Autopsy: Chronic alcohol abuse killed man in Cibola jail

Ruben Toledo died in 2017 after being allegedly denied medical care while going through alcohol withdrawal while at the Cibola County Detention Center, in Grants
• Pathologist Matthew Cain found Toledo died from chronic alcohol abuse
The county is being sued for Toledo’s death

Read more about the case in the write-up

GRANTS, N.M. — An Albuquerque man who died seven days after suffering a seizure in the Cibola County Detention Center was killed by chronic alcohol abuse, according to an autopsy report. However, the report makes no mention of the seizures the man suffered, his apparent alcohol withdrawal or his hospitalization and appears to downplay the circumstances of his death.

Petroglyph National Monument, Albuquerque, N.M. Photo by Angel Schatz/Flickr. CC-BY

Ruben Toledo, 42, died in the University of New Mexico Hospital on July 1, 2017, after being taken off of life support. He was taken to the hospital seven days earlier after going comatose in a shower after suffering multiple apparent seizures.

Office of the Medical Investigator pathologist Matthew Cain wrote, in a heavily redacted autopsy report, that based on the evidence presented to him, Toledo died from chronic alcohol abuse and he had “significant liver disease” and alcoholics are at risk for “metabolic abnormalities” and withdrawal complications.

Toledo’s wife, Natalia Antonio, filed a lawsuit against Cibola County on June 20, 2019. Attorney Alyssa Quijano named warden Adrianne Jaramillo, nurse Michael Hildenbrant, Sgt. Lisa Burnside and physician’s assistant Michelle Lucero as defendants in the lawsuit, in addition to Cibola County.

Quijana wrote in the lawsuit that Toledo collapsed from a seizure in his cell, causing a head wound, on June 24, 2017. He died in the hospital seven days later, on July 1, 2017, after being taken off of life support.

There is no mention of that fall in the autopsy report, the seizures that caused it or that Toledo never regained consciousness after he was transported out of the jail.

Much of the allegations in the lawsuit center around Toledo going through alcohol withdrawal, which is often deadly.

Despite evidence of alcohol withdrawal in the lawsuit, it is not mentioned in the autopsy report, except as a perfunctory note in the summary and opinion that it can cause seizures and death. Neither Cain’s report nor the deputy field investigation by Tom Conklin makes mention of the seizures Toledo suffered, as noted in the wrongful death lawsuit, although it is unclear what was redacted.

Cain wrote that Toledo had no evidence of “significant” injury. However, in the evidence of injuries section of the autopsy report, he listed three wounds on Toledo:

  • A blunt head injury. “Healing laceration on forehead”
  • On the chest: “Faint, black, 7 cm contusion on left side of chest”
  • On the extremities: “Abrasions on left knee.”

Toledo suffered a head wound seven days before he died, Quijana wrote in the lawsuit complaint.

The narrative of the deputy field investigation, by Tom Conklin, is redacted except for two-and-a-half sentences. It makes no mention of seizures or Toledo’s fall:

“Seth advised that the decedent had been incarcerated in the Cibola County Detention Center. The decedent was found shaking on the shower floor. He became unresponsive and bystander (REDACTED).”

The lawsuit

The lawsuit against Cibola County, filed on June 20, 2019, outlines alleged abuses and neglect at the hands of jail guards and medical staff at the jail.

Toledo was initially arrested on June 21, 2017, after being found allegedly drunk in his truck at the federal Petroglyph National Monument. U.S. Park Ranger Steven Powers arrested him on charges of DUI, possession of alcohol in a vehicle and possession of a controlled substance and booked him into the Sandoval County Detention Center, according to federal court documents.

Federal Magistrate Judge Kirtan Khalsa ordered Toledo held without bail during an initial appearance, at the request of U.S. Attorney’s Office prosecutor Nicholas Ganjei. Toledo had no attorney. The entire hearing lasted for five minutes, according to a minutes sheet.

Toledo was transferred from the Sandoval jail to Cibola. His condition quickly worsened until he suffered an alcohol-induced seizure on June 24, observed by Sgt. Lisa Burnside. Toledo could no longer speak and he had dried blood on his forehead, Quijana wrote in the lawsuit complaint.

