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Los Angeles County Jail Monitor Report July 2008

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25th Semiannual Report
by Special Counsel Merrick J. Bobb and Staff
and Police Assessment Resource Center (PARC)
July 2008




Sta f f

Special Counsel


Senior Advisors

Merrick J. Bobb
Police Assessment
Resource Center

Matthew Barge

Chief Thomas Frazier,
Baltimore Police
Department (retired)

Kevin Barry
Lauren Mathews
Camelia Naguib
Tim Shugrue
Norma Zamudio
Lindsey Zwicker

Chief Bernard Melekian,
Pasadena Police

C onte nts

I ntroduction


Women in the Jail




1. Delivery of Medica l Ca re







II. Intake Screening Process


III. Sick Call


IV. Standardized Procedures Certification


Pregna nt a nd Pa renting Inm a tes





II. Inmate Pregnancy and Childbirth


III. Parenting in Custody


Inm a te Com pla ints





II. The LASD’s Inmate Complaint Process


III. PARC’s Complaint Review Process


IV. Non-medical Complaints




Medical Complaints

VI. Conclusion


Litiga tion




Scope of the Review

II. Aggregate Trends in Litigation


III. Litigation in the 2006-2007 Fiscal Year


IV. Conclusion


Shooting and Use of Force Tables


Tw e n t y - F i f t h S e m i a n n u a l R e p o r t

This is the 25th Sem iannual Report by Special Counsel and staff on
the Los Angeles County Sheriff’s Department (LASD or Department).
Our ongoing role has been to examine for the Board of Supervisors whether
the LASD is doing all it could and should to prevent avoidable and unnecessary injury or death in the jails and on the streets. We assess whether the
Department is minimizing liability to County taxpayers for the acts and
omissions of LASD personnel. We assess policies, practices, training, and
performance to test whether legitimate law enforcement ends can be accomplished with less risk to all concerned—the deputy, the suspect, third parties,
and bystanders. Our examination considers the systems the LASD has in
place to identify and correct the persons and situations that have already lead
to injury and subsequent liability or which may lead to liability in the future.
We look for patterns. We look at practices and systems. We focus on the
areas that were the subject of the Kolts Report —LASD practices on the
streets and in the jails that may give rise to complaints or allegations of misconduct about LASD personnel from the persons who come in contact with the
LASD. Use of force by the LASD has been a constant subject of our inquiry,
as has medical care in the jails, the quality of supervision of deputies, deputyinvolved shootings and their investigation and review, the fairness and
objectivity of internal investigations of alleged misconduct, and the proper
use of systems such as the LASD’s early intervention software, the Personnel
Performance Index or PPI.


The LASD is one of a small group of law enforcement agencies that have a
nationwide influence and is looked to for leadership and innovation. It is a
large urban agency serving millions of people in a richly diverse environment.
The challenges facing the LASD in Southern California are often presented
before the balance of the nation will experience them. In policing, as in other
fields of endeavor, it happens first in California, and what California does will
have a disproportionate impact everywhere else.
California was certainly the first place in recent times where use of force
by law enforcement came under intense scrutiny. For the LAPD, it began
with Rodney King and the subsequent Christopher Commission Report
in 1991. For the LASD, it was a series of officer-involved shootings and the
alleged predations of a tattooed gang of LASD officers in Lynwood that led to
the subsequent Kolts Report in 1992. Out of each report came recommendations for ongoing independent outside monitoring and review of law enforcement. In the case of the LAPD, the Police Commission was given wider
powers and the office of Inspector General within the Police Commission was
created. In the case of the LASD, the Office of Special Counsel and later an
Ombudsman and the Office of Independent Review (OIR) came into being.
Los Angeles County’s tripartite structure—Special Counsel, OIR, and the
Ombudsman—has become the gold standard by which monitoring and civilian
oversight have come to be measured. There is an Ombudsman to focus on
the satisfaction of complainants with the investigation and resolution of their
public complaints against LASD personnel. There is the OIR to monitor
individual internal investigations and help make sure the disciplinary outcomes
in individual cases fairly reflect the Department’s policies and aspirations.
There is Special Counsel to examine whether the LASD is doing its best to
avoid unnecessary injury or death. The methods and approaches of Special
Counsel and OIR have been emulated throughout the country and have been
encapsulated in proposed national guidelines for police monitors commissioned


by the US Department of Justice.
This Semiannual Report examines two broad areas of the Sheriff’s operations—the provision of care to women who are inmates in the LA County Jail
and the lessons learned from litigation.

Women in the Jail
Three chapters in this Report are devoted to the provision of care to women
who are inmates in the LA County Jail, where they are currently housed at the
Century Regional Detention Center (CRDF). Our research on the status of
women in the jails, of which these three chapters are a first installment, is
being supported in part by a grant from the John Randolph and Dora Haynes
Foundation, to whom we express our gratitude.
In the first of these chapters, we look at medical care of female inmates,
focusing specifically on the issue of timeliness of evaluation and treatment.
For the reasons discussed in this chapter, we acknowledge progress in the
housing for women who report a medical condition. We saw firsthand the
dedication of many nurses. Nonetheless, there were areas for improvement,
principally because of the dearth of written policies in many important areas,
including delivery and birth, and the lack of accountability to ensure treatment
within 24 hours (72 hours on weekends) as prescribed by authoritative medical
standards in a correction setting. Delays in the provision of medical services
are not even tracked, contrary to good practice as defined by the medical
profession. Our key recommendation is that every woman who asks for medical
attention or to see a nurse gets to do so within 24 hours of the request being
made, except, of course, for medical emergencies demanding immediate attention. The 24 hour requirement may be as simple as a nurse seeing the woman
briefly to assess whether the asserted need for medical attention is legitimate
or not or to ascertain the immediacy of the need for examination and treatment.


We were particularly concerned with the imbalance between demand and
supply for medical services. Sick call, synonymous with nurse clinics, serves
far fewer women on a daily basis than sign up to see the nurse. Yet seeing
the nurse is a necessary first step to seeing a doctor or specialist. The constant
backlog to see the nurse therefore reverberates and causes delay throughout
the system.
Our next chapter considers pregnancy and child care in the jail setting. In a
year’s time, more than 1400 pregnant women enter the Los Angeles County
Jail system. As many as 60 pregnant women will be in the jail at any given time.
All of them will require prenatal care. The LASD, surprisingly, does not
keep track of how many women deliver children while in custody, although
the Department guesses that there are no more than 30 births in a year. Some
women deliver at the jail itself. Others deliver at the jail treatment center or at
County USC Hospital.
Few of the policies and programs relating to pregnancy are reduced to writing.
As a result of this failure to have written policies, we encountered understandable but ultimately unacceptable confusion about actual policies, particularly
those relating to the transportation and restraint of women in labor and shackling
during delivery. We also found inconsistencies in or confusion about the provision of pregnancy tests and the timing of commencement of prenatal care and
postpartum care. All of these should be formalized in written policies. One
key recommendation is that the LASD in written policy and practice conform
to California state law prohibiting the shackling of women before, during, and
after labor and delivery absent extraordinary security requirements.
Although many aspects of its approach to pregnancy and its aftermath are
praiseworthy, Los Angeles County lags behind San Francisco and San Diego
Counties in key areas. In San Francisco, women are allowed contact with their
babies after they return to the jail post-delivery. In Los Angeles County, there
is no such program. In San Francisco, children wanting to visit their mother


are given specific appointment times. The LASD, in contrast, is more like a
lottery. Visitors are taken on a first-come, first-served basis. Children may sit
all day and never get to see their mother. If they come back the next day, it
starts all over: There is no preference given for children who were unable to
see their mother the previous day. A small child could sit in a jail all day for two
days straight and not get to see his or her mom. Our key recommendation here
is that the LASD institute specific appointment times for visits by children
with their mothers. We further recommend that the LASD permit mothers to
hold and touch their infants after the mother’s returned to custody as occurs
in San Francisco.
In San Francisco, any qualified female inmate who desires to do so can sign
up for the Parent-Child Visiting program and then can have direct contact with
her children. Both sentenced and pre-sentenced inmates can participate.
Although the LASD provides a similar program through the La Puente
Hacienda School District, it only serves 10-12 inmates a week. Pre-sentenced
inmates are barred from participation. We urge expansion of that program so
that substantially more women can take advantage of it.
Our third chapter on women in the jail considers the quality of the
Department’s response to inmate complaints. We found that the LASD
does a good job resolving routine complaints from women about conditions
of confinement and a poor job resolving complaints about medical services.
The Department received 214 medical complaints between December 2006
and May 2007, the majority of which centered upon treatment delays. Of
these, nearly one-third had not been completed at the time of our review and
only 38 percent of the remaining complaints were completed within a ten-day
period. Additionally, we found that the referral of 41 complaints by Custody
was unnecessarily delayed, that the level of detail on many medical dispositions was insufficient to determine whether the complaint was adequately
resolved, and that the majority of complainants appear never to have been noti-


fied of the result of their complaints as required by Title 15. Finally, the use of
the category “Request for Service - Routine” to describe nearly every medical
complaint, as well as the failure to make even a token effort to
investigate system or staff performance issues, renders the complaint system
incapable of providing LASD management with any meaningful information
about systemic problems with the delivery of medical services at the facility.
Our key recommendation is that all complaints about medical evaluation and
treatment or delays in the provision of same must be transmitted to Medical
Services within 24 hours and that Medical Services be required to respond
to the complaint within 24 hours. Personnel complaints against medical staff
should be investigated within the normal ten-day deadline.

After six months reviewing the last six full years of litigation against the
Department, from fiscal year 2001-02 until fiscal year 2006-07, we find that the
LASD has experienced a welcome reduction in the number of new lawsuits
filed against it in recent years, strongly suggesting that the Department’s risk
management activities, in the main, have successfully thwarted new litigation,
thus reducing injury, risk, and financial exposure—all for the benefit of the
general public and County taxpayers.
The number of new force-related lawsuits, as well as the number of closed
force-related lawsuits resulting in a payout, has also trended downward.
Force-related litigation comprises less of the Department’s total liability than it
once did. In the 2006-2007 fiscal year, force-related litigation represented
about 35 percent of overall liability, down significantly from 2001-2002, when
force-related litigation constituted a full 66 percent of the Department’s total
liability. Yet gains in the reduction of force-related litigation must be balanced
against increases in litigation arising from custody.


We examined in detail the 17 lawsuits in the 2006-07 fiscal year that settled
for more than $100,000. Of those, six involved in-custody injury or death.
These six cases alone accounted for $5.635 million, or more than half (51
percent) of the Department’s total civil liability across all lawsuits for the 20062007 fiscal year. Plainly, the LASD has to do a better job preventing avoidable
injuries and death in the custody setting. The deeply disturbing apparent
facts in each of the six cases are discussed at length in the Litigation Chapter.
Finally, we want to acknowledge a high degree of cooperation from the
LASD and its personnel in connection with this Report, particularly with
regard to the Department’s review and critique of drafts of the chapters in this
Report. The dialogue was extremely useful and approached constructively
by all. Our special thanks in this regard to Chief Alexander Yim, Chief Dennis
Burns, Captain Michael Kwan, Lieutenant Roger Ross, Nurse Kathleen
Braman, Nurse Barbara Marshall, Sergeant Bob Blanks, Lieutenant Shaun
Mathers, and Sergeant Charla Harris.



De liv e r y of M e dic a l C a r e

In this Report, we look at medical care of female inmates in the Los Angeles
County Jail, focusing specifically on the issue of timeliness of evaluation and
treatment. We were very pleased to find that, in the past year, the facility where
the women are housed has made great improvements in its Inmate Reception
Center (IRC) medical screening process, bringing it for the first time into
substantial compliance with screening provisions of a 2003 Memorandum of
Agreement with the United States Department of Justice. This means that
women with mental health issues are screened within 24 hours of their arrival
at the jail during the week or 72 hours on the weekend. This is a significant
The same does not hold true for women who want to see a doctor or nurse
after the screening process has been completed. As much as we acknowledge
and saw firsthand the dedication of many nurses, the LASD was unable to
demonstrate in the majority of cases that it provides access to nurses within 24
hours (72 hours on weekends) after the inmate has requested to see one, in
derogation of authoritative, medical standards in a jail setting. Delays in the
provision of medical services are not even tracked, contrary to good practice as
defined by the medical profession. As a result, the LASD lacks the basic data
about delays that are necessary to hold medical personnel accountable for them.
Women are currently housed at the Century Regional Detention Facility
(CRDF) in South Los Angeles near the intersection of the Harbor and 105
Freeways. Applicable law requires that jails provide emergency and basic health
care to all of its inmates, including medical screening upon intake, daily sick



call, and provision of medically restricted diets. At the Los Angeles County
Jail, which maintains an average daily population of approximately 19,000
inmates, of which approximately 2200 are women, and which processes about
31,000 women inmates every year, the massive task of evaluating and treating
sick inmates falls to the LASD’s Medical Services Bureau (MSB), an in-house
department of the Custody Division that operates physician and nurse clinics
at each facility as well as the Twin Towers Correctional Treatment Center
We found that although CRDF has a competent and dedicated medical
staff, each nurse clinic serves an average of about ten inmates per day per floor,
which may house up to 496 inmates over four modules. We saw module sick
call lists with the names of ten to 25 inmates waiting to see the nurse, only two
to four of whom would typically be seen that day, and we reviewed many
complaints from inmates claiming to have waited weeks or even months for
medical treatment. We also found that, because the Department does not
keep records of inmates’ sick call requests, it is impossible to accurately
measure how long inmates are waiting to be seen. Given the frequency of
complaints of delay, and without evidence to the contrary, it is more probable
than not that inmates utilizing the sick call process frequently experience
delays longer than the essential standard of 24 hours (72 on the weekend)
before they are seen by a nurse.2 Because the sick call visit is also the mechanism for referral to a physician, delays in the sick call system result in even
longer waits to see a doctor.

1 Several previous Semiannual Reports have looked at the issue of medical care in the Los Angeles County Jail. In our Seventh, Eighth,
and Thirteenth Semiannual Reports, we looked at issues and improvement s in the jail’s medical record-keeping system and its
implications for inmates’health care. Our Ei ghth, Ni nth, and Seventeenth Semiannual Reports contain a discussion of IRC
and medical screening processes, and our Eighth, Thirteenth, and Seventeenth Semiannual Reports focus on inmat e medical
complaints. Medical staffing is discussed in our Ninth and Twelfth Semiannual Reports, and examinations of liability and
medical m alpract ice t rends appear in our Eleventh and Twelfth Semiannual Reports.
2 According to accepted national standards developed by the National Commission on Correctional Health Care (NCCHC), sick call
requests should be triaged daily and t he inmate should be seen by a qualified medical professional within 24 hours (72 hours for a
weekend). NCCHC Standard J-E-07.


In our examination of wait times, we looked at three components of the
jail’s medical care delivery system—medical screening during intake, sick call,
also referred to as nurse clinics, and standardized procedures certification—in
terms of their effectiveness, efficiency, and impact on the overall timeline for
medical treatment, and found the following:
• When CRDF first opened as a women’s jail and inmate reception center,
many inmates awaiting medical evaluation during intake faced long stays
in holding cells without beds or access to showers. Under the direction of
Captain Kwan of the Medical Services Bureau, the Department recently
implemented a new IRC medical screening module in which inmates are
housed in two-person cells, where they have access to a bed and shower.
The Captain monitors the number of inmates awaiting medical screening
through daily reports from the facility, and states that they are now being
seen within 24 hours.
• The facility operates five nurse clinics to provide an opportunity for inmates
to see a nurse during a daily sick call. Yet because the sick call sign-up and
call-out process is, in most cases, managed entirely by deputies, nurses do
not have the capacity to prioritize requests before meeting with the inmate,
a capacity which NCCHC recommends for correctional facilities. The
Department maintains no record of how long inmates wait to be seen by
a nurse, but it appears likely that many are not seen on the day that they
make the request. Accepted national standards require that inmates are
seen by a medical professional within 24 hours.
• The Department has developed a comprehensive set of standardized
procedures that expedites medical care for many inmates by allowing nurses
certified in the procedures to perform protocols traditionally reserved for
physicians. These standards were revised in 2007, requiring recertification
of all nurses in the new procedures in five segments—Series I, II, III, IV,


and V. At the time of our first visit in mid-January 2008, only 19 nurses had
been certified in Series I and only nine nurses had been trained in Series
II. Accordingly, there were too few trained nurses, and many inmates had
to be denied service and be referred to a physician for the designated treatment at a later time. Since January, there has been marked improvement.
As of May 21, 2008, as a result of a sustained effort to provide training at
CRDF, 35 more nurses in the facility had been trained in at least one of the
two series of standardized procedures. This leaves 15 who have not been
trained in Series I and 24 who have not been trained in Series II. Due to
staffing and other constraints, the Department has not yet begun training
in Series III-V.
According to MSB, female inmates at CRDF as a group tend to be in better
overall shape than men, possibly because of the greater likelihood that they
were insured prior to their incarceration. Indeed, a review of medical
complaints filed by inmates at CRDF revealed relatively few complaints by
inmates claiming to have severe illnesses or conditions requiring emergency
care. Nonetheless, the demand for medical services at that facility is significant
and constant. Between May 2007 and April 2008, 16,092 CRDF inmates, a
little more than half of the approximately 31,000 women who are processed
through the jail each year, were seen at least once during their period of incarceration by nurses conducting intake screening or medical call. Five thousand
and ten were evaluated by a physician, and an average of 1360 inmates
received prescription medication every month.
During the past six months, we reviewed the LASD’s policies and procedures to ensure a timely response to inmates’ medical requests. We reviewed
inmate medical complaints, many of which referenced lengthy delays in care;
visited the main clinic and two nurse clinics; interviewed nurses, deputies, and
management staff; consulted legal standards; and compiled written policies on
medical screening and the delivery of medical care.


1. Background
A . Lega l St a nda r ds

Sentenced inmates have a constitutional right to adequate medical care
under the Eighth Amendment, which entitles convicted inmates to “humane
conditions of confinement; prison officials must ensure that inmates receive
adequate food, clothing, shelter and medical care.”3 Because pretrial inmates
retain, under the Fourteenth Amendment, “at least those constitutional rights…
enjoyed by convicted prisoners,” the standard for sentenced inmates applies to
all inmates in the Los Angeles County Jail, whether sentenced or unsentenced.4
The Department is also bound by state standards, codified in Title 15 of
the California Regulatory Act, which include the following requirements:
Section 1200. Responsibility for Health Care Services

[T]he facility administrator shall have the responsibility to ensure provision
of emergency and basic health care services to all inmates… Each facility
shall have at least one physician available to treat physical disorders.
Section 1207. Medical Receiving Screening

With the exception of inmates transferred directly within a custody system
with documented receiving screening, a screening shall be completed on
all inmates at the time of intake. This screening shall be completed in
accordance with written procedures and shall include but not be limited
to medical and mental health problems, developmental disabilities, and
communicable diseases, including, but not limited to, tuberculosis and
other airborne diseases. The screening shall be performed by licensed
health personnel or trained facility staff.
Section 1208. Access to Treatm ent

The health authority, in cooperation with the facility administrator, shall
develop a written plan for identifying, assessing, treating and/or referring
any inmate who appears to be in need of medical, mental health or
developmental disability treatment at any time during his/her incarceration
subsequent to the receiving screening. This evaluation shall be performed
by licensed health personnel.
3 Farmer v. Brennan, 511 U.S. 825, 832-833 (1994) (quoting Hudson v. Palmer, 468 U.S. 517, 526 (1984).
4 Bell v. Wolfish, 441 U.S. 520, 545 (1979).


Section 1211. Sick Call

There shall be written policies and procedures developed by the facility
administrator, in cooperation with the health authority, which provides for
a daily sick call conducted for all inmates or provision made that any inmate
requesting medical/mental health attention be given such attention.
Title 15 provides leeway to each agency in determining the nature of its
healthcare delivery structure and in designing its screening and sick call mechanisms. It also stops short of requiring that inmates be evaluated and treated
within a specified period of time. Nonetheless, the accompanying guidelines,
in discussing sick call processes, specify that the “guiding principle should be
that any inmate requesting medical/mental health attention must receive that
attention as soon as reasonable and possible.”5
Although they do not have the force of law, the National Commission on
Correctional Health Care (NCCHC) “Standards for Health Services in Jails”
are widely considered the benchmark standards for effective and constitutional
jail health care. Originally developed by the American Medical Association, the
standards are now maintained by the NCCHC, which also operates an accreditation program for correctional facilities. According to those standards, inmates
should be able to request medical care on a daily basis, and sick call requests
should be prioritized on a daily basis. No matter how prioritized, all inmates
requesting care should receive a face-to-face sick call visit within 24 hours of
making the request on a weekday, or within 72 hours on weekends. For large
jails with a daily inmate population of more than 200 inmates, sick call should
be held at least five times a week.6 We urge and recommend to the
Department that it seek accreditation by NCCHC and, in the interim,
voluntarily adhere to the NCCHC 24 and 72 hour time limitations.

5 “2005 Title 15 Health Guidelines,” pg 45.
6 “J-E-07: Nonemergency Health Care Requests and Services,” Standards for Health Services in Jails, National Commission on
Correctional Health Care, 2008.


B. I nm a t e Medica l Com pla int s

As part of our examination of the treatment of inmates at CRDF, we
reviewed all complaints made by inmates at the facility between December
2006 and May 2007, including complaints made through the Department’s
grievance procedure and those made through the American Civil Liberties
Union (ACLU). That review, discussed in greater detail in Chapter 3, “Inmate
Complaints,” found that of the 214 medical complaints included in the sample,
85, or approximately 40 percent, directly complained of delays in service,
such as lengthy waits to see a doctor or nurse, obtain a test result, or receive
appropriate medication or diet. For reasons explained in that chapter, the
percentage of complaints about delay may in fact be higher.
The Inmate Complaint Form provides a space for inmates to write down
their complaint in their own words. The form asks inmates to provide some
specific information: “Explain your complaint. Include dates, times, and names
of persons involved.” Nonetheless, many complaints contained vague or
incomplete information about the nature of the inmate’s grievance, sometimes
failing to include the date the inmate had first requested treatment or a clear
description of any medical attention received. As such, it was difficult to assess
average wait times or to identify what, if any, remedial steps had been taken
prior to the complaint being filed. Complaint dispositions, many of which were
never completed, generally offered no additional detail about the length and
cause of these delays. The form should include data fields asking
inmates to provide specific information about the complaint; the
date on which help was requested; treatment, inform ation, or other
aid already provided; the names of involved employees; and the
remedy requested. Regardless of the form’s format, however, the
person investigating the complaint should be required to collect and
docum ent any such information from the inmate and to make some
effort to verify that information by researching the medical record.


Some inmates did provide clear accounts of their long waits for medical care.
In the files that we reviewed, inmates complained of a variety of delays in
receiving attention. Some complained of waiting on the sick call (nurse clinic)
list, while many others mentioned that they had seen a nurse and were waiting
to see a doctor or an off-site specialist. Others complained of delays in receiving
medication, diets, or tests that they claimed had already been ordered.
In this Report, we focus primarily on evaluation and treatment provided
by Registered Nurses (RNs). We do so because nurses, both during IRC
screening and sick call, serve as the initial point of contact with the inmate and
are, in many cases, the conduit for other levels of care. When certified to
perform standardized procedures, they may also preempt the need for further
referral. As such, the sick call list or inmate request form usually represents
the first, and sometimes the only, documented instance of an inmate’s request
for medical attention.

II. Intake Screening Process
Unlike male inmates, who go through the Inmate Reception Center (IRC)
at the Twin Towers Correctional Facility (TTCF) in downtown Los Angeles
regardless of their eventual housing placement, female inmates are booked and
screened directly at CRDF. Upon entry, a reception Deputy, with the help of a
nurse, sorts out inmates based on their apparent health status and ability to
move directly to an appropriate housing unit. Inmates who require immediate
medical attention will not be booked and are to be transported to
Los Angeles County-University of Southern California Medical Center
(LCMC) or another nearby hospital. Inmates who are medically appropriate
for booking but who possess identifiable health problems receive further
medical evaluation.
IRC staff use a 17-question classification screening tool that includes three
medical questions:


• Are you pregnant?
• Are you taking prescription medication that you seriously need within the
next six hours?
• Do you need medical care?
If an inmate responds “no” to all of these questions, along with a question
regarding suicidal thoughts, she will proceed through the booking process.
A nurse or trained Custody staff person will administer an over-the-counter
medical/mental health screening questionnaire that asks more specific questions
about the inmate’s medical or mental health history and any current conditions.
If the inmate answers “no” to all these questions, she will be asked to sign
the sheet stating that she denies any medical or mental health problems. She
is then given a chest x-ray to screen for tuberculosis, and is placed in a holding
cell pending housing placement. According to IRC staff, inmates with no identified medical or mental health problems are usually placed in a housing
module within approximately one hour.
An IRC screening Registered Nurse (RN) then reviews the questionnaire,
the Arrestee Medical Screening form, and any other medical information the
inmate provides during the initial screening process. Inmates who require
time-sensitive, non-emergency medical attention are given “expedite” status
and will be seen in the CRDF Reception Center Clinic for further treatment.
An entry in the Medical Services Database will be opened and Custody
personnel will be notified that this inmate is to be placed in the “expedite”
holding area. Some of the symptoms or medical conditions that will result in
expedited medical screening status include: self-reported insulin diabetes,
cancer, symptomatic hypertension, shortness of breath or cardiac conditions,
pregnancy of 20 weeks or more, violent or combative behavior, suicidal ideation
or 5150/5250 paperwork, HIV/AIDS, communicable diseases, open or draining
wounds, surgeries within the last week, and “any other significant medical
condition referred by the nurse.”


