Analysis of 2018 Inmate Mortality Reviews in the California Correctional Healthcare System, Nov 2019

• Nov. 25, 2019 • Locations: United States of America -> California • Topics: Conditions of Confinement

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ANALYSIS OF 2018 INMATE
MORTALITY REVIEWS IN THE
CALIFORNIA CORRECTIONAL
HEALTHCARE SYSTEM

Kent Imai, MD
Consultant to the California Prison Receivership
11/25/2019

Analysis of 2018 CCHCS Mortality Reviews

TABLE OF CONTENTS
Table of Contents ................................................................................................................................................................. i
List of Tables and Figures...................................................................................................................................................... ii
I.

Introduction .......................................................................................................................................................................... 1

II. Mortality Review Process .....................................................................................................................................................2
III. Definitions............................................................................................................................................................................. 3
IV. The California Prison Population in 2018..............................................................................................................................3
V. Study Findings ....................................................................................................................................................................... 4
A. Number and Causes of Inmate Death .............................................................................................................................4
B. Life Expectancy in the CCHCS, 2018 ................................................................................................................................ 8
C. Expected Deaths in 2018 ................................................................................................................................................. 9
D. Unexpected Deaths in 2018 ............................................................................................................................................ 9
E. Opportunities for Improvement, 2018 ..........................................................................................................................10
1. Opportunities for better education/training and improved documentation on CCHCS emergency medical
response protocols. ........................................................................................................................................11
2. Opportunities to improve care near the end of life. .............................................................................................11
3. Opportunities to improve clinical decision making. ..............................................................................................11
4. Opportunities for improved application of the model of care as outlined in the CCHCS Complete Care Model 11
5. Opportunities to improve medical record documentation. ..................................................................................12
6. Opportunities for improved communication in a care transition .........................................................................12
7. Opportunities to utilize a substance use disorder (SUD) protocol for patients who have opiate addiction.........12
8. Opportunities to address reasons for delays in initiating appropriate treatment. ...............................................12
9. Opportunities to mitigate fall risk. ........................................................................................................................12
10. Opportunities to prevent a pressure ulcer. ...........................................................................................................12
11. Miscellaneous Opportunities for Improvement ....................................................................................................12
F. Delays in Diagnosis, 2018 ..............................................................................................................................................20
VI. Discussion of Trends ...........................................................................................................................................................23
A.Trends in Prison Mortality Rates in California and the United States .............................................................................23
B. Discussion of Trends in CCHCS Mortality Rates .............................................................................................................24
C. Annual Mortality Rates, 2012–2018 ..............................................................................................................................25
1. Drug overdose .......................................................................................................................................................25
2. Cardiovascular Disease ..........................................................................................................................................26
3. Homicide................................................................................................................................................................27

Analysis of 2018 CCHCS Mortality Reviews

4. Suicide ..................................................................................................................................................................28
5. Lung cancer............................................................................................................................................................29
6. Advanced liver disease (end stage liver disease and liver cancer combined) .......................................................30
VII.Quality Improvement Initiatives ...........................................................................................................................................32
VIII.Conclusions ..........................................................................................................................................................................34

LIST OF TABLES AND FIGURES
Figure 1. California Prison Population (averages of quarter-end numbers), 2006–2018. ........................................................... 3
Table 1. Causes of death among all California inmates, 2018. .................................................................................................... 4
Table 2. Top Causes of Death Among California Inmates, 2006–2018. ....................................................................................... 6
Table 3. Top causes of death among California inmates, 2018, compared to American male deaths, 2016. .............................7
Table 4. Ranges and Average Ages at Death Among All California Inmates, 2018. ..................................................................... 9
Figure 2. inmate deaths by expectation and category, cchcs 2018. ..........................................................................................10
Table 5: Opportunities for Improvement – Interim Classification for 2018 Mortality Reviews and Frequency in Unexpected
and Expected Deaths. .........................................................................................................................................................11
Table 6. Opportunities to Improve Clinical Decision Making: Signs and Symptoms Subject to Cognitive Errors, And (in
Parentheses) the Conditions they Portended, CCHCS 2018. ..............................................................................................14
Table 7. Delays in initiating appropriate treatment ..................................................................................................................19
Table 8. Diagnostic Delays, CCHCS 2018. ...................................................................................................................................21
Table 9. Annual Mortality rates among California and U.S. state prison inmates, 2006–2018. ................................................23
Figure 3. Trended Annual death rates among California and U.S. state prison inmates, 2006–2018. ......................................24
Table 10. Numbers and rates of overdose deaths, CCHCS 2012–2018. ....................................................................................25
Figure 4. Numbers and rates of overdose deaths, CCHCS 2012–2018. .....................................................................................26
Table 11. Numbers and rates of Cardiovascular deaths, CCHCS 2012–2018.............................................................................26
Figure 5. Numbers and rates of Cardiovascular deaths, CCHCS 2012–2018. ............................................................................27
Table 12. Numbers and rates of homicides, CCHCS 2012–2018................................................................................................27
Figure 6. Numbers and rates of homicides, CCHCS 2012–2018. ...............................................................................................28
Table 13. Numbers and Rates of Suicides, CCHCS 2012–2018. .................................................................................................28
Figure 7. Suicide rates in CCHCS and U.S. State Prisons, 2012–2018. .......................................................................................29
Table 14. Numbers and rates of lung cancer deaths, CCHCS 2012–2018. .................................................................................29
Figure 8. Numbers and rates of lung cancer deaths, CCHCS 2012–2018. .................................................................................30
Table 15. Numbers and rates of liver disease deaths, CCHCS 2012–2018. ...............................................................................30
Figure 9. Numbers and rates of Advanced liver disease deaths, CCHCS 2012–2018. ...............................................................31

Analysis of 2018 CCHCS Mortality Reviews

Table 16. Comparison of CCHCS Mortality Rates, 2012–2015 and 2016–2018. ........................................................................31
Figure 10. partial view of a CCHCS Healthcare Service Dashboard. ..........................................................................................32

Analysis of 2018 CCHCS Mortality Reviews

INTRODUCTION

The California Correctional Healthcare System (CCHCS) has been under Federal Receivership since 2005.
The receivership was established by the U.S. District Court of Northern California, four years after the settlement
of a class action law suit contesting that medical care in California’s prisons constituted a violation of the Eighth
Amendment. After several years of failure by the State to fulfill court orders to improve care, a Receiver was
appointed to oversee operations and direct improvement in the quality of medical care.
Since then, the Receivership has transformed the system of care in the 35 California prisons. In the Receiver’s
Triennial report in January 2019, the Vision and Mission of the Receivership are as follows:
Vision
As soon as practicable, provide constitutionally adequate medical care to patients of the
California Department of Corrections and Rehabilitation within a delivery system the State can
successfully manage and sustain.
Mission
Reduce avoidable morbidity and mortality and protect public health by providing patients
timely access to safe, effective and efficient medical care, and integrate the delivery of medical
care with mental health, dental and disability programs.
The history of the receivership has been one of continued improvement in the medical systems of care. As noted
in previous reports, the first three years of the Receivership (2006–2008) saw the identification and elimination of
unsafe practicing physicians. The next four years (2009–2013) was a period of significant improvement in the
systems of care. The turnaround plan of 2008 emphasized timely access to competent medical providers in a
newly designed system of primary care which replaced the previous model which, in the Receiver’s own words,
had been “chaotic and largely episodic“. The next four years (2014–2017) were characterized by a shift in the
culture of care to one of continuous quality improvement designed to be proactive, planned, informed, patientcentered, and professional. This period coincided with a court mandated 21% reduction in the size of the prison
population. The effect of this overall trajectory of systemic improvement combined with the reduction in
overcrowding was a reduction of the preventable death rates from 39/100,000 patients in the first three years of
the Receivership to 13/100,000 patients in the last four-year period.
The success of the Receivership in transforming healthcare in the California state prisons had resulted in a process
of revocable delegation. By December of 2018, 19 of the 35 California prison institutions had been delegated
from the Receivership back to the State of California. These delegations are based on favorable reviews of
medical care by the Office of the Inspector General, and are subject to ongoing periodic monitoring by the
Receiver.
This is the thirteenth annual analysis of inmate death reviews in the CCHCS. As in prior years, it will summarize the
causes of death and examine trends in these causes. It will also describe significant changes in the death review
process which were initiated in 2018. There will be attention paid to the general category of “unexpected death”,

Analysis of 2018 CCHCS Mortality Reviews

and what the new death review process has identified as “opportunities for improvement” in the systems of care.
This and all prior death report analyses are available at https://cchcs.ca.gov/reports/.