Burnside ordered guards to take Toledo, incapable of walking, to a shower to clean up while she looked for a clean cell. Guards carried him there and placed him on the ground, Quijana wrote.

“Ruben slumped over on the ground and became unresponsive,” she wrote.

Guards didn’t call for medical staff immediately but once they did, they told the guards to call 911 and started CPR. Once he left the jail, he would never regain consciousness, Quijana wrote.

District Judge Kenneth Gonzales dismissed count one of the lawsuit filed against Hildenbrant and Lucero for violation of due process and inadequate medical care, on the grounds they are entitled to qualified immunity.

motion to dismiss filed by the county is pending.

Downplayed events

The narrative outlined in the lawsuit compares starkly with the outline Cain and Conklin noted in the autopsy report and the deputy field investigation.

In the field investigation, Conklin wrote Toledo was “found shaking on the shower floor.” What happened next is redacted.

In Cain’s summary and opinion, he used the same sentence, that Toledo was “found shaking on the shower floor.” Again, what happened next is redacted.

That compares starkly with the lawsuit allegations, that guards carried Toledo into the shower and he slumped over. Guards then lifted Toledo into a chair and eventually called for medical help, according to the lawsuit.

Neither Cain’s autopsy report not Conklin’s field investigation mention that Toledo was taken to a local hospital, and then to the University of New Mexico hospital, after he lost consciousness at the jail.

Both documents also do not mention that Toledo died after being taken off of life support.

Continue reading “Autopsy: Chronic alcohol abuse killed man in Cibola jail”

Zachariah Stanley Joe: Brett Micah Morgan — 1-3-2019

 

Summary

Zachariah Joe first attacked Brett Micah Morgan after visiting with him and another man at a house in Shiprock. After being tackled to the ground, he locked Morgan and the other man, only identified in court documents as B.M., out of the house. He then found a kitchen knife and stabbed Morgan 10 times in the chest and neck, killing him, according to court records.

Joe pleaded guilty on Oct. 31, 2019 to a single charge of second-degree murder, according to court records.

The binding plea deal states he will receive a sentence of 15 years. However, the magistrate judge in the case has deferred acceptance of the plea agreement until sentencing by a district court judge.

No more hearings have been set in the case.

The incident

Shiprock. Photo by Bowie Snodgrass/Flickr

On Jan. 3, 2019, Zachariah Stanley Joe, 28, showed up at a house where Brett Micah Morgan, 32, and another man, identified by the initials B.M., were hanging out. Joe had just been fired from Burger King in Shiprock, Federal Bureau of Investigations Agent Lance Roundy wrote in an affidavit for a criminal complaint for the arrest of Joe.

Roundy referred to Morgan in court documents initially as “B.M.M.,” then by “John Doe.” The other identifiers Roundy included were Morgan’s year of birth, 1986, and that he was a Navajo Nation tribal member, as is Joe.

Although Roundy only identified Morgan as “B.M.M.” in court documents, he was identified in his obituary in the Farmington Daily Times. In additional to the correct initials, his obituary states he was born in 1986 and he died on Jan. 3, 2019, all details that match with Roundy’s affidavit. The obituary has been archived here via the Internet Archive and here as a PDF.

Roundy wrote someone interviewed B.M., who said Joe had been texting with Morgan while Morgan and B.M. drank at a Shiprock house. During the evening, Joe texted Morgan that he left work, at Burger King, and wanted to come over.

When Joe showed up, he was drunk and upset about being fired, Roundy wrote.

“Joe continued his tirade about losing his job throughout the evening and at one point, JOE violently struck John Doe in the face with the back of his hand, sending John Doe back towards the wood burning stove,” Roundy wrote, citing the interview with B.M.

Joe tried to attack the prone victim but B.M. punched Joe several times in the head and wrestled him to the ground long enough for Morgan and B.M. to get of the house. Joe locked the door from the inside. Morgan and B.M. could hear him searching through kitchen drawers and cabinets in a “violent” manner, Roundy wrote.

