Existing law establishes the Department of Corrections and Rehabilitation, and charges it with certain duties and powers, including, among other things, the operation of prisons and other specified institutions.

This bill would require the department to submit a report, as specified, to the Legislature on or before October 1 of each year, to include, among other things, descriptions of progress toward meeting the departments goals related to the completion of suicide risk evaluations, progress toward completion of 72 hour treatment plans, and progress in identifying and implementing initiatives that are designed to reduce risk factors associated with suicide. The bill would require the report to be posted on the departments Internet Web site.

Existing law establishes the Department of Corrections and Rehabilitation, and charges it with certain duties and powers, including, among other things, the operation of prisons and other specified institutions.

This bill would require the department to submit a report, as specified, to the Legislature on or before October 1 of each year, to include, among other things, descriptions of progress toward meeting the departments goals related to the completion of suicide risk evaluations, progress toward completion of 72 hour treatment plans, and progress in identifying and implementing initiatives that are designed to reduce risk factors associated with suicide. The bill would require the report to be posted on the departments Internet Web site.

Existing law establishes the Department of Corrections and Rehabilitation, and charges it with certain duties and powers, including, among other things, the operation of prisons and other specified institutions.

This bill would require the department to submit a report, as specified, to the Legislature on or before October 1 of each year, to include, among other things, descriptions of progress toward meeting the departments goals related to the completion of suicide risk evaluations, progress toward completion of 72 hour treatment plans, and progress in identifying and implementing initiatives that are designed to reduce risk factors associated with suicide. The bill would require the report to be posted on the departments Internet Web site. The bill would also require the department to make all reasonable efforts to notify the contact person of an inmate, if a contact person is listed on record, within 24 hours in the event of the inmates serious illness or injury resulting in hospitalization or placement in a mental health crisis bed, which would include attempted suicide, as specified, or an inmates death.

Existing law establishes the Department of Corrections and Rehabilitation, and charges it with certain duties and powers, including, among other things, the operation of prisons and other specified institutions.

This bill would require the department to submit a report, as specified, to the Legislature on or before April October 1 of each year, on the departments efforts to respond to and prevent suicides and attempted suicides among inmates, including, among other things, identifying recommendations that would affect the departments efforts to respond to and prevent suicides and attempted suicides among inmates, describing the progress in implementing those recommendations, and describing the departments progress in identifying and implementing mental health programs that may ameliorate risk factors associated with suicides among inmates. to include, among other things, descriptions of progress toward meeting the departments goals related to the completion of suicide risk evaluations, progress toward completion of 72 hour treatment plans, and progress in identifying and implementing initiatives that are designed to reduce risk factors associated with suicide. The bill would require the report to be posted on the departments Internet Web site. The bill would also require the department to make all reasonable efforts to notify the contact person of an inmate, if a contact person is listed on record, within 24 hours by telephone hours in the event of the inmates serious illness, serious injury, illness or injury resulting in hospitalization or placement in a mental health crisis bed, or death, which would include attempted suicide, as specified. specified, or an inmates death.

Existing law establishes the Department of Corrections and Rehabilitation, and charges it with certain duties and powers, including, among other things, the operation of prisons and other specified institutions.

This bill would require the department to submit a report, as specified, to the Legislature on or before April 1 of each year, on the departments efforts to respond to and prevent suicides and attempted suicides among inmates, including, among other things, identifying recommendations that would affect the departments efforts to respond to and prevent suicides and attempted suicides among inmates, describing the progress in implementing those recommendations, and describing the departments progress in identifying and implementing mental health programs that may ameliorate risk factors associated with suicides among inmates. The bill would require the report to be posted on the departments Internet Web site. The bill would also require the department to notify the contact person of an inmate, if a contact person is listed on record, within 24 hours by telephone in the event of the inmates serious illness, serious injury, or death, which would include attempted suicide, as specified.

Existing law establishes the Department of Corrections and Rehabilitation, and charges it with certain duties and powers, including, among other things, the operation of prisons and other specified institutions.

This bill would require the department to submit a report, as specified, to the Legislature on or before April 1 of each year, on the departments efforts to respond to and prevent suicides and attempted suicides among inmates, including, among other things, identifying recommendations that would affect the departments efforts to respond to and prevent suicides and attempted suicides among inmates, describing the progress in implementing those recommendations, and describing the departments progress in identifying and implementing mental health programs that may ameliorate risk factors associated with suicides among inmates. The bill would require the report to be posted on the departments Internet Web site. The bill would also require the department to notify the family of contact person of an inmate, if a family member contact person is listed on record, within 12 24 hours by telephone of an attempted suicide or suicide by the inmate. in the event of the inmates serious illness, serious injury, or death, which would include attempted suicide, as specified.

Existing law establishes the Department of Corrections and Rehabilitation, and charges it with certain duties and powers, including, among other things, the operation of prisons and other specified institutions.

This bill would require the department to submit a report, as specified, to the Legislature on or before April 1 of each year, on the departments efforts to respond to and prevent suicides and attempted suicides among inmates, including, among other things, identifying recommendations that would affect the departments efforts to respond to and prevent suicides and attempted suicides among inmates, describing the progress in implementing those recommendations, and describing the departments progress in identifying and implementing mental health programs that may ameliorate risk factors associated with suicides among inmates. The bill would require the report to be posted on the departments Internet Web site. The bill would also require the department to notify the family of an inmate, if a family member is listed on record, within 12 hours by telephone of an attempted suicide or suicide by the inmate.

Existing law establishes the Department of Corrections and Rehabilitation, and charges it with certain duties and powers, including, among other things, the operation of prisons and other specified institutions.

This bill would require the department to submit a report, as specified, to the Legislature on or before April 1 of each year, on the departments efforts to respond to and prevent suicides and attempted suicides among inmates, including, among other things, identifying recommendations that would affect the departments efforts to respond to and prevent suicides and attempted suicides among inmates, describing the progress in implementing those recommendations, and describing the departments progress in identifying and implementing mental health programs that may ameliorate risk factors associated with suicides among inmates. The bill would require the report to be posted on the departments Internet Web site.

Existing law establishes the Department of Corrections and Rehabilitation, and charges it with certain duties and powers, including, among other things, the operation of prisons and other specified institutions.

This bill would require the department to submit a report, as specified, to the Legislature on or before April 1 of each year, on the departments efforts to respond to and prevent suicides and attempted suicides among inmates, including, among other things, identifying recommendations that would affect the departments efforts to respond to and prevent suicides and attempted suicides among inmates, describing the progress in implementing those recommendations, and describing the departments progress in identifying and implementing mental health programs that may ameliorate risk factors associated with suicides among inmates.

 THIRD READING  

Bill No: SB 960

Author:

: in Assembly

Vote:

SENATE PUBLIC SAFETY COMMITTEE: 7-0, 4/24/18

AYES: Skinner, Anderson, Bradford, Jackson, Mitchell, Stone, Wiener

SENATE APPROPRIATIONS COMMITTEE: 7-0, 5/25/18

AYES: Lara, Bates, Beall, Bradford, Hill, Nielsen, Wiener

SENATE FLOOR: 38-0, 5/30/18

AYES: Allen, Anderson, Atkins, Bates, Beall, Berryhill, Bradford, Cannella, De León, Dodd, Fuller, Gaines, Galgiani, Glazer, Hernandez, Hertzberg, Hill, Hueso, Jackson, Lara, Leyva, McGuire, Monning, Moorlach, Morrell, Newman, Nguyen, Nielsen, Pan, Portantino, Roth, Skinner, Stern, Stone, Vidak, Wieckowski, Wiener, Wilk

NO VOTE RECORDED: Mitchell

ASSEMBLY FLOOR: Not available

SUBJECT: Department of Corrections and Rehabilitation: suicide prevention: reports

SOURCE: Author

DIGEST:

This bill requires the California Department of Corrections and Rehabilitation (CDCR) to report annually on its efforts to respond to and prevent inmate suicides and attempted suicides.

