Ray Vogelman didn’t know why he was attacked in jail as he slept, or by whom.
All he remembered, he told deputies later, was that somebody had knocked his head against a wall of their housing unit in the George Bailey Detention Facility before he lost consciousness.
In a report on the Aug. 3, 2022, incident, a deputy wrote that Vogelman “should not be placed back into Module A upon returning from the hospital.”
Yet a month later, Vogelman was back in the same module. A month after that, he was attacked again, this time fatally.
“The beating was so savage and so prolonged” that nearly a gallon of blood had pooled in his chest cavity and stomach, according to a lawsuit later filed by his mother.
He was taken to Sharp Medical Center but died shortly after arrival.
The deputy’s note a month earlier had never been entered into the system the San Diego Sheriff’s Office uses to determine housing placement.
It should have been, and Vogelman should never have been returned to Module 1A, a dorm-style unit with rows of stacked bunks and a history of violence, his family’s lawsuit argues.
“This module is built in such a way that beatings can occur without immediate notification to the deputies,” the lawsuit filed by his mother, Leslie Crawford, says. “Because the beds are stacked behind each other, there are blind spots that cannot be visualized from the hallway outside.
“Much of the room cannot be seen from the control tower,” the lawsuit continues. “There are no security cameras inside the ‘quads’ or cells.”
In its investigation of Vogelman’s death, the county’s Citizens’ Law Enforcement Review Board, or CLERB, found no policy was violated when Vogelman was placed back into module A.
CLERB investigators saw the deputy’s note in documents turned over by the Sheriff’s Office but determined that “Vogelman had no restrictions that would have prevented him from being housed in module 1A” when he was killed on Oct. 5, 2022.
For each case they review, CLERB staff submits a brief narrative and recommended findings, which are available to the public. Board members get a more detailed briefing on each case in a closed-session meeting and vote on whether to agree with investigators’ findings, disagree or send the case back for further review.
Vogelman’s family is urging the review board to reconsider the finding that Vogelman was properly housed at its meeting tonight.
In a letter sent to the board Wednesday, their attorney Julia Yoo notes that twice he had been placed in enhanced observation housing because he was at risk of harming himself.
“Deputies and medical staff knew that Mr. Vogelman had been placed in (enhanced observation housing) multiple times as a result of his mental illness, hallucinations, delusions and suicidal ideation,” Yoo wrote. “The deputies were aware because they are the ones who placed him in EOH.”
Afterward, and due to his history of mental illness, Vogelman should at least have been housed on the Central Jail’s psychiatric floor, Yoo told The San Diego Union-Tribune. There, she said, he would have been safer than at George Bailey, a high-security jail with a more violent population.
CLERB investigators determined that no one who was in Vogelman’s quad on Aug. 3, 2022, was housed with him on the day he was killed.
To his mother, it doesn’t matter who was in the module — it was dangerous, and her son was vulnerable.
“You can’t throw someone in a shark tank just because there are different sharks each time,” she said.
Yoo’s letter also asks the board to look at what deputies did after finding Vogelman in his bunk on Oct. 5 with a blood-soaked towel covering his face, following a large fight in the module that started when a white man attacked a Hispanic man.
Instead of summoning medical help, a deputy ordered Vogelman to stand up and be handcuffed. Vogelman collapsed, coughing up blood, Yoo’s letter says, but deputies forced him to stand up. Vogelman tried to but fell a second time.
“During these twelve minutes, no one called the paramedics,” Yoo wrote. “Deputies did not give aid to Mr. Vogelman because they did not want to get his blood on them. Instead, these deputies laid him on a gurney and watched his face turn grey from oxygen deprivation. Only then did they call 911.”
According to the lawsuit, one of the deputies had told a homicide investigator that he didn’t provide aid because he didn’t have a pair of gloves, “and I didn’t want that blood on me without protection, until it was like nobody was doing anything — not that nobody was doing anything, but nobody had the presence of mind to do it.”