“B.M. then became upset feeling that his home was being invaded, and subsequently ran to the known residence of JOE and broke a window,” Roundy wrote. “B.M. then returned to his residence approximately five minutes later and found John Doe on the ground just outside the door bleeding.”

Joe was standing over Morgan. At some point two other people, identified as “D.T.” and “V.B.” arrived and drove Morgan to the hospital. Navajo police then arrested B.M. for breaking Joe’s window.

Roundy wrote that the Office of the Medical Investigator found that Morgan suffered from 10 “puncture and/or laceration wounds.” He was pronounced dead at the Northern Navajo Medical Center.

Roundy wrote that someone interviewed D.T., who said that he arrived at the house with V.B. and saw Joe kicking Morgan on the ground, outside the house. D.T. got out of the car and pushed Joe back from Morgan, saw he was unresponsive and heard Joe say that Morgan “was stabbed.”

D.T. then kept Joe at a distance and tried to get Morgan to his feet but realized he was bleeding, put him in a car and drove him to the hospital, he wrote.

D.T., who also lived at the house, later realized a kitchen knife was missing from a drawer, Roundy wrote.

V.B. said during an interview that when she arrived with D.T., she did not notice anything in Joe’s hands.

In the plea deal, Joe attested that he initially hit Morgan. B.M. threw Joe down, but eventually Joe locked them out of the house.

“I located a knife in the residence and armed myself with it,” the plea deal states. “A short time later, I exited the residence and confronted John Doe. I started a fight with John Doe and I stabbed John Doe with the knife approximately 10 times in his chest, side and neck.”

In the plea, he admitted that his stabbing caused Morgan’s death.

“While I stabbed John Doe, he begged for me to stop, but I did not,” the plea deal states. “In doing so, I acted with callous and wanton disregard for human life.”

The U.S. Attorney’s Office for New Mexico only published a press release on the case after Joe pleaded guilty and did not publish one after he was arrested.

The Farmington Daily Times first broke the story on January 14, 2019. Joe was charged on Jan. 4.

Below is the affidavit for a criminal complaint filed by Roundy.

Autopsy report

According to the autopsy report by pathologist Matthew Cain, Morgan has 10 “sharp force injuries” to the head and torso.

“Several stab wounds to the torso injured ribs, lungs, liver, and heart – lethal injuries,” Cain wrote. “A stab wound of the neck injured soft tissue and neck muscle but the spinal cord was uninvolved.”

Two of the stab wounds “injured” the small bowel and Morgan also suffered from blunt trauma, including abrasions, skin tears and bruises in the face, torso and his arms and legs. He died from his stab wounds.

Plea and possible sentence

On Oct. 31, 2019, Joe pleaded guilty to second-degree murder, before he was indicted by a grand jury. He previously waived his right to a preliminary hearing, on Jan. 9.

Magistrate Judge Kirtan Khalsa deferred acceptance of the plea agreement, according to the plea hearing minutes for the Oct. 31 hearing

The case had been continued multiple times because the prosecution and Joe’s defense attorney, Melissa Morris, were trying to reach a plea in “pre-indictment negotiations,” according to the docket and an Aug. 16 motion to continue the grand jury presentment. The plea was also signed by federal prosecutor David Cowen.

The plea agreement states Joe will receive a sentence of 15 years, although the sentencing judge can decide how much, if any, time Joe should spend on supervised release after serving his sentence. She can also levy a fine.

According to the plea, the possible maximum sentence for second-degree murder is life imprisonment.

The plea agreement states the 15-year sentence considers Joe’s acceptance of responsibility and that 15 years is the “appropriate disposition.”

In the plea agreement, Joe attested that he locked Morgan and B.M. out of the house, he found a knife and then confronted Morgan.

“I started a fight with John Doe and I stabbed John Doe with the knife approximately 10 times in his chest, side and neck. These stab wounds caused John Doe’s death. While I stabbed John Doe, he begged for me to stop, but I did not. In doing so, I acted with callous and wanton disregard for human life.”

