California prisons risked thousands of lives in rushed COVID-19 transfers, report says

California prison officials failed to prevent the spread of COVID-19 when transferring medically vulnerable inmates to two California prisons, according to a new report.

The report, from the state Office of the Inspector General, found that the efforts of the California Department of Corrections and Rehabilitation and California Correctional Health Care Services “were deeply flawed and risked the health and lives of thousands of incarcerated persons and staff.”

From May 28 to May 30 of 2020, prison officials transferred 189 medically vulnerable prison inmates from the California Institution for Men in Chino to the California state prisons in Corcoran and San Quentin, in a bid to protect them from COVID-19.

Before inmates were loaded onto buses for transfer, prison officials conducted temperature and verbal screenings. However, the screenings were too early to determine whether the inmates had symptoms of COVID-19, according to the report. As a result, some of the inmates who were transferred may have been experiencing symptoms of the virus.

“Insistence by (prison officials) to execute the transfers and subsequent pressure to meet a tight deadline resulted in the California Institution for Men ignoring concerns from health care staff and transferring the medically vulnerable incarcerated persons, even though the vast majority had not been recently tested for COVID-19,” according to a letter from Inspector General Roy Wesley that accompanied the report.

At San Quentin, nursing staff noticed that two of the inmates arrived with symptoms of COVID-19. Despite this, almost all inmates who arrived were placed in a housing unit without solid doors, allowing air to flow in and out of the cells.

“By the time the prison tested the incarcerated persons for COVID-19, many of those who tested positive had been housed in the unit for at least six days. The virus then spread quickly through the housing unit and to multiple areas throughout the prison. The prison’s inability to properly quarantine and isolate incarcerated persons exposed to or infected with COVID-19, along with its practice of allowing staff to work throughout the prison during shifts or on different days, likely caused the virus to spread to multiple areas of the prison,” according to the letter.

By the end of August, more than 2,230 inmates and nearly 280 staff members had become infected with COVID-19; 28 inmates and one staff member died from complications related to the virus, according to the report.

Corcoran had a much smaller outbreak, “likely because it is a much newer prison consisting mostly of cells with solid doors,” according to the report.

The report also found that both Corcoran and San Quentin prisons failed to properly conduct contract tracing investigations.

“By failing to thoroughly conduct contact tracing, the prisons may have failed to alert some close contacts of the infected individuals, increasing the risk of further spread of the virus,” according to the report.

The letter from Wesley notes that prison officials have since taken several steps to safeguard inmates when transferring them between prisons, “including implementing procedures requiring prisons to conduct COVID-19 testing of transferring incarcerated persons no more than five days before the transfer, followed by a rapid test on the day of the scheduled transfer.”

By the end of 2020 the department reported 8,507 cases of COVID-19 among inmates and 4,333 cases among staff. That includes 130 inmate deaths and 11 staff deaths.

The California Department of Corrections and Rehabilitation and the California Correctional Health Care Services released a joint statement in response to the OIG report:

“We appreciate this report from the OIG, and note that there were many factors that contributed to the need to move medically high-risk individuals from (the California Institution for Men) last May that are not reflected in the report. The transfers were done with the intent to mitigate potential harm to (California Institution for Men) 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. We have acknowledged some mistakes were made in the process of the these transfers, and both CCHCS and CDCR have made appropriate changes to patient movement since that time,” the agencies said.

The changes included more testing, quarantine spaces and additional use of personal protective equipment.

The full report, plus a timelapse video showing how the COVID-19 outbreaks at Corcoran and San Quentin spread, can be viewed at oig.ca.gov.

This story was originally published February 1, 2021 at 12:13 PM with the headline "California prisons risked thousands of lives in rushed COVID-19 transfers, report says."