Assembly Amendments clarify and simplify the information that must be included in CDCR’s report; remove the requirement that CDCR notify the contact person of an inmate within 24 hours by phone in the case of the serious illness, serious injury, or death; and change the date by which CDCR must submit its annual report.

ANALYSIS:

Existing law:

1. Establishes a system of state prisons under the jurisdiction of CDCR. (Pen. Code § 2000 et seq.)
2. Requires CDCR to develop and implement a plan to obtain additional rehabilitation and treatment services for prison inmates and parolees. The plan is required to include, among other things, plans to fill vacant state staff positions that provide direct and indirect rehabilitation and treatment services to inmates and parolees. (Pen. Code § 2061.)

This bill:

1. Requires, on or before October 1 of each year, CDCR submit a report to the Legislature on its efforts to respond to and prevent inmate suicides and attempted suicides.
2. Requires the report to include the following information:
   1. A description of CDCR’s progress toward meeting its goals related to the completion of suicide risks evaluations in a sufficient manner.
   2. A description of CDCR’s progress toward meeting its goals related to the completion of 72 hour treatment plans in a sufficient manner.
   3. A description of CDCR’s efforts to ensure that all required staff receive training related to suicide prevention and response.
   4. A description of CDCR’s progress in implementing the recommendations made by the special master regarding inmate suicides and attempts, including the results of any audits the department conducts.
   5. A description of CDCR’s progress in identifying and implementing initiatives that are designed to reduce risk factors associated with suicides.
   6. A description of CDCR’s efforts and progress to expand upon its process of notifying a designated person in the event of a prisoner’s death, serious illness, or serious injury, including expansion of those notifications in cases of suicide attempts when deemed appropriate by the department, and when inmates have consented to allow release of that information.
3. Provides that the report shall be submitted to the Legislature and posted on CDCR’s Web site in an easily accessible format.

Background

CDCR has a long history of inmate suicides. In 1995, the U.S. District Court in the Eastern District of California ruled that CDCR was not providing adequate mental health care in violation of inmates’ Eighth and Fourteenth Amendment rights. (Coleman v. Wilson (1995) 912 F. Supp. 1282 (now Coleman v. Brown).) As part of that ruling, the court identified six areas where CDCR needed to make improvements, including suicide prevention. The court appointed a Special Master to monitor and report on CDCR’s progress toward providing an adequate level of mental health care. That remedial process has been ongoing.

CDCR’s continued difficulty in remedying the deficiencies of its mental health care system is well documented. A 2013 report to the court by the Special Master criticized CDCR for failing to follow many of the recommendations he had made to the department over a 14-year period. (https://rbgg.com/wp-content/uploads/ Coleman-Report-on-Suicides-Completed-in-the-CDCR-in-Calendar-Year-20111.pdf ; <http://articles.latimes.com/2013/mar/13/local/la-me-ff-court-expert-prison-suicide-rate-20130313 [as of Apr. 17, 2018].) In recent years, an increase in the number of inmate suicides led the Joint Legislative Audit Committee (JLAC) to request that the California State Auditor prepare an audit report concerning CDCR’s policies, procedures, and practices for suicide prevention and reduction, with a particular emphasis on the recently elevated suicide rate at the California Institution for Women. (See <http://www.sacbee.com/news/local/crime/ article41246670.html ; <https://www.theguardian.com/us-news/2016/may/10/ suicide-california-womens-prison-mental-health [as of Apr. 17, 2018].)

Mental health generally

CDCR regulations require the department to provide a broad range of mental health services to inmates by assessing the needs of its population and developing specialized programs of mental health care, to the extent resources are available for that purpose. (Cal. Code of Regs., tit. 15, § 3360, subd. (a).) Necessary and appropriate mental health services must be provided to inmates, and adequate staff and facilities must be maintained for the delivery of such services. (Id.) When an inmate is found to require mental health care that is not available within those resources, but which is available in the Department of Mental Health, the case will be referred to the director for consideration of temporary transfer to that department pursuant to Penal Code section 2684. (Cal. Code of Regs., tit. 15, § 3360, subd. (b).)

All required mental health treatment or diagnostic services must be provided under the supervision of a psychiatrist licensed to practice in the state, or a psychologist licensed to practice in the state and who holds a doctoral degree and has at least two years of experience in the diagnosis and treatment of emotional and mental disorders. (Cal. Code of Regs., tit. 15, § 3361, subd. (a).) All persons committed to CDCR must be informed that mental health services are available to them, and that, upon an inmate’s request, an evaluative interview will be provided within a reasonable period of time by a licensed practitioner, or a specially trained counselor supervised by a licensed practitioner. (Cal. Code of Regs., tit. 15, § 3362.) Upon request, an inmate will be provided with information as to what specialized treatment programs may be available in the department and how such treatment may be obtained. (Id.)

Suicide prevention and response

Each institution head is required to ensure that all employees whose assignments routinely involve inmate contact are trained to recognize signs and symptoms associated with suicide risk, the appropriate procedures for staff intervention, and the appropriate procedures to be followed in response to emergency situations resulting from self-injurious or suicidal actions. (Cal. Code of Regs., tit. 15, § 3365, subd. (a).) Specifically, peace officer classifications are required to complete annual training on suicide prevention. (Department Operations Manual (DOM) § 32010.15)

Each institution head is required to implement a Suicide Prevention Program for inmates who display self-injurious or suicidal behavior or symptoms. These programs must include the following components:

1. Suicide Watch. When medical staff determine that an inmate is actively suicidal, a licensed physician or psychologist must order placement of the inmate on suicide watch in a General Acute Care Hospital (GACH), Correctional Treatment Center (CTC), Skilled Nursing Facility (SNF), Outpatient Housing Unit (OHU), or other appropriate health care facility, for continual observation.
2. Suicide Precaution. When medical staff determine that an inmate is at high risk of attempting self-injurious behavior, a licensed physician or psychologist shall order placement of the inmate on suicide precaution in a GACH, CTC, SNF, OHU, or other appropriate health care facility, for periodic monitoring.
3. Follow-up Treatment. Discharge from suicide watch or suicide precaution must occur when an interdisciplinary team of clinicians determines that the inmate no longer presents a suicide risk. A written treatment plan and follow-up outpatient treatment must be provided by a mental health clinician. (Cal. Code of Regs., tit. 15, § 3365, subd. (b).)

When a suicide attempt is discovered in progress, medical assistance must be summoned immediately to provide emergency medical care. (Cal. Code of Regs., tit. 15, § 3365, subd. (c).) Security and safety procedures must be followed, including the use of required equipment and procedures to deal with bodily fluids. (Id.) A cut-down kit must be immediately accessible on each unit and must be used by staff in case of an attempted suicide by hanging. (Id.) All subsequent activities and procedures must comply with local institutional emergency plans. (Id.) Additional protocols regarding suicide prevention and response are detailed in Chapter 10 of the Mental Health Program Services Delivery System Program Guide. (https://www.cdcr.ca.gov/DHCS/docs/Mental%20Health%20Program%20 Guide.pdf)

Finally, the DOM requires that “incidents, events and activities that occur within the jurisdiction of institutions of immediate interest to the Department, other governmental agencies or the news media” be reported to the Director or the departmental Officer-of -the-Day, or the Deputy Director. (DOM § 51030.1.) Certain incidents are required to be reported, including attempted suicides. (DOM § 51030.3.)

