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Texas Expert Report, Tdcj, 1998, Ruiz v. Johnston

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TELEPHONE (303) 355-6842
FACSIMILE (303) 322-2155

December 31, 1998

Donna Brorby, Esq.
660 Market Street, Suite 300
San Francisco, CA 94104

Texas Department of Criminal Justice

Dear Ms. Brorby:
I have completed my initial assessment regarding issues related to the mental health care
services provided to inmates at the Texas Department of Criminal Justice (TDCJ). I site
visited the Estelle Unit in Huntsville, Texas during December 18-20, 1998. During
December 18, 1998 I met with the following staff:

Tim Simmons (Assistant Warden),
Kent Dickerson (Manager of Health Services),
Dean Buzbee, M.S. (Responsible Psychologist),
Bobby Vincent, M.D. (Facility Medical Director),
Bryan Buck (Captain),
Mary Adams, RN (Facility DON),
Lisa Lopez, RRA (Registered Records Administrator),
Marciano Limsiaco, M.D.,
Robert Komer, D.O.,and
Ray Neuse, M.Ed.

Warden F.E. Figueroa was unavailable for the opening meeting due to another

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Sources of information utilized in this assessment included review of the following
1. Texas Department of Criminal Justice Mental Health Services Policy Manual,
2. a document entitled “University of Texas Medical Branch Managed Healthcare
Psychiatric Inpatient Program” (Jester IV Unit),
3. audits by various psychiatrists (Drs. Wang, Jurczak, Conklin, Stellman, and
Elliott) concerning mental health services offered at the following TDCJ
Diagnostic (Byrd),
Jester IV,
Ramsey I,
Stiles, and
4. a January 1998 audit report entitled “Managed Health Care at the Texas
Department of Criminal Justice” authored by the Office of the State Auditor,
5. the Texas Department of Criminal Justice Formulary (5th Edition, 1998-1999),
6. Manual of Policies and Procedures for Health Services (TDCJ Institutional
7. documents relevant to heat-related illnesses,
8. critical drug list for the Estelle Unit (December 18, 1998), and
9. 30 healthcare charts of inmates at the Estelle Unit.
Overview – Estelle Unit Complex
The Estelle Unit complex generally has an inmate count of about 2800 inmates. The
various facilities within the Estelle Unit usually have the following counts:

Main building: 2268 (which includes a 66-bed segregation unit)
High Security: 640
Geriatrics Center: 60
Substance Abuse Felon Punishment Facility: 188
East Regional Medical Facility: 120

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The High Security Unit, which is a segregation unit, has inmates with Level I, Level II,
and Level III privileges. Level I inmates have seven hours of recreational time per week,
Level II inmates have four hours per week, and Level III inmates have three hours per
week. The security classification levels for inmates in the main building range from
minimum to close security. This facility consists predominantly of celled housing except
for dormitory living in the geriatrics center. All the cells are double-bunked except for
the High Security Unit and the segregation unit within the main building, which are
Information regarding the mental health services at the Estelle Unit was obtained from
Mr. Buzbee. The mental health services have been provided as part of the University of
Texas Medical Branch system for about 1½-2 years. A psychiatrist is the Director of
Mental Health systemwide and has two assistant directors (a nurse for the southern
region, and a masters level LPC for the northern region). The responsible psychologist at
each facility reports to one of the assistant directors.
The funded mental health staff positions were as follows:


2.0 FTE Social Workers,
1.0 FTE Psychiatric Nurse,
3.0 FTE Psychologists (Masters level), and
2 Contract Psychiatrists (providing psychiatric coverage three days per week
for a total of 35 hours per week).

There were currently no vacancies within the mental health staff. Mr. Buzbee reported
that staff vacancies are generally filled within about one month.
There were 222 inmates on the active mental health caseload with housing locations as

High Security Unit (46)
SAFPF (55)
Main Building (103)
RMF (14)
Geriatrics (4)

The mental health caseload represented about eight percent of the inmate population at
the Estelle Unit. In addition, there generally are about 150-200 inmates who are on the
inactive mental health caseload, which means that they have had a history of mental
health treatment within the Texas Department of Criminal Justice but are no longer
receiving mental health treatment. The mental health roster in the main building has been