Following the initial assessment, all inmates needing medical attention will
receive a physical and, if indicated, a psychiatric evaluation, and medication,
treatment, and special housing, as necessary, at the CRDF Reception Center
Clinic. The inmate is then referred back to the IRC custody staff to complete
the booking process.

I RC Housing

When we first began our review of CRDF, we found that inmates needing
medical or mental health evaluation waited for a lengthy period of time before
they were seen, due to backups in the system. A review of the time spent in
intake for inmates who entered the jail between June 2006 and May 2007
shows that although the average time spent in intake was approximately six
hours, large numbers of inmates waited significantly longer. In fact, 5084
women were in intake for more than 24 hours; 831 of those spent between two
and three days in intake, and 27 spent between three and four days.7
These lengthy stays at IRC prompted serious concerns from jail management and outside observers, including the ACLU, due to the holding cells in
which these inmates were housed. CRDF was not originally designed as a
reception center, meaning that the booking area was designed to take inmates
who had already been through the intake process. Its holding cells are not
meant to house inmates for a significant period of time, and thus contain only
narrow metal benches for inmates to sit on. Although inmates can sit or lie on
the floor, this is obviously hellish, and overcrowding makes this alternative
even more difficult or uncomfortable. Another concern was that inmates in the
IRC—many of them coming directly off the street—had no access to showers
or a change of clothes, often causing them to stay in crowded, uncomfortable,

7 An additional 42 inmates are listed as having been housed in the intake modules for more than four days, with a few waiting for
significantly longer. For example, one inmate is listed as having spent 145 days in intake, clearly as a result of a clerical error.
We have chosen not to include those records indicating an intake stay of longer than four days due to the possibility of such errors;
however, it is possible that some inmates were, in fact, at the IRC for a longer period than four days.


and foul-smelling cells for several hours or even days. Such circumstances also
present a potential security and operational management issue for Custody staff.
According to several people we interviewed, the miserable condition of the
IRC holding cells resulted in an overburdened nurse clinic system. Because
it was widely known that answering “yes” to one of the three classification
questions could result in a lengthy stay in an IRC holding cell, inmates learned
not to identify their medical needs during intake, preferring to be transferred
to a housing module immediately. Instead, they would wait to sign up for
nurse clinic when they were settled in a regular housing area, increasing wait
times for an appointment, delaying needed medical care, and potentially
putting other inmates at risk of communicable diseases.
In response to a similar situation at the larger IRC for men at the Twin Towers
Correctional Facility, the ACLU received a temporary restraining order that
prevents the jail from housing men in holding cells for more than 24 hours at a
time. This order does not apply to the IRC at CRDF, but we are pleased to see
that over the past several months, the Department has been actively working
to find a creative solution to the problem of intake housing at that facility.
In mid-2007, the Custody staff at the CRDF IRC began monitoring inmates
awaiting medical evaluation to ensure that they did not spend more than 18
hours in an IRC holding cell. Instead, inmates were moved on a nightly basis
to a special housing area—1200—where they could sleep on a bed in a
two-person cell and receive access to a shower. That area, which can accommodate up to 96 inmates, was not part of the women’s jail proper, but had been
part of a complex used to house male arrestees who were booked through
the Century Station and were awaiting transfer to IRC downtown. Deputies
used a running list to ensure that inmates did not wait past the maximum time;
inmates who spent the night would be transferred back to the holding cell in
the morning to await medical or mental health evaluation, with their 18 hours
beginning again.


This system was improved in January 2008 with the conversion of the 1200
housing module to a permanent medical screening area. Under the current
system, inmates requiring medical attention are moved immediately to that
module to await screening on-site, where they remain in relative comfort until
they are ready to be processed into regular housing, without having to shuttle
back and forth between the screening module and a holding cell. Medical
Services Bureau has set up several workstations with computers where nurses
can interview and evaluate inmates, enter information in their medical record,
and set up appointments and referrals. When we visited in January 2008, we
found the screening area staffed with several nurses; only a few inmates were
awaiting attention.
In October 2007, Captain Michael Kwan also began monitoring the number
of inmates waiting to be triaged to ensure that they were being seen in a timely
fashion. He is sent a daily report noting the following information:
• Number of inmates waiting to be triaged
• Number of inmates triaged
• Number of inmates waiting to be data based
• Number of inmates with data base completed
• Number of inmates waiting to be seen by an MD/RNP
• Number of charts with orders to be transcribed
• Number of inmates waiting to be seen by mental health
According to the Captain, wait times in IRC screening have generally been
reduced to well under 24 hours, and medical staff assigned to intake are often
able to assist screening at the IRC for men through the Department’s telemedicine program during their downtime. In February 2008, the facility was
inspected by an audit team for the US Department of Justice, which monitors
the Department’s compliance with a 2002 Memorandum of Agreement (MOA)
relating to mental health care at the jail. In its report, the team found that


“reception screening operations are, for the first time, in substantial compliance
with the requirements of the MOA. In addition, CRDF now has completed
unit 1200 and opened it for beneficial occupancy and operations, facilitating
the timely completion of follow-up mental health evaluation after 15-question
We applaud the Sheriff’s Department for taking proactive steps to address
the problem of lengthy waits for female inmates during intake and are very
pleased to find that the new system has brought them into substantial compliance with the reception screening requirements of the MOA. Inmates may
now wait for medical attention in much-improved accommodations, with access
to a bed and a shower, while the increased turnaround time should ensure that
appropriate housing placements are made in a reasonable amount of time, and
that serious medical issues are evaluated and treated in a timely fashion.
We will be interested to see whether inmate response patterns change as
a result of the new procedures, increasing the number of those requesting
medical attention upon entry and decreasing demand for the nurse clinics.
In general, the nurse clinics should be focused on routine medical issues that
come up during incarceration, rather than attempting to manage more serious
conditions that should be addressed upon entry.

III. Sick Call
CRDF provides access to several levels of medical care to inmates,
depending on the type of treatment or assessment needed. The primary onsite medical facility is the Main Clinic, a busy 24-hour unit that takes inmates
requiring immediate attention and where physicians and Registered Nurse
Practitioners (RNPs) see inmates referred to them. Inmates may also be sent
to the Main Clinic for special tests or to be assigned an observation bed if
needed. Due to space constraints, the Main Clinic also houses one of the five


Nurse Clinics—the facility contains one for each housing tower floor at CRDF—
which operates regular sick call for that floor. Inmates requiring more intensive
care may also be transferred to the Correctional Treatment Center (CTC) at
TTCF or the jail ward at LCMC (or, in an emergency, the nearest hospital). For
those inmates who need them, appointments with specialists in neurology,
ophthalmology, oncology, and other specialties will be made at LCMC.
Along with the intake screening process, the Sick Call/Nurse Clinic system
is the primary conduit for inmates needing access to most types of non-urgent
care. While inmates in theory should all receive a full evaluation, necessary
referrals, and medication upon entry, in practice some inmates rely on sick call
as the first step in the process of getting medical care. Designed to provide
inmates with basic treatment as specified by written Standardized Procedures—
discussed in the next section—as well as over-the-counter medication and
needed referrals to physicians or RNPs, an efficient nurse clinic system is
crucial to the provision of adequate medical care at the facility.
Each nurse clinic (save for the one housed in the Main Clinic, which uses
a counter and lab space there) consists of a small room with a window at which
inmates may speak to the assigned RN or, if necessary, come in for tests. The
nurse on clinic duty must share the space with staff members managing pill call
and those providing dressings and other treatments, leaving little space to
spread out or for privacy. There is currently no space for an additional clinic
nurse. Each clinic is open during one eight-hour shift, from 6:00 am to 2:00
pm, Monday through Friday, although it usually does not operate for the full
eight hours due to lunch, set-up, and close-down. A nurse clinic generally
serves between eight and 12 inmates, with an average of approximately ten
inmates per shift.
This average is taken from a review of 108 CRDF Nurse Clinic Reports
over a four-month period. We reviewed all available reports for the month
of January 2008 and one-fifth of the available reports for October through


December 2007. Four reports from February were included in the files we
requested and were also included in our analysis. We found that the majority
of nurse clinics—approximately two-thirds—served between eight and 12
inmates, for a total average of 9.9 inmates per shift. One-sixth of the clinics saw
fewer than eight inmates and one-sixth saw more than 12, with a high of 17
inmates. Although they were not included in our statistical analysis, we also
visually reviewed a number of clinic reports from the month of June 2008 and
found that the numbers served fell within the same range. Clinics were open
for an average of 6.5 hours per day, with only five clinics in our sample operating
for a full eight hours.
We also found that in January, the month for which we reviewed all available
reports, there was only one day for which five reports—one for each CRDF
clinic—appeared in the file as expected. For the 20 service days in January
for which there were reports, there were four days for which four reports were
filed, eight days for which three reports were filed, six days for which two
reports were filed, and one day for which one report was filed. There were
no reports for three weekdays in January. It is not clear whether the missing
reports were the result of careless reporting or filing, or whether they are a
signal that all five clinics were not operating regularly. We were pleased to see
that, as of June 2008, the Nurse Clinic Report filing system had been much
improved, with updated forms, fewer errors, and a full five reports for each day.
It is imperative that the nurse clinics be monitored closely to ensure that they
are operating regularly and that they see an adequate number of inmates each
In general, nurse clinics operate on a first come, first served basis. Each of
the five housing floors of the women’s jail houses one nurse clinic that serves
the entire area’s population, with four modules and up to 496 inmates on some
floors. Inmates sign up for treatment by writing their names on a “sick call”
list, sometimes pinned to the bulletin board near the front desk of each module,


which holds up to 25 names (per module). Each module deputy oversees the
list and, when told that the nurse clinic is accepting from that module, sends
inmates to the nurse clinic in the order their names appear. (Inmates may also
request treatment using an Inmate Request or Complaint Form, which is
collected by a Custody supervisor, transferred to a Medical supervisor, and
assigned to the Main Clinic or a nurse clinic, as appropriate.) The clinic works
by rotating modules, a few patients from each module at a time. As a result,
the clinic is able to see an estimated two to four inmates per day from each

A . St a f f ing a nd Ca pa cit y

In looking at the current nurse clinic system and staffing levels, it is clear
that some delay in medical care, as described in inmates’ complaints, is
inevitable. During our visits to housing modules, we found full sick call lists
that, according to one deputy, can take up to two weeks to close out, due to the
clinic’s inability to keep up with demand. This is much longer than the 24
hours recommended by the National Commission on Correctional Health
Care. In some cases, it may take even longer to see a nurse due to court dates,
work assignments, and housing moves. For many, the nurse clinic is the first
step (and bottleneck) to obtaining a referral and appointment to a doctor or
RNP, adding an extra delay for those in need of additional levels of care.
The Department’s ability to increase the daily capacity for nurse clinics is
limited by staffing and space constraints and by the nurse’s responsibility to
open a database record for inmates who are being seen for the first time.
Because some inmates use the nurse clinic system rather than the intake
screening process to obtain initial medical services, the assigned nurse must
open up a computer medical database record for these inmates. This process,
in which the nurse records basic information and vital signs, lengthens the
duration of the visit and limits the number of inmates that can be seen.


We hope that the implementation of the 1200 screening module will change
this dynamic by removing a disincentive for inmates to request medical
attention during intake.
Each facility is authorized to provide sixteen hours of nurse clinic—over
two shifts—per day, with more if demand increases. Although MSB eventually
plans to add a second, afternoon/evening nurse clinic shift per floor each day at
CRDF, they have not been able to do so due to staffing constraints. (Because
of a lack of space, only one RN can staff each clinic at a time.) Not only would
the additional shift potentially double the number of inmates who are seen per
day, it would increase access by accommodating inmates who are unavailable
during the day due to court dates or other obligations.
We must note our frustration and disapproval with the performance of the
LASD in this regard. Since we first looked at medical problems in the jails
more than ten years ago, we have time and again pointed out chronic and
intractable nursing shortages. We recommend that the Department
move imm ediately to im plement an adequate number of clinics to
see and treat all persons signing up for sick call within 24 hours
during the week and 72 hours during the weekend.

In response to our concerns, the Bureau has committed to implementing
changes to ensure that all inmates are seen in the Nurse Clinic within the
recommended time period by improving productivity and adding extra hours
to the Nurse Clinic as needed. According to Bureau management, the number
of inmates seen per shift should be higher than twelve. It will take a careful
look at productivity to see how the number of inmates seen during each shift
can be increased through higher expectations and accountability, additional
training, or improved coordination with Custody staff.
Some of the challenges in the delivery of medical care—particularly for the
nurse clinics, which are relegated to small, shared spaces that offer little room
for privacy—are the result of physical constraints posed by CRDF’s design.


We hope that the Department learns the lessons from the problems at CRDF
and plans how to prevent them when and if the female inmates are moved to
a new facility.

B. Sick Ca ll Pr ocess

Currently, nurses on clinic duty have very little control over the sick call
process, which is usually operated by module deputies. (In some of the lockdown modules, sick call is conducted by the pill call nurse, who will go around
to each cell to assess which inmates need to attend nurse clinic.) During our
tour of each module at the facility, we found that the sick call sign-up process
varies widely among modules and deputies. In general, however, the deputy
on AM shift creates a daily sick call list, which she will either maintain at her
desk or post for inmates to sign up on. She is tasked with ensuring that
inmates whose names appeared on the previous day’s list, but did not see a
nurse, place their names at the top of the new list in similar order. In some
cases, however, the list may begin anew, with no priority given to inmates
waiting from the day before. The deputy may also simply keep a running list
of inmates requesting sick call, which is posted until all inmates on the paper
have been seen. All previous sign-up sheets are discarded, leaving no record of
inmates’ previous requests for medical attention.
Deputies have some responsibility for ensuring that inmates with very
urgent needs receive immediate attention. If an inmate clearly needs immediate
treatment, the deputy can put her at the top of the sick call list or, if necessary,
send her to the main clinic. However, deputies are not medical professionals
and may not have the training to discern problems requiring priority attention.
Additionally, since the inmates sometimes simply write their name on a list, the
deputy may have no way of identifying a serious problem unless she
approaches the inmate directly. The deputy also does not have access to the
inmate’s medical records to see how recently she was seen or what her status


is, or, for inmates moving from another module, how long she’s been waiting.
As such, although the current system is “fair” in treating inmates in the order
they sign up, it does not provide the nurse on duty with any way to prioritize or
effectively manage the list of inmates awaiting attention.8
We recommend that CRDF implement a sick call system that
preserves the nurse clinic while providing the nurse on duty with a
way to track and prioritize inmate requests by date and urgency.
Such a system could include, instead of a posted list, a dated sick
call slip process that allows inmates to privately describe their
medical complaint. As we discuss in the next section, all sick call
requests should be tracked in some way, perhaps on a spreadsheet,
that allows nurses to see how long inmates have been waiting
and what their needs are. While the first come, first served system
should be generally m aintained, new requests that appear particularly urgent should be moved to the top of the list. Submitting sick
call requests from all four modules can further ensure that inmates
are seen in order, and that inmates in modules with shorter lists
are not seen m ore quickly than those in modules with longer lists.

C. D a t a Collect ion

The large number of complaints referencing delays, along with the fact
that nurse clinics serve about 8-12 inmates per day, suggests that inmates often
face long wait times before they can be seen by a nurse or doctor. However,
the length of these wait times is nearly impossible to quantify, because the
Department maintains no record of inmates’ requests for service, other than
the complaint form. By the time an inmate files a complaint, she may have

8 The written Standardized Procedure for Nurse Clinic requires that the RN “[o]btain from Custody the Nurse Clinic-Inmate
Sign Up Sheet…of inmates who have signed up for Nurse Clinic. The list will have the date and approximate time of receipt.
The assigned facility Clinical Nursing Director II may decide if necessary.” The policy does not specify the criteria for
determining whether this procedure is necessary, but it appears that it is not considered necessary at CRDF.


been waiting to be seen for weeks or even months. Although the inmate may
attempt to quantify the length of time she has been waiting, there is no way to
verify her account, which is often vague in the first place.
As discussed, inmates who have already been placed in a housing module
can request medical attention in three ways: the daily sick call list, the Inmate
Request Form, and the Inmate Complaint Form. Both the sick call list and
the request form are discarded upon “completion.” Accordingly, there is no
way to verify that all requests have been completed, just as there is no way to
know how long the inmate waited before being seen.
This lack of data is problematic for several reasons. First, it leaves the
Department effectively blind in assessing the level of staffing needed to match
demand, and the extent to which those staff levels should be adjusted or
maintained. While staff members and inmates are able to offer some estimate
of the wait time, there are no real data to back those estimates up.9 Second, it
robs management of a major tool for keeping its staff accountable. When lists
and requests can simply be discarded without any need to prove that they
have been addressed, there is no way to identify staff members who are not
following procedure, failing to keep up with their responsibilities, or simply
ignoring requests. Third, it hinders the medical staff in effectively managing
demand and ensuring that inmate requests do not fall through the cracks,
particularly when they are moved or repeatedly miss sick call. Finally, it prevents
MSB from conducting substantive investigations of inmates’ complaints of
undue delays or delivery failures. Indeed, we discovered very little effort to
research whether such claims are valid or to find the source of the delays.
Failing to adequately collect data on the dates and substance of inmates’
medical requests does not exempt the Department from ensuring that inmates
receive treatment in a reasonably timely fashion, though it does make it more
9 Fortunately, the Department has recently switched to an electronic appointment system for physician referrals, eliminating the
“doctor’s line.” Because these referrals are entered electronically, the system ostensibly allows LASD to track the length of time
inmates wait to see a physician once they have been referred. The Department should do so also with regard to sick call.


difficult. While the lack of a tracking system may preclude inmates from
proving that they face unreasonable delays in receiving care, it nonetheless
exposes the Department to risk by depriving it of evidence that it is systemically working to ensure that no such unreasonable delays occur. As the 2005
Title 15 Health Guidelines note:
[I]t can prove extremely helpful to retain sick call slips or sick call sign-up
sheets. Clear policy and procedures calling for permanent filing of request
forms affords early protection against charges of impeded medical care or
ignoring health care needs. In some facilities, the sick call slip is added to
the inmate’s medical record and includes a space for the health provider to
note date, time, initials and disposition or treatment, directly under the
inmate’s request. Such slips do not take the place of actual charting…;
however, these slips afford excellent documentation that health care
personnel are addressing inmate needs.10
The LASD obviously is out of compliance with this Guideline.
The LASD should im m ediately implement this Title 15 Guideline by
filing copies of inm ate requests and sick call slips in the medical
chart following each visit. We further recommend that the Department im mediately im plement a system for tracking these slips,
preferably by com puter. Such a system need not be complicated—
it could be as simple as a spreadsheet that is updated by a nurse or
another staff mem ber—but it should be maintained centrally for a
specified period of tim e, perhaps for two years after the inmate
has been released. It should include a way for nurses to “check
off” when an inmate has been seen and to easily search for requests
that have not been addressed.
As we discuss in Chapter 3, “Inmate Complaints,” the Custody
Division is in the process of implementing a new Complaint/Request
system. As part of the new system, the Department began

10 “2005 Title 15 Health Guidelines,” pg. 17.


assigning reference numbers to all but the most minor Inmate
Request Forms, including those requesting medical care, on May 1,
2008. Although this will no doubt impose an additional data entry
burden on Custody staff, we endorse this plan, which will provide
an additional layer of accountability and ensure that there is some
record of each inm ate request made.

IV. Standardized Procedures Certification
As mentioned earlier, a primary role of the nurse clinic is to provide an
initial screening and physician/RNP referral to inmates needing medical care.
As a result, delays in seeing a nurse will compound the length of time an inmate
must wait to see a doctor or RNP. However, RNs who have been certified in
certain standardized procedures may avoid this extra step by providing some
basic care themselves. As a result of the Nursing Practice Act (NPA), enacted
by the California Legislature in the 1973-74 session, RNs have been authorized to perform certain procedures that had previously belonged within the
scope of medical practice: “Once the nurse has observed signs and symptoms
of illness, reactions to treatment, general behavior, or general physical characteristics and determined the presence of abnormal characteristics, the nurse may
administer treatment in adherence to a standardized procedure that authorizes
the nurse to treat.”11
Known as “Standardized Procedures,” these detailed protocols must be
carefully developed and documented by “organized health care systems,” such
as LASD’s Medical Services Bureau, along with a comprehensive education
and certification process. Nurses who have not been certified by proving that
they understand and can adequately perform the relevant functions may not
do so. The procedures must be revised on a regular basis.

11 Scope of Nursing Functions, Board of Registered Nurses.


At the LASD, the standardized procedures are developed by the Interdisciplinary Practice Committee (IDPC), comprising the Unit Commander,
Chief Physician, Clinical Nursing Directors, Chief Pharmacist, Nurse
Practitioners, and RNs. They encompass basic treatment procedures for
conditions over five training series:
• Series I: Nurse Clinic, Pain Assessment, Angina Pectoris, Asthma
• Series II: Acne Vulgaris, Dermatitis, MRSA, Common fungal infections
• Series III: Allergic Reactions, Bee sting, Scabies, Common colds
• Series IV: Diarrhea, Constipation, Gastritis, Hemorrhoids
• Series V: Dental Problems, Dysmenorrhea
Having nurses on nurse clinic duty performing these procedures can eliminate an extra referral step for inmates complaining of these conditions, allowing
them to be treated in a more timely fashion. Otherwise, the inmate would
have to wait an additional amount of time, on top of the time she spent waiting
to see the nurse, to see a doctor for treatment.
At the time of our visit on January 22, 2008, however, the majority of registered nurses within the CRDF Medical Services Bureau were not certified to
perform the LASD standardized procedures. According to Department policy,
which requires that the procedures be reviewed every three years, the IDCP
revised the policies in 2007, meaning that all RNs had to be recertified in the
new procedures. On that date, of 69 nurses, 19 had been certified in Series I
and nine had been certified in Series II. As a result, until they could be certified, nurses on clinic had to revert back to referring patients to a physician for
those services.
The Department began offering training for the new procedures in
September 2007; to date, it has only offered Series I and II. The training for
each procedure takes two hours, for a total of eight hours (four for Series V)
a day. Because all nurses—649 systemwide—have to be trained in the proce-


dures while ensuring that the jails are adequately staffed, certification will be
a lengthy process. Getting the CRDF nurses trained has been a special
challenge as a result of the facility’s location, away from the main jail complex
Since our visit, MSB has conducted a sustained push to train the nurses at
CRDF, including holding seven classes at the facility to increase attendance.
Nurse Managers at the facility are responsible for scheduling nurses for the
training, ensuring that the facility is adequately staffed and that the classes are
scheduled while on duty. As of May 21, 2008, 35 additional nurses had been
trained in Series I and 24 in Series II. However, 15 nurses have yet to complete
Series I and 24 must complete Series II; no nurses have yet been certified in
Series III through V. Although these Series appear to encompass less common
issues—as evidenced by inmate complaints, at least—we hope that these trainings occur in a relatively short time frame to ensure that nurses are able to
perform those procedures.
There has been som e progress in increasing the number of RNs
who are certified for Series I and II standardized procedures.
We recommend that MSB continue to make it a priority to ensure
that all RNs becom e certified in all of the standardized procedures
as soon as possible. While scheduling nurses for the training is no
doubt a drain on the facility, regularly offering the training on-site
at CRDF, perhaps in shorter sessions, might make it easier for more
nurses to attend between shifts or responsibilities. We suggest
that, in scheduling staff for sick call/nurse clinic, Nurse Managers
pay special attention to ensuring that assigned nurses have been
certified in all available procedures. The Departm ent may also
want to consider offering the full range of standardized procedure
trainings in an expedited fashion to RNs who will be assigned to
nurse clinic.


