Three months before Daniel Lee Wright killed himself in Mule Creek State Prison in November 2014, guards discovered the mentally ill inmate had fashioned a noose out of materials in his cell.
This was hardly surprising behavior for Wright, who was serving time for lewd and lascivious acts with young children and a drug conspiracy offense. Wright, 45, had been placed on suicide watch four times earlier that year and previously was found hanging and unconscious in a cell in 2012. Records showed he had at least eight serious suicide attempts.
“He has a lengthy history of suicide attempts dating from age 11 by ingesting gasoline, and in 1998 he cut his wrist, neck, and inner thigh at Mule Creek SP and almost died,” said a mental health treatment plan compiled in 2013 by the California Department of Corrections and Rehabilitation.
Despite this history, Wright was not on suicide watch on Nov. 2, 2014, when guards unlocked the cells in his cellblock and allowed inmates out to the prison yard for 2 1/2 hours, a recently filed federal lawsuit alleges.
Wright stayed alone in his cell. At some point during that period, he used a braided bed sheet noose to hang himself from a metal vent, according to the civil rights suit filed in Sacramento on behalf of Wright’s three children.
“Wright’s unfortunate death comes at the heels of a long line of documented institutional failures by California’s correctional system in its treatment of mentally ill inmates, including many suicides,” according to the complaint, filed Dec. 24 in U.S. District Court by Sacramento attorney Stewart Katz.
The suit, which seeks damages for alleged “deliberate indifference” to Wright’s medical needs, takes aim at the care provided at Mule Creek, a prison near Ione that came under harsh criticism this month in a new audit of suicide prevention practices at 18 state prisons.
Mule Creek is one of the prisons studied by a suicide expert working for a special master appointed by a Sacramento federal judge to oversee mental health care in the state’s 34 adult prisons, and it was described in the report as having policies to keep inmates from killing themselves that are “problematic.”
The prison, the report concluded, “exhibited numerous poor practices in the area of suicide prevention.”
Corrections officials declined to comment, but the prison’s handling of Wright’s case came in for detailed criticism by Lindsay Hayes, a nationally known suicide prevention expert whose report was filed in federal court on Jan. 13.
Hayes found that a psychiatric review conducted two months before Wright killed himself recorded the inmate’s “daily passive suicidal ideation,” but prison health care and management officials developed no plan to address it.
Hayes also found that the prison discharged Wright from a mental health crisis bed on Aug. 25, 2014, and urged him to continue psychiatric treatment and “work on relationships and response to rejection.”
“Such a treatment plan was grossly inadequate and did not contain a strategy to identify the reason(s) behind suicidal thoughts,” Hayes wrote, adding that Wright had a “very significant risk for suicide.”
In addition, Hayes reported, custodial staff knew that Wright had stopped taking all his psychotropic medications days before his suicide.
Wright’s death came at the same prison where the death of another mentally ill inmate one year earlier spawned widespread investigations by corrections officials and a separate civil lawsuit also initiated by Katz.
That litigation stems from the death of Joseph Duran, an inmate who breathed through a tube in his throat and who died after being blasted in the face with pepper spray by guards after he refused to remove his hands from the food port in the door of his cell.
Duran was found dead in his cell seven hours later, after guards refused orders from medical staff that he be removed from his cell, decontaminated from the harsh chemical spray, and monitored for respiratory distress after replacement of the breathing tube that he had jerked out of his mouth.
His death initially was classified as a suicide but later termed accidental by corrections officials, who launched a series of investigations and reform efforts.
Included among those reforms were modified policies on how next-of-kin of deceased inmates should be notified, a product of the fact that Duran’s parents learned their son had died and his ashes scattered at sea only when contacted months later by The Sacramento Bee.
Duran’s parents hired Katz and are pursuing a federal civil rights case against the corrections department. Four days after Katz filed the Wright action, he submitted an amended complaint in the Duran matter accusing the department of a cover-up.
That Dec. 28 complaint also accuses the defendants, including Warden William Knipp and others at Mule Creek, of intentionally delaying notification to the parents that Duran was dead.
“The reason for the plan to delay or totally avoid having Duran’s family notified was to avoid the family’s inquiring into the circumstances of Duran’s death – a frequent occurrence once the family became aware of a death involving both excessive force and negligence and indifference to medical care,” Katz wrote in the complaint.
Corrections officials and advocates for mentally ill inmates have maintained in recent years that great strides have been made in solving many of the problems associated with the handling of such prisoners, whose treatment has been the subject of decades of pitched legal battles.
The special master’s latest report on suicides in the prisons found that California’s rate of inmate suicides continues to rank higher than the national average.
The 2015 figures for California show the state had 23 inmate suicides among its 122,427 inmates, a rate of 19 deaths for every 100,000 inmates.
The rate nationally is 15 deaths per 100,000 inmates, the report said.
Despite that, the report found, conditions are improving.
“This reviewer’s re-audit found that although problems in the area of suicide prevention training have continued, CDCR has made progress toward resolving them,” Hayes wrote.