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as high as 200 in the past. Several months ago the caseload in the main building
significantly decreased related to a transfer of many close inmates to another facility in
exchange for inmates with a minimum security classification due to the need for more
workers at the Estelle Unit.
Twenty-two inmates were receiving individual therapy, fifteen inmates were receiving
group therapy, and the rest of the caseload inmates were receiving case management
services. The three group therapies include one rational behavior therapy group and two
HIV therapy groups. There was not a significant waiting period for group therapies.
Inmates receiving case management services were reported by Mr. Buzbee to generally
be seen on a monthly basis. Very few of the active caseload inmates were not receiving
psychotropic medications.
Co-payments are not charged to inmates receiving mental health services although the
department is able to make such charges related to relevant legislation.
All inmates newly admitted to the Estelle Unit receive a “chain triage” which involves
review of their healthcare records by either the nurse, psychologist, or social worker.
These chart reviews are assigned according to housing units. Mr. Buzbee reported that
interviews triggered by the chain triage are generally performed within 24 hours except
during weekends.
Main Building
I briefly walked through three of the tiers in the A Unit (segregation unit) within the main
building. I talked to three inmates in punitive segregation status and four other inmates
on segregation status. One of these inmates was a caseload inmate and had just recently
been admitted to a pre-hearing detention cell. Several of these inmates were doing
disciplinary time following an infraction related to masturbation. . In general, treatment
is not readily available for inmates with sexual disorders until they are within one or two
years of completing their sentence.
Caseload inmates are seen by a mental health clinician on a weekly basis during the
rounds process. A “boilerplate” progress note is written to document such rounds. These
inmates confirmed that daily rounds were being made by the nursing staff.
I toured several housing units in the main building. Each wing contained three tiers of 21
cells that were all double-celled. The housing units were very clean. The showers were
dark and did not appear to be very clean.
Close security inmates receive two hours per day of recreation time in a group yard.

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During December 20, 1998 I met with two groups of inmates who were receiving mental
health services in the main building at the Estelle Unit (see Appendix I). These inmates
reported that it generally took an hour to go through pill call line in order to get their
medications. They indicated that correctional officers frequently harassed them during
the pill call line. Medications were intermittently not timely renewed which resulted in
lapses of medications for up to a week at a time.
The inmates reported that they do meet with their counselor on a monthly basis but they
do not receive counseling. These meeting were described as being very brief and
characterized by answering the following question: "On a scale of 1 to 5, how do you rate
Most of these inmates reported that their meetings with the psychiatrist was every three
months. They stated that they did not receive education regarding either their
medications or diagnosis.
Information was obtained regarding their experiences at Jester IV and the Skyview Unit.
They reported that several doctors, especially Dr. Tchokoev, treated them disrespectfully.
They frequently were perceived as not telling the truth by him.
It was reported by these inmates that indoor temperatures during the summer get very
hot. However, they indicated that there were not specific provisions made for cooling for
inmates on psychotropic medications except for exempting them from outdoor work.
Two of the inmates reported that they had heat related problems during this past summer.
The charts of these inmates were reviewed (see Appendix II).
A second group of four inmates, who reportedly were receiving mental health services
(see Appendix I), were interviewed. Two of these inmates were now apparently on the
inactive caseload. The inmates indicated that they periodically had problems obtaining
the medications due to pill call line issues. They reported that they had very brief
monthly contacts with their case managers. One of the inmates described his case
manager as speaking to him in a negativistic fashion. Both of the caseload inmates
reported monthly meetings with the psychiatrist. One inmate also reported heat related
problems during the summer months which consisted of feeling dizzy and weak.
However, this inmate did not obtain specific treatment for these symptoms. The charts of
these inmates were briefly reviewed which was generally consistent with information
obtained from them.
Five inmates (see Appendix I), who were all receiving mental health treatment and were
in the SAFP, were interviewed in a group setting. These inmates all reported satisfaction
with the substance abuse program which was a therapeutic community model. They saw
their psychiatrist on a monthly basis and generally had monthly case management

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meetings which were of brief duration. They did not have difficulties obtaining the
medications through the pill call line.
The medical charts of these inmates were reviewed which were consistent with the
information provided by these inmates. These inmates reported that water is available as
needed during particularly hot days. They indicated that they had not experienced heat
related problems.
I met with Marciano Limsiaco, M.D. Dr. Limsiaco had been providing psychiatric
services to the Estelle Unit since 1989. Dr. Komer, who has been working at the Estelle
Unit since 1994, is responsible for the psychiatric coverage for the High Security Unit.
Dr. Limsiaco indicated that Zoloft is the only SSRI on the formulary and that Zyprexa,
Risperdal, and Clozaril are all non-formulary medications. However, he stated that it was
not a difficult procedure to prescribe non-formulary medications and that he was
prescribing such medications to patients.
Dr. Limsiaco generally sees caseload inmates every two to three months once they are
stable. Inmates needing to be seen on a more frequent basis are generally scheduled
every one to two weeks.
It was anticipated by Dr. Limsiaco that inmates would complain about long pill call lines
although they did not have problems obtaining their medications. Most of Dr.
Limsiaco’s caseload were being prescribed medications for treatment of either depression
or anxiety. He estimated that about 20-25 percent of the caseload have a chronic
schizophrenic illness. Inmates in need of a more intense level of mental health care are
transferred to the intermediate care units at Skyview or Jester IV. Dr. Limsiaco reported
that it was not difficult to transfer inmates to these units when clinically appropriate.
I reviewed the December 18, 1998 critical drug list which listed every medication being
prescribed to inmates in this prison complex. I was unable to identify any inmates who had
been prescribed either an atypical antipsychotic medication or a SSRI other than Zoloft.

