by John Bateson
LEARNING HIS WAY AROUND
In the beginning, a correctional officer escorted Holmes from the first gate through an open courtyard into whichever cell block the decedent was in. Entering a cell block meant passing through an air walk and then a series of closed chambers, each chamber secured by locking steel gates and thick iron doors that were manned by other officers. There were at least two doors between anywhere and outside, and usually three or more. No door could be opened until the door behind it had closed with a loud bang. Each CO who manned a door looked through a peep hole to make sure that the person wanting in was authorized before the door was opened.
After a few years, Holmes had been at San Quentin often enough that most COs recognized him. When he got to the open yard between cell blocks, the CO escorting him stopped, pointed across the way to a chain-link fence with a gate that wasn’t locked, and told him to go through the gate to the next cell block, where another CO would meet him. All of the inmates were locked up so no one was in the yard. Still, it was eerie, especially in the middle of the night when the shouts of angry, sleepless, and deeply disturbed men filled the air. Holmes would walk thirty feet into the yard, look around him, and start to think, what if? What if some guy did get out? Holmes would be a sitting duck.
“I was always armed when I arrived at the prison,” he says, “but a person doesn’t go into San Quentin with a weapon so I would check my gun at the front gate. I was never in danger, but I was never certain of that, either.”
Florenzo Ramirez’s death was typical of many others. The twenty-seven-year-old was stabbed in the prison’s South Dining Hall with the right side of a pair of scissors. He was crying for help and trying to climb the security fence between Section 1 and Section 2 in the dining hall while another inmate, Daniel “Termite” Roberts, made repeated thrusts into his back. A third inmate stood close by with a smirk on his face, according to a correctional officer who was the first guard on the scene.
Roberts fled the dining hall as Ramirez was taken by gurney to Neumiller Hospital at the prison. He was then transferred to Marin General Hospital, where physicians pronounced him dead on arrival. Holmes examined him there, supine on a morgue table. Ramirez had multiple puncture wounds and lacerations across his shoulders, arms, and back. His muscular body also featured numerous tattoos. Holmes took seventeen photos of the wounds and tattoos, then Ramirez’s body was removed to a local mortuary for autopsy. The medical cause of death was no surprise—traumatic injuries, including stab wounds. The manner wasn’t a surprise, either—homicide.
Another time, early in Holmes’s career, two inmates got into a fight with knives and one was killed. Holmes was called out to investigate and, as usual, brought his camera as well as his other equipment. The prison didn’t have its own investigative unit at the time, and the officer in charge of the case asked Holmes if he would mind taking a few pictures of the assailant.
Wanting to be helpful, Holmes said okay, adding, “Does he have injuries?”
“Nothing serious,” the officer said, “but both of them were wearing boxer shorts and his knees are all scraped up. I need pictures of them for my report.”
The inmate was cuffed and flanked by two correctional officers. He stood while Holmes knelt in front of him and snapped photographs of his knees. All the while, Holmes had a foreboding feeling.
So many things can go wrong right now, he thought. He has just killed a guy, and here I am, on my knees at his knees, taking pictures and wondering what’s going through his mind. He can raise one leg and hit me square in the forehead, or hit the camera and drive it right into my eye, just because he wants to. Thank God these two mountainous COs are here.
Inmates know the score—they can be executed only once. No matter what they do, the only recourse for officers is to write them up. This gives inmates considerable leverage, and they use it to full advantage. In this instance, the inmate had no interest in Holmes. Instead, he addressed the officers.
“Motherfucker deserved it. Won’t be shooting off his mouth no more.”
When Holmes got to his feet, he breathed a sigh of relief. He also knew that if a similar request was made of him again, he would think twice before he agreed to it.
