Case 2:90-cv-00520-KJM-DAD Document 5259 Filed 01/14/15 Page 1 of 226 An Audit of Suicide Prevention Practices in the Prisons of the California Department of Corrections and Rehabilitation Lindsay M. Hayes, M.S. January 14, 2014 Introduction Over the past several years, the Coleman Court has addressed the continuing problem of inmate suicides in the prisons of the California Department of Corrections and Rehabilitation (CDCR). On April 5, 2013, the Court stated that “for over a decade a disproportionately high number of inmates have committed suicide in California’s prison system. Review of those suicides shows a pattern of identifiable and describable inadequacies in suicide prevention in the CDCR. Defendants have a constitutional obligation to take and adequately implement all reasonable steps to remedy these inadequacies. The evidence shows they have not done so. In addition, while defendants represent that they have fully implemented their suicide prevention program, they have not. An ongoing constitutional violation therefore remains.” (ECF 4539) On July 12, 2013, the Coleman court ordered the establishment of a Suicide Prevention Management Workgroup to address and resolve this problem. Among other things, the Court ordered that: Defendants shall forthwith, under the supervision of the Special Master, establish a suicide prevention/management work group comprised of CDCR clinical, custody, and administrative staff, Department of State Hospitals (DSH) staff, the Special Master’s experts, plaintiffs’ counsel and, as appropriate, the Plata receiver to work under the guidance of the Special Master to timely review suicide prevention measures, suicide deaths, and deaths deemed to be of undetermined cause. (ECF 4693) The Workgroup was organized and met on three occasions, July 31, August 21, and October 17, 2013. Its members decided and agreed that an expert assessment of current suicide prevention practices in all 34 CDCR prisons was needed for the workgroup to carry out its charge. As a result of this decision by the work group, and at the request of the Coleman Special Master, this reviewer was engaged to conduct an audit of inmate suicide prevention practices within the 34 CDCR prisons. The audits began on November 12, 2013 and continued through July 24, 2014. They entailed an on-site assessment of each prison’s suicide prevention practices, and included reviews of suicide prevention local operating procedures (LOPs), selected health care records of inmates currently or recently on suicide precautions/suicide watch status (referred to collectively as “suicide observation” in some portions of this report), hundreds of electronic unit health records (eUHRs) of inmates who had been referred to the mental health program for assessment of suicide risk, minutes of meetings of the institutional Suicide Prevention and Response Focused Improvement Teams (SPRFITs), and all inmate suicides which occurred from 2012 to 1 Case 2:90-cv-00520-KJM-DAD Document 5259 Filed 01/14/15 Page 2 of 226 the times of this reviewer’s site visits by examination of eUHRs, CDCR Suicide Reports, and, where applicable, any Quality Improvement Plans (QIP)1. The audit also included observation of psychiatric technician (psych tech) rounds in administrative segregation units, the intake screening process conducted by nursing staff in the institutional reception centers (RC) and receiving and release units, Inter-Disciplinary Treatment Team (IDTT) meetings, and custody rounds in administrative segregation units and Security Housing Units (SHUs). This reviewer also interviewed numerous custody and health care staff. The order and dates of this reviewer’s on-site assessments were as follows: 1. California State Prison, Los Angeles County (CSP/LAC): November 12-13, 2013 2. California Correctional Institution (CCI): November 14-15, 2013 3. California State Prison, Sacramento (CSP/Sac): November 20-21, 2013 4. Folsom State Prison (FSP): December 3-4, 2013 5. California Institution for Men (CIM): December 5-6, 2013 6. Centinela State Prison (Cen): December 17, 2013 7. Calipatria State Prison (Cal): December 18, 2013 8. Richard J. Donovan Correctional Facility (RJD): December 19-20, 2013 9. California Medical Facility (CMF): January 7-8, 2014 10. California State Prison, Solano (CSP/Solano): January 9-10, 2014 11. San Quentin State Prison (SQ): January 21-22, 2014 12. California Men’s Colony (CMC): February 4-5, 2014 13. Salinas Valley State Prison (SVSP): February 6-7, 2014 14. California State Prison, Corcoran (CSP/Cor): February 18-19, 2014 15. California Substance Abuse Treatment Facility (CSATF): February 20-21, 2014 16. Ironwood State Prison (ISP): March 4-5, 2014 17. Chuckawalla Valley State Prison (CVSP): March 5-6, 2014 18. Wasco State Prison (WSP): March 25-26, 2014 19. North Kern State Prison (NKSP): March 27-28, 2014 20. Central California Women’s Facility (CCWF): April 8-9, 2014 21. Valley State Prison (VSP): April 10-11, 2014 22. Kern Valley State Prison (KVSP): April 22-23, 2014 23. Correctional Training Facility (CTF): April 