Nearly half the inmates at the Santa Clara County Jail suffer from a mental illness, according to the Santa Clara County Sheriff's Department.
Kate Jones, who runs what is called the Jail Observer Program for the Office of Human Relations, said the signs of trouble were there well before the alleged murder of inmate Michael Tyree by jail deputies.
Jones said she told jail administrators at the beginning of the year the jail staff is not adequately trained to deal with inmates suffering from a mental illness. Her remarks are in an annual report on jail conditions for the Office of Human Relations.
"The guards have a tough job and they're being asked to do things for which they are not trained," Jones said.
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Tyree, who suffered from mental illness, was beaten to death at the jail in August. Three jail guards now face murder charges in the case. Was Jones' report a foreshadowing?
"My job as an ombudsman is to give the administration a heads up and a lead on what is coming in," Jones said. "It's my job to do that."
When asked if Jones knew about problems before at the jail she responded: "You say problems, I say gaps. We did know that there were gaps."
Santa Clara County Undersheriff John Hirokawa runs the jails. He said the sheriff's office took Jones' recommendations seriously, along with recommendations from other watchdogs.
The administration was in the process of making changes, like hiring more psychiatrists to meet the demand, when Tyree was allegedly murdered, Hirokawa said.
"I would say yes, but not fast enough obviously, on whether we would have prevented some of the issues," Hirokawa said in response to whether changes were in motion at the jail at the time of Tyree's death.
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Jones is pleased at how the sheriff's office has responded to the jail concerns.
On Monday, NBC Bay Area got a look at what might be in her next report early in 2016. Jones may recommend the hiring of counselors, called psych techs, inside the jail.
"If you're not getting counseling, you're not going to make much progress," Jones said.
Hirokawa said his office has been and will continue to be transparent in how it runs the jails.
New psychiatrists are on their second week of training at the main jail.
The Santa Clara County Board of Supervisors will look at approving a clinical gap analysis to investigate what changes to clinical care need to be implemented.