SAN DIEGO — A citizen's review committee has found that Probation Department Officers failed to check on an at-risk teen inside a San Diego juvenile detention facility prior to his death from a fentanyl overdose. The board also found that deputies were unsuccessful in stopping fentanyl from getting into the Kearny Mesa facility.
The 16-year-old referred to as "A.A.", was discovered dead in his room at the San Diego Juvenile Detention Facility on September 8, 2021, from "acute fentanyl intoxication." Probation officers at the juvenile detention facility found A.A. in his room, rigor mortise already having begun to set in. Inside his room, authorities discovered drug paraphernalia, indicating that he purchased the fentanyl inside the facility.
"Based on a review of all the evidence, it was clear there was a disconnect between how staff conducted safety checks at the time of [A.A.'s] death, and what was required by policy," reads the Citizens' Law Enforcement Review Board's (CLERB) investigation.
Adds the investigation, "It was impossible that 'signs of life' of A.A. in his room was observed by probation staff during each safety check conducted, given [he] was found with postmortem changes on the morning of 09-08-21. Ultimately, it was the responsibility of the Probation Department to ensure its employees were appropriately trained and executed their duties as required."
The Citizens' Law Enforcement Review Board will present its findings during its March 21 board meeting.
The board's decision comes a little more than one month after the teen's mother filed a wrongful death lawsuit against the County of San Diego.
According to the federal lawsuit, 'A.A.' was arrested on May 31, 2021, after he was admitted to Rady Children's Hospital for being under the influence of marijuana, alcohol, and methamphetamine.
The teen, reads the mother's lawsuit, had a history of mental health issues including "hopelessness, insomnia, irritability, and sadness," and was diagnosed with post-traumatic stress disorder, and adjustment disorder. He turned to drugs to ease the pain and lessen his symptoms.
In August, A.A. continued to struggle. During a visit that month, A.A.'s mother "noticed that her son appeared bloated, swollen, had bruises on his cheeks and palms, and was acting lethargic," according to the federal lawsuit.
In her lawsuit, the mother says she contacted the County on several occasions to get help for her son but nothing was done.
On September 5, 2021, officers checked A.A. into the detention facility's clinic due to frequent vomiting as a result of what the lawsuit describes as, "suspect fentanyl use."
The following day, A.A. was allowed to leave the clinic and return to his room.
Then on September 7, A.A. allegedly went to the cell of a known fentanyl dealer and later returned to his room.
Despite numerous checks throughout that night, deputies had failed to notice that A.A. was in the grips of an overdose.
The following day A.A. was dead.
"A.A. was found on his bunk, lying on his back, showing purplish discoloration on his left arm, left leg, and left side of his torso. Dried foam had accumulated around his nose and mouth," says the lawsuit.
But according to the County's Probation policy, when conducting safety checks it is "imperative" that "staff see signs of life...including the rise and fall of the youth’s back and chest while breathing; or seeing the youth’s skin and hearing them breath/snore, or the youth responds to verbal engagement.”
In A.A.'s case, the Citizens' Law Enforcement Review Board found that records showed that officers made 51 safety checks between September 7th and September 8th but failed to see that A.A. had overdosed and was non-responsive.
"Ultimately, it was the responsibility of the Probation Department to ensure its employees were appropriately trained and executing their duties as required," reads the board's investigation.
A.A. was one of 21 juveniles to die from fentanyl since 2019, according to numbers obtained by CBS 8 and one of 1,772 people that have died during that same time from from fentanyl-related causes.
In a February 22, 2023 letter, the San Diego County Sheriff's Department responded to the board's findings stating, "This has been shared with the Detention Services Bureau command staff to determine appropriate administrative action, including additional training and a referral for an Internal Affairs investigation."
Attorneys for A.A.'s mother declined to comment on the lawsuit.
CBS 8 also reached out to the County and the Sheriff's Department and did not receive a response.
The Citizens' Law Enforcement Review Board will meet at the County Administration Center at 5:30 pm on Tuesday, March, 21. The meeting is open to the public.
Editor's note: A previous version of the article and its headline referred to Probation Officers as Deputies. The titles have been changed in the headline and the article.