Audit on CDCR inmate suicides

Pursuant to its duty to complete an audit requested by JLAC, the State Auditor conducted an audit of CDCR’s policies, procedures, and practices for suicide prevention and reduction. The audit included visits to four state prisons, including two women’s prisons and two men’s prisons. The audit report was released in August 2017 and concluded that there were “significant weaknesses in prisons’ suicide prevention and response practices.” The audit found that “the prisons failed to complete some required evaluations to assess inmates’ risk for suicide and those that the prisons did complete were often inadequate… [including] leaving sections of the risk evaluations blank, failing to appropriately justify the determinations of risk, failing to develop adequate plans for treatment to reduce the inmates’ risk, and relying on inconsistent information about inmates to determine risk.” In addition, the prisons reviewed “did not properly monitor inmates who were at risk of committing suicide” and some staff members “had not completed required trainings related to suicide prevention and response.” Finally, the audit found that CDCR had not finished developing an internal audit process for compliance with the department’s policies and procedures related to inmate suicide prevention and response, and did not have a review process for suicide attempts. (https://www. auditor.ca.gov/pdfs/reports/2016-131.pdf)

In order to provide additional accountability for CDCR’s efforts to respond to and prevent inmate suicides and attempted suicides, the Auditor recommended that the Legislature require that CDCR report to it annually on a number of things, including CDCR’s progress toward meeting its goals related to the completion of suicide risk evaluations in a sufficient manner and the status of its efforts to ensure that all staff receive training related to suicide prevention and response. The Auditor also provided several recommendations to assist CDCR in remedying its deficiencies, including implementing a process for identifying prisons where staff are not attending required trainings and for working with the prisons to solve the issues preventing attendance, continuing to explore programs that could address the suicide risk factors unique to female inmates, continuing to develop its audit process and implement it at all prisons by February 2018, and continuing to take a role in coordinating and disseminating best practices related to mental health treatment by conducting a best practices summit at least annually.

FISCAL EFFECT: Appropriation: Fiscal Com.: Local:

According to the Assembly Appropriations Committee:

1. GF costs of at least $185,000 for CDCR to hire one additional psychologist.
2. Unknown additional GF costs for CDCR depending on implementation on this bill and challenges with releasing protected health information.

SUPPORT: (Verified 8/28/18)

California Catholic Conference

California Coalition for Women Prisoners

California Prison Focus

California Public Defenders Association

Californians United for a Responsible Budget

County Behavioral Health Directors Association of California

Depression and Bipolar Support Alliance

Ella Baker Center for Human Rights

Fair Chance Project

National Alliance on Mental Illness-California

National Association of Social Workers, California Chapter

Steinberg Institute

OPPOSITION: (Verified 8/28/18)

None received

Prepared by:

8/30/18 0:06:01

**** END ****

SENATE THIRD READING

STR Bill Id:SB 960

Author:(Leyva)

As Amended Ver:August 23, 2018

Majority vote

SENATE VOTE: 38-0

SUMMARY: Requires the California Department of Corrections and Rehabilitation (CDCR) to submit an annual report to the Legislature on its efforts to respond to and prevent inmate suicides. Specifically, this bill:

1. Provides that, on or before October 1, of each year, CDCR shall submit to the Legislature a report on its efforts to respond to and prevent suicides and attempted suicides among inmates.
2. States that the report shall include the following information:
   1. A description of CDCR's progress toward meeting its goals related to the completion of suicide risks evaluations in a sufficient manner;
   2. A description of CDCR's progress toward meeting its goals related to the completion of 72 hour treatment plans in a sufficient manner;
   3. A description of CDCR's efforts to ensure that all required staff receive training related to suicide prevention and response;
   4. A description of CDCR's progress in implementing the recommendations made by the special master regarding inmate suicides and attempts, including the results of any audits the department conducts;
   5. A description of CDCR's progress in identifying and implementing initiatives that are designed to reduce risk factors associated with suicides.
   6. A description of CDCR’s efforts and progress to expand upon its process of notifying a designated person in the event of a prisoner’s death, serious illness, or serious injury, including expansion of those notifications in cases of suicide attempts when deemed appropriate by the department, and when inmates have consented to allow release of that information.
3. States that the report shall be submitted to the Legislature and posted on CDCR's internet website in an easily accessible format.

EXISTING LAW:

1. Establishes a system of state prisons under the jurisdiction of CDCR.
2. States that it is the intent of the Legislature that CDCR regularly provide information on the outcomes of department operations and activities to allow the Legislature to better assess the performance of the department, including both to evaluate the effectiveness of department programs and activities, as well as to assess how efficiently the department is using state resources.
3. Requires CDCR to develop and implement a plan to obtain additional rehabilitation and treatment services for prison inmates and parolees. The plan is required to include, among other things, plans to fill vacant state staff positions that provide direct and indirect rehabilitation and treatment services to inmates and parolees.
4. Requires the Director of Corrections, upon the entry of a prisoner into CDCR, and every year thereafter, to obtain the name and last known address and telephone or persons who shall be notified in the event of the prisoner’s death, serious illness, or serious injury, and who are authorized to receive his or her body.
5. States that the Director of Corrections shall use all reasonable means to contact the person or persons set forth in the notification list upon the death, serious illness, or serious injury, of the prisoner while confined in CDCR.
6. Outlines the process to be taken when a person confined in any CDCR dies and no demand or claim is made for the body of the deceased inmate.

FISCAL EFFECT: According to the Assembly Appropriations Committee, General Fund costs of at least $185,000 for CDCR to hire one additional psychologist.

COMMENTS: According to the author, ''The disturbing findings in the State Auditor's report underscore the greater need for transparency, training and overall focus on inmate suicides. Incarcerated persons must have access to proper care within the prison so that we can minimize the risk of them harming themselves or others and family members deserve to know promptly if and when their loved one has been hurt or died while in custody. SB 960 is an important step in resolving many of the deficiencies noted in the State Auditor's report as we continue to emphasize the importance of keeping all inmates safe during their incarceration.''

Analysis Prepared by: Liah Burnley / PUB. S. / (916) 319-3744 FN: 0004586

SENATE THIRD READING

STR Bill Id:SB 960

Author:(Leyva)

As Amended Ver:

Majority vote

SENATE VOTE: 38-0

SUMMARY: Requires the California Department of Corrections and Rehabilitation (CDCR) to submit an annual report to the Legislature on its efforts to respond to and prevent inmate suicides. Specifically, this bill:

1. Provides that, on or before October 1, of each year, CDCR shall submit to the Legislature a report on its efforts to respond to and prevent suicides and attempted suicides among inmates.
2. States that the report shall include the following information:
   1. A description of CDCR's progress toward meeting its goals related to the completion of suicide risks evaluations in a sufficient manner;
   2. A description of CDCR's progress toward meeting its goals related to the completion of 72 hour treatment plans in a sufficient manner;
   3. A description of CDCR's efforts to ensure that all required staff receive training related to suicide prevention and response;
   4. A description of CDCR's progress in implementing the recommendations made by the special master regarding inmate suicides and attempts, including the results of any audits the department conducts;
   5. A description of CDCR's progress in identifying and implementing initiatives that are designed to reduce risk factors associated with suicides.
3. States that the report shall be submitted to the Legislature and posted on CDCR's internet website in an easily accessible format.
4. Requires CDCR to make all reasonable efforts to notify the contact person of an inmate within 24 hours, first by telephone whenever possible, or in writing, in the event of the inmate's serious illness or injury requiring hospitalization, or death, including attempted suicide.
5. States that a "serious illness or injury requiring hospitalization" includes an attempted suicide that involved serious self-harm resulting in medical intervention that required hospitalization or placement in a mental health crisis bed.

