Deputies ignored man as he choked on Santa Rita Jail wristband in ‘preventable’ death, lawsuit says

DUBLIN — For an hour and 21 minutes, Jose Pina Cardenas gasped and writhed on the floor of his Santa Rita Jail cell with a plastic wristband lodged in his throat, according to a federal lawsuit filed by his five children.

But instead of helping him, multiple Alameda County sheriff’s deputies allegedly dismissed his distress as “talking” and falsified a colleague’s initials on a cell-check log, according to the lawsuit.

His cell went unchecked for 52 minutes, the lawsuit claims.

Cardenas’ five children now say their father’s death in June 2022 was not only entirely “preventable,” but the “predictable result of a systemic pattern of deliberate indifference” that discriminates against mentally ill inmates, according to the wrongful death lawsuit filed last year against Alameda County.

“It’s horrible — they were supposed to be keeping an eye on him,” said Christina Pallas, 34, who is the mother of Cardenas’ youngest child, a 4-year-old girl. “And I understand deputies have a job, and their job is complex. But when they first saw him laying on the floor, they should have responded then.

The lawsuit represents the latest in a string of legal filings alleging deeply problematic management and neglectful care at the jail, one of the nation’s largest and the location of several inmate deaths over the past decade. In February 2022 — just months before Cardenas’ death — a federal judge approved a sweeping consent decree mandating a host of reforms at the jail, many of them aimed at improving mental health treatment.

Cardenas himself had a history — noted in his jail medical file — of suicide attempts and suffered from several mental conditions, including schizophrenia, bipolar disorder and multiple personality disorder. His treatment at the jail demonstrated “a lack of humanity,” said Zachary Linowitz, an attorney for Cardenas’ family who worked as an Alameda County deputy district attorney tasked with prosecuting alleged wrongdoing by law enforcement officers.

Linowitz, who went into private practice after leaving the DA’s office in early 2025, stressed that the “bare minimum” requirement for deputies that day was to check on Cardenas every 15 minutes, yet those deputies “treated him like he didn’t matter.”

Alameda County Sheriff’s Office spokesperson Sgt. Roberto Morales declined to comment Tuesday on the lawsuit. He said the job statuses of the men named in an updated version of the lawsuit filed Jan. 5 — Sgt. Victor Galindo and deputies Malik Jackson, Allen Lowe and Ruben Ramos — would later be released by the sheriff’s internal affairs unit.

Santa Rita Jail has been the subject of criminal complaints involving concerns that jail staff didn’t adequately check on inmates or lied about doing so. District Attorney Ursula Jones Dickson last year dismissed a case against two deputies accused of falsifying cell-check records in the 2021 death of Vinetta Martin, whose cell went unchecked for an hour and 18 minutes.

Last month, a grand jury returned indictments against three sheriff’s deputies in the 2021 death of Maurice Monk, who died after languishing days in his cell. His death prompted his family to file lawsuits against Alameda County and its jail health care provider, WellPath, that led to settlements totaling $9.5 million.

In some ways, the final days of Monk’s life mirrored Cardenas’ own experience at the jail.

Booked into the jail on a parole violation on May 17, 2022, Cardenas told intake workers that he heard voices in his head suggesting he hurt himself or others, the lawsuit claimed. His comments so alarmed nurses that he was “urgently” referred to the jail’s mental health unit, and deputies were told to check on him every 15 minutes.

Yet from the very start of Cardenas’ stay, deputies appeared to veer from the agency’s protocols.

One deputy, Ramos, prematurely took Cardenas from his intake booth, despite clinicians having activated a red warning light on the booth that barred Cardenas’ removal before his mental health plan was completed, the lawsuit alleged.

On the way to his cell, Cardenas began “mumbling and exhibiting bizarre behavior” and quickly tried moving away from Ramos, according to the lawsuit. That prompted another deputy to tackle Cardenas, while others piled on top of him and handcuffed him, the legal filing said.

Once Cardenas was in his cell, a mental health clinician caught up with deputies and told Ramos that Cardenas had been prematurely taken from the intake booth, according to Cardenas’ family. The lawsuit claimed the deputies were “dismissive” of the concerns, and chose instead to joke about Cardenas’ behavior.

That same night he was booked into the jail, Cardenas intentionally swallowed his plastic jail-issued ID wristband, prompting him to collapse onto the floor of his cell, the lawsuit claimed.

Deputy Jackson peered inside and recorded on a nearby form that Cardenas was “talking,” the lawsuit said.

Twenty minutes later, another deputy, Lowe, watched Cardenas for nearly a minute and left the cell after allegedly signing another deputy’s initials on an observation log, again claiming that Cardenas was “talking,” according to the suit.

Five minutes after that, Jackson again looked inside and said Cardenas was “sleeping,” despite video showing him “still on the floor in medical crisis,” the lawsuit said.

No one checked on Cardenas for the next 52 minutes, the lawsuit said, missing three required checks.

Nurses were called only after a deputy — who was not listed as a defendant in the lawsuit — looked into Cardenas’ cell and saw him “bleeding from his mouth.” The nurse then ordered deputies to call for an emergency response, repeating the order 10 times “due to the apparent lack of urgency from deputies on scene,” the lawsuit claimed.

The lawsuit alleged the deputies repeatedly interfered with medical responders’ efforts to help Cardenas, once by placing a spit guard over his face and other times holding him down and “standing on his restraints.” The placement of the spit guard appeared to violate a sheriff’s office policy barring the use of those devices on people who are struggling to breathe, the lawsuit claimed.

Deputies later wrote in their reports that Cardenas “refused to remove his hand from his mouth” and “refused to be medically evaluated,” while also disobeying an order to not grab a nurse’s shoe, the lawsuit said. One deputy said it was “unclear” whether Cardenas was “suffering from a mental health crisis, a medical emergency only or was being assaultive to staff,” the lawsuit added.

Cardenas died at a Pleasanton hospital about three weeks later, on June 7, 2022.

An autopsy by the Alameda County Sheriff’s Office’s coroner’s bureau found Cardenas died of “complications of alcohol withdrawal,” the lawsuit said, while also naming hepatic cirrhosis, cardiomegaly and morbid obesity as contributing factors.

The autopsy report made no mention of the choking incident involving his jail wristband, Cardenas’ family claimed. Rather, their lawsuit suggested that the incident caused bacteria to get into Cardenas’ lungs, resulting in pneumonia and later sepsis that overwhelmed his body’s organs.

They cited an independent autopsy conducted Aug. 5, which found Cardenas suffered from congested lungs, a swollen liver, a slightly enlarged spleen and a serious kidney condition, while identifying “findings consistent with respiratory compromise and systemic infection.”

Cardenas’ family wasn’t notified of his medical emergency — and subsequent hospitalization in intensive care — for nearly 10 days, the lawsuit claimed.

Pallas, the mother of his youngest child, said that she fell into homelessness after Cardenas’ death. She wants the lawsuit to spur further change at the jail, including more training on how to avoid such situations.

“It’s been very difficult,” said Pallas, referencing the fact that she now raises their daughter alone. “He was my main support in everything.”

Jakob Rodgers is a senior breaking news reporter. Call, text or send him an encrypted message via Signal at 510-390-2351, or email him at jrodgers@bayareanewsgroup.com.