'Failure of the system'

When he died on Sept. 15, 2008, Guadalupe Zavala still had marks from the four bean-bag rounds that, 30 days earlier, hit his chest, stomach and groin with the speed of a line drive. One of the bean bags, which resemble a badminton shuttlecock in shape and are filled with lead pellets, pierced the skin near Zavala’s groin and had to be surgically removed.

San Diego Police officers used the projectiles to force Zavala to drop a shard of glass he’d picked up after breaking out windows in his San Ysidro home, where he’d been locked up by a caretaker.

It’s been nine years since San Diego police officers shot and killed a mentally ill homeless man who was threatening them with a tree branch. Though a shard of glass is arguably more threatening than a branch, the 87-year-old Zavala was in poor health and suffering from dementia, among other illnesses. His agitated state resulted from a simple request that went ignored: He wanted a cigarette.

At 5:45 p.m. on Aug. 16, Zavala’s in-home caretaker called 911, saying the elderly man had threatened her with a stove burner after she refused to allow him to go outside to smoke. She locked him inside the house and went to a neighbor’s house to wait for police. Zavala, meanwhile, armed himself with a stick and was breaking out the windows of the single-story home where he lived with his nephew.

What happened next is documented in a medical examiner’s report and the District Attorney’s review, released March 5, of the events leading up to Zavala’s arrest—the DA’s office conducts a review whenever anyone dies during, or as the result of, an altercation with local law enforcement. The purpose of the review is to determine whether the officers involved are criminally liable. California law says that police officers are permitted to use deadly force if they fear for their personal safety or the safety of others. They’re also permitted to “use reasonable force in making an arrest.” In this case, District Attorney Bonnie Dumanis concluded that the officers’ use of force to arrest Zavala was justified.

On Aug. 10—a week prior his arrest, Zavala had been admitted to the hospital after becoming “agitated and incoherent” the DA’s review says. There, he received a trifecta of diagnoses: “community acquired pneumonia, dementia and stage three chronic kidney disease,” according to the DA’s review.

Zavala was released from a hospital stay on Aug. 14; his relatives arranged for around-the-clock in-home care. To what extent Zavala’s evening caretaker knew his medical history isn’t clear—CityBeat was unable to contact the caretaker, and Zavala’s nephew declined to be interviewed. The caretaker had Zavala’s age wrong, telling a 911 dispatcher that he was 65, and San Diego Police Detective Kevin Rooney said the officers were unaware Zavala had been diagnosed with dementia. In the DA’s report, though, which includes summaries of statements from each officer involved, Zavala is described as “disorientated and confused.” He told officers his name was Ventura Garcia and encouraged them to kill him. Police also noted that he was wearing only a diaper.

The officers came up with an arrest plan and entered the home’s front door, according to the DA’s review. Zavala was standing about 20 feet away. He’d dropped the stick but was still holding a shard of glass. Officer Carlos Ronquillo, who was armed with the bean-bag gun, told a police investigator that Zavala started walking toward him and didn’t comply with an order to drop the piece of glass. “Officer Ronquillo feared Mr. Zavala wanted to die and was going to try to hurt him or one of the other officers,” the DA’s review says. Ronquillo fired one bean-bag round and ordered Zavala a second time to drop the glass before discharging three more rounds. At that point, another officer deployed a Taser, but because only one prong pierced Zavala’s hand, the electrical charge failed—both prongs of a Taser must make contact with a subject’s skin or clothing to emit a charge, Rooney said.

Despite no electrical charge, Zavala fell after being hit by the Taser and was promptly handcuffed and transported to the hospital, where he underwent surgery to remove the bean bag. During his hospital stay, he developed pneumonia and “remained mostly incoherent and sedated,” according to the medical examiner’s report. His health continued to decline, the report says, until his death on Sept. 15. The report lists the cause of death as “complications following blunt force injuries to the chest and abdomen,” and an autopsy report details the elderly man’s poor health: severe lung disease, chronic kidney disease and cancer that had been previously undiagnosed. Zavala’s brain, the autopsy found, was riddled with signs of advanced dementia.

Best practices in dealing with a mentally ill or emotionally distraught people encourage officers to take their time and keep their distance unless the subject is threatening another person’s life. Only 17 minutes elapsed from the time the first officers arrived on-scene to when an ambulance was summoned after Zavala had been handcuffed. The DA’s report says officers initially communicated with Zavala through the home’s broken windows, which were covered by wrought-iron bars. Inside the locked home, Zavala posed a danger only to himself.

Bettie Reinhardt, executive director of the San Diego chapter of the National Alliance for the Mentally Ill, said people suffering from mental illness, dementia included, have an impaired ability to follow rules.

“If somebody had given the man his cigarette, it would have probably made a lot of difference,” she said. “And that’s certainly what we’re discovering in all kind of situations: If people can have some flexibility and don’t get caught up in power plays at the outset of things, it just makes all the difference in the world.”

Recruits receive 11 hours of training in dealing with mentally ill subjects, said San Diego Police spokesperson Monica Muñoz. And, recently, the San Diego and Imperial counties chapter of the Alzheimer’s Association has added a training component for recruits specifically on Alzheimer’s and dementia. Alzheimer’s Association project specialist Melissa Chaty said the goal is to eventually train all local law-enforcement officers. The impetus, she said, is the expected increase in Alzheimer’s diagnoses as Baby Boomers age.

The San Diego Police Department has both its own Crisis Intervention Team of specially trained officers, and the department contracts with the county’s Psychiatric Emergency Response Team (PERT). Rooney said neither team was brought in to assist with Zavala. PERT, he said, isn’t called in when a subject is armed or poses a threat.
Jim Fix, PERT’s executive director, said this policy has recently prompted a review.

“Some questions have come up before on certain barricaded situations with folks with mental illness, and people have asked, ‘Why wasn’t PERT involved?’” he said.

PERT, he said, can get involved behind the scenes, contacting family members or running the person’s name through the county’s mental-health system. PERT also offers 30-hour training courses to local law-enforcement and other first responders, though the training is voluntary.

“Law enforcement’s been put in a position to be the crisis-intervention people,” Fix said.

He added that he didn’t want to second-guess the officers’ choices in the Zavala incident.

“I think the real tragedy here is, here’s a guy with dementia who’s aggressive, and he’s in a setting that maybe wasn’t the best place for him to be,” he said. “He needed to be somewhere with a higher level of care, but the whole system is so difficult to get people in. Kind of a failure of the system—it goes beyond just law enforcement and how they respond to calls.”    

Comments? Tips? Write to kellyd@sdcitybeat.com.