A state office established in 2024 to examine local probes into jail deaths has yet to finalize any assessments of the over 150 individuals who have died while in custody in California’s county jails during the last year and a half.
This delay is due to a lack of access to necessary records for a thorough analysis of the deaths, as stated by the Board of State and Community Corrections (BSCC), a regulatory authority designated by the governor to oversee the state’s jails and juvenile detention centers.
SB 519, enacted in October 2023, founded the In-Custody Death Review Division within the BSCC following a series of fatal incidents in San Diego, Riverside, and Los Angeles county jails.
However, the inadequacies of the new law became evident as the division commenced data collection on deaths that took place after its establishment in July 2024. The preliminary data received from counties lacked adequate detail, with most causes and manners of death reported as “pending investigation.”
Such internal inquiries can take months or even years to conclude.
During initial discussions, counties made it “clear they would not share nonpublic information,” including medical records or investigative materials, as noted by BSCC spokesperson Jana Sanford-Miller.
“Some agencies didn’t send records, and others provided redacted files,” Sanford-Miller remarked. “We have yet to obtain a completed investigation for any in-custody death in a local detention center.”
Consequently, no reviews have been finalized, although there are hopes for future progress.
Late last year, the BSCC collaborated with the governor’s office, the Legislature, and the Department of Finance to include language in a trailer bill tied to the 2025-26 budget, which ensures that the ICDR’s director and employees can access complete, unredacted investigative records, including medical information shielded by federal privacy laws.
Allison Ganter, appointed by Gov. Gavin Newsom to a six-year term as the division’s director in October 2024, emphasized in a statement that her office is “dedicated to conducting meaningful and transparent reviews of deaths occurring in local detention centers.”
“Families endure unimaginable grief when their loved ones die in custody, and that grief intensifies with unanswered questions about their deaths,” she stated. “Our aim is to understand why individuals die in custody, propose recommendations to avert future fatalities, and disseminate our findings to foster systemic change in local detention facilities.”
A spokesperson for Newsom’s office opted not to comment.
Original bill highlighted
Newsom, in response to inquiries in early 2024 from CalMatters regarding rising statewide jail deaths, touted his signing of the legislation, asserting that it would establish “a designated person specifically accountable for overseeing county jails” who would collaborate with California Attorney General Rob Bonta’s Office to advance Department of Justice investigations into the fatalities. Bonta had previously sued Riverside County in 2023 and later filed a lawsuit against Los Angeles County in 2025 regarding “inhumane” jail conditions.
However, the ICDR is “not currently collaborating with the Attorney General’s office on in-custody deaths,” according to Sanford-Miller.
For years, advocates and families of the deceased have urged for independent reviews of in-custody deaths. Official autopsy reports — among the limited publicly accessible records prior to SB 519’s passage — usually do not consider the quality of medical care or how jail conditions may have contributed to an inmate’s death.
Last year, the Southern California News Group analyzed over a thousand pages of lawsuits, audits, coroner reports, and investigative reviews. The analysis revealed that someone died in custody in the jails of Los Angeles, Orange, San Bernardino, and Riverside counties approximately every five days, highlighting instances of institutional neglect and lack of oversight.
In one case, a 61-year-old man was reported to have died of “multiple organ failure” and heart disease in March 2023 by the Los Angeles County Medical Examiner’s Office, but a review by an oversight agency indicated that he had shown symptoms of hypothermia and had a body temperature of 87.6 degrees after heating systems malfunctioned in the downtown Los Angeles jails.
In Riverside County, the cause cited for an inmate’s death in 2020 was acute methamphetamine intoxication, despite the fact that he had been forcefully subdued by correctional deputies within a cell at the Larry D. Smith Correctional Facility in Banning just two days prior to his death.
The four counties experienced almost 500 deaths from January 2020 to the end of 2025, with two-thirds of those who died not having been convicted of any crime.
Some families have resorted to lawsuits and independent autopsies in search of answers.
“Numerous families impacted by these jail deaths find themselves dedicating their entire lives, spending every waking moment, conducting their own investigations,” said Nick Shapiro, a UCLA assistant professor who researches the jails of Los Angeles County.
Law is ‘clawless’
Though there was “cautious excitement” when SB 519 was introduced, the law, as it stands, is “clawless” in terms of holding counties accountable, Shapiro remarked. An earlier version would have empowered county supervisors to remove control of jails from sheriff’s departments that failed to address issues by establishing a separate county Department of Corrections and Rehabilitation.
This provision did not advance beyond the Senate.
Under the final iteration, the ICDR Division is permitted to review investigations into deaths — rather than investigating a death directly — to assess a law enforcement agency’s performance and can evaluate “the circumstances prior to, during, and after the in-custody death incident” as part of that assessment, per a September 2025 fact sheet. It can subsequently recommend improvements to the agency, publicly report its findings, identify jails that are “out of compliance” with the state’s Welfare and Institutions Code, and summon police chiefs and sheriffs to answer before the Board of State and Community Corrections.
However, it lacks the authority to compel sheriff’s departments to comply with these recommendations, and there is no enforcement mechanism outlined if an agency declines to provide the records the ICDR needs.
If the state seeks real oversight and accountability, the ICDR must be granted subpoena power and the ability to conduct its own investigations by interviewing witnesses, reconstructing timelines, and commissioning independent autopsies, Shapiro asserted.
“I hope Sacramento can come together to make this use of taxpayer funds meaningful,” he expressed.
Oversight without enforcement
California has a history of instituting oversight bodies without adequate authority to fulfill their missions, stated Marcella Rosen, a media coordinator for the Care First California Coalition, which advocates for various reforms, including the closure of Men’s Central Jail in Los Angeles County.
“From our viewpoint of genuinely saving lives, it seems it was designed to fail,” Rosen remarked regarding the ICDR. “Oversight bodies without enforcement powers are incredibly limited.”
Some oversight commissions in Los Angeles County possess subpoena powers yet still face challenges in obtaining records from county agencies.
Nevertheless, even without subpoena power, the ICDR could enhance transparency regarding jail deaths, Rosen suggested. The California Department of Justice holds decades of data on in-custody deaths that could be analyzed to detect trends. The records that sheriff’s departments and medical examiners are required to publicly release, while limited, could still offer valuable data for analysis, Rosen added.
Initial reports on the horizon
Following modifications to state law and a budget increase, the ICDR aims to publish its first public reports by the second quarter of 2026.
The state has doubled the ICDR’s funding to nearly $5.4 million and authorized up to 25 positions for the current fiscal year. This additional funding will enable the recruitment of staff with medical and behavioral health expertise to review deaths from those perspectives.
After the trailer bill’s passage, the ICDR began requesting updated information from county agencies, facilitating “initial facility operational reviews of in-custody deaths, analyzing the updated data, developing publicly accessible data dashboards, and initiating trend analysis,” according to Sanford-Miller, the BSCC spokesperson.
While there has been “some hesitance to share sensitive information” during interactions with local agencies, the ICDR has yet to encounter outright “resistance,” according to Sanford-Miller.
The department is still in the process of completing new record requests from California’s 58 counties.
“Incomplete records will affect the timing of our reviews, particularly in complex cases,” she noted. “Once we have a clear understanding of the records we will receive and their submission timeline after a death, we will devise a process for completing initial reviews in these intricate cases and potentially informing initial recommendations before the investigation concludes.”
