Analysis of 2020 California Correctional
Health Care Services Inmate Mortality
Reviews

Kent Imai, MD
Consultant to the California Prison Receivership
12/22/2021

Analysis of 2020 CCHCS Inmate Mortality Reviews

Table of Contents
I.

Introduction ................................................................................................................................................................. 1
A. Mortality review process ........................................................................................................................................... 2
B. Definitions .................................................................................................................................................................... 3
C. The California State Prison Population in 2020 .................................................................................................... 3

II.

2020 Study Findings .................................................................................................................................................. 6
A. Causes of Inmate Death ............................................................................................................................................ 6
B. Average Age at Time of Death in the CCHCS, 2020 ......................................................................................... 10
C. Expected and Unexpected Deaths in 2020......................................................................................................... 11
1.
2.

Expected Deaths .....................................................................................................................................................................11
Unexpected Deaths ................................................................................................................................................................11

1.

Opportunities to improve the application of the “Model of Care” as described in the CCHCS Complete Care
Model ........................................................................................................................................................................................16
Opportunities to improve clinical decision making by improved recognition and management of important
clinical signs and symptoms..................................................................................................................................................18
Opportunities to improve recognition and action in response to abnormal laboratory and other diagnostic test
results ........................................................................................................................................................................................20
Opportunities to improve adherence to policies and procedures and care guides for specific diseases,
conditions, or risk factors .......................................................................................................................................................20
Opportunities to improve communication between providers in primary care teams and care transitions ..........24
Opportunities to improve medical record documentation .............................................................................................25
Opportunities to prevent delays in diagnosis or treatment.............................................................................................26
Opportunities for improving the practice and documentation of emergency medical responses..........................28
Potential Quality Issues (PQI) ................................................................................................................................................28

D. Opportunities for Improvement, 2020 ................................................................................................................. 12
2.
3.
4.
5.
6.
7.
8.
9.

III.

Discussion of Trends ................................................................................................................................................ 29
A. Trends in Overall Prison Mortality Rates in California and the United States, 2006–2020 ......................... 29
B. Selective Causes of Death Contributing to Increased Mortality Rates in 2020 ............................................ 31
1.
2.
3.

COVID-19 .................................................................................................................................................................................31
Infectious Diseases Other Than COVID-19 ........................................................................................................................35
Homicide ..................................................................................................................................................................................36

1.
2.
3.

Drug overdose.........................................................................................................................................................................38
Advanced liver disease ..........................................................................................................................................................39
Suicide.......................................................................................................................................................................................40

1.
2.

Cardiovascular disease ..........................................................................................................................................................42
Lung cancer..............................................................................................................................................................................43

C. Selective Causes of Death Which Had Lower Mortality Rates in 2020 .......................................................... 38

D. Selected Causes of Death - other .......................................................................................................................... 42

IV.

Quality Improvement Initiatives, 2020 ................................................................................................................. 44

V.

Conclusions ............................................................................................................................................................... 45

i

Analysis of 2020 CCHCS Inmate Mortality Reviews

Tables and Figures
Figure 1. California State Prison Population 2006–2020. .................................................................................................. 4
Figure 2. Racial Representation in California General Population and CDCR In-Custody Populations .................. 5
Table 1. Causes of Death Among All California Inmates, 2020. ...................................................................................... 7
Table 2. Top Causes of Death Among California Inmates, 2006–2020. ........................................................................ 9
Figure 3. Causes of Death in California State Prisons, 2019 and 2020. ....................................................................... 10
Table 3. Ranges and Average Ages at Death Among All California Inmates, 2020. ................................................. 11
Figure 4. Inmate Deaths by Expectation and Category, CCHCS 2020. ....................................................................... 12
Figure 5. Deaths and OFI Findings, CCHCS 2018–2020. ............................................................................................... 13
Table 4: Opportunities for Improvement – Interim Classification for 2020 Mortality Reviews and Frequency in
Unexpected and Expected Deaths ............................................................................................................................. 15
Table 5. Signs and Symptoms Incompletely or Belatedly Evaluated and Eventual Diagnoses, CCHCS, 2020. .. 19
Table 6. Significant Delays in Diagnosis or Treatment, CCHCS, 2020. ........................................................................ 27
Table 7. Annual Mortality Rates Among California and U.S. State Prison Inmates, 2006–2020. ............................. 30
Figure 6. CCHCS Annual Death Rate per 100,000 Inmates, 2006–2020 ..................................................................... 30
Table 8. Ethnic Representation in CCHCS COVID-19 Fatalities, 2020. ........................................................................ 31
Table 9. Associated Conditions in CCHCS COVID-19 Fatalities, 2020. ....................................................................... 32
Figure 7. COVID-19 Deaths in California State Prisons, CCHCS 2020. ........................................................................ 33
Figure 8. Numbers and Rates of (non COVID-19) Infectious Disease Deaths, CCHCS 2012–2020 ....................... 35
Figure 9. Death Rates in Select Causes of Infectious Disease, CCHCS 2012–2020 ................................................... 36
Table 10. Numbers and Rates of Homicides, CCHCS 2012–2020, and U.S State Prisons 2012–2018 .................. 37
Figure 10. Numbers and Rates of Homicides, CCHCS 2012–2020, and U.S State Prisons 2012–2018 ................. 37
Table 11. Numbers and Rates of Overdose Deaths, CCHCS 2012–2020, and U.S State Prisons 2012–2018 ...... 38
Figure 11. Numbers and Rates of Overdose Deaths, CCHCS 2012–2020, and U.S State Prisons 2012–2018 .... 38
Table 12. Numbers and Rates of Liver Disease Deaths, CCHCS 2012–2020. ............................................................. 39
Figure 12. Numbers and Rates of Liver Disease Deaths, CCHCS 2012–2020. ........................................................... 40
Table 13. Numbers and Rates of Suicide, CCHCS 2012–2020 and U.S. State Prisons 2012–2018. ....................... 41
Figure 13. Numbers and Rates of Suicide, CCHCS 2012–2020 and U.S. State Prisons 2012–2018. ...................... 41
Table 14. Numbers and Rates of Cardiovascular Deaths, CCHCS 2012–2020. ......................................................... 42
Figure 14. Numbers and Rates of Cardiovascular Deaths, CCHCS 2012–2020. ........................................................ 42
Table 15. Numbers and Rates of Lung Cancer Deaths, CCHCS 2012–2020. ............................................................. 43
Figure 15. Numbers and Rates of Lung Cancer Deaths, CCHCS 2012–2020. ............................................................ 44

ii

I. Introduction
Healthcare services for the California prison system, now called the California Correctional Health Care
Services, or CCHCS, were placed under Federal Receivership in October 2005. The Receivership was
established by the U.S. District Court as the result of a 2001 class-action lawsuit against the state of
California over the quality of medical care in the state's prisons. The court found that the medical care
was a violation of the Eighth Amendment of the U.S. Constitution, which forbids cruel and unusual
punishment of the incarcerated.
Since 2005, the Receivership has been transforming CCHCS in order to provide constitutionally
adequate medical care to the inmates in the 35 prison facilities. By 2015, the Receivership began
delegating institutions back to the California Department of Corrections and Rehabilitation (CDCR). In
the same year, the Complete Care Model, based on the industry standard known as the PatientCentered Health Home, became the foundation for CCHCS health care services delivery.
In January 2020, CDCR and CCHCS released a new, joint vision and mission statement with an
emphasis on restorative justice, successful community reintegration and public safety.
The new vision and mission statement reflected “the ongoing commitment of CDCR and CCHCS to
provide education, treatment, rehabilitation, health care, and restorative justice in a safe and humane
environment.”

Vision

We enhance public safety and promote successful community reintegration
through education, treatment, and active participation in rehabilitative and
restorative justice programs.

Mission

To facilitate the successful reintegration of the individuals in our care back to their
communities equipped with the tools to be drug-free, healthy, and employable
members of society by providing education, treatment, rehabilitative and
restorative justice programs, all in a safe and humane environment.

This analysis of calendar year 2020 inmate mortality reviews in the CCHCS is the fifteenth consecutive
annual report, covering every year of the Receivership.

1

Following the format of prior years, this report will describe the mortality review process and
classification of the causes of deaths in the prison system.
The general categories of “unexpected” and “expected” deaths will be analyzed. Opportunities for
improvement will be categorized and analyzed. California prison mortality rates and trends in specific
causes of mortality will be discussed.
This and all prior death report analyses are available at https://cchcs.ca.gov/reports/.

A. Mortality Review Process
Prior to 2018, the mortality review process was conducted to identify lapses in care which might have
contributed to “preventable deaths” in the prison system. In 2018 a formal assessment of the CCHCS
Mortality Review Policy and Practice, conducted at the behest of the Receiver, recommended focusing
on system improvement rather than individual lapses in keeping with the most current standard of
practice among health care organizations and patient safety programs.
Any inmate death triggers an initial death report generated by the prison in which the death occurs.
This report goes through the Electronic Health Record System to the central headquarters (HQ)
mortality review unit staff. Then a local death summary is submitted to HQ within five business days.
This summary includes significant clinical events, the emergency medical response, any identified
lapses in health care delivery and any systemic issues that may have contributed to the patient’s death.
HQ mortality review staff assigns each death to both a physician and nurse reviewer. An extensive
review of the patient’s clinical record is conducted, dating back at least six months prior to the date of
death. A reviewer may include older records if relevant to determine the antecedents to the terminal
event. The quality of care experienced by the patient is evaluated including the quality of triage and
evaluation, timeliness of access to care, the quality of care for any chronic medical condition,
adherence to published evidence-based care guides and nationally recognized standards of care,
responses to all abnormal laboratory and imaging studies, and the timing and quality of emergency
response.
All suicides or possible suicides undergo an additional, separate case review by a member of the
Suicide Prevention and Response Focused Improvement Team (SPRFIT).
The results of these reviews are then presented at the HQ Mortality Review Committee (MRC). The
MRC membership is appointed by the Statewide Deputy Directors of Medical and Nursing Services.
The MRC consists of three physicians, three nurses, one mental health professional, one custody
representative, and one (non-voting) member of the Quality Management staff. Following discussion

2

of the case, the MRC attributes the cause of death and assigns the death to one of four categories:
expected or unexpected death, with or without findings for opportunity(ies) for improvement.
In addition to Opportunities for Improvement (OFI), the MRC also identifies Potential Quality Issues
(PQI), which refers to incidents with potential quality implication that occur outside the CCHCS prison
system, in one of the Healthcare Provider Networks that contract with the state to provide hospital care
or specialist care.
The final mortality report is sent to Institution (prison) and Regional health care leadership and findings
are entered in the Electronic Health Care Incident Reporting (eHCIR) system.
The overall effort is intended to:
•

Eliminate the “preventable death” finding and replace it with the findings of “expected or
unexpected” death with or without “opportunities for improvement”;

•

Assess the mortality review process by tracking and reporting on OFI generated by the review;
and

•

Utilize identified OFI to design and implement statewide system improvements.

