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Of 426 California Prisoner Deaths in 2006, 66 Found to be Preventable

by John E. Dannenberg

In August 2007, former California Department of Corrections and Rehabilitation (CDCR) federal healthcare Receiver Robert Sillen issued a report titled Analysis of CDCR Death Reviews, prepared by the CDCR’s Death Review Committee (DRC). The 11-page “public version” of the report analyzes the causes of all prisoner deaths in calendar year 2006, and is anticipated to influence the outcome of a three-judge federal panel that is presently considering imposing a population cap on the CDCR due to inadequate healthcare.

The DRC, chaired by the Statewide Medical Director, consists of physicians, registered nurses, healthcare administrators and prison guards. It meets two to four times a month to discuss and analyze each CDCR death. A doctor prepares a preliminary report on each death before the meeting; suicides are reviewed separately by mental health professionals. Each review covers the prisoner’s medical records and any patient/nurse interactions.

If a “significant departure” from community standards of healthcare is discovered, the responsible medical providers are reviewed for fitness to continue employment in the CDCR. As a direct result of this peer oversight process, 56 CDCR medical practitioners were disciplined between June 2005 and July 2007; 41 of those cases were initiated by death reviews.

Of the 426 prisoner deaths in 2006, 43 were suicides and one was an execution. Of 381 remaining deaths reviewed in the report, 315 were ruled “non-preventable,” 18 were “preventable” and 48 were “possibly preventable.” Non-preventable deaths included cancer (105), liver disease (53), sudden cardiac arrest (28), AIDS (17), congestive heart failure (16), homicide (16), coronary artery disease (14), pulmonary disease (11) and kidney disease (10). Five deaths were due to Valley Fever (coccidioidomycosis), a soil-borne fungus that is prevalent at some Central Valley prisons. [See: PLN, June 2008, p.22; Aug. 2007, p.7].

Notwithstanding the Receiver’s finding that 315 of the deaths were not preventable, many were deemed to have occurred prematurely due to “lapses” in healthcare; 66 alone were attributed to poor primary clinician management.

Asthma was the leading cause of the preventable deaths (6), with sudden cardiac arrest (3) and congestive heart failure (2) the next most prevalent. The report detailed specific “lapses” in healthcare that led to those deaths. For example, medical staff dropped the ball with a two-year delay in diagnosis of a patient with chronic testicular pain, who succumbed to then-inoperable testicular cancer.

In the category of “possibly preventable” deaths, the leading cause was sudden cardiac arrest (5), followed by Valley Fever (4) and AIDS (4). In 30 of the cases, lapses were tied to the failure of doctors, nurses and midlevel staff to respond to “red flag” signs and symptoms. Eleven more deaths were due to delayed referrals for specialty care or testing.
Nine deaths were blamed on delays in answering prisoner requests for medical care.

The report then detailed specific failures for each of the death categories, providing a basis for improvement recommendations. Indeed, many of these recommendations had been made in the Receiver’s May 2007 Plan of Action, which encompassed 15 categories of upgrades to CDCR healthcare procedures. [See: PLN, Nov. 2007, p.38]. The Receiver’s office issued a follow-up draft strategic plan for improved CDCR medical care on March 11, 2008.

The weight of the preventable prisoner deaths is also on the shoulders of the three-judge federal panel now considering taking over CDCR to reduce its population to manageable levels, based upon claims of constitutionally inadequate healthcare. [See: PLN, March 2008, p.38]. U.S. District Judge Lawrence K. Karlton seeks to end decades of substandard mental health treatment at CDCR facilities, while U.S. District Judge Thelton E. Henderson seeks remediation of decades of failed medical services through the longstanding Plata litigation (Plata v. Schwarzenegger, U.S.D.C., N.D. CA, Case No. C01-1351). The combined cases are set to go to trial on November 17, 2008.

Following a three-hour initial hearing in September 2007 during which 20 attorneys representing the CDCR, state prisoners, law enforcement, district attorneys, counties and Republican legislators appeared, an exhausted Judge Henderson thanked everyone for being “helpful.” The court admonished the attorneys at the outset that the case would be a judicial, not political, process.

Strange bedfellows surfaced in the hearing when the union representing California prison guards (the CCPOA) actually sided with the prisoners in asking for a speedy resolution of the matter. The CCPOA’s attorney, Ron Yank, also stated that no solution would work without concomitant sentencing reform in California.

One plainly obvious tactic by the state was an attempt to use Assembly Bill 900 – which will create 53,000 new CDCR prison beds to “alleviate” overcrowding – as a smokescreen for delaying immediate reforms to end prisoners’ needless deaths and suffering due to inadequate healthcare. Assembly Bill 900 was signed into law in May 2007; it carries a minimum $7.7 billion price tag.

Donald Specter of the San Quentin area Prison Law Office was designated lead counsel for the prisoners. The court-appointed special masters have recommended that the CDCR’s total population be reduced from 159,000 to 132,500, or even less, noting that much of this reduction can be accomplished without mass releases by ending technical parole violations that fill about 40,000 beds on any given day. Specter is not hopeful that the resolution of the Plata lawsuit will lead to a political solution (i.e., one where reason prevails in the legislature).

Indeed, so far the legislature has mostly complained about the high salaries of the Receiver and his staff, which are paid from the state’s coffers. Not counting benefit packages, these salaries include: Receiver Sillen, $500,000; chief medical officer Terry Hill, $350,000; chief medical information officer Justin Graham, $275,000; chief financial officer Terry Wood, $275,000; and chief information officer John Hummel, $275,000.

Meanwhile, healthcare Receiver J. Clark Kelso, who replaced Sillen in January 2008, is overseeing the construction of a new $160 million hospital at San Quentin State Prison. The next project is improvements at the California Medical Facility (CMF) in Vacaville. CMF’s hospice unit is often the final destination for terminally ill prisoners from around the state, where volunteer prisoners compassionately attend to their dying brethren in a dignified medical setting. See: Analysis of CDCR Death Reviews 2006, California Prison Healthcare Receiver, Inc., August 2007.

Additional sources:, Associated Press, The Reporter

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Related legal case

Plata v. Schwarzenegger