Fremont 20-year-old chained to Santa Rita Jail door with leg irons, cuffs: coroner's report

Christian Madrigal, 20, treated his body like a temple, played soccer regularly and kept a strict vegetarian diet, according to his family. He was especially close with his mother. His stepfather said he had never been in trouble with the law.

Just ahead of the anniversary of their son's death at Santa Rita Jail, Christian Madrigal's parents were out demanding police accountability last week. 

Jose Jaime and Gabriela Covarrubias were moved by the death of George Floyd by a police officer in Minneapolis. But the Fremont couple is also motivated by their personal tragedy.  

The 20-year-old Madrigal was declared dead on June 15, 2019. 

Since that time, his parents do not feel that justice has been served, and their pain has only intensified.

"This year has only gotten worse," said Jaime. He and his wie have sued Alameda County, the sheriff and the jail in a federal wrongful death suit. "The George Floyd situation has only magnified what I already thought. There is a systemic problem embedded in policing. There is so much frustration that they are not taking accountability." 

Coinciding with the anniversary of Madrigal's death, some records showing how he died were revealed this week through the lawsuit and were obtained by KTVU. 

Madrigal was chained with Peerless handcuffs and Smith & Wesson leg irons to an isolation cell door, according to coroner's report and corresponding "incident report." 

Locking an inmate to a door violates the jail's policy. 

The reports also show for the first time that deputies at first had brought out a "Pro Straint" restraint chair to try to get Madrigal to sit up and comply with their orders before a decision was made to ultimately chain him to the door.

Madrigal had first been brought to jail on June 10, 2019 by Fremont police after his family said his behavior had been erratic, paranoid and bizarre. He and his brother had experimented with mushrooms about two weeks prior. His family believes he had some sort of psychotic break after trying the drugs. 

In the end, Madrigal killed himself in the jail with the leg irons that were improperly used to restrain him. Deputies noted he was able to slip out of his handcuffs and use the leg irons around his neck. 

The official cause of his death was cited as suicide by hanging and anoxic encephalopathy, the pathologist, Dr. Angellee Chen found. 

"It appeared Madrigal was able to place himself in a seated position and hanged himself after he was able to move his handcuffed hands from behind his back to the front, and then used the leg iron chain as a ligature," the report concluded.  

Christian Madrigal's mother and stepfather stand in front of Santa Rita Jail. June 13, 2020 Photo: Brooke Anderson Photography

The nature of Madrigal's death was reported last year by the East Bay Express.

But the deputies' notes and coroner's conclusions are the first written accounts from the sheriff's perspective. They lay out in more detail some of what had been verbally described to the public last year.

They also note some of the decisions made that day and the deputies who were there.

Noah Blechman, who is representing Alameda County, has challenged the family claims in court documents and has unsuccessfully tried to dismiss the case. The Sheriff's Office has previously said it doesn't comment on pending litigation.

Lt. Craig Cedergren, who gave the green light to chaining Madrigal to the door, was put on administrative leave since Madrigal's death. Two emails to the sheriff's office to check on Cedergren's status this week went unreturned. 

Efforts to reach Cedergren or his attorney in the past and this week were not successful. 

Fremont father will forever feel guilty for calling police to help his son

Madrigal's family finds it tough to comprehend that he wound up in the county jail. 

Normally, Jaime said his stepson treated his body like a temple, played soccer regularly and kept a strict vegetarian diet. Madrigal had never been in trouble with the law. But he was also upset about moving to Fremont from Mexico. He and a brother tried mushrooms for the first time last Memorial Day. 

His family said Madrigal was never the same after experimenting with the drugs. 

After taking Madrigal to the hospital and then calling the police for a psychiatric hold, Madrigal ultimately ended up at Santa Rita Jail, where deputies described him as "uncooperative" and "resistive." 

Photos from the hospital show what look like to be chain marks around Christian Madrigal’s neck. (Eden Medical Center/Madrigal family)

A closer look at the inmates who have died at Santa Rita Jail 

Madrigal is one of 47 inmates to have died at Santa Rita Jail, which has the highest in-custody jail death rate in the Bay Area.

The sheriff's department did not respond to comment for this story, but in the past has not counted Madrigal's death in the agency's tally, saying he had been let go on "compassionate release." 

The coroner's and incident reports have not been made public despite California Public Records Requests to the sheriff's office. 

The District Attorney's Office has also not made public its findings into Cedergren's actions despite multiple inquiries from KTVU. At last check on Monday, the investigation still had not been made public. It's unclear if it has been completed. 

Instead, the coroner's and incident reports were obtained through the Madrigal's federal civil case. 

Lt. Craig Cedergren's incident report stemming from Christian Madrigal's death on June 15, 2019

What is noticeably absent from these documents is any body camera footage to provide visual evidence of what occurred.

"This gives us their official statement," said the Madrigal's attorney, Adante Pointer of Oakland. "But we can't confirm this is the actual truth. And how is it these deputies have not seen the inside of a criminal courtroom?" 

Santa Rita has a higher jail death rate than Los Angeles 

Pointer plans to file a formal request with U.S. District Court Judge Richard Seeborg on Wednesday to force all the body camera video from inside the jail to become public. 

Even without the video, the deputies' official statements include some vivid descriptions of Madrigal being chained to an isolation jail R-1 cell door in the intake area. 

In the reports, Cedergren tells his staff that he does not find the restraint chair to be appropriate and he cited the use of the leg irons as something that is used in the "core course curricula for entry-level staff and have been utilized in other incidents." 

Deputies then used two sets of handcuffs and leg iron ankle chains, the report indicates. One set of cuffs was secured to the exterior doorknob and locked together at one end of the leg iron ankle cuff. The ankle chain was then passed through the cuffing port of the door and attached to Madrigal's wrists behind his back. 

The reports indicate that Madrigal was left in the room on June 10, 2019 at 2:30 p.m. and then was found at 5:20 p.m., sitting up, unresponsive, in his chair. 

Deputies discovered that Madrigal had slipped off his cuffs from behind his back and had the leg iron chain wrapped around his neck.

About 6:30 p.m. that night, Madrigal's parents came to jail to check in on him. A deputy came out and simply said they couldn't visit. At that point, he had been taken to the hospital, where he was pronounced dead five days after he arrived.

The deputy never mentioned Madrigal's conditions or what had happened with the chains.

"That is so cruel," Jaime said. 

Madrigal's family had been very concerned about internal injuries and a lacerated liver and spleen that doctors at Eden Medical Center noted when the young man arrived at the hospital. Doctors even noted signs of a recent "assault."

The coroner said these injuries appeared old and did not consider them a contributing factor in Madgrial's death. 

Jaime said his stepson had never before been suicidal and he speculates that his son must have been in grave physical and emotional pain to have taken his own life. 

For now, Jaime is vowing to become more vocal about demanding answers. 

This is a new role for him, and one that he's reluctantly taking on.  

Jaime said he has always been the type of law-abiding citizen to buy police a cup of coffee and who prefers to stay out of the limelight.

That's all changed. 

"I"m going to be knocking on doors, talking to politicians and standing at police headquarters," Jaime said. "I have tried to respect the process. But I've been waiting and waiting. I'm tired of being patient." 

Lisa Fernandez is a reporter for KTVU. Email Lisa at or call her at 510-874-0139. Or follow her on Twitter @ljfernandez