B. Definitions
Expected Death: A medically anticipated death which is related to the natural course of a patient’s
illness or underlying condition.
Unexpected Death: An unanticipated death which is not related to the natural course of a patient’s
illness or underlying condition.
Opportunity for Improvement (OFI): An occasion or situation from which it is possible to improve
systems or processes related to the delivery of health care.
Potential Quality Issue (PQI): A health care incident, regardless of severity, which occurs during the
course of treatment by a Healthcare Provider Network facility or provider and requires submission of
a written Potential Quality Issue referral.

C. The California State Prison Population in 2020
The Receivership was created in 2006, when the California prison population numbered 171,310.
Federal Court mandated reductions, upheld by the US Supreme Court, resulted in a significant
decrease in the number of inmates in custody. Additional legislative actions also contributed to the
3

reduction in inmate population. These included Assembly Bill 109 in 2011- an “Alternate Custody
Program”, which had some felonies and parole violations remain in county jail; Proposition 36 in 2012,
the Three Strikes Reform Act; Proposition 47 in 2014, converting some felonies into misdemeanors;
and Proposition 57 in 2017, which increased good behavior opportunities for inmates. By December
31, 2019, the prison population was 124,027. The COVID-19 pandemic resulted in a further reduction
following 1) an Executive Order by the California Governor in March 2020 which suspended the intake
of new inmates from county jails into state prisons and 2) CDCR’s actions in spring and summer of
2020 to reduce population and maximize space. By December 31, 2020, the California prison
population was 95,432, of which 92,116 were housed in the 35 state prison facilities. This population
was 102.8% of the designed capacity of the prisons, the lowest number since 2006.
https://www.cdcr.ca.gov/research/population-reports-2/
Figure 1 shows the prison population from 2006-2020.

CDCR Average In-Custody Population, 2006–2020

Thousands

AB10
180
160

-

-

Lr----, -

-

_,-

-

-

140

Prop
36

Prop
57

Prop
47

~~

I

_.----,,_,~

.r.L....__

120

I

.,,_,..---,_,
,

Gov. Exec Order
re: COVID-19,
Intake
Suspension and
Expedited
Release

- ,-

--

2017

2018

100

'T~

I

80
60
40
20
0

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

2016

2019

2020

I

Population* 171,310170,786170,022169,459166,700161,843134,929133,297135,225128,824128,705130,807128,875125,270107,347

*Calculated as the average of in-custody population figures for Mar 31, Jun 30, Sep 30, and Dec 31 of that year.
Figure 1. California State Prison Population 2006–2020.

The following demographic statistics are sourced from the Offender Data Points report published in
October 2020 by the CDCR Office of Research.
(https://www.cdcr.ca.gov/research/wp-content/uploads/sites/174/2021/06/201906_DataPoints.pdf)
Age – The average age of the California prison population in June 2019 (the latest month for which
there are statistics) was 40.1 years, with males averaging 40.2 and females 38.1. Individuals under 45
represent nearly two thirds (66.2%) of the total prison population.

4

The prison population has been increasing in average age, with prisoners older than 55 comprising 16%
of the CCHCS population in 2019 (Offender Data Points, Table 1.19), compared with 12.5% in 2015.
Sex – In June 2019, there were an average of 119,781 males (95.5%) and 5,691 females (4.5%) in
custody (Offender Data Points, Table 13.1.)
Ethnicity – The In-custody population in June 2019 was 28.3% Black, 44.2% Hispanic, 20.9% White,
with all other ethnicities making up the remaining 6.6%. (Offender Data Points, Table 1.17)
The California Department of Finance estimated the 2019 California general population to be 5.7%
Black Non-Hispanic, 39.3% Hispanic Any Race, 38.3% White Non-Hispanic, 13.1% Asian Non-Hispanic,
0.8% Other Races Non-Hispanic, and 2.7% Multiracial Non-Hispanic.
Figure 2 shows the overrepresentation of California’s Black and Hispanic populations in its prison
system. Black overrepresentation is the most significant, comprising 6.5% of the general population
and 28.2% of inmates. Hispanics are also disproportionately represented, comprising 39.4% of the
general population and 44.2% of inmates.

Racial Representation in California General andMultiple Races,
2.7%
CDCR In-Custody Populations, 2019.
California
General
Population

CDCR
In Custody
Population

Black,
5.7%

Hispanic, 39.3%

White, 38.3%

Hispanic, 44.2%

Black, 28.2%

■ Black

■

Hispanic

■ White

■

Asian

■

Multiple Races

Asian, 13.1%

White, 20.9%

■ All

All other
ethnicitie
s, 0.8%

All other
ethnicities,
6.6%

other ethnicities

Figure 2. Racial Representation in California General Population and CDCR In-Custody Populations

5

II. 2020 Study Findings
A. Causes of Inmate Death
There were 492 inmate deaths in calendar year 2020, 486 in males (98.8%) and 6 in females (1.2%).
Table 1 shows the number and causes of all inmate deaths.
Number
of Cases Category and Causes of Death
141 Infectious Disease (COVID-19)
83 Cancer (CA)
CA-lung (17); CA-colorectal (8); CA-pancreas (8); CA-prostate (7); CA-esophagus
(6); CA-bladder (5); CA-brain (5); CA-unknown primary (4); CA-kidney (3); CA-bile
duct (2); CA-tongue (2); CA-larynx (2); CA-lymphoma (2); CA-stomach (1); CAureter (1); CA-acute myelogenous leukemia (1); CA-acute lymphoblastic leukemia
(1); CA-gall bladder (1); CA-malignant thymoma (1); CA-melanoma (1); CAliposarcoma (1); CA-multiple myeloma (1); CA-nasopharynx (1); CA-parotid gland
(1); CA-thumb (1)
54 Cardiovascular Disease
sudden cardiac arrest (38); congestive heart failure (11); acute myocardial
infarction (4); post-operative cardiac arrest (1)
46 Infectious Disease (non-COVID-19)
sepsis (16); pneumonia (11); endocarditis-infectious (10); pneumonia-aspiration
(3); disseminated coccidioidomycosis (2); abscess, intracranial (1); disseminated
histoplasmosis (1); influenza A (1); necrotizing fasciitis (1)
32 Advanced (End Stage) Liver Disease (ESLD)
ESLD with hepatocellular carcinoma (HCC) (18); ESLD without HCC (14)
32 Homicide
31 Suicide

23 Drug Overdose
fentanyl (6); non-specified opioid (6); heroin (4); cannabinoid (1); fentanyl + heroin
(1); fentanyl + methamphetamine (1); methamphetamine (1); methamphetamine +
morphine (1); morphine (1): other (1)
11 Neurological Disease
dementia (5); Parkinson disease (2); amyotrophic lateral sclerosis (1); central cord
syndrome (1); myasthenia gravis (1); seizure disorder (1)

6

Number
of Cases Category and Causes of Death
10 Pulmonary
chronic obstructive pulmonary disease (7); pulmonary fibrosis (2); pneumoniaaspiration (1)
6 Gastrointestinal Disease
pancreatic abscess with sepsis (1); acute intestinal obstruction (1); intestinal
perforation (1); intestinal perforation with sepsis (1); ischemic bowel (1); upper GI
hemorrhage (1)
4 Auto Immune
autoimmune hemolytic anemia (1); autoimmune hepatitis (1); rheumatoid arthritis
(1); sarcoidosis (1)
4 Accidental Injury
duodenal perforation (1); drug overdose-venlafaxine (1); asphyxiation (1); cardiac
tamponade due to iatrogenic perforation of superior vena cava (1)
4 Cerebrovascular Disease
stroke (3); stroke-hemorrhagic (1)
4 Renal Disease
end stage renal disease (4)

4 Endocrine/Metabolic/Nutrition/Immunity
hypoglycemia (1); diabetic ketoacidosis (1); diabetes mellitus (1); dehydration (1)
2 Circulatory System
pulmonary embolus (1); sudden cardiac arrest with pulmonary embolism (1)
1 Unknown
sudden cardiac arrest (1)
492 Grand Total
Table 1. Causes of Death Among All California Inmates, 2020.

7

The SARS-CoV-2 virus (COVID-19) was the number one cause of mortality in 2020, accounting for 141
or 29% of all deaths in the CCHCS. Four of these patients experienced sudden cardiac deaths and
initially were not suspected to have had COVID-19 infection but review by the MRC concluded that
each had died from COVID-19-related complications. An additional 4 patients were infected with
COVID-19 at the time of death, but COVID-19 was not thought to be causal in these patients’ deaths.
Cancer, with 83 cases, was the second leading cause of death in 2020. Cancer of the lung (17 cases)
was the most common, followed by colorectal (8), pancreatic (8), and prostate (7) cancers. Cancer of
the liver (hepatocellular carcinoma) is not included in this total. The liver cancer deaths are included
in the category of advanced liver disease (as a well-known complication accompanying that disease).
Cardiovascular disease, with 54 deaths, was the third leading cause. Sudden death or sudden cardiac
arrest (38 cases), congestive heart failure (11 cases), and acute myocardial infarction (4 cases), together
accounted for 53 of these. The majority of these are attributed to underlying coronary artery disease.
Infectious diseases excluding COVID-19 caused 46 deaths. Sepsis (16), pneumonia (11) and infectious
endocarditis (10) were the top three causes in this category.
Advanced liver disease, including liver cancer, caused 32 deaths. Homicide also caused 32 deaths in
2020. These two causes of death tied for fifth in 2020.
Suicide (31 deaths), and drug overdose (23 deaths) were the seventh and eighth leading causes.
Neurologic disease caused 11 deaths and noninfectious pulmonary diseases caused 10 deaths.
Table 2 shows the top causes of death in the California prisons from 2006 through 2020.

