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Inspector General Finds Botched Transfers Caused COVID Outbreak at San Quentin, 29 Dead

In late May 2020, the California Institution for Men in Chino experienced a COVID outbreak. Executives from the California Correctional Health Care Services (CHCS) decided to transfer 189 Chino prisoners who were especially vulnerable to prisons that were safe. They pressured Chino officials to do so quickly.

Among the transfers, 172 had not been tested for COVID within the previous two weeks; 55 were not screened for symptoms within six hours of being loaded on the buses. To make matters worse, a CHCS medical executive told Chino it would be okay to exceed the 19-passenger pandemic limit on the buses since they all were housed together and had all tested negative. Prisoners—some showing obvious signs of COVID infection—were crammed onto the buses and sent on their way.

Emails sent between officials on May 27 show that Chino medical staff asked CHCS and CDCR officials whether the transferees should be swabbed for retesting. “No reswabing” was the reply. So, on May 28th and 29th, 67 Chino prisoners were sent to Cocoran. The next day, 122 Chino transferees arrived at San Quentin.

Prior to the arrival of the Chino prisoners, San Quentin had no confirmed positive cases of COVID-19. By the end of June, it would have around 2,000.

Three of the arriving prisoners had obvious signs of COVID-19 infection. San Quentin officials isolated them immediately in cells with solid doors.

The remaining 119 arrivals were housed in the South Block Facility’s Badger Unit, a five-tier cellblock in which the cells have bars and doors made of bars such that air is free to circulate throughout the unit. There were already 201 San Quentin prisoners on the Badger Unit. Within a week of their arrival, 15 of the Chino transferees had tested positive for the virus. By August 6, 2020, 91 of the Chino transferees and 85 of the 201 San Quentin prisoners had tested positive for COVID.

What happened at the Badger Unit would be a disaster by itself, but San Quentin officials made matters worse by failing to conduct contact tracing of the COVID cases and allowing guards who had worked in that unit to work and move throughout the prison. That spread the virus to every part of facility so that, by mid-July, well over half of the around 3,100 prisoners at San Quentin and over 200 staff had tested positive for COVID.

By August 6, 2020, 2,237 prisoners and 277 staff members had tested positive. Additionally, 28 prisoners and one staff member had succumbed to the disease and died.

Cocoran was lucky. Only two of its Chino transferees tested positive. It was better able to isolate prisoners due to a modern design with solid doors, resulting in a less severe outbreak than what happened at San Quentin.

The report found that the CDCR’s efforts to prepare for and execute the transfers “were deeply flawed, and risked the health and lives” of the prisoners and staff at the receiving prisons. It quoted a state judge who found, “By all accounts, the COVID-19 outbreak at San Quentin has been the worst epidemiological disaster in California correctional history.” The CDCR and CHCS released a statement saying, “many factors” related to the transfers were “not reflected in the report,” but magnanimously allowed that “some mistakes were made.” As usual, no government officials have been held accountable for the deaths, sickness and misery their actions caused. 



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