II. MORTALITY REVIEW PROCESS
Every patient death in the custody of the CCHCS is reviewed in a formal death review conducted by the statewide
Mortality Review Committee, formerly known as the Death Review Committee.
Prior to 2018, the major purposes of the mortality review process were to identify patterns in lapses in care,
particularly those that may have contributed to the patient’s death. Each death was classified as preventable,
possibly preventable or non-preventable. A major purpose of the death review process was to reduce the
occurrence of “preventable" death. As was noted in prior analyses, this process had major limitations.
There were no established criteria for attribution of preventability. Reviewing single deaths is problematic
because preventability depends on the reviewer’s subjective judgment. For example, in past years several sudden
cardiac arrests were judged to be “possibly preventable” because of a failure of clinicians to evaluate symptoms
of syncope or chest pain in the weeks or months prior to the patient’s death. Other reviewers might have judged
these same deaths to have been “non-preventable”, because a proper evaluation of these symptoms might not
have prevented the patients’ deaths. Furthermore, many patients with complete cardiovascular evaluations, who
received appropriate medications and who had appropriate interventional procedures, nevertheless succumb to
their disease. One study from the medical literature compared several reviewers’ analyses of hospital deaths,
found agreement only 34% of the time, and concluded that “preventability is in the eye of the reviewer”. (Journal
of the American Medical association, Vol.286, pp 415-423, 2001.)
A “taxonomy of lapses” was used from 2007–2017 to track both individual and system departures from the
standard of care. This taxonomy was a precursor to the current practice of identifying “opportunities for
improvement” — see below.
In December 2017, the Receiver asked for a formal assessment of the CCHCS Mortality Review Policy and
Practice. This assessment was conducted by faculty at the Criminal Justice and Health program at the University
of California at San Francisco (UCSF). The CCHCS mortality review program was compared to standard mortality
review processes in other federal and state integrated health care systems, such as those at UCSF, San Francisco
General Hospital, Kaiser of Northern California, the Mayo Clinic, and the Veterans’ Administration. All of these
systems had moved away from a classification focused on labeling deaths as “preventable/non-preventable” to
ones that classify each death as “expected/unexpected” (or “anticipated/unanticipated”). The Mayo Clinic further
incorporated “opportunities for improvement” into its matrix. The assessment noted that the evolving standard in
mortality review represents a shift away from a person centered (individual lapses) approach toward one of
systemic improvement. Following the completion and submission of this assessment, the Receiver directed that a
series of changes in the Death Review Process occur.
Beginning in 2018, the Mortality Review Unit and the Quality Management division were directed to:
•

Eliminate the “preventable death” finding and replace it with the findings of “expected or unexpected”
death with or without “opportunities for improvement (OFI)”;

Analysis of 2018 CCHCS Mortality Reviews

•

Assess the mortality review process by tracking and reporting on opportunities for improvement (OFI)
generated by death review; and

•

Utilize identified OFI to design and implement statewide system improvements.

III. DEFINITIONS
Expected Death: A death which is related to the natural course of a patient’s illness or underlying condition and is
anticipated within the timeframe in which it occurred.
Unexpected Death: Any death which was not anticipated or predicted to occur, may be related to the natural
course of a patient’s illness or underlying condition, but may also be related to a previously unrecognized
condition, such as an accident, drug overdose, homicide or suicide.
Opportunity for Improvement: An occasion or situation from which it is possible to improve systems or processes
related to the delivery of health care.

IV. THE CALIFORNIA PRISON POPULATION IN 2018
When the Receivership was created in 2006, prison overcrowding was identified as one of the major contributory
factors for poor medical care. The State of California was directed to significantly reduce the state prison
population. Between 2008 and 2012, the California prison population decreased by 21 percent. By 2015, the
average number of inmates in custody was reduced another 3 percent to 128,477.
In 2018, the average number of total inmates was 128,875 (an average of the population in custody at the end of
each of calendar quarter in 2018). The average male population was 123,014, or 95.5% of the total, while the
average female population was 5,861 representing 4.5% of the total inmate population.
FIGURE 1. CALIFORNIA PRISON POPULATION (AVERAGES OF QUARTER-END NUMBERS), 2006–2018.
180,000
135,000
90,000
171,310 170,786 170,022 169,459 166,700 161,843

134,929 133,297 135,225 128,824 128,705 130,807 128,875

45,000
0
2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

2016

2017

2018

The prison population is also gradually aging. From June of 2015 to June of 2018, the number of patients in the
California prison population who were older than 55 increased from 16,212 to 19,389 – from 12.5% to 15% of the

Analysis of 2018 CCHCS Mortality Reviews

total California prison population. (In Custody Population by Age, Offender Demographics, Office of Research,
CDCR.)

V. STUDY FINDINGS
A. Number and Causes of Inmate Death
There were 452 inmate deaths in 2018. Of these, 437 occurred in males (96.7%) and 15 in females (3.3%).
The leading cause of death was cancer (124 cases). This excludes 28 cases of liver cancer, which are instead
counted as cases of advanced liver disease – see below. Of the (non liver) cancer deaths, lung cancer (32 cases)
was responsible for the largest number of deaths. There were significant numbers of cases of colon cancer (9
cases), lymphoma (8 cases), prostate cancer (8 cases), myeloma (7 cases) and pancreatic cancer (7 cases).
The second leading cause of death was cardiovascular disease (66 cases). Sudden cardiac arrest (26 cases), acute
myocardial infarction (17 cases) and congestive heart failure (15 cases) accounted for 89% of all deaths in this
category.
Drug overdose (62 cases) was the third most common cause of death in 2018, overtaking liver disease for the first
time.
Liver disease (57 cases) was the fourth most common cause of death. As in past years, end stage (advanced) liver
disease and liver cancer are grouped together because both are a consequence of chronic hepatitis C infection.
Infectious disease (37 cases) was the fifth most common cause of death. This category includes 22 cases of sepsis
(of which 12 had a known underlying focus of infection), 8 cases of pneumonia without sepsis, 3 cases of
infectious endocarditis, and 2 cases of coccidioidomycosis.
Suicide and homicide (30 cases each) tied as the sixth most common reasons for death in 2018, similar to past
years.
TABLE 1. CAUSES OF DEATH AMONG ALL CALIFORNIA INMATES, 2018.
NUMBER
OF CASES
124

CATEGORY AND CAUSES OF DEATH
Cancer
32 lung; 9 colorectal; 8 lymphoma, (6 b-cell, 2 t-cell); 8 prostate; 7 multiple myeloma; 7
pancreas; 6 esophagus; 5 melanoma; 4 brain; 4 stomach; 3 bladder; 3 unknown primary; 3
leukemia (2 acute myeloblastic, 1 acute lymphoblastic); 2 bile duct; 2 kidney; 2 tongue; 2
malignant neuroendocrine; 1 skin; 1 squamous cell carcinoma; 1 tonsil; 1 larynx; 1 Merkel
cell carcinoma; 1 retroperitoneal sarcoma; 1 myeloproliferative disorder; 1 gastrointestinal;
1 oropharynx; 1 gastric stromal tumor; 1 abdominal wall; 1 gall bladder; 1 testis; 1
sinonasal; 1 penis; 1 sarcoma; 1 breast

Analysis of 2018 CCHCS Mortality Reviews

NUMBER
OF CASES

CATEGORY AND CAUSES OF DEATH

Cardiovascular Disease
26 sudden cardiac arrest; 17 acute myocardial infarction; 15 congestive heart failure; 3
aortic dissection; 1 aortic aneurysm rupture; 1 cardiomyopathy; 1 CHF/aortic valve
stenosis; 1 coronary artery disease; 1 endocarditis, infectious

Drug Overdose
10 methamphetamine; 8 heroin/meth; 7 heroin; 6 fentanyl/meth; 6 opiate; 5 fentanyl; 4
morphine; 2 fentanyl/heroin; 2 fentanyl/meth/morphine/alcohol; 3 unknown; 1 cocaine; 1
fentanyl/morphine; 1 fentanyl/opioids; 1 heroin/amphetamines; 1 meth/morphine; 1
mixed/opioid; 1 narcotic; 1 propranolol; 1 venlafaxine

Liver Disease
29 end stage liver disease; 28 liver cancer (hepatocellular carcinoma or HCC)

Infectious Disease
22 sepsis (9 sepsis, pneumonia; 8 sepsis, without known source; 1 sepsis, axillary abscess; 1
sepsis, Crohn disease; 1 sepsis, colitis; 1 sepsis, endocarditis; 1 sepsis, ESLD); 8 pneumonia
(incl. 1 aspiration); 3 endocarditis, infectious; 2 coccidioidomycosis (incl. 1 disseminated); 1
acute respiratory failure; 1 cellulitis

Suicide

Homicide

Pulmonary
5 chronic obstructive pulmonary disease; 2 interstitial lung disease; 2 pulmonary fibrosis;
1 aspiration pneumonia in Crohn disease

Circulatory System
8 pulmonary embolism; 1 gangrene secondary to peripheral vascular disease

