Alicia Upton paced the concrete floor of her jail cell. She looked around the cramped quarters. Then she pressed the alert button on an intercom attached to the wall.

“What is your emergency?” responded a voice, captured on video footage from a camera in the cell. It was a deputy about 50 feet away, in the control room of the women’s mental health unit where Upton, 21, was being held.

“It’s not an emergency, but — ” she began, then the deputy cut off the call before she could finish. Charged with a misdemeanor, Upton was awaiting a court-ordered evaluation to determine whether she was competent to stand trial.

She took a few more listless steps, the video shows. She paused beneath a buzzing fluorescent light, then picked up a white bedsheet and said, “It’s time to hang myself.”

She was found, limp, 20 minutes later. In the interim, the camera recorded the young woman preparing to end her life. But no guards, who were tasked with monitoring the video feed, noticed until it was too late.

Upton was the first of 19 detainees at Riverside County jails to die in 2022. That total, the highest the department had reported in at least three decades, ranked the jail system among the most lethal in the nation that year.

The deaths, attributed to homicide, overdose, natural causes or suicide, reflected troubling patterns: neglect by jail employees, access to illicit drugs, and cell assignments that put detainees at increased risk of violence or did not allow for close oversight.

The suicides — at least three of the deaths, but most likely four — offer particular insight into some of those institutional problems and lapses, an investigation by The New York Times and The Desert Sun found.

The Riverside County Sheriff’s Office failed at times to adequately monitor detainees and intervene when they attempted suicide. Guards did not always enforce rules prohibiting detainees with mental illnesses from blocking cell windows and cameras, which hinders the required safety monitoring. The department has often isolated detainees with severe mental illness, which can exacerbate suicidal intentions.

And, the investigation found, the department has omitted pertinent facts about the deaths in communications to the families of the dead and to the public.

The department has assumed no responsibility for these deaths. California’s attorney general last year opened an ongoing civil rights investigation into the increase in deaths in custody, and Riverside County agreed to pay more than $12 million to settle lawsuits linked to detainee deaths going back to 2020. At least a dozen cases are still pending.

Sheriff Chad Bianco did not respond to interview requests or comment on detailed questions about the news organizations’ findings. But on an episode of his podcast this summer devoted to inmate deaths, he said that it can be extremely difficult at times to prevent suicides and falsely claimed that there had never been any allegation that the department had “somehow done something wrong, or mishandled inmates, or mistreated inmates, or caused their death.”

The president of the deputies’ union declined to comment.

To understand how the suicides occurred, The Times and The Desert Sun interviewed dozens of people, including current and former jail employees, relatives of the dead, independent medical examiners and civil rights lawyers. The news organizations also reviewed court documents, including arrest records, detainee medical and mental health records, and department notes on jail housing decisions.

Many of the details in this article have never been publicly reported, including the jail security camera footage reviewed by a reporter — material that is rarely seen by outsiders. The department has not released that footage or a dozen other videos requested by the news organizations under the California Public Records Act.

The suicides strongly suggest that, despite a federal class-action suit a decade ago that exposed deficiencies in mental health treatment in Riverside County jails and resulted in new court-ordered requirements, problems persist.

One detainee in 2022, who told guards that he was suicidal, was cleared after a medical check to return to his cell without any suicide-watch protocol. He was found dead about an hour later. He had been in custody for one day.

Another man, who suffered from schizoaffective disorder, had been mostly segregated from other detainees for two years when he was found hanging, and later died. To conceal his actions, he had covered his cell window and camera without any intervention from guards.

No suicides have been reported for 2023, but earlier this year, a man hanged himself while another detainee tried to alert jail guards but couldn’t get their attention.

That suicide and a separate drug overdose prompted Capt. Alyssa Vernal, then the head of the jail, to warn staff members that they were failing to maintain basic jail operating standards, including some of the same lapses identified years ago by the federal court.

Vernal, who did not respond to requests for comment for this article, wrote in an internal email reviewed by the news organizations, “It has become obvious we are not keeping house or following the rules we should be.”

Trouble on the road

When she was 19, Upton hit the road and left everything behind. She piled into a friend’s car in West Virginia and embarked on what would become a cross-country trip.

In an interview, her mother, Nichole Thompson, recalled believing that she was going on a fleeting adventure before settling back home.

“She was resolute when she fixed her mind on something,” said Thompson, a librarian who raised Upton and her older sister in the Appalachian town of Lost Creek.