P r e g n a n t a n d P a r e n ti n g I n m a te s

In a year’s time, more than 1400 pregnant women enter the Los Angeles
County Jail system. As many as 60 pregnant women will be in the jail at any
given time. All of them will require prenatal care. The LASD, surprisingly,
does not keep track of how many women deliver children while in custody,
although the Department guesses that there are no more than 30 births in a
year. Some women deliver at the jail itself. Others deliver at the jail treatment
center or at County USC Hospital.
Few of the policies and programs relating to pregnancy are documented in
the Department’s written materials. As a result of this failure to have written
policies, as well as a compartmentalization of roles, we encountered understandable but ultimately unacceptable confusion about actual policies, particularly
those relating to the transportation and restraint of women in labor and shackling
during delivery. We also found inconsistencies in or confusion about the
provision of pregnancy tests and the timing of commencement of prenatal
care, as well as about postpartum care. San Diego County does have written
policies that address many of these concerns, and a sample of those are
attached to this chapter as Appendix A.
Although many aspects are praiseworthy, Los Angeles County lags behind
San Francisco and San Diego Counties in key areas. In San Francisco, women
are allowed contact with their babies after they return to the jail post-delivery.
In Los Angeles County, there is no such program. In San Francisco, children
wanting to visit their mother are given specific appointment times. The LASD,



in contrast, is more like a lottery. Visitors are taken on a first-come, first-served
basis. Children may sit all day and never get to see their mother. If they come
back the next day, it starts all over: There is no preference given for children
who were unable to see their mother the previous day. A small child could sit
in a jail all day for two days straight and not get to see their mom.
In San Francisco, any qualified female inmate who desires to do so can sign
up for the Parent-Child Visiting program, formerly known as Prison MATCH,
and then can have direct contact with her children. Both sentenced and presentenced inmates can participate and there is no parenting class requirement.
Although the LASD provides a similar program, called TALK, through the La
Puente Hacienda School District, it only serves 10-12 inmates a week. Presentenced inmates are barred from participation, and women must attend at
least three parenting classes before they become eligible for TALK.
Because the LASD does not provide certain services itself, it has coordinated
with volunteer and contracted community service providers. We acknowledge
and commend the excellent work of the Harriet Buhai Center, Center for
Children of Incarcerated Parents, Friends Outside, and the Hacienda La Puente
School District.

I. Background
As a result of the rapidly growing number of women in jails and prisons
nationwide, researchers and correctional managers have begun to look at the
question of how best to meet the unique needs of female inmates.12 Because
women have always composed a minority of jail populations—in Los Angeles
County, they make up approximately 11 percent of all inmates—administrative
policies and procedures generally do not differentiate between male and

12 In 2006, the number of women in prison nationwide increased by 4.5 percent, which is higher than the 2006 growth rate for men
(2.7 percent), as well as the average growth rate for women between 2000 and 2005 (2.9 percent). William J. Sabol, Heather Couture,
and Paige M. Harrison, “Prisoners in 2006,” Bureau of Justice Statistics, US Department of Justice Office of Justice Programs,


female inmates. This approach is appropriate for most areas of jail practice,
in that it ensures equitable treatment for both genders, but it may ignore
significant gender-specific needs.
The primary area in which women in jail differ from men is, of course,
biological. Records for the Los Angeles County Jail show that, between June
2006 and May 2007, 1409 women who entered the jail system were pregnant.
Not being just a medical issue, pregnancy raises a host of complex policy issues,
including prenatal diet and education; appropriate housing and restraint; access
to abortion; transportation and security during labor, delivery, and recovery;
child custody; and visiting.
Issues pertaining to the children of incarcerated parents are, though not
entirely gender-specific, much more likely to affect women than men. While
approximately 55 percent of men in jail have children under the age of 18,
female jail inmates are even more likely to be mothers to minor children.
One study estimates that a full two-thirds of women in jail have children under
age 18.13 Moreover, nearly 85% of these women either had dependent children
in their care at the time of arrest or report plans to live with their children after
they are released, and incarcerated mothers are also predominantly their families’
primary caretakers and wage-earners.14 The plight of the children of inmates
is a concern that has traditionally been outside the scope of correctional policy.
Nonetheless, a growing body of research on the negative effects of incarceration
on children of prisoners, and on the positive effects of the parent-child relationship on prisoner recidivism, has prompted many agencies to implement
programs that strive to maintain or even improve the bond between parents
and their children.
In this chapter, we consider those policies, procedures, programs, and
practices that relate to pregnancy, reproductive care, and parenthood for women

13 Mumola, Christopher, “Incarcerated Parents and Their Children.” Bureau of Justice Reports, August 2000.
14 Id.


in the Los Angeles County Jail. To that end, we compiled and consulted
written LASD policies, regulating standards and state law, and outside
research; interviewed custody, medical, and program staff; and reviewed six
months’ worth of inmate complaints at the Century Regional Detention
Facility (CRDF).

II. Inmate Pregnancy and Childbirth
To get a picture of LASD policy and practices for the custody and treatment of pregnant inmates, we requested and reviewed the written policies
contained in the LASD Custody Division Manual, the CRDF Unit Orders,
Medical Services Bureau general policies, and the Medical Service Bureau’s
CRDF-specific policies. We also received and consulted some pregnancyrelated policies from the LASD’s Correctional Treatment Center (CTC), a
licensed medical facility at Twin Towers that houses inmates in need of more
intensive supervision or care, including female inmates considered to have a
high-risk pregnancy. The CTC policies provide a great deal more detail about
reproductive care procedures, but do not directly apply to inmates housed at
CRDF, as the CTC is authorized to provide a higher level of care. We also
spoke to several LASD, contract, and hospital staff members about various
pregnancy-related policies and procedures, including medical care, the
delivery process, programs and classes, and child custody procedures.
LASD has several important services in place for pregnant inmates,
including three full-time OB-GYN physicians, one of whom focuses primarily
on prenatal care, and a prenatal education program provided by the Center for
Children of Incarcerated Parents. However, we found that only a few of the
policies and programs relating to pregnancy are well documented in the
Department’s written materials. As a result of this lack of documentation, as
well as a compartmentalization of roles, we encountered confusion about some


policies, particularly those relating to the transportation and restraint of women
in labor or delivery. In the following sections, we describe those written policies
that are in place, our understanding of processes that are not documented, and
recommendations for improvement.

A . St a t ut or y Requir em ent s

The Los Angeles County Jail must comply with Title 15 of the California
Code of Regulations, which sets forth the “Minimum Standards for Local
Detention Facilities,” as well as the guiding Penal Code sections on which
they are based. In general, current standards relating to the care and treatment
of pregnant inmates are both broad and brief.
Title 15, which was last revised in 2005, requires that the health authority
(in this case, the Los Angeles Sheriff’s Department) “set forth in writing,
policies and procedures in conformance with applicable state and federal law,
which are reviewed and updated at least annually and include but are not
limited to: …(f) provision for screening and care of pregnant and lactating
women, including postpartum care, and other services mandated by statute.”
It also specifies in the section on nutritional requirements for inmates that
pregnant women are to receive four servings of dairy per day, above the
general requirement of three servings.
These requirements are primarily drawn from Penal Code (PC) §4023.6,
which states that: “Any female prisoner in any local detention facility shall have
the right to summon and receive the services of any physician and surgeon of
her choice in order to determine whether she is pregnant… If the prisoner is
found to be pregnant, she is entitled to a determination of the extent of
medical services needed by her and to the receipt of such services from the
physician and surgeon of her choice. Any expenses occasioned by… services
that are not provided by the facility shall be borne by the prisoner.”
Although abortion is not mentioned in Title 15, the Penal Code specifies


that pregnant inmates are entitled to an abortion as provided by law.
According to PC §4028, “No condition or restriction upon the obtaining of an
abortion by a female detained in any local detention facility, pursuant to the
Therapeutic Abortion Act …, other than those contained in that act, shall
be imposed. Females found to be pregnant and desiring abortions shall be
permitted to determine their eligibility for an abortion pursuant to law, and
if determined to be eligible, shall be permitted to obtain an abortion.”

Assembly Bill 478
The Corrections Standards Authority (CSA) of the California Department
of Corrections and Rehabilitation (CDCR), the agency responsible for the
development, maintenance, and enforcement of state standards for local
facilities, draws its authority from PC §6030. In 2005, at the time of the most
recent revision of Title 15, §6030 did not explicitly address the issue of
pregnant inmates, requiring only that the standards set forth requirements
for “health and sanitary conditions.”
In 2005, however, the California State Assembly passed Assembly Bill
(AB) 478, which details new standards for the treatment and care of pregnant
prisoners. The bill passed both houses and was signed into law by the
Governor. Most of these changes in the new law are directly addressed to
state prisoners in the custody of CDCR, but it also amends PC §6030 to
explicitly require the CSA to include specific standards in Title 15. The
amendments to that section state:
(e) The standards shall require that inmates who are received by the facility
while they are pregnant are provided all of the following:
(1) A balanced, nutritious diet approved by a doctor.
(2) Prenatal and postpartum information and health care, including, but not
limited to, access to necessary vitamins as recommended by a doctor.
(3) Information pertaining to childbirth education and infant care.
(4) A dental cleaning while in a state facility.


(f) The standards shall provide that at no time shall a woman who is in labor
be shackled by the wrists, ankles, or both including during transport to a
hospital, during delivery, and while in recovery after giving birth, except as
provided in Section 5007.7.15
Although PC §6030 instructs the CSA to include these provisions in its
standards by January 1, 2007, those changes have not yet been made, apparently due to the Authority’s long revision process. There is also some question
as to whether the provision regarding the shackling of pregnant women will
be adopted at all. The CSA holds that it lacks jurisdiction over agencies “once
the jail gate closes and the inmate leaves the jail premises,” (in this case, when
the inmate is in transit or at an outside medical facility), since the standards
apply only to local correctional facilities. Nonetheless, it has included in its
Proposed Amendments to Title 15 a recommendation to update the standards
to include guidelines for the treatment of pregnant inmates that comport with
PC §6030.16
Regardless of the vagaries of the Title 15 revision process, the intent behind
AB 478 and the amendments to PC §6030 is clear and should be considered
state policy. Indeed, the CDCR has already implemented the new policies
for California state prisoners. The Los Angeles Sheriff’s Department should
do the same. Accordingly, we recommend that the LASD adopt
verbatim Sections (e) and (f) of the Amendments to §6030.

B. Pr egna ncy Scr eening a nd Pr ena t a l Ca r e

As required by Title 15, the Medical Services Bureau maintains a written
policy for the screening of potentially pregnant inmates. During the reception
process, inmates are asked whether they are pregnant and given the opportunity to request medical care. At this stage, or at any point during their

15 PC 5007.7 allows for shackling of the inmate when it is “deemed necessary for the safety and security of the inmate, the staff,
and the public.”
16 Private correspondence with Rebecca Craig, Title 15 Field Representative.


incarceration, inmates who suspect or allege pregnancy are to be given a
QuickVue urine pregnancy test, similar to a home pregnancy test, which
yields results within three minutes. If the test is positive, the inmate
will be referred to a physician.
CRDF has three full-time OB-GYN physicians on staff. One primarily
covers the IRC, another is focused on prenatal care, and the other works in the
clinic on gynecological care. Because there is an OB-GYN attached to the IRC,
inmates who receive a positive pregnancy result during intake will be immediately referred for a full prenatal appointment and will not be transferred to
regular housing until the appointment is completed. Inmates whose pregnancy is established during nurse clinic will be scheduled for an appointment
with a physician and should generally be seen within one week. In a few
cases, the inmate may see a Registered Nurse Practitioner (RNP) for her initial
assessment. An inmate whose pregnancy has been confirmed will receive a
new wristband from Custody that reflects the word “pregnant.”17
The first prenatal visit will include a full evaluation of the inmate’s condition and pregnancy using the Problem Oriented Perinatal Risk Assessment
System (POPRAS) form. POPRAS is a comprehensive assessment tool that
collects information about the inmate’s medical history, past pregnancies, risk
factors, and current status, including weight and vital signs. It also includes
questions about paternal medical history and about the inmate’s family.
The physician will order lab tests as appropriate, with all pregnant inmates
being offered an HIV test, and the clinic is fully equipped with an ultrasound
machine. Inmates will also be provided with education and counseling about
nutrition, risks, and what to expect. A prenatal diet, including diet and vitamins
and, if necessary, medications, will be ordered at that time. The written policy
does not describe the prenatal regimen, but it appears that pregnant inmates

17 Medical Services Bureau Policy #333: Pregnancy, CRDF Policies and Procedures Manual, Medical Services Bureau:
QuickVue+One Step hCG Urine Pregnancy Test.


will receive, at a minimum, an extra container of milk. The extent to which
any additional dietary changes are necessary, as well as the composition of the
prescribed vitamins, is determined by the physician.
If a pregnant inmate exhibits or describes any conditions indicating distress
or a possible high-risk pregnancy during intake, medical clearance for booking
will not be given, and the inmate must be transported to LCMC for further
evaluation.18 Such conditions include: experiencing labor or threatening
abortion; diabetes; hypertension; bleeding; fever of 100 degrees Fahrenheit
or greater; trauma to abdomen; seizure within last three months; fractures,
dislocations, or other bodily trauma; questionable viability of the fetus/infant;
symptoms of drug or alcohol withdrawal, previous C-section; or dental abscess.
All pregnant inmates are to receive follow-up visits with their OB-GYN
physician, who will schedule regular appointments based upon duration of
pregnancy and special need. Because follow-up treatment is determined on
a case-by-case basis, it is not described in detail in the written policy. In general,
inmates in the earlier stages of pregnancy will see the physician approximately
once a month; as they get close to giving birth, appointment frequency will
be increased to about once a week. In some cases, the attending physician
may decide to transfer the inmate to the CTC, which, as a licensed medical
facility, can provide a more intensive level of care to inmates with higher-risk
pregnancies. Inmates requiring hospitalization will be transferred to the
Women and Children’s Hospital at LCMC, where they will be housed on the
7th or 8th floor until delivery.
Housing considerations for pregnant women do not appear in the Department’s written policies. However, general practice requires that pregnant inmates
be assigned to a lower bunk to avoid the risk of injury. They are restricted
from joining any work crew except the sewing crew, and may not be placed in
the safety chair or—unless absolutely necessary—medically ordered restraints.

18 Medical Services Bureau Policy #201: CRDF Reception Center Health Screening – Female.


Any inmate who experiences a miscarriage, also known as a spontaneous
abortion, is to be transported to LCMC via paramedics.

1. Inmate Complaints
In our review of six months’ worth of inmate complaint files, which we
discuss in more detail in Chapter 3, “Inmate Complaints,” we found 15
complaints, described below, that related to pregnancy screening or the
delivery of prenatal care. Six of these complaints had not been addressed
or completed by medical staff at the time of our review and contained no
information about the validity of the complaint. It is difficult to envision a
legitimate reason for these delays in resolving inmate complaints.
• Four inmates complained that they had not received a pregnancy test, and
had thus not been able to obtain prenatal care. Another inmate complained
that she had first been told that it was too early for the test, and that her
second test had gotten lost. It is not clear from any of the complaints whether
the initial request for a test had been made during intake or through some
other process; it is also unclear how a QuickVue test, which provides on-thespot results, could have been lost. At the time that we reviewed the complaints,
only two of these had been completed by medical staff. In both cases, the
responses said only that the inmates’ tests had come back negative, with no
other information as to whether the test was delayed or lost.
• Five other allegedly pregnant inmates complained that they had not been able
to see a doctor about their pregnancy.19 Four of those complaints had been
completed, with one noting that the inmate’s pregnancy test had come up
negative, and the other three stating that the inmate had seen a physician.
There was no information about how long each inmate had been asking to see

19 One of these inmates filed a second complaint about not receiving prenatal care; that complaint is included in the four files discussed


a doctor, whether and on what date a pregnancy test had been given, and
whether a delay occurred.
• Four inmates complained that they had not yet received a prenatal diet or
vitamins. Two of these complaints had not been completed by medical staff
at the time of our review, although one contained a note from the Custody
investigator that a pregnancy test had been given four days before, and that
it took seven days for the results to come in. Again, this appears inconsistent
with the Bureau’s written policies on pregnancy testing. The other two
complaints had been completed, with both stating that the inmate had since
been seen by a physician and that prenatal care was initiated. One of these
responses also noted that the regular prenatal “diet” (for pregnant inmates
with no complications) simply consists of the regular diet with “extra milk/juice.”
• An inmate complained of being assigned to a top bunk, even though she was
pregnant. The complaint was resolved within one day by a Custody sergeant,
who had her moved to a lower bunk and told the staff that pregnant women
should never be assigned an upper bunk. While it is a good practice, we could
not find this policy in any of the written materials we obtained.

2. Written Policies
These complaints brought up several questions about the policies for the
screening and care of pregnant women at CRDF. The primary policy addressing
these issues is MSB Policy #333, included at the end of this chapter, which
states that “[a]ll female inmates who report being pregnant will be given a
pregnancy test. When positive results are obtained, the inmate will be provided
medical care and counseling.” An accompanying policy from the CRDF manual
describes the procedure for giving the test.
Although the document, which is only two pages long, describes the
screening and evaluation process in very general terms, it lacks detail about


the immediacy and frequency of medical evaluations, the process for ordering
prenatal diet and vitamins, or the nature of the prenatal “counseling.” For
example, it requires a referral by the initial screener to a physician/RNP, who
will perform an evaluation and “order appropriate medication, lab, and follow
up appointment with the OB/GYN physician.” Yet there is no discussion of
a recommended schedule for these appointments or information about the
initiation and character of the prenatal regime.
Some of the responses to inmates’ complaints that we reviewed also seem
to indicate that a 7-day pregnancy test is required before care is initiated. In
fact, the QuickVue test should be offered on the spot when requested, and the
results should be immediately available. Because they are considered to be
“medical” orders and are part of the inmate’s individualized care plan, the prenatal
diet and vitamins must be ordered by a physician. The process should be
clarified to require that inmates claiming to be pregnant receive
both the QuickVue test and result during the intake screening or
nurse clinic visit, at which point she is considered to be pregnant.
As a result of the Clinical Laboratory Improvement Amendments,
nurses administering a urine pregnancy test must receive additional
training and show competency. All nurses who conduct nurse clinic
or IRC screening should be so certified. A second, blood test will be given

by the assigned OB/GYN physician to confirm that pregnancy, but this should
not delay basic prenatal care or affect referral to a physician. We also recomm end that the policy clearly set forth a timeline for the evaluation
process and for the initiation of those components of a prenatal
regim en that do not require a case-by-case physician approval. 20

The written policies also contain little information about non-medical
treatment of pregnant women. Once an inmate has received a positive

20 PC §4023.6 requires that pregnant inmates be allowed to obtain treatment from the physician or surgeon of their choice, at their
expense. It is unlikely that many inmates in the county jail will have the resources to do so, but the pregnancy policy should
nonetheless include a provision for such a case


pregnancy test result, she is to be assigned a yellow wristband marked
“Pregnant.” Yet although considerations for pregnant inmates do appear in
policies from time to time, there is no comprehensive list of special accommodations or considerations for inmates with this designation. Those policies that
do specifically discuss pregnant inmates are:
• “Medically Ordered Restraint Devices”: The use of these devices (which
include 3 and 4-point restraint systems, soft ties, padded belts, and restraint
boards) on pregnant inmates is limited to “the most compelling circumstances
and then only after consulting with personnel.”
• “Safety Chair”: This restraint device may not be used on pregnant women.
• “Inmate Workers”: Pregnant inmates may “only be assigned to the sewing
We came across no policies that address housing accommodations, such as
bunk assignments; general and transport restraint considerations; or prenatal,
childbirth, or parenting education, although at least some of those policies do
exist in practice. We recommend that the Custody Division develop a specific
and comprehensive policy, in accordance with Title 15 and PC §6030, that
addresses each of these areas. As we discuss in the following sections, the
policy should also include information about procedures for steps to take when
an inmate goes into labor, is transported to a hospital for delivery, and returns
to the facility.

C. A bor t ion

Female inmates have the right to terminate pregnancy by abortion.21
An inmate can request an abortion by signing the Department’s Therapeutic
Abortion Request form during nurse clinic. She will be referred to the OB/GYN

21 Medical Services Bureau Policy #333.3: Therapeutic Abortions


physician for proper dating of gestation by ultrasound, and to a registered nurse
practitioner for abortion counseling, where she is provided information about
abortion procedures, options, and what to expect.
Inmates who are identified with severe mental disorder are referred to the
facility Mental Health Unit for evaluation and to determine competency of a
written informed consent. A physician, registered nurse, or registered nurse
practitioner will perform this evaluation.
The registered nurse will facilitate contact between the inmate and an
outside clinic—generally Planned Parenthood—by setting up a phone call in
a private area. The RN informs the clinic staff that the caller is an inmate
and hands the phone over to the inmate to discuss scheduling arrangements.
Once the arrangements have been made, the RN schedules the abortion,
then contacts the custody medical liaison to obtain a court order—generally
obtained by fax on the day of request—permitting transport of the inmate to
the clinic.
Abortions are usually performed at a nearby Planned Parenthood clinic
and require one or more visits, depending on the duration of the pregnancy.
Once the court order has been approved, an appointment will be scheduled
for the inmate to go to the clinic for the abortion or insertion of the laminaria.
For abortions that require insertion of the laminaria one or more days before
the procedure, the inmate will return to CRDF overnight. There, she will
be assessed by an RN, who will contact the on-site physician for an evaluation;
in most cases, the inmate will be moved to one of the observation beds in
the Main Clinic overnight. The next day she will be returned to the clinic
for completion of the abortion procedure. She will again be assessed by a
nurse and evaluated by a physician, and will be admitted to the Main Clinic,
usually for at least 24 hours, so that she can be monitored for bleeding and
We reviewed only one inmate complaint relating to access to abortion.


In that case, the inmate complained of repeated delays in obtaining an abortion,
culminating in the designated outside clinic refusing to perform the procedure
due to a missing court order. Absent other complaints, there is no evidence
that such delays are a systemic problem. However, because the process
requires several steps—including the initial request, appointments with an
OB/GYN and RNP, approval of a court order, and scheduling with the outside
clinic—the potential for delay is significant. Current California law states
that abortions may only be performed on a viable fetus (generally 24 weeks
or more) if a physician judges that the mother’s life or health is at risk.22
While abortions after 15 weeks are relatively rare, it is crucial that inmates not
be made to wait past the point where they can legally obtain the procedure.23
In general, the Departm ent should ensure that inmates can be
scheduled for the procedure within a reasonable period of time
by expediting requests and setting forth a written timeline for
com pletion of the abortion.

D . Pr ena t a l a nd Post pa r t um Educa t ion: MI RA CLE

Approximately 50-60 pregnant women are housed at CRDF at any given
time. The LASD has coordinated with the Center for Children of Incarcerated
Parents (CCIP), a non-profit group that promotes and facilitates family reunification for inmates with minor children, to provide a prenatal and neonatal
educational program for pregnant inmates, known as MIRACLE. An estimated
20-30 women are enrolled in the individualized program at any one time.
MIRACLE operates on multiple funding strings, including public grants and
money from private foundations, and does not receive any money from the
Inmate Welfare Fund. The program offers individualized educational sessions

22 Cal. Health & Safety Code §§ 123464 - 123468
23 According to the Centers for Disease Control, only 5.1 percent of all abortions nationwide were performed after 15 weeks.
(“Abortion Surveillance—United States, 2004,” Centers for Disease Control, 2007.)


as well as group courses, which provide information on breastfeeding, basic
childcare, and nutrition.
MIRACLE provides three levels of service to pregnant women in
Los Angeles County jails:
• Classes for all pregnant women. All pregnant women at CRDF are
eligible to attend classes. Since 2007, MIRACLE has offered prenatal and
child development classes on every other Monday, held from 8:00-10:30
am. Classes alternate Mondays with mothers’ support groups, also held
8:00-10:30 am. All pregnant women may receive these services; enrollment
in MIRACLE is not a prerequisite.
• Individualized Family Services. MIRACLE offers family advocacy
through direct assistance at the jail. Advocates visit inmates once a week
and provide hour-long meetings during which they provide prenatal education and assistance with health and social services needs. After an inmate
is released, an advocate continues to visit at least once a week in the former
inmate’s home, drug treatment program or mother-child prison program in
order to continue case management and child development services. The
organization provides Family Services for up to five years after the birth of
the inmate’s baby.
• Individualized Transitional Services. MIRACLE provides sentencing
advocacy by working with the courts, treatment programs, prison system,
and mother-child prison programs to help inmates get sentenced to a program
where they can live with their infant. MIRACLE also transports inmates
from the jail to program sites when the Community Transition Unit (CTU)
places them in a community treatment program. The program also provides
advocacy for child placement and custody by assisting inmates who give
birth while incarcerated with identifying appropriate infant placement and
help to avoid foster care placement.


