Accounts from behind the gates are raising more questions about inadequate medical care resulting in deaths at Monterey County Jail. Five wrongful death lawsuits from the families of inmates going back to March of 2021 have been filed, which would cost taxpayers millions. Additionally, Wellpath is looking at new court-ordered sanctions, if the company fails to fix its problems. This all comes as previously sealed documents shine a new light on an old problem. David Sand, age 29, diagnosed with schizophrenia and in jail on a probation violation, died Nov. 12, 2022, after drinking an excessive amount of water over a period of time in his cell, a sometimes fatal behavior that can happen with schizophrenia. Another inmate died in the jail in the same manner in December 2019. According to the attorney who worked that case, it was settled for more than $2.5 million less than two months before Sand died. “It is what I call the killing fields of Monterey County. The Monterey County Jail is the killing fields of Monterey County,” said Eric Sand, the father of David Sand. "David is not a violent person. He doesn’t steal things. He doesn’t rob banks. He was mentally impaired, and he had a hard time functioning in society.”Lawyer Jamie Goldstein with Arias, Sanguinetti, Wang & Torrijos in Emeryville is representing the family of David Sand. A lawsuit has been filed for Sand’s case. Four other lawsuits have been filed for other deaths going back to March 2021. “He (Sand) was deteriorating over time. He was showing signs of schizophrenia, worsening. He had hallucinations. He heard voices. He saw things and they didn't do anything for him,” said Goldstein. We are getting more details about David Sand’s death and others through neutral monitor reports. In 2015, the settlement of the Hernandez class action lawsuit filed by inmates required the jail to allow unaffiliated doctors, mental health care professionals and jail operations experts into the jail. These third-party neutral monitors filed regular reports, which were kept sealed by Monterey County. Unsealed last year, reports show Wellpath is out of compliance in at least 43 areas at the jail, including mental health care, clinical staffing, medical intake screenings and chronic care. Wellpath, the health care provider at Monterey County Jail, is now facing sanctions of $25,000 for each of the areas where they are out of compliance at Monterey County Jail. Fines could reach up to a million dollars if Wellpath fails to fix the issues. The company has a deadline of March 25. Neutral monitor reports about David Sand found five areas where staff failed to follow the jail’s implementation plan, noting that he was stabbed several weeks before his death, he did not receive any treatment for schizophrenia, and the delay in discovering his body.“He might as well have been left by the side of the road to die. It would have been no different. His body was discovered hours later after he died,” said Eric Sand. “These are captive people and if you are going to keep them captive you have a responsibility to make sure they are cared for and if you can’t do that you better figure out another way or you better give the keys to someone else,” said Goldstein. Ten days after Sand’s death, the Monterey County Board of Supervisors voted to let Wellpath keep the keys, agreeing to pay them more than $44 million to extend their contract to the end of 2025. None of the supervisors who voted to extend the contract would comment on our story.“I can’t explain why the Board of Supervisors voted unanimously to approve an extension of the contract given the record Wellpath has,” said Eric Sand. “There had to be a mention of the problems Wellpath was having and the deaths of many, many people This isn’t just my son’s death or the others who have died. This is more than a distinct pattern.”These lawsuits come as neutral monitors found 18 out of 19 deaths between 2016 and 2023 either were preventable or involved a violation of Wellpath’s implementation plan. Neutral monitors also found at least five problems with how the jail handled the death of Antonio “Neno” Billante, a 68-year-old retired painter from Salinas who ended up in jail in May of 2023. While in jail, neutral monitor reports show Billante, also suffering from schizophrenia, developed an infection from a wound that was not properly treated, leading to his death. He was taken to Salinas Valley Health in septic shock and with acute respiratory failure after being found unresponsive in his cell. He was put on life support and died shortly after. “He must have been in so much pain when you see the condition he was in,” said Rosa Boschetti Billante, Neno’s sister. “The doctors looked at me with their eyes all big like ‘There is nothing we can do for him.’ He was on life support already. The room smelled like raw meat, like raw skin.” Rosa Boschetti Billante has hired Goldstein and Aaron Fischer with Aaron J. Fischer Law Office to represent her. “He (Neno) was not getting daily wound care. He was not getting medications that he needed, and he wasn’t getting the evaluations necessary to identify if sepsis was developing,” said Fischer. “His legs were black and peeling and he was in such a deteriorating state that doctors weren’t able to do anything at the hospital.” Wellpath never returned our repeated calls for comment, County Counsel Susan Blitch declined to be interviewed, and so did Sheriff Tina Nieto and others named in the lawsuits. While local leadership is not interested in talking, the federal government is paying attention. U.S. Sen. Laphonza Butler of California has joined 11 other senators in raising alarms about Wellpath. They sent a letter in December to the company, writing that Wellpath’s “payment structure incentivizes cutting costs by minimizing the number of healthcare services provided.” The senators' letter also references the case of Jimmy Hall, an inmate at Monterey County Jail with breathing problems who was transferred from prison out of state without his CPAP machine. “He was just a wonderful kid. Losing him...it is like a big part of me is gone,” said Silvia Hall, Jimmy’s mother. Before 39-year-old Jimmy Hall’s death in April of 2023, neutral monitor reports show he requested a CPAP machine for sleep apnea but was denied one. “He asked for a CPAP machine more than once,” said Goldstein. “They basically told him we don’t give CPAP machines and ‘you should just try sleeping on your side.’” Hall, in jail on a theft charge, died of cardiac arrhythmia and subsequent multiple organ failure. He also had traces of fentanyl in his bloodstream. How the drug got into the jail is unknown. Neutral monitor reports show seven issues where the jail was out of compliance with Hall’s care including that he should have been given a CPAP machine and staff failed to give him Narcan. “Moms like me got to deal without having their kid, they are gone. I talk to Jimmy all the time but it is not the same as having them here with you and I just miss him,” said Silvia Hall. Separate from the lawsuits, there could be new court-order sanctions, too. United States District Court, Northern District of California got involved after lawyers for the Hernandez suit filed an enforcement motion to impose civil contempt fines if Wellpath fails to come into compliance. U.S. District Court Judge Beth Labson Freeman did not hold back when expressing her concerns in the Fall of last year saying in a court order; “Wellpath offers absolutely no evidence of substantial compliance being achieved after any of the monitors’ reports were issued.” Marc Stern, who teaches correctional healthcare at the University of Washington, says there are two major issues across the country leading to deaths behind bars. “Number one; lack of financial resources. In other words, low budgets and the second factor would be insufficient oversight by the jail administration,” said Stern. Stern says most preventable deaths in jails and prisons across the U.S. are related to substance use, substance withdrawal, medical problems that are misdiagnosed and suicide. Goldstein is representing the families of several inmates who died by suicide in Monterey County Jail including 47-year-old Jose Garcia Paniagua of King City who was arrested in June of 2023 after acting erratically at his home while under the influence of meth. Neutral monitor reports show he was suicidal. When he arrived at the jail, deputies put him in a holding cell. A few minutes after entering the cell, he wrapped a mounted payphone cord around his neck. Deputies found his body an hour later. The report says Paniagua, a father of four, should have been sent to the hospital for his suicide ideations, he should have been enrolled in a program for methamphetamine withdrawal, and that staff should have intervened to stop his death. The whole thing was recorded on video. It is unclear if anyone was watching which Goldstein said she had watched. "No one should have to watch that video. And no one should have to die that way. No one. And those children should not have lost their father," said Goldstein. Another inmate, Juan Carlos Chavez, 39, in Monterey County Jail on a probation violation was found dead after a suicide in April of 2022. A day before, he tried to strangle himself with the lace of a hooded sweatshirt. The next day, he was found unresponsive with balls of toilet paper