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CDCR Tried to Conceal Report on Prisoner Suicides

A report that linked oppressive conditions in California prisons to preventable prisoner suicides was suppressed by the California Department of Corrections and Rehabilitation (CDCR), while the state tried to convince a federal judge that court oversight was no longer needed in an ongoing class-action lawsuit over deficiencies in mental health care at CDCR facilities.

The 15-page August 2011 report by Lindsay M. Hayes, Project Director of the National Center on Institutions and Alternatives, which had been commissioned by the state, concluded that the CDCR’s suicide-watch practices actually increased the risk of prisoner suicides.

Hayes’ report described suicidal prisoners being stripped of their clothes and possessions, dressed in a “safety smock” and held in small cells where in some cases they had to sleep on the floor. He found that such conditions induced prisoners to falsely claim they were no longer suicidal just so they could get out of the observation cells. Some took their own lives shortly thereafter.

State officials asked Hayes to create a redacted version of his report that omitted the damaging findings, for the limited purpose of providing it to a court monitor and the attorneys representing the prisoner class members in the lawsuit, Coleman v. Brown, U.S.D.C. (E.D. Cal.), Case No. CIV S-90-0520-LKK-JFM-P. Hayes did so. However, when the prisoners’ attorneys obtained a copy of the full version of the report, the state had the temerity to ask the district court to destroy it. The judge declined.

Hayes’ full report noted that the CDCR’s handling of suicidal prisoners was “seemingly punitive” and “anti-therapeutic.” That was partly because guards, and not mental health workers, controlled the conditions within suicide observation cells. Worse, the unabridged version of the report noted that CDCR employees sometimes falsified watch logs indicating when they checked on prisoners in the observation cells.

Specifically, the full report stated that out of 25 suicides reviewed, seven prisoners had killed themselves shortly after being released from suicide watch. Multiple lapses in adequate care, including failure to timely check on suicidal prisoners – and even failure to attempt CPR – characterized 68% of the 25 cases. Only after a prisoner died did prison officials earn high marks from Hayes, for covering themselves by creating exhaustive reports.

At the Mule Creek State Prison, the report stated that “[c]ells utilized to house inmates on suicide observation generally had poor lighting, visibility, and sanitary conditions (i.e., dirty floors and walls, non-sanitized mattresses, etc.).”

At the Deuel Vocational Institution, the conditions “were quite bad, with poor lighting, visibility, and sanitation problems.... Many cells contained tile floors, with pieces of tile previously removed that could easily be utilized for self-injurious behavior.”

The report further observed that at CSP-Sacramento, Outpatient Housing Units used to hold suicidal prisoners “had hazardous ventilation grates that were conducive to a suicide attempt by hanging.”

Hayes also reported staffing shortages; at one prison hospital, employees had been working “under protest.” Psychiatric doctors at Salinas Valley State Prison routinely juggled caseloads of up to 60 patients per day, with some units containing as many as 120 patients, he wrote. Hayes concluded that not hiring more psychiatrists may help to reduce the CDCR’s budget woes, but inadequate staffing causes more employees to leave, which results in worsening conditions both for patients and remaining health care workers.

Hayes was hired in 2010 in response to the state’s initial resolve to improve prison mental health care under duress of federal court oversight. Although his report was submitted on August 16, 2011, none of the follow-up reports and consultations called for in his contract occurred. Rather, his initial embarrassing report was “buried,” according to Robert Canning, a prison official who oversaw Hayes’ work.

Meanwhile, Governor Jerry Brown told the federal court that California’s prison mental health care no longer amounted to unconstitutional cruel and unusual punishment, and the state sought to have the CDCR freed from judicial oversight. In a flurry of speeches in January 2013, Brown cited testimony from state-paid experts who said prisoners received timely and responsive mental health treatment. The state then moved to terminate prospective relief in the Coleman case, which was denied by the court pending the receipt of additional evidence. [See: PLN, March 2013, p.24].

It is now apparent that state officials attempted to deceive both the district court and the prisoners’ attorneys by trying to suppress Hayes’ unredacted report, which found that significant improvements were still needed with respect to mental health care in CDCR facilities.

Dr. Raymond Patterson, a mental health expert hired by the state to address prisoner suicides and review the CDCR’s progress in making improvements, filed a report with the court on March 13, 2013 that essentially found the situation was hopeless.

Dr. Patterson and five other experts reviewed 15 of the 32 CDCR prisoner suicides that occurred in 2012, noting that California’s prison suicide rate of 24 per 100,000 population was significantly higher than the national average for state prisons of 16 per 100,000.
Significantly, prisoners held in CDCR segregation units are 33 times more likely to commit suicide than those not in solitary confinement.

“Overall, defendants rely on the fact that they have a suicide-prevention program to refute claims of deliberate indifference to the problem of CDCR inmate suicides. While they have such a program, it is not effective,” Dr. Patterson stated. “No matter how many times these recommendations are reiterated, they continue to go unheeded, year after year, while the suicides among CDCR inmates continue unabated, and is worsening.”

He concluded that making any additional recommendations for improvements would be “a further waste of time and effort” given the unresponsiveness of prison officials.

Sources: Los Angles Times,,, “CDCR Suicide Prevention Consultation” report by Lindsay M. Hayes (Aug. 16, 2011)

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Related legal case

Coleman v. Brown