
have the necessary staff available to help him.
I asked Lieutenant Cedergren if he also saw Mr. Madrigal had maneuvered his handcuffs
from behind his back to the front of his body, and he told me yes. I asked Lieutenant
Page 104 of 117

 Cedergren if this increased his concern, and he told me yes. I asked Lieutenant Cedergren
why it increased his level of concern. Lieutenant Cedergren told me, “Because now that
they’re to the front – most – he has some flexibility and that he has a longer reach on that
chain – to get to where he needs to be.” I asked Lieutenant Cedergren what Mr. Madrigal
could do, now that he had that slack in the chain. Lieutenant Cedergren told me,
“Eventually what he did.”
I asked Lieutenant Cedergren if, with this information in mind, there was a reason why he
did not just stay there and radio for deputies to respond and assist him in solving the
problem. Lieutenant Cedergren told me, “No there’s not – cuz he – in looking at the log,
he’d been – copacetic to that point, so.”
I asked Lieutenant Cedergren to clarify if he was saying had he been notified earlier that
Mr. Madrigal maneuvered his handcuffs to the front of his body, he would have
recognized it as a significant concern and with ample staff present, he would have
immediately addressed it, and he told me yes. I asked Lieutenant Cedergren if, when he
saw this at 1650 hours, he still recognized it as an immediate concern, and he told me yes.
I asked Lieutenant Cedergren if he was saying the reason he did not immediately address
it was because he did not have the necessary staff to assist him, and he told me yes.
Lieutenant Cedergren told me he was not going to address it by himself, and Deputy
Mineo was fingerprinting inmates, so he had to wait for Deputy Mineo to finish before
Deputy Mineo would have been able to assist him.
I told Lieutenant Cedergren when he and Deputy Ross checked on Mr. Madrigal at 1720
hours and Mr. Madrigal was not responsive, it was obvious Deputy Ross thought it was
possible Mr. Madrigal had used the chain of the ankle restraints to strangle himself. I
asked Lieutenant Cedergren if he failed to realize it was possible. Lieutenant Cedergren
told me, “I realized it was possible then, but originally – no – when his hands to the back,
no. It – it takes – I’d never even dreamed he would slip to the front, cuz most people –
don’t.” I told Lieutenant Cedergren I was asking him if he thought it was possible for Mr.
Madrigal to use the chain of the ankle restraints to strangle himself, after he realized Mr.
Madrigal had maneuvered his handcuffs to the front of his body and there was now slack
in the chain. Lieutenant Cedergren told me, “Yeah, now it was a possibility – cuz that’s
why I wanted to take him out of there. Yes.”
In my opinion, this was a particularly damning answer for Lieutenant Cedergren, as he
just admitted that once he saw Mr. Madrigal had maneuvered his handcuffs to the front of
his body, he now realized Mr. Madrigal could use the chain of the ankle restraints to
strangle himself. There is no excuse for Lieutenant Cedergren failing to immediately
address this concern. Lieutenant Cedergren could have simply stayed by the cell, visually
monitoring Mr. Madrigal, until a sufficient number of staff were available.
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 I asked Lieutenant Cedergren, again, why he failed to immediately do something to
resolve the issue. When Lieutenant Cedergren did not instantly answer me, I asked him if
he was afraid no one would have responded, if he had radioed for additional deputies.
Lieutenant Cedergren told me, “I don’t know – I didn’t ask, but I know –.”
At this point, I interrupted Lieutenant Cedergren and asked him about his answer. Right
after I interrupted Lieutenant Cedergren, he told me, “I don’t know why I didn’t – I –
deputies come when you ask, yes – yes. Even on what you have on staff, and all that –
yes... but see, I – not to justify it – again, you look at the log – standing, standing,
standing, so I had no idea when he slipped. I should have stayed there, but had I known
earlier …”
Lieutenant Cedergren stated when he saw Mr. Madrigal had maneuvered his handcuffs to
the front of his body, he recognized it as an immediate concern. He also admitted that
once he realized there was now increased risks because of this, he never should have left
Mr. Madrigal’s cell, without addressing this safety concern. Having this in mind, I asked
Lieutenant Cedergren why he failed to address this, at that time.
Lieutenant Cedergren stated he did not have adequate staff available to assist him in
addressing this, which I viewed as a very weak excuse in defense of his failure to act. I
asked Lieutenant Cedergren if he was saying he thought deputies would not have
responded if he had asked for assistance on the radio, and he began to tell me he did not
know. Lieutenant Cedergren finally conceded that had he asked for assistance, he knew
deputies would have responded to assist him. In addition, Lieutenant Cedergren admitted
that he did not know why he failed to ask for assistance when he should have. Lastly,
Lieutenant Cedergren admitted, once he realized there were increased risks posed with
Mr. Madrigal maneuvering his handcuffs to the front of his body, he never should have
left Mr. Madrigal’s cell, without addressing the problem.
In our profession, anytime a deputy sheriff, much less a member of command staff, asks
for assistance, any and all available deputies will respond. In fact, oftentimes even busy
deputies will stop what they are doing and respond to assist. In my opinion, it was clear
to me that Lieutenant Cedergren knew how incriminating his answer was and he was
desperately trying to avoid admitting that he could have simply asked for assistance and
he would have gotten it.
During Lieutenant Cedergren’s interview, I told him after he discovered Mr. Madrigal
had strangled himself with the chain of the ankle restraints, he appeared flustered and
overwhelmed. I told Lieutenant Cedergren he repeated and excessively exclaimed the
word “fuck.” I asked Lieutenant Cedergren if it was at that point, he realized he made a
serious error in tethering Mr. Madrigal to the door and he told me yes, saying it was an
“epic” mistake and he was clearly panicked and overwhelmed with the whole situation.
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 I asked Lieutenant Cedergren if, in hindsight, he believed it would have been a better
option to have used the restraint chair versus tethering Mr. Madrigal to the door with
ankle restraints and he told me, “It would have been a better option to do something
different, which might have included the restraint chair. Could have been simple – as you
said, open the door and make him lay on the floor.”
I told Lieutenant Cedergren, right after this happened, he grabbed the restraint log and
forcefully exhaled, as he looked at the log. I asked Lieutenant Cedergren what was
upsetting to him, and he told me he was upset because he had to make the “Code 3” entry
and he realized this was “the ultimate ‘oh fuck’ moment, where you own it – nothing
good is going to come of it – you’re fucked.”
I asked Lieutenant Cedergren if he was speaking candidly in our interview; if he was
admitting responsibility for what happened, as if to say, I own this moment, like “I
fucked up. I own it.” Lieutenant Cedergren told me, “Oh, it’s – owned. It’s gonna – I
know it’s gonna come back to me – I – I have, I’ve had – we’ll get into that part about –
different conversations. I’ll let you finish up what you had – cuz.”
I told Lieutenant Cedergren the definition of negligence was failing to take the proper
care of something and I asked him if he believed he was negligent in his actions as a
supervisor that day. Lieutenant Cedergren stated, at the time, he thought he was doing the
right thing; however, he admitted that now, he recognized his actions that day were
negligent.
I believed Lieutenant Cedergren was being very candid when he acknowledged he lost
his composure that day, after finding Mr. Madrigal unresponsive, and he came to terms
with the gravity of his error in judgement and understood he was going to be held
responsible for the results. When I asked him to tell me if he would summarize the
decisions he made that day as a supervisor and the actions he took as negligent, he
carefully pondered his actions and then admitted he was negligent.
During Lieutenant Cedergren’s interview, I told him after he tethered Mr. Madrigal to the
door and pushed him inside the cell, he walked over to Deputy Comfort and specifically
told him he did not want to use the restraint chair. I asked Lieutenant Cedergren what it
was about the restraint chair that made him not want to use it. Lieutenant Cedergren
stated it was because he had only been briefly trained on the restraint chair, he had never
seen the restraint chair used, he wasn’t familiar with the restraint chair, Sergeant
Moschetti told him about problems he had in using the restraint chair in a past incident,
and, at the time, he did not think it was the best option to use.