Because the program seeks to reunify inmates with their newborn children, MIRACLE strives to assist program participants with housing and
rehabilitation services, education and job training in anticipation of their
release. Program managers and teachers refer interested inmates to the
LASD’s Community Transition Unit (CTU) for assistance in connecting with
DCFS and appropriate child welfare services. CTU also assists inmates in
keeping abreast of court-ordered classes and visits in order to fulfill requirements for child reunification post-release.
For those pregnant women or new mothers who are being transferred from
jail to a state prison, MIRACLE provides assistance during their transition, and
inmates enrolled in the program while in jail are given priority placement in the
California Institute for Women. This state correctional center provides unique
mother-child reunification services, including contact visits between mothers
and infants.
MIRACLE is a well-designed program that provides a much-needed
service to expecting and new mothers in the jail. In doing so, it also fulfills the
state’s requirement that the facility offer prenatal and childbirth education to
pregnant women. Although basic prenatal education is also provided by the
inmate’s OB/GYN physician, the MIRACLE program enhances that service by
providing additional support for women preparing to give birth. However,
information about the program, and its eligibility and enrollment process, does
not currently appear in the department’s written policies. Nor do outreach
CRDF nursing staff is responsible for compiling a weekly list of inmates
who have received a positive pregnancy test and referring it to the CTU,
whose staff will follow up by approaching the inmates directly. The CTU
includes information about the program in its information packet, and inmates
may also learn about this program’s existence through other non-profit inmate
advocacy organizations (such as the Harriet Buhai Center for Family Law and


Friends Outside). Inmates may also request to attend the weekly information
or monthly enrollment session, to which they will be escorted by Officer
Rivera of the CTU. Although it appears that pregnant inmates who want to
participate are able to either receive individualized counseling or attend the
class, there is currently no system to track which inmates are receiving
services, which inmates do not wish to participate, and which inmates wish to
participate but are unable to. We recommend that the Department
im plement such a tracking system.
We also recom mend that the purpose, structure, enrollment
procedures, and outreach process for MIRACLE be specifically
outlined in the LASD’s pregnancy policy. Since healthcare workers
are a prim ary source of outreach for MIRACLE, the MSB pregnancy
policy should also be modified to include procedures for informing
inmates about the program and facilitating access to it.

E. La bor a nd D eliver y

Because of short stays, very few inmates actually give birth while in the
custody of the Los Angeles County Jail. Between May 2007 and April 2008,
three inmates gave birth at CRDF. Although the Department does not keep
statistics for births that occur outside the facility, CRDF and hospital staff
estimate that no more than one or two deliveries occur each month, and that
during some months there are none at all. AJIS data show that of the approximately 1400 pregnant women who entered between June 2006 and May 2007,
about 75% were released within 30 days; 50% were released within ten. Of
the remaining inmates, only seven inmates—less than one percent—were in
custody for over 180 days.24 Maintaining statistics on births and birth outcomes
should thus not be a difficult task. We recommend that the Department

24 Thirty-six pregnant inmates had not been released at the time we received the data set and are not included in this calculation.


track the number of inmates who give birth by location of delivery,
type of delivery, and length of stay in the hospital. It should also
track birth outcom es, including any information about premature
births or infant mortality.

No clear or detailed written policies on managing inmates in labor, childbirth,
or recovery currently exist for CRDF. As a result, the information in this section
has primarily been compiled through interviews with LASD, contract, and
hospital personnel.
In general, inmates do not give birth at CRDF or, for those housed there,
at CTC. When an inmate shows signs of labor, a deputy will escort the inmate
to the health clinic where her and her fetus’s heart rate will be checked (either
by a physician or qualified nurse practitioner). Once her condition is diagnosed, she will be transferred by paramedic to LCMC. If, however, delivery is
imminent and travel time does not permit transport to LCMC, she will be
taken to the nearest hospital (usually the St. Francis Medical Center), and in
some cases, the delivery may even occur at the facility. During transport, the
inmate is in the custody of the accompanying CRDF deputy, who is responsible for all security decisions. Upon arrival at the LCMC, the inmate is usually
taken to the 5th floor maternity ward, rather than the jail ward. Depending on
staffing, a hospital deputy may take custody of the inmate, or deputies from
CRDF may continue to maintain custody throughout the birth and until the
inmate returns to the facility.
There appears to be no clear restraint policy for any step of this process,
and we could find nothing written on the subject other than general restraint
policies for inmates at the hospital. These require that hospitalized inmates
be shackled to the hospital bed:
While at the hospital, the deputy providing security shall ensure that the
inmate is secured to the bed with handcuffs and/or the issued leg chain.
Should it become necessary for the inmate to move from the bed due to


medical treatment, exercise, or to use the restroom, both of the inmate’s
feet shall first be secured with the issued leg chain. If one of the legs
cannot be secured for medical reasons, then the leg chain shall be attached
from one leg to the opposite hand with the minimum amount of slack
necessary to allow movement.25
Although the policy does not mention women who are in labor, delivery,
or recovery, the Custody staff that we spoke to said that they avoid restraining
inmates during delivery, and that decisions are made based on security and
at the deputy’s discretion in consultation with the doctor. However, a delivery
nurse at the Women’s Hospital said that leg chains, which are heavy but long
enough to allow the inmate to get to the bathroom, are often present during
childbirth. All other medical decisions are made by the inmate and the
attending physician, and inmates are entitled to receive the same medical
care as any other patient.
Following birth, the inmate will remain at the hospital for as long as is
medically necessary, which may be from 24 hours up to a week. During that
time (and during the delivery), she may not receive any visits; any family
member or friend who shows up at the hospital is asked to leave.26 In many
cases, the family does not find out about the birth until after the inmate has
returned to jail. While in the hospital, the inmate will be allowed to visit with
and nurse her infant at the deputy’s discretion and under the supervision
of the nurse. According to hospital staff, deputies generally approve such
requests. Throughout the hospital stay, the inmate is supervised by a Custody
deputy, who generally sits outside her locked room, and is usually restrained
using the leg chain.

25 Inmate Detentions at Hospitals 5-03/100.00 Custody Division Manual.
26 In San Diego County, jail inmates who give birth while in custody are assigned a “doula,” a trained birthing assistant who provides
non-medical emotional and physical support during delivery. The doula is assigned upon arrival to the hospital and may not have
contact with the inmate after birth. San Diego County may also allow visits with approved family members at the hospital before
the inmate returns to the facility. We recommend that the LASD consider implementing such a policy.


As previously mentioned, current Title 15 standards do not address restraint
issues for pregnant women. However, PC §6030, from which those standards
flow, does. It states: “The standards shall provide that at no time shall a woman
who is in labor be shackled by the wrists, ankles, or both including during
transport to a hospital, during delivery, and while in recovery after giving birth,
except as provided in Section 5007.7.” Section 5007.7 allows for such restraint
when necessary to maintain security. As stated earlier, we recommend
that the LASD immediately and explicitly adopt this policy, which was
endorsed by the American College of Obstetricians and Gynecologists
(ACOG) and California Medical Association. According to the ACOG,

“Physical restraints have interfered with the ability of physicians to safely practice medicine by reducing their ability to assess and evaluate the physical
condition of the mother and the fetus, and have similarly made the labor and
delivery process more difficult than it needs to be; thus, overall putting the
health and lives of the women and unborn children at risk.” The California
Medical Association concurs: “[S]hackling of a prisoner during childbirth may
be unnecessarily uncomfortable and dangerous for the female inmate, while
providing little additional public safety protections.”27
The LASD restraint policy should define the term “shackling”
and clearly indicate the circumstances under which restraints
may be used on inmates who are in labor, delivery, or recovery.
We recom mend using the same criteria as that for use of medical
ordered restraints for pregnant women: “In considering the use
of restraint devices on pregnant inm ates, personnel shall first
establish articulable facts to dem onstrate that the inmate poses
an immediate threat of great bodily injury or death to herself, her
fetus, others, or who display behavior that results in the destruction

27 Office of Assemblywoman Sally J. Lieber, October 5, 2005,


of property.” The policy should also direct that restraints only be
used under the supervision of medical personnel.
CRDF should also maintain full medical and custody procedures
for inm ates who go into labor, including delivery procedures for
when the birth takes place at the facility. For example, CTC’s medical

policies go into substantial detail about procedures for precipitate delivery—
when there is no time to get the inmate to a hospital in time for the birth.
Three inmates gave birth at CRDF during our review period, but there is no
such policy for that facility. Clear policies for custody deputies about how to
manage an inmate who appears to be going into labor may even decrease the
number of deliveries that take place at the facility.
The policies should also include postpartum procedures, as
required by statute. According to CTC documentation, following release

from the hospital, inmates who have given birth are to be admitted to the CTC
for at least a 24-hour observation period, and should not be given a work
assignment for eight weeks. This policy should be incorporated into the CRDFspecific policy as well. Upon return to the facility, according to Medical Services
management, the inmate can request to pump and store milk at the Main Clinic,
to be given to the family during visiting. However, this procedure does not
appear in written policies and is not well known. According to CRDF staff, no
inmate has taken advantage of the nursing option within the past year. Title
15 requires the maintenance of policies for lactating inmates, and the Department
should fully document this policy and encourage inmates to use the process.
The United States Surgeon General recommends that infants be breastfed for
the first six months of life, and allowing inmates to pump milk while in
custody will allow them to breastfeed when they are released from jail.28

28 U.S. Department of Health and Human Services. “HHS Blueprint for Action on Breastfeeding, Washington, D.C. U.S. Department of
Health and Human Services,” Office on Women’s Health, 2000.


F. Tr a nsf er of t he N ew bor n

After she has given birth, the inmate will complete a “Release of Newborn”
form, provided by the hospital’s social worker. The inmate will designate a
guardian for the infant. If an inmate does not have any child abuse-related
charges or prior children in DCFS custody, the hospital social worker will
approve any guardian designated to take custody of the infant. After the
inmate’s hospital stay is complete, and she is returned to CRDF, the social
worker will notify the designated guardian of the inmate’s new infant and
the guardian may then go to the hospital to obtain custody of the newborn.
Guardians may not be notified of the infant’s birth while the inmate remains
in hospital custody.
If the inmate’s charge is related to child abuse or domestic violence or
if she has any children in DCFS custody at the time she gives birth, Child
Protective Services (CPS) will oversee the infant’s placement in foster care or
with an approved inmate-designated guardian. A social worker and CPS will
only conduct an investigation on the designated guardian’s suitability under
these circumstances.
While decisions made at or soon after the time of delivery may cause the
inmate stress and confusion, short jail terms and the high likelihood that a
pregnant inmate will be released before she delivers often renders any process
for pre-arranging the infant’s custody unnecessary. Furthermore, the social
welfare system’s poor record of successfully maintaining or facilitating family
reunification for female inmates prompt some inmate advocates to recommend
against inviting Child Protective Services or social workers into an inmate’s
familial matters unnecessarily. Absent evidence that the procedures now in
place are not working, we do not recommend making any changes to the
current policy.
There is currently no policy in place allowing special visiting for inmates and
their newborn infants once they leave the hospital. As discussed in the next


section, inmates’ only avenues for visiting with their children are public,
non-contact visiting and structured contact visits through the TALK program.
Although infants are eligible for participation in that program, eligibility is
limited to sentenced inmates, vastly restricting the number of mothers who
can participate. In contrast, many corrections agencies, including the California
prison system, have special programs for new mothers to live with their
newborns. For example, inmates who give birth while incarcerated at the
Riker’s Island jail in New York City may apply to live in a 25-bed nursery
facility with their babies for up to one year.29
The LASD may want to consider implementation of an infant
visitation program for women who give birth while in custody,
similar to the “Baby Visits” program in San Francisco or the nursery
facility at Riker’s Island. Administered by the Northern California Services

League, “Baby Visits” provided for contact visits for inmates and children who
are in the “toddler stage” or younger. This program had no parenting class
requirements and eligibility was determined on a case-by-case basis. Inmates
in high security jails, or under restraining orders or charged with child abuse
are automatically barred from this service. Because San Francisco’s current
parent-child visiting program now allows for inmates to see their children up
to 16 with no parenting class requirement, the Baby Visiting program is no
longer necessary at that facility.30

G . Recom m enda t ions f or I m pr ovem ent

As evidenced by the recent passage of AB 478, legislators, medical professionals, and correctional managers are increasingly concerned about the treatment
of and services provided to pregnant inmates in California jails and prisons.

29 “Facilities Overview: An Overview of NYC DOC Facilities,” New York City Department of Correction.
30 Phone interview with Karen Levine, San Francisco Sheriff’s Department, June 19, 2008.


The rising numbers of incarcerated women and the attendant growth of incustody births have focused attention on the need for specially designed prenatal
and postpartum treatment and services, as well as clear guidelines for the transport and restraint of inmates who are in the process of giving birth. At present,
the Los Angeles County Jail appears to be in basic compliance with most Title
15 standards; in some areas, such as in the provision of prenatal education and
postpartum assistance, it is even ahead of the curve. However, its policies and
practices are not well documented and, as such, lack transparency and are not
fully in compliance with the state health manual standards. The lack of
comprehensive written policies may also lead to confusion about what are the
Department’s policies, such as those involving shackling of women in labor,
leading to practices that do not reflect state law or best practices in the field.
We thus recommend that the Sheriff’s Department devise a set of detailed
written policies and procedures—both medical and custody-related—for
prenatal, delivery, and postpartum procedures, services, and care.

III. Parenting in Custody
It is estimated that more than two-thirds of all women in custody have
children under the age of 18 who were living with them prior to incarceration.31
The effects of the incarceration of their parent on these children, which can
include emotional difficulties, separation from home and family, and involvement
with the public dependency system, can be devastating. Many correctional facilities,
particularly those that house female inmates, have begun to develop programs
and services targeted at maintaining and improving the bond between an incarcerated parent and his or her child. For example, as a result of AB 478, female
state prisoners who give birth while incarcerated may be eligible for transfer
to an alternative community program where they can reside with their infants.

31 “Women in Jail: Facility and Planning Issues,” National Institute of Corrections, U.S. Department of Justice, 1997.


The Los Angeles County Jail established itself as an early leader in this
area through the development of a structured contact visiting program called
Teaching and Loving Kids (TALK), an excellent program that has been
replicated in many other facilities. Enrollment in this program, however, is
effectively capped at about 10 inmates, leaving very few opportunities for
meaningful contact between inmates and their children. In this section, we
detail policies and procedures for visiting at CRDF, both general and through
the TALK program, and offer recommendations for improvements. We also
discuss some of the challenges faced by inmates whose children are involved
in the dependency court system. Although that system is outside the control
of the Sheriff’s Department, we make suggestions for steps that can be taken
by the Department to facilitate communication and compliance with the court.

Effects of Parent-Child Separation on Young Children: The Benefits of Contact Visits
Much of the current body of research on the effects of parent-child
separation has been conducted by Denise Johnston, Executive Director of the
Center for the Children of Incarcerated Parents (CCIP), the organization that
administers the MIRACLE prenatal program in the Los Angeles County Jail.
In her article, “Children of Incarcerated Parents,”32 Johnston explores the
emotional and physical effects of parent-child separation on young children
whose parents are incarcerated. She reports the suddenness of separation
characteristic of a parent’s arrest often produces persistent separation anxiety
among children. When separation is prolonged, children risk becoming
“excessively dependent and fail to develop appropriate self-confidence,” while
the separation-induced emotional stress frequently leads to other forms of
anxiety, aggression, anger, grief and withdrawal. Infants who are separated
from their incarcerated parents at such a young age often experience long term

32 Denise Johnston, “Effects of Parental Incarceration,” in Children of Incarcerated Parents, Eds. Katherine Gabel and Denise
Johnston, Lexington Books, New York (1995).


attachment difficulties and lack of security. Children of incarcerated parents also
experience shame and stigma, often perceiving parental arrest and subsequent
incarceration as rejection or bearing a sense of responsibility for their parents’
In another article, Johnston discusses the ameliorating effects on children’s
separation anxiety and its attendant problems when children have the opportunity to visit their incarcerated parents in jail.33 The degree of improvement
bears a strong correlation to the stability of the parent-child relationship prior
to incarceration and the duration of time the child resided with his or her
incarcerated parent before detention.

A . G ener a l Visit ing Pr ocedur es

Inmates may receive visits from the public from 8:30 am to 3:30 pm and
5:30 pm to 7:30 pm on Saturdays, Sundays, and holidays. Visits are first come,
first served. Each visit can last up to half an hour, and each inmate may only
have one visit per day, or two per weekend. In general, visiting children under
the age of 16 must be accompanied by a guardian at all times, although minors
over 12 may, upon request by the inmate and approval by the captain, be
allowed to attend the visit alone. A maximum of two children (and one
guardian) can visit each inmate at any given time, and inmates and their visitors
are separated by glass at all times.
The potential for meaningful visits between mothers and their children
under this system is limited. Younger children must depend on a guardian to
bring them to the facility and to wait with them, and they do not have the
opportunity to spend time alone with the parent. Depending on the relationships among the child, parent, and guardian, this may be a good thing, but a
sour relationship between the guardian and the inmate may also cause more

33 Denise Johnston, “Parent-Child Visitation in the Jail or Prison,” in Children of Incarcerated Parents, Eds. Katherine Gabel and
Denise Johnston, Lexington Books, New York (1995).


stress for the child. The lack of physical contact and short visiting period may
prove even more painful for young children with a limited understanding of
the circumstances.
The first come, first served policy observed for public visits may also pose
a significant burden for visitors, particularly children, who may sometimes
spend the entire day waiting at the jail for their “turn.” On particularly busy
visiting days, some may not even get the chance to visit, thus rendering their
day-long wait in Lynwood a waste of time. Because the first come, first served
process begins anew the very next day, children who missed their turn to visit
on the previous day have no guarantee that their second day waiting will end
with a visit with their mothers. Furthermore, this lack of guarantee creates
another deterrent for foster parents or other guardians who are not committed
to bring their charges to the jail to visit their biological mothers.
We recommend that the LASD consider implementing a reservation system , used at facilities such as the San Francisco County
Jail, for m inors visiting their parents or legal guardians at CRDF
and other facilities. Appointed, guaranteed visiting times might encourage

temporary guardians or foster parents to bring children to visit with their
mothers. Furtherm ore, permitting children to visit with their
mothers in the designated attorney/social worker meeting rooms—
during professional hours between Monday and Thursday, if
necessary—would afford families a greater degree of privacy when
actual contact visits are impossible. Because visiting a parent in jail

could be a traumatic experience for young children, the added privacy of the
attorney meeting rooms might help to alleviate some of the children’s anxiety
and stress. We also encourage the Department take into account
the needs of children when designing visiting facilities at the future
facility for fem ale inm ates. For example, the facility could include a

children’s play area in the waiting room, child-size furniture for the visiting area,


friendlier colors and surfaces, and even open—if non-contact—visiting for
nonviolent inmates and their children.

B. TA LK: Tea ching a nd Loving Kids

Teaching and Loving Kids (TALK), a program funded and operated by the
Hacienda La Puente School District, allows parenting inmates, both men and
women, to have weekly contact visits with their children who are under the
age of 12. It is modeled after a program called Prison MATCH (Mothers,
Fathers and Their Children), which began at the Federal Correctional
Institution at Pleasanton, California. The program founders’ goal was to work
in cooperation and consultation with institutional staff and inmates to maintain
family ties between inmate parents and their children. MATCH places
emphasis on “developing, through appropriate play and learning activities,
the bonds between parents and children.” The program’s central component
includes facilitating a four hour contact visit between incarcerated parents and
their children once a week in a warm, instructive setting.
In order to participate in the program, inmates must have attended at least
three parenting classes, also provided by Hacienda La Puente, after which they
can submit an application for TALK. At least one parenting class per week
should be offered to each module within the general population, during which
the teachers disseminate information about and application materials for TALK.
Word-of-mouth is the most common form of advertisement for the program.
Inmates must also meet several eligibility requirements, including having
been sentenced to the county jail for at least one charge. While unsentenced
inmates and inmates that have been sentenced to state or federal prison are
free to attend the parenting classes, they are ineligible for TALK. Applications
are processed by the LASD Custody Assistant (CA) assigned to the program,
who usually takes about a week to process each application. Generally, inmates’
children who are in custody of the Department of Child and Family Services


(DCFS) do not participate in TALK. According to jail staff, most foster
parents are unable or unwilling to escort the children to the Lynwood facility.
While there is no written policy preventing an inmate from applying or participating when their children are in DCSF custody, the Custody Assistant
contends that the nature of foster care and the absence of jail visits from a
foster parent’s enumerated obligations create a de facto barrier to contact visits.
The CA takes about a week to process TALK applications. Inmates who
have been arrested or convicted of child abuse or endangerment will be
interviewed on an individual basis, after which the Sheriff’s Department
determines participation eligibility. Inmates who have been in disciplinary
housing two or more times during their current arrest will not be interviewed
by the Sheriff’s Department.
Once the CA approves an inmate for participation, on the Wednesday before
the TALK program that the inmate wishes to attend, the inmate must make
arrangements with her children’s guardian to bring the children to CRDF.

Outreach and Inclusion of Children’s Guardians
Although the CA does not provide outreach to inmates’ relatives and
children’s guardians, she does contact them on the Wednesday before the
TALK program to confirm each child’s plans to attend the session. The CA
also discusses the logistical details and content of the TALK program and
fields questions from guardians of first-time TALK attendees.
Before the start of the 8:00 am program and before the inmates enter the
TALK classroom, guardians of first-time participants are given the opportunity
to meet the TALK teacher and survey the classroom. During the actual
program, guardians are prohibited from contact with inmates and must wait
for the program to end (at 11:00 am) before they can retrieve the children.
One teacher, one deputy and two officers remain in the classroom during
the entire program. After the children leave, inmates clean up and have the


opportunity to debrief and discuss the day’s events.
The designated TALK classroom accommodates 10 – 12 inmates and
about 15 children each week. Although there is no official cap for either
inmates or children, these space and staffing restraints, combined with the
strict eligibility requirements and application process, effectively limits the
number of participants. According to a California Department of Corrections
and Rehabilitation (CDCR) 2006 Jail Profile Survey, a very small minority of
the average daily female population at CRDF (approximately 15 percent) has
been sentenced.34 This low proportion of sentenced inmates, coupled with
restrictions on TALK applicants with “heavy” charges, histories of child abuse,
and children in foster care account for the low number of participants. With
an estimated 85% of incarcerated women who have dependent children at
the time of arrest, a large portion of CRDF inmates and children who stand to
benefit from this program are barred from participation.
The Sheriff’s Department is justifiably proud of TALK. By all accounts, it
appears to be a well-planned, thoughtful program that provides an opportunity
for inmates to have a genuinely meaningful visit with their children. It is
focused on helping to rebuild and maintain that relationship by teaching
inmates how to better interact with their children, to express their feelings,
and to help the children understand what is happening with their parent.
It is unfortunate, then, that the capacity of the program is so small.
We recomm end that the Department work to expand TALK.
Lim iting eligibility to sentenced inmates is a quick way to keep
num bers down, but it also prevents the majority of inmates in the
jail from participating. Other such programs, such as the ParentChild Visiting Program (formerly Prison MATCH) in San Francisco,
do not summarily exclude all unsentenced inmates. 35

35 Phone interview with Karen Levine, San Francisco Sheriff’s Department, June 19, 2008.


The Department should consider whether there are unsentenced
inmates who could benefit from the program without compromising
security and work to expand eligibility to those inmates. It is likely
that dem and is, or will become, higher than current participation.
In collaboration with Hacienda La Puente, it should thus work to
determine the true capacity of each TALK session in terms of
staffing, space, and funding constraints and to assess whether
additional sessions on other days could be added. Adding one or
more alternate sessions might also improve enrollment by providing
guardians, who m ay not be able to bring the child at the current
tim e, with m ore options.

Funding constraints may render a “Baby Visit” program (akin to the
program offered in San Francisco County) unrealistic. However, we mention
it in this Report as part of an overarching goal to improve the likelihood of
family reunification and to reduce childhood stress and trauma related to
incarcerating parents.
While it may be that announcements and inmate word-of-mouth
are effective advertising tools, we nonetheless recommend postings
of MIRACLE, TALK, and parenting classes and their eligibility
requirements on all General Population module bulletin boards.
These postings should be placed in plain view of the common area,
where all resident inmates can read and access the service offerings
and schedules. This will help inmates understand the options
available to them and, where possible, allow them to plan around
those program s that would benefit them.

