A federal judge Wednesday released a scathing internal report about psychiatric care inside California’s prisons that accuses the state Department of Corrections and Rehabilitation of providing care for inmates that is far below what has been mandated by decades of court fights.
“CDCR has a broken system of care because information is not accurately reported upon, and reliable commonsensical action has not been taken,” the 161-page report from Dr. Michael Golding, the chief psychiatrist for the prison system, reads. “I have documented that patients are not getting to appointments on schedule and in confidential spaces, that appropriate consultation is not occurring, and worse, appropriate medical decision making by psychiatric physicians has been overridden.
“I have documented that CDCR has prevented errors from being fixed, and worse, CDCR has not allowed anyone to know that there has been inaccurate reporting to the courts and to our leadership. Such knowledge would allow problems to be identified so they can be fixed. A prison mental health system needs to ensure that patients see their psychiatrists and other mental health providers on schedule, on time and confidentially, in an office.
“CDCR is not doing that, as has been demonstrated in this report.”
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Golding’s report, which he leaked to a federal prison overseer on Oct. 3 after compiling it following visits to various California prisons, was ordered released with some redactions by U.S. District Judge Kimberly J. Mueller, who is expected to call Golding to testify about his findings and whether CDCR committed “fraud upon the court” with inaccurate information. She ordered another hearing in the case for Monday “to discuss options for moving forward in light of the current circumstances.”
Lawyers for the state had fought to delay release of the document until an internal investigation could be done, but Mueller rejected that, and the document filed on the court docket Wednesday morning contains serious allegations about how inmates are being treated, including one incident where a psychotic inmate was not given medication and ended up ripping out her eye and swallowing it.
“She was on one to one suicide watch by an LVN [a licensed vocational nurse]. This LVN 16 was tasked with constantly observing her. MG] and was to be in a strong gown, however refused to comply with issue orders,” Golding wrote. “It was documented that she was ‘psychotic’ at the time of admission.
“Documentation from the one to one observer noted ‘screaming’ every fifteen minutes for most of the four hour period. She did not receive medications during the four hour period prior to the event. The psychiatrist on call was not contacted by [either] nursing, the admitting psychologist, or custody. After touching her eye for several seconds, while in the supine position on the floor, the I/P used her left hand to enucleate her left eye [take out her left eye].
“The alarm was sounded and two correctional officers entered the cell. The I/P was asked to relinquish the eye, however, she put the eye in her 25 mouth and ingested it.”
Corrections officials have declined previously to comment on the report because it is part of pending litigation, but CDCR press secretary Vicky Waters issued a statement Wednesday flatly rejecting Golding’s allegations.
“The department strongly disagrees with this individual’s allegations, and looks forward to a fair and thorough review and hearing of all the facts,” Waters said. “We worked closely with lawyers representing prisoners, as well as the court appointment monitors, for many years to improve the mental health of inmates, and our dedicated and well-trained staff will continue to provide appropriate care and treatment.”
The report concludes that CDCR routinely mischaracterizes the frequency inmates are seen by psychiatrists, and that fewer than 50 percent of inmates are seen on time.
Some inmates lose out on appointments because they are transferred to new prisons and the clock starts all over for them, he wrote.
“Every time a mental health patient is transferred from one institution to another, CDCR resets the clock to the maximum Program Guide interval between psychiatry appointments,” he wrote. “They use this Resetting The Clock strategy to deem as compliant appointments occurring later than the maximum interval the Program Guide permits (such as 170 days rather than 90 days...).
“They reset the clock every time a patient is transferred, irrespective of when the patient last saw a psychiatrist,” meaning that a patient transferred “more than once might not have another psychiatry appointment for eight months.”
Those who are seen by psychiatrists sometimes have their appointments under extreme conditions outside their cells, Golding added.
“Cell side visits often mean talking to patients through a slit in a pretty much solid metal cell door that usually has a tiny window (which really can’t be used when speaking to the patient because of the location of the doctor’s head when speaking through the slit),” he wrote. “And sometimes the doctor has to speak very loudly to be heard, due to extremely noisy conditions.
“Several other patients and custodial officers can then hear what is supposed to be a confidential conversation. And the cellmate who is usually also in the cell can completely hear the conversation.”
Golding has not spoken publicly since the existence of his report became known, and the judge has ordered CDCR not to retaliate against him or anyone who helped him compile the report.
The report also echoes complaints by another whistleblower, Dr. Karuna Anand, a former prison psychiatrist who told The Bee last week that officials routinely allow psychologists to perform duties with patients that should only be allowed by psychiatrists.
“It seems that certain types of decisions, including level of care changes, are made by the supervising psychologist in consult with the clinician (psychologist or social worker),” one psychiatrist — whose name was redacted — wrote to Golding. “In a setting like this, you must choose your battles, so I don’t say anything.
“On a few occasions I did get frustrated because I felt strongly about certain cases and spoke up, expecting people to respect my view, but certain staff just argued against me.”
Michael Bien, the lead attorney representing more than 30,000 inmates who need mental health care in the prisons, said the report’s conclusions were disturbing, but that he was not ready yet to blame CDCR officials for intentionally misleading him and the court about practices inside the prisons.
“I would need to know more about who made what decision and when before I would say it was all intentional,” Bien said. “The biggest thing for me, it seems that there is a devaluation, a denigration of psychiatric care and that, according to Dr. Golding, that put inmates at risk.”