California correction officials ignored warnings from primary care health workers and pressured them to quickly transfer 189 potentially coronavirus-infected inmates from a Chino men’s prison last May, triggering a deadly outbreak of COVID-19 at San Quentin State Prison, reported the state watchdog. Monday.
According to the California Office of Inspector General report, 2,237 inmates and 277 personnel were infected in San Quentin by the end of August. Twenty-eight prisoners and a staff member eventually died there.
The report blamed the California Department of Corrections and Rehabilitation and California Correctional Health Care Services, or CCHCS, for creating a “public health disaster” in San Quentin, the state’s oldest prison. A smaller state prison in Corcoran, which received 67 of the 189 transfers, was less affected.
“Our investigation found that the efforts of CCHCS and the department to prepare and implement the transfers were very flawed and endangered the health and lives of thousands of detainees and personnel,” the report said.
“CCHCS and the department’s push to make the transfers and subsequent pressure to meet a tight deadline led the California Institution for Men to ignore the concerns of health care personnel and the medically vulnerable detainees. even though the vast majority had not recently been tested for COVID-19, ”he said.
By relying on outdated test results, “the prison had no way of knowing if any of the detainees were currently infected with the virus,” the report said.
Chino’s transfers came after corrections, officials and lawyers representing the inmates agreed that the men should be relocated from the prison’s barrack-like enclosure, where the virus spread rapidly.
At the time of the relocations, the Chino prison reported more than 600 cases of COVID-19 and nine deaths. The 189 were among 700 inmates selected for transmission who had medical conditions that made them particularly vulnerable to the virus.
Internal emails cited by the Inspector General showed that the medical staff at the Chino prison raised the alarm before the transfers took place.
The night before the first transfers, a supervising nurse sent an email to alert a medical director that some inmates had not been tested for nearly a month – far too early to be an effective measure of infection.
“Is there a wipe withdrawal criterion that must be met before transfer,” the nurse asked, suggesting retesting was needed.
“Don’t dry out again,” the director replied 11 minutes later.
In another email, a Chino prison manager raised the alarm to a department headquarters manager about possible spread of the virus.
“I’m surprised the headquarters is now looking to relocate our inmates,” the email read. “But we must ensure that we do not infect another institution.”
Those and other internal warnings were pushed aside and the Chino prisoners were taken by bus to San Quentin in late May. Correction officers have violated their own inmate capacity health guidelines on some trips, the inspector general said.
Two of the inmates had COVID-19 symptoms upon arrival, including one with a fever of 101.1 degrees. But while San Quentin’s health personnel suspected the Chino inmates had been exposed to the coronavirus, the prison housed 119 of them in a unit without solid doors, allowing air to flow freely through the cells.
By the time the COVID-19 test results came back, 14 infected inmates had been housed in the unit for at least six days, the report said.
“The virus spread quickly, both to the other inmates transferred from the California Institution for Men and to the 202 inmates already housed in the same unit,” the report said.
By August 6, more than half of the prisoners on the unit had tested positive. Of the 122 newly arrived Chino inmates, 91 ultimately tested positive, and two died of complications related to COVID-19.
In a joint statement on Monday, corrections and prison health officials said the transfers were made “ with the intention of limiting possible harm to Chino inmates ” and were based on “ a thoughtful risk analysis using scientific information released in May 2020. was available on the transmission of this novel disease. “
“We have recognized that there have been a number of errors in the process of these transfers,” the statement said, “and both CCHCS and CDCR have since made necessary changes in patient movements.”
The changes include more testing, quarantine and more use of personal protective equipment, according to the statement.
“Currently, San Quentin has only four patient cases, and as of August the number of COVID-19 positive patient cases has been in single digits,” the statement said.
In addition to San Quentin’s 28 COVID-related deaths, 27 inmates were killed in Chino Prison and three in Corcoran. A total of 192 inmates statewide have died among more than 47,400 who tested positive.
The deaths have sparked outrage from prisoners’ advocates and legal action by the families of some inmates.
In September, lawyers for the family of 61-year-old Daniel Ruiz filed a government claim, a precursor to a lawsuit against the correction agency. Ruiz died on July 11 after contracting the virus while in San Quentin on a minor drug crime.
“It is tragic and unacceptable that some prison bureaucrats treated them as less than human,” said attorney Michael Haddad.
After reviewing the inspector general’s report, he added, “If the goal of these prison officials was to give prisoners COVID-19, it’s hard to imagine what they could have done more effectively.”
Angela Cadena, vice president of the advocacy organization We Are Their Voices, said the report was not surprising to those with loved ones in California prisons.
“This may be news to some, but to us it has been happening since day one,” said Cadena, whose husband is incarcerated at the Richard J. Donovan Correctional Facility near San Diego. He tested positive for the coronavirus, she said, but continued to work as a doorman serving food to other inmates.
“It is traumatic not only for me as a wife, but also for my children,” said Cadena. “They live with the fear of getting that call, and the harsh reality is we got that call.”
Correction officials also defended their transparency on Monday in dealing with the health crisis they helped create.
In October, however, they declined a request for public records from The Times pending since July, looking for emails and other communications related to the failed transfer.
Collecting and assessing this data would divert critical human resources from the public health response in progress in response to the emergency and is not in the public interest, especially when the vast majority of responsive data, if not all data, will be released of disclosure, ”officials wrote when declining the request.
The Inspector General’s report also noted that it was difficult to get data from the department.
Health care in the state prison system has been the subject of lengthy lawsuits dating back to before the pandemic.
In July, J. Clark Kelso, the federal court-appointed trustee who oversees medical care in the prison, announced the removal of Dr. R. Steven Tharratt as the medical director of the system, citing the challenges of the COVID-19 pandemic.
“In order to meet current response needs while working towards further delegation of medical care to the state, it has become clear that a reorganization is necessary for long-term sustainability,” Kelso said at the time.
Tharratt, who was appointed to that post by the trustee in 2010, moved to a special care advisor to the trustee.
Kelso himself has come under fire from state legislatures. In October, six of them asked US District Judge Jon Tigar to immediately remove Kelso and replace him “with a person who is committed to the health and safety of detainees.”
Assembly Marc Levine (D-San Rafael) said, “Mr. Kelso’s mismanagement of the COVID-19 pandemic at CDCR correctional facilities resulted in the worst public health disaster in CDCR history. ”
Kelso did not respond to requests for comment on Monday.
Hadar Aviram, a professor at UC Hastings College of the Law who litigated the release of San Quentin inmates over COVID-19, said correction officers have no excuse for handling the transfers.
“You have black and white evidence that they knew about the danger,” Aviram said. “This is not the same as an error. They made a decision to risk people’s lives. This is the textbook example of willful indifference. “
Army specialist Vincent Polanco, whose father, Gilbert Polanco, died of COVID-19 in August after likely contracting it while working as a San Quentin correctional sergeant, also holds officials accountable.
“Every day I live in dreams about my father, what life could have been like,” said the younger Polanco, who sees the corrections department “as my family” and wants to be a guard himself when he finishes his active duty.
He said the “higher ups” in the system were failing his father.
“Now all of a sudden they are doing everything they should have done from the beginning, now that they are afraid,” he said. “It really pains me to see that leadership really made a mistake and didn’t take the initiative to save my father’s life.”