The Bexar County Sheriff’s Office filed a custodial death report (CDR) about Ed Penix on October 24, 2023. Mr. Penix was 63 years old when he was pronounced deceased on October 10, 2023, his sixth day of incarceration in Bexar County Jail in San Antonio, Texas. The intake process appears to be incomplete because the answer to two standard questions is “unknown,” those questions being whether he exhibited any medical or mental health problems. It is only in the summary of how Mr. Penix’s death occurred that specifics about his medical condition are provided.
A Detainee Dies by Suicide in Bexar County Jail
William James Shandore was 34 years old when he went through intake in Bexar County Jail. Tragically, he died in jail nine days later, on February 19, 2021. The first two weeks of incarceration have been identified as the deadliest days, in terms of detainees committing suicide. Mr. Shandore was within that time frame when suicide prevention measures in Bexar County Jail presumably failed.
Mr. Shandore’s cause of death was asphyxia by hanging. Since hanging is the method used in more than 92% of suicides, jail staff who go through mandatory suicide prevention training are aware of the vulnerability of detainees to this method of taking their own life.
Among other reasons, this website was created to provide detainees in local Texas jails and their families with helpful resources. There is no intention of making insinuations that persons or entities have engaged in wrongdoing.
Silhouette of barbed wires and watchtower of prison.
In the custodial death report (CDR) that the Midland County Sheriff’s Office filed about 29-year-old John Michael Soza, there is a mention that he became catatonic. It was for that reason he was transported by ambulance to the Midland Memorial Hospital on September 25, 2023. Immediately before he experienced catatonia, he had starved himself for 10 of the previous 11 days. In the three weeks that followed, he lost his heartbeat and was resuscitated several times. However, shortly after it again occurred in the wee hours of the morning on October 15, 2023, efforts to revive him failed. Mr. Soza was declared deceased by a physician at 1:54 a.m. that morning.
A Man Dies for Unknown Medical Reasons at Midland County Jail Continued
Savion Vashon Hall was booked into Midland County Jail on June 21, 2019. He exhibited medical problems during intake and received medical treatment at the jail for the condition that caused his death, per the custodial death report (CDR).
On July 11, 2019, Mr. Hall was experiencing breathing problems and received a breathing treatment in the medical unit. Due to his oxygen levels, the jail physician made the decision to send Mr. Hall to the hospital by ambulance. Learn more about this detainee and also see Part 1 and Part 2 of this continuing series.
Providing help to municipal and county detainees in Texas is one of the purposes of this website. There is no intention on this site to accuse any person or institution of unlawful activity.
On October 5, 2023, Ed Penix was booked into Bexar County Jail. Mr. Penix, who was a diabetic, died of unknown causes in the jail five days later, on October 10. According to the custodial death report (CDR), when he was discovered unresponsive, the jail was purportedly preparing to transport him to an emergency room for a higher level of care for an open wound and other conditions. He had been housed in the jail infirmary. The address of the jail is Bexar County Adult Detention Center, 200 N Comal St, San Antonio, TX 78207. Bexar County Jail can house up to 4,563 detainees.
Sepsis is one Cause of a Detainee’s Death in Bexar County Jail
A 44-year-old was placed in the custody of Bexar County Jail in San Antonio, Texas, on January 5, 2023. The man had been involved in an incident with the San Antonio Police Department. He suffered multiple gunshot wounds after he pointed a “look-alike” weapon at the uniformed officers. Although he was placed in the custody of the jail, he was taken to the University Hospital. He was placed on life support, which was removed on January 29, 2023, at the family’s request. He died that night at 9:36 p.m. The manner of the man’s death was ruled a homicide, which includes justifiable homicide. The medical cause of death was “multiple organ failure/sepsis/multiple gunshot wounds.”
Sepsis occurs when the body has an overactive response to an infection. The National Institute of General Medical Sciences has determined that each year over 1 million people in the U.S. develop sepsis, and only about 15% to 30% die from the condition. Anytime a detainee dies from sepsis, an investigation is done that hopefully assumes the possibility of medical neglect.