24-25, 2014 24. Pleasant Valley State Prison (PVSP): May 6-7, 2014 25. Avenal State Prison (ASP): May 8-9, 2014 26. California Institution for Women (CIW): May 20-21, 2014 27. California Rehabilitation Center (CRC): May 22-23, 2014 28. Sierra Conservation Center (SCC): June 10-11, 2014 29. Mule Creek State Prison (MCSP): June 12-13, 2014 30. California Health Care Facility (CHCF): June 24-25, 2014 31. Deuel Vocational Institution (DVI): June 26-27, 2014 1For purposes of this report, all reviews of eUHRs and Suicide Reports do not include critiques of clinical judgment. Rather, these reviews are based upon critiques of implementation and use of suicide prevention practices set by the Coleman Program Guide (2009 revision) and generally applicable standards of care. Suicides by CDCR inmate- patients while in inpatient mental health programs run by the California Department of State Hospitals (DSH) were not included in this audit. 2 Case 2:90-cv-00520-KJM-DAD Document 5259 Filed 01/14/15 Page 3 of 226 32. California Correctional Center (CCC): July 8-9, 2014 33. High Desert State Prison (HDSP): July 10-11, 2014 34. Pelican Bay State Prison (PBSP): July 23-24, 2014 In addition, this reviewer observed a full-day Mental Health Services Delivery System (MHSDS) training workshop at the CDCR Basic Correctional Officer Academy in Galt, California, on November 22, 2013. The workshop included a section on “Crisis Intervention and Suicide Prevention.” Block suicide prevention training workshops were also observed at seven prisons: CIW, CMC, KVSP, PVSP, CSATF, VSP, and WSP. SUMMARY OF FINDINGS AND EMERGING TRENDS It is the opinion and conclusion of this reviewer that the applicable provisions of the Coleman Program Guide on suicide prevention and response provide reasonable and comprehensive guidelines for the identification and management of suicidal inmates. However, the most significant finding from this audit was that suicide prevention practices in the prisons often did not mirror Program Guide requirements. While CDCR has made important advances with its suicide prevention practices, it has not yet fully implemented a thorough, standardized program for the identification, treatment, and supervision of inmates at risk for suicide. As shown in Table 1, from 2010 through 2013, the number of inmate suicides in CDCR prisons annually has remained nearly unchanged. Across the same period the rate of inmate suicides per 100,000 in CDCR prisons has remained substantially higher than the inmate suicide rate of 16 suicide deaths per 100,000 inmates in other correctional systems throughout the United States.2 Although the total number of inmate suicides and the corresponding suicide rate in any prison system should not be the sole barometer by which adequacy of its suicide prevention practices should be measured, they can be important tools in making that assessment. TABLE 1 AVERAGE DAILY INMATE POPULATION, SUICIDES, AND SUICIDE RATE IN CDCR PRISONS, 1999 THROUGH DECEMBER 20143 Year ADP Suicides Suicide Rate 1999 159,866 25 15.6 2000 160,855 15 9.3 2001 155,365 30 19.3 2002 158,099 22 13.9 2003 155,722 36 23.1 2004 163,346 26 15.9 2005 164,179 43 26.2 2006 171,340 43 25.1 2007 172,535 34 19.7 2008 165,700 37 22.3 2See, e.g. Noonan, M.E. (2014), Mortality in Local Jails and State Prisons, 2000-2012 - Statistical Tables, Washington DC: U.S. Department of Justice, Office of Justice Programs, Bureau of Justice Statistics. 3Data does not include suicides of CDCR inmates which occurred in contracted, out-of-state facilities. 3 Case 2:90-cv-00520-KJM-DAD Document 5259 Filed 01/14/15 Page 4 of 226 2009 159,084 25 15.7 2010 165,747 35 21.1 2011 161,818 34 21.0 2012 134,901 33 24.4 2013 132,827 31 23.3 2014 126,619 234 18.2 The best methodology for determining whether CDCR has fully implemented its suicide prevention program is to (1) assess suicide prevention practices within each CDCR prison, and (2) review each inmate suicide in relation to practices in the prison and determine its degree of preventability. The critical measurement tool that was utilized was the Coleman Program Guide. Specific standards on suicide prevention training, levels of suicide observation, suicide risk evaluation (SRE), management of suicidal inmates, emergency medical response, responsibilities of the SPRFITs, and the mortality review process are found in Program Guide Chapter 10, “Suicide Prevention and Response.” Other Program Guide chapters, including “Reception Center Mental Health Assessment” (Chapter 2), “Mental Health Crisis Bed” (Chapter 5), and “Administrative Segregation” (Chapter 7), provided guidance in other suicide prevention-related areas. CDCR has made significant progress in suicide prevention with its creation of important tools including the Suicide Risk Evaluation (SRE) form, the requirement that psych techs conduct daily rounds in administrative segregation units to help identify potentially suicidal behaviors, the establishment of SPRFITs to monitor suicide prevention practices, and comprehensive reviews of each inmate suicide.