From a young age, Upton was an animal lover who would bring home rabbits and raccoons she hoped to keep as pets. At 14, she sold the Xbox she had gotten for Christmas to buy a horse, which she trained herself. To raise money for the road trip, she sold her four-wheeler and some goats, but not the horse, which she left in the care of a friend.

Upton had shown no signs of mental health problems when she left home, her mother said. She had gone to counseling years earlier after the suicide of a close friend, and her mother felt that she was resilient.

The road trip took Upton to Florida, Texas, and across the country through New Mexico and Arizona. Finally, she called home from Hemet.

She sounded happy, her mother recalled. She said California was beautiful. As the weeks wore on, though, she mentioned the car needed costly repairs and that she was often looking for places to sleep.

“I walked a fine line, trying to coax her to come back, but also let her have her freedom,” Thompson said. While some companions left for new destinations, Upton stayed put.

As the months turned into a year, it became clear to Thompson that her daughter was living on the streets.

“She always knew coming home was an option,” Thompson said. “If I pushed her, I felt she would disconnect. She just kept saying she was fine.”

Soon, Thompson became concerned that her daughter might be struggling with drugs. She recalled Upton saying irrational things on the phone, like describing seeing relatives who were thousands of miles away.

Eventually, Upton was arrested twice for minor offenses — shoplifting and trespassing. Both times, she was released. But a third arrest was different.

On April 19, 2022, a woman found Upton on her land in San Jacinto. She later told deputies the young woman appeared to be looking for something. When the landowner found a knife on the ground, the two had a confrontation. Upton left and no one was injured. But she was arrested nearby and charged with possession of drug paraphernalia and making criminal threats, both misdemeanors.

The paper trail of Upton’s incarceration describes her as distraught and combative on arrival at the Robert Presley Detention Center in Riverside. Of the five jails in the county, it is the facility where detainees who need mental health care are most often sent. Reports from the booking note that she did not sign several required documents. One jailer wrote on the signature line that she could not be trusted with a pen.

She was given a mental health rating of “severe” and placed in the women’s mental health housing unit, where each cell was monitored by camera. She was not prescribed any medication. When asked if she had ever attempted suicide, she would not answer.

But, deputies wrote in her file, she said she had “multiple personality disorder” and “stated that she ‘always kinda wanted to die.’ ”

A surge in jail deaths

Long before Upton was sent to the jail, the Sheriff’s Office had struggled to treat mental illnesses among the nearly 3,700 detainees it housed on any given day.

In jail and prison systems across the country, the population of people with mental health needs has surged in recent decades. More than half the detainees in California’s jails have such problems, a 2023 study found. As Riverside County’s jails began to operate as de facto mental health facilities, some detainees who claimed mistreatment took action.

Four sued the county in federal court in 2013, in what would become a class action, claiming the department was not providing adequate care.

When a judge ordered experts to inspect the claims, Dr. Bruce Gage, then chief of psychiatry for the Washington State Department of Corrections, found problems. Some detainees were not receiving prescribed medications. Others were being medicated indefinitely on mere suppositions of mental illness. It was unclear whether the call buttons in the cells even worked.

Gage reported that the jails didn’t monitor suicidal detainees who were awaiting transfer to psychiatric facilities. The jails had no protocol in place to transition someone who was no longer considered suicidal into less-restrictive living conditions. Detainees either were in a general population and could be outside their cells for hours a day, or confined for all but 15 to 45 minutes.

“Riverside County jail system is amongst the most restrictive correctional settings I have visited,” Gage wrote. Those struggling with mental illness, he added, are “placed at greater risk of harming themselves under these conditions.”

Based on the reports, in 2016 a judge ordered a remedial plan that included ongoing inspections of the facilities and the threat of court intervention. Gage noted that the department had faced a staffing shortage since the 2009 recession, but emphasized that basic standards of care were required by law.

Sara Norman, one of the plaintiffs lawyers in the case, said the jail had made progress in improving medical care, but less so with mental health care.

“We have been concerned for years about the dearth of programming and group and individual therapy for people struggling with mental illness in the jails,” she said.

Meanwhile, the county system experienced an increase in jail deaths over the past decade. Among them was a man in 2020 who had been arrested for drug possession and was to be released with a citation for a later court appearance. Instead, he died after being violently extracted from his jail cell by guards while experiencing symptoms of psychosis. His relatives received $7.5 million this year to settle a lawsuit.

The surge of 19 deaths in 2022 made Riverside County’s rate the second-highest in the state, behind Kern County, which had a much smaller jail population. Among the nation’s 15 largest jail systems, Riverside County’s was the second-most deadly, with a rate more than twice that of Chicago, Philadelphia and Dallas.

