Phillip Garcia was in psychiatric crisis. In jail and in the hospital, guards responded with force and restrained the 51-year-old inmate for almost 20 hours, until he died.

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MORENO VALLEY, Calif. — Phillip Garcia was desperate to sit up. His wrists and ankles were bound to a hospital gurney and a hood covered his face. Garcia strained upward and then collapsed as he had countless times that day.

It was shortly after 10 p.m. on March 23, 2017, and he was at the public hospital here in Riverside County in a special unit for inmates.

Some 33 hours before, Garcia was led into a county jail, where he was almost immediately put in isolation for failing to follow orders and yelling irrational threats. When his mental condition worsened, deputies tied down the 51-year-old and eventually took him to Riverside University Health System Medical Center.

The hospital’s detention care unit treats the county jails’ most urgent and complex medical cases, among them inmates like Garcia, who are in mental crisis and need emergency psychiatric care.

But Garcia couldn’t get a bed. For 12 hours, he waited in the emergency room, seemingly unable to stop pulling against the four-point restraints. By the time his gurney was wheeled into the detention care unit, his skin was tearing beneath the straps.

A team of eight Riverside County sheriff’s deputies in helmets and body armor was called to the room. Their mission was to move Garcia 3 feet, from the gurney to the hospital bed that had finally opened up for him. One of them was responsible for recording the operation with a hand-held camera.

Footage shows deputies took positions around Garcia. One of them, Robert Packer, pressed a large plastic shield down on Garcia’s head. The team began pinning, lifting and dragging Garcia from the gurney to the bed.

“Somebody’s gotta help me. Somebody’s gotta help me. Please, man,” Garcia cried out, his voice raspy and muffled by the shield.

He was naked except for the hood and remnants of his green pants around his ankles.

The deputies and nurses fumbled at times as they tried to secure the restraints again. A second later, Packer leaned his chest against the plastic shield, pushing down hard on Garcia’s head and neck. The team’s commander signaled for Packer to ease up, footage shows. Packer stood, lifting his body weight off the shield.

As the scrum of deputies and nurses finished tying down his limbs, Garcia groaned under the plastic shield and bled through the hood.

A nurse asked a colleague to bring in a heart monitor.

One of the detention care unit’s regular guards, Deputy Noemi Garcia, intervened.

“The way he is right now,” she said, “we’ve gotta wait till he calms down before we put that machine on there.”

The nurse left.

Garcia died a few hours later. Earlier in the day, the emergency room had diagnosed Garcia with a potentially fatal condition called rhabdomyolysis, according to court records.

Rhabdomyolysis is brought on by overexertion, and it causes the body’s muscles to break down. It can lead to kidney failure. Garcia had been destroying muscle tissue as he struggled against the restraints, which poured toxins into his bloodstream, autopsy and jail records indicate.

Yet over the last five hours of Garcia’s life, a ProPublica investigation found, nurses and deputies appeared oblivious to both his rhabdomyolysis and his psychosis, doing nothing to treat either.

Video and other records show that during Garcia’s 44 hours in custody, deputies repeatedly struck, shoved and twisted Garcia’s head and limbs when he was already tied down. They falsified jail logs, then made false statements in their reports after he died. The county coroner bureau, which is part of the sheriff’s department, determined that Garcia’s death was a homicide. The same sheriff’s department conducted a review of Garcia’s death and did not discipline any deputies.

Millions of people across the country have joined protests against police brutality over the last few weeks, spurred by the killing of George Floyd in Minneapolis and fueled by the deaths of other unarmed black men at the hands of the police in recent years.

Like some of the most notorious of those killings, Floyd’s death was captured on cellphone video, and his fateful cry for help, heard around the world, has helped galvanize the Black Lives Matter movement and its call for police reform in the United States.

But abuse by law enforcement inside jails remains largely out of sight and harder to document. When it does come to light, it’s less likely to prompt public outrage because the victims have been charged, if not convicted.

And abuse by guards is but one threat facing inmates in many jails. The novel coronavirus has sickened thousands of inmates nationwide, underscoring long-standing problems in jail health services, not least in Riverside County.

