Keith Galen Bach had been dead for several hours. The alarm on his insulin pump was still ringing when an investigator from the medical examiner’s office arrived at Men’s Central Jail after his death last September.
According to autopsy results requested by the San Diego Union-Tribune and released this week by the medical examiner’s office, the pump likely beeped continuously for nearly 24 hours, alerting Bach, who had type 1 diabetes, that she was running low on insulin.
The beeping sound would occur during meal times, when Bach would give his food to other inmates, because eating without insulin could cause his blood sugar to spike to dangerous levels. The beeping sound would occur when Bach and others in his unit repeatedly alerted officers that the insulin pump was empty.
The response by San Diego County sheriff’s deputies to Bach’s health emergency was so inadequate that the medical examiner’s office took the unusual step of ruling his death a homicide, citing “negligence.”
“As a result of insufficient insulin administration while in custody, Mr. Bach developed diabetic ketoacidosis and died,” the medical examiner’s report states.
“This occurred despite medical records documenting his health status, his insulin requirements, when his pump would run out of insulin, and multiple unanswered requests for insulin from 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 imperative that we protect its integrity,” the statement said. “We extend our condolences to Mr. Bach’s family and all those affected by his death.”
The district attorney’s office said the case is now “under review.” Tanya Sierra, a spokeswoman for District Attorney Summer Stephen, said there is no timetable for a decision on charges.
But inmate advocates and corrections health experts were dismayed by the finding. They say Sheriff Kelly A. Martinez must do more to protect people in his department’s custody.
“The description of the inaction by jail staff that led to this in-custody death is unconscionable,” said Aaron Fischer, one of a group of attorneys suing the county over the lack of adequate health services provided to people incarcerated in San Diego County jails.
“No diabetic should be denied the insulin or diabetes management tools they need to survive,” Fischer added. “When you deprive someone of oxygen, they suffocate.”
San Diego County has a questionable record when it comes to jail deaths.
A state audit report released in early 2022 found that San Diego had the highest death rate among California’s largest prison systems, recording 185 deaths in custody between 2006 and 2020.
The report says San Diego County jails are so dangerous that new legislation is needed to force reforms.
These deaths also cost taxpayers 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 from inadequate medical care at the Las Colinas women’s prison in 2019.
Bach, 63, was working as a heating and air conditioning technician when he was arrested by Chula Vista police on Sept. 25, 2023, on suspicion of vandalism and criminal threats. He was never charged by prosecutors.
He was too sick to be incarcerated at the time of his arrest, so Chula Vista police took him to Sharp Mercy Hospital. He was treated for high blood sugar, and hospital staff noticed his insulin pump was beeping and needed to be refilled.
Still, Bach was medically cleared for arraignment within 40 minutes and transported to the city’s central jail.
But Bach collapsed 90 minutes later while being arrested. He was taken back to the emergency room, where he was treated for diabetes and returned to jail early on Sept. 26.
“The orders were to continue using the insulin pump, confirm the metformin dose and add blood glucose checks,” the autopsy results show.
The autopsy report states that Bach cooperated with prison medical staff and allowed nurses to check his blood sugar at least six times, and that he received 10 units of insulin on the afternoon of September 26.
On September 27, shortly after 1 a.m., Bach’s blood glucose level reached a dangerous 322 mg/dL. According to sheriff’s medical records, Bach declined an offer of 10 units of insulin because he felt the dose was too low.
“Mr. Bach ended up [was] “He administered 10 units of insulin at 1:51 a.m., and that was the last documentation of insulin administration,” autopsy results said.
The medical examiner said the nurse requested a new insulin prescription with a higher dosage, but approval was “pending review.”
Dr. Bach was not seen by medical staff for the next 19 hours, the report added. The file does not specify who was responsible for approving the additional insulin recommended by the nurse.
Early in the morning of September 28, he was found unconscious in his cell and not breathing. He was pronounced dead shortly after 4 a.m.
“Death was due to complications of a natural disease,” the medical examiner wrote. “However, given the inaction (i.e., negligence) that characterized the events and led to inadequate care…the cause of death is classified as homicide.”
It is rare for a homicide to be determined to be due to medical negligence.
Only once in at least the past two decades has the medical examiner’s office ruled the death of a person in sheriff’s custody a homicide when the person was not killed by another inmate or deputies.
In 2022, Lonnie Rupard died in the same prison as Bach.
In this case, the medical examiner said that even though Rupard suffered from schizophrenia and other disorders, his death was a homicide because “this deceased was dependent on others for his care.”
Rupard was found in a cell with walls smeared with food and the floor covered in excrement.
Rubbish littered the home and the toilets were clogged with excrement. Rupard had lost a third of his body weight due to malnutrition in the months before his death.
A wrongful death lawsuit against San Diego County was filed by the Rupard family last year and is awaiting trial.
Davis and McDonald write for the San Diego Union-Tribune.