C. D ependency Cour t a nd O t her Lega l I ssues

There are currently no statistics about the number of inmates at CRDF
with pending cases in juvenile dependency court, but it is believed that the


proportion is significant. While some parents may first become involved in
the system as a result of their incarceration, many others may already be in the
process of losing, or working to maintain, their parental rights. For these inmates,
communicating with the court and social workers, following their case plan,
and attending court dates while in jail may prove complicated and bewildering,
their ability to comply affected by circumstances outside their control. Other
inmates may also face other family-related legal issues, such as custody battles,
a child support obligation, or involvement in a domestic violence situation.
LASD has already taken some steps to provide legal education services to
inmates with dependency cases and other family issues by contracting with
two community organizations, the Harriet Buhai Center for Family Law and
Friends Outside. Although its staff may not provide specific legal counsel, the
Harriet Buhai Center provides regular, comprehensive courses to inmates at
CRDF on the following topics:
• Dependency Court: Provides inmates with an overview of the
dependency court system and tools for navigating the system, including
authorizing a caregiver, communicating with a social worker, and obtaining
legal services.
• Domestic Violence, Life Skills and Health: Assists inmates in
identifying domestic violence and provides referrals and information on
obtaining a restraining order.
• Paternity and Child Support: Explains the process for determining
paternity and obtaining child support and details child support obligations
for the inmate.
Friends Outside is a community organization that focuses on facilitating
communication between inmates and family members, outside organizations
and agencies, and even jail staff. Saranella Schulman, the organization’s case
manager at CRDF, serves as an all-purpose information manager, fielding


requests from inmates about everything from medical care to transitional help.
Many of these requests relate to inmates’ dependency court cases, and she
works to help inmates contact social workers, get information about court dates
and deadlines, and obtain credit on their case plan for courses attended in jail.
We were quite impressed by the competency and experience evinced by
both these organizations and by the Harriet Buhai Center’s clear, comprehensive course and referral materials. The Sheriff’s Department is to be
commended for realizing the importance of these programs and for maintaining
them year after year. The effectiveness of these services, however,
would be im proved with the addition of an outreach and tracking
com ponent for inmates with dependency cases. We recommend
that inmates be screened for their involvement with the court upon
intake and that a list of involved inmates be sent to the Harriet Buhai
Center for purposes of outreach. We also recommend that the
Department consider creating a designated dependency court liaison
position, which would be tasked with helping inmates communicate
with their social worker and comply with the case plan and court





I n m a te C o m p l a i n ts

The LASD does a good job resolving routine complaints from women
about conditions of confinement and a poor job resolving complaints about
medical service. The Department received 214 medical complaints between
December 2006 and May 2007, the majority of which centered upon treatment
delays. Of these, nearly one-third had not been completed at the time of our
review in December 2007, and only 38 percent of the remaining complaints
were completed within the recommended ten-day period. Additionally, we
found that the referral of 41 complaints by Custody was unnecessarily
delayed, that the level of detail on many medical dispositions was insufficient
to determine whether the complaint was adequately resolved, and that the
majority of complainants appear never to have been notified of the result of
their complaints as required by Title 15. Finally, the use of the category
“Request for Service – Routine” to describe nearly every medical complaint,
as well as the failure to make even a token effort to investigate system or staff
performance issues, renders the complaint system incapable of providing
LASD management with any meaningful information about systemic
problems with the delivery of medical services at the facility.

I. Background
As part of our examination of the LASD’s ability to meet its female
inmates’ basic needs, we reviewed six months of inmate complaints from
CRDF. In accordance with Title 15 of the California Code of Regulations,



which regulates local detention facilities, LASD policy states that any inmate
may “submit an appeal, and have grievances resolved, relating to any condition
of confinement.”36 Generally referred to as “complaints,” these grievances are
to be collected from each module on a daily basis and logged into a database,
after which they should be investigated, resolved, and discussed with the
inmate promptly. The Department also accepts complaints from third parties
and the American Civil Liberties Union (ACLU). The manual notes that
“whenever possible,” all complaints should be completed within ten days.
The objectives of our review were to learn the types of issues that
inmates complained about; evaluate whether the response by LASD
personnel was fair, thorough, and timely; and assess the effectiveness of the
system for tracking and analyzing the complaints. We have previously praised
that system, based in a database known as the Facilities Automated Tracking
System (FAST), for its ability to provide the Department with information
about potential systemic problems at each facility but had concerns whether
the data was being entered accurately and promptly.
In this current review, we found that approximately 38 percent of the files
contained complaints or questions about basic conditions of confinement.
Most of these complaints were relatively minor and were easily resolved by jail
Custody staff. While we have some suggestions for improving the investigation of complaints, particularly those involving allegations against staff, and
although we questioned some dispositions, we were on the whole satisfied
with the prompt and appropriate resolution of these complaints.
In contrast, the classification, investigation, and disposition of medical
complaints failed to meet the standards set by the Department or by Title 15.
To be sure, the Medical Services staff at CRDF, as at every other LA County
Jail facility, is in a difficult position. As we noted in Chapter 1, “Delivery of
Medical Care,” insufficient nursing staff and space, bureaucratic hurdles, and

LASD Custody Division Manual, Section 5-12/000.00 “Inmate Complaints and Requests,” Revised December 15, 2001.


a disproportionately needy population combines to create a situation in which
delays in treatment are inevitable. However, this does not absolve the
Department of its obligation to provide legally mandated adequate medical
care. It must also work to continuously monitor and respond to areas of risk in
order to reduce its own liability and the potential for inmate suffering or death.

II. The LASD’s Inmate Complaint Process
Title 15 of the California Code of Regulations, “Minimum Standards for
Local Detention Facilities” requires each facility to “develop written policies
and procedures whereby any inmate may appeal and have resolved grievances
relating to any conditions of confinement, included but not limited to: medical
care; classification actions; disciplinary actions; program participation; telephone,
mail, and visiting procedures; and food, clothing, and bedding.”37 According
to the Title, inmates must be afforded the opportunity to appeal the response
to their grievance and are entitled to a written response at every step of the
process, for approvals as well as denials. Such notification must be
documented in writing.
The LASD has devised a complex complaint policy in response to this
standard.38 It has designed a form—a copy of which is included at the end of
this chapter—that provides space for the inmate to write down the complaint
and for the investigating supervisor to document the findings of the investigation. The form also contains a line for the inmate to sign that she has been
advised of the findings, in order to satisfy Title 15 requirements. Each Unit
Commander is responsible for ensuring that each assigned housing unit has
an adequate supply of Inmate Complaint Forms available, and that the

37 “Minimum Standards for Local Detention Facilities, Title 15 – Crime Prevention and Corrections, Division 1, Chapter 1, Subchapter 4,
Section 1072.” California Code of Regulations, 2005.
38 The policy, as well as the complaint form itself, is currently undergoing revision. We discuss possible changes to the policy later in
the chapter.


inmates have unrestricted access to them. (Regardless of the availability of
the forms, staff members are directed to accept complaints on any piece of
paper.) Each module must also have a locked box into which inmates may
deposit their complaints without interference.
All complaint forms must be collected and reviewed by a supervisor at
least once per shift. “Priority complaints” that include mental or mental
health emergencies or other urgent threats to the “inmate’s safety and/or
well-being,” are supposed to be acted upon immediately; in the case of a
medical emergency, the inmate should be taken directly to the main clinic.39
Each complaint should be assigned a reference number from the facility-wide
logging system, which also logs inmate injuries, assaults, searches, uses of force
by staff, requests for mental observation, tours, and hospital runs, crime
reports, and inmate incident reports, and should be entered into the Facilities
Automated Statistical Tracking (FAST) system.
Complaints concerning Medical Services, Mental Health Services, or Food
Services should be forwarded “without delay” to the appropriate units, with
mental health complaints first going to Medical Services. The Custody unit
should still obtain the reference number and initiate the entry into FAST.
In many of the complaints that we reviewed, the supervisor also took initial
steps to investigate or even resolve medical complaints, a practice we commend.
All other routine and jail conditions complaints should be delivered to a
designated Inmate Complaint Coordinator, who assigns them for investigation
and resolution.
Upon completion of the inquiry or referral, the supervisor should fill out
the “Inmate Complaint Disposition Data Form” (included in the Appendix)
by coding each complaint according to type and assigning a disposition code.
The dispositions are “referred,” “founded,” “unfounded,” or “unresolved,”
or a note stating that the inmate had already been released. For cases
39 LASD Custody Division Manual, Section 5-12/000.00 “Inmate Complaints and Requests,” Revised December 15, 2001.


involving more serious allegations, an administration investigation in theory
may also be opened. (As described below, none of the 346 complaints we
reviewed led to administrative investigation, no matter how grievous the
allegations were.) The supervisor also briefly notes the findings on the
back of the complaint form itself and advises the inmate of the results in
person, obtaining her signature on the form. The complaint package must
be approved by the Watch Commander and the Captain or her designee,
after which the disposition is entered into the FAST system.

A . Medica l Com pla int s

Medical complaints are received by Custody and then referred over to
Medical Services. The fact of referral is noted in FAST. Custody refers
complaints about medical services to a designated Complaint Coordinator at
Medical Services, who is then responsible for classifying, researching, and
resolving the grievance using the Medical Services Data Disposition Form
reproduced in the Appendix. Similar to the Custody Division’s disposition
sheet, this form requires the coordinator to code each grievance according to
type—for example, “Service–Delay,” “Request for Service–Routine,” and
“Complaint Against Staff”—and then to assign a disposition. Unlike the
Custody Division, Medical Services does not distinguish between founded,
unfounded, and unresolved cases, although it does provide a “Complaint Not
Valid” option. Instead, dispositions focus on the treatment result, such as
“Examination–Treatment provided” or “Examination–No Treatment necessary.”
The form also designates the medical area involved, such as Nursing, Physician,
or Dental. Finally, it provides a box for the coordinator to mark whether
the complaint was resolved in a timely fashion within ten days of receipt.
Medical dispositions are then entered into the FAST system using the
special Medical Complaints Module. Each medical complaint will thus have
two dispositions within FAST, one for the Custody referral to Medical
Services and another for the final disposition.

B. A CLU Com pla int s

Along with using the LASD form and lockbox, inmates may also make
complaints directly to the ACLU by collect phone call or during a personal
interview with ACLU staff. The ACLU forwards a written summary of the
complaint to Custody Support Services (CSS), where a reference number is
pulled and the complaint entered into FAST. Non-medical complaint files
are then forwarded to the facility, while medical complaints are referred to the
Medical Court Order Unit, then to the facility medical complaint coordinator.
Completed complaints are then returned to CSS, stopping at the Medical
Court Order Unit along the way for entry into FAST, and, ultimately, the
ACLU for final review.

C. The FA ST Syst em

We have praised the Facilities Automated Tracking System (FAST) database in several previous Reports for its ability to provide LASD management
with at least rudimentary information about risk-related trends at LASD
facilities and to track the Department’s response to significant incidents.
We have also made important recommendations about improving FAST, which
have since been implemented.40 Designed by Sgt. Richard Myers and
Deputy Arlan Mulford in 1997, FAST captures information on several types
of incidents, including the use of force by Custody staff; inmate escapes,
injuries, and deaths; over-detentions and early releases; and inmate complaints.
We focus here on the complaint modules, but a more in-depth discussion of

40 In our Seventeeth Semiannnual Report, we recommended that the FAST database be modified to: “(1) identify those officers
who are named in inmate complaints against staff, and (2) specify the type of allegation made against the officer (e.g., excessive
force, discrimination, and the like).” These changes were made, although the database includes only the following categories of
alleged misconduct: “force,” “demeanor,” “service,” and “other.” However, its use as a management tool is limited by the fact
that the information is not easily tracked or reported. The Custody Operations Division acknowledges this limitation and is working
to improve the system’s management capabilities.


FAST, including its history, an overview of the system, and recommendations
for improvement, is contained in our Seventeenth Semiannual Report.
The database has four complaint modules: Inmate Complaints, ACLU
Complaints, Medical Complaints, and Food Services Complaints. When a
complaint is first received, it is entered either into the Inmate Complaints
module (for non-ACLU complaints) or the ACLU complaint module. Upon
completion (for custody-related complaints) or referral, the classification and
disposition are entered into the original module, but the database does not
track detailed information about the substance or findings of the complaint.
Those complaints that are referred to Food or Medical Services receive additional
entries in their respective modules, similarly noting receipt, classification,
and disposition.
The database offers a number of reports that summarize the number and
type of complaints by facility, classification, and disposition for each module.
Other reports list the number of outstanding forms for each module, as well as
those complaints that were referred to one unit by another but never completed.

III. PARC’s Complaint Review Process
For this review, we looked at all complaints by female inmates between
December 2006 and May 2007, based on the date the reference number was
pulled. Because they made up the largest proportion of inmate complaints,
and because they tended to be of a more serious nature, we reviewed the
response to medical complaints at both Custody and Medical Services.
We did not review the final dispositions of complaints referred to other units,
such as Food or Inmate Services.
In all, we reviewed 346 complaint forms (“complaints”), which included
a total of 377 complaint types. These included the following:


• One hundred thirty-two non-medical complaints. These were reviewed
at the CRDF Custody administration office and included 45 non-medical
complaints referred by the ACLU.
• One hundred forty-two medical or mental health-related complaints that
were collected by Custody staff and, after some initial follow-up, referred
to Medical Services, including six complaints that included both nonmedical and medical complaint types. We reviewed all of these at Custody,
but were able to locate only 79 completed files at Medical Services Bureau
(MSB). The remaining 63 had not yet been closed out or sent to MSB
headquarters, and were listed as incomplete or missing in FAST. We were
thus able to evaluate the content of the complaints as well as any actions
taken by Custody staff, but not the final disposition by Medical Services.41
• Seventy-two medical complaints referred by the ACLU, which bypassed
the Custody staff at CRDF altogether. Fortunately, as a result of the
rigorous tracking efforts of Nurse Singh, who manages ACLU complaints
at the Medical Court Orders Unit, all of the ACLU complaints had been
completed and filed.

IV. Non-medical Complaints
In the selected six-month period, female inmates at CRDF filed 132
non-medical complaints about jail policies, staff conduct, or other conditions
of confinement. These ranged from grievances about the size or condition
of their jail-issued clothing or the taste of their food to complaints about
access to showers and use of force by staff. A complete breakdown of the
categories of complaints we reviewed is included in Table 1. Thirty-seven of
these complaints were more appropriately handled by another unit, such as

41 Following our review, Nurse Gonzaque, the new Medical Complaint Coordinator at CRDF, worked to locate and close all outstanding
complaints and concluded that most of the inmates were nonetheless evaluated and treated by Medical staff before release.


Food Services or Inmate Services, and were promptly forwarded, while the
remaining 95 were completed by Custody staff. Our analysis focuses on five
aspects of Custody response in these cases: resolution of inmate concerns,
timeliness, investigation of complaint causes, investigation and adjudication
of complaints against staff, and inconsistent dispositions.

A . Resolut ion of I nm a t e Concer ns

The majority of Custody complaints, though minor, were quickly resolved,
disposed of in a timely manner, and well-documented in terms of the nature
of the complaint, the actions taken, and the response to the inmate. We also
found that the tone of the complaint responses, including when the inmate’s
request was denied, appeared respectful and unbiased, and that investigators
were diligent in responding even when the complaint was very minor. Some
examples of these complaints and their response by Custody are described


An inmate complained that her clothes were too small, making her
uncomfortable. Her clothes were exchanged for a larger size.


An inmate said she had no toilet paper in her cell. This fact was confirmed
by the deputy; toilet paper was located and given to the inmate.


An inmate claimed to be receiving inadequate exercise/recreation time.
The sergeant checked the Uniform Daily Activity Log (UDAL) for the
module and found that inmates had received 16 hours of recreation in
the past week, exceeding the 3 hours mandated by Title 15, and informed
the inmate of this fact.


An inmate had money in her possession upon going to jail, but it had not
appeared in her jail account. Her money was located and deposited into
her account.


Table 1

Classification by Complaint Type

Complaint Type




Complaint Process


Contract Vendor






Housing Location/Reclassification


Inmate Programs
Inmate Work Assignment




Mental Health Services




Money/Inmate Accounts


Policy/Procedures/Enforcement of Rules


Release Information/Sentence






Stores/Vending Machines






Request for Info - No response


Property – Missing (Search)


Property – Other


Complaint Against Staff**


Total Complaint Types ***


Two of these complaints were completed by Custody
and were not referred to Medical Services.

** Includes three complaints about a medical staff member.
All other complaints including an allegation against
a medical staff member were classified as “Medical Services.”
*** Complaints may contain more than one complaint type.
We reviewed a total of 346 complaint forms.



Medical Services*



Facility Condition/Sanitation


An inmate said she never received a receipt for silver rings taken from her
during intake. The investigator found the receipt for the property and
gave it to her.


An inmate complained that a deputy was mispronouncing her name,
which she felt was disrespectful. The investigator documented speaking
to the deputy and explaining that the “J” in the inmate’s Spanish name
should be pronounced like an “H.”
Documentation of the complaint and any actions taken in response

was also, on the whole, good. We found that, with a very few exceptions,
complaints were classified properly and that the brief summaries describing
actions taken, including a description of any interviews with the inmate,
were clear and complete. We also found that the investigator almost always
obtained the inmate’s signature after informing her of the action taken in
response to her grievance, unless the inmate had been released or the
complaint was anonymous. As this step is meant to satisfy Title 15
requirem ents, investigators must ensure that the notification
occurs in every case. If an inmate has already been released, the
investigation should still be conducted to the extent possible and
the reason for the lack of notification clearly marked on the form.

B. Tim eliness

Completion of non-medical complaints was commendably timely. Sixtythree percent of these complaints were disposed of within three days from the
initial complaint by the inmate; nearly a quarter were completed the very same
day. Twenty-two complaints (approximately 18 percent), however, were not
completed within the expected ten-day period, without sufficient explanation.
The majority of these, 16 of the 22, were complaints referred by the ACLU;
on average, ACLU complaints took nearly four times as long to complete as


non-ACLU complaints, taking up to 42 days in one case. This is not due to
any particular complexity in the substance of these complaints. The delay
appears to originate during the assignment process, rather than in the investigation phase, and should be eliminated immediately. While the ACLU
referral process can reasonably be expected to be slightly longer, it should
take no more than two days for the complaint to find its way from CSS to the
assigned investigator, after which it should be completed as quickly as any
other complaint. As for the other six complaints that exceeded the ten-day
guideline, it does appear that the allegations, four of them against a staff
member, merited a longer investigation period. Nonetheless, we urge investigators to clearly document the reasons that an investigation takes longer than
ten days.

C. Focus on r esolut ion, not invest iga t ion, of com pla int s.

Although the resolution of complaints, overall, was generally satisfactory, the
investigation of personnel or systemic complaints could have been improved
in approximately one-fourth of the complaints. In those cases, investigators
focused on solving the inmate’s problem without addressing potential mistakes
or misconduct by staff, or practices that failed to adhere to department policy.
This was true for minor complaints as well as the more serious ones, and was
especially apparent in complaints against staff. For example:
• A group of inmates contacted the ACLU to complain that the inmates in
their module were not receiving enough menstrual pads. The investigator
went to the module and found an adequate supply of pads available, and
marked the complaint unfounded. A more thorough investigation would
have involved talking to at least a few inmates to find out whether they
were having trouble receiving pads and, if so, why and for how long.
• An inmate claimed that she had not had shoes or a bra for five days.


Approximately a month later, the investigator spoke to her and was told
that she now had shoes and a bra. There was no indication that the
investigator made any effort to find out how long the inmate had
actually had to wait for those items and the reason behind any delay.
The complaint was deemed unfounded.
• An inmate complained about not being allowed to attend Bible study.
The investigating sergeant spoke to the deputy, who claimed to be unaware
that inmate had not been able to attend this class and said that it would be
permitted in the future. The sergeant marked the complaint “founded”
and told the inmate to let him know if this reoccurred, but the complaint
mentions nothing about why the inmate was prevented from going in the
first place, or whether any personnel action, such as counseling, occurred.
• An inmate claimed that a deputy had repeatedly opened her cell door for
such a short time that she and her cellmate were unable to get out before
it closed again. She claimed to have missed at least one meal and a pill call,
and that she had tried to file a complaint but was told by a deputy that she
would have to wait until the next day. The supervisor spoke to the inmate
and said he would be monitoring the situation for two days, and that she
should let him know if it happened again, but there was no indication that
he interviewed the cellmate to verify the claims. He also told the deputy
to let him know if the inmate had “trouble leaving” her cell in the future.
Although the file briefly noted that the inmate did not miss a meal or pill
call, there was no further detail or documentation to support this claim, and
there was no mention whatsoever about the relatively serious allegation
regarding the deputy’s refusal to take a complaint, saying she had to wait
until the next day. The complaint about the missing meal and pill call was
determined to be unresolved.


D . Com pla int s A ga inst St a f f

Fifteen complaints were about staff.42 While the majority of these were
relatively minor and involved complaints about a bad attitude or deputies not
following procedure, two involved allegations of force and five complained of
unfair use of authority. It is a credit to CRDF’s staff and management that
the rate is so low. Nonetheless, the complaints that were made were not
always investigated with vigor, and that adjudications, most of which were
either “unfounded” (11 complaints) or “unresolved” (3 complaints), were not
always adequately supported, as demonstrated in the examples below.
• A group of inmates submitted a complaint alleging that a deputy was
showing favoritism, including allowing particular inmates out of the cells
to wander around and play basketball, facilitating sex, and divulging
confidential information. They also claimed that this was the third such
complaint about this deputy. For such a serious complaint, the investigation was extraordinarily brief. The supervisor noted only that based on
his own contact with the deputy, he believed the claims had no merit.
He also said that there were no related problems in her file or in the PPI,
and that at least one of the inmates was complaining because she wanted a
bunk change. The complaint was marked “unfounded,” with no apparent
effort to interview any of the complaining inmates or otherwise look into
the allegations. There is also no mention of any attempt to locate previous
complaints on the same topic.
• An inmate complained that a deputy placed her hands on her, pushing
her and telling her to “hurry up and go.” The file notes only that the
“facts of the investigation determined that the allegation is unfounded,”
without any reference to what the investigation entailed or why the claims

42 Thirteen of these were classified as “complaints against staff,” one was classified as being about the “complaint process,”
and the other was categorized as “exercise.”


were found to be without merit. Again, this alleged use of force, though
relatively minor, should have been more thoroughly and carefully evaluated.
In all, we found seven complaints against staff that should have been
more thoroughly investigated. We recommend that investigating
supervisors pay better and more detailed attention to complaints
involving problem s with jail practices, especially those that may
indicate a failure to m eet Title 15 standards. Complaints against
a particular jail staff m ember should be investigated thoroughly
and explained com pletely.
We also urge supervisors to be vigilant in reviewing complaints
for allegations that should be referred for an administrative
personnel investigation either at the unit level or by Internal Affairs.
In cases where the allegations are sufficiently serious but are
believed to be frivolous or clearly false, the rationale for not making
a referral, along with any supporting evidence, should be well
documented. The complaint about a deputy showing favoritism and facili-

tating sex among inmates is an example of a case that should have been
handled as a personnel complaint.
The complaint that was perhaps the most serious involved a corroborated
use of force against an inmate who was classified as a “keepaway,” or K-10.
She claimed that a deputy grabbed her arm while she was waist-chained,
causing bruising that was verified by medical staff, and that she was told,
“We will see you down here next time. We won’t forget who you are and
this is our house.” The complaint disposition noted that the inmate had been
treated for her injuries and that another inmate had corroborated her claim,
adding that she had seen the deputy pull the other inmate’s hair. This
resulted in an injury report, and a note that the sergeant was opening a
separate inquiry about the incident.
We requested a copy of that investigation and found that the assigned


investigator had conducted interviews of the complainant and the involved
deputy, as well as with one deputy and three inmate witnesses. All of those
interviewed noted that the involved inmate had given a different deputy
permission to remove a sock—used as a hair tie—from her hair and that she
had then exclaimed that the deputy was hurting her. This was followed
by some arguing between the deputies and the inmate. Although all the
witnesses generally agreed that the involved deputy touched or held the
inmate’s arm following the inmate’s exclamation, descriptions of the level
of force used varied, including one inmate’s statement that the deputy “did
not use enough force to hurt [the inmate].” The investigator also viewed the
bruising on the inmate’s arm, which he said looked like “two fingers applied
pressure to each side of the bicep area” and “was not consistent with a firm
grip, [which]… would have markings from the thumb and four fingers.”
As a result of that evidence, the conflicting witness statements, and a
belief that some collaboration on the part of the inmates had occurred, the
investigator concluded that the inmate’s account was “less than truthful.”
There was no real investigation of the inmate’s claims that the deputy had
made threatening remarks. There was also no discussion—in view of the fact
that there was some bruising and that the deputy had actually put her hands
on the inmate—of the appropriate level of force for such a situation. As such,
the investigation was not as thorough as it should have been. Nonetheless,
the investigator documented that he had counseled all of the deputies present
about notifying a supervisor immediately when faced with an “uncooperative,
insubordinate inmate,” so that the situation could be monitored if necessary.
The complaint was marked “unresolved,” but there is no explanation of
that finding, nor is the use-of-force inquiry included in the file. When a
com plaint is investigated via another process, the related investigation and its finding should be fully documented in the original
com plaint file along with the secondary file.