GANG WARFARE
Gangs tend to operate in depressed areas, so one wouldn’t expect them to be present in Marin. Yet the Marin County Civil Grand Jury noted in a 2011 report that numerous gangs, starting with the Norteños, Sureños, and Mexican Mafia, and moving on to smaller gangs such as the Young Hawgz, KUMI-415, Aryan Brotherhood, Crips, Bloods, and Zetas, exist in the county. The title of the report, “Gangs of Marin: A Tale of Two Counties,” referred to the disparity between wealthy Marin, where “affluent citizens walk safe streets with lives largely insulated from the majority of criminal influences found in neighboring counties,” and gangland Marin, where homicides, fights, and graffiti are more commonplace. According to the report, Marin’s geographic isolation, overall affluence, and natural beauty serve to discourage gangs from taking hold. There are only three main routes into and out of the county—two by bridge and one by highway—and police can close these off quickly to prevent someone who commits a crime from escaping. The high cost of living has been a buffer because many gang members can’t afford to live in the county. As for aesthetics, Marin County residents tend to be intolerant of the vehicles that often are favored by gang members: flashy cars and banged-up clunkers.
Offsetting these factors are others, though, that serve to foster gangs. The most notable one is the heavy use of drugs in the county. Much of the dealing, particularly of illegal drugs like heroin, cocaine, and methamphetamine, is done by gang members.
A second factor is that gang activity is high in surrounding counties, and there is spillover into Marin. “The same people who estimated Marin gang members in the hundreds,” said the grand jury report, “estimated up to 1,000 in Richmond [Contra Costa County] and somewhere around 4,000 in Santa Rosa [Sonoma County]. That does not begin to account for other proximate gang regions like Vallejo, Napa, and Oakland.” Each of those communities is only a half-hour drive from Marin County.
Last but not least is the fact that many gang members end up incarcerated at San Quentin. Kingpins can continue to run the gang from their cells, and those in “middle management,” who are free and on the street, want to stay close enough to the kingpins to take and act on orders.
During Holmes’s career, gang-related murders occurred outside San Quentin infrequently, if only because they weren’t recognized as such unless both the decedent and assailant were multiple offenders who were known to local law enforcement. Witnesses rarely talked, so the primary way that gang membership was determined was by the person’s tattoos, which constituted another part of Holmes’s education. There was “X3” for the Sureños and “MS-13” for Mara Salvatrucha-13. A sombrero denoted membership in the Norteños while a shamrock symbolized the Aryan Brotherhood. There also were more universal tattoos such as “ANT,” short for “Ain’t No Talking,” meaning no squealing to police, and a square composed of four dots with a dot in the middle—the four dots symbolizing prison walls and the inner dot representing the inmate.
The placement of tattoos had meaning as well. A gang-related tattoo on the neck, head, or face, for instance, indicated that the person was an upper-echelon member of the gang. The tattoo of a tear below one eye signified that the person had killed for the gang. The tattoo of a wristwatch without hands meant that the person was “doing time”—that is, serving a long prison sentence.
Gang-related tattoos and their placement have to be sanctioned, according to the grand jury report. Any tat that isn’t authorized yet purports to symbolize “work” done for the gang might be removed with a blowtorch or flayed off the person’s skin, the report said. Holmes never heard an instance where that happened, but it was a threat espoused by gang members in order to inhibit other members from inking false claims and also dissuade non–gang members from getting tattoos that made it appear a
s if they had the power of the gang behind them.
In recent years the number of homicides within San Quentin has decreased dramatically, for two reasons. Neither one has anything to do with improved security, better inmate control, upgraded facilities, or effective rehabilitation efforts. Instead, when Pelican Bay State Prison opened in 1989 in Crescent City, three hundred miles north of Marin, many of San Quentin’s worst gang members were transferred there. That reduced some of the inbred animosity that inmates at San Quentin had for one another, with the result that assaults declined. They weren’t eliminated by any means, but they became less frequent.
The other reason for the drop in homicides was that drugs at San Quentin, always available, became even more prevalent. One might think that this would upset prison officials, but they had been aware of it for years and recognized that inmates who self-medicated were less volatile and easier for staff to handle. Stopping incoming drugs was virtually impossible, and officials knew that turning a partially blind eye was one way to keep the lid on a festering cauldron of pent-up anger.
