California law halts medical investigations into deaths of sheriffs in their own jails

By Greg Hart, especially for CalMatters

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While California is statewide the prison population has decreased the number of people dying in prisons has increased in recent years. Too many of these deaths are preventable — including suicides, drug overdoses and murders.

These deaths occur under the watch of county sheriffs, elected officials responsible for the care and custody of people incarcerated in county jails.

Sheriffs also provide police services in parts of their counties and protect courthouses. In 48 of California’s 58 counties, however, the elected sheriff also serves as a coroner, overseeing medical investigations of suspicious and unattended deaths.

What does it mean when someone dies in prison?

In those 48 counties, the same officer charged with keeping inmates alive had the authority to oversee — and sign off on — the medical investigation into what went wrong. This is a clear conflict of interest.

This will no longer be the case.

Alarmed by this conflict, I introduced Assembly Bill 1108 – California Judicial Accountability, Transparency, and Custody Safety (FACTS) Act.. Governor Newsom signed the bill into law in October, ending the practice of allowing sheriffs to oversee medical investigations of deaths that occur in their custody.

In January 2027, independent medical investigations will be required for all deaths in custody — including those in county jails and state prisons, as well as deaths that occur while in custody.

Counties with combined sheriff’s and coroner’s offices will need to contract with another county’s civilian coroner’s office or an independent medical examiner not affiliated with the sheriff’s office. This independent medical examiner will oversee the scope of the investigation and their determination of the cause and manner of death will appear on the death certificate.

Preventable deaths

The conflict of interest addressed by this new law is not hypothetical. This has influenced numerous investigations in recent years.

After a series of preventable deaths at the Santa Barbara County Jail, a civil grand jury took a closer look. Two independent doctors subpoenaed by the grand jury suggested that a death in custody in 2022 should have been classified as a homicide rather than an accident.

The grand jury also found that the investigating sheriff falsely declared the death in 2025 imminent by failing to disclose that the incarcerated man died after being denied potentially life-saving care for two days.

Before San Joaquin County separated the roles of sheriff and coroner in 2018, the lead doctor in the sheriff’s office of the coroner resigned after the sheriff tried to overturn the doctor’s medical evaluation.

Even in the absence of bias or misconduct, optics alone undermine public trust. Families deserve confidence that investigations into the deaths of their loved ones are independent and impartial.

AB 1108 represents an important step toward greater accountability in our prison system. But this work is not finished.

Before serving in the Legislature, I was a county supervisor. I regularly heard from relatives of incarcerated people about the dysfunction of our local prisons. I have reviewed cases of significant mismanagement.

While my colleagues and I had strong views on how to improve prison outcomes, our policymaking body stopped at the prison door.

Writing blank checks

Under current state law, boards of supervisors are effectively required to write blank checks to sheriffs to run county jails — bearing full financial responsibility for the jails but lacking the authority to force necessary operational changes — even as pervasive problems persist year after year.

This was not always the case. From 1957 to 1993, boards of supervisors could appoint an official — other than the sheriff — to run the county jail.

Since 1993 the sheriffs had sole and exclusive authority over prison operations. Three decades later, it is clear that this arrangement prevents meaningful checks and balances.

In February, I introduced another reform to give county governments a tool to better manage prison systems and strengthen accountability. Assembly Bill 2257if passed, it would give counties the option to maintain sheriff-run jails or appoint another official to operate the county jail system.

Failing prisons reduce public safety, disrespect taxpayers, and negatively impact inmates and prison staff.

As our state builds the “California Model” for 21st century corrections and rehabilitation, addressing the crises in our county jails is paramount.

This article was originally published on CalMatters and is republished under Creative Commons Attribution-NonCommercial-No Derivatives license.