“Systemic Failures Persist” in California Prison Mental Health Care, Judge Rules

by | April 8, 2013

California Security Housing Unit Cell
California Security Housing Unit Cell

California Governor Jerry Brown’s bid to end federal control over the state prison system’s mental health system was denied in federal court on Friday, April 5, in a sharply worded ruling by U.S. District Judge Lawrence K. Karlton. In the 68-page ruling, Judge Karlton determined that “systemic failures persist in the form of inadequate suicide prevention measures, excessive administrative segregation of the mentally ill, lack of timely access to adequate care, insufficient treatment space and access to beds, and unmet staffing needs.”

The ruling comes following months of campaigning and litigating by Governor Brown and the California Department of Corrections and Rehabilitation (CDCR) to end federal oversight of the California prison system. Friday’s ruling is the latest enforcement of the 1995 case Coleman v. Wilson, a federal class action suit filed against then-California Governor Pete Wilson, which resulted in  federal oversight over CDCR’s mental health and medical treatment that continues under the jurisdiction of Judge Karlton.

An additional federal class action lawsuit, Plata v. Schwarzenegger was merged with the Coleman lawsuit and in 2009, California was ordered to reduce it’s prison population to 137% capacity, as it was determined that Constitutionally acceptable medical and mental health delivery was hindered by the beyond-capacity prison population, which was deemed an 8th Amendment violation. California in turn appealed the order to reduce it’s prison population and in 2011, in Brown v. Plata, the US Supreme Court ordered California to reduce it’s prison population by 30,000 inmates. Governor Brown has an additional appeal of this order before U.S. District Judge Thelton E. Henderson.

Governor Jerry Brown has gone on the record to claim that California  has “one of the finest prison systems in the United States,” and no longer requires federal oversight. In a January 2013 press release, Governor Brown stated: “After decades of judicial intervention in our correctional system and the expenditure of billions of taxpayer dollars, the time has come to restore California’s rightful control of its prison system.” In February, CDCR announced the completion of a new mental health treatment building at the California Medical Facility, and declared that the facility “reinforces CDCR’s ongoing commitment to provide a constitutional level of mental health treatment in California’s prisons.”

Judge Karlton’s ruling, however, strongly rebukes these claims by Brown and CDCR, saying “based on defendants’ conduct to date, the court cannot rely on their averments of good faith as a basis for granting termination. There is overwhelming evidence in the record that much of defendants’ progress to date is due to the pressure of this and other litigation.”

A major factor in Judge Karlton’s ruling was the significant rate of suicides in the California prison system, which has previously been reported to be well above the national prison average.

“In summary, for over a decade a disproportionately high number of inmates have committed suicide in California’s prison system describable inadequacies in suicide prevention in the CDCR,” Judge Karlton writes,”Defendants have a constitutional obligation to take and adequately implement all reasonable steps to remedy those inadequacies. The evidence shows they have not yet 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.”

Judge Karlton cited the overuse of solitary confinement, particularly among individuals with severe mental health problems, as a continuing problem in the California prison system. The ruling states that such individuals “face substantial risk of serious harm, including exacerbation of mental illness and potential increase in suicide risk.”

The State of California argued before the court that they have “developed and implemented procedures for placing and retaining inmates with mental health needs in any administrative segregation or security housing unit.” Further, the State of California argued that while individuals diagnosed as “mentally ill” are placed in segregation units, their needs are “being appropriately met.”  Judge Karlton dismisses this claim, stating that “this contention is not supported by defendants’ own experts.” He goes on to write that the State of California’s experts “describe the ‘environment of administrative segregation’ as ‘generally non-therapeutic.’ They recommend that housing inmates with serious mental disorders be ‘as brief as possible and as rare as possible.'”

Judge Karlton notes that this does not appear to be the case, and notes that the California’s own experts have commented that these prisoners should be at the top of the list for receiving transfers to mental health facilities. “These issues, until remedied, mean that seriously mentally ill inmates placed in administrative segregation units continued to face a substantial risk of harm,” Judge Karlton writes.

The high rate of suicides in California’s segregation units, where most individuals are held in solitary confinement, has been heavily documented by Dr. Raymond Patterson, a court appointed consultant to CDCR.

In a 255-page report filed in March of this year, Dr. Patterson blasted CDCR for it’s repeated failures to instate any of the suicide prevention measures he has suggested over many years. Dr. Patterson announced in his 14th annual review of prison suicides that was quitting, as “it has become apparent that continued repetition of these recommendations would be a further waste of time and effort.”

The report reviewed 15 of 32 suicides in 2012.

In brief, the report found that:

  • 9 of 15 (60%) committed suicide in single-cell status
  • 9 of 34 (60%) had a history of  suicidal behavior
  • 11 of 15 (73.3 %) had a history of past mental health treatment
  • 6 of 15 (40%) committed suicide in Administrative Segregation
  • 1 of 15 (6.6%) committed suicide in the Security Housing Unit
  •  3 of 15 (20%) suicides were discovered after the process of rigor mortis had begun, indicating 2-3 hours had passed before the individuals were discovered
  • 13 of 15 (86.6%) cases showed significant indications of inadequate assessment, treatment, or intervention

Below is a chart presented in the report indicating the date and location of the suicides. Notable is the high number of suicides committed in segregation units.2012-page-0


The 2012 report notes that people in solitary confinement have a 33 times higher likelihood of committing suicide in the California prison system.