EXISTING LAW:

1. Establishes a system of state prisons under the jurisdiction of CDCR.
2. States that it is the intent of the Legislature that CDCR regularly provide information on the outcomes of department operations and activities to allow the Legislature to better assess the performance of the department, including both to evaluate the effectiveness of department programs and activities, as well as to assess how efficiently the department is using state resources.
3. Requires CDCR to develop and implement a plan to obtain additional rehabilitation and treatment services for prison inmates and parolees. The plan is required to include, among other things, plans to fill vacant state staff positions that provide direct and indirect rehabilitation and treatment services to inmates and parolees.
4. Outlines the process to be taken when a person confined in any CDCR dies and no demand or claim is made for the body of the deceased inmate.

FISCAL EFFECT: According to the Assembly Appropriations Committee, General Fund costs of at least $185,000 for CDCR to hire one additional psychologist.

COMMENTS: According to the author, ''The disturbing findings in the State Auditor's report underscore the greater need for transparency, training and overall focus on inmate suicides. Incarcerated persons must have access to proper care within the prison so that we can minimize the risk of them harming themselves or others and family members deserve to know promptly if and when their loved one has been hurt or died while in custody. SB 960 is an important step in resolving many of the deficiencies noted in the State Auditor's report as we continue to emphasize the importance of keeping all inmates safe during their incarceration.''

Please see the policy committee analysis for a full discussion of this bill.

Analysis Prepared by: Liah Burnley / PUB. S. / (916) 319-3744 FN: 0004100

Date of Hearing: August 8, 2018

ASSEMBLY COMMITTEE ON APPROPRIATIONS

Lorena Gonzalez Fletcher, Chair

SBPCA Bill Id:SB 960

Author:(Leyva) – As Amended Ver:May 25, 2018

Urgency: No State Mandated Local Program: No Reimbursable: No

SUMMARY:

This bill requires the California Department of Corrections and Rehabilitation (CDCR) to submit an annual report to the Legislature on its efforts to respond to and prevent inmate suicides.

FISCAL EFFECT:

1. GF costs of at least $185,000 for CDCR to hire one additional psychologist.
2. Unknown additional GF costs for CDCR depending on implementation on this bill and challenges with releasing protected health information.

COMMENTS:

Background and purpose. In recent years, studies and audits have determined that CDCR has a higher inmate suicide rate than the national average. Some of these reports have found that CDCR did not take all reasonable steps to prevent inmate suicides. This bill requires CDCR to submit a report to the Legislature on inmate suicides and the department’s suicide prevention measures. According to the author:

The disturbing findings in the State Auditor’s report underscore the greater need for transparency, training and overall focus on inmate suicides. Incarcerated persons must have access to proper care within the prison so that we can minimize the risk of them harming themselves or others and family members deserve to know promptly if and when their loved one has been hurt or died while in custody. SB 960 is an important step in resolving many of the deficiencies noted in the State Auditor’s report as we continue to emphasize the importance of keeping all inmates safe during their incarceration.

Analysis Prepared by: Jessica Peters / APPR. / (916) 319-2081

Date of Hearing: June 19, 2018

Counsel: Liah Burnley

ASSEMBLY COMMITTEE ON PUBLIC SAFETY

Reginald Byron Jones-Sawyer, Sr., Chair

SBPCA Bill Id:SB 960

Author:(Leyva) – As Amended Ver:May 25, 2018

SUMMARY: Requires the California Department of Corrections and Rehabilitation (CDCR) to submit an annual report to the Legislature on its efforts to respond to and prevent inmate suicides. Specifically, this bill:

1. Provides that, on or before April 1, of each year, CDCR shall submit to the Legislature a report on its efforts to respond to and prevent suicides and attempted suicides among inmates.
   
2. States that the report shall include the following information:
   
   1. An identification of all recommendations made as the result of an audit, assessment, or other review, that, if implemented, would affect CDCR’s efforts to respond to and prevent suicides and attempted suicides;
      
   2. A description of CDCR’s progress in implementing each recommendation, including the expected timeline for full implementation of each recommendation and the activities taken to fully implement each recommendation;
   3. The results of any audits or reviews that measure the success of the changes CDCR implements as a result of the recommendations;
   4. CDCR’s progress in identifying and implementing mental health programs that may ameliorate risk factors associated with suicides at the prisons;
   5. CDCR’s progress in meeting its goals for completing suicide risk evaluations and comprehensive mental health treatment plans;
   6. CDCR’s efforts to ensure that all mental health staff receive required training and mentoring; and,
   7. CDCR’s efforts to fill vacancies in its mental health treatment programs.
      
3. States that the report shall be submitted to the Legislature and posted on CDCR’s internet website in an easily accessible format.
   
4. Requires CDCR to notify the contact person of an inmate within 24 hours by telephone in the event of the inmate’s serious illness, injury, or death, including attempted suicide.

EXISTING LAW:

1. Establishes a system of state prisons under the jurisdiction of CDCR. (Pen. Code, § 2000.)
2. States that it is the intent of the Legislature that CDCR regularly provide information on the outcomes of department operations and activities to allow the Legislature to better assess the performance of the department, including both to evaluate the effectiveness of department programs and activities, as well as to assess how efficiently the department is using state resources. (Pen. Code, §§ 2064, 2603.)
3. Requires CDCR to develop and implement a plan to obtain additional rehabilitation and treatment services for prison inmates and parolees. The plan is required to include, among other things, plans to fill vacant state staff positions that provide direct and indirect rehabilitation and treatment services to inmates and parolees. (Pen. Code, § 2061.)
4. Outlines the process to be taken when a person confined in any CDCR dies and no demand or claim is made for the body of the deceased inmate. (Pen. Code, § 5061.)

FISCAL EFFECT: Unknown.

COMMENTS:

1. Author’s Statement: According to the author, “The disturbing findings in the State Auditor’s report underscore the greater need for transparency, training and overall focus on inmate suicides. Incarcerated persons must have access to proper care within the prison so that we can minimize the risk of them harming themselves or others and family members deserve to know promptly if and when their loved one has been hurt or died while in custody. SB 960 is an important step in resolving many of the deficiencies noted in the State Auditor’s report as we continue to emphasize the importance of keeping all inmates safe during their incarceration.”
2. Need for the Bill: In 1995, a Federal District Court ruled that CDCR was not providing adequate mental health care in violation of inmates’ Eighth and Fourteenth Amendment rights. (Coleman v. Brown (1995) 912 F. Supp. 1282.) The district court identified six areas where CDCR needed to make improvements, including suicide prevention. (Id.) To remedy gross systematic failures in the delivery of mental health care, the court appointed a Special Master to monitor and report on CDCR’s progress toward providing an adequate level of mental health care. (Id.)
   
   In 2013, the Special Master criticized CDCR for failing to follow many of the recommendations made to the department over a 14 year-period. The Special Master’s report to the court stated that “suicide rate trend analyses continue to show that suicide rates in CDCR consistently exceed the average rates in U.S. state and federal prisons, and are growing” and that “[t]he high rate of inadequacy in assessment, treatment, or intervention is generally consistent with previous years, and remains unacceptably high. Examination of the individual suicide cases revealed that for 25, or 73.5 percent, of the 34 inmates who completed suicides, there had been at least some degree of inadequate assessment, treatment, or intervention.” (https://rbgg.com/wp-content/uploads/Coleman-Report-on-Suicides-Completed-in-the-CDCR-inCalendar-Year-20111.pdf.)
   
   In 2011, the United States Supreme Court cited California’s inmate suicide rate and the percentage of those suicides that involved some measure of inadequate assessment, treatment, intervention, and were therefore most probably foreseeable or preventable as evidence that prisoners in California with serious mental illness do not receive adequate care. (Brown v. Plata, (2011) 131 S. Ct. at 1924-25.) The Court found that California’s 2006 inmate suicide rate was “nearly 80% higher than the national average for prison populations” and “72.1 percent of the inmate suicides in 2006 involved some measure of inadequate assessment, treatment, or intervention, and were therefore most probably foreseeable and/or preventable;” “that percentage rose to 82% in 2007;” that those “numbers clearly indicate no improvement in this area during the past several years, and possibly signal a trend of ongoing deterioration;” and that the “data for 2010 so far is not showing improvement in suicide prevention.” (Id.)
   

