The Sheriff's intake at the San Diego Central Jail is shown on March 11, 2021. (Zoë Meyers/inewsource)

A rare forensic review by the medical examiner’s office contradicts the Sheriff’s Department’s statements about the disputed death of San Diego jail detainee Mark Armendo.

Armendo’s family is suing the county for wrongful death, alleging the 34-year-old contracted COVID-19 in the Vista jail and died from the virus in August 2020. The sheriff’s office has denied the allegations, telling the Union-Tribune last year that Armendo did not contract the virus in custody and was not hospitalized as a result of COVID-19. 

Why this matters

Incarcerated people have higher rates of pre-existing conditions that make them vulnerable to COVID-19, and the virus can spread quickly once inside jails and prisons.

More than 2,000 people incarcerated in San Diego County jails have tested positive for COVID-19 since the pandemic began.

Yet a forensic review completed by the Department of the Medical Examiner in June — and recently reviewed by inewsource — states that Armendo tested positive for COVID-19 on June 29, 2020, the same day he was found unresponsive in his cell and transported to the hospital. 

Federal guidelines indicate that it can take days after someone is first infected with COVID-19 to test positive for the virus. Armendo was incarcerated in county jail during that time.

The medical examiner’s review was not routine — it was conducted following months of questions and disputes over Armendo’s death. 

The office’s original death report, completed last year, says Armendo died from a seizure disorder of “undetermined etiology.” But investigators weren’t immediately notified of his death and couldn’t examine his body. 

Following their second review of the case, which included new blood tests and autopsy reports, the medical examiner’s office changed the cause of death to respiratory arrest due to fentanyl toxicity. Pathologists amended the manner of death from “natural” to “accident.”

The office also added an “apparent COVID-19 infection” as a contributing factor in Armendo’s death.

A COVID-19 diagnosis “was not well established, but would be reasonable based on a positive test result, his condition and risk factors,” the forensic report said.

Citing the family’s lawsuit, the sheriff’s office declined to comment on Armendo’s death and would not explain its previous statements.

The department has come under intense scrutiny for its response to the COVID-19 pandemic, with advocates, attorneys, detainees and their families arguing its officers have not done enough to keep incarcerated people safe from the virus. 

The sign in front of the San Diego County Sheriff’s Department Administration Center, San Diego, August 13, 2018. (Claire Trageser/KPBS)

Over the past few weeks, a surge in coronavirus cases ripped through San Diego County jails, leaving at least 171 incarcerated people infected and three hospitalized. 

“The safety, security, health and well-being of the people in our custody, as well as the deputies and employees who care for them, will always be a priority for the Sheriff’s Department,” the office wrote in a press release announcing the new outbreak.

The medical examiner’s office declined to answer questions about Armendo’s case because of the ongoing lawsuit. An attorney representing Armendo’s family could not be reached for comment.

Roundabout reviews

The sheriff’s department has disclosed little information about what happened to Armendo, causing uncertainty around the circumstances of his death.

Armendo was charged with possession of a controlled substance with intent to sell and booked into county jail in February 2020. Four months later, on June 29, he was drinking coffee in his cell when he suddenly fell from his stool onto the floor and became unconscious. 

Armendo was taken to Tri-City Medical Center and transported to UC San Diego Medical Center days later for a higher level of care. Then, citing a positive COVID-19 test, the court unexpectedly released him from custody. 

But Armendo’s condition didn’t improve, and he remained in the hospital. He died on August 21.

Because he was no longer considered in custody when he died, the sheriff’s office did not immediately report Armendo’s death to the medical examiner’s office for an investigation as expected. Under state law, county coroners must review all in-custody deaths, even if the individual died in a hospital. 

The Sheriff’s Department would not say how many jail detainees during the pandemic have been released from custody while in the hospital.

Instead of undergoing a review at the medical examiner’s office, Armendo’s body was sent to a private pathologist in Los Angeles. There, an autopsy found the cause of death was a COVID-19 infection, complicated by pneumonia and septic shock. 

By the time the medical examiner’s office learned of Armendo’s death at the end of August, it was too late to examine the body. 