8

Top Causes of Death in California State Prisons
YEAR

RANK

1

2

3

4

5

6

7

8

9

2020

Infectious
Disease COVID-19

Cancer

Cardiovascular
Disease

Infectious
Disease (not
COVID-19)**

(tied) Advanced Liver
Disease; Homicide

Suicide

Drug Overdose

Neurological
Disease

2019

Cancer

Drug Overdose

Cardiovascular
Disease

Advanced Liver
Disease*

Suicide

Infectious
Disease**

Homicide

Pulmonary

Neurological
Disease

2018

Cancer

Cardiovascular
Disease

Drug Overdose

End Stage
Liver Disease*

Infectious
Disease**

(tied) Suicide, Homicide

Pulmonary

Circulatory
System

2017

Cancer

Cardiovascular
Disease

End Stage
Liver Disease*

Drug Overdose

Infectious
Disease**

Suicide

Cerebrovascular
Disease

Pulmonary

2016

Cancer

Cardiovascular
Disease

End Stage
Liver Disease*

Infectious
Disease**

Drug
Overdose

(tied) Suicide, Homicide

Cerebrovascular
Disease

Pulmonary

2015

Cancer

Cardiovascular
Disease

End Stage
Liver Disease*

Infectious
Disease**

Suicide

Drug
Overdose

Cerebrovascular
Disease

Pulmonary

2014

Cancer

End Stage
Liver Disease*

Cardiovascular
Disease

Suicide

Drug
Overdose

Pneumonia
**

Homicide

Pulmonary

(tied)
Infectious;
StrokeHemorrhagic

2013

Cancer

End Stage
Liver Disease*

Cardiovascular
Disease

Suicide

Drug
Overdose

Homicide

Sepsis**

(tied) Pulmonary; Pneumonia**

2012

Cancer

End Stage
Liver Disease*

Cardiovascular
Disease

Suicide

Homicide

Drug
Overdose

(tied) Sepsis; Infectious**

Stroke

2011

Cancer

End Stage
Liver Disease*

Cardiovascular
Disease

Suicide

Pneumonia
**

Homicide

Sepsis**

Drug Overdose

Stroke
(tied)
Coccidioidomycosis; End
Stage Renal
Disease; Stroke

Homicide

Homicide

2010

Cancer

End Stage
Liver Disease*

Cardiovascular
Disease

Suicide

(tied) Drug Overdose;
Homicide

Pneumonia
**

Congestive
Heart Failure

2009

Cancer

End Stage
Liver Disease*

Cardiovascular
Disease

Suicide

Drug
Overdose

Pneumonia
**

Congestive
Heart
Failure

Homicide

2008

Cancer

Suicide

End Stage
Liver Disease*

Cardiovascular
Disease

Drug
Overdose

Pneumonia
**

HIV/AIDS

Congestive
Heart Failure

Sepsis**

2007

Cancer*

End Stage
Liver Disease

Cardiovascular
Disease

Suicide

Homicide

HIV/AIDS

Stroke

Drug Overdose

Pneumonia**

2006

Cancer*

Cardiovascular
Disease

End Stage
Liver Disease

Suicide

Drug
Overdose

Homicide

Pulmonary

End Stage Renal
Disease

Stroke

* Liver Cancer was counted as Cancer in 2006 and 2007; as Liver Disease from 2008 onward.
** Beginning with 2015, Pneumonia and Sepsis were included in Infectious Disease, which also includes HIV/AIDS. COVID-19 is its own category.
Table 2. Top Causes of Death Among California Inmates, 2006–2020.

9

Figure 3 compares the causes of death in California inmates in 2019 and 2020.

Causes and Rates of Death in California State Prisons, 2019 and 2020
■

0

20

2019

• 2020

40

60

80

100

120

140

Adverse Medication Reaction
HIV/AIDS
Unknown I
Circulatory System
Endocrine/Metabolic/Nutrition/Immunity
Renal Disease

Cerebrovascular Disease
Accidental Injury
Auto Immune
Gastrointestinal Disease
Pulmonary
Neurological Disease
Liver Disease (incl. HCC)

•
•
•

----

-■II

Drug Overdose

Suicide
Homicide
Infectious Disease (non COVID-19)
Cardiovascular Disease
Cancer
Infectious Disease (COVID-19)
Figure 3. Causes of Death in California State Prisons, 2019 and 2020.

Aside from COVID-19, the death rates for cancer and cardiovascular disease appear much the same
as in prior years, whereas the death rates from homicides and infectious diseases other than COVID19 were higher and the death rates from suicide and advanced liver disease were lower in 2020. The
death rate from drug overdose was strikingly lower in 2020, with 41 fewer deaths than in 2019.

B. Average Age at Time of Death in the CCHCS, 2020
The average age of all male inmates who died in 2020 was 60 years; the average age of deceased
female inmates was 58 years.
In the prison population, the youngest inmate death was at age 21, the oldest at age 90.

10

There is a bimodal distribution of ages at death. Table 4 shows ranges and average ages at death
among California inmates, depending on cause. In 2020, drug overdoses, suicides, and homicides
caused death at an average age of 42, while the average age of death by all other causes, including
COVID-19, was 64.
Age Range

Average Age

Age of all 486 male decedents

21 – 90

60

Age of all 6 female decedents

44 – 72

58

Age of suicides, drug overdoses, and homicides

21 – 75

42

Suicide

21 – 70

40

Drug overdose

21 – 74

41

Homicide

21 – 75

41

Age excluding suicide, drug overdose, and
homicide

28 – 90

64

Table 3. Ranges and Average Ages at Death Among All California Inmates, 2020.

C. Expected and Unexpected Deaths in 2020
1. Expected Deaths
Expected Death: A medically anticipated death which is related to the natural course of a patient’s
illness or underlying condition
The 200 expected deaths in 2020 were the result of chronic disease processes like cancer, end
stage liver disease, chronic infections, cardiovascular processes like congestive heart failure,
pulmonary processes like chronic obstructive pulmonary disease or pulmonary fibrosis, and
neurologic diseases like Parkinson or Alzheimer Disease.

2. Unexpected Deaths
Unexpected Death: An unanticipated death which is not related to the natural course of a patient’s
illness or underlying condition
There were 292 cases of unexpected death in 2020. Drug overdoses, accidents (unintentional
injuries), suicides, and homicides together accounted for 90 (38%) of these. Sudden cardiac arrests
were an additional 37 (12.7%).
Figure 4 compares unexpected and expected deaths in each causation category. COVID-19
appears in both categories, probably due to its variable natural history.
11

Inmate Deaths by Expectation and Category, CCHCS,
2020.
Unknown 1I

• Expected

• Unexpected

Circulatory System 2I

.■
4
■

Renal Disease 13
Endocrine/Metabolic/Nutrition/Immunity
Cerebrovascular Disease
Accidental Injury
Auto Immune
Gastrointestinal Disease

■4

4
■
13
■
6
■

Pulmonary 2 8
Neurological Disease

3 8

Drug Overdose

23

Suicide
Liver Disease (incl. HCC)

31
29

3

Homicide

32

Infectious Disease (non COVID-19)

23

23

Cardiovascular Disease

10

44

Cancer 3

80

Infectious Disease (COVID-19)

32

109
0

20

40

60

80

100

120

140

Figure 4. Inmate Deaths by Expectation and Category, CCHCS 2020.

D. Opportunities for Improvement, 2020
Opportunity for Improvement (OFI): An occasion or situation from which it is possible to improve
systems or processes related to the delivery of health care.
The Mortality Review Committee (MRC) identifies opportunities for improvement and forwards those
findings to the appropriate prison and region for further review.
An OFI cited in a Mortality Review can be relatively minor (documentation inconsistency) or potentially
serious (an important specialist recommendation lost during a patient transfer, resulting in a significant
delay in the diagnosis of a treatable condition).
In 2020, a total of 959 OFI findings were identified, including Potential Quality Issues (PQI). Of these,
571 occurred in unexpected deaths and 388 occurred in expected deaths. This difference of 183 more
OFI in unexpected deaths is almost entirely accounted for by a difference of 88 OFI cited in emergency
responses (since there are usually no emergency protocols initiated in patients whose deaths are

12

expected), and by an additional difference of 104 in the OFI for covid protocols in unexpected vs.
expected deaths.
The average number of OFIs per death was 0.9 in 2018, 1.1 in 2019 and 1.9 in 2020. The emergence
of the COVID-19 pandemic created disruptions in standard procedures and processes, added
uncertainty and required a learning curve for staff and for patients. The increased number of OFI
findings does not necessarily correlate with a poorer quality of health care, but may be due to
increased awareness of the importance of identifying opportunities for quality improvement reflected
in the activity of the MRC.

Deaths and OFI Findings, CCHCS 2018–2020
1000

2.5

900
2.0

Deaths

700
600

1.5

500
400

1.0

300

200

OFIs per Death

800

0.5

100

0

- -

2018

Deaths

0.0
2019

OFIs

2020 (with COVID-19)
Avg OFIs per death

Figure 5. Deaths and OFI Findings, CCHCS 2018–2020.

Additionally, as seen in Table 4 below, there were 230 OFI specifically related to findings regarding
adherence to new and changing COVID-19 policies and processes. The MRC recorded 392 OFI
findings in 2018 and 431 OFI findings in 2019.
The classification system for OFI used in this annual report was devised in 2018 and refined in 2019
and 2020.
Table 4 shows the categories of OFI, the number of OFI findings in unexpected and expected deaths,
and total findings in each category.

13

Opportunities for Improvement

Unexpected
Deaths

Expected
Deaths

Total

1. Opportunities to improve application of the “Model of Care” as described in the CCHCS
Complete Care Model
a. Meeting access timeframes for routine and urgent care

14

19

33

b. Applying complex care management for improved
coordination or continuity

17

19

36

c. Transferring a patient to a more appropriate level of care

20

8

28

32

19

51

ii. Honoring POLST and DNR orders

6

14

20

iii. Improving pain and other symptom management,
especially in cancer care

-

4

4

iv. Offering hospice care to terminally ill patients

6

9

15

e. Improving counseling of non-adherent or non-compliant
patients

4

1

5

f.

Substance Abuse Disorder Program referral indicated but
not made

9

1

10

2. Opportunities to improve clinical decision making by
improved recognition and management of important clinical
signs and symptoms

58

55

113

3. Opportunities to improve recognition and action in response
to abnormal laboratory, imaging and other diagnostic test
results

17

21

38

d. Optimizing care near the end of life…

i. Applying Physician’s Orders for Life Sustaining
treatment (POLSTs) and Do Not Resuscitate (DNR)
orders

4. Opportunities to improve adherence to policies and procedures, and care guides for specific
diseases, conditions, or risk factors
a. COVID-19 Interim Guidance

167

63

230

6

14

20

4

17

21

10

8

18

b. Care Guides

i.

Fall risk

ii. Pressure ulcer (injury) avoidance
iii. Medication management

14

Opportunities for Improvement
iv. Other Care Guides

Unexpected
Deaths

Expected
Deaths

Total

25

13

38

5. Opportunities to improve communication between providers in primary care teams and care
transitions.
a. Specialty care

1

5

6

b. Hospital

6

6

12

c. Emergency Department

2

3

5

d. Mental Health

8

-

8

e. Custody

-

-

-

f.

