Jason Fagone and Megan Cassidy
San Francisco Chronicle
SACRAMENTO — The suicide rate inside California prisons, long one of the highest among the nation’s largest prison systems, jumped to a new peak in 2018 and remains elevated in 2019, despite decades of effort by federal courts and psychiatric experts to fix a system they say is broken and putting lives at risk, a Chronicle investigation has found.
Last year, an average of three California inmates killed themselves each month in state cells — 34 total suicides in a system with 129,000 inmates. That amounts to an annual rate of 26.3 deaths per 100,000 people, the highest rate in California since at least 2006.
That figure is higher than the national average for state prisons (20 per 100,000 in 2014) and federal prisons (14.7 in 2018, according to the Washington Post). From 2001 to 2014, according to the Bureau of Justice Statistics, twice as many people killed themselves in California cells than in the entire federal system, which contains more prisons and inmates. There were 448 total suicides in California prisons during that period and 222 in federal prisons.
The inmate suicide rate has now increased for four straight years in California, and it may rise again in 2019. According to the state, 16 inmates committed suicide during the first six months of this year. Michael Bien, an attorney who represents mentally ill prisoners, said he knows of 10 more inmate suicides since then, for a total of 26 so far in 2019. A state spokeswoman said she couldn’t confirm the 10 recent deaths because “some investigations are still ongoing.”
“It’s really bad,” Bien said. “I can tell you that 2019 is looking, so far, worse than 2018.”
Since 1999 in California, 620 inmates have killed themselves in state prison cells — the most extreme outcomes of a prison system that houses an estimated 38,000 inmates participating in mental health programs.
Experts, judges and public officials say the deaths are the result of a system that for decades has failed to provide proper care. Inmates and advocates say California’s prisons effectively punish those who seek help.
The new figures were obtained from the California Department of Corrections and Rehabilitation and its health care system through a public records request and emails with department of corrections representatives.
They reveal a problem both shocking and stubborn — “a seemingly intractable elevated rate of inmate suicides,” in the words of Raymond Patterson, a psychiatrist who was once appointed to help California reform its system and ultimately quit in frustration. He wrote that phrase in 2013, when the suicide rate was lower than it is now.
The state corrections department declined The Chronicle’s request for an interview. A representative emailed a brief statement about its efforts to “improve early detection” of suicidal inmates.
“We believe that even one suicide is one too many,” the statement said.
Hector Martinez had been refusing meal trays and showers for days before a thump from his cell woke up the inmate next door, James East.
“Did you hear that?” East shouted to his downstairs neighbor, according to an account in a letter he sent to The Chronicle, key details of which are confirmed by public documents.
According to East, he heard the noise during the early morning of June 19, 2017, when he and 35-year-old Martinez were confined to adjacent psychiatric cells at the California State Prison in Sacramento. East had recently grown worried about his neighbor; they were able to communicate by talking through an electrical outlet in the wall, and Martinez had seemed uninterested in food or exercise.
After hearing the thump, East asked Martinez if he was OK. There was no response. Over the next several hours, East said, he heard guards come and go as they always did in the psychiatric unit, performing a welfare check of each cell at 30-minute intervals to make sure the inmates hadn’t killed themselves, as required by department policy.
It wasn’t until later in the day, during a trip to the shower, that East peeked into Martinez’s cell and saw what had happened: Martinez’s body was slumped over a toilet with a sheet wrapped around his neck. He had hanged himself with a makeshift noose.
East told his escorting guard to push the alarm.
“I knew right away that he was gone,” East wrote in the letter. “Mr. Martinez had been dead for hours already. His body was already stiff. ... Mr. Martinez was neglected and left in that cell to die. What happened to him was wrong and the mental health staff let him down here.”
The Department of Corrections and Rehabilitation said it could not comment on Martinez’s suicide or East’s statements, citing medical privacy laws. But a Sacramento County Coroner report obtained by The Chronicle confirms that Martinez died by hanging himself at the Sacramento prison on June 19. Martinez had a “history of suicidal attempts and recent suicidal ideations,” the coroner wrote.