Learn more in this ongoing series.
Among other reasons, this website was created to provide detainees in local Texas jails and their families with helpful resources. There is no intention of making insinuations that persons or entities have engaged in wrongdoing.
Silhouette of barbed wires and watchtower of prison.
On June 28, 2023, 29-year-old John Michael Soza was booked into Midland County Jail. It was noted at intake that he appeared to have mental health issues. Approximately from September 17 through September 25, 2023, he refused to eat except for one tray on September 22. After at least 10 days of refusing food, Mr. Soza was transported to Midland Memorial Hospital, where he was pronounced deceased under a physician’s care on October 15, 2023. The address of Midland County Jail is 400 S Main Street in Midland, Texas 79701. The bed capacity at Midland County Jail is 489.
Catarino Humberto Rodriguez-Borjon Dies in the Custody of Midland County Jail
On February 19, 2021, Catarino Humberto Rodriguez-Borjon was booked into Midland County Jail. At 7:00 a.m. the next morning, when officers conducted rll call in the booking area, Mr. Rodriguez-Borjon refused to return to his cell. An officer pushed him back, and the detainee lost his balance. He fell and struck his head on the concrete bench. Aid was rendered immediately by the officer, and the Midland County Jail medical staff were called. Emergency medical services (EMS) were also called.
Mr. Rodriguez-Borjon soon got up under his own power and walked to the ambulance stretcher. He was transported by ambulance to Midland Memorial Hospital. Once he arrived at the hospital, he was placed on life support. Having never regained consciousness, Mr. Rodriguez-Borjon was pronounced deceased on March 7, 2021. An autopsy was performed, and it was determined that the manner of death was an accident, and the medical cause of death was blunt force trauma of the head.
Learn more in this continuing series.
Providing help to municipal and county detainees in Texas is one of the purposes of this website. There is no intention on this site to accuse any person or institution of engaging in unlawful activity.
A Woman Dies from a Fentanyl Overdose While In a County Jail Outside Texas
In a Pennsylvania county jail, illicit drugs were smuggled in, and two women suffered overdoses of fentanyl. They were treated and survived. Two days later, a 31-year-old woman in the same jail also had a fentanyl overdose, but she died. The woman’s family members are devastated and want to know why the jail staff didn’t take action to ensure that no more potentially fatal drugs were present in the jail. They acknowledge that their loved one had a drug problem and that being incarcerated in the county jail should not become a death sentence.
Meanwhile, another inmate was charged for smuggling the illicit drugs into the jail and supplying them to the other three women.
Cameron County is Listed as Non-Compliant After a Custodial Death
Detainee Johnny Gutierrez was 39 years old when he was booked into Cameron County Jail on January 7, 2023. Tragically, he died of asphyxia by hanging. Using a mattress cover, Mr. Gutierrez hung himself. He was discovered in an unresponsive state on January 26, 2023, and was pronounced deceased the next day.
It is standard procedure for a jail to be inspected following a custodial suicide. A special jail inspection conducted on October 1, 2023, included a review of documentation connected to a custodial death—presumably Mr. Gutierrez’s suicide.
Providing municipal and county jail detainees in Texas with helpful resources is one of this website’s purposes. Suggesting that a person or entity has engaged in wrongdoing is never intended.
Prison guard esicort inmate throught corridor in jail corridor for booking after arrest.
The Roanoke Police Department filed a custodial death report with the State of Texas regarding the death of John Allen Ellingwood. Mr. Ellingwood was 46 years old at the time of his death. We provide in this post information we obtained from that report, and we do not allege that anyone did anything wrong and which caused Mr. Ellingwood’s death.
The summary portion of the custodial death report was relatively short, and it read in its entirety:
“Ellingwood was arrested for Possession Controlled Substance PG 1 < 1G and Evading Arrest Detention. He was placed into double locked handcuffs and seated in the back right seat of the patrol unit. Ellingwood was then transported to the Jail Facility where Medics were called for a possible overdose. Ellingwood did not disclose what he ingested. He was released from custody and transported to the hospital.”