High Security Unit
I interviewed Ray Neuse, M.Ed., who has been working in the prison system for the past
fifteen years and at the Estelle Unit for six months. His primary responsibility is to
monitor inmates on psychotropic medications and to perform mental health assessments.
There are two clinicians assigned to the High Security Unit plus a psychiatrist. The

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psychiatrist had been providing two days of eight hours per day psychiatric coverage but
beginning the week of December 18, 1998 was providing one ten-hour day of psychiatric
coverage per week.
The psychiatrist had been seeing inmates in the triage office on the wing but for the past
2½ months has been seeing inmates in an office setting off of the wings.
Mr. Neuse stated that there were not difficulties transferring inmates to an intermediate
care unit. However, inmates with self-mutilation problems generally were returned to the
High Security Unit within three days following transfer.
Mental health caseload inmates were seen by the mental health clinician on a weekly
basis at the cell front. The rounds process is documented by a typed “form” progress
note, which is used unless the inmate has specific complaints. They are not seen in an
office setting by the psychologist or social worker unless they submit a specific request
for such a meeting. In other words, there were no routine office visits with the clinicians
except by request from the inmate.
During the past week, chain triages were administered to fifteen newly admitted inmates
to the High Security Unit. Mr. Neuse reported that there were about ten to twenty sick
call request forms for mental health that needed to be triaged per week.
During December 18, 1998, I interviewed Robert Komer, M.D. Dr. Komer is now
providing one day per week of 10 hours of coverage to the High Security Unit. He
reported that he generally has 25-35 minutes allotted for a new patient evaluation and
generally 15-20 minutes for follow-up assessments. He usually has follow-up
appointments with his caseload inmates every 14-30 days. He estimated about one-third
of the caseload were receiving antidepressant medications, one-third antipsychotic
medications, and one-third mood-stabilizing medications. Dr. Komer expressed some
hesitancy in prescribing atypical antipsychotic medications due to their newness. He has
not had difficulties obtaining laboratory results.
Dr. Komer reported that there were not significant obstacles in transferring inmates to an
immediate care unit when clinically indicated.
I observed Marianne Anderson, R.N. perform segregation rounds in K unit. This was a
Level I housing unit for gang members. Ms. Anderson was very comfortable with the
rounds process. She reported that the mental health staff are very responsive to referrals
by the medical department. Ms. Anderson indicated it was uncommon to find psychotic
inmates in the High Security Unit. She reviewed with me a nursing protocol that is used
when mental health coverage is provided by the psychiatrist on-call. This protocol
involved obtaining a basic database prior to calling the psychiatrist.

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I walked cell to cell in C Section where I briefly talked with most of the inmates on this
unit and reviewed fourteen of their medical charts (see Appendix III). I also walked on
the D-wing range and attempted to interview six inmates (see Appendix III).
C-wing and D-wing each had two tiers with seventeen cells on either side (total 64 cells).
The noise level on both of these wings was high throughout the site visit which was
described by correctional officers as being a very common. A number of problem
inmates in C section were described as self-mutilators who were not on the mental health
caseload. It is likely that many of these inmates (see Appendix III) had personality
disorders associated with borderline and/or antisocial features which made them very
difficult to treat.
I briefly talked with Captain Franky Reescano who is the captain at the High Security Unit.
He estimated that about four to five inmates per week cut themselves and about 10-15
inmates require use of chemical agents for cell extractions or other similar reasons. Most of
the use of chemical agents and inmates who cut themselves were in wings C, D and H.
Captain Reescano reported that many of the inmates who cut themselves return from
Skyview, apparently have their medications discontinued, and then cut on themselves
several days later. He reported that mental health staff will evaluate these inmates but will
not provide input or consultation regarding management other than reporting that these
inmates were a security problem and not a mental health problem.
Approximately 60-70% of the second shift correctional officers and about 40% of the first
shift correctional officers were new (and very young) officers. It was reported that none of
these correctional officers have received specific training regarding mental health although
many of the older officers did have experience working with psychiatric patients at the old
Estelle Unit when it was a psychiatric facility.

