Keith Galen Bach had been dead for hours. The alarm on his insulin pump was still going off when an investigator from the medical examiner's office arrived at Men's Central Jail after his death last September.
According to autopsy results requested by the San Diego Union-Tribune and released this week by the medical examiner's office, the pump likely beeped nonstop for nearly 24 hours, alerting Bach, who had Type 1 diabetes, that she was out of insulin.
It sounded during meals, when Bach gave his food to other detainees because eating without insulin could cause his blood glucose level to spike to dangerous levels. It sounded when Bach and others in his pod repeatedly alerted officers that the insulin pump was empty.
San Diego County sheriff's deputies' response to Bach's health emergency was so poor that the medical examiner's office took the unusual step of ruling his death a homicide, citing “negligence.”
“Following insufficient insulin administration while in custody, Mr. Bach developed diabetic ketoacidosis and died,” the medical examiner’s report said.
“This occurred despite medical records containing documentation of his medical condition, his insulin requirements, when his pump ran out of insulin, and multiple unanswered requests for insulin from Mr. Bach and other inmates,” it said.
The San Diego County Sheriff's Office said in a statement that it could not comment on the findings.
“This is an ongoing investigation and it is imperative that we protect the integrity of the investigation,” the statement said. “We extend our condolences to Mr. Bach’s family and all those affected by his passing.”
The district attorney's office said the case is now “under review.” Tanya Sierra, a spokeswoman for District Attorney Summer Stephen, said there is no timetable for when charges could be filed.
But inmate advocates and prison health experts were horrified by the finding. They said Sheriff Kelly A. Martinez must do more to protect people in her department's custody.
“The description of the inaction by jail staff that led to this in-custody death is unacceptable,” said Aaron Fischer, one of a group of attorneys suing the county over the lack of adequate health care services provided to people in San Diego County jails.
“No one with diabetes should be denied insulin or the diabetes management tools they need to survive,” Fischer added. “When you deny someone oxygen, they suffocate.”
San Diego County has a questionable track record when it comes to people dying in jail.
A state audit released in early 2022 noted that San Diego had the highest mortality rate among California’s largest prison systems. It documented 185 in-custody deaths between 2006 and 2020.
The report said San Diego County jails were so dangerous that new legislation was needed to force reforms.
The deaths have also cost taxpayers millions of dollars.
Earlier this year, for example, the county agreed to a $15 million legal settlement with the family of Elisa Serna, who died from inadequate medical care inside the Las Colinas women's jail in 2019.
Bach, 63, was working as a heating and air conditioning technician when he was arrested by Chula Vista police on Sept. 25, 2023, on suspicion of vandalism and making a criminal threat. Prosecutors never charged him.
He was too ill at the time of his arrest to be booked into jail, so Chula Vista police took him to Sharp Mercy Hospital. He was treated for elevated glucose levels, and hospital staff noticed his insulin pump was beeping and needed to be refilled.
Bach was nevertheless released from custody within 40 minutes and taken to the central prison in the city centre.
But Bach collapsed 90 minutes later while being processed. He was rushed to the emergency room, where he received further treatment for diabetes and returned to jail early on Sept. 26.
“Orders were to continue using the insulin pump, confirm the metformin dosage and add blood sugar monitoring,” the autopsy findings show.
The autopsy report says Bach cooperated with jail medical staff and allowed nurses to check his glucose levels at least six times and administered 10 units of insulin on the evening of Sept. 26.
Shortly after 1 a.m. on Sept. 27, Bach's blood glucose level reached a dangerous level of 322 mg/dL. According to sheriff's medical records, Bach refused an offer of 10 units of insulin because he felt the dose was too low.
“Mr. Bach finally [was] “Ten units of insulin were administered at 01:51 hours, and this was the last documentation of insulin administration,” the autopsy findings stated.
The medical examiner said the nurse requested a new insulin order with a higher dose, but the approval was “pending review.”
Bach was not seen by any medical staff for the next 19 hours, the report added. It was not clear from the file who was responsible for approving the additional insulin recommended by the nurse.
Early in the morning on September 28, he was found unconscious in his cell and not breathing. He was pronounced dead shortly after 4 a.m.
“Death is due to complications of a natural disease,” the medical examiner wrote. “However, considering the inaction (i.e., negligence) that characterizes the events leading to inadequate care… the manner of death is classified as homicide.”
It is rare for a homicide to be determined to be due to medical negligence.
Only once in at least the past two decades has the medical examiner's office ruled the death of a person in sheriff's custody a homicide when the person was not killed by another inmate or by deputies.
In 2022, Lonnie Rupard died inside the same prison as Bach.
In that case, the medical examiner said that although Rupard suffered from schizophrenia and other disorders, his death was a homicide because “this decedent was dependent on others for his care.”
Rupard was found in a cell with food-stained walls and feces on the floor.
There was rubbish strewn throughout the unit and the toilet was clogged with excrement. Rupard had lost a third of his body weight due to malnutrition in the months before his death.
The Rupard family filed a wrongful death lawsuit against San Diego County last year and is awaiting trial.
Davis and McDonald write for the San Diego Union-Tribune..