E. I nconsist ent D isposit ions

Thirty-seven of the 143 non-medical complaint types were referred to
another unit. In six cases, the inmate had been released before the complaint
was investigated. Of the remainder, 21 (15 percent) were deemed founded,
while the remainder were determined to be unfounded (68) or unresolved
(11). The “unfounded” classification proved to be used inappropriately in
some cases. We found 13 complaints that were marked “unfounded” because
the problem had been resolved, not because there had never been a problem
to begin with. For example:
• An inmate had been charged for a hygiene kit more than once (inmates are
charged a token amount for the kit if they have money in their account).
The extra charges were removed, and the complaint deemed unfounded.
The brief summary does not, however, explain why the inmate was
charged more than once and whether this was the result of human error.
• An inmate claimed she should have been assigned a lower bunk because
she had six rods in her back, and that her medical chart said as much.
The investigator noted simply that she was moved to a lower bunk as a
result of the complaint, without any discussion as to whether the deputy
or deputies involved had refused to change her assignment, whether there
were orders for the lower bunk in her file, and how long she had been
trying to get a change. Despite evidence that her claim was valid—she had
indeed been assigned to a top bunk—the complaint was inappropriately
considered unfounded.
The Custody Division is in the process of revising its complaint procedures
to include a wider group of disposition options, which will be similar to those
currently used for complaints made by members of the public about LASD
service in the community, known as Service Comment Reports. In that
complaint system, the terms “founded” and “unfounded” are reserved for


formal administrative investigations of allegations that are serious enough to
result in discipline. Lower-level complaints, to which most inmate complaints
are analogous, do not result in formal discipline but may merit other corrective
action such as counseling or training. For these, investigators can use the
following findings: “employee’s conduct should have been better,” “employee’s
conduct could have been different,” and “employee’s conduct appears
reasonable.” These findings are all incorporated into the revised form, which
also includes a new finding of “resolved.”
We support these changes, which, if used properly, will provide
managers with a clearer picture of potential problem areas while
allowing supervisors to take appropriate, non-disciplinary
corrective action. However, we stress that the finding of
“resolved” should be clearly defined and carefully circumscribed; it
should not be used for complaints that reference any potential
error, misunderstanding, or misconduct on the part of staff.

V. Medical Complaints
Inmates at CRDF filed 214 medically related complaints between
December 2006 and May 2007. Eighty-five alleged delays in being seen by
medical staff and requested prompt evaluation and treatment.
In this section, we assess the adequacy of the three components of the
medical complaint process: response by Custody staff; the transfer between
Custody and Medical Services; and response by Medical Services Bureau
(MSB) staff.

A . Pr ocessing by Cust ody

The majority of inmate complaints, medical or otherwise, are made directly
to the Department using the Inmate Complaint Form. A Custody supervisor,
generally a sergeant, is responsible for collecting and reviewing these forms

from locked boxes, located in each module, at least once per shift. Priority
medical complaints require a prompt response; in the case of a medical
emergency, the inmate should be taken directly to the main clinic. Non-priority
medical complaints that do not require an immediate response should simply
be referred to Medical Services. Regardless of to whom the complaint is
referred, the assigned Custody supervisor is responsible for pulling a reference
number, completing the disposition sheet, and notifying the inmate about the
referral of her complaint. During our review of these complaints, we considered
whether the investigator properly followed up on medical complaints requiring
a quick response and whether the complaint was processed and referred to
Medical Services in a timely manner.

1. Initial Inquir y by Custody Staff
One hundred and forty-two medical complaints were processed and
completed by Custody. We were pleased to find that in 38 cases, the investigating supervisor went out of his or her way to conduct an initial inquiry into
the inmate’s alleged problem before referring it to Medical Services. This type
of follow-up occurred for both urgent and non-urgent complaints. We found
that although the Custody supervisor was generally unable to immediately
resolve the inmate’s problem, the inquiry process was useful in providing
preliminary information about the validity and urgency of the complaint to the
Medical Services staff person receiving the complaint. Because Custody staff
was fairly consistent in following the notification process, it also served to keep
inmates informed of the status of their medical treatment.
• An inmate’s mother filed a third-party complaint claiming that the inmate,
who only had one kidney, had an infection and that her life was in danger.
The investigating sergeant immediately contacted the nurse in the main
clinic, who looked up the inmate’s chart and found that she had already


been seen by medical staff on several dates and that lab results were
pending. The sergeant went ahead and sent the inmate to the main clinic,
documenting all of her medical treatment up until that point in the
complaint file. He also contacted the mother directly and informed her of
the status of her daughter’s treatment.
• An inmate complained that she had a needle in her left arm that needed
to be removed, and that her transfer to state prison, where the removal
procedure was supposed to occur, had been repeatedly delayed. The
investigating sergeant spoke to a nurse, who verified the needle’s presence
and said that the procedure had been scheduled at LCMC. The complaint
had not been completed by Medical staff at the time of our review, and the
file contained no follow-up to see whether the needle was, in fact,
removed at LCMC.
• An inmate complained that she had been signing up for the dentist for
three weeks and had a great deal of pain in her tooth. The sergeant
followed up and discovered that she had been placed on the doctor’s line
and had been scheduled for a dentist appointment within 3 days. The
Medical disposition noted that she was indeed seen by a dentist three
days after her complaint.
Unfortunately, for every case in which the Custody investigator made an
initial follow-up before referring the complaint, we found nearly three for
which no such follow-up had been conducted. While most of these did not
appear to require immediate attention, twenty-one complaints appeared
somewhat urgent, including the following:
• An inmate claimed to have been experiencing bleeding for two weeks and
passing blood clots. She had spoken to several nurses but had not yet seen
a doctor. The complaint was referred directly to Medical Services, but was
not completed until after our audit. The inmate was never evaluated or


• An inmate complained of having her menstrual period continuously for
two months, a urine infection, diarrhea, and pain when using the restroom.
She worried that she might have gallstones, an ulcer, or need a hysterectomy.
The inmate was released before the complaint was completed two and a
half months later. The complaint disposition noted only that she had had
a “post-op” exam a month after her complaint, and that she had had no
complaints at that time.
• An inmate complained of bad allergies, which caused her to break out in
hives, itching, and swelling. She had been waiting to see someone about it
for two months, and had talked to a nurse twice within the last three days.
In each case, the nurse had said someone would come to see her, but no
one did. The complaint was referred directly to Medical Services, but the
inmate was not seen until more than a month after her complaint was made.
We recom m end that the Custody investigator be required to
conduct initial follow-up for every medical complaint, regardless of
apparent urgency. This preliminary inquiry can ensure that urgent
problem s are prom ptly addressed, that important information is
passed along to Medical Services, and that the inmate receives any
available inform ation about the status of her treatment. It is likely

that in many cases, a lack of information is the most frightening and frustrating
aspect of the inmate’s situation. Finding out that an appointment has been
scheduled, or that lab results are on their way, may allay some of the anxieties
that prompted her to file the complaint. At the same time, we emphasize
that this preliminary phase should not delay referral of the complaint
to Medical Services, which should take no more than one day.
If the process requires a longer time period, it should continue after
the com plaint has been referred.


2. Timely Referral
In terms of disposition and referral, we found that all of the complaints
appear to have been properly referred to Medical Services, regardless of
whether there had been appropriate initial follow-up. In general, this process
was timely; in 63 percent of the cases, the complaint was completed and
ostensibly referred to Medical Services within two days. However, we were
very concerned to find two distinct time periods during which processing of
medical complaints was significantly delayed by Custody staff. Specifically, we
discovered two large sets of complaints for which the reference number date,
assignment date, and completion date were identical.43 Each set contained
complaints going back up to over a month, making it appear that nothing had
happened to them until the day that the reference number was pulled. Most
of the dispositions and comments were identical as well; in some cases, the
inmate’s name was handwritten into a blank spot in the comments, and the
inmate’s signature was often missing. We also found that for eight complaints,
someone (likely the Custody investigator) had crossed out the word
“Complaint” and written “Request,” then sent the form off to Medical
Services without obtaining a reference number. (Requests are currently not
assigned reference numbers and are not entered into FAST; they are simply
discarded upon “completion.”) Unsurprisingly, these two sets of complaints
make up the majority of those for which no follow-up was done before referral.
Overall, there were 41 medical complaints that took more than ten days to be
completed by Custody. These delays often resulted in even longer waits,
or no treatment at all, such as in the following cases:
• On December 13, an inmate complained of a rash on her face that was
spreading, and that this was her second complaint about not being able to

43 Each reference number is composed of 3 sets of numbers: the facility identifier, the date which the reference number was pulled,
and a sequential identifier that is reset each day.


see a doctor. The complaint was completed by Custody on January 25,
received on February 8, and completed on March 2. The final disposition
noted that the inmate was released on February 8 without having been seen.
• On December 22, an inmate complained that she had been waiting over a
month to be seen for a yeast infection, insect bite, and an infection of her
female organs that was causing “pain day and night.” The complaint was
completed by Custody on January 25, received on February 8, and completed
on February 27. The final disposition noted only that she had been seen
on January 19. There was no explanation given for the delay in processing
the complaint. Nor is there any indication that the inmate’s underlying
medical problem had been resolved on January 19 or at any other time.
There was no indication that the inmate had been contacted between
February 8 and February 27 to see if the inmate’s problem had been
resolved in the interim.
• On May 1, an inmate complained of unbearable tooth pain. The complaint
was completed by Custody on May 16, received by Medical on May 18,
and the inmate was released on May 26, without ever being seen. The
complaint was completed on June 2.
When we inquired about these complaints, we were told that the delays
were the result of confusion on the part of certain investigators, who believed
that medical complaints should simply be referred without any action on
the part of Custody. Whatever the reason, such processing delays
should never occur. We urge CRDF’s management to conduct regular
trainings about com plaint processes and to hold supervisors
accountable for the tim ely and thorough disposition of medical
com plaints.


B. Tr a nsf er s

The transfer of inmate complaints between Custody and Medical Services
currently lacks any accountability for delay and, not surprisingly, is the source
of lengthy delays in the response by CRDF to inmate medical complaints.
Current practice is at odds with the policy delineated in the Custody Division
Manual (CDM), which states the complaint is to be time-stamped in the
upper-right-hand corner, photocopied, and delivered to the on-duty supervisor
of those units.44 By contrast and inconsistently, CRDF Unit Order 5-12-010,
which specifies complaint procedures, does not require the time-stamping or
in-person delivery described in the CDM. As such, CRDF complaints to be
referred are simply placed into a Medical Services tray without a time stamp.
In view of lengthy delays in the completion of medical complaints,
we recomm end that the Unit Orders be revised to match the CDM
and that the practice of time-stamping and in-person delivery be
instated imm ediately.

The FAST system was designed to ensure accountability at each step of
the complaint process. When complaints are referred to Medical Services (or
another non-Custody unit) for completion, an entry noting such is supposed
to be entered into the main complaint module in FAST, along with the name
of the person the form was given to. The person receiving the complaint,
generally the Medical Complaint Coordinator, should also make an entry into
FAST, this time into the Medical Complaint Module. FAST is set to automatically record dates in order to prevent inaccurate data entry. If followed
properly, this procedure would serve to encourage quick transfer and
completion of medical complaints while allowing managers to pinpoint problems
when they occur. Unfortunately, the database is only as good as the information
entered into it. Because Custody investigators simply drop the complaints

44 5-12/010.00 “INMATE COMPLAINTS,” Custody Division Manual, June 2006.


into a tray, they do not enter the name of the person receiving the forms, and
there is no incentive for the receiving person to immediately enter them into
FAST. In fact, since the 10-day “clock” effectively begins at the moment that
the person “receives” the complaint, there is actually a disincentive for doing so.
Our review found that only 28 percent of the 142 complaints referred to
Medical Services by Custody between December 2006 and May 2007 were
“received” within 10 days of the listed Custody completion date.45 One case
took 51 days to make the trip from office to office. Even worse, 44 percent of
the referred complaints were never completed at all. Forty-five of the medical
complaints completed by Custody between December 2006 and May 2007
were listed by FAST as “missing.” This means that no one at Medical
Services ever entered them into their FAST module, and that the complaints
were not acted upon until after our review was completed. By that time, all
but two inmates had already been released. Most of those complaints were
found at Medical Services, but had they been discarded, there would have
been no way to know which unit or staff member was responsible.
The implications of this failure are serious. While we were relieved to find
that most of the inmates were eventually evaluated and treated by medical staff
at some point, such visits appear to have occurred despite the complaint process,
not because of it. In many cases, the intervention came weeks or months after
the initial complaint was made, and for 15 inmates, none came at all.

On December 19, 2006, an inmate with a seizure disorder complained that
she was having problems due to receiving a lower dosage of her seizure
medication than she required. The complaint was completed and ostensibly referred to Medical Services that same day, but was not recorded as
“received” until February 8, 2007. The complaint was then completed on
March 8, 2007, noting only that she was evaluated and treated.

45 This number includes two cases that are presumed to have been transferred within one and two days and three that are presumed to
have taken longer than ten. Missing or confusing dates make it impossible to know the exact time.



On January 12, 2007, an inmate, who was missing one leg and confined
to a wheelchair, complained that the module shower was not wheelchairaccessible and that she had fallen down trying to use it. She requested
to be transferred to the clinic, but was told by a nurse to get a basin and
wash in her cell. The Custody investigator spoke to a nurse, who said
she would look into getting her in line for a transfer to the Correctional
Treatment Center at Twin Towers, and referred the complaint to Medical
Services on January 14. The form was then “received” and completed on
February 6 and noted that a nurse had evaluated the inmate and determined that she should remain in general population and continue to use
her wheelchair in the shower. There was no response to the inmate’s
assertion that the shower in the module was not wheelchair accessible.


On May 14, 2007, an inmate complained of waiting for treatment for a
yeast infection for over a month, and said she had a sore throat, earache,
and headache. The Custody sergeant followed up with the main clinic
and learned that the inmate had been put on the doctor’s line, but that
the nurse could not tell her when she would be seen. The complaint
was referred by Custody to Medical on May 15 but was never acted upon.
The inmate was released on June 9, more than three weeks later, without
ever receiving treatment.


An inmate with pinkeye was given an antibiotic by a nurse, but due to
her own training as a Certified Nurse’s Assistant, the inmate decided
not to put it in her eye as directed. She then asked for Extra-Strength
Tylenol but was given something else, which she believed caused an
allergic reaction (she said she was allergic to aspirin). She then asked for
Benadryl, but her request was denied, and she was told to put herself on
the doctor’s line. She claimed that she had done so a month and a half
ago but had not yet been seen. The complaint was referred to Medical
Services, but was not completed until after our review. A follow-up found
that the inmate was released without being evaluated.


The process for referring complaints to Medical Services, as well
as other units, m ust be tightened up immediately. Not only does the

Department have an obligation to respond to inmate’s concerns within a
reasonable period of time, ignoring the complaints, particularly those regarding
potentially serious medical problems, exposes the Department to unnecessary
liability. Current practices make it difficult to assign responsibility for long
wait times, and it is evident that there was very little, if any, oversight of the
process during the relevant time period. In response to our queries, the
Medical Services unit at CRDF quickly moved to locate all of the missing
complaints and to close them out. While we commend them for their prompt
action in this matter, it must be noted that some of the complaints were over
a year old, and that all but two of the inmates had already been released.
We urge the Department to immediately implement the
following procedures for medical complaints:
• All m edical com plaints inquiries should be completed by the
assigned Custody investigator and referred to Medical Services
within one day of receipt. Any action or investigation required
beyond that day, such as when the complaint includes both a
medical and non-medical complaint, must continue after the
initial referral to Medical Services.
• Referred complaints should be delivered in person to the Medical
Com plaint Coordinator or on-duty supervisor, who should sign
their nam es at the bottom of the complaint. The new complaint
form already has a space for this purpose. Each form should
be tim e-stam ped on the top-right-hand corner and photocopied.
Leaving the photocopy, the Custody investigator should take the
original to be filed in the Custody office. The transfer of the
form should be logged into FAST on the same day, with the name
of the person receiving the complaint form entered at that time.


• All inm ate com plaints should be entered into FAST within 24
hours of receipt. Receipt should be defined as the moment
Custody personnel pick up complaint forms on a regular,
frequent, hourly basis each day. Absent good cause being
shown and approved by a lieutenant or captain, all inmate
com plaints shall be resolved within 10 days and its resolution
presented to the inmate for acknowledgment and signature
within the sam e 10 days. The exception will be for inmates
whose complaint includes a request for medical attention or
asserts delays in the receipt of medical attention. Those inmates
must be seen by m edical staff within the recommended 24-72
hours. To the extent that Medical Services has given itself 10
days to respond to such complaints, that practice shall be
• When the com plaint needs to be returned to Custody for a
correction or because a reference number was not pulled, this
should be done promptly and should not stall the complaint
process. The Medical Complaint Coordinator should act on all
com plaints, whether or not there is a reference number.
• All complaints, particularly medical complaints, should be
audited on a regular basis to ensure that this process is being
followed and that completion, referral, and receipt dates match.

In contrast to the referral process at the facility, the referral of ACLU
medical complaints was timely and well-documented. Because the complaints
are faxed from Custody Support Services to the Medical Court Order Unit,
then to the Medical Complaint Coordinator, each file contained a clear record
of the dates of each referral. Perhaps as a result, ACLU complaints were
completed much more quickly than those referred by the facility Custody staff.


C. Response by Medica l Ser vices

All inmate medical complaints are referred to a designated Medical
Complaint Coordinator within Medical Services. Like his or her counterparts
at Custody, the coordinator should research the complaint, resolve the
grievance if appropriate, and complete a form—the Medical Services Data
Disposition Form, or disposition sheet—that describes the type of complaint
and disposition of the complaint. This should occur within ten days of receipt
of the complaint, where possible. The process for completing a complaint
referred from the ACLU is the same except that, upon completion, the
coordinator is to fax the disposition back to the Medical Court Orders Unit
so that it can be forwarded on to the ACLU. We examined 151 medical
complaint disposition files for this review, 72 of which were referred by the
ACLU. As discussed above, an additional 63 medical complaints had not been
completed at the time of our review, and we were not able to evaluate their
disposition. Our review considered the following factors: resolution of inmate
concerns, classification and investigation, and timeliness.

1. Medical Complaint Response
Seventy-one percent of the 214 complaints referred to CRDF Medical
Services were complete at the time of our audit. Disposition documentation
in these cases was minimal, making it difficult to assess the adequacy of the
response. This was compounded by the fact that the inmate’s signature
was missing in 87 percent of the cases, leaving no evidence as to whether
the inmate was consulted about her concerns, notified of the finding, or left
satisfied with the response. In fact, in almost none of the cases did it appear
that the action taken was done so as a result of the complaint. Instead, it
appears that most of the information for the disposition was taken directly
from the inmate’s electronic chart, with the following findings:


• In 46 percent of the cases, the inmate was seen by a doctor or nurse
between the date that she made the complaint and the date that the
complaint was completed. For 29 complaints, this occurred before the
coordinator received the complaint. An additional 15 complainants were
listed as having been evaluated, but the date was not documented.
• In 12 percent of the cases, the inmate had been seen by a doctor or nurse
before their complaint was made. No further action was taken.
• In 11 percent of the cases, a judgment about the inmate’s complaint was
made by looking at her electronic chart; for example: “Chart review shows
inmate is receiving medication ordered by physician.”
• In 7 percent of the cases, a chart review revealed that the inmate had
been referred to either a physician at CRDF or outside specialist and
was still awaiting treatment. In 12 percent of the cases, the inmate was
released before any action was taken.
• One complaint was marked as “not valid.”
• For one complaint, referred by the ACLU, the complaint coordinator
clarified department policy on treatment for colds.
With a few exceptions, descriptions of inmates’ medical treatment consist
of dates seen and a comment that treatment was provided or appropriate
medication provided. This does not necessarily provide information about
whether the inmate’s grievance was addressed, however, particularly in cases
where she is alleging inadequate or incorrect treatment. There is some reason
to keep the description of inmates’ medical treatment and findings brief;
the Health Insurance Portability and Accountability Act (HIPAA) and other
privacy laws set forth strict regulations about patient confidentiality. But this
does not prevent the coordinator from describing his or her response in much
greater detail, including the interview with the inmate, action taken as a result
of the complaint (such as scheduling, chart review, discussion with other
team members, corrective action), and implications of the findings. Also, the


parameters of the confidentiality afforded the inmate in complaint investigations are unclear and should be clarified.
We found only four dispositions that described an interview with the
complaining inmate, and only 19 dispositions documented that the inmate
had been informed of the result of her complaint. This lack of contact with
the inmate is problematic. We reviewed many complaints that were rambling,
poorly written, or otherwise confusing. Others lacked important information
about the problem or the desired resolution. It is incumbent upon the
complaint coordinator to fill in these gaps, generally through a brief interview
with the inmate, and to make sure that the complaint is fully understood.
The inmate must also be notified of the outcome of the complaint; this
process is required by Title 15 and allows the inmate to appeal the result.
Even if the inmate is only making a simple request to see a doctor, she should
sign off on the form noting that her complaint was addressed during the visit.
We recom mend that the Department require an inmate interview
for every medical complaint, and that it fully enforce its notification
requirem ent. In those cases where the inmate is, in fact, released
before one or both of these occur, the delay should be explicitly
justified in the com plaint disposition.

We also urge complaint coordinators to clearly describe other action taken
in response to a complaint, including, where applicable, the implication for
the client. While many of the complaint dispositions listed information such
as dates seen or the results of lab tests, it is difficult to ascertain from the
written summaries whether treatment was provided as a result of the
complaint or some other process. In those cases where the inmate was seen
before the complaint was received or even made, there is no explanation of
why this is considered an adequate response to the complaint. In some cases,
the written response failed to discuss what the final result of the complaint
was. For example:


• In the case of an inmate who claimed to not be regularly receiving an antinausea shot with her Interferon injection, the disposition only notes that
she was supposed to be receiving this shot. It does not describe what
action was taken to determine whether the order was being followed or
to ensure that she received the shot in the future.
• An inmate complained that she had not received a renewal of her Benadryl
or a muscle rub, even though the nurse told her she would. The complaint
disposition states that the medication was never prescribed in the first
place, failing to mention why the inmate thought she was entitled to that
treatment, why the treatment was not merited, or what her actual
treatment plan was.
• An inmate complained that she was not receiving the correct medication.
In the disposition, the complaint coordinator notes only that a “[c]hart
review shows inmate is receiving medication ordered by physician.”
Again, there is no follow-up with the inmate to find out why she believed
her medication was wrong or any apparent consideration of the merits of
her complaint.
While it does appear that most of the complainants in the cases we
reviewed were seen by medical staff after making the complaint, the lack
of detail about the disposition, combined with an apparent failure to discuss
the complaint with the inmate, makes it difficult to assess whether that
response was adequate and appropriate. We urge complaint coordinators
to m ake a full record of all actions taken in response to each
inm ate com plaint, including its final result, in every case.
We also suggest that the Department begin requiring supporting
docum entation of the finding, such as a record of dates the
inm ate was seen by the doctor or received lab results.

We understand that patient confidentiality rights must be considered in
the documentation and storage of inmate complaint files. However, we must


point out that while many of the complaint dispositions were exceedingly
brief, noting only that the inmate was “evaluated and treated” on a particular
date, others were more descriptive, describing test results and other medical
findings. To our knowledge, there are no clear guidelines about the extent
to which privacy concerns apply in this situation, particularly considering the
fact that the internal disposition files are housed within the Medical Services
Bureau. We recom mend that the Department consult with County
Counsel to develop procedures for the proper documentation,
storage, and auditing of the response to medical complaints
without a sacrifice of accountability.

2. Classification and Investigation
Each inmate medical complaint is sub classified according to the nature
of the grievance. Because they have already been classified by Custody, in
most cases, as “Medical – Referred,” the sub classification should provide
more detail about the inmate’s allegation or request. This is the only
description of the complaint that goes into FAST, and can be used by
management to get a quick picture of the types of complaints the facility
has been receiving. The complaint coordinator can choose among the
following types:
• Service – Omission
• Service – Delay
• Service – Incorrect
• Service – Inadequate
• Request for Service – Routine
• Mental Health Issues
• Complaint Against Staff
• Commendation


All but two of the complaints we reviewed were classified as “Request
for Service – Routine,” a result which, considering the content of the inmates’
complaints, is difficult to believe. In fact, we determined that two thirds of the
completed complaints we viewed were misclassified, including the following:
• An inmate complained that she was supposed to have had hand surgery
a month before, but had not yet even been seen by a doctor.
• An inmate claimed that she was not receiving her medication for her
thyroid and an enlarged heart, which she was supposed to get four times
a day. She complained that she had already filed three complaints and
had been waiting on sick call for five days.
• An inmate reported blood clots in her legs that caused swelling, and said
that although a doctor had ordered a wheelchair for her, this order had
been cancelled by a nurse.
• An inmate claimed that she had been on the doctor’s list three or four times
over the past two and a half months, but had not yet seen a doctor for her
severe tooth pain.
• An inmate complained that she had been charged for seeing the doctor
although she had not seen one yet, despite having been on the doctor’s
line for over a month. She also claimed to have filled out several requests
for service and one prior complaint.
• An inmate complained that it had taken her two months to find out that
there was no eye doctor at CRDF, and was concerned that her vision would
be “totally gone” if she did not get help with her eye problem soon.
• An inmate complained of “abdominal pain, back pain, headaches, and blood
spotting” and said that although she had had her vaginal discharge tested
a month earlier, she still had not received her results.
• An inmate complained that she had not seen a doctor since entering the jail
over a month ago, and that her back ailment had gotten worse, to the point
that she was now confined to a wheelchair.