Neurological Disease
3 dementia; 1 amyotrophic lateral sclerosis; 1 aspiration (seizure disorder); 1 dementiaAlzheimer; 1 epilepsy; 1 Guillain-Barré syndrome; 1 Parkinson disease

Renal Disease
6 end stage renal disease; 1 Polycystic kidney disease

Cerebrovascular Disease
5 stroke (3 hemorrhagic; 1 ischemic; 1 non-hemorrhagic)

HIV/AIDS

Analysis of 2018 CCHCS Mortality Reviews

NUMBER
OF CASES

CATEGORY AND CAUSES OF DEATH

Endocrine/Metabolic/Nutrition/Immunity
1 adrenal insufficiency; 1 diabetes mellitus

Unknown

452

Grand Total

TABLE 2. TOP CAUSES OF DEATH AMONG CALIFORNIA INMATES, 2006–2018.
YEAR

RANK

2018

Cancer

Cardiovascular
Disease

Drug
Overdose

End Stage
Liver
Disease*

Infectious
Disease**

2017

Cancer

Cardiovascular
Disease

End Stage
Liver
Disease*

Drug
Overdose

2016

Cancer

Cardiovascular
Disease

End Stage
Liver
Disease*

2015

Cancer

Cardiovascular
Disease

2014

Cancer

2013

(tied) Suicide, Homicide

Pulmonary

Circulatory
System

Infectious
Disease**

Suicide

Homicide

Cerebrovascular
Disease

Pulmonary

Infectious
Disease**

Drug
Overdose

(tied) Suicide, Homicide

Cerebrovascular
Disease

Pulmonary

End Stage
Liver
Disease*

Infectious
Disease**

Suicide

Drug
Overdose

Homicide

Cerebrovascular
Disease

Pulmonary

End Stage
Liver Disease*

Cardiovascular
Disease

Suicide

Drug
Overdose

Pneumonia

Homicide

Pulmonary

(tied)
Infectious;
StrokeHemorrhagic

Cancer

End Stage
Liver Disease*

Cardiovascular
Disease

Suicide

Drug
Overdose

Homicide

Sepsis

(tied) Pulmonary; Pneumonia

2012

Cancer

End Stage
Liver Disease*

Cardiovascular
Disease

Suicide

Homicide

Drug
Overdose

(tied) Sepsis; Infectious

Stroke

2011

Cancer

End Stage
Liver Disease*

Cardiovascular
Disease

Suicide

Pneumonia

Homicide

Sepsis

Stroke

Drug
Overdose

Analysis of 2018 CCHCS Mortality Reviews
YEAR

RANK

2010

Cancer

End Stage
Liver Disease*

Cardiovascular
Disease

Suicide

2009

Cancer

End Stage
Liver Disease*

Cardiovascular
Disease

2008

Cancer

Suicide

2007

Cancer*

2006

Cancer*

(tied) Drug Overdose;
Homicide

Pneumonia

Congestive
Heart
Failure

(tied)
Coccidioidomycosis; End
Stage Renal
Disease; Stroke

Suicide

Drug
Overdose

Pneumonia

Congestive
Heart
Failure

Homicide

End Stage
Liver
Disease*

Cardiovascular
Disease

Drug
Overdose

Pneumonia

HIV/AIDS

Congestive
Heart
Failure

Sepsis

End Stage
Liver Disease

Cardiovascular
Disease

Suicide

Homicide

HIV/AIDS

Stroke

Drug
Overdose

Pneumonia

Cardiovascular
Disease

End Stage
Liver
Disease

Suicide

Drug
Overdose

Homicide

Pulmonary

End Stage
Renal
Disease

Stroke

* Liver Cancer was counted as Cancer in 2006 and 2007; and as Liver Disease from 2008 onward.
** Beginning with 2015, Pneumonia and Sepsis were included in Infectious Disease, which also includes HIV/AIDS.

The next table compares the top causes of death in CCHCS men with those in the non incarcerated American
male population. Significant differences can be seen. In the prison population, cancer (25.3%) was the number
one cause of death while cardiovascular disease (17.5%) was second most frequent and drug overdose (13.7%)
was third. Advanced liver disease (including liver cancer was fourth (12.6%). These four accounted for 68% of all
deaths. For the American male population in 2016 (the last year for which statistics are available), cardiovascular
disease (24.4%) was number one, cancer (22.8%) ranked number two, and accidental injury was a distant third
(6.8%). Chronic liver disease accounted for 1.9% and ranked ninth.
Drug overdose, advanced liver disease, infectious diseases, suicide and homicide were all at significantly higher
percentages in the prison population than in free living American males, whereas cardiovascular disease was
significantly lower.
TABLE 3. TOP CAUSES OF DEATH AMONG CALIFORNIA INMATES, 2018, COMPARED TO AMERICAN MALE DEATHS,
2016.
CCHCS 2018

AMERICAN MALES 2016

Cancer (27.3%)

Cardiovascular (24.2%)
7

Analysis of 2018 CCHCS Mortality Reviews

Cardiovascular (14.6%)

Cancer (22.5%)

Drug overdose (13.7%)

Unintentional injury (7.4%)

Liver disease (end stage, includes liver
cancer) (12.6%)

Chronic respiratory (5.2%)

Infectious diseases (8.2%)

Stroke (4.2%)

Suicide (6.6%)

Diabetes mellitus (3.1%)

Homicide (6.6%)

Alzheimer’s disease (2.5%)

Pulmonary (2.2%)

Suicide (2.5%)

Circulatory System (2.0%)

Chronic liver disease (1.8%)

Neurological disease (1.8%)

Kidney disease (1.8%)

B. Life Expectancy in the CCHCS, 2018
The average age at death of all CCHCS male patients in 2018 was 55.9 years. That of females was 54.3 years. Non
incarcerated American males and females enjoy a life expectancy more than two decades longer. In 2016, the
American male life expectancy was 76.3 years and the average American female lived to be 81.1.
Life expectancy in California prisons is bimodal. Drug overdoses, suicides and homicides cause death at an
average of 40.3 years, whereas prisoners dying from all other causes live to an average age of 61.6 years.

Analysis of 2018 CCHCS Mortality Reviews

TABLE 4. RANGES AND AVERAGE AGES AT DEATH AMONG ALL CALIFORNIA INMATES, 2018.
Age Range

Average Age

Age of all 437 male decedents

19 – 94

55.9

Age of all 15 female decedents

28 – 77

54.3

Age of suicides, drug overdoses, and homicides

19 – 77

40.3

Suicide

22 – 71

38.7

Drug overdose

21 – 71

42.3

Homicide

19 – 77

37.8

25 – 94

61.6

Age excluding suicide, drug overdose, and homicide

C. Expected Deaths in 2018
There were 244 cases of expected death in 2018. All expected deaths were the result of known disease processes.
Cancer, liver disease, chronic cardiovascular disease (mainly congestive heart failure) and infectious disease
processes accounted for nearly 90% of all expected deaths.

D. Unexpected Deaths in 2018
There were 208 cases of unexpected death in 2018. Drug overdose, suicide and homicide accounted for 123 or
59% of all unexpected deaths. Sudden cardiac arrest and acute myocardial infarction were 44 or 21% of all
unexpected deaths. These five causes together were 90% of all unexpected deaths.

Analysis of 2018 CCHCS Mortality Reviews

FIGURE 2. INMATE DEATHS BY EXPECTATION AND CATEGORY, CCHCS 2018.
Cancer
Cardiovascular Disease
Cerebrovascular Disease
Circulatory System
Drug Overdose
Endocrine/Metabol/Nutrition/Immunity
HIV/AIDS
Homicide
Infectious Disease
Liver Disease
Neurological Disease
Pulmonary
Renal Disease
Suicide
Unknown

-=]

■ Unexpected

■

Expected
118
I

42
7 2

02
12

30
16

2I
2 6
1 9
2 5

)

10
0

0
21
55

120

E. Opportunities for Improvement, 2018
The identification of opportunities for improvement (OFI) is now a major responsibility of the Mortality Review
process. In 2018, the Mortality Review Committee identified 392 OFI. Of these, 196 occurred in 162 of the 244
expected deaths and 196 occurred in 140 of the 208 unexpected deaths.
Thus, expected deaths yielded an average of 196/244 or 0.80 OFI per case, whereas the unexpected deaths
yielded an average of 196/208 or 0.94 OFI per case.
A single OFI in a Mortality Review can be relatively minor (minor documentation inconsistencies in notation of
time an incident occurred) or potentially quite serious (lost request for a diagnostic test during a patient transfer
from one institution to another, resulting in significant delay in diagnosis of a treatable condition). There is
currently no standardized way to grade the seriousness of any single OFI. That assessment must take place during
the OFI review process.
The CCHCS is creating a taxonomy for OFIs, but a finalized version is not yet available. Therefore, for the sole
purpose of this review of 2018 deaths, an interim classification system for OFI has been created.