Despite the Supreme Court’s 2011 Plata decision, and the 2013 report of the Special Master, CDCR filed a motion to dismiss the Coleman case and terminate the Special Master, contending that it “now [has] a mental health care delivery system that includes each of the six basic, essentially common sense, components of a minimally adequate prison mental health care delivery system.” (https://www.cdcr.ca.gov/News/docs/3JP-April-2013/Coleman-Termination-Order.pdf.) The court denied CDCR’s motion to terminate because “[t]he facts show, however, that the rate of inmate suicide is not declining, and more than seventy percent of inmate suicides in California involve significant inadequacies about which defendants have known for years. These facts demonstrate an ongoing violation of the Eighth Amendment rights.” (Id.)

Today, inmate suicide remains a pervasive problem at CDCR. In 2016, the Joint Legislative Audit Committee requested the California State Auditor to audit CDCR’s policies, procedures and practices for suicide prevention and reduction, with a particular emphasis on the recently elevated suicide rate at the California Institution for Women. (https://www.auditor.ca.gov/reports/2016-131/summary.html) The audit revealed the following:

• The average suicide rate in CDCR’s prisons was substantially higher than the average of U.S. state prisons;
  
• The rates of female inmates who committed suicide while in CDCR’s prisons have soared in recent years;
  
• Significant weaknesses in compliance with suicide prevention and response policies;
  
• Prisons failed to complete or completed inadequate risk evaluations for many of those inmates who required them;
  
• Prisons did not complete or created inadequate treatment plans for some inmates—plans did not always specify medication dosage and frequency, treatment methods, provider information, or follow-up upon discharge;
  
• Prisons did not properly monitor inmates who were at risk of committing suicide;
  
• Although CDCR has known about many of the issues related to suicide prevention and response policies and practices that we found for a number of years, it has not fully implemented processes to address the issues that have been raised; and,
  
• CDCR could take a more proactive leadership role in identifying programs or best practices and reviewing a prison’s practices following an inmate’s suicide attempt. (Id.)

Not only are inmate suicides a troubling concern at CDCR, the high rate of suicide among CDCR correctional officers also deserves recognition. (See https://www.cbsnews.com/news/study-shows-high-suicide-rate-for-california-prison-guards/.) There were 96 confirmed or suspected suicides among current and retired members between 1999 and 2015 and about 10 percent of prison guards have considered or attempted suicide. (Id.) Researchers cited officers' frequent exposure to violence and injury, their perception of constant danger. (Id.)

This bill would require CDCR provide information about inmate suicide to the Legislature that would help both CDCR and the Legislature better understand the factors contributing to inmate suicide, which could potentially help foster a prison environment that recognizes the value of human life and reduces both inmate and correctional officer suicide.

1. Argument in Support: Writing in support of this bill, the California Coalition for Women Prisoners states, “[this bill] would strengthen oversight of CDCR’s efforts to properly implement suicide prevention policies through reporting and Legislative supervision. The required reports would allow the legislature to more closely monitor CDCR suicide prevention and take further steps to enforce policy compliance if necessary. By requiring annual CDCR reports on suicide and suicides attempts in California prisons, [this bill] will be a key step towards addressing this urgent crisis. It will also position the state to take future action to prevent prison suicides, including eliminating suicide watch as another form of solitary confinement that increases suicide risk, ending all forms of isolated confinement; enforcing fill compliance with the law protecting imprisoned people’s rights and holding correctional officers accountable for deaths that occur due to their neglect.”
   
2. Related Legislation:
   1. AB 2028 (Rodriguez), of the 2017-18 Legislative Session, would also require CDCR to annually and confidentially report to the Joint Legislative Audit Committee, on deficiencies identified during the inspection and audit procedure and the remediation or planned remediation of those deficiencies. AB 2028 is currently pending assignment in Senate Rules Committee.
      
   2. AB 2550 (Weber), of the 2017-18 Legislative Session, this bill would prohibit male correctional officers from conducting a pat down search of a female inmate unless the prisoner presents a risk of immediate harm, and would prohibit a male correctional officer from entering an area of the institution where female inmates may be in a state of undress, or from being in an area where they can view female inmates in a state of undress, unless an inmate in the area presents a risk of immediate harm. AB 2550 is pending hearing in Senate Appropriations Committee.
   3. AB 1971 (Santiago), of the 2017-18 Legislative Session, would state findings and declarations of the Legislature relating to mental illness, including that CDCR estimates that among the 129,000 inmates receiving prison-based mental health services, approximately 35,000 individuals have severe mental illness. AB 1971 pending hearing in Senate Health Committee.
      
   4. SB 990 (Weiner), of the 2017-18 Legislative Session, would require CDCR to annually report its progress towards providing equal access to programs and work opportunities equal access to programs and work opportunities to the Legislature. SB 990 is pending hearing in Assembly Public Safety Committee.
3. Prior Legislation:
   1. AB 1929 (Lackey), of the 2017-18 Legislative Session, would require CDCR and the Office of the Inspector General to monitor and evaluate inmate rehabilitation programs and report to the Joint Legislative Budget Committee, the Assembly and Senate Committees on Public Safety, and the Governor biannually, on or before March 15 and September 15 of each year. AB 1929 was held in Assembly Appropriations Committee.
      
   2. SB 601 (Hancock), Chapter 162, Statutes of 2015, required the Secretary of CDCR to develop a Data Dashboard on a quarterly basis containing specified information regarding each institution, including, among other information, staff vacancies and the number of authorized staff positions, overtime, sick leave, and the number of use of force incidents, and to post those reports on the its Internet website.
   3. AB 1628 (Budget Committee), Chapter 729, Statutes of 2010, required CDCR to provide the Joint Legislative Budget Committee an annual report on the outcomes of department operations, specified activities, and an explanation for why it did not achieve prior target performance goals, and post the report on its Internet website.
      

REGISTERED SUPPORT / OPPOSITION:

Support

California Access Coalition

California Catholic Conference

California Coalition for Women Prisoners

California Council of Community Behavioral Health Agencies

California Prison Focus

California Public Defenders Association

Californians United for a Responsible Budget

County Behavioral Health Directors Association of California

Depression and Bipolar Support Alliance

Ella Baker Center for Human Rights

Fair Chance Project

National Alliance on Mental Illness-California

National Association of Social Workers, California Chapter

The Steinberg Institute

Opposition

None

Analysis Prepared by: Liah Burnley / PUB. S. / (916) 319-3744

 THIRD READING  

Bill No: SB 960

Author:

:

Vote:

SENATE PUBLIC SAFETY COMMITTEE: 7-0, 4/24/18

AYES: Skinner, Anderson, Bradford, Jackson, Mitchell, Stone, Wiener

SENATE APPROPRIATIONS COMMITTEE: 7-0, 5/25/18

AYES: Lara, Bates, Beall, Bradford, Hill, Nielsen, Wiener

SUBJECT:

SOURCE: Author

DIGEST:

This bill requires the California Department of Corrections and Rehabilitation (CDCR) to report and publish annually, as specified, its efforts to respond to and prevent suicides and attempted suicides among inmates, and requires CDCR to notify an inmate’s contact person within 24 hours by telephone in the event of a serious injury, serious illness, or death, if a contact person is listed on record.

