A female inmate at a California prison last year gouged out her own eye and ate it during a psychotic break, according to an internal report blasting the state’s prison system for inadequate care of mentally ill patients.
The report, released last week as part of an ongoing, decades-long federal lawsuit over inmate care, was written by Dr. Michael Golding, the chief psychiatrist for the California Department of Corrections and Rehabilitation. The Los Angeles Times, which reported on the document Monday, said that Golding accused prison officials of hiding the truth about the subpar mental health care they provide to those in custody.
“This group has created a biased and inaccurately positive picture of what is actually a troubled system of care,” Golding wrote in the report, which was obtained through federal court documents.
The Associated Press reported that U.S. District Judge Kimberly Mueller, who made the 161-page report public Oct. 31, is considering appointing a special investigator to look into Golding's claims.
Golding, who wrote the report based on his own visits to prisons across California, alleged that officials lied to Mueller and attorneys in the case about how often inmates were seen by psychiatrists, boasting in 2017 and 2018 that inmates were seen on time by their doctors at least 90 percent of the time. Golding said the actual percentage of on-time appointments was less than 46 percent.
The chief psychiatrist wrote that inmates were denied appointments in confidential offices, instead being seen by a psychiatrist in the prison yard or through a crack in a solid metal door, where other inmates could hear the details of their conversation.
The corrections department also has a “resetting-the-clock” strategy in which a mental health patient’s psychiatric care is “reset” each time he or she is transferred from one facility to another, Golding wrote in the report. The strategy was used to “deem as compliant appointments occurring later than the maximum interval” permitted, he alleged.
“They reset the clock every time a patient is transferred, irrespective of when the patient last saw a psychiatrist,” the report states. “A…patient transferred more than once might not have another psychiatry appointment for eight months.”
The maximum amount of time the federal court allows a patient to wait to be seen is three months, the report said.
Golding wrote that the Department of Corrections and Rehabilitation has a “broken system” because information is not accurately reported and “reliable commonsensical action” is not taken.
Credit: AP Photo/Rich Pedroncelli
Credit: AP Photo/Rich Pedroncelli
“I have documented that patients are not getting to appointments on schedule and in confidential spaces, that appropriate consultation is not occurring, and worse, appropriate medical decision-making by psychiatric physicians has been overridden,” he wrote.
The lack of a proper medical decision was part of the problem for the woman who removed and ate her eye at the California Institution for Women in Chino, the report alleged. Golding wrote that the woman, who he identified as Patient X, presented “relatively well” when she entered the prison system, but she stopped taking the anti-psychotic medication she had been prescribed on the outside.
“Arguably, in situations like this, longer transitions for patients at higher levels of care should be insisted upon when medication from the community is discontinued, even if the patient appears to have the legal right to discontinue medication because of presenting in a logical way,” Golding wrote.
The patient was well for as long as the medication stayed in her system, but eventually, those positive effects wore off and she “did not stay well,” the report stated. Four hours before the April 20, 2017, incident, she was evaluated by a psychiatrist and found to be “gravely disabled,” so the psychiatrist wrote orders for her to be taken to the licensed psychiatric crisis bed unit.
“These admission orders were being followed, except for the order for the patient to go to a crisis bed,” Golding wrote.
Instead, the patient was being monitored in an unlicensed setting that was more like an urgent care facility and, although she was on one-to-one suicide watch as ordered, she was not placed in a “strong gown” because she refused to comply with that order.
Documentation indicated she was actively psychotic at the time of admission, the report said.
“Documentation from the one-to-one observer noted ‘screaming’ every 15 minutes for most of the four-hour period,” Golding’s report said.
Golding wrote that staff members did not contact the psychiatrist on call and the woman did not receive any medication during those four hours. The woman, who was lying face-up on the floor, then touched her left eye for several seconds before removing it from her head.
“The alarm was sounded and two correctional officers entered the cell,” the report stated. “The (inmate patient) was asked to relinquish the eye, however, she put the eye in her mouth and ingested it.”
Golding alleged that multiple psychiatrists who subsequently heard about the incident agreed medication should have been forced on the woman to keep her out of harm’s way. State prison psychologists who evaluated how staff handled the incident, however, determined the failure to contact the psychiatrist on call was not the root cause of the woman’s self-harm.
A psychiatrist, who is a medical doctor, has the ability to prescribe medications, while a psychologist does not. Golding wrote in his report that psychiatrists in the prison system routinely report to psychologists, who make the majority of decisions about system-wide care.
The psychologist in the woman’s case made the decision not to contact the psychiatrist on call, Golding wrote.
He further wrote that the psychologist did not have admitting privileges to the crisis bed unit and that “despite this horrendous event,” the state licensing board was never informed of what happened because the inmate was being held in an unlicensed facility instead of where she should have been.
“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.
A Department of Corrections and Rehabilitation spokeswoman denied Golding's allegations in a statement issued Friday, the Times reported.
"The department strongly disagrees with this individual's allegations and looks forward to a fair and thorough review and hearing of all the facts," press secretary Vicky Waters 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."
Michael Bien, the attorney for California prisoners receiving mental health care, told the Times that the report could throw off the headway made in recent years in improving the programs offered by the prisons. Bien said he had been poised to accept a proposal that would have slashed psychiatric staffing in the facilities by 20 percent, but the agreement has been nixed since Goldberg’s report was released.
"The bigger impact is we felt we were ticking off the last couple of issues before we could end the case," Bien told the Times. "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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