On page 16 of the 2012 report, Dr. Patterson writes:

  • “In 2011, CDCR’s average daily combined population in its segregated housing units (administrative segregation units, SHUs, and PSUs) was 3,771. In 2011, there were 15 suicides in these units, for an incidence of one suicide per every 251.4 inmates in segregated housing units, and for a rate of 397.77 suicides per 100,000 inmates in segregated housing units.
  •  In 2011, CDCR’s average daily population in non-segregated housing was 158,047. In 2011, there were 19 suicides in non-segregated housing units, for an incidence of one suicide per every 8,318.26 inmates in non-segregated housing units, and for a rate of 12.02 suicides per 100,000 inmates in non-segregated housing units.”

The report of Dr. Patterson on the 34 suicides in the California prison system in 2011 provides a similarly bleak picture.

In brief, the report shows that:

  • 24 of 34 (70.6%) committed suicide in single-cell status
  • 20 of 34 (61.8%) had a history of suicidal behavior
  • 30 of 34 (88.2 %) had a history of mental health treatment
  • 9 of 34 (26.5%) committed suicide in Administrative Segregation
  • 2 of 34 (5.9%) committed suicide in the Security Housing Unit
  • 1 of 34 (2.9%) committed suicide on death row
  • 5 of 34 (14.7%) suicides were discovered after the process of rigor mortis had begun, indicating 2-3 hours had passed before the individuals were discovered
  • 25 of 34 (73.5%) cases showed significant indications of inadequate assessment, treatment, or intervention

In the report, Dr. Patterson reported that “the high rate of inadequacy in assessment, treatment, or intervention is generally consistent with previous years, and remains unacceptably high.”


The report also adds further, and disturbing, details to cases of suicides previously reported by Solitary Watch. Pages 211 to 217 document the case of Armando Cruz, who committed suicide on September 20th, 2011 in California State Prison, Sacramento’s Psychiatric Services Unit. Cruz, who was incarcerated at the age of 17 for an attack on a police officer, entered the prison system in 2003 with a highly documented history of schizophrenia. Cruz was repeatedly placed in isolation units for behaviors that were largely committed during hallucinations and bouts of psychosis over the course of eight years. Cruz repeatedly engaged in self-harm, including self-strangulation and self-castration, yet was determined to have a low chance of suicide.

Solitary Watch obtained Cruz’s CDCR documents in late 2012. Documentation of Cruz’s final months, however, were missing from the documents CDCR sent. In April and May, Cruz was noted in the documents to have invented an imaginary family living with him in his isolation cell; he was also noted to have been placed on suicide watch between April 29th, 2011 until May 10th, 2011. Documentation available to Solitary Watch runs out after July. Though the Patterson report fills in this gap and reports previously unknown information:

However, at the end of August 2011, he head-butted and pushed a correctional officer during escort. Subsequently, the inmate received an RVR, a mental health assessment, and was seen by a psychiatrist and by his primary clinician. The last mental health contact was by the primary clinician on 9/09/11. However, according to the suicide report, the inmate did not see a clinician as per guidelines the following week because his primary clinician was away from the institution and there was an emergency absence by the backup clinician. The inmate committed suicide on 9/20/11.

The Patterson report states that when Cruz was found hanging in his cell, he was not given CPR for ten minutes following his discovery, a violation of the prison’s own policy.

The report also sheds light on the final day of Alex Machado, who was incarcerated at Pelican Bay State Prison’s Administrative Segregation Unit. Pages 228 to 237 discuss his suicide. Dr. Patterson found that Machado’s death “appears to have been both foreseeable and preventable. The inmate quite clearly had a history of suicidal ideation and at least one suicide attempt. He was noted to have been decompensating, particularly during the month of October 2011 and especially in the 24 hours prior to his death.”

Dr. Patterson also describes the extent to which Machado had been agitated on his final day:

During the early afternoon at 12:05 p.m., the psych tech checked the inmate’s blood pressure at his request and the inmate said that he would take a PRN medication if it would help….The inmate was again reported as having chest pains at 11:40 p.m. and 11:50 p.m. The log book indicated that the RN was on the unit to see the inmate and the inmate “seems very confused.” The inmate was returned to his cell at 12:15 a.m. Welfare checks were completed between 12:05 a.m. and 12:15 a.m., and again at 12:45 a.m., when the inmate was discovered hanging in his cell.

Friday’s ruling might force CDCR to undertake more serious efforts to preventing more people in their custody from taking their own lives.


