The California Department of Corrections and Rehabilitation risked the health and safety of thousands of inmates and prison staff last year by transferring potentially COVID-19-positive inmates to San Quentin State Prison, according to a report released Monday by the state’s inspector general.
The CDCR and California Correctional Health Care Services, which oversees health care within the state prison system, transferred 189 inmates from the California Institution for Men in Chino between May 28 and 30 of last year amid a coronavirus outbreak at the facility.
According to the report, 67 of the inmates, who had various underlying medical conditions that made them more susceptible to serious illness, were transferred to Corcoran State Prison on May 28 and 122 were sent to San Quentin on May 30 in an effort to protect them from the outbreak in Chino.
However, the report found that the CDCR and CCHCS failed to adequately test the inmates before or after arriving at San Quentin, as well as not properly quarantining inmates with active cases of the virus and contact tracing the cases throughout the prison.
To date, 1,012 coronavirus cases and three deaths have been confirmed at Corcoran and 2,240 coronavirus cases and 28 deaths have been confirmed at San Quentin.
“Our review found that the efforts by CCHCS and the department to prepare for and execute the transfers were deeply flawed and risked the health and lives of thousands of incarcerated persons and staff,” Inspector General Roy Wesley said.
The report argues that CCHCS being intent on transferring medically vulnerable inmates by the end of May 2020 ultimately led to the sloppy transfer and subsequent coronavirus outbreaks at both San Quentin and Corcoran.
To meet that deadline, CCHCS sent most of the 189 inmates to Corcoran and San Quentin without testing them for the coronavirus during the two weeks prior to the end of May, in spite of directions from CCHCS executives to test the inmates within four to six days of the transfers.
Only one of the 189 inmates was tested during that time frame and just three were tested during the two weeks prior to the transfers, according to the report.
In lieu of testing, CCHCS planned to screen all of the transferred inmates for coronavirus symptoms and check their temperatures prior to the transfer.
However, of the 122 inmates sent to San Quentin, 55 had their health screened six or more hours before departing the Chino prison, including one who was screened 25 hours beforehand.
In addition, investigators with the inspector general’s office interviewed 56 of the inmates transferred to the two prisons. Of those, 22 said staff did not take their temperature, according to the report.
“With such outdated test results, the prison had no way of knowing whether any of those persons were infected with the virus,” Wesley said in the report. “This risk was enhanced considering the entire basis for the transfers: that the incarcerated persons were vulnerable to COVID-19 disease and residing at a prison experiencing a significant outbreak of COVID-19.”
In a May 27 email to a medical executive at the California Institution for Men, a nurse at the prison noted that some of the inmates to be transferred had not been tested since May 1 and asked if the facility had testing criteria to be met prior to the transfer.
The executive simply replied, “no re-swabing (sic).”
According to the report, 15 of the inmates tested positive for the virus after arriving at San Quentin, nine of whom were on the same bus for the 11-hour trip. Of the 122 transferred to the prison, 91 would ultimately test positive.
The report also found that CCHCS executives pressured health care staff to increase the number of inmates on each transfer bus from 19 to 25, reducing the amount of space between each bus passenger.
Staff at San Quentin had little advanced knowledge of CCHCS’ plan; the prison’s warden received information about the planned transfer on May 28 around 11:15 a.m., just two days from the planned May 30 transfer date.
“Based on the tenor of the communications among staff at the involved prisons, it appears CCHCS executives were determined to begin the transfers by the end of May 2020, regardless of the pressure they placed on departmental staff and the potential for adverse consequences,” Wesley said in the report.
“The transfers were done with the intent to mitigate potential harm to CIM patients from COVID-19, and were based on a thoughtful risk analysis using scientific information available in May 2020 concerning transmission of this novel disease,” the CDCR and CCHCS said in a joint statement.
“We have acknowledged some mistakes were made in the process of these transfers, and both CCHCS and CDCR have made appropriate changes to patient movement since that time.”
The CDCR and CCHCS also noted that since implementing new inmate transfer protocols like increased testing and use of quarantine spaces, no outbreaks have been linked to transfers.
The Office of the Inspector General did not review the agency’s new transfer protocols for the report.
The report argued that San Quentin ultimately suffered a worse outbreak following the transfer due to its outdated infrastructure, including cells without solid doors that allowed virus particles to travel more freely within the prison.
Just two of the 67 inmates transferred to Corcoran ended up with confirmed cases of the virus, which the report credited to the prison’s more modern infrastructure and solid cell doors that allowed for more effective quarantine.
Across the state’s prison system, 47,461 coronavirus cases have been confirmed since the pandemic’s outset, according to CDCR date. Nealy 2,300 cases remain active and in custody.
The CDCR has also reported 192 inmate deaths due to the virus across the prison system and, as of Dec. 31, 11 coronavirus deaths among prison staff.
“CCHCS’ and the department’s arduous task of containing the virus within its prisons remains unfinished,” Wesley said.