“Over the years, I had many conversations with some of the guys in San Quentin’s Investigations Service Unit,” Holmes says. “We talked about all of the drugs that are there—those that are smuggled in from outside and the ones that inmates manufacture out of anything they can lay their hands on. ISU knows which guys are selling and which guys are using, and they’re thankful because if it wasn’t for the seller, who’s getting cigarettes or sexual favors or whatever, those guys would be absolute animals. It might seem like they’re that way now—and some of them are—but it would be so much worse. The assault rate would climb for everyone—inmates, COs, prison administrators, and medical staff. It’s wrong to condone all of the drug dealing that goes on in the prison, but without it San Quentin would be on fire all the time.”
Early in his career, Holmes examined dead inmates in their cells if that was where they were found. He searched the cell, always with a correctional officer so that there was a witness. They tipped the mattress, looking for cuts that indicated something was hidden, and flattened the pillow to determine whether anything was inside. Other than that, there wasn’t much to check. Later, ISU did that and informed Holmes of anything that was found.
Executions were an exception. The coroner wasn’t involved because there was no reason for an autopsy, much less an investigation. Prison doctors knew the exact time an inmate died, as well as the cause of death—electrocution or cyanide. For manner, Holmes wrote “judicial homicide” on the death certificate because the death was court ordered.
During Holmes’s career, thirteen men were executed at San Quentin. Holmes never observed an execution, not because he was squeamish about it but because he didn’t feel like he needed to. He had been inside the execution chamber and knew how the mechanisms worked because he was part of an oversight committee that was formed when capital punishment was reinstated in California in 1978. (Executions in the state ended in 1972 due to a decision by the California Supreme Court and were reinstated in 1978.)
Because San Quentin is antiquated, there has been talk from time to time of lifting the requirement that all male death row inmates be housed there (women on death row are housed at the Central California Women’s Facility, in Chowchilla). Also, with capital punishment on hold, there is less of a reason to place condemned inmates in the only prison that has an execution chamber. Offsetting this is San Quentin’s proximity to federal and state courts in San Francisco, as well as to metropolitan airports that enable attorneys to have relatively easy access to inmates in preparing challenges to convictions and sentences. In addition, supportive services to death row inmates and their families are established in the area.
Whether the policy will change in the future is unknown. One thing that won’t change, though, is a prevailing sentiment that surprises people outside the system: many death row inmates are in favor of capital punishment. The reason isn’t intuitive, but makes sense after it’s explained. Condemned inmates receive special privileges, such as private cells and personal treatment, including the ability to request meetings with their attorney regarding their defense, meetings in which the state is required to pay the attorney’s airfare and hotel costs. If capital punishment is overturned, then death row inmates will lose these privileges. More important, they no longer will be separated from the rest of the prison population. Even with many gang members transferred to Pelican Bay, those who remain at San Quentin tend to dominate. They are young, tough, and fearless, whereas most death row inmates are in their forties, fifties, or older. They may have been young when they were first incarcerated, but after spending decades on death row they have aged and are no match for young gang members. In 2012 and 2016, the last times a bill was on the California ballot to repeal capital punishment, psychologists at San Quentin worked extra shifts on election night in anticipation of a rash of suicide attempts if the bill passed. When it didn’t, they were able to go home.
CHAPTER 10
AN UNNECESSARY DEATH
In 1986, a brouhaha developed in Marin over whether coroner’s investigators should receive the same safety retirement benefits as police officers and firefighters. Because of the inherent dangers posed by their jobs, cops and firefighters received higher pensions than other county employees. Also, if they developed any serious health problems while they were working, such as heart disease or stomach cancer, it automatically was assumed that the problems were job related and fully covered. As the coroner, Dr. Jindrich argued that his investigators should be treated similarly. Like cops, they carried a gun. Like firefighters, they had to deal with the stress of being woken up in the middle of the night out of a deep sleep, jumping out of bed, and racing to a scene. In addition, every time an investigator went to San Quentin, his life was in danger because inmates often walked unshackled in open areas.