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  • shaypeanut

    This is wrong. Too many in California are in the Shu and thousands have excessive sentences. I say we need the Feds and June 26 2015 ruling on Federal three strikes law needs to be implemented in California. Please sign my petition to help my son locked up in California. http://change.org/p/jerry-brown-reduce-my-son-s-sentence

  • Dean

    Who are the 4 mental health experts that the state hired that reported the mental health care was adequate?

  • Alan CYA # 65085

    Our nation has been juggling the insane from one type of institution to another for at least one hundred and forty years. The nation was still reeling from the civil war when the Long Depression, previously known as the Great Depression, struck in 1873 and lasted until 1896.

    During this period of time our nation had experienced a burst of immigration from Europe, a loss of jobs, and the associated stress levels of this tumultuous change in American society created an intensifying frequency of mental illness. Thus the nation saw a considerable growth in state-sponsored treatment of the mentally ill and a rise in asylum building. This building boom also coincided with the building of juvenile and adult correctional facilities.

    You could say that this was the stimulus package of the 1890’s as small towns across the nation sought to have their towns receive such institutions for the jobs and funds they generated.

    Religious and civic minded people with good intentions naively fought for these institutions. After the buildings were built the funding waned and the abuse of the mentally ill, the orphan, the vagrant, and yes criminals became wide spread in these hidden American Horror Asylums, juvenile houses of refuge, and penal institutions.

    For the wider public at large the benefits were that finally these poor souls were out of sight meant out of mind. But for those in the institutions there was a cruel reality.
    Edward Bunker wrote about his experience in one such CA “hospital” during the 50’s in his memoir, “Education of A Felon”:

    Page 20-22:

    “Pacific Colony was primarily for the mentally retarded, but they took some ninety-day observation cases from the youth authorities. It’s one locked ward was the most brutal place I’ve ever been……Most of my time was spent in the dayroom sitting on the benches…We sat in silence with our arms folded. Any whispering and an attendant…might knock you off to the floor…For entertainment, the attendants staged fights between patients…
    One favored punishment was “pulling the block.” The “block” was a slab of concrete…Wrapped in layers of an old wool blanket…The blanket-wrapped block was pulled up and down the hall twelve hours a day…
    The most brutal punishment was hanging someone by the hands…The miscreant wasn’t actually lifted off the floor, but he had top stand on the balls of his feet or let the weight fall on his arms and wrists. After ten minutes it was torture. In fifteen the victim was usually screaming. The attendants preferred old fashioned beatings….”
    Bunker then goes on to explain in great detail the physical attack on him by staff members that nearly killed him.

    “The Jabber came in with the shivering energy of a badger. Without a word, he punched me in the face with both hands, short punches from someone accustomed to using his fists….He rocked on the balls of his feet, hands up, leering; “I’ll teach you to yell, you little scumbag….”

    I knew fighting back might get me killed.

    They could get away with anything. I’d seen brutalities that would never happen in reform school, or even a prison for that matter….This was a hospital. We were patients being cared for….

    The Jabber left after that. I pulled the cot away from the wall and began to straighten the blankets…

    My door opened again. The Jabber stood there,…behind him were a big redheaded attendant and a patient….

    This time I punched first….The redheaded attendant got an arm around my neck from the rear and pulled me back….

    As the redheaded chocked me, the patient goon lifted my feet off the ground. Someone got on the bed and jumped down on my stomach. Someone else smashed a fist into my face six or seven times….

    When they left I could barely breathe…

    At midnight, when the shift changed, my door opened again and two graveyard-shift attendants came in. the smell of liquor was on his breath…I managed to rise. He knocked me down and kicked me…In his drunken rage he might have kicked me to death if the other attendant had not finally restrained him: “Knock it off Fields. You’ll kill him. He’s just a kid.

    After I was certified as sane they returned me to reform school. Preston School of Industry.”

    In case there is still some doubt:

    In “California Rising: The Life and Times of Pat Brown,” Ethan Rarick writes about the role Brown the Elder, then attorney general of California, played half a century ago in discovering the severe mistreatment of mentally ill patients in state hospitals:
    For three months Department of Justice investigators burrowed their way into the state’s mental hospital in Modesto. They found horror stories. Patients, it was said, had their arms twisted until the bones broke. They were beaten with rubber plungers or forced to drink from toilet bowls. The hair was ripped from their scalps. And if there was little humanity, there was less treatment: few patients received adequate psychiatric care, record keeping was slipshod, doctors shirked their duties …
    There is little doubt that Brown would have been concerned about conditions in the hospital… But he also admitted years later that, influenced by his own ambitions, he worked to his own advantage.

    And so does his son today along with many others.

  • The Governor is a total idiot on this issue… He should be ashamed of himself…

  • Alan CYA # 65085

    California’s Prison Population is 38 percent Latino, 27 percent, white, and 29 percent African American which leaves 6% other.

    Yet the 2011 suicides are 37% white (of 27%), 30% Hispanic (of 38%), 18% other (of 6%) and 15% African American (of 29% of the total population).

    Why do you think this is?

    I have my own opinion and it is not genetics.

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