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Report Number: 2016-131		Abbreviations
California Department of Corrections and Rehabilitation It Must Increase Its Efforts to Prevent and Respond to Inmate Suicides

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• Appendix A


• Appendix B

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Appendix A

RATES OF INMATE SUICIDES AND SUICIDE ATTEMPTS IN STATE PRISONS FROM 2012 THROUGH 2016

The Joint Legislative Audit Committee (Audit Committee) requested that we compare the rates of suicides and attempted suicides for male and female inmates in all state prisons from 2014 through 2016. In order to calculate these rates, we used data from Corrections’ COMPSTAT system because it is the most comprehensive source of publicly reported data for the entire correctional system. Based on our analysis of COMPSTAT data, Table A presents the rates and number of inmate suicides and suicide attempts at each state prison from 2012 through 2016. As we discuss in Chapter 3, the data from COMPSTAT on inmate suicides and attempted suicides are unreliable; however, they are also the most comprehensive, as well as being the data Corrections makes available to the public. Therefore, we present the data here but recommend in Chapter 3 that Corrections take steps to ensure its accuracy in the future.

Table A
Suicides and Suicide Attempts in Each California Prison From 2012 Through 2016

Source: California State Auditor’s analysis of Corrections’ COMPSTAT metrics.

Notes: As we note in Chapter 3 of the audit report, our review of various records from individual prisons revealed that COMPSTAT has consistently underreported the number of suicides in California prisons. The numbers in this table are not adjusted; we present them as they appear in COMPSTAT.

Italicized rows represent the four prisons reviewed in this audit.

* Because we calculated populations based on a 12‑month average, annual population amounts may differ from the total prison populations due to rounding.

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Appendix B

SCOPE AND METHODOLOGY

The Audit Committee directed the California State Auditor to perform an audit of Corrections’ policies, procedures, and practices related to suicide prevention and reduction. We were directed to review the suicide and attempted suicide rates for male and female inmates in all state prisons; Corrections’ policies and procedures for inmate suicide prevention and response, as well as their implementation; and CIW’s implementation of Corrections’ policies. We were also asked to determine areas in which Corrections could improve its mental health services, causes for CIW’s high suicide rates, and the adequacy of mental health and suicide prevention training for CIW staff. Table B lists the objectives that the Audit Committee approved and summarizes the methods we used to address those objectives.

