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href="http://www.sacbee.com/2014/03/08/6221058/another-inmate-death-raises-questions.html">http://www.sacbee.com/2014/03/08/6221058/another-inmate-death-raises-questions.html</a></span>
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<h1 class="title" style="font-weight: normal; max-width: 100%;"><font
face="UICTFontTextStyleBody"><span
style="background-color: rgba(255, 255, 255, 0);">Another inmate death
raises questions about California prison practices</span></font></h1>
<div class="byline"> By <span>Sam Stanton and Denny Walsh</span><br>
<span><span class="org fn"><a href="mailto:sstanton@sacbee.com">sstanton@sacbee.com</a></span></span>
</div>
<div class="pubdates" style="padding-bottom: 1.5em;">
<div class="published" title="2014-03-09T00:06:01-0700"
style="padding-bottom: 0pt;">Published: Sunday, Mar. 9, 2014 - 12:06
am
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<p style="max-width: 100%;"><span
style="background-color: rgba(255, 255, 255, 0);">At 6:10 a.m. on Oct.
15, a medical technician handling the morning “pill pass” at <a
moz-do-not-send="true" rel="nofollow"
href="http://topics.sacbee.com/Pleasant+Valley/"
style="text-decoration: none; max-width: 100%;">Pleasant Valley</a> State
Prison
in <a moz-do-not-send="true" rel="nofollow"
href="http://topics.sacbee.com/Fresno+County/"
style="text-decoration: none; max-width: 100%;">Fresno County</a> spotted
inmate
David Scott Gillian hanging inside cell No. 164 from a bedsheet
tied to an air vent.</span></p>
<p style="max-width: 100%;"><span
style="background-color: rgba(255, 255, 255, 0);">“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.</span></p>
<p style="max-width: 100%;"><span
style="background-color: rgba(255, 255, 255, 0);">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.</span></p>
<p style="max-width: 100%;"><span
style="background-color: rgba(255, 255, 255, 0);">“We need to cut him
down, we need to do CPR,” the tech told the sergeant.</span></p>
<p style="max-width: 100%;"><span
style="background-color: rgba(255, 255, 255, 0);">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.</span></p>
<p style="max-width: 100%;"><span
style="background-color: rgba(255, 255, 255, 0);">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.</span></p>
<p style="max-width: 100%;"><span
style="background-color: rgba(255, 255, 255, 0);">Gillian’s death has
sparked a series of internal investigations at the <a
moz-do-not-send="true" rel="nofollow"
href="http://topics.sacbee.com/California+Department+of+Corrections+and+Rehabilitation/"
style="text-decoration: none; max-width: 100%;">California Department
of Corrections and Rehabilitation.</a> In the review team report,
corrections officials investigating the suicide express “several
concerns” about the circumstances. Among the concerns cited: that <a
moz-do-not-send="true" rel="nofollow"
href="http://topics.sacbee.com/prison+guards/"
style="text-decoration: none; max-width: 100%;">prison guards</a> 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.</span></p>
<p style="max-width: 100%;"><span
style="background-color: rgba(255, 255, 255, 0);">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.</span></p>
<p style="max-width: 100%;"><span
style="background-color: rgba(255, 255, 255, 0);">On Sept. 7, Joseph
Duran, 35, an inmate at Mule Creek State Prison in <a
moz-do-not-send="true" rel="nofollow"
href="http://topics.sacbee.com/Amador+County/"
style="text-decoration: none; max-width: 100%;">Amador County</a> who
suffered from mental illness, died hours after he was blasted in the
face with <a moz-do-not-send="true" rel="nofollow"
href="http://topics.sacbee.com/pepper+spray/"
style="text-decoration: none; max-width: 100%;">pepper spray,</a> 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.</span></p>
<p style="max-width: 100%;"><span
style="background-color: rgba(255, 255, 255, 0);">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.</span></p>
<p style="max-width: 100%;"><span
style="background-color: rgba(255, 255, 255, 0);">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 <a moz-do-not-send="true" rel="nofollow"
href="http://topics.sacbee.com/health+care/"
style="text-decoration: none; max-width: 100%;">health care</a> in
prisons.</span></p>
<p style="max-width: 100%;"><span
style="background-color: rgba(255, 255, 255, 0);">“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?</span></p>
<p style="max-width: 100%;"><span
style="background-color: rgba(255, 255, 255, 0);">“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?”</span></p>
<p style="max-width: 100%;"><span
style="background-color: rgba(255, 255, 255, 0);">Corrections
spokeswoman Deborah Hoffman said she could provide limited information
because the case is under investigation.</span></p>
<p style="max-width: 100%;"><span
style="background-color: rgba(255, 255, 255, 0);">“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.”</span></p>
<p style="max-width: 100%;"><span
style="background-color: rgba(255, 255, 255, 0);">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.</span></p>
<p style="max-width: 100%;"><span
style="background-color: rgba(255, 255, 255, 0);">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.</span></p>
<p style="max-width: 100%;"><span
style="background-color: rgba(255, 255, 255, 0);">“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.</span></p>
<p style="max-width: 100%;"><span
style="background-color: rgba(255, 255, 255, 0);">“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.’ ”</span></p>