A federal judge appointed outside monitors as part of a 2016 settlement to ensure the jails’ health care meets constitutional minimums. The monitors have documented continuing problems. But the monitors’ findings had not been made public until last month when an outbreak of COVID-19 heightened concerns about health conditions in the jails and prompted a lawsuit by lawyers representing inmates.

The newly released reports, covering 2017 to 2019, describe lapses in investigating inmate deaths and inadequate treatment of prisoners with mental illness.

In Garcia’s case, the sheriff’s department resisted disclosure of specifics about Garcia’s time in custody, even to his family. Garcia’s widow filed a lawsuit against the sheriff to get the records released.

Using California’s public records laws, ProPublica obtained 17 hours of surveillance and hand-held video footage documenting Garcia’s time in Riverside County’s jail and medical center, as well as thousands of pages of internal investigation records, facility activity logs, arrest reports, and autopsy and toxicology results. The county withheld these records from court monitors and initially denied ProPublica’s request for them.

ProPublica attempted to directly contact all of the jail and hospital employees named in this story. Many of the employees did not respond, and those who did declined to comment or referred ProPublica to the county.

Sheriff Chad Bianco agreed to an interview but canceled a day before. His department has declined to respond to questions or to a letter listing ProPublica’s findings. Riverside University Health System declined to answer questions related to inmates or hospital employees. In a statement, the health system said that “providing quality care is of utmost importance.”

There are details we don’t know about Garcia’s health history and the treatment he received during his final hours. In the internal files released by the county, Garcia’s medical information was redacted. ProPublica repeatedly contacted Garcia’s wife and sons in person and by phone, email and social media. The family, which agreed as part of a legal settlement not to talk publicly about the death, declined to speak with reporters or share documents.

Still, the records obtained by ProPublica provide an unusually thorough account of a recurrent tragedy — a person in mental crisis dying in law enforcement custody.


Chapter 1

A Life Shaken Apart

Riverside County sprawls from the Arizona border to Orange County, 180 miles of suburbs and desert brush. Garcia was born there in 1965. His family lived in Indio, tucked between Joshua Tree National Park and the San Jacinto Mountains.

He became a repairman and went into business with his friend, Dwight Walker, fixing almost anything that could break in a house. They ran advertisements for P & D Maintenance Service in a local newspaper in 1986, including a photo of them standing beside a pickup truck, the 20-year-old Garcia sporting a tank top and shorts and a thick black mustache.

Birth records show Garcia and his wife, Mary, had their first child the following year, a son. A second son was born in 1993, and they later took in and raised another boy.

On Father’s Day 2019, Garcia’s middle son posted family pictures on Instagram in a remembrance of his dad. One snapshot shows Garcia crouched down and holding a power drill, in the middle of a backyard project. In another, Garcia sits at a dining room table with one of the boys, behind a big sheet cake with white frosting and “Happy Birthday” written in blue icing.

Garcia struggled with alcoholism much of his life, said Christopher DeSalva, a family friend and lawyer. Court records show Mary Garcia accused her husband of domestic violence, and he pleaded guilty to misdemeanor battery in 2006.

In later years, Garcia and his wife shared a home with Walker, their friend and business partner, in Cathedral City outside Palm Springs. Garcia had a history of seizures, mental illness and inconsistent treatment, DeSalva said.

On March 20, 2017, a Monday, Garcia became disoriented. He told his wife an earthquake had knocked things over in the house, but there had been no earthquake. The next day he was out of sorts and couldn’t remember basic things, like whether he’d eaten, Mary Garcia later told the detectives.

Shortly before dawn on Wednesday, March 22, Garcia sprinted around his yard in the dark, shouting obscenities. Neighbors called police after Garcia threw something that shattered their window, and officers from the Cathedral City Police Department arrived to find him in a state of angry disarray. His oversized T-shirt had bloodstains on the front.

Garcia had allegedly assaulted Walker, then 87, earlier that morning, punching and kicking him in the head and arms. The attack was unprovoked and out-of-character, Walker told police, and Garcia had been “rambling, making no sense” all night.