Analysis of 2018 CCHCS Mortality Reviews

TABLE 5: OPPORTUNITIES FOR IMPROVEMENT – INTERIM CLASSIFICATION FOR 2018 MORTALITY REVIEWS AND
FREQUENCY IN UNEXPECTED AND EXPECTED DEATHS.
Frequency in

Unexpected
Deaths

Expected
Deaths

All
Deaths

Opportunities for better education/training and improved
documentation on CCHCS emergency medical response
protocols

Opportunities to improve care near the end of life

Important clinical signs and symptoms that were
subject to errors in decision making

Opportunities for better adherence to the care guides
for a specific disease or conditions

Opportunities to apply complex care management for
improved care coordination

Opportunities to improve access by meeting
timeframes for routine and urgent care
Urgent – Unexpected: 1 Expected: 4
Routine – Unexpected: 4 Expected: 5

Opportunities for better patient counseling or
education in cases where patients do not adhere to
recommendations for appropriate care

Opportunities for improved pain management

Physicians orders for life sustaining treatment not
initiated or patients’ end of life decisions for intensity
of care not followed.
Opportunities to improve clinical decision making

Opportunities for better medication management
Opportunities for improved application of the model of care
as outlined in the CCHCS Complete Care Model
General lack of Primary Care Team model
Opportunities to improve follow-up on abnormal
laboratory and diagnostic imaging reports

Analysis of 2018 CCHCS Mortality Reviews

Frequency in

Unexpected
Deaths

Expected
Deaths

All
Deaths

Opportunities to improve medical record documentation

Opportunities for improved communication in a care
transition

Care Team - Specialty Care

Care Team - Hospital

Care Team - Mental health

Care Team - Custody

Care team - Emergency Dept

PCP - PCP

PCP - Nursing

Opportunities to utilize a substance use disorder (SUD)
protocol for patients who have opiate addiction

Opportunities to address reasons for delays in initiating
appropriate treatment

Opportunities to mitigate fall risk

Opportunities to prevent a pressure ulcer

Miscellaneous opportunities for improvement

196

392

Opportunities to transfer a patient to a more
appropriate level of care

TOTALS

Analysis of 2018 CCHCS Mortality Reviews

The following discussion addresses each of these areas.

1. Opportunities for better education/training and improved documentation on CCHCS emergency
medical response protocols.
Unexpected 53

Expected 5

Total 58

There were 58 total OFI in this category. Fifty-three occurred in the unexpected deaths, and only 5 in the
expected deaths. (There were many fewer emergency protocols initiated in the expected deaths because of prior
discussions resulting in patients electing no resuscitation in case of a terminal event.) Areas singled out for
improvement included more precise documentation and timing of events, earlier initiation of 911 calls, control of
traumatic bleeding, better training in airway and vascular access, and proper response to ECG patterns. In 2019,
because of these OFI and prior years’ experiences indicating a need for improvements in the area of emergency
response, a major statewide initiative of onsite training in Emergency Medical Response was initiated.

2. Opportunities to improve care near the end of life.
a. Physicians orders for life sustaining treatment not initiated or patients’ end of life decisions for intensity of care
not followed.
Unexpected 21

Expected 36

Total 57

The CCHCS honors the ethical principal of patient autonomy and directs physicians to provide a physician order
for life sustaining treatment (POLST) which gives patients that are “elderly, frail, burdened with serious chronic
medical conditions, or have less than six months’ life expectancy” an opportunity to provide specific directions for
their end of life care, including desire to not attempt resuscitation in the event of a terminal emergency. This is
called a DNR/ DNI order (“do not resuscitate/do not intubate”). Periodic discussions regarding goals of treatment
or continued treatment in the face of advanced illness are to be honored. There were 36 OFI in expected deaths
and 21 in unexpected deaths in this category. Of these 57 OFI, 15 patients had specific orders for no further life
sustaining treatment but experienced attempted cardiopulmonary resuscitation or were sent out to hospital
emergency rooms and experienced hospitalizations and heroic life sustaining measures. A few had inoperable or
metastatic cancers or end stage chronic illnesses. In 44 cases, patients who fulfilled POLST criteria had not had
POLST discussions initiated by their physicians or care teams.

3. Opportunities to improve clinical decision making.
a. Important clinical signs and symptoms that were subject to errors in decision making.
Unexpected 24

Expected 26

Total 50

There were 50 OFI in this category, almost equally distributed between deaths that were unexpected (24) and
deaths that were expected (26). (See Table 5 OFI.) Many of these were “red flag symptoms” or potential
13

Analysis of 2018 CCHCS Mortality Reviews

indicators of serious underlying diseases. These included chest pain and atypical left shoulder pain heralding
potentially serious cardiovascular disease. Symptoms and signs of malignancy included unexplained weight loss,
visible hemorrhage (hematochezia, hematemesis, hematuria). sudden alteration in mental status, persistence of
enlarging or painful masses, and persistent localized pain in patients with known cancers. One case involved
visible choking in which the Heimlich maneuver was not done. Table 6 details these OFI.

TABLE 6. OPPORTUNITIES TO IMPROVE CLINICAL DECISION MAKING: SIGNS AND SYMPTOMS SUBJECT TO
COGNITIVE ERRORS, AND (IN PARENTHESES) THE CONDITIONS THEY PORTENDED, CCHCS 2018.
Unexpected Death (24)

Expected (26)

7 chest pain (1 rupture aortic aneurysm,
1 acute myocardial infarction)

3 chest pain (2 coronary artery disease,
1 congestive heart failure)

4 hypertension (1 sepsis)

4 weight loss (liver, bile duct, prostate, esophageal
cancers)

2 weight loss (COPD, myeloma)

1 hypotension (sepsis)

2 hypotension (sepsis, myocardial infarction)

2 tachycardia (sepsis, CHF)

1 tachycardia (pneumonia)

2 melena (ca stomach, esophageal varices)

1 melena or blood in stool (myeloma)

1 abdominal mass (ca, desmoplastic)

1 neck mass (cancer)

1 back pain (metastatic ca)

1 back pain (metastatic lung ca)

2 altered mental status (ca brain)

1 “history of DVT” (pulmonary embolism)

1 numbness (stroke)

1 cough

1 Abdominal pain (liver ca)

1 SOB

1 heartburn, persistent (esophageal ca)

1 dizziness

1 hemoptysis (ca esophagus)
1 skin lesion (melanoma)
1 L arm swelling (breast ca)
1 choking (Heimlich not considered)
1 leg ulcer (gangrene)

Analysis of 2018 CCHCS Mortality Reviews

1 headache
1 hematemesis (ca bile duct)
1 hematuria

b. Opportunities for better adherence to the care guides for a specific disease or condition.
Unexpected 10

Expected 9

Total 19

The Care Guides (https://cchcs.ca.gov/clinical-resources/) are tools for use by clinicians and care teams in the
management of patients with the following conditions: Advanced Liver Disease, Anticoagulation, Asthma, Chest
Pain, Chronic Wound Management, Clozapine, Coccidioidomycosis, Chronic Obstructive Pulmonary Disease,
Cognitive Impairment/Dementia, Diabetes, Dyslipidemia (high or abnormal cholesterol), Foreign body
ingestion/insertion (new), Gender Dysphoria, Hepatitis C, HIV, Hunger Strike, Hypertension, Major Depressive
Disorder, Pain Management, Palliative Care, Schizophrenia, Seizure Disorders, Skin and Soft Tissue Infections,
Tuberculosis, and Weight Management (new).
Similar resources for nursing staff are also in use and include protocols and encounter forms for patients with
Abdominal Trauma, Allergic Reaction(s), Asthma, Burns, Chest Pain, Chest Trauma, Constipation, Dental
Conditions, Earache, Epistaxis, Eye injury/ irritation, Female Genitourinary Complaints, Headache, Hemorrhoids,
Rash, Insect Stings, Intravenous Therapy, Loss of Consciousness, Musculoskeletal Complaints, Respiratory
Distress, Seizure, Tetanus Prophylaxis, Upper Respiratory Infections, and Wound Care.
The 19 OFI in this category were almost equally distributed among unexpected (10) and expected (9) deaths.
There were 10 cases in which the Hepatitis C virus infection or Advanced liver disease guidelines were not
followed. These included 5 cases in which screening for liver cancer was not done according to recommended
intervals or not done at all, 1 case in which screening for esophageal varices was not done at recommended
intervals, 1 case in which consideration for specific HCV treatment was delayed, and 1 case in which
recommended prophylaxis for spontaneous bacterial peritonitis was not prescribed. There were 2 cases in which
the Anticoagulation guide was not followed. There were 3 cases in which statins were not given to patients at risk
for heart attack. There was a case of suspected tuberculosis in which recommendations from the Tuberculosis
guide were not followed. There was a case of congestive heart failure in which weights were not monitored and a
case in which a Foley catheter was not well cared for. Although no specific care guide or protocol exists, the care
for these conditions is included in standardized nursing and physician training of which all clinical personnel
should be aware. There was a case citing a failure to request autopsy when the cause of death was unknown.
c. Opportunities for better medication management.
Unexpected 3

Expected 1

Total 4

Analysis of 2018 CCHCS Mortality Reviews

The four patients in this group were a patient with anemia on daily aspirin, a patient with a history compatible
with substance use disorder prescribed narcotics for chronic pain, a patient with poor medication compliance and
mental illness prescribed an antihypertensive medication, propranolol, as KOP (keep on person), which he later
used to overdose, and a patient with recurrent seizures who had multiple sub therapeutic levels of anticonvulsant
medication.

