California’s Office of the Inspector General (OIG) confirmed what SQ’s COVID-impacted community has known since June — that administrative mistakes “caused a public health disaster at San Quentin State Prison.”
The OIG declared the rushed and “inexplicable” transfers of 122 “vulnerable incarcerated persons” from the California Institute for Men (CIM) last May “deeply flawed and risked the health and lives of thousands.”
The Feb. 1 OIG report outlined a series of ill-fated decisions by the California Department of Corrections and Rehabilitation (CDCR) and California Correctional Health Care Services (CCHCS) which led to over 2,500 COVID infections of SQ prisoners and staff — including 29 deaths.
In April 2020, the California Assembly requested the OIG’s independent prison oversight to “assess the policies, guidance and directives” implemented by CDCR since February 2020 in response to COVID-19.
Previous OIG reports focused on 1) inconsistent COVID screening practices throughout CDCR and 2) how CDCR’s loose enforcement of the proper use of personal protective equipment (PPE) led to inadequate basic safety protocols.
Highlights of Part Three’s 59-page document:
- Interdepartmental emails reveal how CCHCS executives and management pressured CIM to rush the transfers of 189 incarcerated persons to Corcoran and SQ.
- CCHCS pressured CIM to rely on outdated COVID test results so that the rushed transfers of medically vulnerable prisoners would not be delayed.
- Lacking proper guidance from CCHCS, CIM insufficiently screened incarcerated persons for COVID symptoms prior to placing them on buses for SQ.
- CCHCS approved increasing the number of prisoners per busload and thereby circumvented COVID-safe physical distancing protocols.
- Although two persons from CIM displayed noticeable COVID symptoms upon arrival and were quarantined, 119 other transferred persons were housed amongst hundreds of COVID-free SQ prisoners.
- SQ’s physical structure generally does not allow for proper isolation of persons potentially infected with an airborne virus.
- By placing persons suspected of COVID exposure into a COVID-free housing unit, SQ staff jeopardized the health of both new arrivals and current residents.
- SQ allowed staff to work and move throughout the prison, likely transmitting the virus from location to location.
- SQ failed to conduct contact tracing and instead stated that there were too many positive COVID cases at one time to do contact tracing.
The OIG report concluded that if SQ had followed the Center for Disease Control’s (CDC) guidelines on contact tracing:
“They may have reduced the spread of infection to other incarcerated persons, prison staff and transportation staff, and, in turn, reduced transmission from the prison into the community.
“San Quentin’s assertion that its inadequate contact tracing was due to too many positive cases in a short period of time defies public health recommendations as well as the department’s own policies, and we consider its incomplete investigations to be irresponsible.”
According to Bay Area News Group, a CDCR spokesperson released a written statement responding to the OIG’s findings.
“We appreciate this report from the OIG, and note that there were many factors that contributed to the need to move medically high-risk individuals from CIM last May that are not reflected in the report,” said the CDCR statement.
“The transfers were done with the intent to mitigate potential harm to CIM patients from COVID-19, and were based on thoughtful risk analysis using scientific information available in May 2020.
“We have acknowledged some mistakes were made in the process of these transfers, and both CCHCS and CDCR have made appropriate changes to patient movement since that time.”
Inspector General Roy W. Wesley did acknowledge that, since the misguided transfers, “CCHCS and [CDCR] have taken multiple actions to better safeguard incarcerated persons transferring between prisons.
“We did not review the adequacy of the additional steps taken… but if consistently carried out, they should help prevent future disasters such as the one detailed in this report.”