-

-

-

g. Primary Care Physician and Nursing

2

2

4

h. Other

-

2

2

a. Inadequate or inaccurate record

8

11

19

b. Missing Report

5

3

8

c. Missing Physician or Nurse notes

6

2

8

14

8

22

9

9

18

6

25

31

Primary Care Physicians

6. Opportunities to improve medical record documentation

d. Legacy Charting
e. Incomplete Problem List

7. Opportunities to prevent delays in diagnosis and/or
treatment

8. Opportunities to improve the practice and documentation of CCHCS Emergency Protocols
a. Delay calling 9-1-1

30

3

33

b. Documentation lapse

33

1

34

c. Other

32

3

35

14

20

34

571

388

959

9. Potential Quality Issue (PQI) referral
TOTAL

Table 4: Opportunities for Improvement – Interim Classification for 2020 Mortality Reviews and Frequency in
Unexpected and Expected Deaths

15

1. Opportunities to improve the application of the “Model of Care” as described in the
CCHCS Complete Care Model
The Complete Care Model (CCM) is the foundation for delivery of all care in the CCHCS. Adopted
in 2015, the CCM was based on the industry standard “Patient Centered Medical Home”. In the
CCM every patient is assigned to one of several Interdisciplinary Care Teams at an institution. Each
Care Team has the responsibility for promoting and providing continuous, comprehensive,
coordinated, and patient centered care for its panel of assigned patients. Care teams follow
standards for access to primary prevention, wellness services, episodic care, chronic disease
management, urgent and emergent needs, and end-of-life care. The CCM uses processes such as
daily care team huddles, panel management strategies, performance dashboards, master patient
registries, patient problem lists, and decision support tools such as the Care Guides for clinical
support.
a) Meeting access timeframes for routine and urgent care.
33 Total (22 Routine; 11 Urgent):
11 Routine, 3 Urgent in unexpected deaths; 11 Routine, 8 Urgent in expected deaths
The standards for access in the CCHCS are as follows:
•

Primary care: Emergency – same day, Urgent – 1 day, Routine – 14 days, Post hospital discharge
– 5 days

•

Specialty care: High priority – 14 days, Medium priority – 45 days, Routine priority – 90 days

In 2020, examples of cases not meeting these standards included a request for an abdominal CT
scan in a patient who was being evaluated for abdominal pain, whose request was denied “due to
covid”, and many instances of delays in routine requests for care for a variety of symptoms.
b) Applying complex care management to improve care coordination
36 Total: 17 in cases of unexpected death; 19 in cases of expected death
The opportunity to apply complex care management is based on the risk stratification of patients
by the primary care teams. There are criteria for identifying patients who are at high risk for adverse
outcomes. Complex care management involves team based strategies to mitigate the risk and
maximize outcomes. Patients with complex care needs often need coordination of visits to
specialists, appointments for special diagnostic tests or procedures, pre and post-operative
instructions, and other special education and counseling. Candidates for complex case
management include patients with concurrent mental illness, complex conditions such as cancer,
dementia or chronic debilitating conditions like Parkinson disease, patients on multiple

16

medications, advanced age, loss of function requiring assistance with activities of daily living,
hospice level of care, multiple recent hospitalizations and multiple specialists involved in care.
Special populations such as those with Substance Use Disorder or patients with chronic
nonadherence also apply. Risk stratification tools and criteria can be found in the Health Care
Department Operations Manual.
c) Transferring a patient to a more appropriate level of care.
28 Total: 20 in cases of unexpected death; 8 in cases of expected death
These are missed opportunities to timely transfer patients to levels of care more appropriate to
their clinical status. Several patients had “red flag symptoms or signs” such as abnormal vital signs,
shortness of breath, and/or abnormally low oxygen saturation levels but were not sent to an
emergency room for possible hospitalization. There were 7 patients who had oxygen saturation
levels in the low 90’s or high 80’s who were subsequently diagnosed with COVID-19 pneumonia.
(Not all patients with COVID-19 pneumonia and low oxygen saturations are severely symptomatic
and some even deny shortness of breath despite low oxygenation, only to rapidly decompensate.)
d) Optimizing care at the end of life
90 Total: 44 in cases of unexpected death; 46 in cases of expected death
The CCHCS honors the ethical principal of patient autonomy and directs physicians to provide a
Physician Order for Life Sustaining Treatment (POLST) for patients that are “elderly, frail, burdened
with serious chronic medical conditions, or have less than six months’ life expectancy”. These
patients should have the opportunity to provide specific directions for their end of life care. The
primary care team is expected to have periodic discussions regarding goals of treatment or
continued treatment in the face of advanced illness. During these discussions, a patient might
forego resuscitation in the event of a terminal emergency. Such a decision would generate a “do
not resuscitate/do not intubate” (DNR/DNI) order.
i.

POLST/DNR discussions in appropriate patients not initiated
51 Total: 32 in cases of unexpected death; 19 in cases of expected death

These 51 patients were appropriate for POLST discussions, but care teams did not initiate them.
ii. POLST/ DNR in place but patient desires not honored
20 Total: 6 in cases of unexpected death; 14 in cases of expected death
These patients had specific orders written for modifications in their life-sustaining treatment
but nevertheless experienced attempted cardiopulmonary resuscitation or were sent out to

17

hospital emergency rooms and experienced hospitalizations and other life-sustaining
measures against their previously expressed or written desires.
iii. Opportunity to better manage pain, especially in cancer patients
15 Total: 6 in cases of unexpected death; 9 in cases of expected death
The optimal management of pain in cancer patients or patients who have other reasons for
severe or intractable pain is the goal for all primary care teams. The Care Guide for Pain
Management emphasizes a comprehensive approach to diagnosis and management of all
types of pain including the importance of chronic pain as a red flag symptom of underlying
malignancy and other occult conditions. The importance of screening for and making
concurrent depression and the judicious use of non-narcotic and narcotic strategies are
covered in detail.
In 2020, there were 15 OFIs for cases in which patients might have experienced better
management of pain. Ten of these patients had cancer.

2. Opportunities to improve clinical decision making by improved recognition and
management of important clinical signs and symptoms
113 Total: 58 in cases of unexpected death; 55 in cases of expected death
Previous reviews have discussed the concept of “red flag” symptoms or signs as indicators of
potential serious diseases. The term “red flag” was originally associated with back pain, but now
lists of red flag symptoms exist for many other conditions. Examples cited in prior years in the
CCHCS have included chest pain or shortness of breath as indicators of acute coronary syndromes,
unexplained weight loss or prolonged abdominal pain as the first indicator of an underlying
malignancy, and atypical headache or an alteration in mental status as a harbinger of brain tumor
or stroke. In prior years, unsuspected bowel perforation was heralded by hypotension or altered
level of consciousness. Other important red flags included unilateral leg swelling in deep vein leg
thrombus, and a new heart murmur in endocarditis. Specific red flags such as jaundice,
hematemesis or melena are definitely abnormal and should always be quickly investigated. An
extensive medical literature on “red flags” can be accessed in this review article:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6060920/
In 2020, there were 113 OFI for symptoms or signs that were thought to have been incomplete
evaluated or evaluated more slowly than was indicated.
Table 5 shows the most common of these OFI and (if known) the eventual diagnoses.

18

Clinical Sign or Symptom

Number of
Findings

Eventual Diagnoses

abnormal vital signs (fever, tachycardia)

23

COVID 19 (12), sepsis (3), malnutrition
(2), abscess (1)

weight loss

14

CA pancreas (3), esophagus (2) liver (2),
unknown site, stomach, kidney (1each)

abdominal pain

13

CA - bladder (2), CA - unknown primary
(2), CA - pancreas (1), bowel obstruction
(2), advanced liver disease (2)

low oxygen saturation (85-92%)

9

COVID-19 (7), aspiration pneumonia (1)

altered mental status or change in
behavior

9

dementia (2), CA - brain (2), stroke (2)

shortness of breath

7

COVID-19 (4 cases)

pain, miscellaneous - back, groin,
throat, neck

7

CA testis, CA - parotid, CA -esophagus
(1 each)

high blood pressure

6

none known

nausea, vomiting, diarrhea

6

drug withdrawal (1)

cough

5

COVID-19 (5)

dysphagia

4

CA larynx (2), aspiration pneumonia (1)

hematemesis

3

CA - esophagus (1 case)

dizziness

3

no diagnoses

chills, malaise

2

drug withdrawal (1)

headache, chronic

2

CA brain (2)

localized edema

2

abscess, substance abuse disorder

generalized edema

2

none known

suicidal ideation

2

suicide (2)

other: hematochezia (2), reported falls
(2), hemoptysis, thirst, anorexia,
dysphagia, reported “low blood sugar”

9

none known

Table 5. Signs and Symptoms Incompletely or Belatedly Evaluated and Eventual Diagnoses, CCHCS, 2020.

19

3. Opportunities to improve recognition and action in response to abnormal laboratory
and other diagnostic test results
38 Total: 17 in cases of unexpected death; 21 in cases of expected death
Just as there are “red flags” for signs and symptoms, any abnormality in a diagnostic test should
be treated as an indicator of potentially serious disease and needs appropriate followup. All
abnormal test results should be flagged, noted, and explained. There should be a system which
accounts for abnormal results logged in after hours, on weekends and during shift changes.
Communication with specialists, at times of admission and discharge to hospitals and other tertiary
care locations, and at times of interfacility transfers or discharges to parole are important care
transitions during which test results can be lost. Some of the OFI cited in this category led to
significant delays in diagnosis or treatment, as will be discussed in a later section.
In 2020, there were 38 OFI in this category. They included tests indicative of underlying malignancy
in 15 cases: 7 abnormal CT scans, 2 abnormal ultrasounds, 2 anemias, one abnormal urinalysis, one
abnormal liver function, one positive test for fecal occult blood, and one abnormal skin biopsy. An
abnormal white blood cell count, a positive blood culture, and ketones in the urine were abnormalities
in three cases of sepsis. An abnormal chest x-ray was missed early in a case of COVID-19.

4. Opportunities to improve adherence to policies and procedures and care guides for
specific diseases, conditions, or risk factors
328 Total: 212 in cases of unexpected death; 116 in cases of expected death
a) COVID-19 Interim Guidance
230 Total: 167 in cases of unexpected death; 63 in cases of expected death
In 2020 the CCHCS developed extensive COVID-19 guidance for all staff in California prisons.
Based on prevailing standards from the Centers for Disease Control and Prevention (CDC) and the
California Department of Public Health (CDPH), it is a frequently updated guide. It includes
information on pharmaceutical and non-pharmaceutical prevention strategies, infection control,
use of personal protective equipment, respiratory protection, and vaccination; testing and
treatment; and outbreak management strategies including early identification of infection,
isolation of infected patients, identification and quarantine of all contacts, monitoring and treating
infected patients and containing local outbreaks. There are sections governing movement of
patients within and between housing units, hospitals, and other prison facilities, and safe discharge
and follow up of patients to the community.