Table B
Audit Objectives and the Methods Used to Address Them

Audit Objective		Method
1	Review and evaluate the laws, rules, and regulations significant to the audit objectives.	Reviewed relevant state laws and regulations.
2	Evaluate Corrections’ policies and procedures for inmate suicide prevention and response, including those related to instances when an inmate exhibits suicidal behavior. Determine whether such policies and procedures are implemented consistently throughout California’s state prisons.	We judgmentally selected three prisons to review in addition to CIW based on an analysis of the number of suicides and suicide attempts from 2014 through 2016 and of the prisons’ missions: CCWF, RJD, and SAC. We obtained Corrections’ policies and procedures for inmate suicide prevention and response. Further, we reviewed local operating procedures at each of the four prisons. We reviewed the Coleman special master monitoring reports, Corrections’ suicide reports, and the suicide expert’s audits to identify recommendations made to CIW, Corrections, and the other three prisons. We determined if the appropriate policies and procedures reflected those recommendations. We also interviewed relevant Corrections' staff for perspective on the implementation of these recommendations. We judgmentally selected 10 inmate suicides and suicide attempts from 2014 through 2016 from each of the four prisons. We reviewed the records for the 40 inmates' suicides and suicide attempts to determine if the prisons adhered to their local operating procedures and Corrections’ policies and procedures on suicide prevention and response. We interviewed relevant staff at Corrections and at the prisons to obtain perspective on issues we found pertaining to these records.
3	For the most recent three‑year period, compare the suicide and attempted suicide rates for male and female inmates in all state prisons.	To better identify trends, we reviewed the five‑year period from 2012 through 2016. We gathered Corrections’ statistics on inmate suicides and suicide attempts from 2012 through 2016 for all California state prisons from Corrections’ organizational management tool called COMPSTAT. We analyzed the COMPSTAT data to present the inmate suicide and suicide attempt rates by prison in Appendix A. We obtained perspective from Corrections’ officials on any trends or inaccuracies that we observed and the methods Corrections used to gather and track these data. For Table 1 and Table 6, we adjusted the COMPSTAT data we present on suicides for the four prisons we reviewed based on documentation of suicides not recorded in COMPSTAT. In Table 1, we also adjusted the prison populations for the four prisons we reviewed based on average daily populations Corrections provided. In Appendix A, we did not adjust the COMPSTAT data as they are the data Corrections makes available to the public.
4	Identify areas where Corrections can improve its mental health services, particularly with respect to the safety and care for inmates needing mental health treatment.	Using the results of the testing of policies and recommendations in Objective 2, we determined areas in which Corrections could improve its practices. We gathered perspective on these areas of improvement from relevant Corrections' staff. We reviewed the monthly meeting minutes for the statewide suicide prevention team and the suicide prevention teams at each of the four prisons for 2016 to determine the meeting attendees and the topics staff addressed. We interviewed Corrections’ officials and reviewed available documentation to identify the methods used to discuss, document, and disseminate best practices to the prisons related to suicide prevention and response. We obtained Corrections’ reports on position vacancy rates as of December 2016 for social workers, psychiatrists, and psychologists at the four prisons we reviewed and for Corrections as a whole. We interviewed key staff at the four prisons and Corrections' headquarters to gather perspective on staff vacancies.
5	In reviewing the CIW do the following: a.) Evaluate whether CIW appropriately implemented Corrections’ suicide prevention policies.	The procedures we performed in Objective 2 also addressed this objective.
	b.) Identify and analyze CIW’s policies and procedures in the event of a suicide, including any ensuing investigation and communication with the deceased inmate’s family during and after such investigation.	The procedures we performed in Objective 2 also addressed this objective. We reviewed Corrections’ procedures for communicating with a deceased inmate’s family following a death. We reviewed records for six inmates who committed suicide from 2014 through 2016 and determined that CIW complied with Corrections’ policies for communicating with a deceased inmate’s family following a suicide.
	c.) To the extent possible, identify the causes or factors contributing to the higher rates of suicide and suicide attempts at CIW, including any systemic problems or failures.	We interviewed key Corrections' headquarters staff and CIW staff to gather their perspectives on the causes for the higher rates of suicide and suicide attempts at CIW from 2014 through 2016. We evaluated data from CIW and CCWF regarding the suicide attempts by inmates who transferred from VSPW. We reviewed Corrections’ available documentation of the plan to convert VSPW to a men’s prison. We interviewed officials at CIW and Corrections to determine if the conversion process accounted for the effect the transfer of inmates from VSPW would have on CIW.
	d.) Identify and analyze CIW’s policies and practices in the event that an inmate displays suicidal behavior. Evaluate CIW’s ability to appropriately house and treat inmates identified as suicidal and determine whether CIW allows access to inmate program activities or movements such as yard time.	The procedures we performed in Objective 2 for the 40 inmates' suicides and suicide attempts also addressed this objective. We reviewed CIW’s policies and documentation for six inmates regarding access to yard time.
	e.) Evaluate the adequacy of the mental health and suicide prevention training for CIW staff.	From a list containing all employees at CIW, we randomly selected 20 CIW staff members and determined the percentage who received annual suicide prevention training in 2014, 2015, and 2016. From a list containing all mental health staff at CIW, we randomly selected 10 psychiatrists, psychologists, and social workers and determined how many received training on how to complete suicide risk evaluations and other trainings required for mental health staff. We reviewed several suicide prevention trainings that Corrections' staff received to determine if the trainings contained the content Corrections’ policies require and any additional content the suicide expert had recommended. We obtained self‑reported data on selected required trainings from CCWF, CIW, RJD, and SAC and identified instances of low compliance.
6	Review and assess any other issues that are significant to the audit.	We interviewed selected advocacy groups to identify their key concerns related to our audit scope. We addressed concerns related to delays in emergency response and monitoring inmates in Objective 2. We also addressed concerns related to identifying and disseminating best practices in Objective 4.

Sources: California State Auditor's analysis of the Audit Committee's audit request number 2016‑131, planning documents, and analysis of information and documentation identified in the table column titled Method.

Assessment of Data Reliability

In performing this audit, we obtained data from Corrections’ COMPSTAT organizational management tool. The U.S. Government Accountability Office, whose standards we are statutorily required to follow, requires us to assess the sufficiency and appropriateness of computer‑processed information that we use to support findings, conclusions, or recommendations. Corrections’ COMPSTAT tool provides monthly data to stakeholders and the public on a variety of measures at each of Corrections’ prisons and other institutions. We used COMPSTAT data to report on the number of suicides and attempted suicides throughout California’s adult prisons. We performed data‑set verification procedures and found no errors. Further, as reported in Chapter 3, we assessed the accuracy and completeness of COMPSTAT data by comparing the data on suicides and attempted suicides for selected months to incident logs from the four prisons we visited and identified several errors. We also compared the number of suicides reported in COMPSTAT to those in reports from the special master’s suicide experts and found they did not agree. Finally, during the course of our audit work, we identified one suicide each at three of the four prisons we visited that was not included in COMPSTAT. As a result, we determined that COMPSTAT data are not sufficiently reliable for the purposes of this audit. Nevertheless, we present these data in the report because COMPSTAT is Corrections’ comprehensive source of data available on suicides and attempted suicides for each of its prisons, and it contains data Corrections makes publicly available. We discuss our findings in more detail in Chapter 3 and make a recommendation for improving the data.

We also obtained summary data from Corrections on the rates at which its employees attend various trainings. We tested selected employees at CIW and determined they did not all attend required trainings. We requested self‑reported summary data from Corrections for each of the four prisons we visited to determine whether there was evidence at each prison to corroborate our findings at CIW. Because the data corroborated our findings, we determined it would be too resource‑intensive to further test the accuracy and completeness of the prisons’ self‑reported data. Instead, we clearly attribute the data in the report to Corrections.

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