Sentencing date set

Over a year after he pleaded guilty to second-degree murder, Joe will be sentenced to 15 years in prison during a virtual hearing at 3 p.m., Jan. 14, 2021 in the Vermejo courtroom in Albuquerque by District Judge James Browning.

Browning’s only discretion will be in how long Morgan will be on supervised release after serving his prison sentence. Magistrate Judge Kirtan Khalsa initially accepted the plea in October 2019.

Sentencing memorandums

Cowen and Morris both submitted sentencing memorandums imploring Browning to accept the binding plea deal, which mandates a sentence of 15 years for Joe.

Cowen wrote in his sentencing memorandum that Morgan was Joe’s close friend, and cousin, and that his death was “completely avoidable,” although he never specifies how it was avoidable. At the onset of the case, he worked with Morris to “investigate what took place with the goal of working towards a reasonable outcome.”

Cowen wrote that the sentencing guidelines for Joe put his sentence much higher, at just under 20 to to 24 years, but the decrease in sentence will avoid a trial. He wrote:

The proposed plea agreement avoids forcing the victim’s family, who is also Defendant’s extended family, to testify about the facts outlined above. One of the victim’s family members voiced an opinion that the family did not agree with the stipulated 15-year sentence, PSR ¶ 102, but in finalizing the plea agreement the government received support to resolve the case with this proposed 15-year sentence from the victim’s mother and stepfather. This support naturally came with emotion and a realization that no term of imprisonment would bring the victim back to the family.

The plea and 15-year sentence will allow the victim’s family “an opportunity to reconnect with the Defendant’s side of the family,” Cowen wrote.

Joe’s familial history was a childhood of physical abuse perpetrated by his alcoholic father, he wrote.

“According to Defendant’s mother, he unfortunately inherited his father’s tendency to become angry when he drinks alcohol,” Cowen wrote.

Joe had a history of misdemeanor convictions from age 18 to 21, which appear to be two drunk driving arrests and a charge of assault on an officer. He was never convicted of a felony but the convictions gave him a criminal history category of IV, he wrote.

Morris wrote in her sentencing memorandum for Joe that he has been drinking since he was 13 and when he drinks, “his personality changes and he sometimes does things that he would not do otherwise.”

Although his family is “saddened and confused by his actions,” they are still supportive of him. Joe never intended to kill his cousin and does not know how the events leading up to his brutal stabbing resulted in it, she wrote.

“Mr. Joe respectfully submits that this offense, like every other criminal offense he committed in the past, is the product of the disease of alcoholism, which in turn may be the product of his traumatic childhood experiences and his family history of alcoholism,” Morris wrote.

Morris submitted a packet of seven letters on Joe’s behalf, dated around December 2019.

  • Joe’s maternal aunt, Fremina Funmaker, submitted a letter on behalf of Joe and asked that the judge make a decision that “will allow him to seek mental well-being and self-development through sentencing.”
  • Aunt Tiva Esplain wrote that Joe is not a violent person and he has made large and small mistakes in the past and that alcohol caused him to stab his cousin 10 times.
  • Cousin Jerilyn Frank wrote that Joe is one of the “funny guys” and has a contagious laugh.
  • Joe’s mother, Miranda Begay, wrote that Joe and Morgan were “two peas in a pod” and there was not a day that went by when they had not communicated with each other. Without access to alcohol, Morgan would have never died.

Sentenced

On Jan. 14, 2021, Browning sentenced Joe to 15 years, per the plea agreement, followed by three years supervised release. He also ordered Joe pay Morgan’s family $6,546 in restitution.

See all the documents on Google Drive or Document Cloud view the case and documents on Court Listener.

Past stories

Zachariah Joe sentenced to 15 years for stabbing death of cousin, per binding plea

Sentencing date set for Zachariah Joe in stabbing death a year after guilty plea

Shiprock man pleads guilty to second-degree murder for killing fellow Navajo Nation man

Ruben Toledo – Cibola County Detention Center (jail death) — 7-1-2017

 

Summary

After a federal park ranger arrested him on a charge of drunk driving on June 21, Ruben Toledo, of Albuquerque, was transferred to the Cibola County Detention Center, where he proceeded to go through alcohol withdrawals, according to court documents.

