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BOP’s Terminal Island Response Sparked COVID-19 Spread

As chronicled by the Marshall Project, prison officials were also parsimonious with compassionate releases of the prison’s medically vulnerable population, granting just five of more than 256 requests filed while cases of COVID-19 exploded in April and May 2020.

FCI Terminal Island employs 267 BOP staff members to care for 1,091 low security prisoners with “chronic care needs” as well as those needing “specialized medical or mental health care.” After the first employee tested positive for COVID-19 on April 5, 2020, the disease spread to the first prisoner five days later, ultimately infecting over 70 percent of those incarcerated there.

During the same period, COVID-19 cases in the greater Los Angeles community — where the prison is located — spiked 1,292%, exploding from 3,019 to 42,037.

The new report was issued January 13, 2021, by the Office of the Inspector General (OIG) of the federal Department of Justice (DOJ), the parent agency of BOP. It documents how officials at FCI Terminal Island failed to provide social distancing, did not adequately quarantine those who tested positive and lacked adequate personal protective equipment (PPE).

Eight of those who died had pre-existing conditions, and six were older than 65, statistics that reflect the prison’s medically vulnerable population. As of March 28, 2020, nearly 15 percent of prisoners at FCI Terminal Island were age 60 or older — “about 8 percentage points higher than the BOP-wide average,” the report noted.

Investigators also found that prison officials failed to identify the virus with early testing. Five of the ten prisoners who died “did not receive a COVID-19 test until after staff sent them to the hospital,” the report stated.

All Terminal Island prisoners were finally tested for COVID-19 between April 23, 2020 and April 27, 2020. According to a media release on April 28, 2020, BOP had tested “over 1,000” prisoners at the prison, with 443 positive cases, representing 42 percent of the prison’s population, though nine out of ten “were not reporting symptoms prior to testing,” OIG noted.

Eleven days later, the number of positive cases at the prison had increased to 693.

OIG conducted a remote inspection between May 6 and June 25, 2020, using telephone interviews, document review, assessment of prisoner demographic data, as well as staff and prisoner COVID-19 case data. The purpose of the inspection was “to understand how the COVID-19 pandemic affected the institution and to assess the steps that Terminal Island officials took to prepare for, prevent and manage COVID-19 transmission within the facility.”

OIG also issued a survey to more than 40,000 BOP employees at facilities housing prisoners across the country. Of the 267 employees at FCI Terminal Island, 74 —28% —responded.

From these surveys, the report concluded that prison officials had difficulty maintaining social distancing among prisoners housed in open dormitory housing units. Staff also reported that prisoners were not adequately quarantined after testing positive, with 107 inmates who tested negative in two housing units kept with 129 others who had tested positive for a period “between 4 and 5 days after the institution received their test results,” OIG found.

Administrators and their staff also disagreed about the adequacy of PPE, including face masks. Officials at FCI Terminal Island reported that “staff had consistent access to adequate PPE.” But OIG said that staff survey responses and a staff interview “indicated that having adequate PPE was a challenge for staff and inmates.” Far exceeding numbers at other BOP facilities, 60 percent of staff reported not having enough PPE such as gloves, surgical masks, gowns and face shields, while 84 percent cited a need for additional equipment.

One of OIG’s most troubling findings was that prison staff violated BOP policy requiring notification of families of deceased prisoners. According to that policy, a warden or designee is supposed to contact a prisoner’s next of kin to explain the circumstances of death. At FCI Terminal Island, that duty was designated to the Chaplain. However, after two prisoner deaths, family members learned of their loved ones’ death to COVID-19 only through the media.

OIG found that, in at least one instance, BOP officials failed to alert the family of a prisoner who has been hospitalized on a ventilator with COVID-19 for six days before passing away. Officials at BOP’s Central Office and Western Regional Office claimed that the lack of notification was an oversight. But “institution staff” told OIG investigators they never informed the family of at least two inmates infected with COVID-19 “because they did not deem it relevant.”

In response to the OIG report, BOP claims that prison staff now reaches out to every emergency contact on file for all prisoners who are hospitalized with COVID-19. Prisoners are now also allowed to call their emergency contact weekly. 


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