LAKE COUNTY, Calif. – The county of Lake has reached a $2 million settlement in a federal lawsuit filed by the son of a woman who died by suicide in the Lake County Jail in 2015.

The case involves the in-custody death of Elizabeth Dara Gaunt, 56, of Santa Rosa.

In the settlement, the county has agreed to pay $2 million to Gaunt’s son, Dane Shikman, while denying allegations of wrongdoing, according to case documents. The county’s settlement payment will be paid by its insurance.

“I believe it to be the highest sum ever recovered in the state of California involving the suicide of an inmate,” said attorney Michael D. Green of the Santa Rosa law firm Abbey, Weitzenberg, Warren & Emery.

“It was just a fairly egregious case,” he said.

He said a settlement with the county’s private jail medical provider – identified in case documents as California Forensic Medical Group – is confidential. Neither Green nor Shikman could discuss it due to terms of that settlement.

“I brought this litigation not just to vindicate my mom but to expose what I thought was a problem in the system,” Shikman told Lake County News.

County Counsel Anita Grant told Lake County News that the Board of Supervisors approved the settlement following a closed session discussion earlier this year.

Grant did not have information about the settlement with the county’s jail medical provider, California Forensic Medical Group, noting it’s private.

The case had been set to go to trial June 4 at the federal court in Humboldt County. However, in May, the county signed off on the agreement to settle the case, which was then dismissed in federal court, Green said.

Federal court records showed the stipulation in which the parties agreed to the case being dismissed was filed on May 30.

Green litigated the case along with Matt Lilligren of Abbey, Weitzenberg, Warren & Emery and Geri Green of the Law Office of Geri Green.

Last year, Green’s firm reached the $4.5 million settlement with the county of Lake over the Lakeside Heights subdivision landslide, as Lake County News has reported.

The basis of the lawsuit

Gaunt’s death occurred on Aug. 2, 2015, a day after she was taken into custody in Nice when deputies responded to a report of a suspicious woman banging on residential yard gates.

Authorities said she was arrested for giving deputies false identification and being under the influence of a controlled substance, later identified as methamphetamine.

Neither Shikman nor Green knows how she ended up in Lake County or why she had come here in the lead up to her arrest and death.

“I really wish I knew,” said Shikman. “It’s a missing piece of the story for me.”

During booking, Gaunt denied being suicidal and was placed in a sobering cell, where she was kept for more than 24 hours, according to a District Attorney’s Office investigation.

Green said jail staff had requested a medical clearance before placement due to Gaunt’s altered mental status.

He said she repeatedly made urgent requests to see a medical doctor but the county’s jail medical provider failed to contact a doctor and instead sent a licensed vocational nurse – not qualified to perform detailed evaluations, render a diagnosis or make treatment decisions – who met with Gaunt for only 30 seconds and failed to perform a detailed intake medical evaluation or required mental health screening.

The LVN failed to consult with a qualified medical professional prior to accepting Gaunt into the jail, despite acknowledging that Gaunt had a positive psychiatric history, Green said.

While Gaunt was placed into a sobering cell for close observation due to concerns about her safety, Green said jail staff failed to intervene properly.

At one point on the afternoon of Aug. 2, she began asking, then yelling for help, according to the district attorney’s report.

Green said Gaunt’s mental condition deteriorated significantly while in custody, and she began to experience hallucinations and became increasingly agitated and psychotic, which was documented by the LVN who last saw her at 2 p.m., shortly before she was found unresponsive. Green faulted the LVN for failing to perform a medical examination, obtain vitals or contact a medical doctor as required.

Minutes later, Gaunt used torn bedding to hang herself, which Green said wasn’t noticed because a correctional officer failed to enter the cell to make the required direct visual observation of Gaunt.

He said Gaunt was found unresponsive at the next cell check at 2:25 p.m., when, during another cell check, a correctional officer found her on the floor of her cell, a strip of her torn up cell blanket around her neck and also tied to the sink.

Despite attempts by jail staff and doctors at Sutter Lakeside to resuscitate her, Gaunt was pronounced dead at the hospital about an hour after she was found unresponsive in her cell, according to case documents.

The autopsy found she died from asphyxia due to hanging, and had a potentially toxic level of methamphetamine in her system.

Seeking answers

Shikman said he was traveling abroad when his mother’s death occurred. He learned about it the day after he returned to his then-home in Washington, DC, when a police officer showed up at his door.

What followed, said Shikman, was a blur, as he called his father and uncle. “We just cried it out on the phone.”

The same day, he flew to California to try to learn what had happened. “None of the circumstances that have come to light during the process of litigation were disclosed to me at the time,” despite him asking, he said.

In the days that followed, Shikman moved quickly to handle his mother’s final arrangements and continue his quest for answers.

Within a week of her death, he traveled to Ireland, where he scattered her ashes off the western coast. He said she had always talked of Ireland as a spiritual home.

He said he exchanged about half a dozen emails with the county, trying to get information about her death. Shikman said the county either was unresponsive or officials said they couldn’t answer his questions.

In October of 2015, District Attorney Don Anderson completed his report on Gaunt’s death, concluding she had died by suicide but making no determination on wrongdoing,

Shikman said Anderson’s office gave him the report as well as a narrative of a video of his mother in her cell before she died. He said that narrative showed him there was serious wrongdoing. That’s when Shikman – an attorney himself – began consulting other attorneys about taking his case, eventually connecting with the attorneys who made up his legal team.