ANALYSIS:

Existing law:

1. Establishes a system of state prisons under the jurisdiction of CDCR. (Pen. Code § 2000 et seq.)
2. Requires CDCR to develop and implement a plan to obtain additional rehabilitation and treatment services for prison inmates and parolees. The plan is required to include, among other things, plans to fill vacant state staff positions that provide direct and indirect rehabilitation and treatment services to inmates and parolees. (Pen. Code § 2061.)

This bill:

1. Requires CDCR to annually submit to the Legislature, on or before April 1 of each year, a report on CDCR’s efforts to respond to and prevent suicides and attempted suicides among inmates. The information contained in the report must include, but is not be limited to, all of the following:
2. An identification of all recommendations that, if implemented, would affect CDCR’s efforts to respond to and prevent suicides and attempted suicides among inmates and that were made to CDCR or to a prison or institution as the result of an audit, assessment, or other review, whether internally or externally conducted, mandated, or court-ordered.
3. A description of CDCR’s progress in implementing each recommendation identified in an audit or other review, as described above, including the expected timeline for full implementation for each recommendation and the activities undertaken to address each recommendation. If CDCR does not intend to fully implement a recommendation, the CDCR must describe in sufficient detail its reasons for not fully implementing the recommendation.
4. A description of the results of any audit or review CDCR conducts that measure the success of changes it implements as a result of the recommendations made by an audit or other review.
5. A description of the CDCR’s progress in identifying and implementing mental health programs that may ameliorate risk factors associated with suicides at the prisons and institutions.
6. A description of CDCR’s progress in meeting its goals for completing suicide risk evaluations and comprehensive mental health treatment plans in a sufficient manner, including identifying the number of suicide risk evaluations and comprehensive mental health treatment plans completed, describing the criteria CDCR uses to assess the quality of the suicide risk evaluations and comprehensive mental health treatment plans, and reporting on the results of its assessments of the suicide risk evaluations and comprehensive mental health treatment plans. CDCR must present the information regarding its progress in meeting its goals for completing suicide risk evaluations separately from the information regarding the department’s progress in meeting its goals for completing comprehensive mental health treatment plans.
7. A description of CDCR’s efforts to ensure that all mental health staff receive required training and mentoring related to suicide prevention and response, including describing the trainings and mentoring required and identifying the number of individuals required to take each training or to participate in mentoring, and the number of individuals who completed each required training or participating in required mentoring.
8. A description of CDCR’s efforts to fill vacancies in its mental health treatment programs, including its efforts to hire and retain psychiatrists.
9. Requires that the report be posted on CDCR’s Web site in an easily accessible format.
10. Requires CDCR to notify the contact person of an inmate, if one is listed on record, within 24 hours by telephone in the event of the inmate’s serious illness, serious injury, or death.
11. Provides that “serious injury” includes attempted suicide.

Background

CDCR has a long history of inmate suicides. In 1995, the U.S. District Court for the Eastern District of California ruled that CDCR was not providing adequate mental health care in violation of inmates’ Eighth and Fourteenth Amendment rights. (Coleman v. Wilson (1995) 912 F. Supp. 1282 (now Coleman v. Brown).) As part of that ruling, the court identified six areas where CDCR needed to make improvements, including suicide prevention. The court appointed a Special Master to monitor and report on CDCR’s progress toward providing an adequate level of mental health care. That remedial process has been ongoing.

CDCR’s continued difficulty in remedying the deficiencies of its mental health care system is well documented. A 2013 report to the court by the Special Master criticized CDCR for failing to follow many of the recommendations he had made to the department over a 14-year period. (https://rbgg.com/wp-content/uploads/ Coleman-Report-on-Suicides-Completed-in-the-CDCR-in-Calendar-Year-20111.pdf ; <http://articles.latimes.com/2013/mar/13/local/la-me-ff-court-expert-prison-suicide-rate-20130313 [as of Apr. 17, 2018].) In recent years, an increase in the number of inmate suicides led the Joint Legislative Audit Committee (JLAC) to request that the California State Auditor prepare an audit report concerning CDCR’s policies, procedures, and practices for suicide prevention and reduction, with a particular emphasis on the recently elevated suicide rate at the California Institution for Women. (See <http://www.sacbee.com/news/local/crime/ article41246670.html ; <https://www.theguardian.com/us-news/2016/may/10/ suicide-california-womens-prison-mental-health [as of Apr. 17, 2018].)

Mental health generally

CDCR regulations require the department to provide a broad range of mental health services to inmates by assessing the needs of its population and developing specialized programs of mental health care, to the extent resources are available for that purpose. (Cal. Code of Regs., tit. 15, § 3360, subd. (a).) Necessary and appropriate mental health services must be provided to inmates, and adequate staff and facilities must be maintained for the delivery of such services. (Id.) When an inmate is found to require mental health care that is not available within those resources, but which is available in the Department of Mental Health, the case will be referred to the director for consideration of temporary transfer to that department pursuant to Penal Code section 2684. (Cal. Code of Regs., tit. 15, § 3360, subd. (b).)

All required mental health treatment or diagnostic services must be provided under the supervision of a psychiatrist licensed to practice in the state, or a psychologist licensed to practice in the state and who holds a doctoral degree and has at least two years of experience in the diagnosis and treatment of emotional and mental disorders. (Cal. Code of Regs., tit. 15, § 3361, subd. (a).) All persons committed to CDCR must be informed that mental health services are available to them, and that, upon an inmate’s request, an evaluative interview will be provided within a reasonable period of time by a licensed practitioner, or a specially trained counselor supervised by a licensed practitioner. (Cal. Code of Regs., tit. 15, § 3362.) Upon request, an inmate will be provided with information as to what specialized treatment programs may be available in the department and how such treatment may be obtained. (Id.)

Suicide prevention and response

Each institution head is required to ensure that all employees whose assignments routinely involve inmate contact are trained to recognize signs and symptoms associated with suicide risk, the appropriate procedures for staff intervention, and the appropriate procedures to be followed in response to emergency situations resulting from self-injurious or suicidal actions. (Cal. Code of Regs., tit. 15, § 3365, subd. (a).) Specifically, peace officer classifications are required to complete annual training on suicide prevention. (Department Operations Manual (DOM) § 32010.15)

Each institution head is required to implement a Suicide Prevention Program for inmates who display self-injurious or suicidal behavior or symptoms. These programs must include the following components:

1. Suicide Watch. When medical staff determine that an inmate is actively suicidal, a licensed physician or psychologist must order placement of the inmate on suicide watch in a General Acute Care Hospital (GACH), Correctional Treatment Center (CTC), Skilled Nursing Facility (SNF), Outpatient Housing Unit (OHU), or other appropriate health care facility, for continual observation.
2. Suicide Precaution. When medical staff determine that an inmate is at high risk of attempting self-injurious behavior, a licensed physician or psychologist shall order placement of the inmate on suicide precaution in a GACH, CTC, SNF, OHU, or other appropriate health care facility, for periodic monitoring.
3. Follow-up Treatment. Discharge from suicide watch or suicide precaution must occur when an interdisciplinary team of clinicians determines that the inmate no longer presents a suicide risk. A written treatment plan and follow-up outpatient treatment must be provided by a mental health clinician. (Cal. Code of Regs., tit. 15, § 3365, subd. (b).)

When a suicide attempt is discovered in progress, medical assistance must be summoned immediately to provide emergency medical care. (Cal. Code of Regs., tit. 15, § 3365, subd. (c).) Security and safety procedures must be followed, including the use of required equipment and procedures to deal with bodily fluids. (Id.) A cut-down kit must be immediately accessible on each unit and must be used by staff in case of an attempted suicide by hanging. (Id.) All subsequent activities and procedures must comply with local institutional emergency plans. (Id.) Additional protocols regarding suicide prevention and response are detailed in Chapter 10 of the Mental Health Program Services Delivery System Program Guide. (https://www.cdcr.ca.gov/DHCS/docs/Mental%20Health%20Program%20 Guide.pdf)

Finally, the DOM requires that “incidents, events and activities that occur within the jurisdiction of institutions of immediate interest to the Department, other governmental agencies or the news media” be reported to the Director or the departmental Officer-of -the-Day, or the Deputy Director. (DOM § 51030.1.) Certain incidents are required to be reported, including attempted suicides. (DOM § 51030.3.)