As police looked on, Garcia went on slur-filled tirades and threatened to beat up every person around him — neighbors, police, medics. The arresting officers noted Garcia’s bizarre behavior several times in their reports, describing his threats as more irrational than menacing. “Phillip continued to yell incoherently and did not make sense with any of his statements,” one wrote. Garcia told an officer he was going to kill him, and the officer asked why. “Because you are my motherfucker!” Garcia shouted.

A Cathedral City record of Garcia’s arrest shows Mary Garcia told police he had recently stopped drinking and suffered from seizures. She contacted the police again, prompting the arresting officer to take Garcia to an emergency room for a brain scan. The ER cleared Garcia for booking.

On the way to the jail from the hospital, he slammed his head against the Plexiglas barrier inside the patrol car.

The Larry Smith Correctional Facility is the largest of Riverside County’s five jails and on average holds 1,000 defendants awaiting trial, plus a few hundred inmates convicted of nonviolent felonies.

Shortly after noon, the Cathedral City officer delivered Garcia to the intake building, a squat structure next door to multistory housing units. Deputies and nurses are supposed to gather new inmates’ basic medical information, criminal history and other relevant details. From that information, jail staff determine where to house each person and who needs health care.

Garcia’s intake would end abruptly.

On surveillance video, Garcia stood against a high-top table facing forward, with Deputy Amir Khodr behind him. Garcia turned his head to the left, toward Khodr, and said something. There’s no audio on the intake video, but the deputy took exception.

Khodr kicked at Garcia’s feet several times and nearly swept him off balance, the footage shows. Garcia continued to crane his head and talk to the deputy, until Khodr grabbed him by the nape of his neck and forced Garcia to look straight ahead.

Garcia kept talking out of turn, his mouth moving in the pixelated video. Khodr shoved Garcia’s back and pressed his ribs into the table until he cried out. Deputies fingerprinted Garcia’s right thumb, handcuffed him and marched him down the hall to Sobering Cell 1.

The deputies didn’t enter any information about Garcia into the jail’s classification notes, the internal record that details important facts about an inmate. Instead, a day later, jail staff added, “Unknown medical or mental health issues.” The belated entry describes Garcia as “uncooperative” during booking and said he was placed in a sobering cell “for being under the influence.”

Garcia wasn’t intoxicated. He’d shown signs of psychosis for hours. Now he was alone with his thoughts in an isolation cell.

The room had a toilet and a sink, a ceiling light and one roll of toilet paper. There was no bed, no chair and not a single thing to do.


Chapter 2

Unconstitutional Health Care

State and federal courts have cemented a constitutional right to health care for people in jails and prisons in scores of rulings in the past century because jailers so often fail to give basic care.

In the 1980s, jails’ health care demands multiplied as sheriffs nationwide began booking far more inmates with mental illnesses. Jail officials and advocacy groups primarily attribute the shift to the closure of state institutions, which had detained people diagnosed with severe psychological disorders.

Studies over the past 20 years have found about half the jail population has a history of mental illness.

Treatment for schizophrenia, manic depression, bipolar disorder and post-traumatic stress disorder is typically limited to medication in jails. When the medicines don’t work, are not given on schedule or inmates refuse to take them, guards frequently put inmates with symptoms of mental illness in solitary confinement. This can be as punishment for disruptive behavior or a safety measure that keeps vulnerable or violent inmates from others.

Mental health experts have discouraged the practice for years.

“The effect of solitary confinement on mentally ill prisoners is almost always adverse,” states a 2014 report from the Treatment Advocacy Center, a nonprofit that works to improve access to care for people with severe mental illness. “The lack of stimulation and human contact tends to make psychotic symptoms worse.”

Sheriffs complain their jails are not designed, or funded, to treat chronic illnesses, though in practice, they are some of the nation’s largest mental institutions.

Elected sheriffs run nearly all of California’s county jails. James Sida, a jail consultant and former California state corrections official, said that voters care about street patrols, and that there is little political benefit when sheriffs spend more money on inmates. “Your jail will never get you elected,” Sida said. “It will get you fired.”

More often, sheriffs get sued.

In 1981, Riverside County inmates filed a class-action lawsuit against the sheriff’s department to improve jail conditions, most notably overcrowding that forced inmates to sleep on the floors, insect infestations, and a lack of clean clothes and medical care. A state court judge ordered the sheriff to increase staff and minimize overcrowding.