Allegedly denied adequate medical care, he became so weak he could not walk but, after suffering at least one seizure, a nurse directed he be put into a shower on June 24. Guards carried him there, where he slumped over, before calling for emergency medical attention. When emergency staff arrived, they began CPR and Toledo was transferred to the Cibola hospital, and then to the University of New Mexico Hospital because his condition was so bad. He was taken off of life support on July 1, 2017. He never regained consciousness after he left the jail, according to a lawsuit complaint, filed Aug. 8, 2019.

Federal District Judge Kenneth Gonzales dismissed one count of the lawsuit filed against nurse Michael Hildenbrant and physician’s assistant Michelle Lucero, for violation of due process rights for inadequate medical care, on the grounds they are entitled to qualified immunity, in an order dated Sept. 2, 2020.

Read stories about the case or see the case documents on Google Drive or Document Cloud

 

Initial arrest

On June 20, 2017, U.S. Park Ranger Steven Powers arrested Ruben Toledo, 42, on charges of DUI, possession of alcohol in a vehicle and possession of a controlled substance.

Petroglyph National Monument, Albuquerque, NM. Photo by Mike Tungate/Flickr. CC-BY-ND

Powers wrote in an affidavit for a criminal complaint that he pulled up to Toledo’s truck, in the parking lot of the Petroglyph National Monument, because it was near closing time. Toledo appeared to be drunk and there were two open beers on the floorboard. Another unnamed person was also in the truck.

After conducting a field sobriety test, followed by a breath test, Powers arrested Toledo. The breath test came back at 0.27. During a search of the truck, Powers found marijuana, he wrote.

After taking him to a Albuquerque Police Department substation, Toledo’s blood-alcohol content came back as between 0.23 and 0.20, he wrote.

He was booked into the Sandoval County jail, Powers wrote.

Held without bail

On June 21, Toledo was also brought into court, in front of Magistrate Judge Kirtan Khalsa, for an initial appearance. Prosecutor Nicholas Ganjei, with the U.S. Attorney’s Office, moved for Toledo to be held without bail. Toledo had no attorney and Khalsa ordered him held without bail. The entire hearing lasted for five minutes, according to a minutes sheet.

It is not clear if this was before or after he was transferred from the Sandoval County Detention Center to the Cibola County Detention Center.

A preliminary detention hearing was supposed to be set for the next day, June 22, but there are no more docket entries after those for June 21, which included a notice of an oral detention order issued by Khalsa and the appoint of Christopher Lucero as Toledo’s attorney.

Although the docket does not reflect when it was edited, Toledo was “terminated” as a part to the case on June 23.

Nothing else exists on the docket, even though Toledo would remain in the state’s custody until his death 10 days later at the University of New Mexico Hospital in Albuquerque, after being taken off life support.

Lawsuit against Cibola County Detention Center

On June 20, 2019, Toledo’s wife, Natalia Antonio, filed a lawsuit through attorney Alyssa Quijano against the Cibola County, warden Adrianne Jaramillo, nurse Michael Hildenbrant, Sgt. Lisa Burnside and physician’s assistant Michelle Lucero, for Toledo’s wrongful death. The following is from the amended complaint filed on Aug. 8, 2019.

June 21

Toledo was “quickly transferred” from the Sandoval County Detention Center to the Cibola County Detention Center the day following his arrest, June 21, 2017, attorney Alyssa Quijano wrote in an amended complaint against the Cibola County Detention Center for Toledo’s wrongful death.

“When Ruben arrived at the facility, he told staff he suffered from depression and anxiety, and staff noted that he was chemically impaired,” she wrote.

Toledo said he had been drinking the day prior to being booked and his vital signs were abnormal — his blood pressure was 169/94, his pulse was 100 beats per minute and he had a glucose level of 161. Jail staff cleared him to be housed in general population, Quijano wrote.

Toledo remained in the general population for two days and he began to suffer from alcohol withdrawal, she wrote.

