Ten Deaths At San Quentin from Macabre" Healthcare

by Marvin Mentor

San Quentin State Prison (SQ), a scant 25 miles from the San Francisco courtroom of Plata v. Schwarzenegger Judge Thelton E. Henderson, was high on the court's agenda for improved medical care. [See related story, p.1.] In the four-phase Plata statewide healthcare improvement rollout, SQ was due to finish court-ordered upgrades by January 1, 2005. The court appointed nationally renowned experts Dr. Michael Puisis and Dr. Joe Goldenson, along with Madie Lemarre, CFNP, to inspect and evaluate SQ's healthcare commencing January 24, 2005. Judge Henderson personally toured SQ with these experts on February 10, 2005. The experts' shocking 53 page report to the court of macabre" healthcare issued April 18, 2005.
We begin with its summary. [SQ] is so old, antiquated, dirty, poorly staffed, poorly maintained, with inadequate medical space and equipment and over-crowded that it is our opinion that it is dangerous to house people there with certain medical conditions and is also dangerous to use this facility as an intake facility. In addition, the overcrowding and facility life-safety and hygiene conditions create a public health and life-safety risk to inmates who are housed there. We therefore strongly recommend as a life-safety issue that a census cap be initiated, that the existing Outpatient Housing Unit be closed or used for a different purpose, and that the mission of reception be re-directed to a different facility. SQ should be viewed as needing to start from the beginning. It's mission should be re-evaluated.

Decrepit Housing Conditions

Housing arrangements at SQ are so decrepit that it is degrading and dangerous to house human beings in them for extended periods of time. Hundreds of inmates crowd in long double tiers of double bunks in walkways called broadways' [where they] are subject to cascading material thrown down from the five tiers above them, including excrement.... Only two toilets were available for somewhere between one and two hundred inmates. ... There were no functional doors for those toilets. The rooms were filthy. ... Sinks did not appear to work. There was no soap. ... Fire safety ... and local public health authorities should review these conditions.

Waste water [from leaking sewer pipes] drips ... onto the floor below creating pools of waste water that staff walk through." In addition, inmates take showers in standing water [due to plugged drains] and the water spills ... onto the walkway so that the nurse has to walk through it to get to the adjoining medical room. The [waste] water routinely creeps into this examination area.

The prison hospital's Outpatient Housing Unit's (OHU) 32 cells have solid doors and no paging system. Not one cell can be heard or seen from the remote nurse's station. One prisoner there had a heart attack and pounded helplessly on the door for hours before guards heard him and alerted healthcare staff. There is no examination room in the OHU, so examination of patients is done in the cells by healthcare staff who must kneel over the 18" high bunks, with no direct lighting. Mental health patients sleep on a mattress on the floor. The cell doors do not admit wheelchairs. Custody severely restricted the schedule when healthcare staff could visit patients. The lack of beds meant sending critically ill patients back to general population, where some died.

The other 50 hospital beds (BHU) have an associated examination room. But BHU is mopped once a week by a prisoner porter, who also then empties the trash. No surfaces are ever sanitized. BHU houses 24 severely ill HIV patients.

Prisoners from general population North Block had sick call in a trailer in the main yard. The waiting room" for up to 30 prisoners at a time was a locked toilet-less outdoor cage with a dozen chairs, where ill patients had to remain up to five hours in the rain or hot sun to see the doctor.
Death Row prisoners on the night watch were in special jeopardy, because security procedures kept cell keys several blocks" from their housing, and required the Watch Commander to access them. This virtually ensured that a late night medical emergency could not gain prompt relief.

But these are highlights from only the first 15 pages of the 53-page single-spaced report. The balance of it reviewed ten SQ prisoner deaths and 26 other non-fatal medical files. The ten deaths are summarized below.
Prisoner # 1 went to the emergency clinic on January 28, 2005 at 2015 hours, complaining of an ongoing bad cough. His vital signs were consistent with shock, requiring immediate acute hospitalization. Dr. X" [later identified as Dr. Garen Vong; see related story in this issue of PLN) diagnosed bronchitis and influenza, ordering Tylenol, Benadryl, cough syrup and antibiotics and sent him back to his housing unit. On the way back, he collapsed and was brought back to Dr. X, who ordered an IV started. Staff was unable to start an IV, so he was returned to his housing unit. The next morning he was seen by a Medical Technical Assistant (MTA) for follow-up. The prisoner said he felt the same. No vital signs were documented. At 1616 hours, after he complained of coughing up blood for two days, he was put on oxygen and taken to the clinic. A different doctor saw him, and recognizing shock, sent him to the outside hospital at 1700 hours. The prisoner died there at 0207, but hospital records were not available. The provisional cause of death was pulseless heartbeat secondary to irreversible pulmonary hemorrhaging.