Nevertheless, many county inmates remained packed into group cells, where they received substandard health care in the years after the settlement.

As the housing crisis crippled the economy in 2009, the county’s board of supervisors cut spending, singling out inmate health care in particular.

More than 150 nurses cared for roughly 3,500 inmates in five jails before the cuts. By 2011, only 47 remained, a county grand jury found. The board cut the number of doctors to three from 11. Two of the remaining physicians resigned, leaving one doctor to serve a jail system that books 50,000 people a year.

Medical care hardly functioned after the cuts, making jail conditions unconstitutional, said Stan Sniff Jr., who had taken over over as Riverside County sheriff in 2007 and served until 2018.

In 2011, supervisors put the Riverside University Health System in charge of inmates’ medical care. The sheriff’s department negotiated an agreement with the county health agency, requiring that medical and mental health staff operate at every facility, that nurses evaluate inmates at booking, and that medicines be distributed consistently.

But in 2013, a group of inmates filed a federal lawsuit against Riverside County, alleging it provided incompetent care, violating their constitutional rights. Court filings described the jails’ intake process as cursory, with deputies failing to document an inmate’s history of seizures. The plaintiffs described care for the mentally ill as especially dreadful. “Acute psychiatric symptoms, such as hearing voices, have been ignored by Riverside jail mental health treatment staff,” the complaint states.

The county and inmates reached a settlement two years later, with the government agreeing to spend tens of millions of dollars more a year on staff and treatment. The court brought in experts to evaluate the jails’ medical operations and the plan to fix them. While the experts noted recent upgrades, they continued to find problems.

Dr. Scott Allen, a professor of clinical medicine at the University of California, Riverside, and one of the experts, found in 2015 that local judges were issuing 150 orders a month to the sheriff’s department to force it to provide medical or mental health treatment to inmates.

“The current level of care in Riverside County jails is inadequate, poses a significant risk of serious harm to inmates confined there and in the opinion of this expert does not meet minimal constitutional standards,” Allen wrote in his report to the federal court that November.

The deficiencies were widespread. Treatment for inmates’ chronic conditions was inconsistent, poorly documented and plagued by long waits. The sheriff’s investigations of inmate deaths were incomplete or nonexistent.

Allen, who had served as state medical director for Rhode Island’s prisons and jails, described the Riverside County jails as among the most restrictive facilities he’d ever seen, severely limiting inmates’ movement in ways that could block them from medical care, putting their health in danger. Instead of assessing which inmates posed threats, deputies treated all of them “as if they are high risk,” Allen said.


Chapter 3

“EMPTY”

The surveillance video from Sobering Cell 1 showed Garcia shirtless and standing by the door. It was 2:45 p.m. on March 22, 2017. Deputies had seized Garcia’s T-shirt as evidence and didn’t provide him a jail garment.

Video files from that camera only show fragments of live action and then freeze on a single frame for long stretches of time. There is no audio, the image resolution is poor. The footage is revelatory, nonetheless.

Sheriff’s policy requires deputies to check on inmates in sobering cells at least once every 30 minutes and to document the checks. The log provides space for “comments regarding welfare of inmates.” On the log for Garcia, deputies scribbled the same thing for each check-in: “C-4,” the department’s code for “all clear.”

All the while, Garcia continued to act strangely. At 6:04 p.m., footage shows him wearing toilet paper around his neck as a scarf, and he’d littered the floor with shredded tissue. Garcia then ripped part of the scarf, crumpled it and compulsively wiped at the cell window.

A log entry shows one of the jail’s nurses, Alejandra Moreno-Ibarra, evaluated Garcia at 6 p.m., just as the camera recorded him wearing toilet paper. Moreno-Ibarra didn’t describe Garcia’s behavior or physical condition in the log, nor did she call for a mental health worker to assess his well-being.

At 9:40 p.m., Deputy Athena Hickman-Gallegos wrote that staff removed Garcia from Sobering Cell 1 and the room was “EMPTY.” The supervisor, Sgt. Aaron Nelson, confirmed the transfer more than an hour later, also writing “EMPTY” in the log. Deputies wrote that they moved him to an unspecified holding cell.