As in Toledo’s case, alcohol withdrawal is often be deadly. (At least three cases currently in the jail death database were from alcohol withdrawal, although this is incomplete and many autopsy reports are pending or have not been requested yet).

Toledo asked to be moved out of the general population because he feared he was in danger from other inmates attacking him and he was beginning to have hallucinations, a symptom of severe alcohol withdrawal, also known as delirium tremens, Quijano wrote.

June 23

On June 23, two days after he had been transferred to the Cibola County Detention Center, Physician’s Assistant Michelle Lucero saw him. He reported is daily alcohol use before being booked and she found his blood pressure and pulse were elevated, she wrote.

Lucero found that Toledo was a “difficult historian” with a “poor memory” and he has a “knowledge deficit.”

“Despite obvious signs and symptoms of alcohol withdrawal, Defendant Lucero failed to provide any treatment for his withdrawal,” Quijano wrote. “Instead, Defendant Lucero ordered Mr. Toledo be given Lisinopril, a blood pressure medication, and Metformin, a medication used to treat diabetes. Ruben was sent back to his cell with no further care or monitoring ordered.”

Later that day, Toledo called the master control room, screaming, to be let out of his cell, as he had been hallucinating. When guards opened his door, he tried to get out. Guards handcuffed him and brought him to the medical unit. There, he told staff he was experiencing alcohol withdrawal and was hallucinating, she wrote.

The medical staff called nurse Michael Hildenbrant, who does not have prescribing authority and was not at the facility, said to put him on their alcohol withdrawal “protocol,” which included prescription medications. He should have been hospitalized, she wrote.

Quijano wrote, “When this medication was prescribed, Ruben’s vitals were still abnormal, with a blood pressure of 179/100 and a pulse of 120 beats per minute. Until this point, Ruben had not been monitored for his withdrawal. In light of his severe symptoms of withdrawal, Ruben should have been hospitalized. Instead, Ruben was sent to segregation.”

Hildenbrant prescribed Librium (Chlordiazepoxide) and clonidine. However, his condition had so deteriorated that the Librium “amounted to no care at all,” Quijano wrote.

While in segregation, Toledo was to be periodically monitored by jail guards, but not by medical staff. He continued to act strangely, including weeping in his cell, chanting and wrapping himself in toilet paper.

“Despite this, Ruben received no medical attention in response to his erratic behavior,” Quijano said.

Later that evening, presumably June 23, medical assistant Rayleen Ray went to his cell to give him his medication. He was lying on the ground. He refused to take his medication and eventually agreed, but only if he could take it standing up, she wrote.

Toledo’s condition was so bad that he could not stand up on his own and guards had to help him to his feet. He was still not provided any medical care, she wrote.

A few hours later, Ray went to check on Ruben and looked at him through the food port. She told the segregation guard to alert if if things were not “looking good,” Quijano wrote.

June 24

The next morning, Toledo had an alcohol-induced seizure. Sgt. Lisa Burnside was called to Toledo’s cell and looked at him through the food port. He was on the floor, seizing, Quijano wrote.

Officers entered the cell and once he stopped, Burnside asked if he was OK. Toledo looked at her but he could not speak. She saw dried blood on his forehead an indication that he suffered a head injury while in his cell, likely from a seizure, she wrote.

“Rather than call 911, Defendant Burnside directed officers to take Ruben to the shower to clean up,” Quijano wrote.

Burnside went to find Toledo a new, clean cell, she wrote.

“Ruben needed a hospital, not a new cell,” Quijano wrote.

Toledo was so weak that he could not walk on his own. Guards carried him to the shower, Quijano, wrote.

“When officers got him to the shower, Ruben was unable to stand on his own, so he was placed on the ground,” she wrote. “Ruben slumped over on the ground and became unresponsive.”

The guards did not call for medical staff, 911 or other emergency medical services. Instead, they tried to lift Toledo into a chair, before “eventually” calling for medical staff.

“When they arrived, medical staff directed officers to call 911 and begin CPR,” Quijano wrote.

Once he left the jail, he would never regain consciousness, she wrote.