Review of Other Estelle Unit Audits
The July 29, 1998 mental health audit report concerning the Estelle Correctional Facility
by Dennis Jurczak, M.D. was reviewed. Dr. Jurczak reported finding “serious
deficiencies in psychiatric care during this audit… [he] was also struck by the number of
inmates who apparently had Axis I diagnoses in the past but who were now on the
inactive list with no present Axis I diagnosis… .” Dr. Jurczak concluded that “the High
Security Unity is not an appropriate setting for the housing and/or care of mentally ill
prisoners… the number of mentally ill inmates on the High Security Unit are not now
being afforded adequate psychiatric treatment… several obviously psychotic and

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extremely disruptive inmates are receiving no psychiatric care… .” Dr. Jurczak
expressed significant concerns regarding the lack of usage of newer antipsychotic
medications within the Estelle Correctional Facility.
Thomas Conklin, M.D. also evaluated aspects of the mental health care within the Estelle
Unit during July 1998. His August 1998 report focused on review of suicide attempts
and gestures among inmates in the Estelle Unit. He concluded that “review of the
thirteen charts of suicide attempts and ‘self-mutilation’ inmates previously mentioned
revealed some disturbing practices. These are as follows:
1. All suicide gestures by inmates are seen as manipulating the correctional
system with the conscious intent of secondary gain. In not one case was the
inmate’s behavior seen as reflecting mental pathology that could be treated.
2. Diagnoses in these cases were always one of the following:
‘no Axis I diagnosis’
‘no diagnosis’
‘ASPD’ (antisocial personality disorder)
‘ASPD’ with borderline features’ ”
Dr. Conklin reported that “the mental health staff is of the opinion that all of these
conditions are untreatable and so no treatment is given… .”
Dr. Conklin concluded that “the staff is too meager and too ill-trained for the job they
have to do. There is no program available for seriously or chronically psychologically
impaired individuals. Either a hospital system or at the minimum group and supportive
therapy should be available. None of them are seen as requiring mental health services
and that simply is not so… .”
ASSESSMENT: Significant problems were found in the mental health care delivery system
at the Estelle Unit complex. In general, the mental health treatment available to inmates in
this complex consisted of the use of psychotropic medications and case management. Case
management in this context is best described as periodic monitoring in contrast to actual
treatment. However, even this monitoring has significant flaws which included brief
meetings with inmates and cell front assessments in the segregation units.
Psychopharmacological treatment was problematic due to a formulary which did not include
atypical antipsychotic medications and only one SSRI medication. There were also
significant problems pertinent to the diagnostic assessment process.
Many inmates with significant behavioral problems and functional impairments, who have
been diagnosed in the past as having a serious mental illness associated with psychotic
features, are frequently diagnosed as either malingering or having no Axis I diagnosis.
Consequently, they were not receiving mental health follow-up and/or psychotropic
medications. Axis II diagnoses were either not mentioned or, when diagnosed, did not have

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a treatment plan formulated relevant to the particular Axis II diagnosis despite significant
associated functional impairments.
Ironically, many inmates who are diagnosed with serious mental illnesses associated with
psychotic features receive little more treatment than those diagnosed without a disorder
except for the use of psychotropic medications. However, these inmates were often
uninformed regarding the use of their particular medications and/or have not received
therapeutic trials of newer medications available such as Risperdal or Olanzapine.
The lack of a specific treatment program for inmates with serious mental illnesses is
particularly problematic at the Estelle Unit complex. There was a significant number of
inmates with serious mental illnesses who were housed within the High Security Unit.
Such inmates were generally housed in wings C, D, and H. It was in this unit that case
management services were particularly ineffective related largely to the cell front
interview process in contrast to meeting with a clinician in a reasonably private office
setting. Unfortunately, inmates with serious mental illnesses often did not even receive
cell front monitoring due to past assessments that they did not have an Axis I disorder
and/or were malingering. These diagnoses were often formulated at the Skyview Crisis
Management Unit (see Appendix IV). Reference should be made to Dr. Stellman’s
report (see “Review of Other Mental Health Audit Reports” section) which summarizes
the deficiencies in the assessment process at the Skyview Crisis Management Unit.
There clearly have been problems concerning a “heat plan” relevant to inmates being
prescribed psychotropic medications. Reference should be made to Appendix II which
provides an example of the potential dangers associated with lack of an adequate plan.
Review of pertinent discovery documents indicated that remedial measures have been
instituted relevant to this issue although I was unable to find a comprehensive policy and
procedure concerning this issue relative to inmates receiving psychotropic medications.
The placement of inmates with serious mental illnesses in the High Security Unit,
without adequate mental health resources being available to such inmates, has resulted in
many of these inmates having their psychiatric symptoms intensified which has
contributed to a harmful environment within several of the High Security Unit wings.
Review of Death Records
The medical charts of eight inmates who died during the past two years within the TDCJ
were reviewed (see Appendix V). This review revealed significant system problems related
to poor documentation, diagnostic assessments, and frequent determinations that an inmate
did not require treatment due to “no diagnosis on Axis I.” These records also revealed some
of the significant obstacles faced by many inmates who were attempting to obtain mental
health treatment.