Even though there were only three investigators, county administrators didn’t want to incur any added expenses, and Jindrich’s request was denied. Moreover, he was told that if it was dangerous for investigators to go to San Quentin, they shouldn’t go there. As a result, from that time forward all deaths at the prison were examined in an outside hospital or mortuary.
That was where Sammie Marshall’s body was taken in June 1997 after he was forcibly removed from his cell by five correctional officers—three big men who went into the cell to get him, and two female COs who observed from outside. Holmes was the assistant coroner at the time, and one of his investigators, Don Cornish, was the one who observed Sammie’s body at the mortuary. Cornish noted minor abrasions on Sammie’s face, hands, and one knee, plus torn fingernails. In addition, clear liquid was exuding from Sammie’s nose.
Holmes reviewed Cornish’s written report as well as written reports that were filed by prison personnel afterward. According to the watch commander, when the three male correctional officers came to Sammie’s cell, he barricaded himself inside and tied the door shut. The officers used OC spray (commonly known as pepper spray) to subdue him before they dragged him out. Shortly thereafter, Sammie had some sort of seizure and died. That didn’t make sense to Holmes, and he asked prison officials for permission to interview selected staff.
It was a delicate situation, and Holmes knew that he had to be careful and not accuse anyone of wrongdoing. It was his responsibility to determine whether prison protocols were followed, however, and whether Sammie’s death could have been avoided. To do that he needed to understand how a man with no obvious health problems died while being extricated from his cell.
Sammie Marshall was fifty-one years old, African-American, and big. He had been incarcerated at San Quentin nearly ten years, after being convicted of killing a prostitute in Los Angeles. Three psychiatrists had testified that he wasn’t mentally competent, but the judge in the case overruled them. Prison psychologists subsequently diagnosed Sammie as “actively psychotic” and his condition as “chronic.”
Holmes says, “Sammie was somewhat overweight, bu
t still formidable. He only had a grade school education and was easily confused, sometimes paranoid. When prison officials told him that they were moving him to another cell, he didn’t understand. He had been in the same cell a long time and didn’t want to leave it. No one bothered to tell him why he was being moved.”
Over the course of four days, Holmes was able to talk to all but one of the key participants at the prison and piece together the story. The one exception was a correctional officer who, Holmes was told, had been injured recently and no longer was at San Quentin.
Holmes explained at the beginning of each interview that his purpose was to gain more insight into the circumstances surrounding Sammie’s death. The written reports described the actions of everyone, he said, but didn’t include any spoken words, feelings, or impressions of the event as it unfolded. Also, the autopsy and toxicology reports didn’t explain why Sammie died, and Holmes was attempting to substantiate or rule out the possibility that Sammie had a condition known as “excited delirium,” in which a person becomes agitated, incoherent, hyperaggressive, and displays extraordinary strength—characteristics that were hinted at in the reports.
Three of the correctional officers were forthcoming and expressed genuine interest in assisting Holmes with his inquiry. One male CO was reluctant to answer Holmes’s questions, saying that he would need to refer to his written report before commenting. All said that they were surprised by Sammie’s death, which seemed sudden to them. Each had participated in cell extractions before, and said that this wasn’t the first cell extraction involving Sammie.
By this time Holmes had enough firsthand experience to know how prison officials operated. “The way a prison system handles someone who isn’t obeying orders,” he says, “is to overpower him, and Sammie knew that. As the COs slid his cell door open—it doesn’t open very wide—they shot pepper spray from a few inches away into Sammie’s face. It irritates a person’s eyes, causing pain, tears, and temporary blindness. Each burst was two seconds, they said, as per regulations, with an appropriate interval in between. All of them were spraying Sammie at once, however, multiple times, and probably for more than two seconds.”