Family seeks answers, alleges ‘deliberate indifference' in S.F. jail overdose death

San Francisco Chronicle​

2 days ago

The parents of a 33-year-old man who died from a fentanyl overdose roughly 28 hours after he was booked into San Francisco County jail on misdemeanor charges this spring have sued the city as they press for more answers about what happened to their son.
Theris Coats Sr. and Andrea Coats filed a civil rights lawsuit last week in the Northern District of California alleging jail staff did not provide adequate medical care for their son, Theris Coats II, before a deputy found him on the morning of March 20 unresponsive in a cell bed with vomit on the floor.
With multiple investigations still ongoing nearly five months after Coats' death, his father said there are 'too many unanswered questions' haunting the family.
'I don't know who dropped the ball,' Coats Sr. said in an interview. 'All I know is that our son ended up deceased, so I want answers.'
San Francisco officials, including the mayor's office, sheriff's office and Department of Public Health, who are named as defendants in the lawsuit, declined to comment on the pending litigation.
'All pre-trial and post-conviction inmates at San Francisco County Jail are afforded medical care through Jail Medical Services, under the Department of Public Health,' said Jen Kwart, communications director for the San Francisco City Attorney. 'If a lawsuit is served upon the City, it will be thoroughly reviewed and addressed in the normal course of any court proceedings.'
Coats was booked into jail around 3:30 a.m. March 19 on outstanding warrants for possession of drug paraphernalia, petty theft and commercial shoplifting, according to the complaint.
According to medical records referenced in the complaint, Coats suffered from substance abuse disorder and had his leg amputated due to an infection in November 2024. Coats reported to medical staff that he ingested alcohol and fentanyl daily, including on the day prior to his arrest, the complaint said.
Nurses who evaluated Coats in jail determined that he was at high risk for alcohol and opiate withdrawal, but recorded few symptoms of withdrawal in his medical records other than drowsiness, according to the complaint.
The complaint alleges that Coats' condition deteriorated inside the jail the following day. Medical records accompanying the lawsuit show that Coats refused medication and assessment when medical staff visited him in the early hours of the morning of March 20.
Coats was reported to be alive during a bed check at 5:56 a.m., according to a complaint, but was found laying unconscious in bed with vomit on the floor less than an hour later at 6:49 a.m.
A deputy called for medical help and initiated CPR. Within ten minutes, medical staff delivered two doses of Narcan, a drug that can rapidly reverse an opioid overdose. The complaint said Coats was pronounced dead at 7:27 a.m.
An autopsy found that Coats died from the toxic effects of fentanyl, and officials ruled the death an accident, according to his death certificate.
But questions surrounding the circumstances of the death remain, including whether Coats ingested the fatal dose of fentanyl before or after he was jailed, according to his family and their attorney.
Mark Merin, the attorney representing the Coats family, said the jail has so far provided no records from the incident in response to a public records request. He aims to uncover more information through the course of litigation.
'They had lots of opportunity to intervene in a positive way and instead ignored his significant medical need, which is deliberate indifference,' Merin said of medical staff at the jail. 'That's the main pervasive problem that I see in this case.'
Coats was the second person to die of an overdose at San Francisco County Jail in the span of about six months. Aamonte Hadley, 22, was found unresponsive in her cell on Sept. 3, 2024.
Hadley was charged with a string of alleged armed robberies and had been in jail for nearly two years at the time of her death. The San Francisco Medical Examiner ruled Hadley's cause of death an accidental overdose from toxic effects of methadone and oxycodone, according to her autopsy report.
The sheriff's office Criminal Investigations Unit and the Department of Police Accountability have launched investigations into the deaths of both Hadley and Coats but those investigations remain ongoing, according to the agencies.
At a sheriff's department oversight board meeting in June, Dr. Lisa Pratt, director of San Francisco Jail Health Services, said nurses in the jail reverse about three overdoses a month.
Pratt, who is named as a defendant in the Coats' lawsuit, said recently arrested inmates who are addicted to opioids are at a heightened risk of overdose. Going through withdrawal, their tolerance is lowered, and using even a small amount of opioids could be fatal, she said.
'Those things go very, very quickly,' Pratt said. 'One minute someone's breathing, and then two minutes later, they're not breathing and they're not recoverable. So that is a real testament to what (the nurses) do.'
As the Coats family waits for answers, they have channeled their grief into advocacy.
Coats Sr. co-founded a nonprofit called BADD, or Brothers Against Drug Deaths, which raises awareness about the addiction and mental health crises that his son battled for years on the streets of San Francisco.
Coats Sr. said his son was rambunctious and full of life as a child. He played football and basketball before setting his sights on a dream of becoming a Gospel rapper. His parents encouraged him to read and write, buying him journals and notebooks that he filled with song lyrics, and he later recorded multiple songs.
The younger Coats began battling mental illness as a pre-teen, and after earning a college scholarship in Texas, he soon dropped out of school and returned to California. Recent years were spent cycling between jail, hospitals and homeless shelters, Coats Sr. said, but before parting ways, his son always said, 'I love you.'
'I hold onto that to this day,' Coats Sr. said. 'I would rather have my son back, but I think that what we're doing is needed too. I think we can shed a light on this stuff happening, and prevent it from happening to somebody else's child.'