Over an eight-year period, nearly 800 female prisoners underwent operations that could have resulted in sterilization, according to a California state audit.
In most of these cases, sterilization was an unintended consequence of hysterectomies intended to treat cancer and other health problems.
However, “144 female inmates were sterilized by a procedure known as bilateral tubal ligation, a surgery generally performed for the sole purpose of sterilization,” according to the report.
Under California Department of Corrections and Rehabilitation (CDCR) rules, bilateral tubal ligation is a procedure that is not medically necessary. The last of these sterilizations occurred in 2011.
State regulations require informed consent before a woman can be sterilized; “however, Corrections and the Receiver’s Office sometimes failed to ensure that inmates’ consent for sterilization was lawfully obtained,” the audit reports.
INCONSISTENCIES WITH INMATES’ INFORMED CONSENT
Thirty-nine inmates were sterilized following deficiencies in the informed consent process. The audit noted two types of deficiencies: physician signatures and waiting period violations.
A physician is supposed to sign the consent form immediately before performing the surgery. This is to ensure that the mandatory waiting period has elapsed, that the patient is mentally competent and that she understands the lasting effects of the operation.
However, in 27 cases of the 39 cases, the physician failed to sign the required consent form.
The waiting period — a minimum of 72 hours from the time the patient signs the consent form until the time of the operation — is intended to allow the patient time to think about the choice she is making. She can change her mind at any point.
But in 18 instances, the audit found possible violations of this waiting period.
Six inmate sterilizations involved the violation of both these requirements.
Compounding these problems with informed consent, the audit found that inmates who consented to sterilization likely did so without a witness of their choice. This witness serves as another safeguard to ensure that the patient both understands and desires the procedure. The witness can also protect the state from accusations that an inmate was coerced into sterilization.
“The unwillingness or inability of the Receiver’s Office to provide inmates with the opportunity to have a witness of their choice — as required by Title 22 — serves to reinforce and highlight the problematic process that prison medical staff followed when obtaining inmates’ consent for sterilization,” the audit stated.
Although the sterilization procedures were performed by general acute care hospitals, not by prison doctors or the federal receiver’s employees, the auditor “concluded that they had a responsibility to ensure that the informed consent requirements were followed in those instances in which their employees obtained inmates’ consent, which was the case for at least 19 of the 39 inmates.”
Additionally, the true number of women sterilized without lawful consent may be higher.
“For example, one hospital destroyed seven inmate medical records in accordance with its records retention policy” the audit stated. “Five of these seven inmates consented to the sterilization procedure while in prison, and it is unclear — based on available records — whether physicians signed the sterilization consent forms just prior to surgery.”
For all 144 cases in the audit, “prison medical staff failed to document what was discussed with the inmate, as required by prison medical procedures.”
The audit could not determine if inmates were properly informed about the “sensitive and life-changing” procedure whether through education materials or by medical staff.
The audit determined that the “failure to obtain the necessary approvals was systemic.”
Only one bilateral tubal ligation procedure received all the required levels of approval, according to the audit.
RECOMMENDATIONS
The auditor recommended that the Receiver’s Office report to the California Department of Public Health and the Medical Board of California the names of all hospitals and physicians associated with inmates’ bilateral tubal ligations so that both educational and disciplinary action might be taken.
The Receiver’s Office should draft and implement a plan to monitor how its medical staff and contractors adhere to the informed consent requirements by the end of this year, stated the audit.
Finally, the report recommended that medical staff should improve the quality of information they document in inmate medical records.
