The coronavirus outbreak inside San Quentin State Prison killed 28 incarcerated people and 1 officer, infected over 2,000 and shook the prison to its core.
“San Quentin is now the epicenter of the Coronavirus pandemic in California,” reported the local ABC television station news on June 30..
On the local PBS television news on June 26, Marin County Public Health Officer Dr. Matt Willis
confirmed that 121 incarcerated people, some of whom were infected with COVID-19, had transferred from the California Institute for Men in Chino during an outbreak there in May. He reported that the large cell blocks in San Quentin with hundreds of incarcerated people breathing the same air under one roof were highly conducted to the spread of the respiratory illness.
Willis said almost 600 incarcerated people were already confirmed to have coronavirus and they should be ready for at least a few hundred more.
By June 29, Gov. Gavin Newsom had announced that 1,011 San Quentin residents had tested positive, more than at any other prison. The same day, the Marin County coroner’s office reported the first confirmed SQ COVID-19 related death: a 71-year-old man found unresponsive in his cell.
Long before these headlines made the news, the coronavirus pandemic jolted the lives of the thousands of people who live, work, visit, and volunteer in San Quentin.
The prison began restricting incarcerated movement from cell blocks as a preventive measure on March 14. All in-person education classes, rehabilitation groups, religious services, visits, volunteer entry, non-essential work, and non-essential medical services were terminated within days. The library and chow-halls were closed.
San Quentin, CDCR’s shining model for rehabilitative, vocational, educational and restorative opportunity, was suddenly shut down like a high-security prison.
The procedures changed daily, but the average schedule for the first three months consisted of being locked in a small cell all day and night—getting out only to pick up a tray of food to take back to eat in the cell and a couple of hours every three days or so to go outside to the recreation yard, take a shower and maybe make a phone call.
Although some enjoyed the break from busy schedules, the abrupt social isolation and uncertainty quickly evolved into frustration and anxiety even before any contagion was confirmed.
Prison administrators addressed the concerns, reported program and medical updates and encouraged cooperation and patience through memoranda and videos to the incarcerated population.
A March 27 memo from Acting Warden Ron Broomfield and Acting CEO of SQSP Healthcare Matt Verdier reported that a staff member “tested positive for COVID-19” and that contact tracing was underway.
“We have the utmost faith in our health care, custody, and administrative professionals to protect this institution—and this community—from this virus,” the report said.
SQ medical providers issued a memo the same day, announcing postponement of regular medical appointments, plans for telemedicine and distribution of monthly (instead of daily) supplies of medications to reduce daily lines and increase social distancing.
The medical providers encouraged their patients to wash their hands, practice social distancing and report symptoms.
“We have no cases among our patients,” reported their April 15 memo that described symptoms to watch for and explained how the coronavirus is spread by respiratory droplets. The medical providers stated that residents assigned to jobs in factories are “working very hard to make cloth masks for the incarcerated population. They will be distributed soon.”
By May, most incarcerated people diligently wore masks, washed their hands and practiced social distancing. Some stayed in their cell all the time—“staying home, saving lives.” Not every incarcerated people, however, had that luxury.
Many essential workers preparing, serving and cleaning up after meals were required to work closely together. Some residents spent hours every day, visiting cell to cell and hanging out on the tiers talking face-to-face, maskless.
After the transfer from Chino, staff and a few residents were tested for coronavirus in May. But widespread testing of the population began in June. San Quentin’s medical staff tested about 100 West Block residents by the first week of June, followed by about 200 more, mostly from tiers one and two, on June 25
“West Block is now on medical quarantine,” announced an officer over the loudspeaker the next day. Recreation yard and phone access stopped.
On June 29, about 300 more West Block residents were tested. Then healthcare staff began notifying the residents whose tests the previous week resulted positive for COVID-19. Paper “quarantine” tags were taped on the front of their cells. On the second tier alone (of five tiers), 40 of the 90 cells were tagged.
“There ain’t no hidin’ it now. We’re all gettin’ COVID,” said one incarcerated carrying his breakfast tray past dozens of cells with infected people living inside. He had tested negative.
The quarantine signs made it clear that the viral contagion was rampant, but there were earlier signs. People were getting very sick. First one or two in mid-June, then more. By the end of the month, residents were taken out of West Block for emergency care every day.
In the middle of the night, yells of “Man down!” relayed along the length of the cells to alert the officer at the desk, who in turn called for medical response.