4. Opportunities for improved application of the model of care as outlined in the CCHCS Complete
Care Model
The model of care outlined in the Complete Care Model (CCM) is the foundation for delivery of all care in the
CCHCS. Based on the industry standard of the Patient Centered Medical Home, the CCM creates Interdisciplinary
Care teams and assigns each patient to such a care team’s panel of patients. CCM policies and procedures are
intended to ensure continuous, comprehensive, coordinated and patient centered care which meets standards
for access, prevention, screening and evidence based management of acute and chronic illnesses. It makes use of
standardized processes such as daily care team huddles, panel management strategies, performance dashboards,
master patient registries, patient summaries, and decision support tools such as the Care Guides.

a. General lack of Primary Care Team model
Unexpected 1

Expected 11

Total 12

There were 12 total OFI citing a general failure to apply a care team model of care as outlined in the CCHCS
Complete Care Model. The majority of these noted the presence of multiple primary care providers (up to 8 in a
single case) in cases of complex medical illness, or in cases in which patients may have been transferred several
times, causing discontinuity and difficulty with needed care coordination.
b. Opportunities to improve follow-up on abnormal laboratory and diagnostic imaging reports.
Unexpected 14

Expected 13

Total 27

There were 27 OFI in this category, almost equally divided between the unexpected deaths (14) and expected
deaths (13). The majority of these cases occurred because of a lack of continuity of providers, poor
communication on weekends or shift changes, or lack of adherence to procedures intended to ensure that all test
results are conveyed in a timely manner to a member of the patient’s care team.
c. Opportunities to apply complex care management for improved care coordination.
Unexpected 8

Expected 13

Total 21

There were 21 OFI in this category. All of these patients had multiple chronic diseases, recent hospitalizations, or
end stage illnesses. These patients fall into the category of “high risk, high utilization”. They typically generate
large numbers of encounters with the need for multiple laboratory tests, diagnostic imaging and special
procedures, specialty care visits, special treatments such as chemotherapy and hemodialysis, emergency
16

Analysis of 2018 CCHCS Mortality Reviews

department visits, and hospitalizations. They are at risk for events that lead to rapid changes in their clinical
conditions, and would benefit from special attention by a member or members of the care team, so called “case
management” or “complex care management”.
d. Opportunities to improve access by meeting timeframes for routine and urgent care.
Unexpected 5

Expected 9

Total 14

Urgent 1

Urgent 4

Subtotal (5)

Routine 4

Routine 5

Subtotal (9)

There were 14 OFI citing standards of access not being met. Of these, 5 were urgent and 9 were routine.
The following 5 cases did not meet the 2-week standard for an urgent referral.
1. Urgent abdominal MRI referral for pelvic mass - 2 weeks and 5 days
2. Urgent colonoscopy referral for rectal bleeding- 3 weeks
3. Urgent cardiology referral for chemotherapy clearance - 6 weeks
4. Urgent radiation oncology referral for liver cancer therapy - 3 months
5. Urgent echocardiogram referral for congestive heart failure. Not done, and the patient expired 3 weeks
after order submitted.
e. Opportunities for better patient counseling or education in cases where patients do not adhere to
recommendations for appropriate care.
Unexpected 4

Expected 6

Total 10

There were 10 OFI when patients who had refused recommended treatments or tests might have benefitted from
targeted counseling and more or better documented education by the care team.
f.

Opportunities for improved pain management.
Unexpected 4

Expected 5

Total 9

There were 9 cases in which an OFI for improved pain management was cited. The application of the CCHCS Care
Guides for Pain Management and for Palliative Care were mentioned in these cases.
g. Opportunities to transfer a patient to a more appropriate level of care.
Unexpected 1

Expected 4

Total 5

There were 5 OFI citing a missed opportunity to move a patient to a level of care more appropriate to their clinical
severity. There were 2 patients with foot ulcers who might have benefitted from more aggressive monitoring and
referral to the CCHCS Wound Management Team (see Care Guide for Chronic Wound Management). One patient
17

Analysis of 2018 CCHCS Mortality Reviews

might have benefited from a higher level of care for progressive end stage liver disease. Another patient with end
stage liver disease who decompensated one day after discharge from the local hospital might have benefited
from immediate transfer to a higher level of care. A cancer patient with increasing debilitation might have
benefited from transfer to a higher level of care. All of these cases placed the responsibility on the primary care
team for evaluation of the whole patient, especially after a deterioration in the patient’s clinical condition.

5. Opportunities to improve medical record documentation.
Unexpected 18

Expected 24

Total 42

The adoption of the electronic medical record has created a requirement for more complete documentation of
visits, which has been time-consuming for provider staff. This in turn has created an unfortunate workaround by
some providers who “cut and paste” sections of prior patient encounters in service of personal efficiency (termed
legacy charting). Time pressure also can result in inadequate or inaccurate documentation. The need to
incorporate records of patient encounters outside the prison system of care (such as outside specialist notes or
hospital or emergency room visits) can result in such encounters being unavailable or missing for a time. The 42
OFI in this category showed 14 inadequate, 20 missing, 4 inaccurate and 4 legacy charting citations. All of these
were referred to the institutions where they occurred for local action.

6. Opportunities for improved communication in a care transition
Unexpected 10

Expected 17

Total 27

Care Team - Specialty Care

Care Team - Hospital

Care Team - Mental health

Care Team - Custody

Care team - Emergency Dept

PCP - PCP

PCP - Nursing

The accurate transfer of clinical information between care teams at transitions of medical care is important for
high quality patient care. Lost or inaccurate information as to patients’ end of life wishes for care, for example,
can lead to unnecessary procedures or expensive and painful efforts to prolong life in the emergency room,
hospital, or intensive care unit. Missed information from specialists to the primary care teams can lead to critical
tests being delayed or not done. There were 27 OFI in this general category. Of these, 7 cited deficiencies in
communication between the primary care team and the hospital facility, 5 cited care team - emergency room
communication, 6 cited care team - specialist consultation, 5 cited care team - mental health, 4 cited care team custody and 1 each cited primary care provider - primary care provider, and primary care provider - nursing
communications.
18

Analysis of 2018 CCHCS Mortality Reviews

7. Opportunities to utilize a substance use disorder (SUD) protocol for patients who have opiate
addiction.
Unexpected 16

Expected 1

Total 17

During 2017 the CCHCS developed a proposal to revise and expand existing Substance Abuse Disorder training,
including the incorporation of Medication Assisted Treatment (MAT) for patients identified as having Substance
Use Disorder (opiate addiction). This treatment of SUD as a chronic medical condition has been shown to
significantly reduce overdose deaths in non prison populations. There were 16 patients who might have qualified
for a SUD protocol. Of these, 15 were patients who had died from opiate overdose.

8. Opportunities to address reasons for delays in initiating appropriate treatment.
Unexpected 2

Expected 6

Total 8

There were 8 OFIs in which a delay in initiating appropriate treatment was cited. These cases are described in
Table 7 below.

TABLE 7. DELAYS IN INITIATING APPROPRIATE TREATMENT
Unexpected Deaths
1. 8 month delay in treatment of a cancer of the vocal cord - multifactorial (lack of coordinated care)
2. 9 month delay in treatment of scalp cancer - due to lack of coordination of care, case management
Expected Deaths
3. A 3 week delay initiating treatment for melanoma because of lost specialty referral requests during a
period in which electronic medical record was being installed at the institution.
4. A 12 hour delay initiating treatment for central line bacteremia with positive blood culture. The provider
was aware but did not initiate rx because “visual inspection of IV appeared normal “.
5. Indeterminate delay in initiating transfer to hospice - reason not cited
6. A 3 week delay in obtaining a staging CT scan for pancreatic cancer staging (ordered “routine” instead of
“urgent”)
7. A 7 month delay in the diagnosis of pancreatic cancer. The specialist recommendation for CA -19 lab test
was either lost or not acted upon.
8. A delay initiating oxygen therapy for a patient with COPD and low oxygenation.

