A federal judge said this week that she will begin fining California potentially tens of thousands of dollars a day after more than 200 inmates committed suicide during eight years in which state corrections officials failed to complete court-ordered suicide prevention measures.
In response to a chronic tragedy that has plagued the state for decades, U.S. District Chief Judge Kimberly Mueller said she will enter into fines April 1 — $1,000 a day for each of 15 unmet warrants until all 34 prisons fully compliant for adults of the state.
At the same time, she will impose fines for the state’s failure to hire enough mental health professionals. And she set up a hearing for August to collect more than $1.7 million in fines accrued since 2017 under an earlier order to sanction delays in transferring inmates to state psychiatric facilities.
“The court is at a critical crossroads” Muller wrote weeks before her order, which was made public on Tuesday. She said inmates with severe mental disorders make up more than a third of California’s prison population of about 96,000 and that they have been waiting “way too long for constitutionally adequate mental health care.”
State officials said they will review the judge’s orders. Vicky Waters, spokesperson for the California Department of Corrections and Rehabilitation, said in a statement that “suicide prevention is a very important issue to us.”
In lawsuits, state officials objected to Mueller’s determination of “an unworkable, anything but impossible standard.” They pointed to lower suicide rates in the past two years, after two decades of California consistently exceeding the national suicide rate for state prison systems. The 15 suicides in 2021 were the fewest in two decades and half the annual average over that period. Lawyers representing detainees say there were 19 suicide deaths last year, though the official report has not yet been released.
The recent lower suicide rates are “significant improvements and absolute evidence of success,” Paul Mello, a lawyer representing the state, told Mueller at a Feb. 10 hearing.
A court-appointed suicide prevention expert, Lindsay Hayes, said the reasons for the sudden drop are unclear and the effect of the COVID-19 pandemic needs to be analysed.
Suicides in California prisons have long been seen as an important indicator that the prison system is not providing enough mental health care. Mueller’s predecessor ruled 27 years ago in the class action lawsuit that California was unconstitutionally providing poor mental health care to inmates. Still, federal judges are struggling to enforce improvements, despite repeated orders in the case.
This time, Mueller steps in after Hayes found the department still falls short of standards despite a 2015 injunction. The safeguards include suicide prevention training, suicide risk assessments, suicide-resistant cells, and checking vulnerable inmates every 30 years. minutes or more to ensure prisoners do not harm themselves.
“They’re very standard for prisons and jails across the country, and they don’t do them,” said Michael Bien, one of the attorneys representing inmates.
Among those who corrections officials say committed suicide is 31-year-old John Pantoja. According to the Sacramento County coroner, he died in June by hanging using a ligature torn from a sheet.
Pantoja was a funny, loving, caring, healthy, athletic young man until he entered California’s juvenile justice system at age 16, his sister and father told Kaiser Health News in an interview Tuesday.
Five years later, he appeared a changed man, they said.
“He came out with a totally exhausted mental state,” with multiple mental health diagnoses, including schizophrenia, and mood swings consistent with bipolar disorder, Elizabeth Pantoja said. “Before we went in, we didn’t see those signs. … That was the opposite of how we knew him.
Within a few months of his release from juvenile detention, he was involved in a 2012 robbery and shootout with the Chula Vista Police Department. His defense at the time was that he had attempted “cop suicide” in which he had tricked an officer into killing him. Once in prison, Amado Pantoja said, John heard voices he blamed on the mental health drugs he was prescribed. Amado and Elizabeth said John was looking forward to a birthday visit from his family and a parole hearing in 2026 based on his young age at the time of his crime.
His mental health has really taken a turn for the worse over the past five years, as he was repeatedly placed in solitary confinement during the pandemic and unable to make family visits, they said. More recently, the television he treated as a form of therapy had broken down, though his family sent him a new one, and he had seen medical staff complaining of chronic pain.
He died the next day with half a dozen drugs in his system, including drugs for depression, pain and seizures.
In a report on prisoner suicides between January 2020 and April 2022, Hayes described frequent missed opportunities to prevent deaths:
- An inmate at a Sacramento County maximum security prison committed suicide with punctures on his neck on Christmas Eve 2020, hours after he was spotted drinking liquid detergent in his cell. Correctional officers said he was also “behaving irrationally, stressed, pacing back and forth, crying, upset after a series of phone calls with his family.” A crisis counselor approached him at his cell door for refusing to come out, but he denied intending to commit suicide. Counsel asked no further questions, citing a lack of privacy, and the prisoner committed suicide several hours later.
- An inmate at Tehachapi State Penitentiary was found hanging from a ventilation grille on a sheet in his cell on January 5, 2020. He had a years-long history of slitting his wrists and other self-destructive behaviors, even as recently as two days before his death. Hours before his suicide, a counselor decided he wasn’t serious. But a subsequent review felt his self-harm — along with his “bizarre statements and heightened paranoid delusions” — should have been warning enough. He left a note stating that he feared other inmates were plotting his murder.
- An inmate was found the day before Thanksgiving 2021 hanging from a sheet in his cell at Corcoran addiction clinic. His 11 years in prison were mostly spent in mental health programs for repeatedly cutting himself and hallucinating voices saying people were trying to kill him. An entry on the medical card seen by a counselor on the day he died “was forged by the clinician.” A departmental investigation found “a worrying pattern” of mental health providers saying they would offer him interventions but never deliver them.
Mueller, who had indicated for weeks that she would impose daily fines, said at the February hearing that they were needed to “ensure that the recommendations are implemented” after the state repeatedly missed deadlines to comply with nearly half of its the guarantees imposed by the court.
“The court finds any further delay in the full implementation by the defendants of required suicide prevention measures unacceptable,” Mueller wrote in her final order.
Mueller also ordered fines for any unfilled position that exceeded a vacancy rate of more than 10% in the required number of mental health professionals needed to care for inmates with severe mental disorders. Those fines will be based on the maximum salary for each job, including some that reach or nearly $300,000 a year, and Mueller said she would schedule a hearing to find the state contemptuous and order payment if the fines extend for three consecutive accumulating months. .
The state has failed to fill the vacancies for more than four years, Mueller said, noting that there are more than 400 positions vacant statewide.
Mueller imposed fines of $1,000 a day in 2017 in an effort to end a chronic backlog of sending inmates to mental institutions. She never collected the money — but now she’s set the August hearing to do so.
Under her current order, the fines will continue to mount in the same manner as long as Hayes determines that the state is not compliant. Once the review is complete — a process that previously took many months — Mueller said she would schedule a hearing on the payment of fines.
This story was produced by KHN (Kaiser Health News), an editorially independent newsroom of KFF (Family Kaiser Foundation).