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Custodial Death Report: Nicholas Brown
The OIR conducted an independent review of the custodial death of Nicholas Brown. We examined the circumstances surrounding the death of Nicholas, a 28-year-old man who was in the custody of the Orange County Sheriff's Department (OCSD).
On April 9, 2022, Nicholas Brown (“Brown”) was booked into the Orange County Jail’s Intake Release Center (IRC). Brown exhibited delusional behavior during booking and, following a mental health evaluation, he was flagged as “Gravely Disabled”. On April 12, 2022, Brown was housed by himself in Cell 5 in Sector 19 of Module L, an Acute Mental Health Housing Unit, where he remained until his death.
During his time in custody, Brown experienced periods of delusion, refused or was not given prescribed medication, did not wear clothing, and rarely communicated in a coherent manner with staff.
On April 20, 2022, at approximately 8:28 a.m., Brown was discovered unresponsive in his cell by a deputy and a nurse distributing medication in the module. Various personnel attempted to rouse Brown from the threshold of the cell. When additional deputies arrived three minutes later, they entered the cell and moved Brown outside to treat him. He had no pulse, no respirations, and his pupils were fixed. Medical staff and deputies performed cardiopulmonary resuscitation (CPR) continuously until paramedics arrived. Paramedics found Brown's skin to be cyanotic, cold to the touch, and he showed signs of rigor mortis. Brown was pronounced deceased at 8:43 a.m.
An autopsy was conducted on April 27, 2022. The forensic pathologist determined Brown’s cause of death was dehydration due to probable lack of water intake. The manner of death was undetermined.
After a thorough review, the OIR found several important issues. Those issues include that Brown was not provided over half of his meals in the days leading up to his death; that medical personnel inaccurately documented Brown’s alleged refusal of medication and labs; and that deputies generally did not allocate the time or attention needed during safety checks to ascertain Brown’s physical condition. Brown also reportedly flooded his cell, which resulted in jail staff shutting off the water to his cell, though it is unknown when the water was shut off and for how long. The OIR has made several recommendations to the OCSD and Orange County DA's Office related to safety checks, investigations, and administrative changes.
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