SAN QUENTIN — California prison system officials created a “public health disaster” at San Quentin and Corcoran prisons last year by transferring inmates from other prisons through a poorly-planned and rushed process while COVID-19 rates were spiking across the state, according to a damning report by a state oversight agency.
The 69-page report, released Monday by the Office of the Inspector General, found that transfers to San Quentin from California Institution for Men in Chino made in the spring and summer of 2020, “were deeply flawed and risked the health and lives of thousands of incarcerated persons and staff.” The report found staff relied on outdated or inadequate testing, that officials were pressured to rush the transfers, and that staff who raised concerns were largely ignored.
A health care executive at CIM even “explicitly ordered that the incarcerated persons not be retested the day before the transfers began,” the report found. The problems were so obvious that at least two California prisoners exhibited obvious coronavirus symptoms when they got off the bus from CIM to San Quentin.
Twenty-eight people died of COVID-19 at San Quentin, and more than 2,000 cases — about two-thirds of the prison’s population at the time — contracted the virus, according to data released by the California Department of Corrections and Rehabilitation.
“Our review also found that when staff became aware of the positive test results shortly after the incarcerated persons arrived, both prisons failed to properly conduct contact tracing investigations,” Inspector General Roy Wesley wrote in the report’s cover letter. “According to San Quentin, there were too many positive cases over a short period of time to conduct contact tracing.”
Wesley’s letter notes that since the transfer debacle, the prison system has “taken multiple actions to better safeguard incarcerated persons transferring between prisons, including implementing procedures requiring prisons to conduct COVID-19 testing of transferring incarcerated persons no more than five days before the transfer, followed by a rapid test on the day of the scheduled transfer.” Wesley noted, though, his office has not yet reviewed these new implementations.
Asked for comment on the findings, a CDCR spokeswoman released a prepared written joint statement from her department and California Correctional Health Care Services.
“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,” the statement says. The transfers were done with the intent to mitigate potential harm to CIM patients from COVID-19, and were based on a thoughtful risk analysis using scientific information available in May 2020 concerning transmission of this novel disease. 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.”
The outbreak has become the subject of an investigation by the State Senate, as well as several lawsuits. It is also a sticking point for decarceration advocates, who held a rally over the weekend — a car caravan across the Bay Bridge — calling on Gov. Gavin Newsom to follow advice by health care officials to authorize thousands of releases from the state prison system.
The inspector general’s report is Part III of long-term review by the agency, and the findings thus far haven’t been great. A report released October found that while PPE was widely available in the prison system inspectors observed that “staff and incarcerated persons frequently failed to adhere to those basic safety protocols.” An August report found that vague screening directives “appear to have caused inconsistent implementation among the prisons.”
While San Quentin’s COVID-19 rates have fallen drastically since mid-2020, there are still more than 2,200 active cases across the state prison system. Nearly 200 incarcerated people have died, according to CDCR data.
Monday’s report suggests that many in CDCR and CCHCS saw the disaster coming. An email by a “CCHCS nurse executive” sent May 27 — one day before the transfers commenced — notes that inmates were tested three weeks earlier, “way too many days ago” to safely conduct prison transfers, even if the prisoners were quarantined upon arrival at the new prison. Another email from “California Institution for Men Manager,” said that “it’s difficult to get things right when there is a rush…I’m surprised HQ wants to move our inmates right now.”
Out of those transferred, 189 were medically vulnerable and therefore posed a higher risk of death if they contracted the virus, according to the report. Just one day before the first bus left CIM, officials were still debating key details, such as how many people to put on each bus, and where to house them upon their arrival to Corcoran and San Quentin. When the inmates arrived, their property was so disorganized it was impossible for staff to immediately figure out what belonged to whom.
“Not only had the prison failed to recently test the transferring incarcerated persons to ensure they were not infected with COVID-19 at the time of the transfers, but prison health care staff conducted verbal and temperature screenings too early for several incarcerated persons scheduled to transfer to be able to effectively determine whether they had symptoms of COVID-19 when they boarded the buses to Corcoran and San Quentin,” the report says.
Contributed by local news sources