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Report points to sheriff's 'abject failure' to protect inmate in mental crisis

Unsecured inmate banged his head in a van many times, suffered a serious head injury and was left alone to bleed

A newly released report identifies failures in the transport of Andrew Hogan, an inmate who suffered a major brain injury while being transported to the Santa Clara County Main Jail in San Jose on Aug. 25, 2018. Embarcadero Media file photo by Magali Gauthier.

Editor's note: Some descriptions in this article may be disturbing.

The Santa Clara County Sheriff's Office's handling of a mentally ill inmate who suffered life-altering brain damage during transport was a colossal failure, the Office of Correction and Law Enforcement Monitoring (OCLEM) said in a report issued Tuesday to the Santa Clara County Board of Supervisors.

The report provides a harrowing look into the failures that led to inmate Andrew Hogan's injury. It also cited multiple failures by Sheriff Laurie Smith to release information OCLEM needs to evaluate, comment and make recommendations on disciplinary action — or lack thereof — by the Sheriff's Office in connection with Hogan's case.

The incident cost the county more than $10 million in a damages settlement, and a confidential report by the county counsel from Feb. 10, 2020, found the county had significant liability. The Board of Supervisors voted unanimously on Aug. 17 to waive attorney-client privilege and to release the counsel's report.

Hogan, who was in a mental health crisis, was being transported in a van from the Elmwood Correctional Facility in Milpitas to the psychiatric unit at the Main Jail in San Jose on Aug. 25, 2018. He was not secured with a seat belt and sustained major head trauma after beating his head against a metal cage that separated him from deputies. Once at the facility, despite apparent bleeding and injuries, he was left without aid and was locked in the van. When he was removed, he was unconscious, according to the report.

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The OCLEM report found "no available evidence" that the Sheriff's Office has held anyone accountable; nor has it made significant changes to remedy the problems that resulted in Hogan's incapacitating injuries.

"Irregular procedures and incomplete explanations have compounded the initial concerns that were generated by the incident itself. This reality falls well short of the reasonable expectations for transparency and understanding that are sought by your Board and the general public," the report said.

It noted the sheriff's "abject failure" despite the agency's responsibilities to protect mentally ill inmates.

Negligence and a lack of relevant policy

The Sheriff's Office didn't have a policy on how to safely transport mentally ill inmates at the time of Hogan's injury, the county counsel found. The existing policy stated that inmates could be transported by ambulance to a medical facility, but in practice an ambulance was never used to transport inmates between Elmwood and the Main Jail. The inmates were driven in a van without seatbelts or any other restraints, the OCLEM report noted.

Hogan had stated he wanted to engage in self-harm when he was first brought into custody on Aug. 10, 2018. His behavior became increasingly erratic over the days he was held in the jail. He began to speak incoherently, and deputies decided to transfer him to the Main Jail's psychiatric unit, a distance of about 5 miles.

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Hogan was hesitant to exit the jail cell and enter the van, requiring significant coaxing. When he was finally convinced to enter the transport van and its cage area, he was not secured. He remained manacled and chained at the waist.

The report states that while en route, Hogan violently banged his head on the roof and steel beam in the back of the van at least 50 times, one of the deputies who transported him said. A deputy in the passenger seat saw that Hogan was bleeding profusely and called a supervisor for instructions. The deputies were told to continue their journey to the Main Jail and were not advised to take Hogan to a hospital for medical treatment, according to the OCLEM report.

Supervisor 1, who was not named in the report, met the van at the Main Jail after receiving a call from the Elmwood complex advising that they had a "combative" inmate and he was coming to the psychiatric unit. The inmate had to be placed "by force" into the van, Supervisor 1 stated in a follow-up report, but video later showed that was not the case, the OCLEM report noted.

Supervisor 1 and a nurse who met the van learned from the deputies that Hogan had been banging his head and there was blood and excrement "everywhere." Opening the van's side doors, Supervisor 1 later wrote there was an "extreme amount of blood coming from the top of his head dripping onto his face."

Video footage later showed that Hogan was yelling.

"Get me out of here. I am f----n' dying. Please get me out. Please, I need medical. Hey, my f----n' head split open. My f----n; head is bleeding. Please, get me out of here. I need to talk to a doctor. I need water… ," the OCLEM report noted.