Notification requirements for inmate death, serious injury, or serious illness

The DOM provides that CDCR must treat the death, serious injury, or serious illness of an inmate with dignity and respect as is regularly accorded persons who are not incarcerated. (DOM § 51070.2.) The procedures to be followed after death, serious injury, or illness must comply with the requirements of all applicable laws. (Id.) The DOM includes detailed protocols for prison staff after an inmate’s death. Among the responsibilities and duties for prison staff following an inmate’s death, include pronouncement of death, preparing a written summary of the circumstances surrounding the inmate’s death, signing the death certificate, and identifying the decedent. (DOM §§ 51070.4-51070.8.)

The DOM also provides the notification requirements following an inmate’s death. For example, an inmate’s death must be reported to the county sheriff and coroner within two hours of the death. (DOM § 51070.9.) The DOM specifies that Receiving and Release staff in Reception Centers obtain primary and alternate emergency contact information for each incoming inmate. (DOM § 51070.10.) This information is stored in two CDCR databases and is required to be updated annually as part of the classification review process, upon recommendation of transfer by a classification, and whenever an inmate advises his or her correctional counselor of a desire to change the information.

DOM section 51070.10 lays out the protocol that CDCR staff must follow with respect to notifying an inmate’s emergency contact in the event of the inmate’s death, serious injury, or serious illness. In the event of a death, serious injury, or serious illness, the Warden or designee at the level of Correctional Lieutenant or Correctional Counselor II or above is required to use all reasonable means to contact the person identified on the notification form. CDCR is required to notify the emergency contact person as soon as possible, and notification via phone must be used whenever possible. If notification cannot be immediately made, the DOM specifies that all reasonable means to make contact with family members must be used, including searching the inmate’s personal property, reviewing the inmate’s visiting file, contacting the previous parole agent, if any, contacting the arresting agency, or contacting the Office of Correctional Safety (OCS) to locate contact information, among others.

The DOM further provides that if notification with the contact listed cannot be made within 72 hours, the Warden must notify their respective Associate Director that all reasonable means for obtaining contact information have been exhausted. The Associate Director is then required to make contact with the OCS for any additional assistance in locating the next of kin.

In addition to the notification requirements described above, CDCR is required to report inmate suicides and other critical incidents within a specified timeframe to the Office of the Inspector General, the agency tasked with providing oversight to California’s correctional system.

Audit on CDCR inmate suicides

Pursuant to its duty to complete an audit requested by JLAC, the State Auditor conducted an audit of CDCR’s policies, procedures, and practices for suicide prevention and reduction. The audit included visits to four state prisons, including two women’s prisons and two men’s prisons. The audit report was released in August 2017 and concluded that there were “significant weaknesses in prisons’ suicide prevention and response practices.” The audit found that “the prisons failed to complete some required evaluations to assess inmates’ risk for suicide and those that the prisons did complete were often inadequate… [including] leaving sections of the risk evaluations blank, failing to appropriately justify the determinations of risk, failing to develop adequate plans for treatment to reduce the inmates’ risk, and relying on inconsistent information about inmates to determine risk.” In addition, the prisons reviewed “did not properly monitor inmates who were at risk of committing suicide” and some staff members “had not completed required trainings related to suicide prevention and response.” Finally, the audit found that CDCR had not finished developing an internal audit process for compliance with the department’s policies and procedures related to inmate suicide prevention and response, and did not have a review process for suicide attempts. (https://www. auditor.ca.gov/pdfs/reports/2016-131.pdf)

In order to provide additional accountability for CDCR’s efforts to respond to and prevent inmate suicides and attempted suicides, the Auditor recommended that the Legislature require that CDCR report to it annually on a number of things, including CDCR’s progress toward meeting its goals related to the completion of suicide risk evaluations in a sufficient manner and the status of its efforts to ensure that all staff receive training related to suicide prevention and response. The Auditor also provided several recommendations to assist CDCR in remedying its deficiencies, including implementing a process for identifying prisons where staff are not attending required trainings and for working with the prisons to solve the issues preventing attendance, continuing to explore programs that could address the suicide risk factors unique to female inmates, continuing to develop its audit process and implement it at all prisons by February 2018, and continuing to take a role in coordinating and disseminating best practices related to mental health treatment by conducting a best practices summit at least annually.

FISCAL EFFECT: Appropriation: Fiscal Com.: Local:

According to the Senate Appropriations Committee:

1. CDCR anticipates personnel costs of about $185,000 to hire 1.0 Senior Psychologist Specialist to conduct the evaluation and develop the report. (General Fund)
2. Unknown, but less cost than before to CDCR to notify inmates’ contact person during the occurrence of specified incidents. (General Fund)

SUPPORT: (Verified 5/25/18)

California Catholic Conference

California Coalition for Women Prisoners

California Prison Focus

California Public Defenders Association

Californians United for a Responsible Budget

County Behavioral Health Directors Association of California

Depression and Bipolar Support Alliance

Ella Baker Center for Human Rights

Fair Chance Project

National Alliance on Mental Illness-California

National Association of Social Workers, California Chapter

Steinberg Institute

OPPOSITION: (Verified 5/25/18)

None received

Prepared by: Stephanie Jordan / PUB. S. /

5/29/18 10:54:28

**** END ****

SENATE COMMITTEE ON APPROPRIATIONS

Senator Ricardo Lara, Chair

2017 - 2018 Regular Session

SB 960 (Leyva) - Department of Corrections and Rehabilitation: suicide prevention: reports

*********** ANALYSIS ADDENDUM – SUSPENSE FILE ***********

The following information is revised to reflect amendments

adopted by the committee on May 25, 2018

Bill Summary:

SB 960 would require the Department of Corrections and Rehabilitation (CDCR) to report and publish annually, as specified, its efforts to respond to and prevent suicides and attempted suicides among inmates and would require the department to notify an inmate’s contact person within twenty-four hours by telephone in the event of a serious injury, serious illness, or death if a contact person is listed on record.

Fiscal Impact:

• The department anticipates personnel costs of about $185,000 to hire 1.0 Senior Psychologist Specialist to conduct the evaluation and develop the report. (General Fund)
• Unknown, but less cost than before to CDCR to notify inmates’ contact person during the occurrence of specified incidents. (General Fund)

Committee Amendments:

Strike notification requirement for mental health diagnoses.

-- END --

SENATE COMMITTEE ON

Senator Ricardo Lara, Chair

2017 - 2018 Regular Session

SB 960 (Leyva) - Department of Corrections and Rehabilitation: suicide prevention: reports

This bill meets the criteria for referral to the Suspense File.

Bill Summary:

SB 960 would require the Department of Corrections and Rehabilitation (CDCR) to report and publish annually, as specified, its efforts to respond to and prevent suicides and attempted suicides among inmates and would require the department to notify an inmate’s contact person within twenty-four hours by telephone in the event of a serious injury, serious illness, or death if a contact person is listed on record.