Those were lies. Garcia was still in the sobering cell, video shows, and remained there the whole night without a mattress, a blanket or even a shirt.

After falsifying the log, deputies no longer wrote down when, or if, they checked on him.

Over the next several hours, Garcia’s behavior grew more bizarre and self-destructive. Garcia was dancing at 2:53 a.m. He swayed, clapped and shimmied in front of the window.

Shortly before 6 a.m., the video shows Garcia jump at the security camera and his hand came just inches short of the lens. He staggered once back on the ground. Garcia touched his brow, which was bleeding from fresh cuts above and below his left eye. He was frantic to get deputies’ attention.

Garcia climbed up on the short privacy wall in front of the toilet and pulled at the ceiling light’s metal frame. Jail staff yelled at him to stop. Garcia came down and told them to let him out of the sobering cell. Then he went back on the wall. This sequence repeated several times.

The intake staff changed shifts and asked for assistance in dealing with Garcia. Deputy Leo Llanos responded, reaching the sobering cell at 6:15 a.m. According to Llanos’ report, the deputy told Garcia to stop damaging the light, “but Garcia refused to listen.” Then Llanos ordered Garcia to face toward the back wall and place his hands behind his back so deputies could handcuff him. Garcia climbed on the privacy wall.

Did Garcia understand the order? Was he capable of following it? The video images alone cannot answer those questions. The Riverside County sheriff’s deputies believed Garcia was intentionally defying them, according to their written reports.

Garcia slammed his head against the window a moment later, deputies’ reports state. The cuts on his face had been bleeding heavily and left a pool of red that dripped down the Plexiglas.


Chapter 4

“They’re trying to kill me, baby”

Isolation had failed to convince Garcia to follow orders, so jail staff got more aggressive. The Riverside County jail’s tactical teams are called on to remove inmates from cells by force, including inmates like Garcia, who wouldn’t place his hands behind his back, or “cuff up.”

Around 6 a.m., a dozen deputies assembled outside Sobering Cell 1, most of them equipped for confrontation. Their camouflage-green hazmat suits shine in the hallway surveillance video, which they wore over body armor, riot helmets and gas masks. Internal records show the team had a simple plan: overwhelm Garcia, handcuff him, put him in a restraint chair and wheel him into a safety cell a few feet away.

Deputy Andrew Pearson aimed a paintball gun under the cell door and fired a barrage of pepper balls toward Garcia. The balls burst when fired, releasing a chemical that causes a painful burning sensation in people’s eyes and airways.

The pepper balls only hindered Garcia briefly, Pearson’s report states.

The team leader, Deputy James Steele, went to the window and gave Garcia a final chance to comply to be handcuffed.

Garcia ran to a back corner of the cell and cowered.

The tactical team opened the operation with a stinger grenade, an explosive device that emits a piercing sound, a blinding light and rubber pellets, and then spews smoke.

Steele opened the cell door just enough for another deputy, Robert Figueroa, to throw the grenade toward the back wall. For a split second, the video shows Garcia sprint toward the door and away from the explosive that was throwing off red sparks. Then the grenade detonated and a flash filled the cell’s camera frame.

Deputies in hazmat suits surged to the door, the one in front gripping a large plastic shield designed to corral people during riots. The lead deputy struck Garcia with the shield, knocking him on the floor, and the rest piled on top of him. They yelled at Garcia to put his hands behind his back as they pushed and wrestled with him.

“Due to Garcia refusing to comply with commands,” Deputy Nigel Hinson reported, “I punched him five to six times on the right side of his face and back.”

Several deputies punched Garcia’s head and upper body, internal records show. Figueroa fired Taser prongs into Garcia’s abdomen, the voltage causing his body to go limp.

The team handcuffed and lifted Garcia to a restraint chair. Dark smoke wafted from the cell.

They wheeled him 10 feet into another cell across the hall. Jail staff had described him as agitated before the assault. He was frenzied after, the video shows. Now pinned down in a restraint chair, Garcia would never freely move his arms and legs again.