Hogan was not provided with water or medical assistance. Instead, the supervisor closed the door after only eight seconds and Hogan was left by himself, according to the OCLEM report. The nurse notified Supervisor 1 that the injury was serious and stated they should call a Code 3 ambulance, which responds to calls with its lights and siren on.

Concerned about jail staff being contaminated from Hogan’s bodily fluids, Supervisor 1 decided that Hogan would stay in the van until the jail's emergency response team could be protected in haz mat suits to help remove Hogan.

"The audio from jail cameras recorded Supervisor 1 saying that, in the meantime, Mr. Hogan could 'do all the damage he wants,'" the OCLEM report noted.

No one stayed to monitor Hogan, and he began to rapidly decline.

"Mr. Hogan can be heard over the course of several unattended minutes, repeatedly yelling irrational statements with less and less vigor as he eventually lapses into unconsciousness," the report said.

Video showed that a second supervisor briefly talked to Hogan. That person, Supervisor 2, told Supervisor 1 that mental health and medical staff needed to be on scene while they were waiting for the ambulance to help calm Hogan and to administer emergency triage as needed. The video footage showed that Supervisor 2 also didn't make any attempt to secure the needed treatment.

When the ambulance arrived, paramedics waited six minutes for the jail's emergency response team to arrive to help move Hogan out of the van. Advised of the medical waste situation, the ambulance paramedics put on protective gear. A third supervisor's report noted when they opened the van door, they could see Hogan was lying immobile and face down on a bench inside the steel mesh holding cage.

Supervisor 3 advised the paramedics not to open the cage door until the emergency response team arrived in case Hogan was still hostile and combative. Supervisor 3 said Hogan's immobility might have been a ploy, according to the third supervisor's report, OCLEM noted.

When an emergency response team arrived they directed Hogan to exit the van, but he didn't respond, according to the team's report filed on the incident. The team carried him while he was unconscious from the van and he was transported to the hospital.

The OCLEM report found multiple inconsistencies in the emergency response team's report, however, compared with video footage. There was no evidence in the video or otherwise to suggest that Hogan was "combative” in the sense of being physically aggressive to any jail, medical or mental health staff. They also found no evidence that Hogan "refused" to get out of the transport van prior to the emergency response team's arrival. Hogan was never ordered to exit the van by initial jail staff and he was nonresponsive to verbal commands issued by Supervisor 3.

"And Mr. Hogan 'refused' to comply with ERT’s (emergency response team's) orders to get out of the van because he was apparently unconscious when those orders were given," the OCLEM report noted.

A failure to cooperate

The report has also faulted the Sheriff's Office for failing to provide documentation to OCLEM for its investigation. The Board of Supervisors approved an ordinance in 2018 to form OCLEM, which is to provide independent monitoring of county correction and law enforcement services. In 2019, the county also contracted with OIR Group to begin monitoring the law enforcement and correction services in January 2020.

The sheriff has dragged out producing most of the documentation requested by OCLEM/OIR, according to the report. OCLEM began making requests to the Sheriff's Office starting in April for materials related to the Hogan incident. Initially, they only received two documents related to current inmate transport policy. After much public scrutiny, OCLEM recently received more materials related to the incident itself, including summary reports, attachments, videos and photographs.

Much of the material that would be most significant to OCLEM's report to the Board of Supervisors has yet to be provided by the sheriff, according to the report.

The Sheriff's Office began an internal affairs investigation into the Hogan incident on Sept. 25, 2018, but it ordered internal affairs to shut down the investigation for unknown reasons. Internal affairs was never able to complete its investigation nor reach any findings, including whether anyone was disciplined or if any meaningful change was ever made, the county counsel report also noted.

OCLEM made four requests, but Sheriff Laurie Smith "has expressly declined to provide us any information relating to the Internal Affairs investigation," the OCLEM report said. Smith also declined OCLEM's access to Sheriff's Office supervisors who are familiar with the internal Affairs investigation, from whom OCLEM wanted to gain insight into the internal affairs' substantive and procedural histories.

"Without this information, we cannot answer this Board's question about whether any meaningful Internal Affairs investigation was conducted and/or appropriate disciplinary action taken. Accordingly, we plan to use our subpoena authority granted by this Board to compel the Sheriff to provide the critical information," the report said.

