A new report released today by the Santa Cruz County Grand Jury examines five in-custody deaths that occurred at the County Jail during an 11-month period.

For each of the five deaths that occurred at the Main Jail between August 2012 and July 2013, the jurors created a detailed timeline aimed at identifying what was done and what improvements could be made.

In each death, the jurors found critical errors were made in the way the inmates were classified, monitored and/or treated.

The report acknowledges that steps are being taken to improve inmate safety but also makes numerous suggestions for improvement.

The report's findings included issues with inadequate communication between Dominican Hospital and jail medical staff as well as problems with how inebriated inmates were dealt with. Of particular note were issues with the way users of certain drugs were dealt with. At least four of the individuals who died had drugs or alcohol in their systems, according to toxicology reports.

Recommendations include creating a formal protocol by which medical staff at the jail is directly notified of any changes to an inmate's medical record while at Dominican Hospital, improved training when it comes to recognizing and treating methadone overdoses, among others.

The full report from the grand jury is here.  Members of the jury plan to hold a press conference this afternoon (Wednesday) outside the Santa Cruz County Superior Court.

Deputy Ryan Kennedy, a spokesman with the Santa Cruz County Sheriff's Office, which operates and oversees the jail, said the department will comment on the findings soon.

"We are very appreciative of the grand jury's hard work on the report," Kennedy said.

The Santa Cruz County Grand Jury is a 19-member group of volunteers chosen from voter rolls and driver registration records. Jurors serve for one year, though some may elect to serve a second year. The Grand Jury term begins each year on July 1st and ends the following June 30th.