Adams County jail deputies failed to follow best practices and sheriff’s office policy when they restrained a handcuffed inmate experiencing a medical emergency face-down on a gurney before he died, according to a 17th Judicial District grand jury report released Thursday.
The grand jury did not issue an indictment in the death of 38-year-old Arthur Roybal, who had a medical emergency in his cell the morning of Dec. 24, 2022, according to a report released by the district attorney’s office.
Jurors found “no individual person responsible” for causing Roybal’s death, the report states. The Adams County coroner’s office ruled Roybal’s death a homicide and found he died from acute methamphetamine toxicity with “prolonged restraint in a prone position” as a contributing factor.
The grand jury did not agree with that assessment, finding the coroner’s office used only video and not physical evidence to determine restraint was a factor in Roybal’s death.
But jurors said they were concerned about deputies putting Roybal at risk for suffocation by restraining him face-down on a gurney for 15 minutes while he was handcuffed.
Jail deputies first responded to a strange noise in Roybal’s cell just before 7:30 a.m. and found him having an “apparent psychotic episode,” according to the report. They could not communicate with him as he exhibited “odd behavior” and spoke nonsensically.
Deputies pulled Roybal out of the cell, handcuffed his hands behind his back and carried him downstairs to a gurney, where they placed him face-down and fastened straps across his back as he continued to yell and struggle.
The sergeant on duty rejected other forms of restraining Roybal that would have kept him upright, according to the grand jury’s report.
Roybal was spitting blood, and deputies briefly put a spit mask over his mouth. He had a harder time breathing as he was moved to an area of the jail where he could be transferred to a hospital, and he stopped breathing at 7:47 a.m., 15 minutes after he was strapped down.
Deputies monitored his breathing during those 15 minutes, the grand jury found. When he stopped breathing, deputies removed his handcuffs, turned him over, administered Narcan and started CPR. Roybal later was pronounced dead.
During the investigation, jurors interviewed a police expert who “questioned why any deputy or sergeant would suggest that Mr. Roybal be placed face-down on the gurney, as that necessarily increases the risk of causing injury or death,” according to the report.
The expert told jurors “there was no valid reason” to use the gurney when other restraint devices were available.
“The same individuals who appeared to act in Mr. Roybal’s best interest (when removing him from the cell) failed to exercise generally accepted best practices when they restrained him face-down on the gurney, thus increasing the risks associated with his medical condition,” the report states.
Adams County sheriff’s policy also states inmates should only be restrained face-up, the grand jury found.
“The involved deputies recognized, or at least should have recognized, the risks associated with this extended period of prone restraint,” jurors wrote.
The grand jury report recommended the sheriff’s office enhance training on using restraint devices and risks of “positional asphyxia” and improve communication between medical workers and deputies.
In a letter attached to the report, Adams County Sheriff Gene Claps said the agency agrees with the grand jury’s recommendation for enhanced training in using restraint devices and that training has been implemented.
Inmate restraint, transportation and positioning will be part of an internal investigation into Roybal’s death, Claps said.
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