[Pnews] Another Inmate Death raises questions about CA prison practices

[Prisoner News]

http://www.sacbee.com/2014/03/08/6221058/another-inmate-death-raises-questions.html 



  Another inmate death raises questions about California prison practices

By Sam Stanton and Denny Walsh
sstanton at sacbee.com <mailto:sstanton at sacbee.com>
Published: Sunday, Mar. 9, 2014 - 12:06 am

Read more here: 
http://www.sacbee.com/2014/03/08/6221058/another-inmate-death-raises-questions.html#storylink=cpy

At 6:10 a.m. on Oct. 15, a medical technician handling the morning “pill 
pass” at Pleasant Valley 
<http://topics.sacbee.com/Pleasant+Valley/> State Prison in Fresno 
County <http://topics.sacbee.com/Fresno+County/> spotted inmate David 
Scott Gillian hanging inside cell No. 164 from a bedsheet tied to an air 
vent.

“Gillian is hanging in his cell,” the tech called to a nearby guard, 
then rushed off to grab the “cut down scissors” and begin the process – 
mandatory under corrections department policy – of trying to revive the 
inmate through cardiopulmonary resuscitation, according to an internal 
department review of the incident.

Guards and medical staff converged at the cell door, according to the 
internal report. A sergeant and the medical technician entered the cell 
where Gillian was housed alone and found no pulse or signs of breathing.

“We need to cut him down, we need to do CPR,” the tech told the sergeant.

Instead, the sergeant refused, according to the review team report; he 
ordered the cell door closed and locked, even after a doctor and another 
medical staffer demanded they be allowed to perform CPR. Gillian, 52, 
would remain hanging for nearly four hours before he was cut down.

The confidential corrections department report, obtained by The 
Sacramento Bee, summarizes the findings of a suicide review team 
assigned to investigate Gillian’s death. All suicides in California 
state prisons are reviewed by a team of corrections officials. The 
report obtained by The Bee, based on the review team’s interviews with 
prison staff and inmates, chronicles events leading up to and following 
Gillian’s hanging.

Gillian’s death has sparked a series of internal investigations at the 
California Department of Corrections and Rehabilitation. 
<http://topics.sacbee.com/California+Department+of+Corrections+and+Rehabilitation/> In 
the review team report, corrections officials investigating the suicide 
express “several concerns” about the circumstances. Among the concerns 
cited: that prison guards 
<http://topics.sacbee.com/prison+guards/> prevented medical staffers 
from trying to revive Gillian; and that guards may not have made their 
regularly scheduled rounds that day, possibly causing a delay in 
discovering his suicide.

The incident is at least the second documented case in recent months of 
disputes between medical staffers and guards over when a cell door 
should be opened to provide emergency medical care and assistance to an 
inmate.

On Sept. 7, Joseph Duran, 35, an inmate at Mule Creek State Prison in 
Amador County <http://topics.sacbee.com/Amador+County/> who suffered 
from mental illness, died hours after he was blasted in the face with 
pepper spray, <http://topics.sacbee.com/pepper+spray/> according to an 
internal department review of that case. Duran had undergone a 
tracheotomy years before, and breathed through a hole in his throat. 
Agitated and coated with spray, he yanked out the tube he relied on for 
air, according to the review team report. Guards refused to intervene, 
despite repeated demands from medical staffers to allow them to enter 
his cell, decontaminate him and reinsert the tube, according to staff 
interviews contained in the internal report. Duran was found dead, alone 
in his cell, seven hours later.

That incident, laid out in a January story in The Bee, prompted U.S. 
District Judge Lawrence K. Karlton to reopen an evidentiary hearing in 
Sacramento federal court inquiring into the alleged use of excessive 
force on mentally ill inmates in California prisons.

Gillian was not in a mental health unit at Pleasant Valley prison, 
though he had been treated for major depressive disorder in other 
prisons, according to the internal corrections department report. Inmate 
advocates say his case underscores why they have been fighting for 
decades to improve access to medical and mental health care 
<http://topics.sacbee.com/health+care/> in prisons.

“This is outrageous, it actually defies the human race,” said Donald 
Specter, director of the Prison Law Office, which has been fighting 
through the courts to improve conditions for inmates for 35 years. “And 
the reason for it makes no sense. It’s a crime scene in a single ... 
cell? How can that be?