Analysis of 2018 CCHCS Mortality Reviews

Delays in initiating treatment can be the result of poor decisions, failed processes, or both. Mistakes in judgment
led to an incorrect action or lack of action in cases 1, 4, 6, and 8. Systemic problems led to delays in cases 2, 3, 5,
and 7.

9. Opportunities to mitigate fall risk.
Unexpected 0

Expected 7

Total 7

The local operating procedures for Falls Risk Assessment is intended to provide guidelines for the prevention of
falls, for post-fall assessment, treatment, and intervention. There were 7 OFI citing high fall risk, all in chronically
ill patients who eventually had expected deaths. These patients had either not had a fall protocol applied to their
care, or in some cases, fall protocols were not followed.

10. Opportunities to prevent a pressure ulcer.
Unexpected 1

Expected 2

Total 3

There were 3 OFI in which patients developed pressure ulcers. One developed in a bed bound patient with
myeloma, and two others developed in patients during prolonged hospitalizations at outside facilities.

11. Miscellaneous Opportunities for Improvement
Unexpected 1

Expected 1

Total 2

There were 2 miscellaneous OFIs. One cited a delay in delivery of prescribed medication - a man who had
resection of a malignant brain tumor who missed starting a seven day taper of dexamethasone by 24 hours after
discharge from the hospital where he had undergone tumor resection. A second case cited possible inappropriate
housing when a patient with severe mental illness who had expressed fear of “enemies” was placed at risk in a
double cell.
A process for tracking, analyzing and prioritizing of OFI is being integrated into the overall Quality Improvement
Program. This process is expected to be formalized in the revised Mortality Review and Reporting policy by the
end of 2019.

F. Delays in Diagnosis, 2018
Delays in diagnosis should be avoided whenever possible. There were 37 cases in which significant delays were
noted in 2018. All of these cases generated “opportunities for improvement”. They are gathered here to allow
analysis of the specific categories of OFI which carried the greatest risk for delays in diagnosis.
20

Analysis of 2018 CCHCS Mortality Reviews

TABLE 8. DIAGNOSTIC DELAYS, CCHCS 2018.
“Red flag” symptom or sign

Diagnosis

Delay

weight loss

esophageal cancer

4 weeks

weight loss

cholangiocarcinoma

6 weeks

weight loss

multiple myeloma

indeterminate

weight loss

liver cancer

indeterminate

persistent pain (“rib”)

neuroendocrine tumor

6 months

persistent pain (back)

metastatic cancer

indeterminate

persistent pain (mid sternum)

metastatic round cell ca

8 months

suspicious skin lesion

melanoma

3 months

suspicious skin lesion

squamous cell ca, scalp

9 months

abnormal history: ”I have DVT”

deep vein thrombosis

20 days

abnormal history: “I have prostate cancer”

prostate cancer

3 years

persistent sore throat

tonsillar cancer

3 months

persistent hoarseness

laryngeal cancer

7 months

heartburn

esophageal cancer

3 years

hemoptysis

esophageal cancer

5 months

hematochezia

stomach cancer

5 months

persistent neck mass

base of tongue cancer

3 months

hemisensory numbness

brain cancer

6 weeks

Abnormal test

Diagnosis

Delay

chest x ray

lung cancer

4 months

chest x ray

lung cancer

6 months

chest x ray

lung cancer

3 years 5 months
21

Analysis of 2018 CCHCS Mortality Reviews

chest x ray

mediastinal mass

6 months

pancytopenia

lymphoma

5 yr 3 mo (also patient refusal)

pancytopenia

myeloproliferative disorder

11 months

fecal blood test

rectal cancer

16 months

prostate specific antigen

prostate cancer

7 months

CT pelvis

sarcoma

33 days

liver biopsy

amyloidosis in myeloma

3 months

liver function

liver cirrhosis

6 years (also patient refusal)

Access to Specialist

Diagnosis

Delay

oncology

colon cancer

1 month

dermatology

melanoma

2 months

oncologist

liver cancer

6 months

tumor board

liver cancer

10 months

Screen

Diagnosis

Delay

ultrasound

liver cancer

indeterminate (years)

“surveillance”

testicular cancer

indeterminate

Miscellaneous

Diagnosis

Delay

two interfacility transfers

anal melanoma

3.5 months

multiple PCPs over years

cardiomyopathy with sudden
cardiac arrest

4 years

A delay in diagnosis can occur when an error in clinical judgment results in a failure to properly evaluate an
important clinical sign or symptom.

Analysis of 2018 CCHCS Mortality Reviews

There were 18 of these “red flag” cases in the 2018 mortality reviews, resulting in a range of delays from 20 days
to 3 years. Eleven were in expected deaths and 7 were in unexpected deaths. Sixteen of these cases resulted in a
delayed diagnosis of cancer. One resulted in a delayed diagnosis of a deep vein thrombosis.
Inexplicable loss of weight was nearly always an indication of serious underlying disease, usually cancer. Persistent
symptoms or symptoms involving blood loss or focal pain were also red flags signifying potential cancers.
Suspicious skin lesions should have been referred expeditiously for biopsy.
Abnormal diagnostic test results which were lost, not noted or not followed up resulted in 11 cases of delayed
diagnosis ranging 3 months to 6 years. The vast majority of these (10 cases) occurred in expected deaths. Two
cases were complicated by prolonged patient non adherence to recommendations for follow up testing.
A delay in access to one or more specialist consultations resulted in significant delays in 4 cases. In one of these,
the diagnosis had been made but availability of a tumor board opinion delayed treatment recommendations.
Recommended screening intervals were not followed, resulting in diagnostic delay in 2 cases.
Miscellaneous systemic reasons were cited in 2 cases as reasons for diagnostic delay.
In all, 34 of the 37 cases resulted in a delayed diagnosis of cancer.

VI. DISCUSSION OF TRENDS
A. Trends in Prison Mortality Rates in California and the United States
The following table shows the number of deaths and the corresponding mortality rates from 2006–2018. (U.S.
State Prison figures from the Bureau of Justice Statistics 12/15/2016 (most recent available):
.https://www.bjs.gov/index.cfm?ty=pbdetail&iid=5866 )
TABLE 9. ANNUAL MORTALITY RATES AMONG CALIFORNIA AND U.S. STATE PRISON INMATES, 2006–2018.
YEAR

CCHCS NUMBER
OF DEATHS

CCHCS NUMBER OF CCHCS DEATH RATE TOTAL U.S. STATE PRISON
INMATES
PER 100,000
DEATH RATE PER 100,000

2006

424

171,310

248

249

2007

395

170,786

231

256

2008

369

170,022

217

260

2009

393

169,459

232

257

2010

415

166,700

249

245

2011

388

161,843

240

260
23

Analysis of 2018 CCHCS Mortality Reviews

2012

362

134,929

268

265

2013

366

133,297

275

274

2014

319

135,225

236

275

2015

355

128,824

276

not available

2016

334

128,705

260

not available

2017

388

130,807

297

not available

2018

452

128,875

351

not available

260 (217–351)

260 (245–275)

Average (Range)

The following figure shows the trended death rates for the CCHCS from 2006–2018, and the trended death rates
for all US prisons from 2006–2014 (most recent available). The rate of death in California prisons has risen in each
of the past two years, and appears to be on a generally upward trend since 2014 - 2015.
FIGURE 3. TRENDED ANNUAL DEATH RATES AMONG CALIFORNIA AND U.S. STATE PRISON INMATES, 2006–2018.

eath rate per 100,000
inmates

CCHCS
425
360
295
230
165
100

2006

2007

2008

2009

2010

TOTAL U.S. State Prison

2011

2012

2013

2014

2015

2016

2017

2018

B. Discussion of Trends in CCHCS Mortality Rates
In 2018, the 452 CCHCS deaths and the mortality rate of 351/100,000 were the highest in the 13-year history of
this report. Possible reasons for this include the general aging of the prison population, as well as specific causes
that contribute disproportionally to the increase.
1. Aging. It is known that death rates in general increase with age. And as was noted in a previous section of this
report, the age of the CCHCS population has been gradually increasing, especially over the years from 2015–2018,
when the number of patients over the age of 55 increased from 12.5% to 15% of the population.

Analysis of 2018 CCHCS Mortality Reviews

An analysis was performed by CCHCS staff, comparing age adjusted mortality rates for “non natural” versus
“natural” causes of death. (Non natural causes were considered to be accidents, homicides, suicides and drug
overdoses. Natural causes were all other.)
The analysis concluded that there was no statistically significant increase in age adjusted deaths from natural
causes but there was a statistically significant increase in age adjusted deaths related to drug overdoses, suicides
and homicides.
2. Specific causes. The inmate population reached a new lower baseline after the mandated reduction was
accomplished in 2012. For this 2018 analysis, an adjusted baseline mortality rate is established for the period
between 2012 and 2015. This is then compared to the mortality rates in the subsequent three year period, 2016–
2018, a period during which the aging of the general population was demonstrated.
The trends in mortality for the non natural causes drug overdose, homicide, and suicide are discussed. Trends in
mortality for three of the natural causes – cardiovascular disease, lung cancer and advanced liver disease – are
also discussed.

