The Citizens’ Law Enforcement Review Board has found that two San Diego County sheriff’s deputies engaged in criminal conduct in connection with the jail death of a man who repeatedly pleaded for help as he struggled to breathe.
Bobby Ray Patton died Dec. 28, 2024, in the Vista Detention Facility after hours of worsening respiratory distress that went largely ignored, according to findings late last week by the civilian oversight board, also known as CLERB.
In an unprecedented move, the board sustained allegations of criminal negligence against two deputies — identified as Deputy 3 and Deputy 1 — concluding that both failed to respond to clear signs that Patton needed medical attention.
A sustained finding means board members found sufficient evidence that the misconduct occurred. Those conclusions were first recommended by CLERB investigators and later adopted by the board.
“(A) person acts with criminal negligence when: He or she acts in a reckless way that creates a high risk of death or great bodily injury and a reasonable person would have known that acting in that way would create such a risk,” the investigative findings say, quoting case law.
It’s the first time the board, which oversees the Sheriff’s Office and Probation Department, has made such findings. It’s also the first time CLERB will refer its findings to the District Attorney’s Office for potential criminal charges.
“I will be providing the board’s findings to the district attorney for review,” Brett Kalina, the review board’s executive officer, said by email. “CLERB is an advisory body. CLERB has no authority to impose discipline.”
A spokesperson for District Attorney Summer Stephan said her office reviews referrals but declined to discuss the Patton case specifically.
Patton, who was 46, had been booked into the Vista jail in late November after being arrested on a warrant for a probation violation.
During intake, he reported a history of fentanyl use and said he was enrolled in a methadone treatment program. He was placed on detox monitoring, which was later discontinued after his condition appeared stable.
He was diagnosed with influenza days prior to his death and was being treated for pneumonia. Deputies had escorted him to the jail’s medical clinic the night before he died, after he reported chest pain and shortness of breath.
The CLERB findings identified one of those escort deputies as Deputy 3.
At about 6 a.m. the next morning, Deputy 3 approached Patton’s cell during a routine safety check. Body-worn camera footage captured Patton saying “I can’t breathe” and “I’m having chest pain so bad.”
According to the board’s findings, the deputy looked into the cell, then turned away and continued toward the exit.
As the deputy walked away, Patton said, “Please help me.”
The deputy exited the module and turned off the body camera.
The board concluded that this failure to act amounted to criminal negligence and sustained allegations that Deputy 3 failed to respond to a medical emergency, failed to complete a safety check and acted in a manner that created a high risk of death.
Less than an hour later, another deputy encountered Patton under similar circumstances.
At about 6:55 a.m., Deputy 1 conducted a safety check and briefly looked into Patton’s cell while audible moaning could be heard, according to the report. The deputy then continued on without intervening.
The board also sustained multiple findings against Deputy 1, including failure to recognize or respond to a medical emergency, failure to follow required count procedures and criminal negligence.
During safety checks, deputies are required to check for signs of distress through “direct visual observation” of people in custody, state regulations say.
At 7:51 a.m., another deputy conducted a safety check. Body-worn camera footage showed Patton lying on the cell’s lower bunk, groaning.
That deputy finished the safety check and, roughly 15 minutes later, returned to Patton’s cell, opened the door and interacted with him briefly, before leaving the module and returning a few minutes later with members of the medication-assisted treatment team and a nurse.
But by then, it was too late.
Deputies and the nurse attempted to take Patton’s vital signs, but he soon became unresponsive.
Paramedics arrived shortly after 8:30 a.m.; Patton was pronounced dead at 8:45 a.m.
The board emphasized that its criminal conduct findings against Deputies 1 and 3 were based on a “preponderance of the evidence” — meaning it is more likely than not that the misconduct occurred — rather than the higher “beyond a reasonable doubt” standard required in criminal court.
In an emailed response to questions last week, a spokesperson for the Sheriff’s Office rejected the allegation that any crime occurred.
Lt. David Collins said homicide investigators reviewed the case and found no evidence of criminal conduct. He noted that the county medical examiner ruled Patton’s death an accident related to health complications.
“Therefore the case was not referred (by the sheriff) to the District Attorney’s Office,” Collins said.
The autopsy attributed Patton’s cause of death to acute bacterial bronchopneumonia complicating an influenza A infection, with methadone use as a contributing factor.
Patton had been taking methadone, a treatment for opiate use disorder, under the jail’s medication-assisted treatment program. He was supposed to be on a methadone taper, Chief Deputy Medical Examiner Jonathan Lucas noted in his report, but toxicology testing detected methadone at a higher concentration than expected.
As a respiratory depressant, the drug likely contributed to his death, Lucas noted.
While CLERB serves in an advisory role — meaning its findings don’t require Sheriff Kelly Martinez to act — its criminal conduct findings could trigger further review.
State rules require law enforcement agencies to report findings of serious misconduct — including those identified by civilian oversight bodies — to the state Commission on Peace Officer Standards and Training, which has the authority to suspend or revoke an officer’s certification.
Kalina, CLERB’s executive officer, said it will be up to the Sheriff’s Office to forward the findings to the Commission on Peace Officer Standards and Training. He said he will be sharing the board’s findings with the District Attorney’s office.
Separately, the Sheriff’s Office’s internal Critical Incident Review Board conducted its own review of Patton’s death. A brief summary states that the panel identified no “action items.”
Collins said that internal board does not make findings of misconduct and instead focuses on assessing the county’s potential civil liability.
“The fact that there are no ‘action items’ does not mean there were no issues,” he said.
An expert who reviewed the case for The San Diego Union-Tribune said the failures described in CLERB’s report are not uncommon.
To George C. Klein, a former FBI researcher and criminal justice professor, the findings suggested that deputies did not follow basic safety protocols.
“Deputy 3 did not conduct a safety check,” Klein said. “If government agencies act recklessly, intentionally or with gross negligence, they are acting with ‘deliberate indifference’ and are legally liable.”