View the full report:

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Report points to sheriff's 'abject failure' to protect inmate in mental crisis

Unsecured inmate banged his head in a van many times, suffered a serious head injury and was left alone to bleed

by / Palo Alto Weekly

Uploaded: Fri, Sep 17, 2021, 4:45 pm

Editor's note: Some descriptions in this article may be disturbing.

The Santa Clara County Sheriff's Office's handling of a mentally ill inmate who suffered life-altering brain damage during transport was a colossal failure, the Office of Correction and Law Enforcement Monitoring (OCLEM) said in a report issued Tuesday to the Santa Clara County Board of Supervisors.

The report provides a harrowing look into the failures that led to inmate Andrew Hogan's injury. It also cited multiple failures by Sheriff Laurie Smith to release information OCLEM needs to evaluate, comment and make recommendations on disciplinary action — or lack thereof — by the Sheriff's Office in connection with Hogan's case.

The incident cost the county more than $10 million in a damages settlement, and a confidential report by the county counsel from Feb. 10, 2020, found the county had significant liability. The Board of Supervisors voted unanimously on Aug. 17 to waive attorney-client privilege and to release the counsel's report.

Hogan, who was in a mental health crisis, was being transported in a van from the Elmwood Correctional Facility in Milpitas to the psychiatric unit at the Main Jail in San Jose on Aug. 25, 2018. He was not secured with a seat belt and sustained major head trauma after beating his head against a metal cage that separated him from deputies. Once at the facility, despite apparent bleeding and injuries, he was left without aid and was locked in the van. When he was removed, he was unconscious, according to the report.

The OCLEM report found "no available evidence" that the Sheriff's Office has held anyone accountable; nor has it made significant changes to remedy the problems that resulted in Hogan's incapacitating injuries.

"Irregular procedures and incomplete explanations have compounded the initial concerns that were generated by the incident itself. This reality falls well short of the reasonable expectations for transparency and understanding that are sought by your Board and the general public," the report said.

It noted the sheriff's "abject failure" despite the agency's responsibilities to protect mentally ill inmates.

The Sheriff's Office didn't have a policy on how to safely transport mentally ill inmates at the time of Hogan's injury, the county counsel found. The existing policy stated that inmates could be transported by ambulance to a medical facility, but in practice an ambulance was never used to transport inmates between Elmwood and the Main Jail. The inmates were driven in a van without seatbelts or any other restraints, the OCLEM report noted.

Hogan had stated he wanted to engage in self-harm when he was first brought into custody on Aug. 10, 2018. His behavior became increasingly erratic over the days he was held in the jail. He began to speak incoherently, and deputies decided to transfer him to the Main Jail's psychiatric unit, a distance of about 5 miles.

Hogan was hesitant to exit the jail cell and enter the van, requiring significant coaxing. When he was finally convinced to enter the transport van and its cage area, he was not secured. He remained manacled and chained at the waist.

The report states that while en route, Hogan violently banged his head on the roof and steel beam in the back of the van at least 50 times, one of the deputies who transported him said. A deputy in the passenger seat saw that Hogan was bleeding profusely and called a supervisor for instructions. The deputies were told to continue their journey to the Main Jail and were not advised to take Hogan to a hospital for medical treatment, according to the OCLEM report.

Supervisor 1, who was not named in the report, met the van at the Main Jail after receiving a call from the Elmwood complex advising that they had a "combative" inmate and he was coming to the psychiatric unit. The inmate had to be placed "by force" into the van, Supervisor 1 stated in a follow-up report, but video later showed that was not the case, the OCLEM report noted.

Supervisor 1 and a nurse who met the van learned from the deputies that Hogan had been banging his head and there was blood and excrement "everywhere." Opening the van's side doors, Supervisor 1 later wrote there was an "extreme amount of blood coming from the top of his head dripping onto his face."

Video footage later showed that Hogan was yelling.

"Get me out of here. I am f----n' dying. Please get me out. Please, I need medical. Hey, my f----n' head split open. My f----n; head is bleeding. Please, get me out of here. I need to talk to a doctor. I need water… ," the OCLEM report noted.