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Review of Other Mental Health Audit Reports
Jester IV Unit
The December 6, 1998 report by Roberta Stellman, M.D. was reviewed. Dr. Stellman
described a staffing shortage that included both psychiatrists (one physician per 50 acute
care patients) and other professional staff. The consequences of these staffing shortages
included inadequate psychiatric assessments on the crisis management unit and
noncompliance with the ten hours per week treatment recommendations by TDCJ and
The complete lack of privacy for the inmates housed within the Jester IV unit was
striking. Dr. Stellman indicated that there was “no attempt at establishing a private,
confidential, and therapeutic atmosphere most conducive to self-disclosure.”
The lack of adequate assessments within the crisis management pod resulted in a high
rate of inmates receiving no Axis I diagnosis. “In this system, the primary treatment in
this entry pod is isolation, superficial evaluation, and discharge back to the same
environment that precipitated the admission in the first place. Almost all contacts with
the patients are made cell side, with an interviewer standing in the corridor, outside the
cell… .”
The over-reliance on imprecise diagnostic categories of not otherwise specified (NOS)
and the absence of a diagnosis in those individuals admitted to crisis management was of
significant concern. “Even patients who formerly were hospitalized and diagnosed with
schizophrenia are treated in this facility under a non-specific category of “psychosis
NOS. The documentation does not contain the physician’s rationale for change in
diagnosis or deletion of a former illness. There is an underutilization of Axis I diagnoses
in those people admitted to the crisis management pod… The unavailability of crisis
intervention therapy is evident in this facility as it elsewhere in this system. The most
likely explanation is that treatment on crisis management can not be accomplished with
as great a number of patients compared to so few staff… there is simply too little time to
gather significant past personal and family history to accurately develop a good
differential diagnosis… .”
Gatesville Unit
Dr. Stellman’s December 10, 1998 report indicated that the “overall care at Gatesville is
quite poor… psychological and psychiatric notes do not provide adequate present, past,
and family history. Documentation of risk factors for dangerousness is obviously
lacking… the gatekeepers of psychiatric care do not have the training and competencies

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necessary to carry out this role with the absolute authority they are given. Inmates have
no recourse or access to medical care if the gatekeeper denies it… the complete lack of
privacy during psychological encounters in the high stress segregation units is
unjustified… treatable conditions are not diagnosed and treatment, therefore, is not
initiated… surprisingly, many inmates are not given an Axis I diagnosis. Yet the more
difficult diagnosis of a personality disorder is readily made, usually antisocial personality
disorder without [adequate] documentation… self-injury is too often labeled ‘attentionseeking’ and again the dynamics of the behavior are disregarded… being assigned or
scheduled for ‘counseling’ may only mean one visit by the psychologist… women
returning from Mountainview, Jester IV, or Skyview may not be seen routinely upon
their return for an assessment of their adjustment… even when an inmate repeatedly
requests a doctor’s visit, staff not necessarily trained to recognize, diagnose, and treat
severe psychopathology block these requests… even women on the caseload may not be
seen in a timely fashion when medications are changed, their assignment is altered, or if
they return from a psychiatric unit… .”

Skyview Unit
The December 13, 1998 report by Dr. Stellman summarized significant problems in the
mental health care provided to inmates at this unit. Inmates on the crisis management
unit received little therapeutic contact except for brief encounters and no crisis
intervention treatment other than environmental isolation. “All too often previous
diagnoses are removed.” Dr. Stellman noted “an absence of Axis I diagnosis particularly
in crisis patients… even when an individual has a major Axis I diagnosis, the label
malingering is added inappropriately. Attempts by inmates to manipulate intolerable
situations by self-injury and transfer are treated with a rapid return to the UOA [with] no
development of treatment plan to develop better coping skills.” Insufficient staffing to
meet UTMB program requirements was present.
A November 2, 1998 report by Richard Elliott, M.D., Ph.D. was reviewed. Dr. Elliott
indicated that approximately one-third of inmates referred to Skyview are retained for
more intensive treatment and two-thirds are returned to the referring units. “Inmates are
returned after an evaluation period of approximately three days which they usually do not
receive medication or further treatment services.” A preliminary study of clinical
recidivism was done during August 1998. “Of 47 discharges during that month, 14
returned in the next one to two months. This leads to an estimate of a clinical recidivism
rate of approximately thirty percent in two months.”
Dr. Elliott concluded that “based on the information available at this time, I believe there
are several significant deficiencies in the care of inmates on the acute unit at Skyview.
First, there is a lack of physician input into assessments and medication management… .”

