San Diego County District Attorney Summer Stephan has declined to file criminal charges against anyone in the 2023 death of Keith Bach, a diabetes patient who died in sheriff’s custody after being denied life-saving insulin.
The district attorney’s office said Thursday that numerous people were responsible for the failures that led to Bach’s death in the Central Jail downtown and that prosecutors were unlikely to prove that any crime had been committed.
Last year, The San Diego Union-Tribune obtained a copy of Bach’s autopsy and reported that the medical examiner’s office had classified his death as a homicide.
Records showed that deputies and medical staff failed to provide Bach insulin, even though the alarm on his insulin pump had been beeping for at least 19 hours.
“While there was a series of events that led up to Mr. Bach’s death, insufficient evidence exists to prove beyond a reasonable doubt that the actions, or inactions, of any specific individual was a substantial cause in Mr. Bach’s death,” spokesperson Steve Walker said in a statement Thursday.
“Further, California law has no statute by which criminal liability can be imposed upon a government organization,” he said.
The decision not to pursue criminal charges came six months after the case was referred to the district attorney’s office.
It also came just over a year after jail nurse Danalee Pascua was acquitted of involuntary manslaughter in the case of Elisa Serna, who also died after jail staff failed to provide proper medical attention.
A separate jury was unable to reach a verdict in a case against Friederike Von Lintig, the physician responsible for Serna’s medical care, and prosecutors opted not to seek a new trial.
The district attorney’s office said the outcome of the criminal cases filed in the wake of Serna’s death only partly informed the decision not to proceed in the Bach case.
“Although we take previous jury verdicts into consideration, our decisions are ultimately made on the unique facts and evidence in each case,” Walker said.
But the announcement Thursday that no charges would be filed in the Bach case angered his family.
“I am totally disgusted with the DA,” Bach’s mother, Grace Larson, said by email after learning of the decision. She said the prosecutor who told her “hemmed and hawed for at least five minutes on how the law would not allow them to charge anyone.
“With the county self-insured, the sheriff, the DA and others paid by San Diego County, no one has to take responsibility,” she added.
Bach’s widow, Cecilia, filed a civil lawsuit against the county last year, one of scores accusing the Sheriff’s Office of negligence and misconduct that have collectively cost taxpayers more than $80 million in recent years.
Her litigation is still pending. The Serna family agreed to a $15 million settlement last summer.
Bach was 63 and working as a heating and air technician in September 2023 when he was arrested by Chula Vista police on suspicion of vandalism and making a criminal threat.
He managed his diabetes with an insulin pump but on occasion would experience mood swings if his blood sugar level peaked or fell outside the normal range — not uncommon for diabetics, said attorney John Gomez, whose law firm is representing Cecilia Bach.
In the past, Cecilia had called 911, and paramedics would help stabilize Keith, Gomez said at a news conference in October. But on Sept. 25, 2023, Chula Vista police officers showed up instead.
“The police arrived and arrested Keith because he had thrown a remote control — his own remote control, inside of his own home,” Gomez said. “That’s what got him arrested that day.”
He was too sick from his Type 1 diabetes to book into sheriff’s custody, so police transported him to a nearby hospital for treatment. Once he was stabilized, Bach was taken to jail.
But he fainted some 90 minutes later and had to be rushed back to the hospital. After additional treatment, Bach was returned to jail early in the morning of Sept. 26. Records show jail staff gave him 10 units of insulin at the time but none after that.
Bach received no additional treatment for at least 19 hours, even though the alarm on his insulin pump was beeping, signaling that it was empty. He was declared dead early on the morning of Sept. 28.
According to her lawsuit, Cecilia Bach was receiving notifications on her cellphone that her husband’s insulin pump was empty.
“She frantically visited the jail multiple times trying to deliver insulin to Keith but was told by defendants that he would be taken care of by the SDCJ medical staff and deputies,” the lawsuit says.
The doctor who conducted the autopsy said the response by jail staff to Bach’s health emergency amounted to “neglect” and declared the case a homicide.
“Following insufficient insulin administration while in custody, Mr. Bach developed diabetic ketoacidosis and died,” the medical examiner’s report stated.
“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 added.
The medical examiner’s findings were highly unusual.
Only once before in at least the past 20 years had the office issued a homicide finding in a San Diego County jail death that was not allegedly committed by another incarcerated person.
That was in 2022, when Lonnie Rupard died from pneumonia, dehydration and malnutrition in the same jail as Bach. Pathologists said Rupard lost 60 pounds over the last three months of his life and jail staff never treated his schizophrenia.
“While elements of self-neglect were present, ultimately this decedent was dependent upon others for his care; therefore, the manner of death is classified as homicide,” the autopsy report said.
Gomez said he was disappointed by the DA’s decision. He described the actions of jail staff as “grossly negligent.”
“The District Attorney’s office correctly points out that California law does not allow criminal charges to be filed against an entire governmental entity, such as the Sheriff’s Department,” he said. “However, our civil justice system does allow us to prosecute the entire department to seek justice for our client and the many others who have been hurt or killed by the Sheriff’s Department. We look forward to doing just that.”
The Sheriff’s Office is also facing a class-action lawsuit alleging inadequate care for people in custody with a mental or physical illness or a physical disability.
Aaron Fischer, one of the attorneys in that case, said Bach’s death was preventable and underscores the need for better policies and training.
“There may have been individual staff member failures leading up to Mr. Bach’s death, but let’s not forget that this incident occurred in a place with systemic deficiencies,” he said. “If Mr. Bach’s death does not serve as a wake-up call, I don’t know what will. More people’s lives are at stake.”
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