The report says nothing regarding the time period during which events in described in the summary portion occurred. Further, the Roanoke Police Department failed to provide any information in the following fields in the report: Death Code; Custody Code; Code of Charges; Intoxicated; and Medical Treatment Description. The Roanoke, Texas Police Department did indicate that Mr. Ellingwood did not make suicidal statements, did not exhibit any medical problems, and did not exhibit and mental health problems.
The 14th Amendment to the United States Constitution guarantees the right of pre-trial detainees to receive reasonable medical care and mental health care. This is an important right, because people in custody no longer have control over their ability to obtain medical care. Thus, if someone dies in a Texas jail, and jailers are deliberately indifferent to, or act unreasonably regarding, a prisoner’s medical needs, then those jailers could be liable to certain surviving family members. These cases are typically brought in federal court.
Dean Malone is the founder of Law Offices of Dean Malone, P.C., a jail neglect civil rights law firm. Mr. Malone earned his bachelor's degree at the University of Texas at Dallas, graduating summa cum laude with a 4.0 GPA, and from Baylor University School of Law with a general civil litigation concentration. Mr. Malone served in several staff positions for the Baylor Law Review, including executive editor. Mr. Malone is an experienced trial lawyer, trying a number of cases to jury verdict and also handling arbitrations through final hearing. He heads the jail neglect section of his law firm, in which lawyers litigate cases involving serious injury and death resulting from jail neglect and abuse. Lawyers frequently refer cases to Mr. Malone due to his focus on this very complicated civil rights practice area.
Interior of solitary confinement cell with metal bed, desk and toilet in old prison.
The Reeves County Sheriff’s Department, in Pecos, Texas, filed a custodial death report regarding the death of Norma Barrera Avila. Ms. Avila was only 54 years old at the time of her death. We provide in this post information obtained from that report, and we make no allegation of any wrongdoing against anyone.
Our Texas civil rights law firm frequently reviews custodial death reports regarding those dying in Texas county and city jails. The report regarding Ms. Avila is perhaps one of the shortest we have ever reviewed.
The summary portion of the report regarding Ms. Avila’s death literally reads, “Summary can not [sic] be completed until autopsy results are returned.” Therefore, the Reeves County Sheriff’s Department decided not to provide any details at all as to what led to Ms. Avila’s death, whether she had been checked by jailers, or any other material information regarding any illness and/or other occurrences which led to her death.
The Reeves County Sheriff’s Department also failed to provide any information in response to the following fields in the report: Death Code; Manner of Death Description; Custody Code; Code of Charges; Intoxicated; and Medical Treatment Description. The Reeves County Sheriff’s Department did indicate that Ms. Avila did not make suicidal statements, did not receive medical treatment, did not exhibit any medical problems, and did not exhibit any mental health problems.
We know very little regarding Ms. Avila’s death, with the sparse information provided in the report. However, it is our experience that the Texas Rangers investigate deaths such as Ms. Avila’s.
Texas county jail inmates have the right, pursuant to the United States Constitution, to receive reasonable medical care and mental health care. If someone does not receive such care, and dies as a result, then certain surviving family members may have claims as a result of the death.
Dean Malone is the founder of Law Offices of Dean Malone, P.C., a jail neglect civil rights law firm. Mr. Malone earned his bachelor's degree at the University of Texas at Dallas, graduating summa cum laude with a 4.0 GPA, and from Baylor University School of Law with a general civil litigation concentration. Mr. Malone served in several staff positions for the Baylor Law Review, including executive editor. Mr. Malone is an experienced trial lawyer, trying a number of cases to jury verdict and also handling arbitrations through final hearing. He heads the jail neglect section of his law firm, in which lawyers litigate cases involving serious injury and death resulting from jail neglect and abuse. Lawyers frequently refer cases to Mr. Malone due to his focus on this very complicated civil rights practice area.
Interior of solitary confinement cell with metal bed, desk and toilet in old prison.