Garcia waited more than an hour before a nurse entered the cell to remove the Taser prong embedded in Garcia’s side. Five deputies pinned his already restrained limbs. One deputy, Pearson, who fired the pepper balls, held Garcia’s neck in a painful pressure-point hold and shoved Garcia’s head as he left.

Jail staff noted that Garcia “continually yelled for family members to rescue him” and made “bizarre statements” suggesting the deputies wanted to kill him.

At 9 a.m., Adelaide Aplin, a clinical therapist at the jail, stood outside the safety cell, the activity log shows. She was there to evaluate Garcia, his first interaction with mental health staff. She was supposed to speak to him face-to-face. But on video, the door slot opened and Garcia turned his head and talked to the therapist. Then she was gone and the slot closed. The exchange lasted 27 seconds.

Aplin documented that Garcia was in a psychiatric crisis and cleared the jail to transfer him to the county hospital. Deputies covered his head in a hood to keep him from spitting on them before carting him out of the intake building.

“They’re trying to kill me, baby, these motherfuckers,” Garcia yelled, a plea to loved ones recorded by the intake camera. “Hurry up!”


Chapter 5

Violent force to the end

The detention care unit is a cellblock in the middle of a public teaching hospital, with concrete walls and cement floors. Deputies effectively control most of the unit’s operations, but the hospital is legally required to provide the same standard of care to the people there as to any other patient.

ProPublica reviewed a sample of the detention care unit’s activity logs documenting 50 days from the last three years. The unit has room for 22 patients from the Riverside County jails and nearby California state prisons. Patients receive physical therapy and breathing treatments, CT scans and ultrasounds, and occasionally undergo surgery in other parts of the hospital.

However, the unit is primarily a psychiatric ward for the county jails.

The logs show, on average, two-thirds of the detention care patients came in on mental health holds. Several days last year, psychiatric patients from the jail occupied 19 of the rooms. The unit runs short on space, and expertise.

Nurses in detention care earn less than those working in any of the hospital’s other departments, according to the county employment contract. The only certification required of nurses on the inmate unit is for “management of assaultive behavior.”

Garcia reached the county hospital’s ER at 10:05 a.m., March 23, 2017. The jail assigned a pair of deputies to guard him while he waited to get into the detention care unit. With no beds open, Garcia remained strapped to the restraint chair, his face covered by a hood, straining to the point of self-destruction.

The sheriff’s department entirely redacted medical records in the case files it released to ProPublica and the county health system refused to release documents, citing patient privacy. Garcia’s family declined to provide any information. As such, ProPublica is not able to say with certainty how much medical care Garcia received in various parts of the hospital.

But records from the sheriff’s death investigation provide key details and a chronology.

At about 11:30 a.m., the deputies guarding Garcia called their supervisor and reported that medical staff had just given Garcia “an unknown type of sedative,” a detective’s report states. The coroner’s investigator documented that over the course of a day, the ER gave him four small doses of lorazepam, a sedative that hospitals often use to relieve anxiety, and zyprexa, an antipsychotic medication.

The ER drew Garcia’s blood at 12:55 p.m., presumably to evaluate his condition. Thirty minutes later, deputies and hospital workers moved him out of the chair and onto a gurney. Garcia had spent six hours in the restraint chair, two more than what the sheriff’s policy advises as the maximum. Deputies again locked down his wrists and ankles.

The investigator’s timeline does not document that an emergency room doctor had diagnosed him with rhabdomyolysis, the potentially fatal condition brought on by the restraints. It fails to note when nurses placed the intravenous lines, one in the crook of his right arm and another a few inches away in his forearm. It does not say what medicines or fluids emergency staff flowed through those lines as Garcia idled all day.

Whatever treatment Garcia received during his 12-hour wait in the emergency room bed, surveillance video makes clear that by the time he finally arrived in the detention care unit, around 10 p.m., he was in terrible shape. And still struggling against the straps.

ProPublica consulted with two forensic psychiatrists with extensive experience in prisons and jails about how medical staff should treat inmates showing acute signs of mental illness.

After reviewing footage and records, experts said it was troubling if medical staff did not consider why the patient was so agitated after hours in restraints. They added, it is also possible the nurses were simply unwilling to intervene in the deputies’ handling of Garcia. They emphasized that medical staff need to direct and approve any use of restraints, and force should not be used on a patient who is restrained.

