A Covid-19 outbreak that led to dozens of deaths at California’s oldest prison last summer was likely triggered by “deeply flawed” detainee transfers, the state inspector general says.
The state’s Office of the Inspector General released a report this week detailing how corrections officials handled the response to the Covid-19 pandemic and the decision to transfer medically vulnerable detainees to San Quentin State Prison.
San Quentin, just north of San Francisco, witnessed one of worst coronavirus outbreaks in California’s prison system last summer.
When Covid-19 spread inside the California Institution for Men in Chino in May, the California Department of Corrections and Rehabilitation and California Correctional Health Care Services (CCHCS) decided to transfer some detainees to facilities that were not experiencing outbreaks.
A total of 122 detainees were transferred to San Quentin on May 30, leading to a public health disaster, the report said.
In the three months following the transfers, the number of Covid-19 cases soared to more than 2,200 among its approximately 3,300 inmates, and 28 detainees died of Covid-19 complications, according to the report.
Of the 122 detainees who had arrived from Chino, officials say, 91 tested positive and two died from Covid-19 complications.
“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,” the report stated.
The state’s inspector general said officials ignored the concerns raised by health care staff prior to the transfers, including an email from a supervising nurse at the California Institution for Men asking whether detainees needed to be tested for the virus because some had not been tested for nearly a month.
Prison health care staff did conduct verbal and temperature screening on several detainees, the report says, but it was too early to determine whether they had Covid-19 symptoms when they boarded the buses that would take them to San Quentin and a smaller prison in Corcoran.
The report also indicates that the number of detainees on the buses was higher than the one previously recommended for social distancing, and that corrections officials failed to conduct contract tracing when some of the detainees who were transferred tested positive for Covid-19.
In a joint statement, the California Department of Corrections and the California Correctional Health Care Services acknowledged that “some mistakes were made in the process of the these transfers” but there were many factors that contributed to the need for the transfers that were not reflected in the report.
The agencies said they have implemented several changes, including increased testing, isolation and quarantine spaces and the use of personal protective equipment.
Since those measures were implemented, the statement says, “there have been no outbreaks attributed to institution transfers.”
“Our first and foremost priority is to ensure the health and safety of all who live and work in the state’s prisons and surrounding communities. We will continue to work collaboratively with all stakeholders to ensure we are doing everything we can for the people in our care throughout and beyond the pandemic,” the statement said.
In an interview, a detainee at San Quentin told CNN he feared he would die after getting sick with Covid-19 last year.
“As far as Covid-19 goes, this is a crime scene. This place should have like a spotlight and yellow tape wrapped around it,” said Larry Jerome Williams.
“I wasn’t sentenced to death — I was sentenced to five years and four months,” he added.
The number of Covid-19 infections has since declined in San Quentin but has surged in other facilities in recent months as officials try to control the rampant spread across the state.
Since the pandemic started, there have been 47,826 cases and nearly 200 deaths reported in state facilities, according to state data. As of Thursday, there were 1,854 detainees in custody who tested positive for the virus.
The state’s prison system has worked to combat potential outbreaks for months by releasing hundreds of detainees early.