blocking his airwaves. Neutral monitor reports raise questions about the death, noting there was “absent satisfactory response from the mental health staff” and questions why he was not sent to the hospital. Almost a year earlier, Carlos Patino Regalado, a 22-year-old inmate with schizophrenia died of hanging in March of 2021. His death happened after spending two weeks at Nativad’s Mental Health unit following an earlier suicide attempt. Doctors at Natividad Medical Center cleared him to come back to jail but said he should be on suicide watch. When he returned to the jail, neutral monitor reports showed he was taken off suicide watch after a few hours. He then hanged himself from a vent in his cell. Neutral monitor reports show that “mental health care provided to Regalado appeared to be inadequate and that death appeared to be preventable.”These lawsuits are being pursued in court with hearings and trials on these deaths likely to continue through at least 2025, according to Fischer. It is still unclear how much the lawsuits will cost. Another lawyer, Lori Rifkin, represented five families of people who died in Monterey County Jail between 2013 and 2019. Rifkin and her co-counsel for four of those cases, Hadsell Stormer & Renick, obtained more than $9 million in total judgments and settlements for those families.There have been at least 28 in-custody deaths since the Hernandez settlement, according to lawyers for that case.Wellpath is the largest prison health contractor in the country, serving around 300,000 patients in at least 34 states.In January, KSBW reached out to Monterey County for comment on this story. Maia Carroll, a communication management analyst responded writing: “The County of Monterey has no comment on this topic which includes active litigation.”On the day KSBW 8’s investigation aired Monterey County changed course and released a longer statement: “The County is deeply committed to the well-being and safety of all its residents, including those who are incarcerated. We acknowledge the challenges posed by the widespread use of drugs such as methamphetamines, opioids, and fentanyl, which have tragically claimed numerous lives in our county, state, and nation in recent years. In recognition of these challenges, the County of Monterey has made substantial investments, amounting to millions of dollars, to enhance conditions within our jail facilities. These efforts have included the implementation of suicide prevention measures and the installation of advanced security and safety systems. Moreover, it is essential to address the unintended consequences of Assembly Bill 109 (April 2011), which was approved and signed into law by the Governor. This legislation has necessitated a significant shift in the composition of the incarcerated population at the Monterey County Jail. Individuals who would have previously been housed in state prisons, due to the nature of their offenses and longer sentences, are now being accommodated in our local jail facilities. It is important to note that county jails were not originally designed to fulfill such functions. Despite these investments, it is imperative to acknowledge that the safety of our Sheriff's Deputies working in the Jail remains a constant concern. Recent events, including serious assaults and attempted murders of Deputies earlier this week, underscore the ongoing challenges faced by our law enforcement personnel within the jail environment. These incidents serve as stark reminders of the risks inherent in their daily duties and further emphasize the importance of our continued efforts to enhance security measures and support for those serving on the front lines. The County of Monterey, along with our elected officials, remains steadfast in our commitment to continuous improvement and proactive engagement in finding solutions to the multifaceted challenges confronting the County Jail. We recognize the complexities inherent in this issue and are dedicated to working collaboratively with stakeholders to ensure the safety and well-being of both incarcerated individuals and the broader community. We welcome constructive dialogue and remain open to feedback as we strive to uphold our responsibilities to all residents of Monterey County.”In-Custody DeathsThere have been at least 28 in-custody deaths since the Hernandez settlement, according to lawyers for that case. The list below is not a complete list. The Monterey County Sheriff’s Office would not participate in our story, nor would they provide us with a list of in-custody deaths.Timeline of deaths: May 2013: Joshua Claypole Cause of Death: Suicide Lawsuit: Settled before trial for $1.1 million Source: Lawyer Lori Rifkin