While some people at the jails were serving criminal sentences, most — including those who died by suicide — were detainees awaiting trial or other resolution of their cases.

Robert Robinson, 41, was arrested in September 2022 for trying to cash a fraudulent check at a casino. Because he was a gang dropout, he was considered a likely target of violence and was housed alone.

He told jailers while being booked that he was having suicidal thoughts, according to a lawsuit filed by his relatives. He was placed in a cell without a camera and was not put on suicide watch, records show.

The next day, he told deputies he was suicidal, and he met with a medical provider and a mental health nurse, according to court documents. Both cleared him to return to his cell alone. About an hour later, a deputy discovered he had hanged himself. Riverside County settled the civil suit with his relatives in August for $1.8 million, with no admission of wrongdoing. His family did not respond to requests for comment.

Aaron Aubrey, 28, had an extensive history of mental illness and violence. During his three-year incarceration awaiting trial on a murder charge, he was housed in a mental health unit. He spent significant time in isolation after he was charged with killing another detainee in 2020.

In December 2022 a guard saw that Aubrey had blocked his window and covered his camera, but took no action, according to the coroner’s report. During another security check 40 minutes later, the detainee was found hanging. He died six days later at a hospital.

And this year, Reynaldo Ramos, 55, hanged himself even as a cell neighbor twice tried to alert guards over the intercom, according to a complaint filed with the county by the man’s relatives. The guards didn’t respond, the complaint said.

The claim attributed that account to an anonymous letter sent to the family’s lawyer and separately to a reporter for The Times and The Desert Sun, containing those closely guarded details. A person who had reviewed jail surveillance video of the unit also described the failed alert efforts.

Ramos, who had been given a mental health rating of severe when admitted to the jail on drug charges, was discovered unresponsive during a routine safety check, according to an internal incident report provided to the Times.

‘Man down!’

In the days after Upton’s arrest, her mind continued to fray.

On April 28, 2022, a judge ordered her to undergo a mental competency evaluation. Her criminal case was suspended, and with it the possibility of bail, until the findings were reported. When she was admitted to the jail, she had briefly been placed in a safety cell, without access to items that could be used for self-harm. Soon after, she was placed in the mental health unit.

That evening, the surveillance video showed, she was restless. Her cellmate was asleep on the top bunk as Upton paced and looked out of the cell door’s window. Meal trays were stacked at the foot of the bed and clothes were scattered nearby.

At 8:13 p.m., she pressed the intercom button, but got only a few words out before the deputy hung up. Moments later, Upton can be heard in the video saying she intends to hang herself.

She looped the bedsheet around her neck and, for a few minutes, tried anchoring it. She smacked her head three times. She looked toward the camera. At one point, it sounded as if she was weeping.

Sitting on the bottom bunk, she tied the sheet above her and tightened it around her neck.

At 8:18 p.m., Upton raised a middle finger to the cell camera. Over the next few minutes, the video captured her final movements. By 8:22, she was still.

It all unfolded in view of the deputies who were supposed to monitor the feed from her cell. A guard at a workstation near the control room was responsible for constantly tracking the video footage of the unit, according to three former jail employees speaking on the condition of anonymity for fear of reprisals from the department.

Meanwhile, a deputy in the control room reminded a trainee to occasionally scan the images. They looked up at the feeds from the roughly 40 cameras, two of the former employees said. Spotting Upton, the deputy shouted over the radio, “Man down!”

She had been hanging by the bedsheet for 16 minutes before guards flashed lights signaling an emergency, video footage shows. Two deputies and a jail nurse entered her cell and began resuscitation efforts, but it was futile.

The next morning, back in West Virginia, Upton’s mother woke to pounding on her door, she recalled in an interview. It was a local deputy, who told her to call the Riverside County Sheriff’s Office.

She remembers asking, “Does this mean she’s dead?”

Yes.

“I thought my heart would stop,” she said.

sheriff is coroner

In Riverside County, the final accounting of how people die depends to a large extent on Bianco.

A veteran of the department, Bianco was first elected sheriff in 2018. He has cast himself as a right-wing firebrand at odds with the state’s left-leaning Legislature and governor. He has also criticized Attorney General Rob Bonta’s investigation of jail deaths as a “political stunt.”

California is one of just three states that allow elected law enforcement officials to oversee coroners’ offices. Until recently in Riverside County, that meant the Sheriff’s Office typically investigated deaths at its jails while also supervising the pathologists conducting the autopsies. (This year, the department began outsourcing those autopsies.) The final report about the cause of death is signed by the sheriff, who also serves as the coroner.