Prisoner # 2, a 58 year-old deaf mute with hypertension, was seen in the clinic after he fell back on his head in his cell. He was bleeding from the ear and put on oxygen. By 3 a.m., he was in shock, and Dr.X" ordered him sent to the prison hospital, planning to see him in the morning. Dr. X" saw # 2 at 0820 and ordered him sent via Code 2 ambulance for a head CT scan at Novato hospital. That hospital declined on the phone and recommended he be sent to Marin General for a neurosurgeon. Before # 2 was taken anywhere, he died at 0915. The cause of death was not provided.
47 year-old patient # 3 had a history of hypertension and schizophrenia. Dr. X" saw him in the clinic at 1120 hours, where the patient was disoriented and had blood in his mouth. Dr. X" referred him to a psychiatrist. At 1240, the psychiatrist observed declining vital signs, blood in his mouth and jaundiced eyes. He sent him back to the clinic where they gave him oxygen and started an IV. At 1400 hours, he had a seizure. Dr. X" called for an ambulance, but # 3 died shortly thereafter. Cause of death was septicemia (mass infection), with acute respiratory distress, kidney and liver failure.

The experts' assessment of Dr. X" in all three cases was extremely poor clinical judgment." Dr. X" was put on administrative leave because of the death of #1, but not before he had failed the needs of # 2 and # 3.
Prisoner # 4, 54, had never been evaluated at intake or ever filed a health request form. On May 20, 2004, he was seen for a swelling on the side of his head. The doctor gave him a high dose of prednisone for four days but no follow-up occurred. The diagnosis was temporal arteritis (inflamed blood vessel), although this was not supported by the physical exam or lab tests, which indicated an infection (which prednisone is known to exacerbate). By the 24th, the doctor sent # 4 to Novato hospital where his white blood count was 19,000 and a CT scan showed a cranial infection. # 4 refused head surgery, and, after being diagnosed with penicillin-resistant staphylococcus aureus (MRSA), came back to SQ with two oral antibiotic prescriptions. But these were not filled by SQ for two days. On the 26th, the SQ doctor drained the abscess. # 4 died later that day. The assessment was misdiagnosis and wrong therapy, plus failure to give timely medication.
# 5 was a transferee from a Sacramento prison, who had end-stage liver disease. No doctor at SQ saw him for six weeks after his arrival. Medication was prescribed for two weeks on the day of his admission, but he was never given it. When he was seen, he was prescribed ten days of medication but not scheduled to be seen for a month. He had gained 25 lbs. of water from liver dysfunction. He went to the clinic three days later with ascites, and lab tests were ordered. He was scheduled to been seen every two weeks for two months, which did not happen. Sonograms were ordered but not performed. His treatment went on for a year, but a serious MRSA infection was not properly treated and he died from an abdominal abscess. The assessment was poor physician management of his liver disease.
Prisoner # 6 survived 1 ½ years at SQ, diagnosed with hypertension. But for almost a year, his medications were not supplied. He went to the clinic October 5, 2004 where he collapsed and vomited. His blood pressure was 193/116, and he died four days later, from a stroke. The assessment was that # 6 was basically neglected" for over a year.

39 year-old patient # 7 lasted only six months at SQ. He arrived with diabetes and a heart murmur but there was no follow-up. His blood pressure was 134/98. His intake exam showed normal," in spite of a glucose reading of 242. Three weeks later, he complained of swollen legs and stomach. Lasix and lab tests were ordered, but neither were provided. # 7 wasn't seen again until the sixth month, for declining mental status. He died a week later. Assessment was misdiagnosis of his swollen legs, and failure to given him lab tests while giving him diuretics.

Patient # 8 also lasted just six months at SQ. His intake diagnosis was Parkinson's Disease, weakness, inability to walk, and no bladder control. He had a history of hypertension; his blood pressure measured 184/100. No other evaluation occurred and he was recommended a wheelchair. After one near-death from interaction between blood pressure and Parkinson's medications, he finally succumbed. His death was due to drug interaction caused by substandard patient management.

Prisoner # 9 died of hypertension on December 13, 2003. His last medical visit had been August 5, 2002, where his blood pressure was 211/114, and he was prescribed medications which were continued until he died. There was never any lab work or other evaluation. Assessment: the patient died of abject neglect for 16 months.

Patient # 10 arrived at SQ in October 2003 with a known diabetic condition and hypertension. His triglycerides were a whopping 903 and his cholesterol was 287. Although he was repeatedly seen and medicated, there were numerous documented major errors, and he died a year later. Assessments were preventable death," multiple and repeated medical errors," and multiple contraindicated medications." The care was extremely substandard.
The balance of the experts' report covered 26 other cases of substandard medical care, but with the patients still alive.

Additional drama occurred when court monitors (lawyers from the Prison Law Office (PLO)) were denied answers to their inquiries during the court-ordered evaluation at SQ on April 27, 2005. SQ's Chief Medical Officer Dr. Robert Chapnik said that Warden Jill Brown threatened him with disciplinary action for talking to the plaintiff attorneys. The PLO complained that Brown was invoking a code of silence" to frustrate the court. Brown was swiftly removed from SQ.

It was perhaps an understatement that the experts rated SQ's compliance with the Plata Agreement, after the one-year long roll out," as non-existent." See: Plata v. Schwarzenegger, U.S.D.C. (N.D. Cal.), No. C-01-1351 TEH, Medical Experts' Report On San Quentin, April 8, 2005."

Other sources: San Jose Mercury News; Los Angeles Times; Associated Press.

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