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Dr. Elliott concluded that there was an inadequate psychiatrist to patient ratio at Skyview
which, when the vacant psychiatric position was filled, would result in five psychiatrists
for over 400 inmates. This was described as being “an unacceptable ratio given the high
number of admissions to Skyview.”
Stiles Unit
Dr. Stellman indicated in her December 1, 1998 report that “observed practices and
frequency of visits, monitoring of drug levels and assessment of mentally ill inmates off
the caseload is at variance with reported practices by the staff.”
The diagnostic categories of not otherwise specified was reported to be used too
frequently and there was an absence of the development of a differential diagnosis.
“Diagnoses made at an early date are not picked up and carried through… when a
diagnosis is dropped, the record does not reflect the rationale for deleting this from
consideration. There is an absence of the assignment of an Axis II diagnosis… the
individual treatment plan is frequently absent, when it is filled out, major problems are
omitted, goals are too global, and there is no update [in the] chart if the goals are met or
modified… .”
Management and assessment of inmates in isolation units were not adequate. “Several
inmates were obviously psychotic or seriously impaired but were not under any
professional scrutiny.” Lack of timely follow-up of inmates transferred back to the Stiles
Unit from an acute unit was reported.
Problems were also present concerning the use of seclusion. “Those most distressed
individuals are allowed to be housed for up to three days without being seen by a trained
mental health professional. There is little documented evidence of adequate crisis
intervention treatment and an over reliance on isolation and transfer to a crisis
management unit.” There was also not enough clinical staff to provide adequate
treatment to the inmates on the mental health caseload.
Woodman Unit
Dr. Stellman’s December 5, 1998 report described inadequate numbers of clinical staff
available (2.0 FTE Master level psychologists) to provide mental health services to this
900-bed women’s unit. “Formulary and non-formulary medications are discontinued
frequently upon entry into Woodman. All non-formulary medications are stopped by
non-psychiatric staff without substitution or regard for consequences of the
discontinuation, including withdrawal seizures and at least one case of transfer to
Mountainview. Patients are not consulted about the discontinuation nor are they given
information regarding possible risks concerning this practice. The medical staff do not

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automatically refer any patient entering on psychotropics to the psychiatrist. Even when
psychotropics are continued, there most often is a three-day delay in initiating
Dr. Stellman assessed the “psychiatric practice at this facility [to be] abysmal. Patients
are routinely not seen by psychiatry and there is poor responsiveness to requests for
consultation by psychology or medical.” Lack of timely assessments by the psychiatrists
was described by Dr. Stellman.
Ramsey I Unit
Dr. Jurczak indicated in his December 11, 1998 report that “the ambulatory psychiatric
care provided at Ramsey I is adequate.”

James Byrd Unit
Dr. Jurczak’s October 19, 1998 report indicated that “the medical and psychiatric
screening, intake evaluation, care and treatment provided at the James Byrd Unit is
timely and medically appropriate, the facilities are adequate for the provision of care and
the staff appear professional in attitude and appearance… .”
Thomas Goree Unit
Dr. Jurczak concluded in his October 19, 1998 report that “the medical and psychiatric
care provided inmates at the Thomas Goree Unit is timely and medically appropriate.
The facilities are adequate and the staff appeared professional in appearance and
attitude… .”
Huntsville Unit
Dr. Jurczak’s October 19, 1998 report indicated that “the ambulatory psychiatric clinic
facilities at the Huntsville Unit are adequate, the staff are professional in demeanor and
appearance, and that a good working arrangement exists between the medical and
psychiatric staffs… .” Problems in the psychiatric care described by Dr. Jurczak included
documentation of baseline laboratory studies and minimizing patients’ signs and
symptoms which have led to “the placing of patients on the inactive list resulting in the
discontinuance of treatment and monitoring.”
John P. Montford Psychiatric/Medical Facility
The December 14, 1998 report by Richard Elliott, M.D., Ph.D. was reviewed. It was Dr.
Elliott’s opinion that “overall, psychiatric care at the Montford Unit is consistent with