20

The COVID-19 and Seasonal Influenza: Interim Guidance for Health Care and Public Health
Providers included over 100 revisions and updates in calendar year 2020. It can be accessed at
https://cchcs.ca.gov/covid-19-interim-guidance/
In 2020, there were 230 OFI addressing improved adherence to COVID-19 policies and
procedures. This represents 24% of all the OFI noted by the MRC. There was a significant additional
workload imposed on CCHCS staff by all the new COVID-19 containment strategies, from universal
screening to twice daily quarantine rounding, to daily detailed clinical assessments and treatments
of all infected patients, and proper documentation of all of the foregoing. The burden of
documentation, in particular, created an unusual number of “legacy charting” citations, in which
templated rounding was often placed in patients charts for dates during which the patient was no
longer in the institution. (Some templates were revised in response to these findings.)
b) Care Guides
98 Total: 45 in cases of unexpected death; 53 in cases of expected death
The Care Guides are tools created by the CCHCS for use by clinicians and care teams in the management
of patients. In 2020, the following 30 Care Guides were available, and they can be accessed on the
CCHCS website - cchcs.ca.gov/clinical-resources. with the following diseases or conditions:
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•

Advanced Liver Disease*
Anticoagulation
Asthma
Chest Pain
Chronic Wound Management
Clozapine
Coccidioidomycosis (Valley Fever) Chronic Obstructive Pulmonary Disease
Cognitive Impairment/Dementia
Diabetes (Type 2)*
Dyslipidemia (high or abnormal cholesterol)
Foreign body ingestion/insertion
Hepatitis C*
HIV*
Hunger Strike
Hypertension*
Intoxication and Withdrawal*
Major Depressive Disorder
Medication Assisted Treatment for Opioid Use disorder in Pregnancy
Pain Management
Palliative Care
Post Renal Transplant*
Primary Care Guide to Foot Care*
21

•
•
•
•
•
•
•

Schizophrenia
Seizure Disorders
Skin and Soft Tissue Infections
Substance Use Disorder*
Transgender*
Tuberculosis
Weight Management

Care Guides new or revised in 2020 are noted by an asterisk (“*”).
Similar resources for nursing staff are also in use and include protocols and encounter forms for
patients with:
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•

Abdominal Trauma
Allergic Reaction(s)
Asthma
Burns
Chest Pain
Chest Trauma
Constipation
Dental Conditions
Earache
Epistaxis
Eye injury/irritation
Female Genitourinary Complaints
Headache
Hemorrhoids
Rash
Insect Stings
Intravenous Therapy
Loss of Consciousness
Musculoskeletal Complaints
Respiratory Distress
Seizure
Tetanus Prophylaxis
Upper Respiratory Infections
Wound Care

i.

Opportunities to mitigate fall risk
20 Total: 6 in cases of unexpected death; 14 in cases of expected death

Patients at risk for falls are expected to be identified by their care teams. All patients are
screened for risk for falling, including any history of falls, current ambulation, vision and balance
22

status, measuring of blood pressures supine and upright, presence of chronic disease, and
medications that might increase fall risk. Patients should also be reassessed for fall risk
whenever their clinical condition changes significantly or worsens. Measures are then put into
place to mitigate fall risk. These might include adequate room lighting, beds placed in a lower
and safer position, call devices available within easy reach, handrail safety, mobility support
items, non-slip footwear, and traffic paths free of clutter.
Of the 17 OFI in this category, twelve of these patients experienced falls and on case review
were found not to have had fall assessments done despite being at high risk — wheelchair
bound, confusional state, dizziness, etc. Several of these patients were on palliative care for
cancer or dementia. Four of the OFI involved falls experienced when protocols were not being
followed. One case was a Potential Quality Issue sent to an outside hospital where a patient
had experienced multiple falls.
ii. Pressure Ulcer (Injury) Avoidance
21 Total: 4 in cases of unexpected death; 17 in cases of expected death
Pressure injuries are a major source of patient morbidity at hospitals and long-term care
institutions. Risk factors for pressure injury are immobilization, malnutrition, sensory loss and
decreased circulatory perfusion. Patients with stroke, severe arthritis, paralysis or weakness,
advanced age, and patients in restraints are all at risk for developing pressure injury. The
development of a pressure injury or ulcer (known as a decubitus ulcer) increases the risk for
local and systemic infection which can lead to sepsis and death. All CCHCS patients with risk
factors are expected to be screened for pressure injury risk and any patient at risk is given a
prevention and treatment plan to mitigate the risk of further injury, infection, and sepsis.
Of the OFI cited for pressure injury in 2020, 6 cases were acquired during inpatient stays at
contracted hospitals, and 15 were acquired by severely ill and bedridden patients at CCHCS
institutions.
iii. Medication Management
18 Total: 10 in cases of unexpected death; 8 in cases of expected death
In 2020 there were 18 OFI in which the management of prescribed medication could have
been improved. Diabetes management was cited in 4 cases: one patient had recurrent
hypoglycemia which was not well managed, one patient received no medication for persistent
increases in blood glucose, one patient had suboptimal insulin management, and one patient
did not have oral medications adjusted for poor kidney function. There were 2 cases in which
anticoagulation could have been better managed - one in which prophylactic anticoagulation
23

for the prevention of post-operative deep vein thrombosis was prolonged past the two week
recommendation, and one in which prescribed anticoagulant may not have been indicated in
a patient with a terminal prognosis. There were 2 cases each involving suboptimal use of
antibiotics, nonsteroidal anti-inflammatory agents, and proton pump inhibitors. And there was
one case each of the following: inappropriate use of an anti-fungal agent, cholesterol lowering
agents indicated but not prescribed, a corticosteroid not tapered as recommended,
acetaminophen ordered despite a history of allergy, serum sodium not being monitored as
indicated in patient with hyponatremia induced by oxcarbazepine, and the hoarding of a
narcotic ordered by directly observed therapy, later to be used in an overdose attempt.
iv. Other
38 Total: 25 in cases of unexpected death; 13 in cases of expected death
There were 38 additional OFI in the area of adherence to recommended practices in care
guides or deviations from standard nursing protocols. These included 6 references to the
Advanced Liver Disease Care Guide, 4 references each to the Anticoagulation and Wound Care
Guides; 3 references each to Suicide prevention and monitoring, the use of cardiac risk
profiling in patients with dyslipidemia, and recommendations in the Chronic Obstructive
Pulmonary Disease Guide; 2 references each to the Hunger Strike and Diabetes Care Guides;
2 references each to Nursing documentation and sexual assault protocols; and one OFI in each
of the following cases: lung cancer screening in a high risk patient, aortic aneurysm screening
in an older smoker, improper use of respiratory therapy equipment, a lapsed developmental
disability evaluation, and physical therapy not given to a non-ambulatory patient recently
discharged from the hospital.

5. Opportunities to improve communication between providers in primary care teams
and care transitions
37 Total: 18 in cases of unexpected death; 19 in cases of expected death
The accurate transfer of clinical information between care teams at transitions of medical care is
important for high quality patient care. Lost information as to patients’ end of life wishes for care,
for example, can lead to unnecessary procedures or expensive and painful efforts to prolong life
when the patient is transferred to the ED or hospital. Poor communication between specialists and
primary care teams can lead to critical tests being delayed or not done. Information missing or lost
when patients are transferred can lead to missed diagnoses or delayed treatment. Within care
teams there is also potential for missed communication. There were 37 OFI in this general category.
Of these, 12 cited care team – hospital communication, eight cited poor primary care – mental
health interaction, six cited miscommunication between the primary care team and the specialist,
five cited care team – emergency room, four cited care team – nursing, and two cited other
24

communications issues. No cases cited OFI related to primary care – primary care, or primary care
– custody communications.

6. Opportunities to improve medical record documentation
75 Total: 42 in cases of unexpected death; 33 in cases of expected death
The adoption of the electronic medical record (EMR) was completed in 2017. It has resulted in
more complete documentation of visits and improved systems for storing and sharing information.
There are several areas in which opportunities for improvement exist.
a) Inadequate or inaccurate documentation of care which occurs inside the CCHCS.
19 Total: 8 in cases of unexpected death; 11 in cases of expected death
b) Incomplete or missing documentation
8 Total: 5 in cases of unexpected death; 3 in cases of expected death
This can occur when, for example, care is provided outside of the CCHCS, and information may
not be transferred from one EMR system to another. A record of a patient encounter in an outside
emergency room, hospital, or specialist’s office may be unavailable or missing for a time
c) Missing physician or registered nurse notes
8 Total: 6 in cases of unexpected death; 2 in cases of expected death
Examples include a lack of progress notes or shift entries, a missing note for pain medication, or
no order written for a given medication.
d) Legacy charting
22 Total: 14 in cases of unexpected death; 8 in cases of expected death
“Legacy charting” is a term used to describe a workaround by some providers who “cut and paste”
sections of patient encounters in order to save time.
e) Incomplete “problem list”
18 Total: 9 in cases of unexpected death; 9 in cases of expected death
The problem list captures a patient’s known medical and psychiatric conditions and is to be always
kept current. Examples include an acute overdose, an abnormal chest x-ray, obstructive sleep apnea,
and multiple surgeries for colostomy that were not documented on the patients’ problem lists.

25

The 75 OFI captured in this category do not include the documentation lapses cited during an
Emergency Medical Response, the documentation of POLST and DNI/DNR orders or the numerous
documentation lapses cited for the new COVID-19 procedures. These are all counted in their
respective sections.

7. Opportunities to prevent delays in diagnosis or treatment
31 Total: 6 in cases of unexpected death; 25 in cases of expected death
In 2020, there were 31 cases in which delays were noted, the same number of cases as in 2019.
Table 6 describes the reason for delay, the approximate duration of delay, and the eventual
diagnosis.

Delay
“Red flag” symptoms or signs: 8 cases
1. Weight loss (20#)
2. Swelling in groin
3. Weight loss, hematuria
4. Weight loss (56#)
5. Chest pain, recurrent
6. Vertigo, recurrent
7. Weight loss (10#), hematuria
8. Dysphagia, heartburn
Abnormal laboratory or other diagnostic test results: 4 cases
1. Blood glucose (labile 56-600)
2. Fecal occult blood
3. Abdominal CT
4. Elevated calcium
Delayed referral to specialist: 4 cases
1. Oncology
2. Surgery
3. Diagnostic imaging (PET scan)
4. Surgery
Other - Interfacility transfer while evaluation ongoing: 2 cases
1. Oncology
2. Pulmonary
Multifactorial: 13 cases
1. Abdominal pain, delayed referrals
2. Interfacility transfer, denial CT request
3. Multiple referrals, delayed
4. Abnormal physical exam, abnormal bone scan, abnormal CT
scan, abnormal biopsy

Duration
3 months
6 months
7 months

Eventual Diagnosis
Cancer - pancreas
Cancer - testis
Cancer - prostate

9 months
9 months
18 months
30 months
36 months

Cancer - gastrointestinal
Cancer - gastric
Cancer - brain
Cancer - renal cell
Cancer - esophageal

9 days
4 months
11 months
30 months

Diabetic ketoacidosis
Cancer - colon
Cancer - liver
Hyperparathyroidism

2 months
4 months
8 months
13 months

Cancer - recurrent brain
Cancer - squamous cell (thumb)
Cancer - recurrent laryngeal
Cancer - squamous cell (eyelid)

1 month
12 months

Cancer -melanoma
Usual interstitial pneumonia

3 months
4 months
5 months
5 months

Cancer - unknown primary source
Cancer - pancreas
Cancer - esophagus
Cancer -recurrent- tongue

26

Delay
5. History of “throat cancer”, routine ENT referral, patient refusal
of referral, abnormal CT, biopsy positive for cancer,
6. Abnormal abdominal CT, patient refusal
7. Abnormal abdominal CT, delay referral
8. Abnormal chest x-ray, abnormal CT chest, abnormal PET, biopsy
positive, delay repeat PET
9. Dysuria, recurrent abdominal pain, denied prostate
ultrasound, interfacility transfer, delay surgery
10. Hoarseness, delayed ENT referral
11. No recommended screening for liver cancer, abnormal CT chest
12. Hoarseness, weight loss (13#), dysphagia, abnormal CT,
patient refusal
13. Recurrent pain of neck, jaw, ear, abnormal MRI

Duration
6 months

Eventual Diagnosis
Cancer - recurrent - esophagus

7 months
7 months
14 months

Cancer - pancreas
Cancer - liver
Cancer - lung

15 months

Cancer - urinary bladder

15 months
17 months
21 months

Cancer - laryngeal
cancer - liver
cancer - esophagus

30 months

cancer - parotid gland

Table 6. Significant Delays in Diagnosis or Treatment, CCHCS, 2020.

