Santa Rita Jail

The former Alameda County sheriff's lieutenant who used chains to tether a 20-year-old Fremont man to a cell door in the Santa Rita Jail in Dublin admitted during an investigation that he made an "epic mistake" that resulted in the man's suicide. A department report concluded the lieutenant was negligent in his duties.

Lt. Craig Cedergren told an investigator that after finding Christian Eduardo Madrigal unresponsive with a chain wrapped around his neck, he realized he had made a serious error tying Madrigal to the door. The prisoner was "clearly panicked and overwhelmed with the whole situation," the internal affairs investigation said.

Madrigal died five days later in a hospital. The coroner's office determined he died from the cessation of blood flow to his brain because of hanging, and ruled the death a suicide.

"I asked Lt. Cedergren if, in hindsight, he believed it would have been a better option to have used the restraint chair versus tethering Mr. Madrigal to the door with ankle restraint. He told me, 'It would have been a better option to do something different, which might have included the restraint chair. Could have been simple – as you said, open the door and make him lay on the floor,'” Alameda Sheriff Sgt. Mark Pickett wrote in his June 30, 2019 report.

The statements and Pickett's conclusion that Cedergren was negligent in his duties that day and failed to turn on his body camera were contained in a 117-page comprehensive report involving interviews with Cedergren, five deputies, two sergeants, another lieutenant and two captains involved in the case. The document’s contents were first reported Sept. 7 by KTVU, which obtained the report through a Public Records Act request and posted the findings on the station's website.

KTVU previously reported that Cedergren retired last year, four days before he was to be fired. The Alameda County District Attorney's Office declined to file criminal charges against Cedergren or any other deputies, saying "criminal negligence involves more than ordinary careless, inattention or mistake in judgment."

The investigation stemmed an incident on June 10, 2019, when Fremont police officers were called to Madrigal's home. According to the District Attorney's Office report, Madrigal's family members had surrounded him while he behaved erratically. He admitted to using hallucinogenic drugs. The encounter was the third for law enforcement with Madrigal that week. On June 6, 2019, Madrigal tried to bypass security at San Jose International Airport and was shot with a Taser when he fought with police. He was placed in a hospital for psychiatric observation and released two days later.

On June 9, 2019, Madrigal's stepfather called Fremont police to the house when Madrigal became aggressive and was screaming and throwing things at family members. Madrigal told officers he had used marijuana and ingested  "mushrooms," or psilocybin, which causes hallucinations.

Police officers did not arrest or detain him.

During the last encounter, police arrested him on suspicion of being under the influence of a controlled substance. He was taken to the Fremont jail, but became combative with officers and was transferred in restraints and a "spit mask" to the Santa Rita Jail.

At the Santa Rita jail, two deputies suggested securing Madrigal to a "restraint chair," where he would have been strapped down. But Cedergren overruled them and had him placed in ankle restraints and handcuffs. A chain was tethered to the cell door. Later that day, Madrigal was found hanging from the chain around his neck.

During the investigation, several of the deputies with more experience working in the jail than Cedergren — who had arrived in his position just a few weeks earlier — said they believed his unfamiliarity with the restraining chair resulted in his decision not to take his subordinates' advice to utilize it.

"Deputy (Chris) Comfort elaborated on this point. He explained that because Lieutenant Cedergren was acting as if he was the 'tip of the spear,’ he was not going to bring in a device he did not know how to operate while he was in charge," Pickett wrote.

Another deputy said she had never tethered an inmate to the door, or seen a fellow officer do it. Deputy Tiffany Ross told the investigator she was surprised that Cedergren arrived on the scene and went “hands on” with the deputies. She said he did not take the time he needed to understand what they were doing, the report said.

"I asked Deputy Ross if she remembered anyone being upset and/or making comments about why the restraint chair was not utilized," Pickett wrote. "Deputy Ross told me ‘yes,’, saying she remembered everyone was pretty upset about it. Deputy Ross also confirmed Sgt. Johnnie Graham was baffled and appeared to have been confused as to why Lt. Cedergren had not approved the use of the restraint chair."

None of the deputies, however, tried to change Cedergren's decision, the report said.

Madrigal's family has filed a wrongful death suit against the Sheriff's Office.