“All this was a clear violation of the department’s suicide and 
attempted suicide policies. The first priority is supposed to be save 
the life, not preserve a crime scene, even if there is one. Can you 
imagine how gruesome that was for a body to be hanging there for almost 
four hours and everybody working there and all the prisoners in the unit 
knew it?”

Corrections spokeswoman Deborah Hoffman said she could provide limited 
information because the case is under investigation.

“All inmate suicides are thoroughly investigated,” she wrote in an 
email. “An investigation into this inmate’s suicide was launched 
immediately and is ongoing. If it is determined any employee violated 
policy we will take appropriate action.”

Hoffman said Gillian was supposed to be monitored by staff twice an hour 
but did not provide information on whether those checks were conducted. 
The Fresno County coroner, in an autopsy report, said the condition of 
Gillian’s body indicated he could have been dead “anywhere from 4 to 8 
hours and beyond” when he was finally cut down.

Corrections Secretary Jeffrey Beard, during an interview last month 
regarding the Duran case, said he does not believe there is a widespread 
problem in communication between guards and medical personnel.

“I don’t think in general from what I’ve seen around the department that 
there has been – that there’s been a breakdown in communications,” Beard 
said. “I think, in this particular case, a mistake was made.

“How serious, how direct, that’s what the investigation has to find. But 
in general, I just recently met with superintendents and asked them if 
they’re aware of other cases like this. And you know, I didn’t get 
anyone coming out and saying, ‘Oh yeah, we have cases like this all the 
time.’ ”

Beard added that “sometimes you’re going to have breakdowns, sometimes 
mistakes might get made,” but said the department is working to avoid 
such situations.

Suicide rate a recurring issue

The two cases come as the corrections department battles legal action on 
several fronts tied to medical and mental health care inside 
California’s 34 adult prisons. Last month, a three-judge court agreed to 
give California two more years to reduce its inmate population to 137.5 
percent of capacity, a benchmark designed to reduce the overcrowding 
that the court in 2009 found is the primary reason for subconstitutional 
levels of medical and mental health treatment for inmates.

Revelations about Duran’s death have complicated matters for the 
department in a separate inquiry: the hearing before Karlton involving 
use of force on mentally ill inmates. Attorneys representing the state’s 
mentally ill inmates did not learn of the circumstances of Duran’s death 
until they were contacted by The Bee in January, and they have accused 
the state of covering up his death and the fact that pepper spray was 
used. The hearing on use of pepper spray and discipline against mentally 
ill inmates began Oct. 1 and went into November in Karlton’s court in 
Sacramento, during the same period that corrections officials were 
reviewing Duran’s death.

Corrections officials deny they were suppressing the Duran incident, but 
Karlton ordered a hearing on use of force reopened and has scheduled a 
court session partially devoted to Duran’s death for Monday afternoon.

Duran’s parents would not learn until four months after his death – when 
a Bee reporter called to ask questions – that their son had died in 
prison and that his body had been cremated 17 days later, scattered at 
sea off the Marin County coast. They are preparing to sue the state for 
civil damages.

Gillian’s parents are also waiting for answers.

Their son had been in prison since May 2001, serving a sentence of 21 
years and four months for voluntary manslaughter, assault with a deadly 
weapon and burglary, convictions out of Contra Costa County stemming 
from his having stabbed a former girlfriend to death with an ice pick in 
her trailer home in Concord, according to information provided by the 
corrections department.

He was transferred to Pleasant Valley in Coalinga, about 200 miles south 
of Sacramento, in October 2012, and last July was placed in the 
administrative segregation unit – solitary – after he attacked a fellow 
inmate in the prison’s kitchen, where Gillian worked.

He had been a cement worker who injured his back on the job and spent 
years battling chronic pain, according to his family. The internal 
corrections department report stated he had a history of heroin and 
methamphetamine use, as well as convictions for DUI and being drunk in 
public.

In the weeks leading up to his suicide, he kept a detailed daily 
calendar chronicling his pain, according to the internal report.

Gillian’s parents say they were notified by prison officials the day of 
his death. But they said they’ve gotten few details about the circumstances.