C. Annual Mortality Rates, 2012–2018
1. Drug overdose
TABLE 10. NUMBERS AND RATES OF OVERDOSE DEATHS, CCHCS 2012–2018.
Year

CCHCS drug
overdoses

CCHCS Overdose
Rate/100,000

2012

11.1

2013

2014

14.1

2015

14.7

2016

22.5

2017

30.6

2018

48.1

Analysis of 2018 CCHCS Mortality Reviews

FIGURE 4. NUMBERS AND RATES OF OVERDOSE DEATHS, CCHCS 2012–2018.

70.

CCHCS drug overdoses

Rate/100,000

Linear (Rate/100,000 )

52.5
35.
17.5
0.

2012

2013

2014

2015

2016

2017

2018

There has been a dramatic increase in the number of deaths and death rates from drug overdose from 2016–
2018, reflecting the experience in the non incarcerated general population of the United States. Of the 62
overdose deaths in 2018, there were only two in which a prescribed drug was used. One of these cases involved
the antidepressant venlafaxine (thought to be an unintentional overdose). One other case was a probable
intentional overdose with prescribed propranolol. The overwhelming majority of other cases were caused by illicit
opioids and/or amphetamines. Various opioids (heroin, morphine, fentanyl, opioids, codeine) either alone or in
combination, were detected in 47 of these cases. Fentanyl, a powerful synthetic opioid increasingly seen in
overdoses in the civilian population, was detected in 17 cases. Methamphetamines, either alone or in
combination with opioids, were detected in 28 cases. As in the past several years, none of these deaths were
caused by opioids prescribed to the patients by CCHCS physicians.

2. Cardiovascular Disease
TABLE 11. NUMBERS AND RATES OF CARDIOVASCULAR DEATHS, CCHCS 2012–2018.
Year

Cardiovascular Deaths

Rate/100,000

2012

31.9

2013

37.5

2014

39.9

2015

48.1

2016

40.4

2017

2018

51.2

Analysis of 2018 CCHCS Mortality Reviews

FIGURE 5. NUMBERS AND RATES OF CARDIOVASCULAR DEATHS, CCHCS 2012–2018.
Cardiovascular Deaths
87.5
70.
52.5
35.
17.5
0.

2012

2013

2014

2015

2016

2017

2018

There has been an increase in the average numbers and rates of deaths due to cardiovascular disease between
the two periods of 2012–2015 and 2016–2018. Most of this increase has been in sudden cardiac arrest,
myocardial infarction and congestive heart failure. The CCHCS Care Guides for chest pain, diabetes, dyslipidemia
and hypertension all address the management of the significant risk factors for coronary heart disease. They
contain “state of the art” evidence-based guides for management of known coronary heart disease and
congestive heart failure and recognition of red flag symptoms indicating acute coronary syndromes. Nevertheless,
the frequency of known risk factors including smoking, hypertension, hyperlipidemia and diabetes mellitus is high
in this population and a renewed emphasis on prevention and control might be warranted.

3. Homicide
TABLE 12. NUMBERS AND RATES OF HOMICIDES, CCHCS 2012–2018.
Year

CCHCS Homicides CCHCS Homicide
Rate/100,000

2012

15.6

2013

2014

6.7

2015

12.4

2016

20.2

2017

14.5

2018

23.3
27

Analysis of 2018 CCHCS Mortality Reviews

FIGURE 6. NUMBERS AND RATES OF HOMICIDES, CCHCS 2012–2018.

37.5
30.
22.5
15.
7.5
0.

15.6

15.
6.7

2012

2013

2014

CCHCS Homicides

12.4

2015

20.2

2016

23.3
14.5

2017

2018

The numbers and death rates for homicide trended up for the period 2016–2018. In 2018, the homicide
mortality rate (23.3/100,000) was the highest since these reports have been tracking them. Accounting for this
increase is beyond the scope of this report, except to note that the homicide rate continues to be more than 3
times the national average for state prisons, which was 7.0 for the three-year average from 2012–2014.
(bjs.gov/content/pub/pdf/shspli.pdf)

4. Suicide
TABLE 13. NUMBERS AND RATES OF SUICIDES, CCHCS 2012–2018.
Year

CCHCS Suicides

CCHCS Suicide
Rate/100,000

2012

23.7

2013

22.5

2014

2015

18.6

2016

20.2

2017

23.7

2018

23.3

Analysis of 2018 CCHCS Mortality Reviews

FIGURE 7. SUICIDE RATES IN CCHCS AND U.S. STATE PRISONS, 2012–2018.

28.
21.
14.
7.
0.

CCHCS Suicide Rate/100,000

23.7

22.5

2012

2013

17.

20.2

18.6

2014

U.S. State Prison Suicide Rate/100,000

2015

23.7

2016

2017

23.278

2018

The numbers and rates of suicide for the period of 2016–2018 show a slight increase over the baseline period of
2012–2015. There have been ongoing persistent efforts to recognize and treat severe depression and suicidal
ideation and to improve the communication between the behavioral health and the medical departments of
CCHCS.

5. Lung cancer
TABLE 14. NUMBERS AND RATES OF LUNG CANCER DEATHS, CCHCS 2012–2018.
Year

CCHCS lung cancer deaths

CCHCS lung cancer
mortality rate/100,000

2012

14.8

2013

15.8

2014

12.6

2015

2016

14.8

2017

9.9

2018

24.8

Analysis of 2018 CCHCS Mortality Reviews

FIGURE 8. NUMBERS AND RATES OF LUNG CANCER DEATHS, CCHCS 2012–2018.

40.

Lung Cancer Deaths

30.
20.
10.
0.

2012

2013

2014

2015

2016

2017

2018

The change in mortality rates from lung cancer between the two periods is not significant. There is no obvious
explanation for the spike in the rate of CCHCS lung cancer deaths in 2018. Lung cancer is also the leading cause of
cancer death in males in the United States. Interestingly, in recent years there has been some movement toward
the evidence based recommendation for screening for lung cancer at an earlier stage. In 2014 ,the US Preventive
Services Taskforce issued a Grade B recommendation for the use of low dose CT scanning to screen for lung
cancer in patients older than 55 who have a long history of smoking. The CCHCS has not yet adopted this
recommendation.

6. Advanced liver disease (end stage liver disease and liver cancer combined)
TABLE 15. NUMBERS AND RATES OF LIVER DISEASE DEATHS, CCHCS 2012–2018.
YEAR

Liver Cancer
Deaths

Cirrhosis Deaths Total Hepatitis C
Deaths

CCHCS Number
of Inmates

CCHCS HEP C
ASSOCIATED
DEATH RATE
PER 100,000
INMATES

2012

134,929

53.4

2013

133,297

52.5

2014

135,225

50.3

2015

128,824

43.5

2016

128,705

31.9

2017

130,807

29.8

2018

128,875

44.2
30

Analysis of 2018 CCHCS Mortality Reviews

FIGURE 9. NUMBERS AND RATES OF ADVANCED LIVER DISEASE DEATHS, CCHCS 2012–2018.

80.

CCHCS Total Hepatitis C Deaths

60.
40.
20.
0.

2012

2013

2014

2015

2016

2017

2018

The CCHCS has created a number of initiatives to improve the screening for and treatment of hepatitis C with the
new direct acting antiviral agents, for the use of ultrasound screening for liver cancer in these high risk patients,
and for improving the overall care of patients with advanced liver disease by recommending evidence based
screening and treatment strategies for specific complications such as esophageal varies and spontaneous
bacterial peritonitis. The overall course of disease progression in these patients is many years in duration, but it
appears that significant improvements in mortality might be a result of these efforts.
TABLE 16. COMPARISON OF CCHCS MORTALITY RATES, 2012–2015 AND 2016–2018.
Mortality Rates

2012–2015
mean (range)

2016–2018
mean (range)

Delta

Mortality Rate, overall

264 (236 –- 276)

303 (260 - 351)

+39

Drug Overdose

14.5 (11.1 - 18.0)

33.7 (22.5 - 48.1)

+29.2

Cardiovascular

39.6 (31.9 - 48.1)

47.8 (40.4 - 51.9)

+8.2

Homicide

12.4 (6.7 - 15.6)

19.3 (14.5 - 23.3)

+6.9

Suicide

20.5 (17.0 - 23.7)

22.4 (20.2 - 23.7)

+1.9

Lung Cancer

16.1 (12.6 - 21.0)

16.5 (9.9 - 24.8)

+0.4

Advanced Liver Disease

50.0 (43.5 - 53.4)

35.3 (29.8 - 44.2)

-14.7

Analysis of 2018 CCHCS Mortality Reviews

The overall mortality rate increased by 39/100,000, from an average of 264/100,000 in 2012–2015 to an average
of 303/100,000 in 2016–2018. Drug overdose (+29), cardiovascular diseases (+8), homicides (+7), and suicides
(+2) were the major contributors to the increase in mortality rates, whereas change in lung cancer mortality
(+0.4) was negligible. Advanced liver disease mortality, although much higher in 2018 alone, actually decreased
significantly from 2012–15 to 2016–2018.

