Cass County Courthouse

PLATTSMOUTH – A grand jury has recommended Cass County Sheriff’s Office personnel receive additional training after an inmate at Cass County Jail died earlier this year.

Sixteen grand jury members convened in Cass County District Court Aug. 21-22 for an investigation into the death of Murdock resident Dustyn Gandara. He was being held in Cass County Jail when he died in February. Nebraska law requires a grand jury to be impaneled anytime there is a death of an inmate being held in state custody.

Cass County authorities arrested Gandara, 40, in November 2018 after his pickup struck the Hilltop Fill Stop convenience store on Highway 50. He pled guilty to a charge of driving under the influence of alcohol in Cass County Court on Feb. 6. He was ordered to pay a $500 fine and serve a term of 30 days in jail.

The grand jury ruled unanimously that Gandara died Feb. 9 of natural causes due to complications of chronic alcoholism. They examined evidence that indicated Gandara was suffering from a condition known as refeeding syndrome. His body was unable to reintroduce regular nutrition appropriately due to chronic alcoholism.

The grand jury found there were no offenses from authorities that would violate state law regarding Gandara’s death.

The grand jury’s investigation revealed Gandara had been hospitalized for medical complications due to alcoholism on Dec. 1, 2018. He refused placement in an addiction treatment center on Dec. 3 and said he would follow up with his primary care physician.

Grand jury members learned that jail staff noted the odor of alcohol on Gandara’s breath shortly after he was sentenced on the morning of Feb. 8. Staff members placed him in a cell in the booking area of the jail on a 30-minute watch. A nurse evaluated Gandara at the jail and recommended he remain on a 30-minute watch.

Jail staff asked Gandara to move to a maximum-security cell outside of the booking area at 2:13 a.m. on Feb. 9. This request was made to temporarily allow another inmate to be placed in the booking area.

He remained in the maximum-security cell until approximately 1:45 p.m. He then returned back to a cell in the booking area after jail staff asked him to do so. Jail staff checked on Gandara at 9 p.m. and noted he appeared to be sleeping.

“The grand jury finds staff did their due diligence at that time and did not observe anything out of the ordinary,” the report said.

Staff looked at Gandara again in his cell at 9:11 p.m. and became concerned that he had not moved. He did not respond when they tried to talk to him. Staff then opened the cell door and made physical attempts to get him to respond.

Jail staff requested emergency medical service personnel to come to the jail after they checked Gandara’s pulse and did not detect any movement. Staff began to perform CPR and continued until rescue squads arrived at 9:19 p.m. Rescue squads continued to perform lifesaving efforts until Gandara was declared deceased at 9:45 p.m.

Grand jury members said their investigation revealed that there were several checks required by jail policy that were missed by staff during Gandara’s incarceration. They said he should have been placed under a 15-minute watch instead of a 30-minute watch due to his intoxication. The 15-minute timeframe is included in Policy J-05.

Grand jury members determined the less-frequent checks did not contribute to Gandara’s death. They said he had been checked 11 minutes prior to being found unresponsive, which was within the 15-minute timeframe of Policy J-05.

The grand jury made five recommendations for Cass County Sheriff’s Office staff to follow in the future:

* The grand jury recommended CCSO staff be given further training regarding inmate watch and/or check policies in order to ensure knowledge of the policies and strict adherence to them.

* The grand jury recommended CCSO policy be clarified in order to ensure which staff members are responsible for each watch and/or check.

* The grand jury recommended CCSO policies be amended to allow supervisors to reassess the necessity of a watch and/or check every 24 hours.

* The grand jury recommended CCSO staff receive further CPR training and/or updates at least once per year.

* The grand jury recommended CCSO staff conduct practice drills to promote preparedness and a quick response time in the event of a medical emergency.

Grand jury members spent time both Aug. 21 and 22 listening to witness testimony and reviewing evidence. This included pathology and toxicology test results from experts. The grand jury made its ruling on a 16-0 vote. Members were discharged from further duty Aug. 22 after rendering their verdict.

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