Toledo was transported to the Cibola General Hospital. When he arrived, he was unresponsive. Blood work showed his sodium levels were “critically high” and his carbon dioxide levels were “critically low,” she wrote.

“Medical staff also noted Ruben suffered significant bruising,” Quijano wrote.

He was also extremely dehydrated. His condition was so severe that they were not able to treat him and he was transferred to the University of New Mexico Hospital, she wrote.

Toledo remained on life support until July 1, 2017. Soon after he was taken off, he was pronounced dead. The county closed the jail three weeks later, she wrote.

Deprivation of civil rights

Quijano sued Lucero, Burnside and Hildenbrant for violation of Toledo’s due process rights through inadequate medical care and wrote that if Toledo received the medical attention he needed as he experienced alcohol withdrawal, he would have survived.

District Judge Kenneth Gonzales dismissed count one of the lawsuit filed against Hildenbrant and Lucero on the grounds they are entitled to qualified immunity.

“Defendants knew they were incapable of providing adequate medical care at CCDC,” Quijano wrote. “Defendants failed to obtain medical care until Ruben was slumped over and unresponsive. Ruben never regained consciousness after this.”

Cibola County, Lucero, Burnside and Hildenbrant are also being sued for negligent maintenance of a medical facility and negligent provision of medical care.

“Defendants routinely provided substandard care, or no care at all, to inmates in their facility,” Quijano wrote. “Upon information and belief, Defendants do not transport inmates to the emergency room to avoid costs of treatment.”

Quijano also lodged one count of a custom and policy of violating constitutional rights against warden Adrianna Jaramillo, alleging that during her tenure and that of her predecessors, the jail provided inadequate medical care to inmates.

She cited the case of Douglas Edmisten, who died in the jail in 2016 from internal bleeding. His family filed a wrongful death lawsuit and it settled for $5 million.

A motion to dismiss filed by the county is pending.

Autopsy report

Office of the Medical Investigator pathologist Matthew Cain wrote, in a heavily redacted autopsy report, that based on the evidence presented to him, Toledo died from chronic alcohol abuse and he had “significant liver disease” and alcoholics are at risk for “metabolic abnormalities” and withdrawal complications.

Despite evidence of alcohol withdrawal in the lawsuit, it is not mentioned in the autopsy report, except as a perfunctory note in the summary and opinion that it can cause seizures and death. Neither Cain’s report nor the deputy field investigation by Tom Conklin makes mention of the seizures Toledo suffered, as noted in the wrongful death lawsuit, although it is unclear what was redacted.

Cain wrote that Toledo had no evidence of “significant” injury. However, in the evidence of injuries section of the autopsy report, he listed three wounds on Toledo:

  • A blunt head injury. “Healing laceration on forehead”
  • On the chest: “Faint, black, 7 cm contusion on left side of chest”
  • On the extremities: “Abrasions on left knee.”

Toledo suffered a head wound seven days before he died, Quijana wrote in the lawsuit complaint.

The narrative of the deputy field investigation, by Tom Conklin, is redacted except for two-and-a-half sentences. It makes no mention of seizures or Toledo’s fall:

“Seth advised that the decedent had been incarcerated in the Cibola County Detention Center. The decedent was found shaking on the shower floor. He became unresponsive and bystander (REDACTED).”

The narrative outlined in the lawsuit compares starkly with the outline Cain and Conklin noted in the autopsy report and the deputy field investigation.

In the field investigation, Conklin wrote Toledo was “found shaking on the shower floor.” What happened next is redacted.

In Cain’s summary and opinion, he used the same sentence, that Toledo was “found shaking on the shower floor.” Again, what happened next is redacted.

That compares starkly with the lawsuit allegations, that guards carried Toledo into the shower and he slumped over. Guards then lifted Toledo into a chair and eventually called for medical help, according to the lawsuit.

Neither Cain’s autopsy report not Conklin’s field investigation mention that Toledo was taken to a local hospital, and then to the University of New Mexico hospital, after he lost consciousness at the jail.

Both documents also do not mention that Toledo died after being taken off of life support.

Read stories about the case or see the case documents on Google Drive or Document Cloud