The recent deaths of two workers at a Vallejo market and the poisoning of two others there from carbon monoxide raise questions about the state’s system designed to protect workers, one worker safety expert says.
“These are…deaths that never should have happened,” said Garrett Brown, a retired investigator with Cal/OSHA, the state’s worker safety agency, about the deaths of Moises Martinez, 67, and Raul Contreras Cervantes, 75.
Both men worked behind the meat counter at La Tapatia on Broadway in Vallejo. Both died in an upstairs storage area at the market, which included a staff bathroom, three months apart. Both suffered carbon monoxide poisoning. OSHA’s investigation found the odorless, colorless potentially lethal gas likely leaked from a water heater, next to the bathroom.
The first sign of trouble came on Halloween of 2023, when a cashier left the upstairs storage room in the middle of the day, and collapsed in the market. She was rushed to the hospital.
Just hours later, butcher Moises Martinez complained he wasn’t feeling well and sat down to rest in that storeroom upstairs, where he sometimes slept. The next day, he was found dead.
Experts question how authorities handled the unexplained death case.
“It definitely is a sequence of errors, but it’s hard to blame one person individually because it’s multiple levels of errors,” said Judy Melinek, a forensic pathologist and former assistant medical examiner in San Francisco, who reviewed OSHA documents and the autopsy findings from the ensuing investigation.
“The investigation is really rudimentary for a death that is in a workplace and where someone is found in a storage room,” she said, noting that investigators failed to take into account that Martinez was found near a water heater, a common source of carbon monoxide. As a result, she says, his blood wasn’t tested. “It is not a routine test,” Melinek noted, “but it is routinely asked for when the scene indicators are there.”
Three days later, another red flag — a 16-year-old stock clerk collapsed in the same upstairs bathroom. He was rushed to the hospital, suffering from unexplained brain damage, according to a lawsuit filed on his behalf.
“This is a clear indication that something’s going on in this part of the workplace,” said Brown, who noted that under state worker safety regulations, the market should have taken action based on the warning signs.
“You have a death, and then you have a hospitalization shortly thereafter — the employer should have at that point all on their own, done an investigation,” he said.
But without the market doing that investigation, according to OSHA, and the coroner stumped as of January, 2024, there was nothing to prevent another tragedy in that same upstairs storage area.
In February, 2024, La Tapatia butcher Raul Cervantes died within minutes of going upstairs to use the bathroom. In the second death, however, first responders got sick as well. Blood tests finally confirmed carbon monoxide poisoned Cervantes and new tests turned up carbon monoxide in the blood taken from Martinez three months earlier.
“A $20 CO monitor from Home Depot installed in the bathroom would have fixed the problem,” Brown said.
But the market’s attorney told OSHA that the deaths were the result of an “unpredictable” but “very human event” for the market – arguing the owners had no way of knowing about the blocked venting of carbon monoxide from its water heater.
The lawyer was responding to the $56,000 citation OSHA issued against the market, alleging that it failed to install carbon monoxide monitoring for the storage area and lacked a worker safety plan. Such a plan, the agency said, mandates employers probe any potentially unsafe condition.
But the market’s lawyer said it was a gap in the law related to carbon monoxide monitoring, not any lack of a safety plan, that was to blame for the deaths. In an appeal of the citation, the attorney concludes that no “detector was required by law, although probably would’ve saved lives.”
Yet according to the coroner’s report, Martinez sometimes slept in the storeroom.
“It’s a totally tragic situation,” said Brown, who still tracks OSHA staffing levels at local offices, like the one in American Canyon, at the worker safety agency he formerly worked at.
He noted that at the time of the incidents, the local office was operating with more than a third of its inspector slots unfilled.
That short staffing, he says, could help explain why the agency not immediately launching probes into unexplained workplace death cases like Martinez.
Had that happened, he says, a life might have been spared.