“I don’t think they want to tell us,” his mother, Mary Whitaker, said in 
an interview at her Antioch home. “I think that’s a cover-up. ...

“I think it was negligence on their part and I’m very upset about it,” 
she said. “I’m upset because I think his life could possibly have been 
spared. There was definitely that chance.”

Along with mental health care and medical treatment inside California’s 
prisons, the issue of inmate suicide has been the focus of ongoing legal 
disputes. An expert for the court-appointed special master who oversees 
the handling of mentally ill prisoners has complained repeatedly that 
prison officials have rejected recommendations for improvements, 
including additional staff training and follow-up checks on suicidal 
inmates.

The expert, Dr. Raymond F. Patterson, has compiled 14 annual reports on 
suicides in California prisons. Last March, Patterson cited the state’s 
lack of progress and declared the report would be his last because it 
would be “a further waste of time and effort” to continue.

That final report noted that suicide rates in California prisons had 
continued to increase over the years and consistently were above the 
national average. He calculated 32 suicides in 2012, a rate of 23.72 
suicides per 100,000 inmates. The national average was 16 per 100,000 
inmates.

The corrections department maintains it has increased training and 
conducts 95,000 mental health treatments monthly. It recorded 30 
suicides last year and five so far in 2014.

‘Then it got quiet’

The internal suicide review team report on Gillian’s death cites 
concerns about the staff response but draws no conclusions about whether 
his death could have been prevented.

An inmate in a cell near Gillian’s told investigators that on the night 
of Oct. 14 he heard odd sounds coming from Gillian’s cell.

“I heard him talking to himself and answering himself the night before 
he hung himself,” the inmate told investigators, according to the documents.

“Personally, I don’t think he was wrapped too tight. He fell one time. 
He was cussing. I heard the air come out of him. He fell again and then 
it got quiet.”

An autopsy report by the Fresno County coroner cited evidence that 
Gillian may have tried unsuccessfully to hang himself earlier that 
night. The report said a knotted ligature that had torn was found in the 
cell’s sink, and he had suffered wounds to the right side of his face 
and his nostrils.

A separate ligature fashioned from a white bedsheet was knotted around 
his neck and woven through air vent holes.

In interviews with investigators, prison staffers said there was no sign 
of life when Gillian was discovered hanging, according to the review 
team documents. He was first assessed at 6:11 a.m. and found to have no 
pulse, but the sergeant who went into the cell with a medical technician 
refused to allow him to be cut down, declaring that “at this point it is 
a crime scene.”

At 6:28 a.m., a doctor called an ambulance and ordered guards to allow 
medical staffers inside “to perform their duties,” the documents state. 
Eight minutes later, a nurse told guards the doctor wanted CPR started, 
but they again refused.

“No, I’m not opening the door,” the internal report quotes a sergeant as 
saying.

At 6:50 a.m., an ambulance arrived from the Coalinga Fire Department and 
a paramedic entered the cell and pronounced Gillian dead five minutes later.

But his body remained hanging until the coroner arrived at about 9:45 
a.m., and the internal review team raised concerns about the fact that 
no life-saving efforts were conducted.

The department’s operations manual details precisely how prison 
officials are supposed to respond to a possible inmate death, and it 
requires them to “make every effort to preserve life.” The policies, 
which were last updated Sept. 6, state that CPR must be started and 
continue until a doctor pronounces the inmate dead, or “emergency 
responders are unable to continue because of exhaustion or safety and 
security of the rescuer or others is jeopardized.”

“Only a doctor of medicine shall pronounce a person dead,” the manual 
states.

Michael Bien, the lead attorney in the excessive force hearing before 
Karlton, said the failure to perform CPR or other measures makes no sense.

“The policy is explicit that life-saving measures must come before 
anything else,” Bien said. “The only time immediate CPR is not required 
is when the head is cut off.”



-- 
Freedom Archives 522 Valencia Street San Francisco, CA 94110 415 
863.9977 www.freedomarchives.org


-------------- next part --------------
An HTML attachment was scrubbed...
URL: <http://freedomarchives.org/pipermail/ppnews_freedomarchives.org/attachments/20140312/acc80e59/attachment.htm>