The State Worker

More women in California prisons are trying to kill themselves. What can the state do to protect them?

Six of the seven female inmate suicides that have occurred in California prisons since 2013 took place at the California Institution for Women, according to a new state audit.
Six of the seven female inmate suicides that have occurred in California prisons since 2013 took place at the California Institution for Women, according to a new state audit.

California’s corrections department’s failure to prepare when it moved hundreds of high-security female inmates from a Central Valley prison to one in inland Southern California may have contributed to a recent spike in suicide attempts by women prisoners, according to a new state audit.

Between 2013 and 2016, women made up 4 percent of the state’s prison population but accounted for 11 percent of the system’s suicides, according to the audit.

That spike prompted an audit that revealed uneven adherence to suicide prevention plans and a staffing shortage among mental health workers in state prisons.

“It is critical that inmates in our prison system do not view suicide as a viable option and that state prisons provide them with the necessary mental health care and other support systems to improve their health and well being,” said Sen. Connie Leyva, D-Chino, who requested the audit..

Although the number of female inmate suicides in state prisons is small, six of the seven self-inflicted deaths since 2013 took place at a single institution: the California Institution for Women in Chino.

That prison in late 2012 absorbed 400 inmates from a women’s prison in Chowchilla that the state converted to a men’s facility. The new inmates changed the culture of the Chino prison, drawing a more dangerous group of female prisoners and increasing the prevalence of drug use there, corrections officials told auditors.

Prison staff anticipated a disruption, auditors wrote, but they did not take special precautions when they blended the two groups.

“Although corrections acknowledged at the time that the conversion of (the Chowchilla prison) to a men’s prison might significantly affect (the state’s remaining women’s prisons), it did little to prepare those prisons,” the audit said.

The number of suicide attempts recorded at the two women's prisons in the study – the one in Chino and Central Valley Women's Facility in Chowchilla – climbed from 18 in 2012 to 49 last year, according to the audit.

The new report reflected a well-documented shortage of mental health staff in state prisons. Almost one-third of the state’s positions for psychiatrists are vacant, the audit said.

“When prisons do not maintain adequate mental health staff, their ability to provide quality mental health care to inmates can suffer,” auditors wrote. At one prison, staff told auditors that “a shortage of psychiatrists has a trickle-down effect, because if inmates do not receive the proper medication, they may act out more and require additional attention or therapy, exacerbating mental health staff’s already heavy workloads.”

Auditors focused on four prisons, including California State Prison, Sacramento, and found that corrections staff had an uneven performance in adhering to their suicide prevention plans.

For instance, staff at four state prisons failed to complete risk evaluations after suicide attempts in 70 percent of the cases that auditors reviewed.

Prison employees also tended to miss the required 15-minute checkups on suicidal inmates. Auditors wrote that in eight cases, prison employees appeared to fabricate the forms they fill out to show that they’re monitoring high-risk inmates.

Out of 25 inmates who required treatment plans, prison employees did not write adequate plans for 23 of them and failed to write plans entirely in two cases.

In some cases, prison employees did not bring proper tools or have the right training to respond to suicide attempts. In 15 hangings auditors studied, prison staff did not bring cut-down kits to three of them.

And, in one instance, prison staff acknowledged they did know how to relieve pressure on someone’s throat after a hanging. That was considered a basic element of their required training.

“We find it concerning that Corrections omitted this critical information from this training, as its mental health policies have specified since 2009 that responding prison staff must relieve pressure on the inmate’s airway,” the audit said.

The state corrections department has been trying to reduce its suicide rate for several years. It has hired a suicide expert to conduct audits, and refined training programs, the new audit said. Corrections Secretary Scott Kernan wrote in a response to the audit that the department is developing special substance-abuse and domestic-violence programs for female inmates, too.

Still, California prisons have a higher suicide rate than other states, with 22 self-inflected deaths per 100,000 inmates. The average among other states is 15.7 percent.

Auditors recommended that the corrections department tighten its suicide-prevention training and study suicide attempts with the same scrutiny it applies to internal reviews of self-inflicted deaths. Auditors also suggested the Legislature require the department issue annual reports on its suicide-prevention efforts.

Leyva said she plans to introduce legislation in coming months to follow up on the report.

Adam Ashton: 916-321-1063, @Adam_Ashton. Sign up for state worker news alerts at