• An inmate claimed that she had already complained twice before about not
being able to get medication for her itchy feet and that the nursing staff
was giving her attitude about it.
It is not clear why these and other cases were labeled and treated as routine
requests for service, even though they include complaints about service delays,
serious medical needs, improper medication or treatment, problems with the
complaint process, and inappropriate staff behavior. It may be a reflection of
the complaint findings, such as the staff’s assessment that an inmate’s ostensibly urgent problem is actually routine, or that a certain delay in obtaining
treatment is to be expected. Nonetheless, the classification of a complaint
should not include such considerations and should refer only to the nature
of the grievance itself; findings of fact should be reflected in the disposition
field instead. An example of this would be if an inmate complains of being
prescribed the wrong medication and is referred to a doctor, who examines
her and finds that her medication is correct. The complaint should properly
be classified as “Service – Incorrect,” even though her complaint is ultimately
unfounded. An appropriate disposition would be “Complaint Not Valid,” with
an explanation of how that was determined.
The largest category of misclassified complaints were those that referenced
lengthy delays in seeing a doctor or otherwise receiving treatment. As we
discussed in the preceding chapter, such delays represent business as usual
at CRDF, as a result of large numbers of inmates requesting treatment, space
constraints, and a relatively small medical staff. Yet while long waits to see
a nurse or doctor may be the norm, it is nonetheless important for the
Department to register and track complaints about these delays. Doing so
allows the Department to collect data about how long inmates are actually
waiting, and to identify those cases involving unusually long delays or lapses
in regular procedure. We recommend that the Department develop a
reasonable tim eline for the evaluation, treatment, and referral of


inmates by both nurses and physicians, and that it use the complaint
process to flag and explain those instances where an inmate’s wait
time exceeded these timelines. Where the delays are the result of
procedures or staff mistakes, managers can then move to take
corrective action or to adjust procedures as necessary. The complaint
coordinator should also ensure that any inmate whose complaint
contains a request for service be seen within 24-72 hours of receipt
of the complaint, as recommended by the NCCHC standards.

A second category of misclassified complaints is smaller but nonetheless
significant: those alleging incorrect treatment or medication, or that otherwise
complain about the performance or demeanor of medical staff members.
It is imperative that these allegations be fully investigated and adjudicated.
It is not enough to simply correct the problem and consider the matter resolved.
While it may be that such complaints are the result of inmate confusion or
dissatisfaction, the Department is accountable for the full investigation of such
claims. We were dismayed to find that although there were very few (only 25)
complaints against medical staff, not one of these appears to have been
properly pursued, including the following:
• An inmate with AIDS claimed that although she had been prescribed
Darvoset four times a day, a particular nurse (whom she described but was
unable to identify by name) had refused to give it to her more than once
a day and that he had told her that “as long as he’s working here, [she] will
only get it once a day.” Before referring it to Medical Services, the
Custody sergeant made some inquiries and discovered that the inmate’s
description of her prescription was correct. This complaint was not
completed until after our audit; the eventual disposition stated that the
inmate was evaluated and treated before release. There was no indication
that the apparent highly inappropriate and health threatening conduct of
the nurse was investigated and proper action taken.


• An inmate complained that she was not always given an anti-nausea shot
before her Interferon injection as part of her treatment for Hepatitis C, and
that this had caused her to refuse one or more injections. This complaint
was classified as a routine request for service, and the final disposition
noted only that the inmate was, in fact, supposed to be receiving the antinausea shots. There was no discussion of why she had not gotten the
shots or who was responsible.
• An inmate’s attorney reported to the ACLU that the inmate was given
an unnecessary knee x-ray without her consent, was not issued tampons
during her period, and had a red rash that needed attention. Custody
staff originally marked this as a complaint against staff, but then changed
it to a medical referral, apparently because it involved medical staff.
At Medical Services, the complaint was classified as a request for service,
and investigation of the complaint was minimal. The inmate was released
before the complaint was ostensibly received (nearly three weeks later);
subsequent investigation consisted of looking at her chart to see whether
she had actually received an x-ray (she did). The other issues listed in
the complaint were apparently ignored.46
We urge m edical com plaint coordinators to be vigilant for
grievances that m ake allegations against medical staff, or that
complain of m istakes or incorrect treatment. These should be
accurately classified and carefully investigated. While m ost of
the inm ates also include a request for treatm ent, ignoring clearly
articulated com plaints about the provision of medical services
cannot be tolerated. Judgments about the merits of the complaint

46 This complaint file contained several revisions. The original response stated that "Complaint received 2-14-07, inmate released
2/5/07 prior to receiving complaint. Per medical record bilateral knee xrays were taken 1-11-07.” It was revised with the following
note: “3-23-07 no order for bilateral knee xray.” A third comment was added by Nurse Singh at the Court Orders Unit to say:
“*Contents noted; Bilateral knee x-ray 1-11-07 per powerchart.” An attached printout of the powerchart showed that the x-ray had
been given on that date. However, there was no investigation of the inmate’s claim that the test was unauthorized.


should be reserved for the disposition process, and should be fully
supported by a thorough and well documented investigation.

3. Timeliness
In general, timeliness of the disposition of medical complaints at CRDF
was poor. As noted previously, 44 percent of the complaints referred to
Medical Services by Custody between December 2006 and May 2007, or 29
percent of all medical complaints, were not completed until after our audit in
December 2007. This is an unacceptable result. That these complaints were
outstanding was a fact easily discovered by any manager with access to FAST,
and any missing complaint forms could have been quickly replaced by Custody.
Fortunately, a follow-up by the new Medical Complaint Coordinator found
that the majority of the complainants managed to get seen by a nurse or
doctor at some point before their release, but the potential for liability, should
just one seriously ill inmate fall through the cracks, is significant.47 Medical
Services Bureau already has a procedure in place to track and collect
outstanding com plaints; we recommend that the unit act quickly
to strengthen this m echanism to ensure that such a situation does
not reoccur. We also urge the Department to immediately review
inm ate com plaint statistics for other facilities and make sure that
all complaints over one month old are completed immediately.

Even when the complaint was completed, disposition was often less than
prompt. Again, Department policy states that, whenever possible, complaints
should be completed within ten days of receipt by the medical coordinator.
However, we found that only 38 percent of dispositioned complaints were
completed within this time frame, with an average length of approximately 15

47 For seventy-three percent of complaints closed after our review, the inmate was found to have been evaluated by a medical staff
member. In ten percent of the cases, the inmate was released without being seen; in eight percent the complaint was missing
altogether. The remainder of complaints were referred to another unit or determined to be invalid.


days. (Those statistics do not include complaints that were still open at the
time of our audit; when they are included, the proportion of timely dispositions
falls to only 27 percent.)
Considering the nature of medical complaints, most of which contain
requests for service, such delays are alarming, particularly when compounded
by referral and service delivery delays. Interestingly, 30 of the late complaints
had apparently been mooted within the ten-day period, but there is no
evidence that the complaint coordinator knew this before completing the
complaints. The files contain no mention of any preliminary review and
triage of the grievances by medical staff, and there is no clear pattern that
differentiates timely dispositions from untimely ones. As such, and without
any written explanation for the delays, we cannot conclude that the delays
were justified by a lack of urgency, a shortage in resources, or any particular
complexity. In fact, some of the complaints with the longest delays appeared
relatively serious, such as the following:
• On December 4, 2006, the ACLU forwarded a complaint from an inmate
who claimed that although she had a court order for evaluation by a doctor
for cysts, lymphoma, and a hernia, she had only been able to see a nurse.
The complaint, now overdue, was resent on January 24, and the inmate
was evaluated on January 28. The complaint was closed on February 2.
• On May 3, 2007, the ACLU referred an inmate’s complaint that she was
supposed to have had an MRI several months before due to “headaches
accompanied by lost control of left side of body, throbbing blood vessel in
the back of head, [and] worsening eyesight and eye pressure.” The
complaint was not completed until July 18, stating that on June 19 the
inmate had refused to go to a neurology appointment at LCMC and had
signed a release of responsibility. The disposition also noted that this was
her initial appointment and that there was no record of a previous MRI
appointment. There is no description of what action (if any) was taken


during the more-than-month-long period between the complaint and the
LCMC appointment, why the inmate had refused the appointment, or
what her current situation was. It is also not clear why it took more than a
month from the date of her appointment to close out the complaint.
There was a statistically significant difference between the average
completion length for Custody-referred complaints and that of a complaint
referred by the ACLU. Approximately 57 percent of ACLU complaints were
completed within 10 days (with an overall average of 13 days), while only 20
percent of Custody-referred complaints were completed within that timeframe
(with an overall average of 18 days, excluding outstanding complaints). More
importantly, all of the ACLU medical complaints had been completed at the
time of our audit. We attribute this variation to the ACLU complaints being
subject to more rigorous accountability, with both Nurse Singh at the Medical
Court Orders Unit and, ostensibly, the ACLU tracking their response and
disposition. Indeed, those ACLU complaints that took the longest time to
complete bore evidence that they had been marked “overdue” and resent to
CRDF by Nurse Singh. While she is to be commended for doing her job
well, there is no reason why Custody-referred complaints should not be
tracked in the same manner.
Each medical disposition form has an area in which the complaint coordinator must mark whether the disposition was timely (i.e., within ten days of
receipt). Accordingly, only about 38 percent of the complaints had been
marked timely, although these did not always correspond with those complaints
completed within ten days. The disposition forms contained no explanation or
justification of the delays, and we could find no evidence of any follow-up by
managers. We recom m end that the Department policy require that
all m edical com plaint investigations and resolutions be completed,
and the resolution presented to the inmate for acknowledgment
and signature, within ten days. An exception should be made for


inmates whose complaint includes a request for medical attention
or asserts delays in the receipt of medical attention. In these cases,
the inmate must be seen by medical staff within the recommended
24-72 hours. To the extent that Medical Services has given itself 10
days to respond to such complaints, that practice should be
abolished. We also urge the Department to conduct regular audits
to ensure that complaints are being completed in a thorough and
timely manner.

VI. Conclusion
Our overall assessment of the effectiveness of CRDF’s inmate complaint
system is mixed. The primary goal of the LASD’s inmate complaint system,
of course, is to provide inmates with a mechanism for the fair resolution of
grievances about conditions of their confinement. For those grievances that
we reviewed, we were first struck by the low number (only 40) of those that
allege misconduct, deliberate indifference, or even significant mistakes on
the part of CRDF Custody or Medical staff. Accordingly, we commend the
staff and management at CRDF for their excellent record. Second, our review
found that, on the whole, inmates’ requests were properly considered and
usually granted. This is especially true for Custody-related, non-medical
complaints, which were almost always resolved promptly and appropriately
by a Custody supervisor. While inmates with medical complaints were usually
examined and treated by a medical professional, this did not always occur in
a timely manner, and not necessarily as a result of their complaint.
While the resolution of inmate complaints was generally good, we found
that the complaint system was not as effective in achieving its other goals: the
thorough investigation of potential personnel or systemic issues, and the
accurate tracking of risk, particularly in the delivery of medical care, at the


facility. Specifically, the assigned staff member often failed to look beyond the
inmate’s immediate request in order to find and correct the cause of the
situation. The poor classification and disposition of the medical complaints
rendered FAST less than effective in pinpointing problems or areas of risk
at the facility. By failing to fully investigate and document the causes of the
inmate’s complaints, the Department hinders its ability to move proactively
to avoid further problems and reduce liability.
Finally, at the time of our review, the process for transferring, addressing,
and disposing of medical complaints lacked accountability and oversight, resulting
in large numbers of complaint forms that were simply ignored. Many of those
that were completed took weeks or months, and some disposition summaries
lacked sufficient information to determine the adequacy of the response.
These deficiencies must be corrected immediately. While we understand
that the person responsible for completing medical complaints has since been
replaced, we must emphasize that it is ultimately the facility and Bureau
management who are accountable for ensuring that complaints are disposed
of promptly, appropriately, and thoroughly.
As previously mentioned, the Custody Division is currently revising its
inmate complaint procedures. Expected changes include the combining of
the request and complaint forms, clear guidelines about the classification of
requests and complaints, revised dispositions, and procedures for the
documentation of transfers between units. The new forms will be printed
in triplicate, allowing inmates to keep a copy of the complaint for themselves.
We expect that these revisions will improve the inmate complaint process
and in theory will address many of the concerns brought up in this Report.
However, maintenance of a high standard by the chain of command will be
integral to the success of the new system.






L i ti g a ti o n

After six months reviewing the last six full years of litigation against the
Department, from fiscal year 2001-02 until fiscal year 2006-07, we find that the
LASD has experienced a welcome reduction in the number of new lawsuits
filed against it in recent years, strongly suggesting that the Department’s risk
management activities, in the main, have successfully thwarted new litigation,
thus reducing injury, risk, and financial exposure— all for the benefit of
County taxpayers. The number of new force-related lawsuits, as well as the
number of closed force-related lawsuits resulting in a payout, has also trended
downward, validating the combined efforts of LASD leadership and external
civilian oversight that Special Counsel and the Office of Independent Review
(OIR) in different roles provide.
These trends have not, however, coincided with decreases in the total
dollars paid out in litigation or in the average amount paid out per closed case.
Particularly troubling in this regard are six cases involving in-custody injury or
death that accounted for $5.635 million, or more than half (51 percent), of the
LASD’s total civil liability across all lawsuits for the 2006-2007 fiscal year.
The Department’s liability, in terms of money paid out, has gone up recently.
While the inability to reduce the overall financial cost to County taxpayers
should give the LASD pause, and should precipitate more effective risk
management in the jails, it does not, for reasons set forth below, imply that the
LASD has not made significant strides in other areas.
We have noted frequently since the Kolts Report that measuring trends
in litigation reflects the Department’s progress in mitigating personnel
misconduct and managing risk. Consideration of the volume of lawsuits



brought against the Department, the size of judgments and settlements,
and the nature of the cases generating liability can reveal substantive areas
in which the LASD can or should improve and issues that it must address.
We return here to consideration of trends in liability through litigation and the
implications for future efforts to manage effectively the risk of that liability.

I. Scope of the Review
For the present report, we reviewed overall trends in litigation since the
2001-2002 fiscal year through the 2006-07 fiscal year. The County’s fiscal
year runs from July 1 of one year through June 30 the next.
Litigation is an imperfect indicator of the efficacy of risk management
because it is a “trailing” indicator. Lawsuits often are not filed until well after
an incident has occurred and often take significant time to work their way
through the court system to a resolution. By the time that a lawsuit is settled
or resolved via verdict, it is not uncommon for several years to have elapsed.
Aggregate statistics on litigation-related liability for each fiscal year thus provide
only a delayed snapshot—rather than a contemporaneous assessment—
of the Department’s liability risks. A risk manager studying litigation must
accordingly factor in changes in policies, procedures, and culture that may
have lowered the apparent risk in the interim.
Litigation is, similarly, an imperfect indicator of the level of overall officer
misconduct to the extent that the legal system, through pre-trial motions or
the inclusion or exclusion of particular evidence, can alter the risk management
calculus such that settlement is more cost effective for the Department even
if the Department believes that the case has no merit. That is, the Department
may settle to mitigate costs, and the evaluation of the aggregation of such
settlements for a specific timeframe may reveal only the strength of the
Department’s advocates in court or the legal soundness of the Department’s


position related to evidence rather than the overall level of officer misconduct.
Litigation does, however, still reveal much. As we noted in our Fifteenth
Sem iannual Report, “often, with regard to an instance or allegation of

police misconduct, it is litigation that produces the fullest record,” as the
litigation process differs from internal investigations about an incident—such
as citizen’s complaint investigations, force reviews, and administrative investigations—because litigation is external and adversarial. (Fifteenth Semiannual
Report, 85). Because it introduces external and adversarial parties to the
truth seeking process and includes the likelihood of deposition and crossexamination under oath, litigation may be more likely in many instances to
test and challenge asserted facts than a limited internal investigation might.48
Litigation, however, is a bed of roses only for those who don’t mind sharp
thorns. Positions harden, war chests are raised and then rapidly depleted,
faces must be saved, and emotions arm wrestle with pragmatism.
Nonetheless, litigation, in common with external civilian oversight, has
the potential to examine a law enforcement agency and its practices with
more professional skepticism than internal forms of review. Accordingly,
a department’s demonstrated ability to learn from litigation by reducing
potential sources of liability will be reflected in fewer total lawsuits, fewer
lawsuits in the higher risk categories, less total exposure, and fewer taxpayer
dollars spent on judgments and settlements. These trends are a fundamental
sign that systemic reforms in the realm of policy, procedure, and training are
taking hold.
Our Fifteenth Sem iannual Report in July 2002 set forth substantial
concerns about the Department’s risk management programs and their
inability to identify and apply lessons learned from incidents that generated
financial liability in the past to prevent similar incidents in the future.

48 Some cases brought against the Department may inevitably be based on fraudulent claims. In such instances, litigation may prove to
be a less efficient process for determining facts while costing the Department disproportionately more to resolve.


We noted then that the Department tended both to settle cases too liberally,
in order to dispatch of them at or below the anticipated cost of trial, and not
liberally enough, refusing to acknowledge internally that, in some instances,
the Department was more clearly at risk of substantial liability and that such
a case should be dispatched as cheaply and quickly as possible.
Our Nineteenth Semiannual Report in February 2005 followed up
and reported that, in the intervening period, the LASD began to address
these concerns by introducing new management practices in the Civil
Litigation Unit of the Risk Management Bureau. These practices included a
commitment to settling lawsuits quickly where appropriate, in order to
minimize attorney’s fees and the likelihood that a plaintiff will “dig in their
heels” for a large settlement or await a generous verdict, and the mounting
of a vigorous defense if a Critical Incident Analysis meeting—an evaluation
of pending litigation for more major or complex lawsuits involving risk
management staff, County Counsel, the Office of Independent Review
(“OIR”), the involved commander, and others—deems the Department
to be not at fault or a plaintiff’s demands unreasonable or excessive.
It is our understanding, through interviews with the Civil Litigation
Unit, that these commitments have endured in the more than three years
since our last, in-depth look at litigation and the Risk Management Bureau.
We applaud the spirit behind these commitments.
Currently, it is also our understanding that all claims that the Civil Litigation
Unit receives are subject to a preliminary investigation and recommendation
to deny, pay, or settle by a sergeant or deputy within the Unit. The
Lieutenant in charge of the Unit reviews the preliminary materials, reviews
the recommendation, and makes direct recommendation to Los Angeles
County Counsel. Recommendations of settlement in amounts greater than
$100,000 require the concurrence of the Division Chief and Undersheriff.
The Lieutenant also recommends whether the case should be the subject


of a Critical Incident Analysis Meeting. Generally, cases that the Lieutenant
determines are likely to result in a judgment against the Department or
settlement in excess of $100,000 are recommended for review in a Critical
Incident Analysis meeting.49
We do note that the process for determining precisely who makes recommendations as to how best to proceed with a given lawsuit — whether to settle
sooner, settle later, or go to trial— is an inherently nebulous and variable one,
at least on the LASD end, as the processes utilized for review are informed by
the hopefully critical judgment of Civil Litigation Unit investigators, leadership,
and those who convene in the context of the Critical Incident Analysis Meeting.
While the business of risk management, insofar as it relates to making decisions
as to how to proceed with lawsuits that might generate financial liability, inherently involves people with different perspectives commonly exercising good
judgment, the Department and the Risk Management Bureau should take
great pains to ensure a reasonable uniformity process for determining who
reviews what cases when.
We focus on lawsuits rather than on claims for multiple, related reasons.
First, only a small fraction of the Department’s overall financial liability stems
from money paid in claims. For instance, in the most recent, 2006-2007 fiscal
year, money paid in claims constituted just 1.9 percent of the Department’s
total liability. Second, liability that is addressed via litigation, rather than
through a claims process, almost always involves at least the assertion, whether
or not they lead to ultimate payment or settlement at all, of more serious
accusations. Finally, and given the often more serious nature of the facts
and situations at issue within lawsuits, a lawsuit is more likely to result in a
significant liability, whether in the form of a sizeable settlement or award,
for the Department than a claim, by its basic nature, could.

49 Lawsuits are also reviewed through a County Counsel Roundtable while they are pending. Such meetings involve representatives
of the Risk Management Bureau, County Counsel’s office, and the County’s Chief Executive Office and attempt to keep all major
players current as to the status of ongoing litigation.


We do note briefly, however, that the trends in claims (excluding lawsuits)
against the Department are encouraging. The number of new claims (848)
against the Department in 2006-2007 is down compared to the number six
years prior, in 2001-2002 (or 1,077)—though the number of new claims has
gone both up and down over the past several years. Also heartening is a
steady decrease in money that the Department paid out in claims since the
2003-2004 fiscal year. The total paid for claims against the Department in
2006-2007 ($209,214.14) was, in fact, less than one-third what it paid in
2003-2004 ($692,709.46). Still, because such sums constitute such a small
percentage of the Department’s total liability, we do not consider the claims
process further at present.

II. Aggregate Trends in Litigation
The trends in liability generated from litigation since the start of the
2001-2002 fiscal year are mixed. The overall amount paid out in settlements
and judgments is, in both comparisons of single years and clusters of years,
somewhat higher recently. The average amount that the Department pays
per closed lawsuit is, similarly, higher recently. Nonetheless, the number of
new lawsuits filed against the Department is down, and the numbers for a
significant sub-class of litigation— those relating to excessive or improper
use of force—have been pointing in a positive direction in recent years.

A . O ver a ll A m ount Pa id in Set t lem ent s a nd Judgm ent s

The LASD’s liability from litigation increased slightly, from nearly $10.6
million in 2001-2002 to $10.8 million in 2006-2007.50 (See Table 1). Also, the

50 As the Civil Litigation Unit has observed, direct comparison between 2001-2002 and 2006-2007 may not be the most useful or
accurate for judging overall trends, as such a comparison does not take into account basic inflation nor the general expansion of the
LASD in terms of overall budget, enterprise, and potential for liability given such expanded activity.


amounts paid in settlements and judgments in the years since 2001-2002
have fluctuated significantly. The Department enjoyed a significant reduction
in litigation-related liability in 2003-2004 and 2004-2005, with approximately
$5.5 million paid out in each of those years. Nonetheless, liability spiked
significantly in 2005-2006, to $15.1 million, and remained higher in 2006-2007,
at $10.8 million.

Table 1

Overall Litigation Trends
Number of
New Lawsuits


$ Paid in

Average Paid
per Closed Lawsuit
















Three-Year Average
(2004-2005 through 2006-2007)




















Three-Year Average
(2001-2002 through 2003-2004)





Individual deviations from year to year, and rudimentary comparisons
between given years, may be deceptive, however, as a given year’s overall
totals in the amount paid in judgments or settlements might be artificially
high as the result of more isolated, “outlier,” or high-impact cases that may not
represent the Department’s broader risk management capabilities
undertaken or in effect during that year.51 Accordingly, we compared the most

51 For instance, in the fiscal year 2000-2001, which we do not consider as part of the data set that forms the foundation for the present
report, the overall amount paid in settlements and judgments was nearly $19 million; $13 million of that liability stemmed from a
single lawsuit that originated from 1984. The significant magnitude of the Department’s financial liability related to litigation in that
fiscal year certainly does not necessarily relate directly, then, to the Department’s management of risk in that year.


recent three-year period (fiscal year 2004-2005 through 2006-2007) with the
prior three-year period (fiscal year 2001-2002 through 2003-2004). Such aggregated time periods, because they reflect a larger number and array of cases, may
reflect broader trends better to the extent that the effects of a statistical
outlier—a big-ticket settlement—may be situated in a broader context.
For the most recent three-year period, the Department’s total litigationrelated liability averaged about $10.5 million per year. For the earlier threeyear period, the total average payout per year was $9.9 million. The level of
the Department’s overall, litigation-related liability has, therefore, increased
slightly recently.