Hogan was not provided with water or medical assistance. Instead, the supervisor closed the door after only eight seconds and Hogan was left by himself, according to the OCLEM report. The nurse notified Supervisor 1 that the injury was serious and stated they should call a Code 3 ambulance, which responds to calls with its lights and siren on.

Concerned about jail staff being contaminated from Hogan’s bodily fluids, Supervisor 1 decided that Hogan would stay in the van until the jail's emergency response team could be protected in haz mat suits to help remove Hogan.

"The audio from jail cameras recorded Supervisor 1 saying that, in the meantime, Mr. Hogan could 'do all the damage he wants,'" the OCLEM report noted.

No one stayed to monitor Hogan, and he began to rapidly decline.

"Mr. Hogan can be heard over the course of several unattended minutes, repeatedly yelling irrational statements with less and less vigor as he eventually lapses into unconsciousness," the report said.

Video showed that a second supervisor briefly talked to Hogan. That person, Supervisor 2, told Supervisor 1 that mental health and medical staff needed to be on scene while they were waiting for the ambulance to help calm Hogan and to administer emergency triage as needed. The video footage showed that Supervisor 2 also didn't make any attempt to secure the needed treatment.

When the ambulance arrived, paramedics waited six minutes for the jail's emergency response team to arrive to help move Hogan out of the van. Advised of the medical waste situation, the ambulance paramedics put on protective gear. A third supervisor's report noted when they opened the van door, they could see Hogan was lying immobile and face down on a bench inside the steel mesh holding cage.

Supervisor 3 advised the paramedics not to open the cage door until the emergency response team arrived in case Hogan was still hostile and combative. Supervisor 3 said Hogan's immobility might have been a ploy, according to the third supervisor's report, OCLEM noted.

When an emergency response team arrived they directed Hogan to exit the van, but he didn't respond, according to the team's report filed on the incident. The team carried him while he was unconscious from the van and he was transported to the hospital.

The OCLEM report found multiple inconsistencies in the emergency response team's report, however, compared with video footage. There was no evidence in the video or otherwise to suggest that Hogan was "combative” in the sense of being physically aggressive to any jail, medical or mental health staff. They also found no evidence that Hogan "refused" to get out of the transport van prior to the emergency response team's arrival. Hogan was never ordered to exit the van by initial jail staff and he was nonresponsive to verbal commands issued by Supervisor 3.

"And Mr. Hogan 'refused' to comply with ERT’s (emergency response team's) orders to get out of the van because he was apparently unconscious when those orders were given," the OCLEM report noted.

The report has also faulted the Sheriff's Office for failing to provide documentation to OCLEM for its investigation. The Board of Supervisors approved an ordinance in 2018 to form OCLEM, which is to provide independent monitoring of county correction and law enforcement services. In 2019, the county also contracted with OIR Group to begin monitoring the law enforcement and correction services in January 2020.

The sheriff has dragged out producing most of the documentation requested by OCLEM/OIR, according to the report. OCLEM began making requests to the Sheriff's Office starting in April for materials related to the Hogan incident. Initially, they only received two documents related to current inmate transport policy. After much public scrutiny, OCLEM recently received more materials related to the incident itself, including summary reports, attachments, videos and photographs.

Much of the material that would be most significant to OCLEM's report to the Board of Supervisors has yet to be provided by the sheriff, according to the report.

The Sheriff's Office began an internal affairs investigation into the Hogan incident on Sept. 25, 2018, but it ordered internal affairs to shut down the investigation for unknown reasons. Internal affairs was never able to complete its investigation nor reach any findings, including whether anyone was disciplined or if any meaningful change was ever made, the county counsel report also noted.

OCLEM made four requests, but Sheriff Laurie Smith "has expressly declined to provide us any information relating to the Internal Affairs investigation," the OCLEM report said. Smith also declined OCLEM's access to Sheriff's Office supervisors who are familiar with the internal Affairs investigation, from whom OCLEM wanted to gain insight into the internal affairs' substantive and procedural histories.

"Without this information, we cannot answer this Board's question about whether any meaningful Internal Affairs investigation was conducted and/or appropriate disciplinary action taken. Accordingly, we plan to use our subpoena authority granted by this Board to compel the Sheriff to provide the critical information," the report said.

View the full report:

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