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 I summed up Lieutenant Cedergren’s response aloud, by saying it sounded like his
overall reason for not using the restraint chair was a lack of familiarity with it. However,
Lieutenant Cedergren summed up his answer by saying the reason he did not use the
restraint chair was not necessarily because he wasn’t familiar enough with the restraint
chair, but more so because he just did not believe in it.
I asked Lieutenant Cedergren if he needed to understand every detail of how something
worked, before he could authorize someone else to use it. When Lieutenant Cedergren
did not answer me, I provided an example of my work computer malfunctioning and me
not knowing the intricacies of how to fix it. I explained that in this instance, I would call
someone from IT and have them fix it. I asked Lieutenant Cedergren if I needed to
understand exactly what they were doing to fix my computer or if it would be acceptable
to trust in the process that has been put in place and allow the IT staff to fix my computer,
while overseeing the repair. Lieutenant Cedergren told me in that instance, it would be
permissible. However, he stated if the scenario involved liability like teaching someone
how to fire a gun that did not know how to fire a gun, then no.
I found Lieutenant Cedergren’s analogy confusing and very different than the analogy I
had just presented to him. Not only was Sergeant Graham familiar with the restraint
chair, but Sergeant Graham also knew how to use the restraint chair, his team of deputies
knew how to use the restraint chair, and everyone had just received formal training on the
restraint chair at the summer range program. In addition, Sergeant Graham had personally
conducted recent muster training on how to use the restraint chair with the deputies in
ITR. If Lieutenant Cedergren authorized the use of the restraint chair, he did not need to
teach anyone how to use it, the only liability he would have incurred would have been if
he allowed to be used, when there was no reasonable justification for using it, which was
objectively not the case involving Mr. Madrigal.
I told Lieutenant Cedergren that in specifically talking about the restraint chair, I asked
him if he needed to know exactly how the restraint chair functioned, such as which button
to push, which belt to pull, or which clip went where, to supervise the use of the restraint
chair, but he did not answer me.
I asked Lieutenant Cedergren again, if he needed to know exactly what everything on the
restraint chair did, to supervise its use. Lieutenant Cedergren told me, “It would be nice
to – but I don’t – before I put my faith in somebody else – yes.” I told Lieutenant
Cedergren that it may be nice to know everything about the restraint chair, but I asked
him again, as a lieutenant, if he needed to know exactly how everything on the restraint
chair worked, before he could authorize its use. Lieutenant Cedergren stated, “As a
lieutenant in general – no, for me – I would want to know.”

