Federal judge wants investigation into mental health care at California prisons following scathing report

A medical worker sits outside an isolation cell containing an inmate who authorities fear might attempt suicide at California State Prison, Sacramento in Folsom, Calif., on March 30, 2008.
(Rich Pedroncelli / Associated Press)

A federal judge on Monday said she plans to appoint an investigator to launch a probe into whether California has painted an inaccurately rosy picture of psychiatric care inside its prison system as part of a lawsuit against the state that has spanned nearly three decades.

U.S. District Judge Kimberly Mueller’s move comes on the heels of a 161-page report written by the chief psychiatrist for the prison system alleging the California Department of Corrections and Rehabilitation has concealed issues surrounding the adequacy of mental health care and staffing in prisons from officials who could mandate changes.

“This group has created a biased and inaccurately positive picture of what is actually a troubled system of care,” Dr. Michael Golding wrote.


Golding’s report, based on his visits to various state prisons, was filed in federal court as part of a lawsuit against the state that began in 1990 which asserts that psychiatric care in prison is a constitutional right.

Details about what the investigator will study have not been hammered out. Mueller is expected to file a written explanation detailing the specific allegations in the document that she wants investigated. Attorneys will be able to weigh in on the issue again before someone is appointed.

To highlight how the state’s alleged deficiencies have affected psychiatric care for people behind bars, Golding’s report details a gruesome incident last year at the California Institution for Women in Chino in which an inmate who had not been medicated during a “psychotic” episode ripped out her own eye and swallowed it inside her prison cell.

A key problem, Golding said, is that medical decisions, including the drugs inmates need and the type and frequency of care they require, often are assigned to psychologists inside prisons rather than psychiatrists, who are medical doctors. This can lead to discrepancies in decisions that can be problematic for patients, he said.

In the case of the woman who ripped out her eye, the psychologist who evaluated her did not call a psychiatrist to administer drugs, despite doctors later saying the patient had given every indication that she needed medication immediately, even if it was given by force. Nurses and psychologists later said the failure to provide medicine was not a root cause of the patient removing her eye.

“The tragedy is that any competent psychiatric physician or general medical physician would have medicated the patient, and likely the patient’s eye would still be in her head had that happened,” Golding wrote.


Golding also said patients frequently aren’t seen on time or in spaces that give them the freedom to talk openly with mental health staff.

The report alleges that the state Department of Corrections mischaracterized how frequently inmates are seen by psychiatrists in data provided to the court in 2017 and 2018, which boasts that 90% and 94% of appointments in those years, respectively, were on time. Golding contends that less than 50% of inmates are seen on time by mental health staff.

Patients also aren’t brought to psychiatry appointments in confidential offices, Golding wrote. Instead, the psychiatrist searches the prison yard looking for patients or communicates with them through a crack in a nearly solid-metal cell door where conversations can be overheard by others, according to Golding. The system, he wrote, is “by no means conducive to good patient care.”

Sometimes inmates face significant delays between scheduled appointments because they are transferred to a another prison, Golding said. With each transfer, the agency resets the clock on appointment times, so if an inmate is transferred multiple times, he or she can wait up to nine months between psychiatrist appointments, despite the courts having mandated that patients wait no longer than three months between appointments, the report states.

Vicky Waters, press secretary for the California Department of Corrections and Rehabilitation, rejected Golding’s allegations in a statement last week.

“The department strongly disagrees with this individual’s allegations, and looks forward to a fair and thorough review and hearing of all the facts,” she said. “We have worked closely with lawyers representing prisoners, as well as the court appointment monitors, for many years to improve the mental health of inmates, and our dedicated and well-trained staff will continue to provide appropriate care and treatment.”


The report has come at a precarious time for the state prison system. A federal court determined in 1995 that prisons had failed to provide proper treatment for thousands of mentally ill inmates.

A judge at the time ordered the appointment of a special master to oversee psychiatric care reforms and to work with experts to develop improved programs. Headway in recent years has led both sides to anticipate a return to state oversight, but the latest report could throw a wrench in that plan.

Michael Bien, an attorney representing state prisoners receiving mental health treatment in the case, said he was prepared to accept a proposal to reduce psychiatric staff positions by nearly 20% when he received Golding’s report. That agreement has since been called off.

“The bigger impact is we felt we were ticking off the last couple of issues before we could end the case,” Bien said. “Now I have to go back and check all those assumptions. The most serious thing is the allegation that misrepresentations were made to the court. That really forces all of us to question what’s been going on.”

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