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Vogelman’s death is one of six jail deaths on CLERB’s Thursday agenda. Two of those deaths have, like Vogelman’s, prompted lawsuits — and as in his case, CLERB investigators found no wrongdoing by deputies.
Aaron Bonin, 43, was removed from life support on Nov. 1, 2022, after suffering cardiac arrest in San Diego’s Central Jail a week earlier. He had been transferred to the jail from a state psychiatric hospital for a hearing to determine whether he should continue to be involuntarily committed.
In addition to severe mental illness, Bonin had been diagnosed with kidney disease that required dialysis.
A lawsuit filed by his mother, Barbara Brisson, argues that jail medical staff did not provide her son with a renal diet, a diet typically advised for patients with kidney disease that excludes high-potassium foods, like bananas. Blood tests conducted after Bonin was transferred to the Central Jail repeatedly showed dangerously high levels of potassium.
Bonin was scheduled to receive dialysis on Oct. 24. Around 11 p.m. on Oct. 23, the lawsuit says, a deputy found him on the floor of his cell. He told her he wasn’t feeling well and asked if she could check his blood pressure.
She did and assured him it was OK, the lawsuit says.
That night, three deputies were on duty in Bonin’s module. According to the lawsuit, he continued to plead for medical help, including while deputies were conducting routine safety checks.
He was told that his blood pressure had been checked and he was fine.
“As time went on, Aaron’s pleas became more desperate,” the lawsuit says. “He begged to be taken to the hospital.”
Other detainees tried to help, asking deputies to check on him and using the call buttons and intercoms in their cells, to no avail, according to the suit.
Bonin’s cries for help “fell quieter and weaker until he fell silent around 3:00 a.m.,” the lawsuit says.
Bonin was found unresponsive on the floor of his cell at 3:16 a.m., during a routine safety check.
His brain had been deprived of oxygen for too long, the lawsuit says. He remained in a coma until his mother opted to withdraw life support eight days later.
CLERB investigators found that deputies made all the required hourly safety checks and initiated CPR when they found Bonin unconscious.
Jail surveillance video does not capture audio. But Lauren Mellano, Brisson’s attorney, said at least six other detainees told homicide investigators that Bonin was calling for help and three reported hitting their call buttons to get deputies’ attention.
Sheriff’s investigators also found that the intercom button in Bonin’s cell was not working, Mellano said.
The Sheriff’s Office conducts a homicide investigation when a person dies in custody.
Kalina said CLERB reviewed the homicide investigation. If any men detained in Bonin’s module had reported that deputies ignored Bonin’s requests for help, that could be a policy violation, he said. But no such violation is included in CLERB’s findings.
Mellano said she emailed Kalina asking to discuss Bonin’s case. Kalina told her he couldn’t due to confidentiality restrictions, but noted that CLERB allows members of the public to address the board at the beginning of each meeting. Mellano said she would.
“We hope that knowing Aaron and others were unable to reach deputies or convince them to take Aaron’s health concerns seriously will result in the correct finding — that Aaron’s death was the result of misconduct,” Mellano told the Union-Tribune.
CLERB currently has no jurisdiction over medical staff, meaning investigators were unable to look into whether Bonin had been placed on a restricted diet. But the board’s authority could soon expand to include them.
In October, CLERB Chair MaryAnne Pintar and county Supervisor Monica Montgomery Steppe proposed granting CLERB the power to investigate allegations of misconduct by medical and mental health staff in death cases. In December, county supervisors signed off on the plan, over objections from Sheriff Kelly Martinez.
A recent memo from the county’s deputy chief administrative officer says the board will be the first in the U.S. to have such authority, though it will require adding staff and could take a year to implement.
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CLERB also found no misconduct in the 2023 death of Roselee Bartolacci.
Bartolacci, 32, was developmentally disabled and suffered from schizoaffective disorder, a more pernicious form of schizophrenia. A lawsuit filed last year by her mother, Roseann, describes Roselee as functioning at the level of a young child.
