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Report Number: 2016-131


California Department of Corrections and Rehabilitation
It Must Increase Its Efforts to Prevent and Respond to Inmate Suicides



The California Department of Corrections and Rehabilitation (Corrections) is responsible for protecting the public by safely and securely supervising adult and juvenile offenders, providing effective rehabilitation and treatment, and integrating offenders successfully into the community. It operates two adult women’s prisons and 33 adult men’s prisons across the State.1 According to a report Corrections issued in 2017, 123,540 male inmates and 5,876 female inmates were incarcerated within its facilities as of December 31, 2016. Figure 1 shows the locations of Corrections’ prisons and highlights the four prisons we selected for review during the course of our audit work.

Figure 1
Map of Adult Correctional Institutions and the Four Prisons We Visited

Figure 1 is a map of California showing all Adult Correctional Institutions emphasizing the four we visited.

Source: Corrections.

Corrections is responsible for the provision of mental health care to all of its inmates, including receiving, evaluating, housing, treating, and referring those inmates who are unable to appropriately function within the constraints of the usual correctional environment because of mental illnesses. Its Division of Health Care Services (health care division) provides mental health services through its Mental Health Services Delivery System (mental health system), the mission of which is “to provide inmates with an appropriate level of treatment and to promote individual functioning within the clinically least restrictive environment consistent with the safety and security needs of both [the inmates and prisons].” Corrections employs numerous individuals, such as psychiatrists, psychologists, social workers, and nurses, to provide mental health services to inmates (mental health staff). Prison staff may refer inmates to the prison’s mental health program, or inmates may submit requests for services to the prison’s mental health staff for their approval.

Despite the mental health services that Corrections provides, the rate at which its inmates commit suicide has generally been higher than the rates in most other states. Table 1 shows the number of attempted suicides and suicides from 2012 through 2016 at the four prisons we reviewed, and Appendix A presents these data for all the State’s prisons. According to a 2016 report by a mental health expert appointed by a U.S. district court, the average suicide rate in Corrections was 22 per 100,000 inmates from 2005 through 2013, significantly higher than the average rate of 15.66 per 100,000 inmates in U.S. state prisons during the same period. Although Corrections’ 2014 inmate suicide rate of 16.97 per 100,000 inmates was lower than the 2014 rate of 20 per 100,000 inmates for all U.S. state prisons, Corrections’ inmate suicide rates have been higher on average than those of U.S. state prisons since 1999.

The suicide rate of Corrections’ male inmates remained relatively static from 2012 through 2016; however, the suicide rate of its female inmates increased. In 2012 female inmates accounted for about 5 percent of Corrections’ inmate population and for 4 percent of its suicides. However, although female inmates made up about 4 percent of Corrections’ inmate population from 2014 through 2016, they accounted for about 11 percent of the suicides. Almost all of the suicides during this period occurred at the California Institution for Women (CIW). In fact, concern about CIW’s high suicide rate was the impetus for this audit.

Table 1
Suicides and Suicide Attempts at the Four Prisons We Visited,
From 2012 Through 2016

Population* 2,931 1,642 3,539 2,698
Suicides 0 1 0 1
Attempts 5 13 28 22
Population* 3,531 2,082 3,364 2,246
Suicides 0 1 3 1
Attempts 8 15 33 32
Population* 3,648 2,005 3,070 2,218
Suicides 0 2 1 2
Attempts 6 15 22 11
Population* 3,002 1,882 3,096 2,237
Suicides 0 2 2 3
Attempts 11 34 51 12
Population* 2,865 1,863 3,094 2,327
Suicides 1 2 0 3
Attempts 25 24 59 8
Population* 3,195 1,895 3,233 2,345
Suicides 1 8 6 10
Attempts 55 101 193 85

Source: California State Auditor’s analysis of Corrections’ COMPSTAT metrics from 2012 through 2016, and the average daily population for each prison as reported by Corrections.

* Population is based on Corrections’ average daily population. The total represents the average of the five years’ populations.

The numbers we present here reflect our amendments to Corrections’ COMPSTAT data. As we discuss in Chapter 3, our review of various records from individual prisons revealed that COMPSTAT has consistently underreported the number of suicides in California prisons. We have therefore adjusted the number of suicides in 2013, 2015, and 2016 to include three suicides that we identified at CIW, RJD, and SAC; however, we caution that these numbers may still not be accurate.