The state Legislature has considered bills to separate the offices but none have passed. The California Medical Association has long advocated a separation, saying that the consolidation of the responsibilities of sheriff and coroner is an “immense conflict of interest.”

The Times and The Desert Sun found discrepancies when comparing the department’s public death summaries of the 2022 suicides against jail records turned over in civil suits, the video of Upton’s death and information provided by current and former employees.

Mario Solis, who had a history of mental illness, was jailed after a scuffle with a grocery store security guard over a stolen bag of Skittles, according to court records. In September 2022, his mother, Sara Solis, was told that he had died alone in a cell — but not much else. About six months later, she received the department’s summary report.

It included findings from an autopsy conducted days after Solis, 31, died in the mental health unit of the jail in Murrieta. Inside his mouth and throat were two pencils, a toothbrush, a plastic cap and bars of soap, the report said. It also noted cut marks on his arms.

A deputy coroner wrote that Solis had “an unspecified mental health history” and had been prescribed two psychiatric medications.

Bianco attributed Solis’ death to suffocation and blood loss after his jugular vein was punctured. He certified the death as an accident.

More than a year later, a lawyer representing the Solis family in a suit against the county received a trove of information the Sheriff’s Office had not previously disclosed. Jail medical staff had treated Solis for schizophrenia, including with antipsychotic medication. On three occasions, he said he was suicidal and talked about stabbing himself with a pencil.

During a chaotic five-month incarceration, he was transferred 10 times among four county jails and did two stints in intensive psychiatric treatment.

From the start, Solis had pleaded for help and medication, his scribbled notes show: “I am not well. Please help me before things worsen,” one read. In another, he requested a psychiatric visit, which was arranged but later canceled.

On Sept. 2, 2022, Solis was ruled incompetent to stand trial and ordered to a hospital for treatment. The next day, he was found unconscious in his cell. He had lacerations on his wrist and neck, a nurse wrote. His neck was red and bruised. His mouth and nose were bloody.

Photos of the cell show flooding from the toilet that soaked books and trash. One wall was filled with erratic writing.

The department’s reports do not explain why Bianco determined the death was accidental.

Bianco has accused media outlets and advocacy groups of misrepresenting the jail deaths to the public, including on his podcast episode on the topic, which was promoted on the department’s social media channels.

Without naming names, the sheriff said that a detainee who had died after swallowing objects, including a pencil, had a “propensity to eat things.”

“They suffocated themselves, basically,” Bianco said. “But we don’t believe it was a suicide.”

In 1,600 pages of jail medical notes, there is no mention of Solis habitually swallowing harmful objects, as the sheriff claimed.

“This is not someone who accidentally died,” Hugo Solis, one of Solis’s brothers, said in an interview. “He killed himself in despair. And the sheriff knows that.”

A forensic pathologist and a medical anthropologist reviewed the coroner’s report for this article. Both said that, aside from the mention of Solis’s psychiatric history and prescriptions, it was unclear whether the coroner staff had reviewed his extensive mental health records or knew about his suicide threats. Both said that information was crucial for determining whether the death was a suicide.

Judy Melinek, a board-certified forensic pathologist, asked, “Why was he left alone and unsupervised after showing severe signs of mental health deterioration?”

‘It was their job’

Thompson, Alicia Upton’s mother, said she was stunned at how little information the Riverside County Sheriff’s Office would share about her daughter’s death.

For weeks, she said, she struggled to learn even basic details about the events leading up to the suicide. She asked to see any reports and obtain any surveillance video, though she wasn’t sure if she could bear to watch it. But the department declined to provide much of the material she requested.

Thompson sued the Sheriff’s Office last year, saying it had failed to monitor and protect her daughter. In its response, the county denied that deputies had failed to monitor Upton at the time of her suicide. However, according to two former employees, two jail workers faced discipline for lapses.

When a reporter described to Thompson the footage from the jail cell, she said she had long suspected that her daughter had been desperate for help but had been ignored.

“It was their job to keep her safe,” Thompson said. “It was their job to monitor her. They didn’t care to do it.”

If you are having thoughts of suicide, call or text 988 to reach the 988 Suicide and Crisis Lifeline or go to SpeakingOfSuicide.com/resources for a list of additional resources.

Christopher Damien is reporting about law enforcement in Southern California’s inland and desert communities as part of The New York Times’ Local Investigations Fellowship.

Justin Mayo and Ana Facio-Krajcer contributed reporting. Julie Tate contributed research.

This article was reported in partnership with Big Local News at Stanford University.