In unusual rebuke of San Diego County sheriff, coroner rules diabetic man’s jail death a homicide by neglect

SAN DIEGO —  Keith Galen Bach had been dead for hours. The alarm on his insulin pump was still beeping when an investigator from the medical examiner’s office arrived at the central jail here after his death last September.

According to autopsy findings requested by the San Diego Union-Tribune and released this week by the medical examiner’s office, the pump probably was beeping nonstop for nearly 24 hours, alerting Bach, who had Type 1 diabetes, that it had run out of insulin.

It beeped during mealtimes, when Bach gave his food to fellow detainees because eating without insulin could cause his blood glucose level to spike to dangerous levels. It beeped as Bach and others in his module repeatedly alerted deputies that the insulin pump was empty.

The response by San Diego County sheriff’s deputies to Bach’s health emergency was so severely lacking that the medical examiner’s office took the unusual step of ruling his death a homicide, citing “neglect.”

“Following insufficient insulin administration while in custody, Mr. Bach developed diabetic ketoacidosis and died,” the medical examiner’s report states.

“This occurred despite medical records containing documentation of his medical condition, insulin requirements, when his pump would be depleted of insulin, and multiple unanswered requests for insulin by 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.

“This is an ongoing investigation and it is imperative we protect the integrity of the investigation,” the statement said. “We extend our sympathies to Mr. Bach’s family and to those affected by his passing.”

The San Diego County district attorney’s office said the case is now “under review.” Tanya Sierra , a spokesperson for Dist. Atty. Summer Stephen, said there is no timetable for when any charging decisions might be made.

But inmate advocates and correctional health experts were aghast at the finding. They said Sheriff Kelly A. Martinez needs to do more to protect the people in her department’s custody.

“The description of inaction by jail staff that led to this in-custody death is beyond the pale,” said Aaron Fischer, one of a group of lawyers suing the county over the lack of proper healthcare services being provided to people in its jails.

“No one with diabetes should be denied insulin or the diabetes-management tools they need to survive,” Fischer added. “When you deny someone oxygen, they suffocate.”

San Diego County has a dubious track record when it comes to people dying in jail.

A state audit released in early 2022 noted that San Diego had the highest mortality rate among California’s largest jail systems. It documented 185 in-custody deaths between 2006 and 2020.

The report said San Diego County jails were so dangerous that new legislation was needed to force reforms.

The deaths also have cost taxpayers millions of dollars.

Earlier this year, for example, the county agreed to a $15-million legal settlement with the family of Elisa Serna, who died from inadequate medical care inside the Las Colinas women’s jail in 2019.

Bach, who was 63, had been working as a heating and air technician when he was arrested by Chula Vista police Sept. 25, 2023, on suspicion of vandalism and making a criminal threat. He was never charged by prosecutors.

He was too sick at the time of his arrest to be booked into jail, so Chula Vista police took him to a hospital. He was treated for elevated glucose, and hospital staff noted that his insulin pump was beeping and needed to be refilled.

Even so, Bach was medically cleared for booking within 40 minutes and transported to the downtown central jail.

But Bach fainted 90 minutes later while in the process of being booked. He was rushed back to the emergency room, where he was further treated for diabetes and returned to the jail early on Sept. 26.

“Orders were to continue using the insulin pump, confirm metformin dose and add blood sugar checks,” the autopsy findings show.

The autopsy report notes that Bach cooperated with jail medical staff and allowed nurses to check his glucose levels at least six times, and he was given 10 units of insulin on the afternoon of Sept. 26.

Just after 1 a.m. on Sept. 27, Bach’s blood glucose level hit a dangerously high level. According to sheriff’s medical records, Bach refused an offer of 10 units of insulin because he believed the dose was too low.

“Mr. Bach eventually [was] administered 10 units of insulin at 0151 hours, and this was the last documentation of insulin administration,” the autopsy findings said.

The medical examiner said the nurse requested a new insulin order with an increased dosage, but the approval was “pending review.”

Bach was not seen by any medical staff for the next 19 hours, the report added. It was not clear from the record who was responsible for approving the additional insulin recommended by the nurse.

Early on the morning of Sept. 28, he was found unresponsive in his cell and not breathing. He was declared dead just after 4 a.m.

“The death is due to complications of a natural disease,” the medical examiner wrote. “However, considering the inaction (i.e. neglect) characterizing the events leading to inadequate care … the manner of death is classified as homicide.”

A homicide determination due to medical neglect is rare.

Only once in at least the last two decades has the medical examiner’s office ruled the death of a person in San Diego County sheriff’s custody a homicide when they were not killed by another inmate or by deputies.

In 2022, Lonnie Rupard died inside the same jail as Bach.

In that case, the medical examiner said that even though Rupard suffered from schizophrenia and other disorders, his death was a homicide because “this decedent was dependent on others for his care.”

Rupard was found in a cell smeared with food on the walls and feces on the floor.

Trash was strewn about the unit, and the toilet was clogged with excrement. Rupard had lost one-third of his body weight due to malnutrition in the months before he died.

A wrongful-death lawsuit against the county was filed by the Rupard family last year and is awaiting trial.

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