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 Lieutenant Cedergren was very resistant to admit the simple fact that as a supervising
lieutenant it was not necessary to know exactly how to manipulate every function of the
restraint chair before he could have authorized its use. At the end of his statement, he
admitted while it was not necessary for lieutenants to know this, he still decided it was
necessary to him, for him to know everything about the restraint chair before he would
authorize its use for his own personal reasons.
I told Lieutenant Cedergren, in speaking to almost everyone else involved, the most
reasonable answer other people gave me, as to why they thought he did not use the
restraint chair, was because he was “running the show” and he was not going to bring in a
device he did not know how to operate. I asked Lieutenant Cedergren if it was fair to say
his lack of familiarity with the restraint chair was a significant factor in his decision not
to use it, and he said yes.
It was clear to me Lieutenant Cedergren appeared steadfastly opposed to using the
restraint chair, and nothing was going to change his mind. I believe the main reason
Lieutenant Cedergren did not want to use the restraint chair was because it was “new” to
him, and he did not understand how it functioned. Lieutenant Cedergren, by his own
admission, preferred to step outside of his supervisory role to go “hands on,” and without
a working knowledge of how to manipulate the various functions of the chair, I believe
he knew he would be unable to physically assist and secure Mr. Madrigal in the restraint
chair, nor would he be able to continue his micromanaging of the ITR staff on scene.
During Lieutenant Cedergren’s interview, I asked him to confirm he attended the summer
range training program on May 29, 2019, which covered the use of the restraint chair.
Lieutenant Cedergren told me he did, saying he remembered Sergeant Smitherman had
covered the Agency policy on the use of the restraint chair and she demonstrated how the
restraint chair worked. While Lieutenant Cedergren stated he remembered the time of
classroom instruction went less than the time allotted for covering the restraint chair, he
told me he never raised any concerns about his understanding of the restraint chair and
how it worked to her, either inside or outside of the classroom.
Not only did Lieutenant Cedergren receive formalized training on the restraint chair only
a few weeks before the incident, but so did his entire ITR staff. In addition, Sergeant
Graham was very familiar with the restraint chair, and he knew how to use it. Also,
Sergeant Graham had personally conducted recent muster training on how to use the
restraint chair for the deputies in ITR. If Lieutenant Cedergren authorized the use of the
restraint chair, he did not need to teach anyone how to use it, the only liability he would
have incurred would have been if he allowed it to be used, when there was no reasonable
justification for using it, which was certainly not the case involving Mr. Madrigal. It is
also worth noting, Sergeant Graham was not asking Lieutenant Cedergren to assist in
placing Mr. Madrigal in the restraint chair. He was only asking for authorization to use
Page 109 of 117