<p style="max-width: 100%;"><span
style="background-color: rgba(255, 255, 255, 0);">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.</span></p>
<p style="max-width: 100%;"><span
style="max-width: 100%; font-weight: bold; background-color: rgba(255, 255, 255, 0);">Suicide
rate
a recurring issue</span></p>
<p style="max-width: 100%;"><span
style="background-color: rgba(255, 255, 255, 0);">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.</span></p>
<p style="max-width: 100%;"><span
style="background-color: rgba(255, 255, 255, 0);">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.</span></p>
<p style="max-width: 100%;"><span
style="background-color: rgba(255, 255, 255, 0);">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.</span></p>
<p style="max-width: 100%;"><span
style="background-color: rgba(255, 255, 255, 0);">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.</span></p>
<p style="max-width: 100%;"><span
style="background-color: rgba(255, 255, 255, 0);">Gillian’s parents
are also waiting for answers.</span></p>
<p style="max-width: 100%;"><span
style="background-color: rgba(255, 255, 255, 0);">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.</span></p>
<p style="max-width: 100%;"><span
style="background-color: rgba(255, 255, 255, 0);">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.</span></p>
<p style="max-width: 100%;"><span
style="background-color: rgba(255, 255, 255, 0);">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.</span></p>
<p style="max-width: 100%;"><span
style="background-color: rgba(255, 255, 255, 0);">In the weeks leading
up to his suicide, he kept a detailed daily calendar chronicling his
pain, according to the internal report.</span></p>
<p style="max-width: 100%;"><span
style="background-color: rgba(255, 255, 255, 0);">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.</span></p>
<p style="max-width: 100%;"><span
style="background-color: rgba(255, 255, 255, 0);">“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. ...</span></p>
<p style="max-width: 100%;"><span
style="background-color: rgba(255, 255, 255, 0);">“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.”</span></p>
<p style="max-width: 100%;"><span
style="background-color: rgba(255, 255, 255, 0);">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.</span></p>
<p style="max-width: 100%;"><span
style="background-color: rgba(255, 255, 255, 0);">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.</span></p>
<p style="max-width: 100%;"><span
style="background-color: rgba(255, 255, 255, 0);">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.</span></p>
<p style="max-width: 100%;"><span
style="background-color: rgba(255, 255, 255, 0);">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.</span></p>
<p style="max-width: 100%;"><span
style="max-width: 100%; font-weight: bold; background-color: rgba(255, 255, 255, 0);">‘Then
it
got quiet’</span></p>
<p style="max-width: 100%;"><span
style="background-color: rgba(255, 255, 255, 0);">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.</span></p>
<p style="max-width: 100%;"><span
style="background-color: rgba(255, 255, 255, 0);">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.</span></p>
<p style="max-width: 100%;"><span
style="background-color: rgba(255, 255, 255, 0);">“I heard him talking
to himself and answering himself the night before he hung himself,” the
inmate told investigators, according to the documents.</span></p>
<p style="max-width: 100%;"><span
style="background-color: rgba(255, 255, 255, 0);">“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.”</span></p>
<p style="max-width: 100%;"><span
style="background-color: rgba(255, 255, 255, 0);">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.</span></p>
<p style="max-width: 100%;"><span
style="background-color: rgba(255, 255, 255, 0);">A separate ligature
fashioned from a white bedsheet was knotted around his neck and woven
through air vent holes.</span></p>
<p style="max-width: 100%;"><span
style="background-color: rgba(255, 255, 255, 0);">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.”</span></p>
<p style="max-width: 100%;"><span
style="background-color: rgba(255, 255, 255, 0);">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.</span></p>
<p style="max-width: 100%;"><span
style="background-color: rgba(255, 255, 255, 0);">“No, I’m not opening
the door,” the internal report quotes a sergeant as saying.</span></p>
<p style="max-width: 100%;"><span
style="background-color: rgba(255, 255, 255, 0);">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.</span></p>
<p style="max-width: 100%;"><span
style="background-color: rgba(255, 255, 255, 0);">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.</span></p>
<p style="max-width: 100%;"><span
style="background-color: rgba(255, 255, 255, 0);">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.”</span></p>
<p style="max-width: 100%;"><span
style="background-color: rgba(255, 255, 255, 0);">“Only a doctor of
medicine shall pronounce a person dead,” the manual states.</span></p>
<p style="max-width: 100%;"><span
style="background-color: rgba(255, 255, 255, 0);">Michael Bien, the
lead attorney in the excessive force hearing before Karlton, said the
failure to perform CPR or other measures makes no sense.</span></p>
<p style="max-width: 100%;"><span
style="background-color: rgba(255, 255, 255, 0);">“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.”</span></p>
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