Filing suit

The suit was filed in 2016. It faulted the county and California Forensic Medical Group for failing to give Gaunt – who needed “acute mental health treatment” – a detailed medical screening, mental health evaluation or intervention by a medical doctor despite her repeated requests.

The suit cited seven causes of action, the first three of which referenced the US Constitution’s Fourteenth Amendment, which speaks to due process and equal protection under the law: deliberate indifference to serious medical/mental health needs and failure to protect Gaunt against harm; inadequate policies, customs and/or practices resulting in deprivation of medical/mental health care to Gaunt and failure to protect her against harm; and failure to train/supervise.

The other four claims included wrongful death arising from negligence; violation of California Government Code 845.6, which is the failure to furnish or obtain medical care for a prisoner; violation of the Americans with Disabilities Act for failing to accommodate Gaunt’s mental disability and discrimination against her based on that disability; and violation of the Unruh Act, which also alleged failure to accommodate for her disability and discrimination against her for it.

“We took about 30 depositions in the case,” said Green.

He said they went into great detail in looking at policies and procedures and where there are gaps where people can fall through.

“From our perspective, she should never have been kept in the jail,” said Green.

Gaunt, he said, “was having a mental decomposition” and should have been sent to an appropriate facility.

Green faulted correctional officers in particular for not doing a proper cell check at the time Gaunt’s suicide was occurring. “They should have gotten her out of there. They didn’t,” he said, adding that they should have appreciated the acute psychotic situation she was in.

In February 2017, as the litigation was under way, Green said the California Board of Vocational Nursing notified California Forensic Medical Group that its policy and practice of using LVNs to make disposition decisions at intake – such as the decision to send an inmate to the hospital for evaluation or instead clear for placement in sobering cell – violates the LVN’s scope of practice under California law.

At the time of Gaunt’s death, it was California Forensic Medical Group’s practice that an individual such as Gaunt who arrived to the jail on the weekend would not receive a required mental health evaluation until the following Monday, Green said.

Since initiation of this lawsuit, Green said that medical provider has revised its policies and practices to conform to California law.

Change also have come from the sheriff’s office, he said.

“I think Sheriff Martin has taken a more proactive approach,” Green said, noting those early changes made weren’t part of the settlement requirements.

Green said Martin – who at the time of Gaunt’s death had been sheriff for seven months – “stepped up relatively promptly” to make a series of changes.

“We did recognize that there were some improvements to be made,” Sheriff Martin told Lake County News.

Martin said that they increased the size of video monitors, replaced the old blankets with new tear-resistant ones that also are much harder to tie around things, added a system where correctional officers must go up to a cell to check them and added clocks within the booking area that go off at designated times to remind correctional officers to do inmate checks.

He said they’ve also implemented suicide and crisis response and intervention training. There have been no suicides since Gaunt’s death, and Martin credited those improvements – as well as interventions – with helping stop them.

Martin said there is always room for improvement. “There’s not a 100-percent foolproof system.”

Other improvements made at the jail cited by Green include a requirement that all inmates receive a mental health evaluation before being admitted into the jail, updates to written policies and inmate observation logs to better ensure the correctional officers are performing safety checks and inmates evaluations in a timely manner, and a requirement that supervisors review inmate logs closer and more frequently to ensure compliance.

Green said the suit ultimately was settled in a couple of pieces, one at the end of May, the other within the month previous.

He said the settlement amount was basically a forecast of what a jury would do. “The county and the county’s medical provider settled it because of the risk of trial.”

Shikman said he’s happy with some of the changes made by the county, including the use of tear-resistant blankets, mental health evaluations, and safety checks and observation logs. “That’s good to see.”

Authorities have to take responsibility for those they arrest, and people have a right to know that family members will be safe when police take them into custody. “That didn’t happen here.”

Shikman said he wants exposure of the structural inadequacies of the law enforcement system, where medical providers want to maximize profits and will skimp if they can. “That’s unacceptable.”

While there are many questions he still hasn’t found answers to, “As to the facts, yeah, I think I have everything I need.”

Green said this was the third lawsuit against Lake County involving a jail suicide. All were different in their circumstances, but similar in that the people who died shouldn’t have been in jail and that all of them, like Gaunt’s case, resulted in a large settlement.

Remembering the woman

For Shikman, it’s important that his mother be remembered as the fully formed person she was, a loving and involved mother, a good friend and a star student in grad school. He doesn’t want her to be defined for her death or for her struggles with substance abuse, which she faced just as millions of others do.

“She was just the best mom that anyone could ask for,” he said, explaining that his parents separated when he was 2 and she was a single mother. “She really devoted her whole life to being a mom to me.”

Gaunt was a social worker who was trained to be a licensed therapist and worked as a substance abuse counselor. She was effective in helping helped others who struggled with drug and alcohol abuse, serving the homeless and disabled, he said.

Prior to her death, Gaunt was preparing to apply for licensure as a marriage and family therapist, Green said.

“She was constantly thinking of others first,” Shikman said, noting that people who she had helped had written to her to tell her of how she impacted their lives.

Shikman said his mother also had integrity and unflappable principles, was uniquely intelligent, a constant reader and a woman with a great sense of humor.

“She was really goofy and laughed at herself all the time,” Shikman said.

He said his mother was a shining star who lit up every room she was in.

Shikman added, “Just because someone has drug or alcohol problems, doesn't mean they’re less than. I think we have a tendency in our society to think that.”

Email Elizabeth Larson at This email address is being protected from spambots. You need JavaScript enabled to view it.. Follow her on Twitter, @ERLarson, or Lake County News, @LakeCoNews.