Court-Ordered Oversight of Corrections’ Mental Health Services

As Figure 2 shows, federal courts have monitored Corrections’ delivery of mental health services to its inmates for over two decades as a result of a decision on a lawsuit that began in 1990—Coleman v. Brown (Coleman).2 This federal class action lawsuit alleged that Corrections failed to provide constitutionally adequate mental health care to mentally ill inmates. The court identified that Corrections had failed to provide timely access to necessary care, which exacerbated inmates’ suffering and illnesses. In addition the court found that Corrections had an inadequate screening system for mental illnesses, deficient medical recordkeeping, improper administration of medication, and insufficient staffing. In December 1995, the court in Coleman appointed a special master to oversee and work with Corrections to address the constitutional violations, monitor implementation of court‑ordered remedial plans, and submit reports on Corrections’ progress in implementing improvements. Over the next decade, the special master submitted 15 reports to the court, which noted that although Corrections had made some progress, it still had not met its constitutional obligation to provide inmates with adequate mental health care during that time. Further, the special master’s fifteenth report in January 2006 indicated a reversal in Corrections’ progress. Specifically, this report noted systemwide increases in staffing vacancy rates and rates of inmate suicide.

In April 2001, another class action lawsuit, Plata v. Brown (Plata), alleged constitutional violations in Corrections’ delivery of medical care to inmates that resulted in unnecessary pain, injury, and death.3 These violations included delays in or failure to provide access to medical care, untimely responses to medical emergencies, and the interference of custodial staff with the provision of medical care. After the plaintiffs filed the lawsuit, they and Corrections agreed that Corrections would implement certain policies and procedures to improve its delivery of medical care, which the court entered as an order in 2002. However, in 2005 the federal court determined that Corrections had yet to ensure that its medical system met constitutional standards. As a result, the court appointed a receiver in February 2006 to provide leadership and executive management of Corrections’ medical health care delivery system. This receivership is still in place.

Figure 2
Timeline of Court-Ordered Oversight of Corrections

Figure 2 is a timeline showing key events related to court-ordered oversight of Corrections from 1990 through 2016.

Sources: Reports from the special master’s suicide expert in 2015 and 2016, court documents, and minutes of the California State Legislature’s Joint Legislative Audit Committee.

In 2007 the courts in Coleman and Plata recommended that both cases be assigned to a three‑judge panel to address prison overcrowding. In August 2009, the three‑judge panel noted that in 2006—the same year that the Coleman special master’s report noted a reversal in Corrections’ delivery of mental health services and the court in Plata appointed the receiver—California’s prison population reached a historic high of more than 170,000 inmates. This historic high led to unprecedented overcrowding of California’s prisons. The three‑judge panel found overcrowding to be the primary cause of many of the issues relating to inadequate mental health and medical care in California’s prisons. Therefore, the three‑judge panel ordered Corrections to develop a plan to reduce its prison population, which at that time was at about 190 percent of capacity, to 137.5 percent of capacity. In 2011 the Legislature passed various laws that realigned the criminal justice system, which reduced overcrowding by allowing for inmates who were not convicted of serious or violent crimes, or felonies requiring registration as a sex offender, to serve their sentences in county jails instead of state prisons.

Although these efforts resulted in the reduction of Corrections’ inmate population, a March 2013 Coleman special master’s report identified continuing inadequacies in Corrections’ delivery of mental health services. The special master had repeatedly identified many of these inadequacies in earlier reports, such as Corrections’ failure to enforce its own policies regarding the delivery of mental health services and the prisons’ failure to provide adequate emergency responses to suicides. In response to the report, the court in Coleman ordered Corrections to establish a suicide prevention and management work group consisting of members of Corrections’ clinical, custody, and administrative staff; experts appointed by the special master; and others. The workgroup engaged a nationally recognized suicide prevention expert (suicide expert) to conduct a review of the suicide prevention practices at each of Corrections’ prisons. In January 2015, the suicide expert filed his report, which contained 32 recommendations to Corrections. The suicide expert issued an update to this report in January 2016, in which he evaluated Corrections’ progress in implementing the recommendations through a review of 18 prisons. We discuss the suicide expert’s report and update in Chapter 3.

Suicide Prevention and Response

As we mention earlier, the goal of Corrections’ mental health system is to provide appropriate levels of mental health treatment to seriously mentally ill inmates in the least restrictive environment. As presented in Figure 3, Corrections provides escalating levels of mental health care to inmates, up to and including referrals to Department of State Hospitals' facilities if Corrections cannot meet inmates’ mental health needs.

Figure 3
Levels of Care in Corrections’ Mental Health System

Figure 3 is a chart in the form of a pyramid that describes the Levels of Care in Corrections’ Mental Health Services Delivery System.

Source: Corrections’ 2009 Mental Health Program Guide (program guide) and 2014 Annual Accomplishments report.