“Keep the setting as therapeutic and calm as possible, so an agitated patient can actually relax and feel safe,” said Jhilam Biswas, a forensic psychiatrist and director of the Psychiatry, Law, and Society Program at Brigham and Women’s Hospital in Boston. The approaches of medical and security staff can clash, she added, and the best facilities have drills where clinicians lead security personnel to manage acute crises.

One of the outside jail monitor’s criticisms in the recently released reports was a lack of joint decision-making between mental health and security staff in Riverside’s jails. And the reports make clear, the detention care unit of the hospital must comply with the hospital’s standards of care.

There is a gap in the surveillance video Riverside County released, and the footage provided to ProPublica does not show the detention care unit providing Garcia with care. After the tactical team violently moved Garcia to a hospital bed, the unit’s regular staff kept using force on the patient. They shifted and tightened his restraints again and again. As others worked the straps, Deputies Victor Martinez and Noemi Garcia took turns shoving his head down with two hands.

Sweat poured from Garcia and puddled on the mattress in the last images of him alive.

At 2 a.m., a detention care nurse injected Garcia with an antipsychotic drug, sheriff’s records state. The sheriff’s department did not release footage of this moment. A state prison guard in the room later told detectives he heard Garcia make a strange, growling sound. Then the patient seemed to stop breathing. The guard peeled back the hood over Garcia’s face and saw his eyes had rolled back.

Garcia didn’t have a pulse.

The nurse alerted the unit and started trying to resuscitate the patient.

With Garcia’s heart stopped, his medical care became the chief concern. A surveillance camera recorded as staff from the ER flooded in minutes later. A scrum of nurses and doctors compressed his chest, pumped air into his lungs, ran tubes down his throat, sent electric shocks to his heart.

His body laid motionless for the first time in days.


Epilogue

The Riverside County Sheriff’s Department posted a press release on its website at 6 p.m. on March 24, 2017, to notify the public of an in-custody death. The release explained that “a 51-year-old male housed in the secured detention unit at the Riverside University Health System experienced a medical emergency.” Medical staff tried to save his life but were unsuccessful.

“At this time, no foul play is suspected,” the release stated. The department was investigating. “The subject’s identity is being withheld pending notification to next of kin.”


Two hours later, a pair of sheriff’s investigators sat in Mary Garcia’s home in Cathedral City, questioning her about her husband’s medical history. Christopher DeSalva, a friend and the family’s attorney, joined them. The investigators recorded the conversation.

Investigator Lester Harvey explained there had been “a series of events” related to Garcia’s medical condition.

“Mental or physical?” DeSalva asked.

“A little bit of both,” Harvey answered.

For 20 minutes, Mary Garcia and DeSalva provided information about Phillip Garcia’s medical and mental health history. Finally, Harvey delivered the news. “While he was being treated there early this morning, about 4 this morning, he became unresponsive.”

“Did he die?” DeSalva broke in. “Ultimately, yes,” the investigator said, “he did pass away.”

Sobs filled the recording.


Ten months later, on Feb. 8, 2018, Sheriff Stan Sniff signed off on Garcia’s autopsy results. (In Riverside County, the sheriff is also the coroner.) The cause of death was a diagnosis of “sudden death in schizophrenia” combined with “rhabdomyolysis in association with physical exertion by subject and application of control methods.” Jail deputies used force and restraints on a mentally ill man, who died straining in vain to free himself.

Garcia died at the hands of other people, Sniff ruled, and that made his death a homicide.

Garcia’s family filed a wrongful death lawsuit in federal court against Riverside County in October 2018, accusing jail and clinical staff of excessive force and inadequate medical care. “Medical records show that Mr. Garcia never regained mental awareness while at the hospital,” the complaint reads, “and spent all of his time in Riverside County Sheriff’s Department custody in a psychotic state.”

The county denied the allegations and admitted no wrongdoing, but it settled the lawsuit last June and paid Garcia’s family $975,000.

“Somebody’s Gotta Help Me” 1 Phillip Garcia. (Nicole Rifkin for ProPublica)