 the restraint chair, as he was required to do, after making a full assessment of the
situation, something Lieutenant Cedergren neglected to do.
During Lieutenant Cedergren’s interview, I asked him if he ever called his supervisor and
talked to him, right after this incident occurred. Lieutenant Cedergren stated he called
Captain Mattison and told him Mr. Madrigal had been restrained to the door and he had
had hung himself. I asked Lieutenant Cedergren if he told Captain Mattison something
had happened, it was his fault, and an inmate was likely to die as a result. Lieutenant
Cedergren told me he did not specifically remember saying that, but he admitted he could
have said that. I asked Lieutenant Cedergren if he remembered telling Captain Mattison
the reason he chose not to use the restraint chair, and he told me no. I told Lieutenant
Cedergren, Captain Mattison told me Lieutenant Cedergren stated he was uncomfortable
using it. Lieutenant Cedergren told me he did not recall saying that, but he admitted it
was possible he had said that or something like that.
I asked Lieutenant Cedergren if Captains Mattison, Hesselein, or Russell ever told him
not to use the restraint chair, and he told me no. I asked Lieutenant Cedergren if anyone
in a management position ever told him not to use the restraint chair, and he told me no.
I asked Lieutenant Cedergren if he and Sergeant Graham ever got into a disagreement
with how Mr. Madrigal was ultimately restrained, and he told me no, not that he recalled.
I asked Lieutenant Cedergren if Sergeant Graham ever asked him why he did not approve
the use of the restraint chair, and he told me no, saying not specifically; however,
Lieutenant Cedergren admitted Sergeant Graham may have asked him, but he did not
specifically recall this happening.
I told Lieutenant Cedergren Sergeant Graham told us he confronted him about why he
had not authorized the use of the restraint chair, to which Lieutenant Cedergren told him,
“The captain didn’t want deputies using the restraint chair, as they had problems with it
the other night and policy still needed to be worked out on it.” Lieutenant Cedergren
stated, he had no idea which captain it would have been who told him that and he added
that the policy on the restraint chair had been revised several times before it was
finalized. Lieutenant Cedergren said if Sergeant Graham had made this statement, it
might have been his understanding that he was told this.
Captain Christy asked Lieutenant Cedergren if he was saying he did not tell Sergeant
Graham that someone in management told him not to use the chair until they got
additional training. Lieutenant Cedergren said he did not even know who this person in
management would have been, but he also stated it was possible he did tell Sergeant
Graham this and he just did not remember that occurring.

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 I asked Lieutenant Cedergren if he ever told Lieutenant McComas that management did
not want deputies using the restraint chair because there were problems with it the last
time it was used, and the policy still needed to be worked out. Lieutenant Cedergren
stated he could have mentioned the story Sergeant Moschetti told him to Lieutenant
McComas, but he did not specifically remember anyone in management ever saying yes
or no to using the restraint chair.
I asked Lieutenant Cedergren if he remembered talking to Lieutenant McComas about
management not wanting deputies to use the restraint chair, and he told me no, saying he
could have said it in passing, but he did not specifically remember saying that.
I asked Lieutenant Cedergren what reasoning or justification he provided Sergeant Estep, as to
why he did not authorize the use of the restraint chair. Lieutenant Cedergren told me he did not
know.
I asked Lieutenant Cedergren if he ever told Sergeant Estep that the way he had restrained Mr.
Madrigal was the same way he had restrained inmates in the past, and he did not think it was
necessary to use the chair. Lieutenant Cedergren told me, “It’s possible.” I asked Lieutenant
Cedergren if that sounded like something he would have said, and he told me, “It could be –
yeah.”
I asked Lieutenant Cedergren if he told Sergeant Estep something similar to, “In the old days we
used to cuff people in this manner. It’s not necessary to use a chair, I’ve done it this way before
and it was fine.” Lieutenant Cedergren stated while he did not remember using those specific
words, he assumed he did have a conversation with Sergeant Estep saying something like that,
when Sergeant Estep would have checked in with him that day.
According to previous interviews, Sergeant Graham stated he confronted Lieutenant
Cedergren and asked him why he did not authorize the use of the restraint chair, to which
Lieutenant Cedergren told him “the captain” did not want deputies using the restraint
chair because of problems deputies had with it, and the necessity of policy changes that
needed to be addressed. Lieutenant McComas stated he confronted Lieutenant Cedergren
about his decision not to use the restraint chair, to which Lieutenant Cedergren told him
that management did not want deputies using the restraint chair, because there were
problems with it the last time it was used, and the policy still needed to be worked out on
it. Sergeant Estep stated Lieutenant Cedergren told him the reason he decided not to use
the restraint chair was because the way Lieutenant Cedergren had restrained Mr.
Madrigal was the same way he had restrained inmates in the past, and he did not think it
was necessary to use the restraint chair. Captain Mattison stated Lieutenant Cedergren
had called him right after this incident and told him the reason he chose not to use the
restraint chair was because he was uncomfortable using it.
Page 111 of 117

