Keith Galen Bach had been dead for hours. The alarm on the insulin pump was still ringing when investigators from the medical examiner’s office arrived at the Men’s Central Jail after the death last September.
According to autopsy findings requested by the San Diego Union-Tribune and released this week by the medical examiner’s office, the pump may have beeped nonstop for nearly 24 hours, signaling Bach, who had type 1 diabetes, that he had run out of insulin.
Beep at mealtimes, when Bach feeds the prisoners because eating without insulin can cause blood glucose levels to rise to dangerous levels. It sounded as Bach and others in the module repeatedly alerted the representative that the insulin pump was empty.
San Diego County sheriff’s deputies’ response to Bach’s medical emergency was so poor that the medical examiner’s office took the unusual step of ruling her death a homicide, citing “neglect.”
“After insufficient insulin administration while in custody, Mr. Bach developed diabetic ketoacidosis and died,” the medical examiner’s report said.
“This is despite medical records containing documentation of medical conditions, insulin requirements, when the insulin pump will run out, and multiple unanswered requests for insulin by Mr. Bach and his fellow inmates,” he 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 important to protect the integrity of the investigation,” the statement said. “We offer our sympathies to Mr. Bach’s family and those affected by his passing.”
The district attorney’s office said the case is currently “under review.” Tanya Sierra, spokeswoman for Dist. Atty. Summer Stephen, said there is no timetable for when any power decisions can be made.
But inmate advocates and correctional health experts were shocked by the findings. He said Sheriff Kelly A. Martinez needs to do more to protect people in her department’s custody.
“The description of inaction by jail staff that led to the death of this inmate is beyond the pale,” said Aaron Fischer, one of a group of attorneys suing the county over the lack of health care it provides to people in San Diego County. jail.
“No one with diabetes should be denied insulin or the diabetes management tools they need to survive,” Fischer said. “If you deny a person oxygen, they suffocate.”
San Diego County has an unbelievable track record when it comes to jail deaths.
A state audit released in early 2022 noted that San Diego has the highest death rate among California’s largest prison systems. It recorded 185 deaths in custody between 2006 and 2020.
The report says San Diego County jails are so dangerous that new laws are needed to force reforms.
Death also has a cost of 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 due to inadequate medical care at the Las Colinas women’s jail in 2019.
Bach, who was 63 years old, had been working as a heating and air technician when he was arrested by Chula Vista police on September 25, 2023, on suspicion of vandalism and making criminal threats. He was never charged by prosecutors.
He was so ill during his arrest that he was booked into jail, so Chula Vista police took him to Sharp Mercy Hospital. He was treated for elevated glucose, and hospital staff recorded his insulin pump beeping and needing to be refilled.
Even so, Bach was medically released for booking within 40 minutes and transported to the downtown jail.
But Bach passed out 90 minutes later during the booking process. He was rushed back to the emergency room, where he was further treated for diabetes and returned to jail early on September 26.
“Orders should continue using an insulin pump, confirm metformin dosage and increase blood sugar checks,” the autopsy findings show.
The autopsy report noted that Bach cooperated with prison medical staff and allowed nurses to check his glucose level at least six times, and that he was given 10 units of insulin on the evening of September 26.
After 1 a.m. on September 27, Bach’s blood glucose level reached a dangerously high 322 mg/dL. According to sheriff’s medical records, Bach declined the offer of 10 units of insulin because he felt the dose was too low.
“Mr. Bach was finally given 10 units of insulin at 0151 hours, and this is the last documentation of insulin administration,” the autopsy findings said.
The medical examiner said the nurse requested a new insulin order with an increased dose, but the approval was “pending review”.
Bach was not seen by medical staff for the next 19 hours, the report added. It is not clear from the records who is responsible for approving the additional insulin recommended by the nurse.
On the morning of September 28, he was found unresponsive in his cell and not breathing. He was pronounced dead shortly after 4am
“Death was due to natural complications of disease,” the medical examiner wrote. “However, considering the lack of action (i.e. neglect) that represents an event that leads to inadequate care … the manner of death is classified as homicide.”
Manslaughter determinations due to medical neglect are rare.
Only once in at least two decades has the medical examiner’s office ruled the death of a person in sheriff’s custody a homicide when it was not killed by another inmate or by a deputy.
In 2022, Lonnie Rupard died in the same prison as Bach.
In that case, the medical examiner said that while Rupard suffered from schizophrenia and other disorders, his death was a homicide because “this person was dependent on others for care.”
Rupard was found in a cell with food smeared on the walls and feces on the floor.
There was trash in the unit, and the toilet was clogged with feces. Rupard had lost one-third of his body weight due to malnutrition in the month before his death.
A wrongful death lawsuit against San Diego County was filed by Rupard’s family last year and is awaiting trial.
Davis and McDonald write for the San Diego Union-Tribune.