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community psychiatric inpatient care. The primary area of concern would be the lack of
physical assessment prior to initiating treatment with psychotropic medication. A
secondary area of concern is a shortage of psychiatrists… .”
Neal Unit and Clements Unit
The November 24, 1998 mental health audit report by Stanley Wang, M.D. was
reviewed. Dr. Wang described significant shortages of mental health clinical staff at the
Neal Unit (essentially one FTE ACP II for 350 caseload inmates). In addition, there was
a full-time nurse practitioner and a part-time psychiatrist who provide medication
management services to inmates at the Neal Unit. Dr. Wang concluded that “the
psychiatric staffing is woefully inadequate… .”
Problems related to the pill call line and tracking medication non-compliance were
summarized by Dr. Wang. These problems included long lines, arbitrary decisions by
either the CMA or other pharmacy personnel “to simply cut the line off and shut the
pharmacy pill dispensing,” and intimidation by gang members.
Managed Healthcare at the Texas Department of Criminal Justice
A January 1998 audit report entitled “Managed Health Care at the Texas Department of
Criminal Justice,” which was authored by the Office of the State Auditor, was reviewed.
Significant problems in the monitoring of the TDCJ managed healthcare system were
described. This report concluded that “although a number of processes exist to evaluate
and/or monitor aspects of performance, these processes do not interface or link with each
other to provide a comprehensive monitoring and evaluation system. Because the basis of
several of the monitoring processes is self-monitoring, review of operations by another party
becomes even more necessary.”
Specific problems were found with the TDCJ’s operational review process. These problems
a) No criteria of performance standards exist to determine, quantitatively, when a
unit is assessed to be in compliance with the Ruiz final settlement and the
department policies and procedures.
b) Compiling the results of individual unit Operational Reviews audits does not
provide a systemwide identification and assessment of trends or specific and
recurring areas of non-compliance.
c) Although the department’s Health Services Division administers the Operation
Review process and must approve the unit’s corrective action plans, it lacks the
authority to enforce the corrective action plans.

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d) One-fourth of the units audited during 1996 did not have at least an 80 percent
compliance rate.
The audit report also described significant gaps in the current QI/QM system that is
maintained by each prison. For example, “some units continue to report each year on
indicators that have been at 100 percent compli[ance], instead of focusing on other
problem areas that could benefit from scrutiny.” The department’s health services
division does not verify that corrective actions take place in response to various units’
QI/QM findings. Medically related information and feedback received from the
grievance and liaison correspondence processes were noted to not be effectively
managed, communicated, or evaluated.
Other findings included the lack of a standardized system to ensure that monitoring is
performed consistently across all units and the need for improvements to be made
concerning the credentialing processes for practitioners.
Appendix V of this report, entitled “An Evaluation of Managed Healthcare in the Texas
Prison System,” which was written by Jacqueline Moore and Associates (Consultants to the
Correctional Managed Healthcare Advisory Committee) was reviewed. This report
specifically did not review mental health services “because they were recently transferred to
the managed care system and sufficient data was not available to evaluate the effect of
managed care.” The current medication administration process was difficult to audit related
to missed medications or not-given medications due to the nature of the pharmacy tracking
system. It was also noted that the current operational review process for TDCJ did not audit
the pharmacy system
Manual of Policies and Procedures for Health Services for the TDCJ Institutional
The TDCJ Manual of Policies and Procedures for Health Services was reviewed. This
section will highlight selected policies and procedures pertinent to the mental health care
delivery system. They included the following:
TDCJ Policy number A-09.1 (Privacy of Care) indicates that “clinical encounters will be
performed in private (i.e., only authorized health services staff will be present), with a
security chaperone present when the offender proposes a probable risk of safety to himself,
the healthcare provider or others.”
TDCJ Policy number C-20.1 (Training for Correctional Officers) does include a requirement
for training to include the area of recognizing signs and symptoms of mental illness and
suicide prevention. However, this training is for an unspecified amount of time, which is to
occur at least every two years for all correctional officers who work with offenders.

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TDCJ Policy number C-24.1 (Staffing Levels) indicates that “a written staffing plan shall be
established by each facility to assure that a sufficient number of qualified health care
personnel of varying types are available to provide adequate evaluation and treatment
consistent with contemporary standards of care.”
TDCJ Policy number G-51.1 (Special Needs Offenders) defines offenders with special
mental health needs to include, but not be limited to, “self-mutilators, sex offenders, the
aggressively mentally ill, suicidal offenders, and substance abusers.” This policy indicates
that TDCJ will provide services for offenders who require close medical supervision and/or
multidisciplinary care. Offenders with special mental health needs are included in this group
of offenders. This policy also requires the development of a written individual treatment
plan for offenders receiving such treatment.
Heat Related Illnesses
I reviewed reports relevant to inmates experiencing heat-related illnesses. There were at
least sixteen inmates who experienced significant symptoms related to hyperthermia from
June 10 - July 30, 1998. Three of these inmates died as a result of hyperthermia. At least
four of these inmates were known to be either receiving psychotropic medications or having
a history of mental illness. However, in general, these reports did not make reference to the
presence or absence of psychotropic medication use. There was documentation that at least
one inmate who died due to hyperthermia had initially became symptomatic during a bus
trip. Inmates on the same bus reported that the correctional officers were non-responsive to
their complaints of elevated temperature within the bus.
Mr. Archie White died at the age of 48 years during June 30, 1998 due to exogenous
hyperthermia. This inmate apparently had been prescribed tricyclic antidepressant
medications based on the toxicology report. It is interesting that the autopsy report did not
make a connection between the use of antidepressant medications and exogenous
Mr. Anselmo Lopez was a 41 year old man who died during July 14, 1998 due to probable
hyperthermia. A review of the autopsy report did not reference whether antipsychotic
medications had been prescribed to this man. However, review of other documents did
indicate that this inmate had been prescribed psychotropic medications.
Mr. James Moore was a 47 year old man with a history of paranoid schizophrenia who died
during July 30, 1998 due to hyperthermia. Mr. Moore was receiving Haldol and Cogentin
which are medications that put him at higher risk of developing hyperthermia during times
of elevated environmental temperatures. The autopsy report did not make reference to the
probable relationship between elevated temperatures, use of psychotropic medications, and