A delay in diagnosis may occur when clinical “red flags” are not pursued. Unexplained weight loss,
symptoms indicating blood loss, any persistent or recurrent pain, hoarseness, or difficulty
swallowing (dysphagia) or urinating (dysuria) were red flags signifying potential cancers.
The proper recognition and management of abnormal laboratory or diagnostic imaging results is
dependent on an integrated care team process. Workflows involve the ordering of tests,
processing of orders, recording test results, tagging abnormal results, and appropriate and timely
clinician response. Each of these steps carries potential for delay. Patients with abnormal imaging
tests suggesting malignancy might benefit from special attention with care coordination strategies,
involving individual case managers. Ten cases had abnormal test results suggesting malignancy.
A delay in access to specialists contributed to delays in 8 cases.
Patient non-adherence to recommendations for follow-up testing or referral to specialists can also
be a significant factor contributing to delays. Case management aimed at counseling of patients
can help with this problem.
Patients with a history of prior cancers should be worked up expeditiously to rule out recurrences.
There were three such cases in 2020.
Untimely interfacility transfers delayed case evaluations in 3 cases.
In all, 27 of the 31 cases resulted in delayed diagnosis and/or treatment of cancers.

27

8. Opportunities for improving the practice and documentation of emergency medical
responses.
102 Total: 95 in cases of unexpected death; 7 in cases of expected death
In 2019, there were 50 OFI in this category. A statewide quality initiative to redesign the Emergency
Medical Response (EMR) Program began in 2018. The EMR Program was rewritten in March of
2019 and training commenced in 14 institutions by the end of 2019. The COVID-19 pandemic
caused a temporary suspension of training in 2020, and training resumed in May of 2021.
Since there were many more emergency responses activated in cases of unexpected death, these
accounted for 95 of the 102 OFI.
Delays in activation of a 9-1-1 call were noted in 33 cases. These delays ranged from 3 to 41
minutes.
Other citations included lapses in documentation, the underuse of Narcan to reverse possible
narcotic overdose, difficulties in securing intravascular access, response to abnormal ECG patterns,
not checking blood glucose for hypoglycemia, and improper use of emergency equipment.

9. Potential Quality Issues (PQI)
34 Total: 14 in cases of unexpected death; 20 in cases of expected death
Potential Quality Issue: A health care incident, regardless of severity, which occurs during the course
of treatment by a Healthcare Provider Network facility or provider and requires submission of a
written Potential Quality Issue referral.
Primary health care is provided to California’s inmate population in outpatient and inpatient units
within the 35 CDCR institutions. For specialty care services, emergency department and hospital
based care CCHCS has contracted with an independent outside contractor, Health Net. Mortality
reviews which discover OFI involving contracted services will generate a PQI which is forwarded
to the appropriate emergency department, hospital, or specialist for their further review and
action.
In 2020, there were 34 PQIs, compared with 24 in 2019.
•

Thirteen (13) PQI referrals involved pressure injuries/ulcers developing in hospitalized patients.

•

Eight (8) patients were discharged prematurely from the hospital and readmitted within 24-48
hours of discharge.

28

•

Six (6) patients had iatrogenic injuries: a neck hematoma developed following surgery; a
pleural fluid infection followed a thoracentesis; a perforated superior vena cava complicated
the removal of an implanted cardiac defibrillator; a neck fistula developed following placement
of a central venous catheter; peritonitis complicated a partial colectomy for cancer; and a fall
resulted in a fractured radius requiring surgical repair.

•

Three (3) patients were discharged from the ED or hospital without having had an appropriate
evaluation: one patient with multiple risk factors for acute myocardial infarction whose chest
pain was not evaluated expeditiously; a patient with a penetrating facial injury could have been
urgently referred to a higher level of care; and a patient with clinical evidence of sepsis who
was discharged back to the institution rather than admitted to the hospital.

•

Four (4) miscellaneous PQIs were as follows: a patient was intubated despite having a DNR/DNI
order; a patient was discharged without the appropriate bottle for draining a pleural effusion;
a patient did not have indicated COVID-19 testing performed; and a patient’s chart had
documentation inconsistencies.

All PQIs are managed by the entity to which the PQI was forwarded.

III.Discussion of Trends
This section examines mortality trends in key areas. Where referenced, comparative U.S. State Prison
data are sourced from the U.S. Bureau of Justice Statistics (BJS) Mortality in State and Federal Prisons,
2001-2018 – Statistical Tables, Table 4 (NCJ 255970, April 2021).

A. Trends in Overall Prison Mortality Rates in California and the United States,
2006–2020
The following table shows the number of deaths and the corresponding mortality rates in California
prisons from 2006–2020, compared to mortality rates at all U.S. state prisons.
Death Rate per 100,000 Inmates
CCHCS Number
of Deaths

CCHCS Number
of Inmates

CCHCS

U.S. State
Prisons*

2006

424

171,310

248

249

2007

395

170,786

231

256

2008

369

170,022

217

261

YEAR

29

Death Rate per 100,000 Inmates
CCHCS Number
of Deaths

CCHCS Number
of Inmates

CCHCS

U.S. State
Prisons*

2009

393

169,459

232

259

2010

415

166,700

249

246

2011

388

161,843

240

260

2012

362

134,929

268

265

2013

366

133,297

275

274

2014

319

135,225

236

274

2015

355

128,824

276

296

2016

334

128,705

260

303

2017

388

130,807

297

323

2018

452

128,875

351

344

2019

399

125,270

319

not available

YEAR

(all) 492

2020

458

107,347

(non-COVID-19) 351

not available

327

*May have been revised by BJS from previously published statistics.
Table 7. Annual Mortality Rates Among California and U.S. State Prison Inmates, 2006–2020.

Figure 6 charts the trended death rates for the CCHCS from 2006–2020, and the trended death rates
for all US prisons from 2006–2018 (most recent year available).

Comparison of U.S. State Prison and CCHCS Annual Death Rate
per 100,000 Inmates
500
450
400
350
300
250
200
150
100
2006

2007

2008

2009

TOTAL CCHCS

2010

2011

2012

2013

2014

CCHCS non-COVID-19

2015

2016

2017

2018

2019

2020

TOTAL U.S. State Prison*

Figure 6. CCHCS Annual Death Rate per 100,000 Inmates, 2006–2020

30

The spike in mortality in 2020 was due almost exclusively to the coronavirus. The COVID-19 mortality
rate for 2020 was 141/107,347 or 131/100,000. All non-COVID-19 causes were responsible for an
annual mortality rate of 351/107,347 or 327/100,000. This non COVID-19 mortality rate in 2020 is still
the second highest since 2006, exceeded only by 351 in 2018.

B. Selective Causes of Death Contributing to Increased Mortality Rates in 2020
1. COVID-19
The first COVID-19 death in the California prison system occurred on April 19, 2020. By the end of
the year, the COVID-19 pandemic had caused 141 deaths.
Age – The age range of COVID-19 fatalities was 30 to 86, with a median age of 63 years.
Sex – 140 Male; 1 Female
Unlike what has been noted in the general population regarding the disproportionate
burden of COVID-19 deaths among some racial and ethnic minority groups (https://www.cdc.gov/
coronavirus/2019-ncov/community/health-equity/racial-ethnic-disparities/disparities-deaths.html#ref1),
the ethnic composition of COVID-19 decedents is fairly consistent with that of the inmate
population, suggesting that the social determinants of systemic health inequities are more
responsible for the disparity than any genetic racial differences.

Ethnicity

COVID-19 Deaths
Number

%

% Inmate
Population

Hispanic

63

44.7%

44.2%

White

37

26.2%

20.9%

Black

31

22.0%

28.2%

All Others

10

7.0%

6.6%

141

100.0%

99.9%

Grand Total

Totals may not equal 100% due to rounding.

Table 8. Ethnic Representation in CCHCS COVID-19 Fatalities, 2020.

Individual Patient Risk factors — The CDC keeps an updated list of the risk factors for severe illness
or death from COVID-19. The knowledge base continues to expand and is updated periodically
https://www.cdc.gov/coronavirus/2019-ncov/science/science-briefs/underlying-evidence-table.html
There is a high burden of chronic illness in CCHCS patients. COVID-19 high risk conditions and
the number of CCHCS COVID-19 fatalities with each are listed in the table below. A total of 135 of
31

the CCHCS COVID-19 fatalities had one or more of these conditions. Only six of the 141 cases had
no contributing conditions.
Most Common Associated Conditions

Number of cases

Essential (primary) hypertension

76

Overweight and obesity

50

Type 2 diabetes mellitus

50

Chronic obstructive pulmonary disease

25

Chronic ischemic heart disease

24

Disorders of lipoprotein metabolism and other lipidemias

23

Chronic kidney disease (CKD)

16

Fibrosis and cirrhosis of liver

16

Various cancers

12

Sleep disorders

12

Asthma

11

All others (less than 10 each)

91

Table 9. Associated Conditions in CCHCS COVID-19 Fatalities, 2020.

In addition to individual patient risk factors, there are other well known risk factors related to the
prison environment itself. These include overcrowding, congregate living such as dormitories, lack
of space for proper ventilation, isolation and quarantine, and the high disease prevalence in the
prison population and their families.
The next chart shows the distribution of the COVID-19 deaths by specific prison, with CIM and SQ
the top two prisons with 26 and 27 deaths respectively. The next five prisons accounted for 12, 9,
9, 9, and 8 deaths — a total of 47 deaths. These seven prisons had 71% (100 cases) of all CCHCS
COVID-19 deaths. Seventeen prisons experienced from 1 to 6 deaths. Nine California prisons had
no COVID-19 deaths.

32

COVID-19 Deaths in California State Prisons, CCHCS 2020
60

50

40

30

20

10

0

Apr

May

Jun

■ CAL

■ HDSP
■ SAC
■ SVSP
■ CIW
■ SOL
■ CEN
■ VSP
■ FSP
■

.
.

.
.

.
.

.
.

+

+

+

.

.

+

.
.

.
.