 While Lieutenant Cedergren told me he did not specifically recall most of these
conversations taking place, he admitted that it was possible all of these conversations had
occurred.
Sergeant Graham and Lieutenant McComas both told me they attempted to verify
Lieutenant Cedergren’s statement, that a captain or someone in management told
Lieutenant Cedergren they did not want the deputies in ITR to use the restraint chair
because of issues with the chair and/or policy changes that needed to occur, but they were
unable to verify anyone told Lieutenant Cedergren that. I found this troubling, as I
strongly doubt Sergeant Graham, Lieutenant McComas, Sergeant Estep, and Captain
Mattison all lied to me in their interviews.
It is my belief Lieutenant Cedergren fabricated the story that a captain or anyone in
management told him not to use the restraint chair, when he told Sergeant Graham and
Lieutenant McComas this in an effort to justify his reasoning for not using the restraint
chair.
When I relayed the information from the interview, where Lieutenant Cedergren told
Sergeant Estep he did not use the restraint chair because he had tethered inmates to the
door before, and he did not think the restraint chair was necessary, Lieutenant Cedergren
admitted this sounded like something he may have said. When Lieutenant Cedergren told
Captain Mattison he did not use the restraint chair was because he was uncomfortable
using it, he also admitted this, or something similar, was something he may have said.
Based on the above findings, as to the allegation that on June 10, 2019, Lieutenant Cedergren
was negligent in his duties as the ITR supervisor, I conclude the following: SUSTAINED.