In the daytime, nurses doing their twice-daily cell-to-cell vital sign checks discovered serious symptoms in patients and called for emergency response. Weakness, pain, difficulty breathing, fever, dizziness, and collapse were common complaints.
Night and day, San Quentin emergency responders administered oxygen, and carried the very ill on gurneys down the cellblock tiers to the prison medical facility for observation and treatment.
The coronavirus outbreak in West Block in June was mirrored simultaneously in the other three housing blocks: North, East and South. All four blocks are five to six tiers high with between 500 and 900 incarcerated people mostly two per cell. None have solid cell doors to prevent the spread of infectious respiratory droplets.
As residents fell ill and tested positive for the disease, efforts were made to medically isolate them. Empty cells in South Block, where reception to new residents had closed, plus a few in the Adjustment Center, the only housing with solid doors, quickly filled.
With about 1,400 active cases of COVID-19 in crowded cellblocks infecting more people every day and nowhere to isolate them, San Quentin’s coronavirus crisis peaked in early July.
The incoming waves of seriously sick patients infected with the highly contagious and deadly virus overwhelmed prison medical facilities and staff. According to Marin County Public Health, dozens of the most critically ill were sent to outside hospitals, threatening to exhaust local medical capacity.
Ambulances stationed outside the prison gates awaited falling COVID-19 victims day and night.
The California Governor’s Office of Emergency Services, California Department of Public Health, Marin County Public Health, Emergency Medical Services Authority, many private contractors and the National Guard combined forces with the California Department of Corrections and Rehabilitation (CDCR) and California Correctional Health Care Services (CCHCS) to mitigate the pandemic pandemonium at San Quentin.
Retired CDCR Undersecretary Terri McDonald returned to serve as a Senior Executive in the Emergency Command Center established to coordinate the response. More than 150 medical and custody staff came in from other prisons to cover for infected San Quentin staff. An outside vendor was contracted to provide hot meals to alleviate the crisis in the kitchen.
A tent city was set up on the recreation yard to temporarily house about 100 infected residents. Incarcerated people were moved into the gymnasium. Four chapels were converted into temporary housing. A factory was converted into an Alternative Care Site and a supplemental medical team was contracted to house and care for over 200 of San Quentin’s sickest patients.
The incarcerated patients who had a television in their cell continued to watch for coronavirus updates on San Quentin and around the world. Many of San Quentin residents’ staunchest supporters, including the Prison University Project (Mount Tamalpais College), Ella Baker Center and Restore Justice were on the local news, advocating outside the prison for the health and safety of those on the inside. In his noon COVID-19 press conference on July 6, Gov. Newsom announced that critically ill San Quentin patients needing hospitalization would be sent to Marin General, St. Francis Memorial, and Seaton hospitals.
A little before 6 p.m. that evening, the names of about 50 residents were called over the loudspeaker. “Pack your stuff, you’re moving to tent city,” announced the officer. The relocation of hundreds of West Block residents for medical isolation within the prison peaked in July.
A July 9 memo from Warden Broomfield and newly appointed CEO of SQSP Healthcare Clarence Cryer reported the staffing crisis, disruption of services, and mitigation actions to “deal with this horrific COVID-19 pandemic.”
SQSP Chief Medical Executive Alison Pachynski said in a video message, “There are still patients in your housing units that are negative. It’s our goal to keep them negative through this event. So if you do get a test that is positive, please let us move you so that we can protect those around you.”
Many incarcerated people, however, did not want to move and live with a bunch of infectious people in a temporary facility with unknown conditions. Shockwaves of the contagion killing another incarcerated person every day or two through the month of July sapped their confidence.
Many preferred their own cell, with their own food, hot pot, sink, toilet and television where they are comfortable. Moving risked losing their property, their cell, or their cellmate.
An estimated 75 West Block residents refused to move, be screened, or tested for COVID-19.
On July 15, KQED radio reported 11 confirmed COVID-related deaths of San Quentin residents: four from Death Row and seven from the general population. The cause of death of two additional Death Row residents, who died in outside hospitals, was being investigated. The report said that about half the entire population of the prison had been infected and 1,200 cases were currently active.
The surge in active cases began to decline from its peak of 1,400 two weeks earlier, but the virus continued to kill prisoners one after another.
By August 9, 25 incarcerated people and one officer had died of the disease, according to CDCR.
