This story is one part of a three-part CalMatters series called "Locked Up and Dying" examining deaths in California jails.
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VISALIA – Lt. Buddy Hirayama sagged into his desk chair after a busy morning on his first day leading a county jail system running along the eastern edge of California’s San Joaquin Valley.
A call crackled across his radio:
“Man down. Unresponsive.”
Hirayama and almost two dozen deputies raced to a cell where a man appeared to have overdosed on something. Deputies pounded on his chest, administering CPR. Emergency medical crews arrived.
“Ultimately,” Hirayama said, “they were unable to bring him back.”
The June 5, 2023, fentanyl overdose death of Ignacio Garcia, 32, was the second in Tulare County jails last year, and the first on Hirayama’s watch. Those deaths followed the deadliest year in the jail’s history when eight inmates died in 2022, four of them by suicide.
Similar scenes have been playing out all over California. The year 2022 was the deadliest on record for California’s jail system, when 215 people died in county-run lockups from natural causes, suicide, overdoses and homicides. Death rates in jails remained high statewide in 2023, as they have been every year since 2019.
The jail deaths led to calls for more oversight. A new state law created additional seats on the board that oversees jails and jailers while the state pledged to conduct more inspections.
But the state doesn’t manage California’s county jails, the lockups where people await trials or serve relatively shorter sentences. Locally elected sheriffs run them.
Changes, if they happen, will have to take place at the local level, in places like this Central Valley jail, and they’ll have to come from Hirayama and other commanders like him.
He didn’t expect to face an in-custody death so quickly. He had to ask himself whether anything he could do would make a difference.
Photo by Larry Valenzuela, CalMatters/CatchLight Local
“I was honestly completely overwhelmed,” he said. “I just had a thousand questions about how the facility runs. I had a thousand questions about how the deputies are supposed to prevent this. I had a thousand questions about medical staff and what their roles and responsibility is in this.
“And then I have a thousand questions on the mental health side of this thing. What went wrong and how did it go wrong? And what could we have done to prevent it all the while?”
Hirayama knew he couldn’t control everything in the jail. A substantial number of its inmates come from rival gangs, and keeping them apart is critical to limiting violence. Tulare County, like many local governments, hires outside contractors to provide health care and mental health treatment to inmates. They don’t report to Hirayama.
He focused on something he could control: creating a less-predictable system of checks meant to keep inmates guessing about when deputies would pass by them.
Hirayama made other changes, too, as he stepped into his new role leading the jails. He hoped they would improve deputy morale and yield more cooperative inmates.
But mostly, he had to stop people from dying.
Mental health crises in California jails
New inmates are welcomed with a “fish kit,” the toothbrush, soap and other basic hygiene supplies they’ll save or trade while they’re incarcerated. But just as important is the mental health check they’re given by an intake nurse or medical assistant when they’re first processed, said Dr. Abdolreza Saadabadi, the jail’s psychiatrist employed by the private company Precision Psychiatric Services.
Jails have become this country’s mental health wards, Saadabadi said. Mental illness that goes untreated on the outside becomes mental illness that must be addressed inside, he said. Worse, he said, is when inmates who have been treated before for mental illness may not like the drugs they were given, or feel ashamed to admit their diagnosis, so they don’t disclose it.
“When they don’t share, it’s difficult to project what they might or might not do,” Saadabadi said.
Curtis Peck was facing a long prison sentence when he killed himself in his Tulare County jail cell on Sept. 27, 2022. He was 45.
His father, a retired prison guard of more than 26 years at California State Prison, Corcoran, doesn’t believe the sheriff’s office could have done anything to stop him.
“I had to accept that he took his own life rather than go back to prison,” Roger Peck said. “He wasn’t convicted yet but he had been most of his adult life in and out of prison.”
Roger Peck’s three eldest sons spent time in prison, but Peck said Curtis’ latest charges would send him away for a long time. Peck has family and friends in the Tulare County Sheriff’s Office, and asked one of them to investigate his son’s death.
“I asked my sister’s neighbor to look into it,” Peck said. “It was a single cell, no one in there with him. Everything proves that he took his own life.
“He knew what he was looking at in prison.”
Other families are not as resigned to the outcome.