The Bee County Sheriff’s Department, located in Beeville, Texas, filed a custodial death report with the State of Texas regarding the death of Bryan Lee Nix. Mr. Nix was only 31 years old at the time of his death. Information in this post was obtained from that report, and we make no allegation of any wrongdoing related to Mr. Nix’s death.
The new format for custodial death reports in Texas requires only a 2-page form, as opposed to the older 6-page form. This is unfortunate, because the public is not provided as much information regarding deaths occurring in custody. Regardless, the 2-page form regarding Mr. Nix’s death provided very little information. It did indicate that Mr. Nix did not make suicidal statements, and did not exhibit any mental health problems. Fields regarding Mr. Nix’s manner of death, death code, custody code, any medical treatment, and whether Mr. Nix was intoxicated, were left blank. Further, the summary portion of the report was relatively short:
“At 8:57pm the doctors at Spohn Bee County Emergency Room ruled inmate Bryan Nix passed away at the emergency room at Spohn Beeville at this time due to unknown reasons. He was brought in to the Bee County Jail at approximately 6:00 pm, by the Beeville Police Department, and was having trouble breathing. Bee County Jail staff performed CPR until EMS arrived and was transported to the emergency room at Spohn Bee County where he later passed away. Investigation is being conducted by our criminal investigation division and the Texas Rangers.”
Federal law, arising from the United States Constitution, provides that people who are arrested in Texas and jailed, whether in a city holding facility or a jail, or a county jail, are entitled to reasonable medical care. If a jailer and/or arresting officer fails to obtain such medical care, and in doing so is deliberately indifferent and/or acts in a unreasonable manner, then such person(s) may be liable to family members surviving a person who dies as a result. Likewise, a Texas city, town, and/or county can be liable for such a death, if a policy, practice, and/or custom caused the death.
Dean Malone is the founder of Law Offices of Dean Malone, P.C., a jail neglect civil rights law firm. Mr. Malone earned his bachelor's degree at the University of Texas at Dallas, graduating summa cum laude with a 4.0 GPA, and from Baylor University School of Law with a general civil litigation concentration. Mr. Malone served in several staff positions for the Baylor Law Review, including executive editor. Mr. Malone is an experienced trial lawyer, trying a number of cases to jury verdict and also handling arbitrations through final hearing. He heads the jail neglect section of his law firm, in which lawyers litigate cases involving serious injury and death resulting from jail neglect and abuse. Lawyers frequently refer cases to Mr. Malone due to his focus on this very complicated civil rights practice area.
Danger on the street. Blue flasher on the police car at night.
The Kermit Police Department, in Winkler County, Texas, filed a custodial death report regarding Jesse Lewalter Pritchard with the Attorney General of Texas. Mr. Pritchard was 39 years old at the time of his death. We provide information in this post which we obtained from that report, and we make no allegation of any wrongdoing against anyone related to Mr. Pritchard’s death.
The report indicates that several officers were involved in arrest of Mr. Pritchard, who was apparently arrested for public intoxication. Our Texas civil rights law firm frequently reviews custodial death reports in Texas, regarding those who die either in county jails or shortly after arrest. Some such reports are written in favor of law enforcement and omit material and important details. Clearly, we are uncertain as to whether the report regarding Mr. Pritchard’s death includes most material details. However, the narrative section is longer than what we typically see, and reads as follows:
“On Wednesday May 13, 2020, at approximately 2048 hours, Officer’s responded to a 911 emergency call at 316 Bert St in reference to an intoxicated person, who was naked outside of his residence. Officer Reynolds and Officer Wood were the 1st officer’s on scene, officer’s made contact with the intoxicated/naked suspect. Officer’s determined Pritchard was intoxicated on an unknown substance, and determined Pritchard was danger to himself and or others. Officer’s advised Pritchard’s father if he could get Pritchard some clothes to put on. Officer Reynolds gave Pritchard the opportunity to put clothing on, Pritchard refused.