“NOT BROUGHT IN,” a staff member wrote on a cause of death worksheet, which classified the case as a “death in custody.” 

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Based on the limited information available — and without the results from the private autopsy to work off of — the medical examiner’s office attributed the death to complications from a seizure disorder. Blocked arteries in the lungs, pneumonia and a staph infection were listed as contributing factors.

Then in March of this year, Armendo’s case went through another review, this time by the Citizens’ Law Enforcement Review Board, which investigates jail deaths and alleged misconduct by sheriff’s deputies.

The law firm representing Armendo’s family had asked the board to examine whether Vista jail had taken proper COVID-19 precautions and responded appropriately to Armendo’s medical emergency. 

The review board found that guards were justified in how they assisted Armendo when he collapsed in his cell. But its investigation didn’t include the actions of medical personnel inside the jail, who are not sworn members of the Sheriff’s Department.

“We don’t have jurisdiction over medical services,” said Paul Parker, executive officer for the review board. “We want that to be our jurisdiction, and we are in the process of requesting that that be the case.”

“We think we’re not getting the whole picture of deaths without jurisdictions over health care,” he added.

A new cause of death

The review board’s investigation uncovered that the Sheriff’s Department was in possession of a key piece of evidence — a blood sample taken when Armendo was in the hospital. There was “no indication” the medical examiner’s office knew the blood was available for testing, the board found.

When the board shared that information with the medical examiner’s office, pathologists agreed to re-examine the case and run their own toxicology report. 

Armendo’s blood tested positive for fentanyl “just below what has been reported to be fatal,” the forensic report says, noting that “the specimen and circumstances of the testing were not ideal.”

The medical examiner’s report also mentions that drug paraphernalia was present in Armendo’s cell when he collapsed, and his condition stabilized when he was given Narcan — a nasal spray used to revive people experiencing opioid overdoses. 

Based on its second review of the case, pathologists officially amended the cause of death in the case. They concluded Armendo died from complications of resuscitated respiratory arrest, primarily caused by fentanyl toxicity. 

As a part of its investigation, the medical examiner’s office also reviewed the results from the private autopsy conducted in Los Angeles, which had attributed Armendo’s death to COVID-19. County pathologists noted in their report that Armendo tested negative for COVID-19 three times in mid-July, about two weeks after his positive test.

Ultimately, the medical examiner’s office added “apparent COVID-19 infection” as a contributing factor in Armendo’s death, along with seizure disorder.

In the ongoing lawsuit, Armendo’s family contends that sheriff’s deputies knew he was sick with COVID-19 and experiencing respiratory distress in the time leading up to his collapse, but officers did not conduct adequate welfare checks on him.

The department “failed to implement strategies needed to address COVID-19 in County jails,” the complaint says.

The lawsuit was transferred to federal court in December 2020. A settlement conference is scheduled for April 2022.

San Diego County Sheriff Bill Gore is shown at the Sheriff’s Department headquarters in Kearny Mesa on Friday, Feb. 21, 2020. (Nicholas McVicker/KPBS)

Armendo’s death was referenced in another lawsuit filed in March by the San Diego chapter of the American Civil Liberties Union. The class action suit claims Sheriff Bill Gore has inflicted cruel and unusual punishment by housing detainees in crowded, unsanitary spaces without adequate medical care during the pandemic. 

“We continue to demand Sheriff Gore utilize alternatives to custody, limit transfers and new admissions, and release enough people to prevent any further outbreaks,” ACLU San Diego Staff Attorney Jonathan Markovitz said in a statement last week.

Throughout the pandemic, the county sheriff’s office has pointed out numerous precautions it has taken to protect people in custody from the virus, including frequent testing, daily temperature checks, isolating those who are sick and offering vaccinations.

The ACLU’s case is scheduled to go to trial in July 2022.

Type of Content

News: Based on facts, either observed and verified directly by the reporter, or reported and verified from knowledgeable sources.

Jill Castellano is an investigative data coordinator for inewsource. When she's not deep in a spreadsheet or holed up reporting and writing her next story, she's probably hiking, running or rock climbing. She also loves playing board games and discussing the latest chapters with her book club. Jill...