These two accounts of Martinez’s death also match up with a report by a national expert in suicide prevention, Lindsay Hayes, who works for a federal court that tracks California’s inmate suicides. Twenty-four years ago, in 1995, the court discovered a “systematic failure” by the state “to deliver necessary care to mentally ill inmates” and ruled that California was violating those prisoners’ constitutional rights.
Ever since, a special master appointed by the court has tried to force changes in the system; the case, now known as Coleman vs. Newsom, is still active. As part of the process, Hayes files reports for the special master that include summaries of particularly troubling suicides by California prisoners.
One of those summaries matches the date, location and other identifying details of Martinez’s suicide. Because of privacy regulations, Hayes refers to the inmate as “SAC 8.”
In his analysis of the case, Hayes found neglect and violations of prison policy during the lead-up to SAC 8’s suicide and in the immediate aftermath as well.
Starting in 2015, prison staff had treated the inmate several times for depression, severe mood swings and suicidal thoughts. Required nursing records weren’t filed on several dates, Hayes found.
Then, in May 2017, shortly before his death, the inmate spent almost five weeks in a “mental health crisis bed” for reasons of “danger to self and grave disability.” Soon after being discharged into a solitary holding cell, he hanged himself, and, by the time his body was discovered, it was “rigid, with signs of rigor mortis,” Hayes wrote. Rigor mortis takes two to four hours to appear. Therefore, Martinez must have been dead for some time and unnoticed by Sacramento prison guards, who said they checked his cell every 30 minutes.
The circumstances of Martinez’s death weren’t unique. According to reports from the Coleman case and investigations by county coroners, many California prisoners who commit suicide have displayed previous signs of self-harm or suicidal intent, and the bodies of inmates who kill themselves are routinely discovered in a state of rigor mortis.
In 2017 alone, Martinez was one of four prisoners who killed themselves and lay dead in their cells for hours, rigor mortis setting in, despite welfare checks on their cells at 30-minute intervals.
So who is responsible for California’s high inmate suicide rate? Reports by the Coleman experts, as well as a 2017 investigation by the California state auditor, pin the blame squarely on the state prison system, describing “a pattern of identifiable and describable inadequacies in suicide prevention” in the corrections department, as the Coleman court wrote in 2013.
These failures include long wait times for mental care; high vacancy rates for prison psychiatrists; failure to monitor inmates with suicidal tendencies; failure to perform 30-minute welfare checks; falsification of welfare-check logs; failure to refer sick inmates to a higher level of mental care; lack of suicide prevention training for prison staff; dangerous delays in performing CPR; and cells with ventilation grates that make it easy for inmates to hang themselves.
Starting in 2013, the Coleman court decided that California was making little headway on the issue and began to monitor inmate suicides more closely, dispatching Hayes to personally inspect state prisons. Since then, the Department of Corrections and Rehabilitation has adopted several of Hayes’ suggestions and made some reforms, retrofitting some cells to make them suicide-resistant, and creating a tool that helps prison officials “quickly assess and respond to deficiencies by adjusting practices or modifying policies,” the department wrote in an October 2018 letter to the special master.
The special master replied last year that the quality tool was still being tested and for the state to declare victory was “incredibly premature given the continued findings of problematic suicide prevention practices.” These legal filings and expert reports in the Coleman case are quite costly, and the tab is picked up by state taxpayers — $123 million since 1997, according to a corrections spokesman.
As recently as July, a federal judge presiding over the case said the department still isn’t doing enough to prevent suicides, blasting the state for delaying crucial fixes ordered by the court.
“While some progress is being made,” she wrote, “a substantial amount of work remains, and implementation is dragging out and taking too long.”
In August, the corrections department told the court that it has only 72% of the psychiatrists it needs to provide mental care for inmates. Attorney Bien, who represents inmates in the Coleman case, says that’s not good enough.
“You can’t just continue killing people, letting them die,” he said. “You have to do something.”
Over the years, major political and judicial figures in the state and beyond have also tried to persuade California to address its prison-suicide problem, to little effect.