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A July 28, 1998 memorandum from Gary Johnson (Director, Institutional Division) to
Wayne Scott (Executive Director) regarding heat was reviewed. This memorandum
provided a synopsis of actions taken by TDCJ during the past several months “in preparation
for and response to the Texas summer heat.”

Summary and Opinion
Unfortunately, the significant problems found in the mental health care delivery system at
the Estelle Unit appear to reflect systemwide deficiencies based on my review of
healthcare records and other mental health audit reports. These significant problems
included not recognizing or minimizing symptoms indicative of major mental illnesses by
either over-diagnosing malingering or “no Axis I diagnosis.” There appeared to be a
variety of reasons for these problems which included staffing shortages, inadequate
assessment procedures (e.g., cell side assessments), staff education issues, and probable
clinical biases. It was striking that these problems were commonly described in the
various audit reports summarized in this report.
There appeared to be a clear perception, based on review of healthcare records, by the
mental health clinicians that mental health treatment was not be offered to inmates whose
dysfunctional behaviors were assessed to be due to Axis II problems. Such a practice did
not appear to be consistent with TDCJ Policy number G-51.1 (Special Needs Offenders).
Many inmates with serious mental illnesses are not receiving adequate treatment as a
result of this practice. This was particularly true for inmates who have been labeled as
being “self-mutilators, manipulators, or having no Axis I diagnosis.” The consequences
for such inmates have included increased suffering and death (see Appendix IV – Review
of Death Records).
Inmates with serious mental illnesses often have their symptoms intensified due to not
only receiving inadequate treatment but by being placed in an environment that makes
their mental illnesses worse, such as the High Security Unit. The housing of inmates
with serious mental illnesses who continue to be symptomatic with non-mentally ill
inmates creates an environment that is detrimental to both staff and inmates.
The death review process was problematic related to documentation concerning
identified problems and proposed corrective actions. The review of death records (see
Appendix IV) almost uniformly revealed systemwide problems related to documentation,
diagnostic assessments, and inadequate treatment services. Problems related to accessing
mental health treatment were clearly experienced by Inmate 805040 who encountered

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major obstacles by various clinicians relative to obtaining treatment. The death of Inmate
692804 appears to have been related to a grossly negligent diagnostic process.
The number of inmates experiencing hyperthermia during the past year was very
alarming. Review of discovery materials contain documentation of similar problems
occurring during 1997. It is encouraging that remedial actions were developed during
July 1998 although it is unclear why it took so long for such a plan to be developed. It is
also unclear from review of the discovery materials the specific nature of a “heat plan”
for inmates receiving psychotropic medication. It was alarming that the various autopsy
reports and incident reports relevant to inmates experiencing hyperthermia did not often
reference or assess the relationship between the hyperthermia and use of psychotropic
Systemwide problems related to the use of psychotropic medications are present based on
review of the various mental health audit reports. These problems included many
inmates not having reasonable access to the use of atypical antipsychotic medications and
SSRI medications (other than Zoloft), medication distribution problems, abrupt
discontinuation of psychotropic medications without adequate or timely psychiatric
assessments, and an unclear system relevant to monitoring patient compliance with
psychotropic medications.
Significant staffing shortages are present in various units as summarized in the mental
health audit reports. Credentialing of mental health staff also appears to be problematic
based on the audit report by the Office of the State Auditor. It would be useful to obtain
further discovery relevant to corrective action taken by TDCJ pertinent to the Office of
the State Auditor’s report concerning monitoring the healthcare system and the QI/QM
Please do not hesitate to contact me if I can answer any further questions.

Jeffrey L. Metzner, M.D.
Diplomate, American Board of Psychiatry and Neurology