66 California Inmate Deaths Preventable According to Prison Receiver Robert Sillen

Analysis in letter sent to Governor and legislators may presage evidence before The Judge Federal Panel next Monday

[Editor's note: Robert Sillen, appointed as the receiver of the California Prison medical care system by Federal Court Judge Thelton Henderson has send the following letter to the Governor, legislators, and others about deaths in the prisons in 2006. We expect more reports and documents to be forthcoming in advance of the September 24, 2007 court hearing before a three judge panel in the Federal Courts that is contemplating early release and other remedies for a system already determined to not meet constitutional standards.]

Letter from the Receiver
19 September 2007

When U.S. District Court Judge Thelton E. Henderson found that the state’s prison medical care violated the Eighth Amendment of the U.S. Constitution, forbidding cruel and unusual punishment, he knew that meant virtually every aspect of the system was broken. That was in 2002. For years after, court experts continued to provide compelling evidence of the degraded conditions, patient suffering and death and state intransigence that blocked necessary reform.

Finally, Henderson’s “drastic but necessary remedy” -- the Receivership -- got underway just over a year ago. Thus began the dual task of planning and implementing long-term improvements to California’s prison medical system while also taking over the reigns for daily operations and crisis management in 32 adult prisons.

The Receivership inherited the state’s dysfunctional system and has been working to prioritize and realize changes, many of which are starting to be felt system-wide and in individual institutions in the field. These include an overhaul of the pharmacy system, bringing medical staff salaries up to market levels, providing prisons with needed equipment and supplies to deliver health care, revamping medical contracting and personnel practices, supporting physician and nurse leaders in the field, developing a new method for hiring health care executives and managers, constructing an adequate emergency room at San Quentin, providing prisons with transport vehicles, coordinating remedial efforts with those in federal mental health, dental and disabled inmates cases, and launching a project to build up to 5,000 medical and 5,000 mental health beds statewide. (See upcoming Quarterly Report to the court to be filed 9/24/07 and previous reports to the court posted on our web site www.cprinc.org.)

As important as these accomplishments are, they are first steps. There is still a mountain to climb. But as medical and custody staff in the field experience the positive change, more have joined and continue to join the effort.

A wake-up-again call comes in the form of a new analysis of California Department of Corrections and Rehabilitation (CDCR) inmate deaths in 2006. Of 426 deaths that year, 66 of them — or 15 percent — were preventable (18) or possibly preventable (48). Among the non- preventable medical deaths (315), more than half reflected lapses in care that may have contributed to earlier death or more suffering among terminal patients.

Every inmate death that occurs in California’s prisons is examined by the CDCR Death Review Committee, a multi-disciplinary group chaired by the Statewide Medical Director and made up of doctors, nurses, health care administrators and correctional officers. The system’s suicides (43 in 2006) are forwarded to a separate subcommittee composed of mental health, nursing and corrections representatives.

A first-of-its-kind analysis commissioned by the Receiver of last year’s death reviews paints a picture of a system that fails its charges. When six inmates die of asthma in one year, we all know something is terribly wrong. No one should die of asthma in California in 2006, and yet, in its prisons, that is the number one cause of preventable death. The full report is available on our web site, in the Resources section.

Across the board we see delays in diagnosis and access to care and needed tests; misfiled, incomplete or illegible medical records; lack of space, sanitation and staffing; botched handoffs of medical information during inmate transfers; failures by clinicians to recognize and evaluate “red flag” symptoms, follow published guidelines, perform basic physical examinations, or respond to patient complaints; abdication of responsibility for patient care and lack of critical thinking or requests for help in difficult cases. All of these elements contributed to needless deaths and are reflective of the degree of systemic change that must be planned and implemented over time.

In a sense, none of this is new. These tragic deaths depict the very problem that the court ordered the state to solve years ago, and that the Receiver must now take on. The Receiver’s team of health care and corrections experts has developed a Plan of Action to achieve a constitutional medical system that addresses the deficiencies identified in the death review analysis. It is clear that every aspect of the system contributes to its current problems, and each area must be addressed in turn to achieve the complete transformation required.

For instance, we are placing asthma at the top of the list for clinical emphasis. We are developing a system for tracking and following up on abnormal lab and test results. We also have improved the system of provider peer review, allowing findings like those above to see the light of day, and action to be taken against incompetent or uncaring clinicians when appropriate. We have raised the standards for physician hiring and will soon embark upon a major recruitment effort to bring more good doctors into the prisons. We already have recruited nearly 800 Licensed Vocational Nurses and some 300 Registered Nurses to help fill the prisons’ chronic staff shortages. Good people are the fundamental building blocks of good organizations. As the system is populated with additional expertise and resources (space, equipment, training, etc.), we will document beneficial impacts on patient care and outcomes.

It will take years to get where we need to go. But, we are already on our way. Dedicated clinicians within the system are being joined by new hires eager to help make a difference. Wardens and correctional leaders are working together with the Receiver’s team to ensure access to care and sufficient space become available. It is an exciting time of change and opportunity. Everything is on the table.
The current death review report serves as a sobering reminder of why the Receivership is here. The stakes are high. Our work is about patient care. Remember, all of our actions have one bottom line in mind: To create a system where custody and health care staff together guarantee that access to care and quality of medical services in California prisons meet constitutional standards.

Together, we will accomplish the transformation of California’s prison medical care, creating a new system of which we can all be proud.

Robert Sillen
Receiver

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