Analysis rips 66 prison deaths

A new report by the prison medical czar has found that 66 inmates succumbed to "preventable" or "possibly preventable" deaths in the California correctional system last year due to lapses in their medical care.

The report issued by federal receiver Robert Sillen blamed some of the deaths on individual doctors. For the most part, it attributed the fatalities to a "systemic" failure in the prison medical care system.

"You can't expect clinicians to practice good medicine if they don't have good medical records, if they don't have lab results to help diagnosis, if they don't have a pharmacy system to support the right order of medications, if you don't have a culture within (the California Department of Corrections and Rehabilitation) that says, 'My goodness, these are human beings and they ought to be treated as human beings,' " Sillen said in an interview Wednesday.

Sillen, who took charge of prison medical care in April 2006, said the report establishes a base line by which to judge future progress of his efforts to bring the system into constitutional compliance.

U.S. District Judge Thelton Henderson, who appointed Sillen, found in 2005 that one inmate "needlessly dies every six to seven days due to constitutional deficiencies in the CDCR's medical delivery system."

Prison officials declined to comment on the report.

A CDCR committee under Sillen's direction reviewed 381 of the 426 deaths in the prison system in 2006, excluding suicides and an execution. Of the 66 deaths flagged, the committee found 18 were preventable and 48 were possibly preventable.

Six of the preventable deaths were attributed to asthma. Sudden cardiac arrest claimed three inmate lives, congestive heart failure two more, with acute myocardial infarction, a perforated duodenal ulcer, hypothermia, incarcerated hernia, acute pancreatitis, stroke and testicular cancer accounting for the rest of the preventable deaths.

The report found "significant lapses in care" in more than half of the deaths reviewed and in all of the preventable and possibly preventable cases.

Individual practitioners, the report found, missed "potentially serious signs and symptoms," failed to "tailor the pace of evaluation to the clinical situation" and didn't follow "well-established guidelines for care," among other shortcomings.

Systemically, the department allowed "delays in triaging" and "fragmentation of care and clinical inertia." It had "poorly managed transfers of care" and inadequate "practice environments" that were "noisy, unkempt, crowded" and "lacking privacy."

Ironically, the report noted "prolonged delays in specialty referrals" in the prison system. Earlier this year, Sillen terminated a deal a Florida firm had arranged with the state to provide those services. The company, Medical Development International, which had been praised by correctional officials and inmate rights lawyers, has since filed a claim against Sillen and the state.

Donald Specter of the Prison Law Office in San Rafael said the report "shows once again that a prison sentence can turn into a death sentence in California."

"My belief is that these deaths represent just the tip of the iceberg of prisoners who have been harmed by inadequate care," Specter said.

Dr. Stuart Bussey, president of the Union of American Physicians and Dentists, which represents about 250 doctors in the prison system, did not take issue with the report.

"We feel that doctors have been working in a battlefield situation," Bussey said. "We concur with the receiver's attempts to streamline the medical systems in prisons."

In his 17 months on the job, Sillen has boosted prison doctors' pay to $168,000, established a new peer review system, ordered a new medical facility at San Quentin State Prison, increased nurses' pay and reduced vacancies among their ranks to below 10 percent and converted the old medical technical assistant positions to licensed vocational nurses. He also has brought in an outside contractor to fix the pharmacy system.

He said in the interview that he expects it will take him 10 years to bring the system into constitutional compliance.

"There are still too many preventable deaths or possibly preventable deaths," Sillen said. "That's the bottom line."

To view the report online, go to: www.cprinc.org/docs/" target="_blank">http://www.cprinc.org/docs/ resources/AnalysisOfCDCRDeathReviews2006.pdf.

About the writer:

• The Bee's Andy Furillo can be reached at (916) 321-1141 or afurillo@sacbee.com.