VII. QUALITY IMPROVEMENT INITIATIVES
Over the past five years, CCHCS has developed a Strategic Plan which adopted the Complete Care Model as the
basis for its overall system wide healthcare delivery approach. Many clinical tools have been introduced to help
staff reach performance targets in the service of this model.
These tools include:
1. Institution Dashboards and Care Team Registries with monthly performance reports. The Statewide and
Institution dashboards track key performance indicators including access, patient outcomes, utilization and
cost. CCHCS leaders regularly assess progress in meeting performance objectives and to identify areas that may
need improvement. Examples of the Institution dashboards can be accessed via the CCHCS website:
https://cchcs.ca.gov/reports
FIGURE 10. PARTIAL VIEW OF A CCHCS HEALTHCARE SERVICE DASHBOARD.

HEALTHCARE SERVICES DASHBOARD
Statewide
December 2018
SCHEDULING & ACCESS TO CARE

----- =
-2..Ml!...fu!!l!

ACCESS

Medical Services

Dental Services
Meotal t:tealtb Seryir;;es
APPTS COMPLETED AS SCHEDULED

Cam:elled Dui;: to Custotb~

Seen as Scheduled
EFFECTIVE COMMUNICATION

Effecti:v:e Commuoi,atio□ ero:v:ided
Sign l anguage Interpreter (SU) Provided

SW.

............

------ -- --

POPULATION HEALTH MANAGEMENT

Therapeutic Anticoagulation

Diabetes Care
End Stage Liver Disease Care
Colon Cancer Screening

Women's Care
Diagnostic Monitoring
Utilization Specialt y Services
Polypharmacy Medication Review

-2..Ml!...fu!!l!

SW.

0-0-0-0-0-0

86%

0-0-0-0-0-0

87%

0-0-0-0--

1111111

0-0-0--0-0-0

86%

0-0-0-0-0-0

87%

Source: https://cchcs.ca.gov/wp-content/uploads/sites/60/QM/Public-Dashboard-2018-12.pdf
The Care Team Registries and other clinical tools are used by care teams to manage their paneled patient
populations, enabling identification of individual patients in need of recommended screening. They are used to
monitor key performance indicators in the management of chronic diseases like asthma, diabetes and
advanced liver disease. Patients on multiple medications should have periodic medication reconciliation.
Adherence to scheduling and access standards for primary care and specialty care are monitored. These

Analysis of 2018 CCHCS Mortality Reviews

monthly dashboards are used by health care managers in each of the 35 CCHCS facilities to track performance
and to target areas needing improvement.
2. Patient registries assist care teams and institutions to identify overdue or missing services in their high risk
patients. Registries for patients with Advanced Liver Disease, Diabetes, and Hypertension are examples.
3. Care Guides for specific clinical conditions. These have been described previously.
4. Initiatives to improve CCHCS processes. A process for the classification, tracking and analysis of opportunities
for improvement (OFI) will be completed by the end of 2019. Currently, all mortality reviews are entered into
the electronic Health Care Incident Reporting System and are reviewed by the Health Care Incident Reporting
Committee. High priority OFI are identified and forwarded to the Statewide Patient Safety Committee.
Selection of quality improvement initiatives is based on information from mortality review, the health care
incident reporting system, and other sources. In addition to the formal Mortality Reviews, incidents are also
reported from anywhere in the organization. Types of incidents reported include patient safety issues, medication
errors, and errors that may have caused patient harm or were a “near miss” for patient harm or death. The
Quality Management Program is responsible for reviewing health care areas considered to be high risk, high
volume, high cost, and problem-prone and identifies organization-wide improvement priorities.

Each of the initiatives and activities listed below were identified as priorities based on mortality review OFI and
other health care incident data. For example, CCHCS workgroups have revised standards for screening and
treatment of for hepatitis C, and for expanding appropriate screening for liver cancer, and have directed
significant resources to these recommendations.
•

Statewide Provider/Healthcare Staff Education:
o

Lessons from Death Review — Uses specific cases to discuss how delay in diagnosis or error(s) in
clinical decision-making affected patients’ outcomes.

Cognitive Errors Webinar — Uses specific cases to discuss various types of cognitive errors and
how they may have affected patient outcomes.

•

Emergency Medical Response — Statewide initiative for onsite hands on training with a standardized
curriculum, crash carts and tools for resuscitation.

•

Integrated Substance Use Disorder Treatment Program (approved July 2019) — Substance use disorder
screening for all new patients. Medication assisted treatment (MAT) with buprenorphine, naltrexone, or
methadone offered to patients with opioid use disorder who meet criteria. All appropriate providers are
to receive training in order to receive waivers allowing prescription of MAT.

•

Hypertension — New registry for care teams to more closely monitor patients whose blood pressure is
not yet controlled and ensure appropriate monitoring of renal function and lipids.

Analysis of 2018 CCHCS Mortality Reviews

•

Palliative Care — Workgroup to identify areas for improvement including seeking end-of-life preferences
earlier in the patient's illness. Develop scripts to assist with end of life conversations. Create registry to
track current POLST in high risk patients.

•

Falls — Falls are multi-factorial and, despite existing Fall Protocols being used, some patients continue to
fall. This is due in part to the limited access of healthcare staff to some patients who may be in locked
single cells. Nursing will be working with custody to address this and other issues to further mitigate fall
risk.

•

Advanced Liver Disease Registry — The end-stage liver disease registry has been renamed Advanced Liver
Disease. Evidence based criteria for hepatocellular carcinoma screening expanded to include patients
with Stage 3 liver fibrosis. Reemphasis on screening and prophylaxis for esophageal varices.

•

Hepatitis C Treatment — CCHCS has a markedly increased prevalence of hepatitis C virus infection
compared to the community. Chronic HCV is the precursor to advanced liver disease. The availability of
Direct Acting Agents for HCV has been associated with decreases in liver-related death, need for liver
transplantation, hepatocellular carcinoma rates, and liver-related complications, even among those
patients with advanced liver fibrosis. Aggressive treatment of hepatitis C started in fiscal year 2017-2018.
In fiscal 2018-2019, treatment was expanded to all HCV risk groups. Treatment is now completed in more
than 10,000 patients.

Some of these activities address potential cognitive errors and behavior trends, such as clinical inertia. Lessons
from Death Review and the Cognitive Errors webinars, for example, were developed in response to OFI in the
categories of Improving Clinical Decision Making, Avoiding Delays in Treatment, and Improving Communication in
Care Transitions.
Other initiatives address the need for attention to patient centered workflows, or specific policies and
procedures. The Emergency Medical Response Trainings are a response to Mortality Review findings of OFI in
unexpected deaths. The Palliative Care initiative is a response to OFI in initiating POLST conversations earlier in
suitable patients and preventing overaggressive treatment in patients who have made informed decisions to limit
care. The Falls Initiative is a response to the number of patient falls noted system wide (the mortality reviews
contributed several OFI in this area.)
The Integrated Substance Use Disorder Treatment Program has the potential for mitigating the rising number of
unexpected deaths from drug overdose.
The hypertension and advanced liver disease registries and the hepatitis C treatment initiative address
opportunities for improving management and decreasing morbidity and mortality for the large number of CCHCS
patients with these chronic diseases.

VIII. CONCLUSIONS
A recent rise in the CCHCS mortality rate culminated in 2018 with a mortality rate of 351/100,000 — the highest
in the past 13 years. This increase in the all-cause CCHCS death rate is attributed to the aging of the prison

Analysis of 2018 CCHCS Mortality Reviews

population as well as to a disproportionate number of deaths from unnatural causes — drug overdose, suicide
and homicide. A recent somewhat higher mortality rate for cardiovascular disease may also be contributing.
At the same time there has been a recent lower rate of mortality from advanced liver disease, attributed to
initiatives directed at identification and treatment of chronic hepatitis C infection. CCHCS appears to be on track
for a much lower number of deaths in 2019.
In 2018 the Mortality Review Process for the CCHCS underwent significant transformation. The practice of
identifying lapses in care which could inform the avoidance of preventable death was replaced by an effort to
identify systemic opportunities for improvement. The tracking and analysis of these opportunities for
improvement is integrated into a system of total quality improvement which results in the planning and
implementation of major improvement activities and projects.
The continued maturation of the Complete Care Model coupled to transparent use of process and outcome data
dashboards and the system wide implementation of improvement projects should result in further demonstrable
improvements in the care of patients in the CCHCS.