Officer Reynolds, and Officer Wood tried placing handcuffs on Pritchard, Pritchard pulled away, Pritchard was placed against a chain linked fence in standing position. Officer Reynolds and Officer Wood assisted Pritchard to the ground, Pritchard had his hands in front of his body underneath his stomach area, and refused to put his arms behind his back. Officer Reynolds advised Sgt. Sanchez back up was needed. Sgt. Sanchez arrived at said location, Sgt. Sanchez gave Prichard commands, and if Pritchard did not follow the commands he would be tased. Prichard did follow Sgt. Sanchez commands and placed his hands behind his back to be handcuffed, Prichard was never tased.
Officer’s tried to get Pritchard to walk voluntarily to Officer Reynolds patrol unit, Pritchard refuse to walk to the unit. Sgt. Sanchez and Officer Reynolds carried Pritchard by his arms to Officer Reynolds patrol unit. Officer’s asked Pritchard to get in the back seat of the patrol unit, and Pritchard refused. Officer’s assisted Pritchard into the back seat of the patrol unit. Sgt. Sanchez contacted Sheriff Darin Mitchell to get confirmation to accept Pritchard to the Winkler County Jail due to Covid 19 restrictions. Sheriff Mitchell did confirm he would accept Pritchard into Winkler County Jail. Officer Reynolds and Officer Wood transported Pritchard to the Winkler County Jail, where Officer Reynolds states Prichard was banging his body against the metal divider during transport.
When officer’s assisted Prichard out of the unit they laid him on the ground waiting for chair to transport Pritchard into the jail. When helping Pritchard into the chair, officer’s noticed Pritchard was pale, and laid him back on the ground handcuffs were removed. Jailer Oscar Castillo begin CPR, Sgt. Sanchez called for EMS. EMS arrived at jail sally port, and transported Pritchard to Winkler County Hospital Emergency Room. Sgt. Sanchez was advised Pritchard had a pulse and was being transported to Medical Center Hospital in Odessa Tx, by Aero Care.
On Monday May 18, 2020 Lt. Richard Abalos was contacted by Ector County Medical Examiner Investigator Robin Wood. Lt. Abalos was advised by Wood Pritchard was on a ventilator and had no brain activity. Wood advised Lt. Abalos the family wanted to remove Pritchard from the ventilator. Wood asked Lt. Abalos if Kermit Police Department was requesting an autopsy on Prichard. Lt. Abalos advised KPD would be requesting an autopsy. Phone number was given to Wood, to contact Justice Of The Peace Precinct 1 Keri Jones, to set up autopsy in Lubbock Tx, South Plains Forensic Pathology. On Tuesday May 19, 2020 Lt. Abalos was informed autopsy for Prichard was set for Wednesday May 20, 2020 at 8:30 AM. On Wednesday May 20, 2020 at 8:30 AM, Lt. Abalos was present at Pritchard’s autopsy, at South Plains Forensic Pathology, Lubbock Tx. Autopsy performed by Dr. Thomas Parsons. Pending pathology report.”
When reading this case, it reminded our firm of another case recently decided by the Fifth Circuit Court of Appeals. the Fifth Circuit Court of Appeals is a federal appellate court which has jurisdiction over Texas, Mississippi, and Louisiana. Even though the cases are somewhat similar, once again, we are not alleging in this post any wrongdoing related to Mr. Pritchard’s death.
In that case, the parents of a young man who was arrested and died after his arrest, as representatives of his estate, filed suit against paramedics and police officers asserting that they were deliberately indifferent to injuries resulting in their son’s death, occurring from self-inflicted head trauma while in police custody. The court dismissed claims against the paramedics but retained claims against the officers.
The young man in that case, after being arrested, and while being driven to the police station, violently bashed his head over 40 times against the interior of a patrol car. The family member bringing the lawsuit alleged, through her attorneys, that police officers’ failure to act showed deliberate indifference to the young man’s serious medical needs.
The court determined that a reasonable jury could find that the officers were aware that the young man, “in the grip of a drug-induced psychosis, struck his head violently against the interior of [an officer’s] patrol car over 40 times in route to jail and thereby sustained severe head trauma.” The court also noted that one or more officers told a jail sergeant that the young man had been “medically cleared at the scene.” Ultimately, the court determined that a reasonable jury could find that the man’s injuries, from which he died within roughly 24 hours, were so severe, and the cause being so evident to the officers, that the officers acted with deliberate indifference by failing to seek medical attention, by failing to inform jail personnel about the man’s injuries, and by informing jail personnel only that he had been “medically cleared” before arriving at the jail.
