With two new ones filed in recent weeks, San Diego County is now facing dozens of lawsuits over in-custody deaths — most of them alleging broad systemic failures in how it houses and treats people with mental illness.
The families of Pedro Junior Ornelas and Eric Van Tine have joined scores of other plaintiffs who turned their grief into civil legal complaints against the county and its sheriff.
Relatives of Ornelas and Van Tine separately sued in San Diego federal court last month, accusing county officials, correctional workers and others of failing to properly care for the men while they were incarcerated — and adding to a growing collection of litigation that has cost taxpayers millions of dollars.
Both complaints note that jail staff knew the men suffered from debilitating mental illness. In Van Tine’s case, he was in a state of acute psychosis when he was booked into the Central Jail on assault charges in December 2023.
In Ornelas’ case, after his requests for psychiatric care went ignored, he hanged himself in his jail cell.
“The nurse who conducted the medical receiving/screening process had access to his medical records and chart from previous incarcerations,” the Ornelas suit says. “Despite his history of mental health issues and history of psychiatric care, Pedro Junior was not evaluated by a mental health clinician or referred to a psychiatrist.”
A county spokesperson said he could not comment on the pending litigation but said the Sheriff’s Office “is committed to improving our jail system and ensuring the jails are safe for those who are incarcerated and for our employees.
“The Sheriff’s Office expects all employees and contractors to provide high quality care to all individuals in our jails and will hold accountable those who fail to meet the core values, policies and the expectations of the public we serve,” spokesperson Chuck Westerheide said via email.
NaphCare, the correctional healthcare provider named in the Ornelas complaint, did not respond to a request for comment. The company in recent years has been the subject of multiple orders from the county to do a better job.
Ornelas was 27 when he died by suicide inside San Diego’s Central Jail two years ago.
According to a civil rights lawsuit filed on behalf of his mother, Julie Ruffin, and his young daughter, in the days before he died jail staff ignored his requests to see a psychiatrist. Jail records from 2019 show that Ornelas suffered from depression and anxiety and had previously been placed on suicide watch.
Under the sheriff’s policies and procedures, Ornelas would have been flagged in the jail’s electronic medical records system as requiring behavioral health services — an alert that should have shown up when he was booked in June 2023, the lawsuit says.
During intake, he answered “no” when asked whether he were feeling suicidal, but shortly after booking, he submitted at least two requests for medical attention. Neither were fulfilled.
“May I see the psych please for a re-evaluation to get back on my medication?” Ornelas wrote in his first call for help. He repeated his request a second time, pleading to “get back on my meds please.”
Both requests were entered into his medical chart, but no follow-up was documented, the lawsuit says. Jail policy requires that such requests be triaged within 24 hours and followed by a face-to-face assessment.
“There is no indication that Pedro Junior’s requests were reviewed by any mental health clinician, or that any mental health clinician reviewed his mental health history,” the lawsuit says.
On June 26, just 10 days after he was booked, jail deputies found Ornelas dead in his cell. He died two days later at UC San Diego Medical Center.
His family’s lawsuit says the Sheriff’s Office and NaphCare violated Ornelas’ constitutional rights by failing to provide necessary mental health care.
It also alleges the department knew that staff should review medical records from prior incarcerations to assess suicide risk — one of many recommendations made in 2018 by the sheriff’s own consultant, nationally recognized suicide-prevention expert Lindsay Hayes.
Other corrections experts have cited deficiencies in San Diego County jail practices that lead to injuries, deaths and lawsuits.
Dr. Pablo Stewart, for example, who has studied psychiatric care in jail and prison for years, wrote at length about Ornelas’ death in a report submitted last year by plaintiffs in a separate class-action lawsuit seeking to improve conditions in San Diego jails.
Stewart described Ornelas’ suicide as “an egregious example” of a systemwide failure.
“There was zero psychiatric care provided despite documented psychiatric history available to jail staff and multiple requests for such care,” he wrote after touring several of the county’s jails and meeting with people in custody.
Even NaphCare’s internal post-death review of the Ornelas case noted that “closer psychiatric follow-up/care” was warranted.
Stewart called that finding “a gross understatement.”
“In my more than 35 years evaluating and working in detention facilities, I have come across very few, if any, mental health care systems so lacking in effective systems and levels of care,” he wrote in his 165-page report.
The Van Tine lawsuit, filed earlier last month, asserts some of the same allegations as the Ornelas complaint.
Eric Van Tine, right, is seen with his mother Carol, older brother Brian and Brian’s husband Josh. (Photo courtesy of Matthew Van Tine)
According to Van Tine’s family, the Sheriff’s Office ignored state regulations that prohibit housing three people with mental illness in a cell designed to hold two people after they booked Van Tine into jail in 2023.
The close quarters triggered a fight between Van Tine and cellmate Walt Mehran, who beat Van Tine until he was unconscious. The 41-year-old suffered severe brain damage and spent four months in a coma.
When he awoke, Van Tine was unable to feed or bathe himself and struggled to communicate. In October, he developed a lung infection and ended up on life support. His family chose to withdraw care on Nov. 6.
The district attorney charged Mehran with attempted murder. Just last week, Mehran pleaded guilty and agreed to a 12-year prison sentence to avoid being charged with murder.
California law prohibits triple-bunking in county jails, and the Sheriff’s Office has been told repeatedly by state inspectors to stop the practice, including as recently as last November.
The lawsuit, filed on behalf of Van Tine’s mother, Carol, notes that both Mehran and Van Tine had a history of mental illness and violent behavior. Yet they were placed together in a 75-square-foot cell with a third man who also had a history of mental illness.
The third cellmate told sheriff’s investigators that Van Tine had threatened Mehran. He said he thought the two had settled the argument, but after Van Tine fell asleep, Mehran dragged him from his bunk and beat him repeatedly.
Even if triple bunking had been allowed, the jail failed to properly assess whether the men should be placed in a cell together, Van Tine’s family’s lawsuit says.
Deputies “failed to properly place Eric in a cell where he could be monitored for his acute psychosis,” it alleges. “Instead, they placed him in a cell with two other mentally ill and assaultive cellmates.”
More than 240 people have died in San Diego County jails since 2006, according to a state audit released in 2022 and Sheriff’s Office records posted online. The deaths have prompted dozens of lawsuits that have cost the public tens of millions of dollars in recent years.
Sheriff Kelly Martinez, who was elected to a six-year term in 2022, said she has taken significant steps to improve jails since she was sworn into office. New initiatives include improving screening of people coming off opioids or alcohol, having nurse practitioners on hand to evaluate people during booking and implementing periodic wellness checks.
Westerheide, the county spokesperson, said Martinez has led “a significant shift in priorities, approach and processes in the County’s jails, which are implemented on a continuing basis, as the needs of our incarcerated population evolve.”
Since she took office, San Diego jails have seen deaths drop from a high of 19 in 2022 to 13 in 2023 and nine in 2024. Five people have died in jail so far this year.
Gay Grunfeld, one of a team of lawyers pursuing a class-action lawsuit against San Diego County and its troubled jail system, said she was not surprised by the allegations in the Ornelas and Van Tine lawsuits.
“They illustrate the Sheriff’s Office’s continuing deliberate indifference to people detained within the jail system,” she said. “Both men were pretrial detainees, presumed innocent. Both men died needlessly.”
Grunfeld said the county keeps getting sued for the same and similar lapses in coordinated care for people in sheriff’s custody.
“The jail’s medical system fails to timely respond to requests for mental health care and relies on a mix of private providers and county employees lacking oversight, training and accountability,” she said.
A hearing on the class-action case is scheduled in San Diego federal court later this month.