In 2006, Gov. Arnold Schwarzenegger declared a state of emergency over conditions in state prisons, calling attention to overcrowding and citing the high suicide rate as a reason for concern. Five years later, the U.S. Supreme Court argued that mental health care in the state system was abysmal and the overcrowding would make it worse. “Prisoners in California with serious mental illness do not receive minimal, adequate care,” Supreme Court Justice Anthony Kennedy wrote. “Because of a shortage of treatment beds, suicidal inmates may be held for prolonged periods in telephone-booth sized cages without toilets.” And in 2017, the California State Auditor found that the department had “failed to provide the leadership and oversight necessary to ensure that its prisons follow its policies related to inmate suicide prevention and response.”
Inmates and advocates interviewed by The Chronicle say the corrections department’s practices deter inmates from seeking treatment.
If an inmate expresses a desire to harm himself or herself, a typical response is removal from the regular housing unit and placement in an isolation cell, said Keith Wattley, a prisoner advocate and attorney who specializes in parole hearings.
The isolation units sometimes include padded walls; others are essentially a cinder block room, where inmates are held with no clothes. Sometimes doctors will allow the inmate to wear what’s known as a safety smock, which Wattley described as a sort of full-body oven mitt, intended to serve as a blanket, clothing and a mattress all in one.
“It’s absolutely the case that people are discouraged from seeking help, and so they don’t, and so they hurt themselves,” said Wattley, who worked on the Coleman case as one of the plaintiffs’ attorneys several years ago. “And help isn’t really help. It’s not meaningful.”
George “Mesro” Coles-El, an inmate who has been at San Quentin State Prison for close to nine years, said the lockup’s bulletin boards are covered with suicide prevention signs offering help.
“It looks like, ‘Oh man, I could get some help from these guys,’” Coles-El said in a recent phone call with the Chronicle.
But the signs are misleading, he said, confirming Wattley’s account of the prisons’ anti-suicide policies.
“Their idea of suicide watch is to wrap you in a mattress suit and put you in a cell by yourself until you don’t have these feelings anymore,” he said. “I don’t feel like that’s a very effective way to treat someone who feels like their life should end prematurely.”
Coles-El, who attempted suicide before his lockup, said thoughts of self-harm can manifest behind bars. There are bouts of extreme isolation and hopelessness, and bad news can be fatal for those who don’t seek intervention.
But those feelings can also be temporary. Coles-El recalled a friend who was weeks away from from a parole hearing when he received word that his mother had died. Coles-El found him standing on the ledge on the fifth tier, where there aren’t railings.
“I like had to grab him and pull him back,” he said. “I was like, look man, this isn’t the answer. Your mom would want you to live.”
Three months later, Coles-El said, “he got the parole and went home.”
Some grassroots efforts to stop suicides have emerged at individual prisons in recent years, with pockets of success.
Former inmate Marvin Mutch co-created a peer-to-peer crisis intervention program at San Quentin after the suicide of his good friend Robert Dubner.
The two had dined together for 17 years and had established a morning routine. They’d talk about the politics of the day at breakfast, then part ways so Dubner could exercise in the yard while Mutch worked in an office.
Feb. 17, 2005, began in the same way, but Dubner never made it to the yard. Instead, he returned to his cell and hanged himself with a bedsheet.
“I could not understand how this person, who I loved, frankly, could be an hour away from making such a fatal decision,” Mutch said in a recent Chronicle interview. “I did not see it.”
Mutch and others created a group called Brother’s Keepers, which tapped the Bay Area Women Against Rape organization to train inmates to inmates to act as counselors for one another. They’d offer to take a lap together in the exercise yard and let it be known that they were there to talk.
Mutch, who was freed in 2016 after 41 years behind bars, is now an associate at the Humane Prison Hospice Project, which expands the Brother’s Keepers training into the area of compassionate end-of-life care.
Mutch believes the Brother’s Keepers model could have a marked impact on suicide rates if adopted across the system.
“We found that the secret sauce was that prisoners were able to let this out in a safe way … in a secure and comforting bubble,” he said. “People are just loath to go to the people who are locking their cage and tell them they are depressed about this lock.”
©2019 the San Francisco Chronicle