Kelsi Fahrni was 29 when she hung herself in her jail cell on Aug. 12, 2022. In previous stays in jail, Fahrni had swallowed razor blades, jumped off a second-story railing and tried to hang herself.
After she was booked and admitted to using fentanyl daily, she was put in a cell, alone.
“Fahrni deteriorated and began self-harming behaviors,” alleges a lawsuit her family filed last year in federal court against the Tulare County Sheriff’s Office and Precision Psychiatric Services.
Deputies didn’t check on Fahrni for more than two hours, the lawsuit alleges, despite California laws mandating at least hourly checks on inmates.
The lawsuit accuses the jail system of failing to implement suicide prevention policies; failing to classify, house and monitor inmates suffering from mental illness; and “permitting unlicensed and/or untrained medical staff to remove severely mentally ill inmates from suicide watch.”
“Fahrni’s history of self-harm was known to Defendants,” the lawsuit alleges.
Hirayama took over eight months after Fahrni’s death.
Photos by Larry Valenzuela, CalMatters/CatchLight Local
Photos by Larry Valenzuela, CalMatters/CatchLight Local
Photo by Larry Valenzuela, CalMatters/CatchLight Local
Preventing suicides in jail
California sheriffs have long known that preventing suicides is among their most serious challenges.
“Jail suicides are extraordinarily difficult to protect against,” said John McGinness, a retired Sacramento County sheriff. “Protecting you from somebody else is fairly easy to do. But protecting you from yourself is a greater challenge.
“And we did all kinds of things, even in my limited experience with getting different kinds of bedding that couldn’t be fashioned into a noose, shorter socks for the same reason. Welding the bed frames to the walls so if they were able to fashion something into a noose, they wouldn’t have a way to apply it.”
Hirayama’s boss, Tulare County Sheriff Mike Boudreaux, shares the same view: “The reality of it is when someone is severely intent and depressive and decides that they’re going to take their life, they’re going to do whatever they can to do that,” he said.
Hirayama tried to make a difference by focusing on the hourly checks guards are required to make on the inmates under their watch.
Deputies have the same number of rotations as before, but Hirayama said he has staggered the times they walk the block. Sometimes, a deputy will check on an inmate considered at risk, then rotate right back minutes later to make sure nothing has changed.
Deputies are now instructed to check for signs an inmate is breathing, especially at night.
Photo by Larry Valenzuela, CalMatters/CatchLight Local
No inmate has died in the Tulare County jail in the past seven months.
He also took steps to change the atmosphere in the jails. Small stuff, like buying something to get at the cobwebs in high places, was accompanied by more safety measures, like small rubber U-shaped door stops for deputies who walk into cells to check on inmates.
“If we let the doors close behind us in the haste of trying to help, you’re locked in, and that’s not good,” Hirayama said. “Only a couple deputies had (the doorstops) and had to buy them themselves. So, holy smokes, I can spend roughly $300 and outfit my whole facility.”
They flipped every mattress, looking for drugs and weapons. For a couple of months at the beginning of his term as commander of the jails system, Hirayama was disrupting the way things had always been. More inmates were fighting.
“Let’s just turn this place upside down, open doors that we haven’t opened for years, see what we can fix on the mechanical and aesthetic side,” he said. “I’m looking at how I can make the jail more ‘appealable,’ as awkward as that sounds in a jail environment.”
Nearly a year after his first day, Hirayama said he hopes his changes will have a lasting effect. For now, he’s satisfied that the suicides have stopped.
Photos by Larry Valenzuela, CalMatters/CatchLight Local
Photos by Larry Valenzuela, CalMatters/CatchLight Local
Hirayama has a number he usually keeps to himself: five.
That, he said, is the number of suicides his staff has prevented since he took over, the most recent one in December. A deputy checked on an inmate who was deemed a suicide risk, then, per the staggered patrols, came back 10 minutes later instead of the usual 30 minutes or hour.
“She caught him and he was blue in the face, tied something around his neck, he was unconscious, at that teeter point,” Hirayama said.
The deputy untied the sheet. Medical help arrived. The man was conscious and talking soon after.
“I talked to him, not as Lt. Hirayama, but man to man. I read him the riot act,” Hirayama said. “Not to give him the guilt trip of it. Just to have the emotional conversation of suicide. It’s one of the most crippling things you can do to a family because they’re the ones left behind.”