Page 112 of 117

 As to the allegation that on June 10, 2019, Lieutenant Cedergren handcuffed Mr. Madrigal
to a cell door and then left him there as punishment for not cooperating with the deputies
during the booking process, I conclude the following: NOT SUSTAINED.
The following is the basis for my findings.
During Lieutenant Cedergren’s interview, I asked him if he could understand how the act of
leaving an inmate chained to the door, could be considered cruel and unusual and he told me yes.
I asked Lieutenant Cedergren if he left Mr. Madrigal tethered to the door for over two hours as a
form of punishment for not cooperating with him, and he told me no, saying he would have been
able to remove Mr. Madrigal at any time, whenever Mr. Madrigal became compliant.
While Lieutenant Cedergren told me he understood how someone else could view the act of him
tethering Mr. Madrigal to the door as cruel and unusual, he told me this was not his intention.
Rather, Lieutenant Cedergren stated he only intended to leave Mr. Madrigal tethered to the door
until he cooperated. In addition, Lieutenant Cedergren confirmed a restraint log was started, to
ensure deputies checked on Mr. Madrigal on a regular basis.
I showed Lieutenant Cedergren video of a previous incident he was involved in, which occurred
on July 23, 2017, in Housing Unit 2, on the east side of the housing unit, in F-Pod. This video
was from video of Deputy Ahlf’s BWC, which documented an inmate who refused to lock down
in his cell, while deputies and Sergeant Aniasco talked to the inmate through the open cuffing
port of the F-Pod door. Lieutenant Cedergren arrived on scene and approached the inmate and
asked him what his name was. As the inmate extended his wrist, so Lieutenant Cedergren could
read his wristband, Lieutenant Cedergren reached through the open cuffing port and grabbed the
inmate’s wrist and pulled it out of the door and ordered deputies to open the door. Once deputies
did, Lieutenant Cedergren assisted deputies in pulling one of his arms around the door, before he
handcuffed the inmate’s wrists together, effectively handcuffing the inmate to the door, while the
inmate was straddling the edge of the door on his knees, before he told the inmate, “Chill
motherfucker!” and walked away.
I asked Lieutenant Cedergren how long he left the inmate on his knees, handcuffed to the door.
Lieutenant Cedergren told me he left the inmate that way until medical staff arrived, but he was
unsure how long that was. I asked Lieutenant Cedergren if it would surprise him to know he left
the inmate on his knees, handcuffed to the door, for over ten minutes. Lieutenant Cedergren
agreed that it could have been ten minutes that he left the inmate there.
I asked Lieutenant Cedergren what his justification was, to leave the inmate handcuffed in that
manner for that long of a time and he told me he did this, so he would only have to move the
inmate one time.
I told Lieutenant Cedergren that his statement of “Chill motherfucker!” sounded like it may have
been punitive, as if he left the inmate in that position for not cooperating. Lieutenant Cedergren
told me he had no punitive intentions when he said or did this, rather he was frustrated, and his
emotions got the better of him when he cursed at the inmate.
While Lieutenant Cedergren’s actions in this past incident were unprofessional when he cursed
at the inmate after handcuffing him to the door, he admitted he was frustrated, and his emotions
got the better of him. When I asked Lieutenant Cedergren if he left that inmate handcuffed to the
Page 113 of 117

 door for punitive reasons, he told me no, saying he only left the inmate handcuffed to the door
until the nurse could respond.
When I spoke to Deputies Ross, Comfort, Sergeant Graham, and Lieutenant McComas during
their interviews, they all told me they never heard Lieutenant Cedergren say anything or do
anything that day that would have led them to believe Lieutenant Cedergren left Mr. Madrigal
tethered to the door for punitive reasons.
Based on the above findings, as to the allegation that on June 10, 2019, Lieutenant Cedergren
handcuffed Mr. Madrigal to a cell door and then left him there as punishment for not
cooperating with the deputies during the booking process, I conclude the following: NOT
SUSTAINED.

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 As to the allegation that on June 10, 2019, Lieutenant Cedergren failed to activate his Body
Worn Camera (BWC) as required by Alameda County Sheriff’s Office General Order 8.17,
I conclude the following: SUSTAINED.
Concerning the above allegation, I conclude the following violations occurred:
•

Civil Service Law and Rules Section 2104 (c) - Inefficiency

•

Civil Service Law and Rules Section 2104 (d) – Neglect of duty

•

Sheriff’s Office Rules and Regulation – 2.1.13 –Performance of Duty

•

Sheriff’s Office General Order 8.17 – Body Worn Cameras

The following is the basis for my findings.
During the interview with Lieutenant Cedergren, I asked him if he was familiar with our BWC
policy and he told me yes. I asked him if he was aware of the specific section of our policy that
covered D&C and he told me yes. I asked Lieutenant Cedergren if he could provide me with
examples of when he would be required to activate his BWC in the jail. Lieutenant Cedergren told
me a placement like Mr. Madrigal, cell searches, entering a housing unit, and for evidentiary
purposes.
Our Agency’s BWC policy in General Order 8.17 under D&C mandates staff activate their BWC
anytime an inmate is removed from their holding area, anytime staff enters a cell occupied by an
inmate, during inmate count, during meals, during window checks, during observation checks,
during general observations, while completing IOL’s and other regular checks, when contacting
an inmate inside their cell (including conversations through the window), during medical
emergencies, during any other inmate contact when recordings are not prohibited, and during
the processing of new arrestees (except for medical screenings).
Lieutenant Cedergren told me he did remember to activate his BWC after he found Mr. Madrigal
unresponsive. After reviewing Deputy Ross’ BWC video, I confirmed it was apparent Lieutenant
Cedergren intentionally activated his BWC, prior to beginning chest compressions on Mr.
Madrigal.
During Lieutenant Cedergren’s interview, I told him the Agency’s BWC G.O. clearly outlined
how this incident with Mr. Madrigal required him to activate his BWC. I told Lieutenant
Cedergren once he went “hands on” with Mr. Madrigal I would have expected his camera to
have been activated, to further emphasize the fact he needed to use his BWC. Since Lieutenant
Cedergren only intentionally appeared to activate his BWC after he found Mr. Madrigal
unresponsive, I asked him if that meant he did not know he should have activated his BWC at
any other time, during this incident. Lieutenant Cedergren told me, “No, it does not mean – that I
did not know so – I had it in the buffering I – somewhere I thought – either I hit it, or I didn’t or I
– it wasn’t on. I admit it – it wasn’t on.”

