San Diego County coroner rules prison death of man as negligent homicide

Keith Galen Bach had been dead for hours. The alarm on his insulin pump was still beeping when a coroner's investigator arrived at Men's Central Jail after his death last September.

According to autopsy results commissioned by the San Diego Union-Tribune and released this week by the medical examiner's office, the pump likely beeped nonstop for nearly 24 hours, signaling Bach, who has Type 1 diabetes, that his insulin was running out.

It beeped during mealtimes when Bach passed his food to fellow inmates, because eating without insulin could raise his blood sugar to dangerous levels. It beeped when Bach and others in his module repeatedly alerted officers that the insulin pump was empty.

The response of 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 classifying his death as a homicide due to “neglect.”

“Due to inadequate insulin administration during his detention, Mr. Bach developed diabetic ketoacidosis and died,” the medical examiner’s report states.

“This occurred despite medical records containing his medical status, his insulin requirements, information on when his pump ran out of insulin, and numerous unanswered requests for insulin from Mr. Bach and fellow inmates,” it said.

The San Diego County Sheriff's Office said in a statement that it could not comment on the findings.

“The investigation is ongoing and it is imperative that we protect the integrity of the investigation,” 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 currently “under review.” Tanya Sierra, a spokeswoman for District Attorney Summer Stephen, said there was no timetable for when charges could be decided.

But inmate advocates and prison health experts were appalled by the findings, saying Sheriff Kelly A. Martinez must do more to protect the people in her care.

“The description of the inaction of prison staff that led to this death in custody is outrageous,” said Aaron Fischer, one of a group of lawyers suing the county over inadequate health care for people in San Diego County jails.

“No one with diabetes should be deprived of insulin or the diabetes management tools they need to survive,” Fischer added. “If you deprive someone of oxygen, they suffocate.”

When it comes to deaths in prison, San Diego County has a questionable track record.

A state study released in early 2022 found that San Diego had the highest death rate among California's largest prison systems, documenting 185 deaths in custody between 2006 and 2020.

The report said San Diego County prisons were so dangerous that new laws were needed to enforce reforms.

In addition, the deaths have cost taxpayers millions of dollars.

At the beginning of the year, for example, the county reached a $15 million settlement with the family of Elisa Serna. Serna died in 2019 in Las Colinas women's prison as a result of inadequate medical care.

Bach, 63, was working as a heating and air conditioning technician when he was arrested by Chula Vista police on Sept. 25, 2023, on charges of vandalism and criminal threats. Prosecutors never charged him.

At the time of his arrest, he was too sick to go to jail, so Chula Vista police took him to Sharp Mercy Hospital. He was treated for high blood sugar, and hospital staff discovered that his insulin pump was beeping and needed to be refilled.

Nevertheless, within 40 minutes, Bach was medically cleared for admission and taken to the central prison in the city center.

But Bach fainted 90 minutes later during registration. He was taken to the emergency room, where he received further treatment for diabetes. He returned to prison early on the morning of September 26.

“Instructions were to continue using the insulin pump, confirm the metformin dose, and perform additional blood glucose checks,” the autopsy results show.

The autopsy report notes that Bach cooperated with prison medical staff and allowed nurses to check his blood sugar levels at least six times. He was also given ten units of insulin on the afternoon of September 26.

Shortly after 1 a.m. on September 27, Bach's blood sugar level reached a dangerous high of 322 mg/dL. According to the sheriff's medical record, Bach refused an offer of 10 units of insulin because he thought the dose was too low.

“Mr. Bach [was] “At 1:51 a.m., 10 units of insulin were administered. This was the last documented insulin administration,” the autopsy results state.

The coroner said the nurse had requested a new insulin prescription at a higher dose, but approval was “still pending review.”

Bach was not seen by any medical staff for the next 19 hours, the report said. The file did not indicate who was responsible for approving the additional insulin dose recommended by the nurse.

He was found unconscious and not breathing in his cell early on the morning of September 28. He was pronounced dead shortly after 4 a.m.

“Death was due to complications of natural disease,” the medical examiner wrote. “However, given the inaction (i.e., neglect) that characterized the events and resulted in inadequate care, … the manner of death is ruled a homicide.”

The determination of manslaughter due to medical negligence is rare.

Only once in the last two decades has the coroner ruled the death of a person in sheriff's custody a homicide when the person was not killed by another inmate or by police officers.

In 2022, Lonnie Rupard died in the same prison as Bach.

In this case, the coroner ruled that Rupard's death was a homicide despite his schizophrenia and other illnesses because “the deceased was dependent on the care of others for his care.”

Rupard was found in a cell whose walls were smeared with food scraps and whose floor was smeared with feces.

There was garbage all over the apartment and the toilet was clogged with excrement. Rupard had lost a third of his body weight due to malnutrition in the months before his death.

The Rupard family filed a wrongful death lawsuit against San Diego County last year and is currently awaiting trial.

Davis and McDonald write for the San Diego Union-Tribune.