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California Legislature

California corrections officials fail to ensure prisons monitor inmates at risk for suicide, state audit finds

Two inmates are walked from their cells to the medical unit at Pelican Bay State Prison in Crescent City. (Mark Boster / Los Angeles Times)
Two inmates are walked from their cells to the medical unit at Pelican Bay State Prison in Crescent City. (Mark Boster / Los Angeles Times)

California corrections officials have failed to ensure prison staff members properly evaluate, treat and monitor inmates at risk of taking their own lives, according to a scathing state audit released Thursday.

The California State Auditor report, requested by a joint legislative audit committee, found state prisons failed to follow their own suicide prevention and response policies, while their average suicide rate was substantially higher than the average of U.S. state prisons — 22 per 100,000 inmates versus 15.66 per 100,000 inmates.

The state auditor's office reviewed 40 files on prisoners who committed or attempted suicide at four state prisons. Thirty-six inmates required suicide-risk evaluations, but mental health staff failed to complete at least one required risk evaluation for 10 prisoners and completed inadequate risk evaluations for 26 others.

Prison staff members were said to have left some sections of these evaluations blank. They often didn't appropriately justify determinations of suicide risk, or failed to develop adequate plans for treatment, the report said. Court-appointed mental health experts had alerted corrections officials to the problems for the past several years, it found.

Out of 25 inmates requiring treatment plans, prison staff members did not develop adequate approaches to care for 23 and failed to create any plans for two, the audit found. Staff at all four prisons insufficiently monitored inmates at risk of suicide, failing to check in on them at the required 15-minute intervals, auditors found.

The rates of women who have committed suicide in California state prisons soared, according to the report. From 2014 through 2016, women comprised about 4% of the total inmate population but accounted for roughly 11% of its inmate suicides. Almost all occurred at the California Institute for Women in San Bernardino.

Although drug involvement and domestic violence were among factors that could have contributed to the higher rate of female inmate suicides, state auditors said, state prisons had not made sure staff were trained on suicide prevention and response.

The California Department of Corrections and Rehabilitation provides mental healthcare to roughly 123,000 men and 5,800 women incarcerated at its facilities. 

State auditors recommended that the state Legislature require corrections officials to properly train staff and continue to develop their oversight processes, including audits of prisons’ risk evaluations and treatment plans. The department should be required to report its progress each year, the report said.

Corrections officials said no suicides had been reported at the California Institute for Women this year, where new programs to help suicide prevention offer brief, discreet counseling services.

In a statement, state corrections secretary Scott Kernan said the department "has made a great deal of progress implementing policies, training, and support for suicide prevention practices statewide, and acknowledges there is further progress to make."

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