In early 2023, the psychiatric medication Roselee relied on stopped working. “She was hearing voices and suffering paranoia,” the lawsuit says. “She experienced intermittent outbursts of anger and aggression.”
On April 6, 2023, Roselee hit her mother with a hammer. Roseann called the county’s psychiatric emergency response team seeking help but was told that no mental health clinicians were available. Sheriff’s deputies arrived instead.
According to the lawsuit, Roseann told the deputies about her daughter’s mental illness and asked them to take her to a psychiatric hospital where she could be medicated and stabilized.
She told them Roselee was experiencing a mental health crisis and was a client of San Diego’s Regional Center, which provides services to people with developmental disabilities.
Instead, Roselee was arrested and booked into jail.
The lawsuit alleges that deputies failed to tell intake staff that Roselee was experiencing a mental health crisis or that she was a regional center client. Sheriff’s Office policy requires that regional centers be notified within 24 hours when one of their clients is taken into jail custody.
Roselee was deemed “uncooperative” by medical staff and placed in administrative segregation, a form of solitary confinement. Over the next seven weeks, she repeatedly refused medication, food and liquids, the lawsuit says, and would not take her medication.
She was taken to the hospital twice.
Records from one visit describe Roselee as covered in feces and urine.
Records from a second in late April show she was suffering from acute renal failure, malnutrition, sepsis and several other ailments.
The admitting emergency room doctor noted that Roselee “had a high probability of imminent or life-threatening deterioration,” the lawsuit says.
“They left Roselee in her cell crying and moaning and sucking her thumb, speaking in gibberish and sitting in her own urine,” Yoo, her family’s lawyer, told The San Diego Union-Tribune last year.
On May 25, medical staff noted that Roselee had refused food and liquid for 48 hours.
“Late in the evening of May 28, 2023, Roselee was found cold and unresponsive in her filthy cell,” the lawsuit says. She had lost 44 pounds over her six weeks in jail.
Kalina said CLERB was limited in what aspects of Roselee’s case his staff could review. He said investigators looked into Roselee’s arrest — and whether deputies violated policy or protocol by not taking her to a psychiatric hospital or conveying information provided by her mother — but said he could not give details due to confidentiality restrictions.
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Three weeks before Ray Vogelman died, his attorney had asked a judge to release him from jail so he could enroll in a mental health treatment program.
Vogelman had been arrested twice for entering an apartment when the occupant was away. After years of sobriety, he had fallen back into addiction and was in the throes of a psychotic break. He was convinced the apartment’s occupant was a family friend, court records show.
“Pretrial diversion is available to an individual who has a mental disorder that was a significant factor in the commission of a charged offense,” Vogelman’s attorney Ryan Maguire-Fong wrote to the judge. “Mr. Vogelman reports he is committed to returning to a sober lifestyle and intends to follow recommendations from his psychiatrist.”
A hearing was scheduled for Oct. 24, but a court record from that day notes that Vogelman was dead.
Vogelman’s girlfriend, Wendy Herckt, said she talked to him the night before he died; he told he was going to be released soon.
“We got to share how much we missed each other. He told me he was sorry. And most importantly, we got to say ‘I love you,’” she recalled. “Had I known that that would be the last time I ever spoke to him, I would’ve had so much more to say.”
The two had met in 1995 at a 12-step program in Orange County. Vogelman was the lead singer for the punk-rock band Bonecrusher, whose fans knew him as “Raybo.”
His stage presence could be chaotic and gruff, but offstage he was the opposite, Herckt said.
“He was and is one of the most compassionate, kind, caring, loyal, creative people I’ve ever met,” she said. “He was loved by everyone he met.”
He should never have been placed at George Bailey, Herckt said.
“They failed him. They failed to protect him. He wasn’t a criminal. He suffered a mental crisis. And instead of getting the mental health treatment he needed, deputies watch him die on the detention center floor.”