Note: Not all institutions contain all levels of care.

A primary component of Corrections’ mental health system is crisis intervention, which is treatment for rapid‑onset or worsening symptoms of mental illness in inmates. Such symptoms may include thoughts of suicide. Corrections has identified factors that can lead inmates to experience mental health crises while in prison, including the loss of an existing support system outside of prison, the restrictions of incarceration, and fears of being unable to cope with the outside world upon release. Corrections’ policy states that staff must refer inmates who are dangers to themselves to crisis beds, an inpatient treatment setting for inmates who have acute symptoms of serious mental disorders or are suffering from significant or life‑threatening disabilities. If no crisis beds are available at a prison, staff must place an inmate in a temporary housing location in the prison—known as alternative housing—pending admission to a crisis bed. Under these circumstances, policy requires prisons to transfer an inmate to a crisis bed at another prison if the other prison can provide the same level of custody and security.

Terms Related to Inmate Suicide

Suicidal ideation: Thoughts of suicide or death. Such thoughts may be either specific or vague and may include the desire to be dead.

Suicidal intent: The intention to deliberately end one’s life.

Self-harm without intent: An act of purposeful self-harm without suicidal intent.

Suicide attempt: An act of purposeful self-harm with the intent to die.

Suicide: An act of purposeful self-harm that causes or leads to one’s own death.

Sources: Corrections’ 2009 program guide and suicide risk evaluation training documents.

Corrections’ policies outline specific steps prison staff must take when they become aware of inmates’ suicidal ideation, suicidal intent, or self‑harm, which the text box defines. If prison staff become aware of any of these conditions, Corrections’ policy requires that they place inmates under observation until mental health staff can conduct a suicide risk evaluation (risk evaluation). As we discuss in Chapter 1, mental health staff use these evaluations to determine inmates’ risk of suicide and to make specific recommendations regarding the level of care required.

Corrections also has a policy that prison staff must follow when staff discover inmates who are attempting suicide. When responding to a suicide attempt in progress, Corrections’ policy requires prison staff to sound an alarm to summon additional personnel, respond appropriately when blood is present, neutralize any significant security threats to themselves or others, and initiate life‑saving measures consistent with training. When medical personnel arrive, they take over responsibility for the medical treatment and life‑saving measures.

Following the admission of inmates to crisis beds as a result of suicide attempts, ideation, or self‑harm, prison staff must complete various steps in order to provide treatment. Figure 4 provides a summary of these steps. For example, while inmates are in crisis beds, prison staff must keep them under observation. Depending on whether inmates are in immediate danger, staff must either maintain continuous visual contact with them or perform checks at staggered intervals not exceeding once every 15 minutes. Further, while inmates are in crisis beds, prison staff must complete treatment plans. According to Corrections’ policies, crisis‑bed stays are supposed to last for up to 10 days, although inmates may stay longer with the approval of a prison’s chief of mental health.

Figure 4
Corrections’ Process for Inmates’ Admission to and Discharge From Crisis Beds

Figure 4 is a flow chart that depicts Corrections’ process for Inmates’ Admission to and Discharge from Crisis Beds.

Source: Corrections’ 2009 program guide and related policy memos.

Note: Not all institutions contain all levels of care.

Corrections has taken certain actions to ensure that the prisons comply with its policies and to identify additional ways to prevent inmate deaths due to suicide. For example, Corrections has established its own Suicide Prevention and Response Focused Improvement Team (suicide prevention team) and established suicide prevention teams at each prison. The purpose of these teams is to provide staff with training and guidance with regard to suicide prevention, response, reporting, and review. The suicide prevention teams at each prison are also responsible for monitoring and tracking all self‑harm incidents, suicide attempts, and deaths, as well as reviewing the prison’s policies to ensure consistency with Corrections’ policies. According to Corrections’ policies, these teams must be composed of certain prison staff representing multiple disciplines, such as the chief psychologist and chief psychiatrist, and must meet once per month.

In addition, following each suicide, Corrections completes a review of the prison’s compliance with policies and procedures, including examining the history of the inmate’s mental health care while incarcerated and the prison’s emergency response to the suicide. It describes the results of its review in a report (suicide report) that it provides to the prison. When warranted, Corrections makes recommendations to the prison to improve the quality of care and ensure compliance with its policies and procedures.


1 Corrections houses women within other facilities, including some medical facilities and a small facility at Folsom State Prison. In addition, Valley State Prison housed women before Corrections converted it to a men’s facility in 2013. Go back to text

2 When this case was filed, it was called Coleman v. Wilson. Go back to text

3 When this case was filed, it was called Plata v. Davis. Go back to text

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