At 6:10 a.m. on Oct. 15, a medical technician handling the morning pill pass at Pleasant Valley State Prison in 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 Gillians 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 teams interviews with prison staff and inmates, chronicles events leading up to and following Gillians hanging.
Gillians death has sparked a series of internal investigations at the 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 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 who suffered from mental illness, died hours after he was blasted in the face with 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 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. Its a crime scene in a single ... cell? How can that be?
All this was a clear violation of the departments 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 inmates 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 Gillians 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 dont think in general from what Ive seen around the department that there has been that theres been a breakdown in communications, Beard said. I think, in this particular case, a mistake was made.
How serious, how direct, thats what the investigation has to find. But in general, I just recently met with superintendents and asked them if theyre aware of other cases like this. And you know, I didnt get anyone coming out and saying, Oh yeah, we have cases like this all the time.
Beard added that sometimes youre 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 Californias 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 Durans 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 states mentally ill inmates did not learn of the circumstances of Durans 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 Karltons court in Sacramento, during the same period that corrections officials were reviewing Durans 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 Durans death for Monday afternoon.
Durans 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.
Gillians 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 prisons 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.
Gillians parents say they were notified by prison officials the day of his death. But they said theyve gotten few details about the circumstances.
I dont think they want to tell us, his mother, Mary Whitaker, said in an interview at her Antioch home. I think thats a cover-up. ...
I think it was negligence on their part and Im very upset about it, she said. Im 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 Californias 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 states 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 Gillians 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 Gillians told investigators that on the night of Oct. 14 he heard odd sounds coming from Gillians 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 dont 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 cells 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, Im 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 departments 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.
Call The Bees Sam Stanton, (916) 321-1091.