Without regard to either case, as a general matter, the United States Constitution guarantees the right of pretrial detainees and arrestees to receive reasonable medical care. Police officers cannot be deliberately indifferent and/or act objectively unreasonably regarding an arrestee’s self-harm and/or need for medical care. If officers are deliberately indifferent and/or act in an objectively unreasonable manner, and a person dies as a result, then certain surviving family members may be able to bring a lawsuit against the officers and/or their employer.
Dean Malone is the founder of Law Offices of Dean Malone, P.C., a jail neglect civil rights law firm. Mr. Malone earned his bachelor's degree at the University of Texas at Dallas, graduating summa cum laude with a 4.0 GPA, and from Baylor University School of Law with a general civil litigation concentration. Mr. Malone served in several staff positions for the Baylor Law Review, including executive editor. Mr. Malone is an experienced trial lawyer, trying a number of cases to jury verdict and also handling arbitrations through final hearing. He heads the jail neglect section of his law firm, in which lawyers litigate cases involving serious injury and death resulting from jail neglect and abuse. Lawyers frequently refer cases to Mr. Malone due to his focus on this very complicated civil rights practice area.
The Aransas County Sheriff’s Department, in Rockport, Texas, filed a custodial death report with the Attorney General of Texas regarding the death of Thomas S. Kitchens. Mr. Kitchens was 66 years old at the time of his death. We make no allegation of any wrongdoing against anyone regarding Mr. Kitchens’ death but instead are simply providing information.
On October 26, 2019, Mr. Kitchens was arrested by the Texas Department of Public Safety for driving while intoxicated in Aransas County. He was then transported to the Aransas County Detention Center. At approximately 9:35 p.m., he was received in jail intake.
At 9:43 p.m., after telling one or more jailers that he needed medications, and that he had pre-existing medical conditions, Mr. Kitchens was provided with a telephone to call an unknown person to bring his medications. Three minutes later, he was placed into a holding cell.
At approximately 4:28 a.m. the next day, Mr. Kitchens was provided breakfast. At approximately 4:40 a.m., he was brought out to be fingerprinted. At approximately 4:55 a.m., he was placed into a cell and then ultimately allowed to make phone calls using the inmate telephone system.
At 6:58 a.m., Mr. Kitchens was authorized to make a phone call to attempt to have someone to bring his medications. At approximately 7:05 a.m., Mr. Kitchens was moved to a general population cell along with seven other inmates who were already in the same cell. At approximately 8:22 a.m., Mr. Kitchens was found unresponsive when officers entered the cell block. The report does not indicate whether periodic face-to-face observations were being made. Mr. Kitchens was ultimately pronounced deceased by a justice of the peace at 9:01 a.m.
The report indicates that preliminary results from the Nueces County Medical Examiner indicated that Mr. Kitchens was found to have scar tissue from a previous heart attack and signs from a recent heart attack and kidney damage. The report regarding Mr. Kitchens’ death was not file for several months after his death. This is a violation of Texas law, requiring a custodial death report to be filed no later than 30 days after a custodial death.
Dean Malone is the founder of Law Offices of Dean Malone, P.C., a jail neglect civil rights law firm. Mr. Malone earned his bachelor's degree at the University of Texas at Dallas, graduating summa cum laude with a 4.0 GPA, and from Baylor University School of Law with a general civil litigation concentration. Mr. Malone served in several staff positions for the Baylor Law Review, including executive editor. Mr. Malone is an experienced trial lawyer, trying a number of cases to jury verdict and also handling arbitrations through final hearing. He heads the jail neglect section of his law firm, in which lawyers litigate cases involving serious injury and death resulting from jail neglect and abuse. Lawyers frequently refer cases to Mr. Malone due to his focus on this very complicated civil rights practice area.