+
+

1

+
+

MCSP

■ CCI
■ PVSP
■ CMC

■ KVSP
■ COR

+
+

■ SATF
■ ASP

3

■ CVSP

2

■ RJD

■ LAC

CTF

■ CIM
■ SQ

1

9

6

Jul

r

Aug

r

r

r

r

r

.
.

.
.

.
.

.
.

.
.

.
.

1

.
.

.
.

1

1

r

r

r

r

r

r

2

r

r

r

r

r

r

r

r

3
19

r

Oct

Nov

Dec

1
1
1
1
1
1
1

1
1
3
1

1

1

2

1
4
3

1

r

r

Sep

1

r

r

■ CHCF

■

r

4
2

1

1

3

3

3

2

1

9
9
1

2

2

2

7

1

9

3

Figure 7. COVID-19 Deaths in California State Prisons, CCHCS 2020.

33

The chart shows a frequency distribution of the COVID-19 deaths by month. From April 19 to June
3, the California Institute for Men (CIM) experienced the first fifteen COVID-19 deaths
accompanied by a very high rate of COVID-19 infection. Because of the high and rising prevalence
of COVID-19 infection among inmates at CIM, a decision was made to transfer at risk patients from
one particular dormitory at CIM to San Quentin (SQ) and one other prison. Unfortunately, pretransfer testing results were delayed or unknown prior to transfer, and on arrival at SQ, it was found
that 25 out of the 122 transferees were COVID-19 positive. The subsequent outbreak at SQ was
associated with a toll of 27 deaths between June 24 and September 25. On June 12, 2020, the
Receiver commissioned a team from UCSF and the Berkeley School of Public Health to conduct an
on-site assessment. The team reported deficiencies in the physical plant, support staffing, and testing
(see

https://amend.us/wp-content/uploads/2020/06/COVID19-Outbreak-SQ-Prison-6.15.2020.pdf

for the full report and recommendations).
At CTF, 11 of the 12 COVID-19 deaths occurred in the six weeks between November 19 and
December 30. RJD and LAC each experienced nine COVID-19 deaths in the month of December.
The control of COVID-19 was the Receiver’s highest priority during 2020. CCHCS began its COVID19 policy development in late February 2020, when it became apparent that the virus had spread
into the United States and was likely to pose a high risk to incarcerated populations and staff, where
close contact, dense living situations, and high rates of inmate and prison staff movement were
problematic.
Beginning in March 2020 an extensive mitigation and control strategy was launched.
Communication with all staff and inmates was ongoing. The COVID-19 and Seasonal Influenza:
Interim Guidance for Health Care and Public Health Providers provided an integrated approach to
preventing, monitoring, and containing outbreaks of infection caused by SARS-CoV-2 (the virus
that causes COVID-19). Based on standards and recommendations from the CDC and the CDPH,
it includes sections on prevention strategies, including infection control, respiratory protection,
and vaccination; testing and treatment; and outbreak management strategies including mass
testing, quarantine, and isolation of select populations. These protocols were continuously
monitored and revised based on the epidemiology and expanding knowledge base regarding
COVID-19 infection. More than 100 revisions were published in calendar year 2020. Details of this
comprehensive mitigation and control strategy are beyond the scope of this report but can be
found on the CCHCS website: https://cchcs.ca.gov/covid-19-interim-guidance/
A summary of the policy development, testing strategies, early release programs, protocols
addressing the movement of inmates between institutions, and lessons learned from local
outbreaks can be found in the 44th, 45th and 46th Triannual Reports of the Federal Receiver,
covering CY 2020. https://cchcs.ca.gov/archived_tri_annuals/
34

COVID-19 vaccination was not available in time to have any effect on 2020 mortality.
(Although not covered by this report, the effects of the COVID-19 pandemic on CCHCS and CDCR
healthcare and custody staff was also very significant, with over 20 COVID-19 staff deaths occurring
in 2020.)

2. Infectious Diseases Other Than COVID-19
The 47 deaths from non-COVID-19 infectious diseases were an increase from prior years, with a
mortality rate of 44/100,000 compared to 21/100,000 in 2019. The number of deaths from three
causes — sepsis (16), pneumonia (11), and infectious endocarditis (10) — were significantly higher
in 2020 and contributed to the higher rate of death in this category.
The next table shows the non-COVID-19 infectious disease mortality rate for the years from 2012
to 2020. Prior to 2020, the total infectious diseases mortality rates ranged from 16/100,000 in
2014 to 29 in 2018, averaging 21.5. The rate of 44 in 2020 is significantly higher. The major
contributors to infectious disease deaths in 2020 were sepsis (15/100,000), pneumonia
(13/100,000) and infective endocarditis (9/100,000).

50

-

Numbers and Rates of (non-COVID-19) Infectious Disease
Deaths, CCHCS 2012–2020
CCHCS Infectious Disease Deaths

Rate/100,000

Linear ( Rate/100,000 )

40
30
20
10
0
2012

2013

2014

2015

2016

2017

2018

2019

2020

Figure 8. Numbers and Rates of (non-COVID-19) Infectious Disease Deaths, CCHCS 2012–2020

Figure 9 shows the sepsis, pneumonia, and infectious endocarditis mortality rates for each of the
years from 2012 to 2020. Prior to 2020, the total infectious diseases mortality rates ranged from
16/100,000 in 2014 to 29 in 2018, averaging 21.5. The rate of 44 in 2020 is significantly higher. The
major contributors to the higher infectious disease death rate in 2020 were sepsis (15/100,000),
pneumonia (13/100,000) and infective endocarditis (9/100,000).

35

Death Rates in Select Causes of Infectious Disease, CCHCS 2012–2020
18
16
14
12
10
8
6
4
2
0

Sepsis

2012
r

10

Pneumonia

4

Infectious Endocarditis

3

2013

l

9
7
0

t
t
+

2014

2015

2016

2

12

11

2
1

0

+

2017

2018

2019

2020

11

6

17

6

15

7

11

6

9

13

1

3

2

3

9

Figure 9. Death Rates in Select Causes of Infectious Disease, CCHCS 2012–2020

Sepsis mortality rates for 2012-2020 ranged from a low of 2 in 2014 to a high of 17 in 2018. The
2020 rate of 15 is higher than the average and compatible with a rising death rate from sepsis. The
source of systemic infection in the 16 cases of sepsis were known or suspected in nine cases — a
diabetic foot ulcer, a shoulder abscess, a sacral pressure ulcer, ischemic bowel injury, a perforated
bowel, a diseased gall bladder, osteomyelitis of the lumbar spine, and two cases of urinary tract
infection — and unknown in seven.
Pneumonia mortality rates for 2019 ranged from 2 in 2015 to 13 in 2020. The 2020 rate of 13
contributed to a rising rate of death from pneumonia over the past nine years.
Infective endocarditis mortality rates ranged from 0 in 2013 and 2014 to 3 in 2019. The 2020 rate
of 9 was much higher than in any previous year. The 10 patients who died of infective endocarditis
in 2020 were all known to have had substance use disorder and five had known intravenous drug
abuse. Seven of these patients were not referred for evaluation or treatment for substance use
disorder. Three patients had been referred but had not been seen before their deaths from
infective endocarditis. While not classified as drug overdose deaths, these ten represent a subset
of death due to narcotic injection.

3. Homicide
Table 10 and Figure 10 show the numbers and mortality rates from homicides in the CCHCS from
2012-2020 and in all US prisons from 2012-2017.

36

CCHCS Homicides

CCHCS Rate/100,000

U.S. State Prison
Rate/100,000

2012

21

16

7

2013

20

15

7

2014

9

7

7

2015

16

12

7

2016

26

20

8

2017

19

15

9

2018

30

23

10

2019

22

18

NA

2020

32

30

NA

Year

Table 10. Numbers and Rates of Homicides, CCHCS 2012–2020, and U.S State Prisons 2012–2018

........

Numbers and Rates of Homicides, CCHCS 2012–2020,
and U.S State Prisons 2012–2018

........

CCHCS Homicides
U.S. State Prison Rate/100,000

CCHCS Rate/100,000
Linear (CCHCS Rate/100,000)

Linear (U.S. State Prison Rate/100,000)

35
30

25
20
15
10

5
0
2012

2013

2014

2015

2016

2017

2018

2019

2020

Figure 10. Numbers and Rates of Homicides, CCHCS 2012–2020, and U.S State Prisons 2012–2018

The 33 homicides in 2020, a death rate of 31/100,000, continues a trend that has been rising since
2014. The homicide rate in California State Prisons is now more than three times higher than the
rate for other U.S. state prisons.

37

C. Selective Causes of Death Which Had Lower Mortality Rates in 2020
1. Drug overdose
Table 11 and Figure 11 show the numbers and mortality rates from drug overdose in the CCHCS
from 2012-2020 and in all US prisons from 2012 -2017. (U.S. State Prison data also includes drug
and alcohol intoxication.) As in prior years, none of these deaths were attributable to narcotics
prescribed to the patients by physicians in the CCHCS.

CCHCS drug overdoses

CCHCS Rate/100,000

U.S. State Prison
Rate/100,000

2012

15

11

3

2013

24

18

4

2014

19

14

4

2015

19

15

7

2016

29

23

8

2017

40

31

17

2018

62

48

21

2019

64

51

NA

2020

23

21

NA

Year

Table 11. Numbers and Rates of Overdose Deaths, CCHCS 2012–2020, and U.S State Prisons 2012–2018

Numbers and Rates of Overdose Deaths, CCHCS 2012–2020,
and U.S State Prisons 2012–2018

-

........

CCHCS drug overdoses
U.S. State Prison Rate/100,000
Linear (U.S. State Prison Rate/100,000 )

........

CCHCS Rate/100,000
Linear (CCHCS Rate/100,000 )

70
60
50
40
30
20
10

0
2012

2013

2014

2015

2016

2017

2018

2019

2020

Figure 11. Numbers and Rates of Overdose Deaths, CCHCS 2012–2020, and U.S State Prisons 2012–2018

38

The year 2020 saw a very significant decrease in the drug overdose rate, reversing a trend that had
begun in 2015. Reduction in overdose deaths was associated with an ongoing statewide initiative,
the Integrated Substance Use Disorder Treatment Program (ISUDT). This evidence-based program
frames drug addiction as a chronic disease, screens all patients for SUD, and offers treatment to all
positive patients. The use of medication assisted treatment with suboxone, cognitive behavioral
interventions, support in special housing units, and facilitated transition to community-based post
release programs are key elements. The ISUDT program began implementation in late 2019, the
Care Guide for SUD was released in May 2020 (https://cchcs.ca.gov/isudt/) and training was
completed in all 35 facilities by the end of 2020.
As of December 31, 2020, there were 7,287 patients receiving Medication Assisted Treatment
(MAT), and 6,679 patients awaiting an initial consultation for MAT.
Another association with this reduction in overdose deaths was a significant reduction in inmate
movement, restricted internal programming for inmates, and reduced outside visitation during
much of 2020, reducing the opportunities for illicit drug trafficking.