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 I asked Lieutenant Cedergren if he received training on BWC, and he told me yes. I asked
Lieutenant Cedergren if both he and his sergeants talked in briefings about the importance of
everyone activating their BWC’s, and he told me yes.
I asked Lieutenant Cedergren if, when he decided to go “hands on” with Mr. Madrigal, that
heightened his awareness that he was required to activate his BWC. Lieutenant Cedergren stated
if he would have remembered it, he would have turned it on.
I asked Lieutenant Cedergren if there was a reason why he did not follow the Agency policy and
activate his BWC when he decided to assist the deputies with Mr. Madrigal, and he told me there
was no reason it was not activated.
I asked Lieutenant Cedergren if there was a reason why he did not follow the Agency policy and
activate his BWC when he assisted with removing Mr. Madrigal from the WRAP, and he told me
no.
I asked Lieutenant Cedergren if there was a reason why he did not follow the Agency policy and
activate his BWC when he assisted with pushing and/or pulling on Mr. Madrigal’s body, and he
told me no.
I asked Lieutenant Cedergren if there was a reason why he did not follow the Agency policy and
activate his BWC, when he assisted with pulling on the ankle restraint chain that was attached to
Mr. Madrigal’s handcuffs, and he told me no.
I asked Lieutenant Cedergren if there was a reason why he did not follow the Agency policy and
activate his BWC when he conducted a general observation check of Mr. Madrigal, and he told
me no.
I asked Lieutenant Cedergren if there was a reason why he did not follow the Agency policy and
activate his BWC when he conversated with Mr. Madrigal to remove his handcuffs, and he told
me no.
Lieutenant Cedergren’s consistent failure to activate his BWC on numerous occasions is
inexcusable. Lieutenant Cedergren admitted he knew his actions required him to activate his
BWC, per the Agency policy, which he repeatedly failed to do. The BWC policy was put in
place to protect staff, inmates, and the Agency. It was evident every other deputy sheriff who
was involved in the incident abided by the BWC policy, except for Lieutenant Cedergren. As a
manager, he should have been leading by example, and yet, he failed to do so.
Based on the above findings, as to the allegation that on June 10, 2019, Lieutenant Cedergren
failed to activate his Body Worn Camera (BWC) as required by Alameda County Sheriff’s
Office General Order 8.17, I conclude the following: SUSTAINED.

Page 116 of 117

 ATTACHMENTS
Notice of Administrative Investigation and Interview form ........................................ Attachment # 1
Interview Information Subject Form……………………………………......………. Attachment # 2
Lybarger Admonition……………………………….…………………...…………...Attachment # 3
Interview Information Witness Forms ......................................................................... Attachment # 4
Memorandum from Lt. Hamman to Cmdr. Madigan (dated June 11, 2019) ............... Attachment # 5
Incident Report #19-009845 ........................................................................................ Attachment # 6
Miscellaneous booking sheets and in-custody paperwork for Mr. Madrigal ...……...Attachment # 7
Restraint Observation Log (ROL) for Mr. Madrigal ................................................... Attachment # 8
Lieutenant Cedergren’s Individual Activity Log 2017 – 29019……………........…..Attachment # 9
Pertinent Civil Service Laws and ACSO Rules and Regulations…………………..Attachment # 10
BWC video on DVD-R & audio-recorded interviews re: Mr. Madrigal ................... Attachment # 11
ITR Hallway Video (2 discs) ………………………………….…………….…..…Attachment # 12
BWC video ACSO Report# 17-012847……………………………………….……Attachment # 13

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