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More Suicides, Overdoses and Murders in California Prisons, According to Death Review Report

While California’s prison population is down, homicides among state prisoners in 2013 were up sharply over previous years. Deaths from drug overdoses in California prisons were up, too, and the suicide rate among state prisoners was more than 40% above the national average.

That was the analysis of the federal Receiver’s office, which since 2006 has been tasked with fixing the California Department of Corrections and Rehabilitation’s broken medical care system. In October 2014, the Receiver issued a report that examined 366 prisoner deaths that occurred across the state during the previous year.

“A major piece of the quality improvement program is the death review,” Kent Imai, M.D., wrote in his report for the federal Receiver’s office. “Rigorous peer review of all prison deaths identifies serious lapses in care and records numbers of preventable deaths. The death review has been used to find opportunities for systemic improvement and to identify, counsel, and sanction any unsafe [medical] providers.”

Of the 366 prisoners who died in 2013, the death reviews found that 35 were “possibly preventable,” meaning that more adequate medical care “might have prevented or significantly delayed the patient’s death,” according to Imai’s analysis.

By comparison, as previously reported in PLN, 48 out of 426 prisoner deaths in 2006 were deemed to have been “possibly preventable,” with another 18 being deemed “preventable.” [See: PLN, Sept. 2008, p.18].

In the 35 “possibly preventable” 2013 deaths – including those resulting from cardiovascular disease, various cancers, liver disease and suicide – the death reviews found 97 lapses in medical care ranging from treatment delays to “fragmentation” in patient care or a failure to identify symptoms, as well as almost a dozen other deficiencies.

In the “possibly preventable” death of a 35-year-old male prisoner – who reportedly had “a history of tracheostomy and tracheal stenosis” – multiple lapses in care contributed to his death, according to Imai’s report. The night the prisoner died, he had been placed on suicide watch in an acute mental health ward. Yet he was still able to insert food and feces into his tracheostomy, remove the “tracheostomy appliance” and “self-traumatize” his trachea before guards and medical staff intervened.

Guards used pepper spray on the prisoner to subdue him, then “refused to extract the patient for decontamination and assessment of airway adequacy, despite a medical order to do so, citing a danger of assaultive behavior,” Imai wrote.

After harming himself, the prisoner was under observation by nursing staff at purportedly regular intervals, but several hours later was found unresponsive in his cell. It took 10 minutes for staff to initiate resuscitation, according to Imai, who noted that the cause of death was “asphyxiation from foreign material and blood in his airway.”

Suicide, at 8% of prisoner deaths, was among the top six causes of death in California prisons in 2013, in addition to cancer (26%), end-stage liver disease (19%), cardiovascular disease (14%), drug overdoses (7%) and homicide (5%). The rate of suicides (22.5 per 100,000 prisoners in 2013) was 41% higher than the U.S. average the previous year.

There were 20 homicides in California prisons in 2013, including the death of a 69-year-old man who was sexually assaulted by another prisoner. His death was considered “possibly preventable” because medical staff had failed to conduct a complete examination that would have identified the injuries that led to his death.

In 2008, three years before the U.S. Supreme Court affirmed an order requiring California to reduce its prison population due to overcrowding, there were just seven homicides in state prisons (a rate of 4.1 per 100,000, compared to 15 per 100,000 in 2013). In addition to a “gang subculture” and the “violent lifestyle for many of the incarcerated population,” Imai reported that overcrowding still contributed to the “high incidence of homicide in the prison population.”

He also wrote that both drug addiction and depression were major factors in the 24 drug overdose deaths that occurred among prisoners in 2013. In fact, the rate and number of overdoses were the highest since the federal Receiver was appointed to improve medical care.

Even among the 331 prisoner deaths in 2013 that were deemed “not preventable,” peer reviews cited 206 lapses in medical care. But for the first time since the Receiver began overseeing prison medical care, Imai wrote, there were no “definitely or likely preventable” deaths in California’s prison system.

Imai’s report – aside from the analysis of suicides, drug overdoses and homicides – was decidedly upbeat about prisoner healthcare in California, citing “significant progress on several fronts” and “favorable trends in the rates of preventable cardiovascular death, preventable cancer death” and deaths resulting from valley fever, a fungal disease. [See: PLN, June 2015, p.46; July 2013, p.28].

“The continued emphasis on accountable primary care, the focus on ongoing clinical education and training through the use of care guides and other tools, the planned concentration of patients with severe chronic diseases into new medically oriented prison facilities, and the continued reductions in the California state prison population,” Imai concluded in his report, “are expected to result in further measurable improvements in the prevention of unnecessary suffering and death.”

On July 30, 2015, Imai released another report detailing California prison deaths during 2014, which examined the cases of 319 prisoners who died that year. The top five causes of death were the same as in 2013, with cancer claiming 88 prisoners (28%), 68 deaths due to end-stage liver disease or liver cancer (21%), 54 deaths due to cardiovascular disease (17%), 23 suicides (7.2%) and 19 drug overdoses (6%). Homicide was displaced from the sixth most frequent cause of death to seventh, at nine murders (2.8%).

The Receiver’s report on deaths in California’s prison system in 2015 has not yet been released. Deaths that year included the particularly gruesome murder of 24-year-old prisoner Nicholas Anthony Rodriguez, who, according to The Guardian, was found at CSP Solano in May 2015, “sawed nearly in two, with his abdominal organs and most chest organs removed.” His body was stuffed in a trash can in a bathroom area. Rodriguez’s cellmate, Jesus Perez, 46, who is already serving a life sentence, was charged with murder and has pleaded not guilty.

Sources: “Analysis of 2013 Inmate Death Reviews in the California Correctional Healthcare System,” by Kent Imai, M.D. (Oct. 27, 2014); “Analysis of 2014 Inmate Death Reviews in the California Correctional Healthcare System,” by Kent Imai, M.D. (July 30, 2015);;

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