2. Advanced liver disease
Advanced liver disease including liver cancer, caused 32 deaths in 2020. Liver cancer accompanies
cirrhosis. In the prison population, both are caused by the high prevalence of chronic hepatitis C
infection. Table 12 and Figure 12 show the numbers, rates and trends of liver cancer deaths,
cirrhosis deaths and total advanced liver disease deaths represented by chronic hepatitis C
infection in the years 2012–2020.

YEAR

CCHCS Liver
Cancer
Deaths

CCHCS
Cirrhosis
Deaths

CCHCS Total
Hepatitis C
Deaths

Rate/
100,000

CCHCS
Number of
Inmates

2012

25

47

72

53

134,929

2013

27

43

70

53

133,297

2014

21

47

68

50

135,225

2015

19

37

56

44

128,824

2016

23

18

41

32

128,705

2017

18

21

39

30

130,807

2018

28

29

57

44

128,875

2019

32

13

45

36

125,270

2020

18

14

32

30

107,347

Table 12. Numbers and Rates of Liver Disease Deaths, CCHCS 2012–2020.

39

Numbers and Rates of Liver Disease Deaths, CCHCS 2012–2020

-

80

CCHCS Total Hepatitis C Deaths

Rate/100,000

Linear (Rate/100,000)

70
60
50
40
30

20
10

0
2012

2013

2014

2015

2016

2017

2018

2019

2020

Figure 12. Numbers and Rates of Liver Disease Deaths, CCHCS 2012–2020.

The CCHCS has adopted a number of initiatives to improve screening and treatment of hepatitis
C. These include the Care Guide for Advanced Liver Disease (revised in July 2020) which advocates
staging of liver fibrosis to identify all candidates for biannual ultrasound screening for liver cancer,
clinical strategies for addressing specific complications such as esophageal varices and
spontaneous bacterial peritonitis, and the initiative for treatment of hepatitis C with safe and
effective agents. Over 6,000 eligible patients were treated in 2018 and 2019, and an additional
4,559 (~380/month) were treated in 2020. All these initiatives may have contributed to a
continuing reduction in advanced liver disease mortality.

3. Suicide
There were 31 suicides in 2020. While this was 7 fewer than in 2019, the rate dropped only slightly,
from 30 in 2019 to 29 in 2020. Table 13 and Figure 13 show the numbers, rates, and trends of
suicide from 2012 through 2020.

CCHCS Suicides

CCHCS
Rate/100,000

U.S. State Prison
Rate/100,000

2012

32

24

16

2013

30

23

15

2014

23

17

20

2015

24

19

18

Year

40

CCHCS Suicides

CCHCS
Rate/100,000

U.S. State Prison
Rate/100,000

2016

26

20

21

2017

31

24

21

2018

30

23

26

2019

38

30

NA

2020

31

29

NA

Year

Table 13. Numbers and Rates of Suicide, CCHCS 2012–2020 and U.S. State Prisons 2012–2018.

-

........

Numbers and Rates of Suicides, CCHCS 2012–2020,
and U.S State Prisons 2012–2018

........

CCHCS Suicides
U.S. State Prison Rate/100,000
Linear (U.S. State Prison Rate/100,000)

CCHCS Rate/100,000
Linear (CCHCS Rate/100,000)

40
30

.····· .............

20
10

0
2012

2013

2014

2015

2016

2017

2018

2019

2020

Figure 13. Numbers and Rates of Suicide, CCHCS 2012–2020 and U.S. State Prisons 2012–2018.

Apart from the years 2014–2016, numbers and rates of suicide for the period of 2012–2020 were
statistically static. Almost all the suicide patients were being followed by mental health providers
concurrently with medical providers. The recognition and treatment of severe depression and suicidal
ideation and close communication between the mental health and medical departments of CCHCS
are ongoing.
Since 1995, a federal court appointed a special master to oversee CDCR’s mental health care system.
The system of suicide risk evaluations, prevention and treatment is in place for all CDCR staff, all
potential first responders to suicides, and all mental health clinicians. Videos, pamphlets, suicide
prevention events and procedures for protecting inmates during vulnerable periods are also in place.
The 2020 annual report to the California State legislature on Suicide Prevention and Response in CDCR
is available at https://cchcs.ca.gov/wp-content/uploads/sites/60/MH/CDCR-2020-SB-960.pdf

41

D. Selected Causes of Death - Other
Trends in mortality for cardiovascular disease and lung cancer were discussed in previous years and
are discussed again here.

1. Cardiovascular disease
Cardiovascular disease was the second most common cause of all deaths in 2020. Table 14 and
Figure 14 show the numbers, rates, and trends of cardiovascular death from 2012 through 2020.
Year

CCHCS Cardiovascular Deaths

Rate/100,000

CCHCS Number of Inmates

2012

43

32

134,929

2013

50

38

133,297

2014

54

40

135,225

2015

62

48

128,824

2016

52

40

128,705

2017

68

52

130,807

2018

66

51

128,875

2019

52

42

125,270

2020

54

50

107,347

Table 14. Numbers and Rates of Cardiovascular Deaths, CCHCS 2012–2020.

-

Numbers and Rates of Cardiovascular Deaths, CCHCS 2012–2020

80

CCHCS Cardiovascular Deaths

Rate/100,000

Linear ( Rate/100,000 )

70
60
50
40
30
20

10
0
2012

2013

2014

2015

2016

2017

2018

2019

2020

Figure 14. Numbers and Rates of Cardiovascular Deaths, CCHCS 2012–2020.

42

There was a slight increase in the number and rate of cardiovascular death in 2020. Of note, there
was a large increase in the number of sudden cardiac arrests as a cause of sudden death in inmates
in 2020. A number of these might have been missed acute myocardial infarctions (three fewer in
2020 than in 2019) or cardiac arrhythmias (2 in 2020, none in 2019). The CCHCS Care Guides for
chest pain, diabetes, dyslipidemia, and hypertension, provide clinicians with advice for the
management of the significant risk factors for coronary heart disease, the judicious use of statins
to prevent coronary events, the importance of diabetes control, smoking cessation, and the
importance of management of clinical red flag symptoms indicating acute coronary syndromes or
exacerbations of congestive heart failure. Significantly, in 2020 there was only one OFI citation for
failure to recognize and manage acute chest pain.

2. Lung cancer
Lung cancer has been the leading cause of cancer death, both in CCHCS and in the general
population. But 2020 saw 17 deaths from lung cancer, fewer than the historic numbers and rates,
as seen in the following Table 15 and Figure 15.

Year

CCHCS Lung Cancer Deaths

Rate/100,000

CCHCS Number of Inmates

2012

20

15

134,929

2013

21

16

133,297

2014

17

13

135,225

2015

27

21

128,824

2016

19

15

128,705

2017

13

10

130,807

2018

32

25

128,875

2019

27

22

125,270

2020

17

16

107,347

Table 15. Numbers and Rates of Lung Cancer Deaths, CCHCS 2012–2020.

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Numbers and Rates of Lung Cancer Deaths, CCHCS 2012–2020

-

40

CCHCS Lung Cancer Deaths

Rate/100,000

Linear ( Rate/100,000 )

2016

2018

30
20
10

0
2012

2013

2014

2015

2017

2019

2020

Figure 15. Numbers and Rates of Lung Cancer Deaths, CCHCS 2012–2020.

This one year experience my not signal a trend, but in 2014 the US Preventive Services Task Force
published a Grade B recommendation to screen all heavy smokers over age 55 for lung cancer
with annual low dose CT scanning. The CCHCS had not yet formally adopted this recommendation
in 2020, but some individual patients may have undergone this screening.

IV.

Quality Improvement Initiatives, 2020

Although the COVID-19 response dominated clinical quality improvement efforts in 2020, a number of
initiatives were ongoing as a result of the 2019-2022 Performance Improvement Plan. These included:
•

Hepatitis C Treatment — Chronic hepatitis C virus (HCV) infection is the cause of almost all cases
of advanced liver disease among CCHCS patients. The use of direct-acting agents for the
treatment of HCV has been associated with decreases in liver-related death, even among those
patients with advanced liver fibrosis. Treatment of hepatitis C started in 2017, and in 2018
treatment was expanded to all HCV risk groups. This program is associated with a sustained
decrease in advanced liver disease mortality.

•

Integrated Substance Use Disorder Treatment Program — Substance use disorder screening is done
for all new patients. Medication-assisted treatment (MAT) with buprenorphine, naltrexone, or
methadone is offered to patients with opioid use disorder who meet criteria. All appropriate providers
receive training in order to receive waivers allowing prescription of MAT. The rising incidence of drug
overdose made it the second leading cause of death in 2019, but the implementation of the ISUDT
was associated with a dramatic decrease in drug overdose deaths in 2020.

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•

Emergency Medical Response — The statewide initiative for onsite hands on training with a
standardized curriculum, crash carts and tools for resuscitation was deferred during 2020 and will
be resumed in 2021.

•

Several Complex Care Initiatives

V. Conclusions
The COVID-19 pandemic dominated the healthcare landscape in 2020 and was responsible for driving
overall CCHCS mortality to the highest level since these reports began analyzing California prison
mortality reviews in 2006. Mortality curves in the CCHCS mirrored those experienced by the rest of
the U.S. and the world. The CCHCS responded by rapidly developing and implementing a
comprehensive mitigation and control strategy for COVID-19 infection. This effort overshadowed all
other activities in calendar year 2020. Positive results from this strategy as well as the availability of the
COVID-19 vaccines and the development of effective treatment stratagems for early COVID-19
infection hold promise for 2021 and beyond.
The reduction in the population of the state’s prison system found additional impetus from the
governor’s COVID-19 mandate and has now reached levels approaching the design capacity of the
prison system.
Mortality rates from homicide continued an upward trend which began in 2014. The year also saw an
unusually large number of deaths from infectious endocarditis resulting from intravenous drug abuse.
There were areas of significant progress in 2020.
Statewide initiatives contributed to sustained lower death rates from advanced liver disease.
There was a very significant lowering in the number of cases of drug overdose death, from 51/100,000
patients in 2019 to 21/100,000 in 2020, a 60% reduction. This lower rate of mortality from drug
overdose was associated with system wide implementation of the Integrated Substance Use Disorder
Treatment Program (ISUDT), and widespread availability of medication assisted therapy for patients
with substance use disorder. Reduced opportunities for socialization among inmates, and between
inmates and their visitors, may also have contributed to the decrease by limiting access to illicit drugs.
Mortality review continues to evolve, with attention to the identification of opportunities for system
improvement. There was a near doubling in the number of OFI findings in 2020.
The success of the Receivership in transforming healthcare in the California state prisons resulted in a
process of revocable delegation of 19 the 35 California prisons by the end of 2019. Although
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temporarily stalled by the pandemic, there should now be a resumption of the detailed audits
necessary to continue delegation of more prisons’ healthcare to the control of the State of California.
A further evolution in the partnership of CCHCS and the CDCR resulted in the adoption of new vision
and mission statements focusing on public safety through restorative justice and the successful
community reintegration of all inmates.

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