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Decapitated Prisoner Shows CDCR Safety Standards Still Headed in the Wrong Direction

California Inspector General’s office issues another reports highly critical of  health care at Corcoran and statewide prison employee disciplinary process

by Matt Clarke

In April 2021, the California Office of the Inspector General (OIG) issued a report highly critical of the medical care prisoners received at the 2,976-man California State Prison at Corcoran. It rated the overall quality of prisoner medical services at Corcoran inadequate. In May 2021, the OIG issued a second report highly critical of the investigation of employee misconduct and the employee disciplinary process in the California Department of Corrections and Rehabilitation (CDCR), giving it an overall rating of poor.

One of the cases highlighted in the latter report involved the decapitation of a prisoner newly arrived at Corcoran who was housed in segregation with a prisoner who had a history of assaulting his cellmates and murdering and dismembering people. While the prisoner was being tortured, decapitated and dismembered, several guards failed to properly perform cell checks and falsified documents saying they saw the beheaded prisoner alive. One later lied to investigators.

A lawsuit filed by the mother of the decapitated prisoner brought many of the facts of the case to light. [PLN, Oct. 2020, p. 42]. The OIG report found that the incident was poorly investigated and the issue of who put the mismatched prisoners in the same cell was never investigated. Further, there were multiple needless delays at various stages of the disciplinary process and none of the guards were recommended for termination despite the seriousness of the infractions and the fatal outcome.

Unfortunately, this was not atypical. After monitoring 138 cases, the OIG’s report rated the CRDC’s investigative and disciplinary process during the period from July 2020 through December 2020 as poor with an overall weighted average of 66%.

Below 70% is considered poor while 70% - 80% is satisfactory and above 80% is superior. Of the six indicators the OIG rated, the CDCR was barely satisfactory in four and poor in two. It was not superior in any indicator.

The CDCR was satisfactory in the discovering misconduct and referring misconduct cases (70%), making initial determinations regarding referral of the cases to the Office of Internal Affairs (OIA) (71%), investigating the cases (72 %), and providing legal advice during the investigation (70%). It was poor in the appropriateness of its findings (64%) and providing legal representation during litigation (64%).

The performance indicator most significant in affecting the CDCR’s rating of poor performance was the investigative and disciplinary findings of the hiring authorities (HAs) after the OIA investigation was completed. In 45% of the monitored cases, the performance in that indicator was poor. In 35% of the monitored cases, there was no timely consultation with the OIG or departmental attorney regarding sufficiency of evidence, investigation, findings or disciplinary determination.

Untimely service of disciplinary actions was another important factor in the poor performance rating. This occurred in 53% of monitored cases. The legal representation provided by CDCR attorneys and employee relations officials during litigation was poor in 46% of the cases, helping to drag down the overall rating.

The quality and timeliness of the HAs’ decision-making regarding the OIA investigations, allegations, case processing and service of disciplinary actions was poor, partly because the HAs failed to conduct investigative and disciplinary findings conferences in 35% of the monitored cases. Despite all of the issues with poor performance, the OIG found that the HAs’ disciplinary determinations were appropriate in 92% of the monitored cases in which findings were made. Disciplinary penalties were imposed in 73% of those cases and the OIG determined that the appropriate penalty was chosen 80% of the time. However, in 53% of the cases there were excessive delays after the imposition of discipline in service of the disciplinary decisions.

The OIG disagreed with the OIA’s frequent failure to conduct an investigation when employees were arrested by outside agencies for non-work-related offenses such as domestic violence, DUI, public intoxication, or trespassing. The OIG recommended investigation in 44 of 51 cases but the OIA returned 37 of the cases to the HAs for disciplinary action without further investigation, relying solely on the information in the arrest report.

Although the OIG found CDCR attorneys’ performance to be satisfactory during OIA investigations, it rated the attorneys’ performance during litigation as poor. This was primarily due to untimely service of disciplinary actions, which occurred in 51% of the monitored cases.

The OIG’s medical inspection report on Corcoran covering the period of August 2019 through January 2020 gave the overall quality of health care a rating of inadequate. Using a scoring system that rated below 75% as inadequate, between 75% and 85% as adequate and 85% or above as proficient, Corcoran achieved a proficient rating in only two of ten applicable health care indicators measured for compliance and a rating of inadequate in seven.

Of the 13 applicable health care indicators, ratings dropped severely in one, dropped in three, remained the same in eight and rose in only one—health information management. The severe drop was in preventative services.

In a comprehensive review of 20 health care cases, the OIG medical team rated 14 as adequate and six as inadequate. In reviewing 957 medical events, the OIG team of physicians and nurse consultants found 270 deficiencies, 61 of which were so serious as to likely contribute to patient harm if left unaddressed. The same team assessed ten of the 13 indicators applicable to Corcoran and found seven were adequate and three inadequate.

In comparison with non-prison health care programs, Corcoran scored higher in three diabetic measures, about the same on controlling blood pressure, and much lower on eye examinations.

The OIG rated access to health care at Corcoran as adequate, noting that most nurse and specialty appointments were timely. It rated diagnostic services as inadequate overall, mostly due to untimely completion of lab tests and retrieval of lab results. An exception was radiology, which was praised for its timely performance. Case review results were rated adequate.

Emergency services received an overall adequate rating as did the health information system. Health care environment was rated inadequate with criticism for inadequate space in examination rooms, expired medical supplies, missing paperwork and staff failing to sanitize their hands between examinations. Patient transfers were rated inadequate overall due to delays in appointments for newly-arrived patients and lapses in continuity of care.

Medication management was rated inadequate overall as were prevention services and nursing performance. Provider performance received an overall inadequate rating as did administrative operations. Specialized medical housing and specialty services were both rated as adequate overall.

The OIG’s reports reveal the clear need for improvement in the CDCR staff disciplinary process and in medical services at Corcoran. Unfortunately, the history of OIG reports show that the CDCR rarely improves its performance in response to them. 




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