California prison officials ignored warnings from frontline health professionals and urged them to quickly transfer 189 potentially infected coronavirus prisoners from a Chino male prison last May, triggering a deadly outbreak of COVID-19 at San Quentin State Prison , reported the state watchman Monday.
In late August, 2,237 prisoners and 277 employees were infected in San Quentin, according to a report from the Office of the Inspector General of California. Twenty-eight prisoners and an official died there.
The report blamed the California Department of Corrections and Rehabilitation and the California Correctional Health Services, or CCHCS, for creating a “public health disaster” in San Quentin, the state’s oldest prison. A smaller state prison in Corcoran, which received 67 of the 189 transfers, was affected to a lesser extent.
“Our analysis revealed that the efforts of the CCHCS and the department to prepare and carry out transfers were deeply flawed and put the health and lives of thousands of people and prisoners at risk,” the report noted.
“The CCHCS and department’s insistence to carry out transfers and the subsequent pressure to meet a tight deadline resulted in the California Institution for Men ignoring the concerns of the health team and transferring clinically vulnerable prisoners, although the vast majority have not been recently tested for COVID-19, ”he said.
By relying on outdated test results, “the prison had no way of knowing if any of the people incarcerated were infected with the virus,” the report said.
Chino’s transfers came after the prison authorities and lawyers representing the prisoners agreed that the men should be removed from prison barracks, where the virus was spreading rapidly.
At the time of the changes, Chino prison recorded more than 600 cases of COVID-19 and nine deaths. The 189 were among 700 inmates selected for transfer who had medical conditions that made them especially vulnerable to the virus.
Internal e-mails cited by the inspector general showed that the medical staff at the Chino prison set the alarm before transfers were made.
The night before the first transfers, a supervising nurse sent an email to alert a medical executive that some of the prisoners had not been tested for almost a month – too early to be an effective indicator of infection.
“Is there a re-smear criterion to be met before the transfer?” Asked the nurse, suggesting that a new test was needed.
“Nothing to pass on the swab,” replied the executive 11 minutes later.
In another email, prison manager Chino raised the alarm to a manager at the department’s headquarters about the possibility of spreading the virus.
“I am surprised that HQ wants to change our prisoners now,” said the email. “But we have to make sure that we are not infecting another institution.”
This and other internal warnings were dismissed, and Chino prisoners were taken by bus to San Quentin in late May. Prison officers violated their own health guidelines for prison capacity on some of the trips, according to the inspector general.
Two of the prisoners had symptoms of COVID-19 upon arrival, including one with a 101.1 degree fever. But while the San Quentin health team suspected that Chino prisoners had been exposed to the coronavirus, the prison housed 119 of them in a unit without solid doors, which allowed air to circulate freely through the cells.
By the time the results of the COVID-19 test returned, 14 infected prisoners had been staying in the unit for at least six days, the report noted.
“The virus spread quickly, both to the other incarcerated people who were transferred from the California Institution for Men, and to the 202 incarcerated people already housed in the same unit,” said the report.
On August 6, more than half of the unit’s inmates had tested positive. Of the 122 newly arrived Chino prisoners, 91 eventually tested positive and two died of complications related to COVID-19.
In a joint statement on Monday, prison and prison health officials said the transfers were made “with the intention of mitigating potential harm” to Chinese prisoners and were based on “a careful risk analysis using scientific information available in May 2020 on the transmission of this disease novel. “
“We recognize that some mistakes were made in the process of these transfers,” said the statement, “and both the CCHCS and the CDCR have made appropriate changes to the patient’s movement since then.”
The changes included more testing, quarantine and improved use of personal protective equipment, according to the statement.
“Currently, San Quentin has only four patient cases and has remained in single digits in terms of COVID-19 positive patient cases since August,” said the statement.
In addition to the 28 COVID-related deaths in San Quentin, 27 inmates died in Chino prison and three in Corcoran. In all, 192 inmates died across the state, among more than 47,400 who tested positive.
The deaths sparked outrage among prisoner defenders and legal action by the families of some prisoners.
In September, Daniel Ruiz’s family lawyers, 61, filed a lawsuit from the government, a precursor to a lawsuit against the prison. Ruiz died on July 11 after contracting the virus while serving time in San Quentin for a minor drug-related crime.
“It is tragic and unacceptable that some prison bureaucrats treat them as less than human,” said lawyer Michael Haddad.
After reviewing the inspector general’s report, he added: “If the aim of these prison officials was to give prisoners COVID-19, it is difficult to imagine what they could have done more effectively.”
Angela Cadena, vice president of the We Are their Voices inmate defense organization, said that for those with loved ones in California prisons, the report was not surprising.
“This may be news to some, but for us it has been happening since day one,” said Cadena, whose husband is incarcerated at the Richard J. Donovan Correctional Center, near San Diego. He tested positive for coronavirus, she said, but continued to work as a porter serving food to other prisoners.
“It is traumatic not only for me as a wife, but also for my children,” said Cadena. “They live in fear of receiving that phone call, and the harsh reality is that we received that phone call.”
Prison officials on Monday also defended their transparency in dealing with the health crisis they helped to create.
In October, however, they denied a request for public records from The Times that had been pending since July, seeking e-mails and other communications related to the flawed transfer.
“The collection and review of these records would divert essential staff resources from the ongoing public health response in response to the emergency and is not in the public interest, particularly when the vast majority of responsive records, if not all records, will be exempt from disclosure, ”Officials wrote denying the request.
The inspector general’s report also found it difficult to obtain records from the department.
Health care in the state prison system has been the subject of long-standing disputes prior to the pandemic.
In July, J. Clark Kelso, the federal court-appointed administrator who oversees prison health care, announced the removal of Dr. R. Steven Tharratt as medical director of the system across the state, citing the challenges of the COVID-19 pandemic.
“In order to meet current response needs while we work to delegate more medical attention to state control, it became evident that a reorganization is necessary for long-term sustainability,” said Kelso at the time.
Tharratt, who was appointed to this position by the trustee in 2010, has moved on to become a special health advisor to the trustee.
Kelso himself was criticized by state legislators. In October, six of them asked US District Judge Jon Tigar to remove Kelso immediately and replace him “with an individual committed to the health and safety of incarcerated people”.
Deputy Marc Levine (D-San Rafael) said: “Mr. Kelso’s mismanagement of the pandemic COVID-19 in the correctional units of the CDCR resulted in the worst public health disaster in the history of the CDCR. ”
Kelso did not respond to requests for comment on Monday.
Hadar Aviram, a professor at UC Hastings College of the Law who litigated the release of prisoners from San Quentin because of COVID-19, said prison officials have no excuse for handling transfers.
“You have black and white evidence that they knew about the danger,” said Aviram. “This is not the same as a mistake. They made the decision to risk people’s lives. This is the classic example of deliberate indifference. “
Army Specialist Vincent Polanco, whose father, Gilbert Polanco, died of COVID-19 in August after probably hiring him while working as a prison sergeant in San Quentin, also holds officers accountable.
“Every day I live in dreams with my father, as life could have been,” said young Polanco, who sees the prison department “as my family” and wants to be a guard himself when he finishes his active service.
He said that the “superiors” in the system had failed his father.
“Now, all of a sudden, they are doing everything they should have done from the beginning, now that they are scared,” he said. “It really hurts me to see that the leadership really broke down and didn’t take the initiative to save my father’s life.”