B. A m ount Pa id per Closed La w suit

The average amount that the Department pays out per lawsuit that it
closes—by settlement or verdict at trial—has also increased in recent years.
Analysis of average amounts paid per closed case takes into consideration
factors overlooked by a simple comparison of total amounts paid over given
fiscal years to the extent that the averages take into account those lawsuits
that were dismissed, in which the Department’s liability was nothing, as well
as those that were settled for relatively small amounts, which can provide a
more realistic statistical context for otherwise potentially distorting higher or
lower settlement or verdicts.52 53
The average amount paid per closed lawsuit at $46,433.42 was higher in
2006-2007 than it was six years earlier at $39,971.86 per closed lawsuit, in
2001-2002. The Department did manage to get its average per closed lawsuit

52 For instance, in a lawsuit that the Department settled in the 2006-2007 fiscal year, in which the plaintiff alleged being involved in a
traffic collision with a deputy sheriff, the settlement totaled $3.96.
53 The simple consideration of the amount paid per closed lawsuit does not take into account the effects of the reduction in the number,
or volume, of lawsuits that we detail in Section C, below. For simplicity of analysis, we do not endeavor the more complicated
statistical analysis necessary to control for deviations in overall litigation activity over the years compared. Still, the amount paid per
lawsuit does partially, though not entirely, help mitigate against the effects of statistically outlying, or abnormally large or small,
litigation outcomes.


down to $18,461.41 in the 2003-2004 fiscal year. That both the average amount
per closed lawsuit, and the total amount paid across all lawsuits, have been
higher in the last two fiscal years (2005-2006 and 2006-2007) than in the two
before them (2003-2004 and 2004-2005) is somewhat concerning.
A broader comparison of the most recent three-year period to the similar
preceding period also indicates that the average amount paid per closed
lawsuit has been higher recently. The average amount that the Department
paid out for the 700 cases closed in the three years between 2004-2005 and
2006-2007 was $44,804.42. The average amount paid out for the 900 cases
closed between 2001-2002 and 2003-2004 was $33,021.47.

C. N um ber of N ew La w suit s

A good deal of a law enforcement agency’s success in risk management
may be said to reside in the number of lawsuits not filed—those instances in
which policies, protocols, and training have eliminated what otherwise would
be a high risk of exposure. Accordingly, the number of new lawsuits filed
going down would suggest that the law enforcement agency is making strides
in mitigating its exposure to liability.
With small variations, the number of new lawsuits filed against the LASD
has gone down since 2001-2002. In that year, 282 lawsuits were filed against
the Department; in 2006-2007, 208 lawsuits were filed. More importantly, in
the past three years (fiscal year 2004-2005 through 2006-2007), the Department
averaged about 231 new lawsuits per year, which constitutes a nearly 18 percent
drop in the number of new lawsuits from the previous three-year period
(fiscal years 2001-2002 through 2003-2004, in which there were an average
of 281 new lawsuits per year). This drop in the number of new lawsuits
generated each year strongly suggests that the Department’s risk management
strategies are making a difference, the magnitude of which is hard to determine
from the facts at hand. A more precise analysis would attempt to correlate


the reduction in lawsuits to other possible causes, including the crime rate, the
number of arrests, the number of contacts by deputies with the public, the
frequency of in-service training, and the like — an analysis we did not have
the resources to perform.

D . For ce- Rela t ed Lit iga t ion

One area of litigation that has historically generated significant liability for
the Department is force-related litigation. Such litigation can generate high
costs, large settlements, and significant publicity, and it has, consequently,
been a consistent concern since the Kolts Report some sixteen years ago.
We have highlighted the Department’s force-related liability in numerous
Semiannual Reports since. Recognizing the importance of such litigation to
its liability exposure, the Department’s Civil Litigation Unit includes a separate,
specific summary of force-related litigation in its reports.
The number of new force-related lawsuits appears to have been trending
down. There were 78 new force-related lawsuits in 2001-2002 and 66 in
2006-2007. (See Table 2). In the intervening time, the numbers have moved
both up and down. A comparison of three-year averages, however, reveals
that, generally, the number of new force-related lawsuits has trended down,
with the Department seeing an average of 62 new force-related lawsuits per
year in the most recent three-year period as compared to approximately 68 in
the preceding three-year period—a nine percent decline.
Significantly, the number of force cases requiring an ultimate payout by the
County also appears to have gone down. While, again, the overall numbers of
cases requiring payment have fluctuated over the past years, the Department
lost or settled an average of nearly 23 cases per year for the most recent threeyear period as compared to about 30 per year for the similar preceding period.


More importantly, the percentage of force cases that the County closes,
whether by dismissal, verdict, or settlement, that require at least some payout
to the plaintiff, appears to be trending down. The average percentage of cases
that required payment, due to settlement or verdict against the Department,
was about 35 percent in the three-year period from fiscal year 2004-2005
through 2006-2007, as compared to the nearly 44 percent of cases that
required payout in the preceding three-year period from 2001-2002 through
2003-2004. Further, the percentage of cases requiring payout are down
significantly from the early part of the decade, when nearly half of closed
cases involving force, in both 2001-2002 and 2002-2003, resolved in a manner
that required payment. Since 2002-2003, the percentage of force-related
litigation that ultimately required the County to pay has not risen above 39
percent of closed cases.
Part of the decline may be attributable to a more aggressive litigation
strategy. More cases have gone to trial and the County has prevailed in a
greater percentage of them.54 The County has averaged about 8 verdicts in
its favor per year in the most three-year period compared to approximately 5
per year for the prior three-year period. In the context of closed cases overall,
about 5 percent more cases were closed with the County prevailing at trial
during the most recent three-year period than the preceding such period.
The Department’s overall financial liability stemming from this lower level
of force-related litigation has been trending down. (See Table 2). Although
the Department paid out more than $3.7 million in settlements and verdicts
in force-related lawsuits in the 2006-2007 fiscal year, which is the highest
amount in raw dollars since the 2002-2003 fiscal year, the Department has
paid much less in litigation involving claims of excessive force over the past

54 The Department taking more cases to trial and prevailing could also suggest that the procedures related to documentation and
investigation of use of force, and the existence or intervention of the Office of Independent Review (“OIR”), have provided sounder
factual foundations from which to give input on whether to try or settle a case.


Table 2

Force-Related Litigation Trends


















































Three-Year Average
(2004-2005 through 2006-2007)

Three-Year Average
(2001-2002 through 2003-2004)

Percent of
cases requiring

Number of
Verdicts Won
(at trial)

Percent of
Closed Cases
with Verdict

Total Paid in ForceRelated Litigation
(in Judgments
and Settlements)







































Three-Year Average
(2004-2005 through 2006-2007)

Three-Year Average
(2001-2002 through 2003-2004)


Percentage of
Overall Liability
Stemming From

three years than in the similar, previous time period.55 For the most recent
three-year period, the Department paid out an average of $2.6 million per year
in force-related lawsuits; for the previous three-year period, the Department
paid an average of nearly $4.2 million. That Decrease amounts to a drop of
some 38 percent.
Force-related litigation comprises less of the Department’s total liability
than it once did. Although 2006-2007 saw force-related litigation representing
a larger portion of the Department’s liability, or about 35 percent of overall
liability, than it had in the previous fiscal year, where force-related liability
was 16 percent of total liability, the levels were still down significantly from
2001-2002, when force-related litigation constituted a full 66 percent of the
Department’s total liability. The associated three-year averages show forcerelated lawsuits to be making up for less of the Department’s overall liability,
with such lawsuits on average representing nearly 27 percent of liability in
the three most recent fiscal years compared to over 42 percent in the previous
three-year period.
In sum, that new force-related lawsuits are trending down and the number
of such lawsuits requiring payout is also trending down suggests that, in the
area of force, the Department has made strides in managing its risk. A more
sophisticated analysis would attempt to correlate the reduction in force lawsuits
to other possible causes, including the crime rate, the number of arrests, the
number of contacts, use of force to arrest ratios, the increased reliance on new
force instrumentalities, etc.— an analysis we did not have the resources to
perform at this time.
55 The Department has noted that the $3.7 million cited here includes, by their estimation, $2.8 million related to sexual misconduct
cases. We concur that such cases should not automatically be considered to be force-related. Our criteria for inclusion in the
category of force-related, however, is the Department’s own, with all such cases reflecting some allegation of “excessive force”
within the Personnel Performance Index (PPI) database system. In its Civil Litigation Summaries, generally published quarterly with
an annual review of the most recent fiscal year, the Department does appear to include many sexual misconduct cases as “forcerelated,” as our data obtained from the PPI closely follow the data previously presented in these reports. In the absence of comprehensive qualitative consideration of all force-related litigation over the past six years, our analysis defaults to the Department’s
categorization. We recommend that the Department change its classification or coding criteria, for purposes of the PPI, if it believes
that a class of cases involving sexual assault should not necessarily be coded within the system as also involving “excessive force.”


III. Litigation in the 2006-2007 Fiscal Year
For the most recent fiscal year, from July 1, 2006, through June 30, 2007,
the total amount paid in settlements and judgments was a little more than
$10.8 million over the 233 total lawsuits that were closed—or resolved via
verdict, settlement, or discontinuation of legal action—during the fiscal year.
The County paid at least some amount in 69, or about 30 percent, of those
closed lawsuits. Of the 69 closed lawsuits in which there was a payout, 62
were settled and seven closed as a result of a judgment for the plaintiff.
In 52 of the closed lawsuits, the County paid less than $100,000; in the
remainder, or 17 cases, it paid more than $100,000. The average award was
$160,999.80, with payouts ranging from $3.96 at the least to $2.8 million at
the most.
In the 17 lawsuits that closed for amounts over $100,000, six involved incustody injury or death. Four involved auto liability, three involved excessive
force against individuals not in custody, three involved sexual assault, and one
involved harassment. Accordingly, in-custody injury or death contributed,
across categories, to the largest number of the cases that closed for the highest
sums. The Department does not, however, currently classify, either in its
publications or within the Personnel Performance Index (“PPI”), deaths or
injury that occur to an individual in its custody as such. As we indicate below,
we strongly recommend that it add this extra detail for a more accurate representation of where the Department’s liability risk ultimately resides.
The six cases settled for more than $100,000 that involved in-custody
injury or death alone accounted for $5.635 million, or more than half (51
percent) of the Department’s total civil liability across all lawsuits for the 20062007 fiscal year. By comparison, the four cases settled for more than $100,000
involving auto liability cost the Department $736,596.64 (or 7 percent of the
Department’s total liability), the three cases involving excessive force against
parties not in custody cost $375,000 (3 percent of total liability), the three


sexual assault cases cost $2.8 million (one-quarter of total liability), and the
harassment lawsuit $325,000 (3 percent of total liability).
In-custody injury and death accounted, then, for an undeniably significant
portion of the Department’s civil liability in the 2006-2007 fiscal year. While
the statistics cited here account for those cases that ended during the 20062007 fiscal year, they involved litigation commenced in 1999, 2003, 2004, 2005,
and 2006. Lawsuits relating to in-custody injury and death that have resulted
in significant payments to plaintiffs are not a relic of the past but rather point
to an ongoing and continuing source of liability.

I n- custody D ea th a nd I njury Settlem ents in 2006- 2007

We examined the six cases involving in-custody injury and death that
closed in 2006-2007, all of which resolved via settlement. In four cases, we
reviewed memos from Los Angeles County Counsel to the County Claims
Board seeking authority to settle each case. Such memoranda summarize
the factual record and offer County Counsel’s evaluation of the case and
settlement recommendation. In two cases, this sort of documentation was not
available to us, as memoranda referencing the case are deemed attorney-client
communications from County Counsel directly to the Board of Supervisors.
1. In April 1998, Long Beach Police arrested a man on an outstanding
warrant for failing to complete court-ordered counseling pursuant to a
previous criminal matter. The man was placed in LASD custody at the
North County Correctional Facility.
In November 1998, the man was discovered dead in his cell. A subsequent autopsy, homicide investigation, and Inmate Death Review all
determined that the man died from a ruptured aneurysm. The man’s
family hired a forensic pathologist who indicated that he located a “microfracture of the neck, caused by blunt force trauma, that preceded and


caused the ruptured aneurysm.” Two experts hired by the County
squarely disagreed with him.
The man’s 12-year-old nephew and 13-year-old niece testified later at
deposition that “after a visit with their uncle on the day of his death,
they saw him being hit and choked by a Sheriff’s Deputy,” though such
information “was never reported to the homicide investigators.”
County Counsel concluded the case to be “of questionable liability”
considering that the county’s “experts are definite” that the man did not
suffer a fracture of the neck and the “suspect” testimony of the man’s
niece and nephew. Still, noting that a jury might believe “the expert
testimony form the plaintiff’s pathologist” and conclude that the man
“died at the hands of another,” the memo recommends a settlement of
$110,000, which is the amount for which the county ultimately settled.

2. A 71-year-old man with a “long history of heart disease” and “in a
wheelchair,” who brought several medications with him, was placed in
LASD custody in March of 2002.
Two and a half weeks after coming into LASD custody, on March 28, 2002
at 8:20 A.M., the man “was found on the floor of his cell.” He complained
to LASD personnel that he was experiencing shortness of breath. Later in
the day, “the personnel noted that [the man] was having a crackling sound
in his lungs and that his urine had become dark.”
The personnel did not “transfer the inmate” to the Los Angeles County
USC Medical Center, or LAC+USC, for medical treatment.
Later that night, at 10:10 P.M., the man “was again found on the floor of
his cell,” where, “by 11:52 P.M., the inmate was suffering from shortness
of breath and low blood pressure.” On this occasion, “medical treatment


was administered and an order was placed to transfer the inmate to
LAC+USC” for medical treatment. An ambulance arrived at 12:25 A.M.
The man was transported at 12:40 A.M. The man arrived at the medical
facility at approximately 1:00 A.M. The man “was pronounced dead”
later that day, at 2:56 P.M.
Because of the failure to respond appropriately to the inmate’s medical
emergency, the Claims Board approved a $475,000 settlement.

3. On September 21, 2003, a 62-year-old man was arrested for assault with
a deadly weapon and spousal abuse. The man was under the custody of
the LASD within the Inmate Reception Center.
On the morning of September 24, 2003, LASD nursing personnel examined
the man. During the examination, the man “was unable to state his name
and age,” and nursing personnel “noted that Mr. Wilson was suffering from…
hypertension.” The nursing personnel recommended that the man “undergo
a more thorough medical evaluation.” Later on the same afternoon, a mental
health nurse examined the man, observing him to be “anxious, confused,
and suffer[ing] from poor judgment and delayed speech.” “Despite the
fact that [the man] was scheduled to undergo a more thorough medical
evaluation,” the man “was discharged from IRC” without such examination.
On the next day, September 25, medical personnel “realized that [the
man] had not been seen by a physician as planned.” While nursing staff
“placed an order for the inmate to be examined,” they “failed to contact
the inmate’s housing unit” to ensure that the order was carried out.
The man’s wife visited him at the jail on October 10, 2003, and she
represents that “she saw her husband grab his chest and double over.”
She claims that “one of the Deputies…assured her” that her husband
“would be seen at the clinic.” He was not.


On October 14, 2003, the man experienced pains in the chest. By the
time that medical personnel arrived, the man was “lying on the floor.”
Paramedics were called, and they continued attempts to resuscitate the
man begun by personnel as they transported him to the Los Angeles
County USC Medical Center. The man died in transport.
An autopsy revealed the cause of death to be blood clots in the lungs
attributable to deep vein thrombosis, or the amalgamation of blood clots
in deep blood vessels in the legs. In her lawsuit, the man’s wife claimed
that, had LASD medical personnel more carefully and thoroughly
examined the man, as their own orders revealed that they should have,
“his serious medical conditions would have been diagnosed and he would
have been placed under the appropriate medical care, which would have
prevented the condition which led to his death.”
Given that a jury might return with a verdict for the plaintiff, finding that
medical staff were deliberately indifferent to the man’s care, the County
approved a settlement of $700,000.

4. A man sentenced to 180 days at the Pitchess Detention Center was
“assaulted by four inmates” on May 24, 2004. “The assailants were angry
at [the man] because he had taken the personal property” of one of the men.
The attackers “took [the man] to an area” of the dormitory facility “where
they knew it would be difficult for Deputies to monitor their activities.”
When the incident occurred, the Deputy assigned to the Dormitory
Control Office had left, believing that a replacement Deputy was on his
way to take the assigned Deputy’s place. He was not, which left the
“post…vacant for approximately 20 minutes.”
An inmate alerted another Deputy to the disturbance. When the Deputy


responded, the man was found unconscious. The man sustained “significant neurological damage” resulting from head injuries suffered during
the attack. He reported to also suffer from “blurred vision, slurred speech,
impaired balance, and impaired judgment” prior to the attack, though
county experts were prepared to “refute the extent of [the man’s] injuries”
in court.
Given that the incident occurred when the assigned Deputy had left the
post unattended, the County approved a settlement of $750,000.

5. A 41-year-old man accused of child molestation was placed in a dormitory
at Men’s Central Jail in December 2003 despite jail personnel issuing a
special order for the man to be held separate from the general population.
The man was assaulted by a group of prisoners when they learned of the
nature of the allegations against him, and he suffered extensive injuries
that require lifelong care.
The Board of Supervisors voted unanimously to settle the man’s lawsuit
for $2.8 million, which was the most sizeable settlement that the Board has
approved for a case involving in-custody injury.

6. A man was placed in a locked room with 29 high-risk inmates at Men’s
Central Jail. Two inmates attacked the man, knocking him to the ground,
stomping on his head, neck, and chest, and beating him with metal food trays.
The case was settled for $800,000.

It is troubling that six large settlements that stem from in-custody injury
and death constituted a majority of the Department’s liability in 2006-2007.
The events that precipitated such lawsuits occurred in an environment
designed to give the Department, and its officers, maximum control over the


individuals occupying or housed within it. Unlike the largely uncontrollable
environment in the “field” or “the real world,” the Department and its
employees exert far more direct control of variables when an individual is
under and within its custody.
To manage its risk effectively in the future, the Department must
recognize the significant, fundamental, and distinctive exposure that it
encounters by virtue of taking and holding people in custody for extended
periods of time. The first step in doing so is for the Department to give a
supplemental designation of “in-custody” litigation to, lawsuits or claims
stemming from incidents that occurred when an individual was in custody.
Under current practice, the six cases outlined above are classified in the Risk
Management Bureau’s most recent “Civil Litigation Summary” for the fiscal
year 2006-2007 under at least two categories: “wrongful death” and “failure
to protect an inmate.” Both categories are appropriate. An additional classification for “in custody death or injury” will bring more focused attention on
the particular circumstances causing liability in the jail context.

IV. Conclusion
We applaud the Department and the Risk Management Bureau for the
recent and relatively stable decreases in new lawsuits brought against the
Department. We commend Lt. Shaun Mathers for his excellent leadership.
We applaud the Department for encouraging recent trends in force-related
litigation and urge the Department to ensure that these trends continue.
These decreases in new and force-related lawsuits have not yet translated
into enduring decreases in the overall amount paid out per year in settlements and judgments, and this should be some grounds for concern. We are,
however, confident that unrelenting high-quality investigation, active risk
management, and fair and decisive personnel decisions will benefit the
Department financially and otherwise.


S h o o t i n g a n d U s e o f F o r c e Ta b l e s

Table A

Total LASD Shootings
On Duty

Non-Hit 2
Accidental Discharge3
Animal 4
Warning Shots 5
Other Shooting Incidents6


Off Duty




On Duty


On Duty Off Duty

Hit 1
Non-Hit 2
Accidental Discharge 3
Animal 4
Warning Shots 5
Other Shooting Incidents6



Off Duty




On Duty

Off Duty



2006 7


On Duty


Off Duty






On Duty

Off Duty





1 Hit Shooting Incident: An event consisting of one instance or related instances of shots (excluding stunbags) fired by a deputy(s) in which one or
more deputies intentionally fire at and hit one or more people (including bystanders).
2 Non-Hit Shooting Incident: An event consisting of one instance or related instances of shots (excluding stunbags) fired by a deputy(s) in which
one or more deputies intentionally fire at a person(s), but hit no one.
3 Accidental Discharge Incident: An event in which a single deputy discharges a round accidentally, including instances in which someone is hit by
the round. Note: If two deputies accidentally discharge rounds, each is considered a separate accidental discharge incident.
4 Animal Shooting Incident: An event in which a deputy(s) intentionally fires at an animal to protect himself/herself or the public or for humanitarian reasons, including instances in which a person is hit by the round.
5 Warning Shot Incident: An event consisting of an instance of a deputy(s) intentionally firing a warning shot(s), including instances in which
someone is hit by the round. Note: If a deputy fires a warning shot and then decides to fire at a person, the incident is classified as either a hit or
non-hit shooting incident.
6 Other Shooting Incident: An event consisting of an instance or related instances of a deputy(s) intentionally firing a firearm but not at a person,
excluding warning shots (e.g., car tire, street light, etc.). Note: If a deputy fires at an object and then decides to fire at a person, the incident is
classified as either a hit or non-hit shooting incident.
7 Revised. One on-duty shooting was reclassified from “accidental discharge” to “hit shooting” by the Executive Force Review Committee.


Table B

LASD Shootings 2000 to 2007

Non-hit shootings
Hit shootings



Source: Internal Affairs Bureau






Table C

LASD Hit Shootings by Unit

Number Of Incidents
Altadena Station
Carson Station
Century Station
Cerritos Station
Community Colleges Bureau
COPS Bureau
Compton Station
Court Services Bureau
Crescenta Valley Station
East Los Angeles Station
Industry Station
Lakewood Station
Lancaster Station
Lennox Station
Lomita Station
Lost Hills/Malibu
Major Crimes Bureau
Marina Del Rey Station
Men’s Central Jail
Mira Loma Facility
Miscellaneous Units
Narcotics Bureau
North County Correctional Facility
Norwalk Station
Operations Bureau
Operation Safe Streets a
Palmdale Station
Pico Rivera Station
San Dimas Station
Santa Clarita Valley Station
Special Enforcement Bureau
Temple Station
Transit Services Bureau
Walnut Station
West Hollywood Station
Number of Suspects Wounded
Number of Suspects Killed






10 e


2006 g

1 bd




Formerly Safe Streets Bureau.
Includes one incident in which more than one person was shot.
One shooting (7/8/03) involved three units (Safe Streets Bureau, Compton Station, and Transit Services Bureau).
Off duty shooting.
One shooting (1/5/04) involved four units (Century, Compton, Operation Safe Streets and Operations) and resulted in the deaths
of two suspects.
f. Both shootings occurred while assisting outside agencies (2/8/05 Downey Police Department; 6/7/05 California Highway Patrol).
g. Revised. One on-duty shooting was reclassified from “accidental discharge” to “hit shooting” by the Executive Force Review Committee.
Source: Internal Affairs Bureau


Table D

LASD Non-Hit Shootings by Unit

Number Of Incidents
Carson Station
Century Station
Century/Compton Transit Services
COPS Bureau
Crescenta Valley Station
East Los Angeles Station
Gang Murder Task Force
Homicide Bureau
Industry Station
Lakewood Station
Lancaster Station
Lennox Station
Lost Hills Station
Marina del Rey
Men’s Central Jail
Narcotics Bureau
Norwalk Station
North County Correctional Facility
Operation Safe Streetsc
Palmdale Station
Pico Rivera
San Dimas Station
Santa Clarita Valley Station
Special Enforcement Bureau
Temple Station
Transit Services Bureau
Twin Towers
Walnut Station




2005 d









a. Off-duty shooting.
b. One shooting (2/6/04) involved two units (Carson and Century).

Incidents Resulting in
Force/Shooting Roll-Out
Source: Internal Affairs Bureau









Table E

LASD Force

Department Wide*






2007 **

Force Incidents (Total)
Total Force/100 Arrests
Significant Force:
Hospitalization/Death/100 Arrests
Significant Force:
Visible Injury/100 Arrests
Significant Force:
Complaint of Pain/100 Arrests
Significant Force:
Other/100 Arrests
Less Significant Force Incidents/100 Arrests
OC Spray/100 Arrests































Field Operation Regions (FOR)






2007 **

Region I Force Incidents
Per 100 Arrests







Region II Force Incidents
Per 100 Arrests







Region III Force Incidents
Per 100 Arrests













FOR and OHS Total Force Incidents
Per 100 Arrests







Field Operation Regions (FOR)






2007 **

Regions I, II & III and OHS Significant Force Incidents,
Per 100 Arrests







Office of Homeland Security (OHS) Force Incidents
Per 100 Arrests

* Includes all patrol stations and specialized units, including custody and court services.
** CAASS Arrest Data.

Source: Management Information Services


Table F

LASD Force/100 Arrests All Patrol Stations







2007 **

Crescenta Valley
East LA
Lost Hills/Malibu
Santa Clarita
Region I Totals







Community College
Marina del Rey
Transit Services Bureau*
West Hollywood
Region II Totals







Pico Rivera
San Dimas
Region III Totals







Transit Services Bureau*
Metro-link Bureau
Office of Homeland
Security Totals








* In 2006, Transit Services Bureau was moved from Region II to the Office of Homeland Security.
**CAASS Arrest Data
Source: Management Information Services