January 2015: Jacob Parenti Age: 33Cause of Death: Flu-like symptoms ignored. Lawsuit: Settled before trial for $385,000 Source: Lawyer Lori RifkinMarch 2015: Mark Pajas Sr.Age: 56Cause of Death: Drug withdrawalLawsuit: Plaintiffs won a jury verdict of $1.6 million and settled for a total of $2.875 million. Source: Lawyer Lori RifkinMay 2015: Sandra VelaAge: 52Cause of Death: SuicideLawsuit: Settled for $2.85 million after the family won a summary judgment against the county.Source: Lawyer Lori RifkinAugust 18, 2015, Hernandez Settlement: Court approves a settlement agreement after a federal class action lawsuit was filed challenging certain conditions at the Monterey County Jail. The Jail must develop and implement plans to reform certain policies, procedures, and practices by which it provides security, medical care, mental health care, and disability accommodations to prisoners in the Jail. The agreement allowed unaffiliated doctors, mental health care professionals and jail operations experts into the jail. These neutral monitors filed regular reports which were sealed by Monterey County until July of 2023.December 2015: Larra GillisAge: 47Cause of Death: Found unresponsive inside a padded, isolated "safety cell" on Dec. 5, 2015. She had been locked in the cell for 28 hours, and despite yelling "help me," she was not given medical attention while detoxing and suffering from an infection, according to a lawsuit.Lawsuit: Settled for more than $800,000. Gillis’ family was represented by Lawyer Jamie Goldstein. December 2019: Rafael Ramirez Lara Age: 57Cause of Death: Died in a pool of his own vomit after compulsively drinking an excessive amount of water—he drowned to death—because of untreated schizophrenia.Source: Lawsuit filed by lawyer Lori Rifkin Lawsuit: More than $2.5 million March 19 2021: Carlos Patino Regalado Age: 22 Cause of Death: suicide by hangingNamed in Lawsuit: County of Monterey, former Sheriff Steve Bernal, former Chief Deputy of Corrections at the Monterey County Jail James Bass, former Undersheriff John Thornburg, Wellpath and others. Regalado’s family is being represented by Lawyer Jamie Goldstein. April 20, 2022: Juan Carlos ChavezAge: 39Cause of Death: suicide Named in Lawsuit: County of Monterey, former Sheriff Steve Bernal, former Chief Deputy of Corrections at the Monterey County Jail James Bass, former Undersheriff John Thornburg, Wellpath and others. Chavez’s family is being represented by Lawyer Jamie Goldstein. November 12, 2022: David SandAge: 29Cause of Death: Hyponatremia due to Acute Water Intoxication due to Psychogenic Polydipsia due to Schizophrenia.Named in Lawsuit: County of Monterey, former Sheriff Steve Bernal, former Chief Deputy of Corrections at the Monterey County Jail James Bass, former Undersheriff John Thornburg, Wellpath and others. Sand’s family is being represented by Lawyer Jamie Goldstein. November 22, 2022: Monterey Board Supervisors extends Wellpath’s contract for more than $44 million.January 4, 2023: Matthew Medina Cause of Death: Suicide, Asphyxia-HangingNamed in Lawsuit: County of Monterey, Sheriff Tina Nieto, Monterey County Sheriff’s Undersheriff Garrett Sanders,Chief Deputy Jeff Hoyne, Wellpath and others.Medina’s family is being represented by Lawyer Jamie Goldstein. April 7, 2023: Jimmy Steven HallAge: 39Cause of Death: Multiple organ failure following resuscitated cardiopulmonary; Probable cardiac arrhythmia; Hypertensive cardiovascular disease with left anterior fascicular block.Hall’s family is being represented by Lawyer Jamie Goldstein. Named in Lawsuit: County of Monterey, Sheriff Tina Nieto, Monterey County Sheriff’s Undersheriff Garrett Sanders, Chief Deputy Jeff Hoyne, Wellpath and others.May 22, 2023: Michael MartinezAge: 63Cause of Death: Accident, OverdoseNo lawsuit filed.June 9, 2023: Jose Garcia PaniaguaAge: 47 Cause of Death: SuicideLawsuit: The family of Jose Garcia Paniagua has hired attorney Jamie Goldstein. Lawsuit has not been filed yet. July 4, 2023: Antonio “Neno” BillanteAge: 68Cause of Death: Infection that was not properly treated. Taken to Salinas Valley Health in septic shock and with acute respiratory failure after being found unresponsive in his cell. Died at hospital. Lawsuit: The family of Antonio “Neno” Billante has hired attorney Jamie Goldstein. Lawsuit has not been filed yet. July 18, 2023: Unnamed inmate Age: 68 Cause of Death: Cancer No lawsuit filedJuly 20, 2023: Court releases neutral monitor reportsOctober 24, 2023: Edgar MaldonadoAge: 34 Cause of Death: Accident; Fentanyl, Buprenorphine, Hydroxyzine and Sertraline Intoxication Lawsuit: The family of Edgar Maldonado has hired Jamie Goldstein. Lawsuit has not been filed yet.