“People are recovering—their cases are being resolved,” said Lt. Sam Robinson, SQ Public Information Officer, in a video message to residents on August 19. He mentioned the names of people “who unfortunately will never make it back here because this ugly pandemic has taken their lives.”
By that time there were 2,093 resolved cases within San Quentin’s population of 3,125, according to a prison health care newsletter. Among the staff, 275 had tested positive and 101 had resolved and returned to work.
As the spike of infection diminished, so did the need for medical isolation space. Most of the temporary sites emptied and closed in August. Patients returned to their regular housing.
Remarkably, there were no infections among the hundreds of residents in the dormitories of H-Unit, a separate facility at San Quentin, according to staff.
West Block residents were again allowed out of their cells for an hour once every three to four days. Food was delivered to their cells. Locked in their cells 24 hours a day, incarcerated people read books delivered from the prison library, watched TV and the prison’s movie channels and did legal work, some resulting from the pandemic.
All housing units were still on medical quarantine through November.
Criticism of the transfer that preceded the COVID-19 outbreak inside San Quentin reverberated across the state.
Local journalist Otis R. Taylor Jr. reported on July 6, “San Quentin State Prison had no coronavirus cases among its prisoners until an ill-fated transfer from California Institute for Men in Chino at the end of May. Somehow, the nearly 200 men from Chino, home of the deadliest outbreak in the state’s prisons [before San Quentin’s outbreak] weren’t tested for weeks before getting on the transfer bus. At San Quentin, where the 121 men were sent, 25 of them tested positive.”
The same day, Courthouse News Service reported that state legislators, including Sen. Nancy Skinner who chairs the Public Safety Committee, “blasted the corrections department for its mismanagement of the health crisis.”
Gov. Newsom in his noon coronavirus press conference, also on July 6, said that the incarcerated people from Chino should not have been transferred.
Moving incarcerated peoplesfrom The Q out to other prisons was also an issue.
According to local NBC news on July 1, a transfer of prisoners from San Quentin to California Correctional Center (CCC) in Susanville preceded an outbreak there. CDCR data showed 223 active cases in CCC on July 7, with zero resolved. On August 7, data showed 118 active cases from 596 total cases (active and resolved) in CCC.
Plans to send incarcerated people from SQ to North Kern State Prison were reported by NBC on June 26.
The July 9 memo from Acting Warden Broomfield and Healthcare CEO Cryer to the incarcerated addressed “one of the most pervasive rumors spreading around the facility.”
“There are no plans to transfer anyone from San Quentin at this time,” read the message.
An update to incarcerated people from the Ella Baker Center reported, “In mid-July, the Marin County Superior Court issued orders to show cause in 42 consolidated court actions filed by people incarcerated at San Quentin who are seeking release due to the COVID-19 pandemic.”
California Assemblymember Marc Levine called the San Quentin outbreak “the worst prison healthcare screw-up ever,” amid calls for the Governor to step in, in a local ABC TV report on July 9.
CDCR Secretary Ralph Diaz and CCHCS Federal Receiver Clark Kelso addressed transfers during the pandemic in a video message to the statewide incarcerated population.
“Many of you have moved to alternative housing units or even to different prisons to increase physical distancing to slow the spread of COVID-19,” said Kelso. “Several institutions have experienced significant outbreaks.”
“We know that the design of our prisons and the number of people in them present unique challenges to fighting this virus,” said Diaz in the 10-minute video that aired on SQ televisions in August.
“We transferred individuals to other institutions to open up space, but some tested positive upon arrival.”
Kelso said, “This virus has been humbling since it first arrived at our gates.” He described lessons learned about the importance of testing, quarantine, isolation and communication.
Diaz said, “We’ve adjusted our quarantine, testing, and transfer protocols accordingly, but I do want to let you know and acknowledge the impact these decisions have had on the receiving institutions.”
“Mr. Kelso and I share the responsibility for all decisions that are made—from how we respond to the outbreaks to how we prevent them.”
On August 29, local KCBS radio news reported that Diaz announced plans to retire on Oct. 1, Governor Newsom has named department veteran Kathleen Allison to replace Diaz as CDCR Secretary.
By November 11, the total number of prisoners statewide who had tested positive for COVID-19 was 16,921 and incarcerated deaths totaled 82, according to CDCR data. A total of 4,631 staff members were infected with Covid-19, 4,098 have returned to work and 10 have died.