Fiscal Impact:

The department anticipates costs in the range of $50,000 to $100,000 annually to obtain contract staff to conduct the evaluation and produce a report as required by this bill. The cost estimate, in diverted resources, would be within the same range if CDCR were to rely on department staff to conduct the evaluation and develop the report. (General Fund)

Committee staff estimates minor and absorbable costs relative to notifying emergency contacts for most of the events that would be required by this bill, as CDCR has a process in place and does this already, albeit within a seventy-two hours period and not for attempted suicides that do not result in a serious injury. There could be increased workload costs of an unknown amount related to notifying emergency contacts about mental health diagnoses. The department has indicated that new mental health diagnoses are made dozens of times a day and providing the required notifications for these events likely would take significant staff time and resources. Moreover, this could lead to additional litigation costs of an unknown amount, as disclosing protected healthcare information without the subject’s authorization is a violation of existing privacy law. (General Fund)

Background:

According to the analysis of this bill by the Senate Committee on Public Safety:

The [Department Operation Manual (DOM)] provides that CDCR must treat the death, serious injury, or serious illness of an inmate with dignity and respect as is regularly accorded persons who are not incarcerated. (DOM § 51070.2.) The procedures to be followed after death, serious injury, or illness must comply with the requirements of all applicable laws. (Id.) The DOM includes detailed protocols for prison staff after an inmate’s death. Among the responsibilities and duties for prison staff following an inmate’s death, include pronouncement of death, preparing a written summary of the circumstances surrounding the inmate’s death, signing the death certificate, and identifying the decedent. (DOM §§ 51070.4-51070.8.)

The DOM also provides the notification requirements following an inmate’s death. For example, an inmate’s death must be reported to the county sheriff and coroner within two hours of the death. (DOM § 51070.9.) The inmate’s death must be reported to the district attorney in the county in which the prison as well as specified CDCR officials within 24 hours. The DOM specifies that Receiving and Release staff in Reception Centers obtain primary and alternate emergency contact information for each incoming inmate. (DOM § 51070.10.) This information is stored in two CDCR databases and is required to be updated:

• Annually as part of the classification review process.
• Upon recommendation of transfer by a classification.
• Whenever an inmate advises his or her correctional counselor of a desire to change the information.

DOM section 51070.10 lays out the protocol that CDCR staff must follow with respect to notifying an inmate’s emergency contact in the event of the inmate’s death, serious injury, or serious illness. In the event of a death, serious injury, or serious illness, the Warden or designee at the level of Correctional Lieutenant or Correctional Counselor II or above is required to use all reasonable means to contact the person identified on the notification form. CDCR is required to notify the emergency contact person as soon as possible. Notification via phone must be used whenever possible. If notification cannot be immediately made, the Warden or designee at the level of Correctional Lieutenant or Correctional Counselor II or above must use all reasonable means to make contact with family members, including but not limited to: assigning Investigative Services Unit staff to utilize telephone signup sheets, Inmate Monitoring and Recording Systems, searching the inmate’s personal property, reviewing the inmate’s visiting file, contacting the previous parole agent, if any, contacting the local coroner’s office, contacting the arresting agency, reviewing social media, or contacting the Office of Correctional Safety (OCS) to locate contact information. All efforts made to notify the next of kin must be documented on a specified form.

The DOM further provides that if notification with the contact listed cannot be made within 72 hours, the Warden must notify their respective Associate Director that all reasonable means for obtaining contact information have been exhausted. The Associate Director is then required to make contact with the OCS for any additional assistance in locating the next of kin.

In addition to the notification requirements described above, CDCR is required to report inmate suicides and other critical incidents within a specified timeframe to the Office of the Inspector General, the agency tasked with providing oversight to California’s correctional system.

Proposed Law:

This bill would require CDCR to submit to the Legislature and post on its website, a report, as specified, on or before April 1 of each year on the department’s efforts to respond to and prevent suicides and attempted suicides among inmates. The report must include, among other things, identifying recommendations that would affect the department’s efforts to respond to and prevent suicides and attempted suicides among inmates, a description of the progress in implementing those recommendations, and a description of the department’s progress in identifying and implementing mental health programs that may ameliorate risk factors associated with suicides among inmates. Additionally, it would require the department to notify the contact person of an inmate, if one is listed on record, within twenty-four hours by telephone in the event of the inmate’s serious illness, serious injury, or death, which would include attempted suicide, as specified.

Related Legislation:

In 2016, at the request of the author of this measure, the Joint Committee on Legislative Audit approved a request to the California State Auditor to review and report back on CDCR’s policies, procedures, and practices for suicide prevention and reduction, with a particular emphasis on the recently-elevated suicide rate at the California Institution for Women. (For more information, see the analysis of this bill by the Senate Committee on Public Safety.)

-- END --

SENATE COMMITTEE ON PUBLIC SAFETY

Senator Nancy Skinner, Chair

2017 - 2018 Regular

Bill No: SB 960 Hearing Date: April 24, 2018

Subject: Department of Corrections and Rehabilitation: Suicide Prevention: Reports

HISTORY

Source: Author

Prior Legislation: None

Support: California Catholic Conference; California Coalition for Women Prisoners; California Prison Focus; California Public Defenders Association; Californians United for a Responsible Budget; Depression and Bipolar Support Alliance; Ella Baker Center for Human Rights; Fair Chance Project; National Association of Social Workers, California Chapter; Steinberg Institute

Opposition: None known

PURPOSE

The purpose of this bill is to: 1) require the California Department of Corrections and Rehabilitation (CDCR) to submit an annual report on CDCR’s efforts to respond to and prevent suicides and attempted suicides among inmates to the Legislature; 2) make this report available on CDCR’s website; and 3) require CDCR to notify an inmate’s contact person within 24 hours by telephone in the event of a serious injury, serious illness, or death, if a contact person is listed on record.

Existing law establishes a system of state prisons under the jurisdiction of CDCR. (Pen. Code, § 2000 et seq.)

Existing law requires CDCR to develop and implement a plan to obtain additional rehabilitation and treatment services for prison inmates and parolees. The plan is required to include, among other things, plans to fill vacant state staff positions that provide direct and indirect rehabilitation and treatment services to inmates and parolees. (Pen. Code, § 2061.)

This bill requires CDCR to annually submit to the Legislature, on or before April 1 of each year, a report on CDCR’s efforts to respond to and prevent suicides and attempted suicides among inmates. The information contained in the report must include, but is not be limited to, all of the following:

• An identification of all recommendations that, if implemented, would affect CDCR’s efforts to respond to and prevent suicides and attempted suicides among inmates and that were made to CDCR or to a prison or institution as the result of an audit, assessment, or other review, whether internally or externally conducted, mandated, or court-ordered.
• A description of CDCR’s progress in implementing each recommendation identified in an audit or other review, as described above, including the expected timeline for full implementation for each recommendation and the activities undertaken to address each recommendation. If CDCR does not intend to fully implement a recommendation, the CDCR must describe in sufficient detail its reasons for not fully implementing the recommendation.
• A description of the results of any audit or review CDCR conducts that measure the success of changes it implements as a result of the recommendations made by an audit or other review.
• A description of the CDCR’s progress in identifying and implementing mental health programs that may ameliorate risk factors associated with suicides at the prisons and institutions.
• A description of CDCR’s progress in meeting its goals for completing suicide risk evaluations and comprehensive mental health treatment plans in a sufficient manner, including identifying the number of suicide risk evaluations and comprehensive mental health treatment plans completed, describing the criteria CDCR uses to assess the quality of the suicide risk evaluations and comprehensive mental health treatment plans, and reporting on the results of its assessments of the suicide risk evaluations and comprehensive mental health treatment plans. CDCR must present the information regarding its progress in meeting its goals for completing suicide risk evaluations separately from the information regarding the department’s progress in meeting its goals for completing comprehensive mental health treatment plans.
• A description of CDCR’s efforts to ensure that all mental health staff receive required training and mentoring related to suicide prevention and response, including describing the trainings and mentoring required and identifying the number of individuals required to take each training or to participate in mentoring, and the number of individuals who completed each required training or participating in required mentoring.
• A description of CDCR’s efforts to fill vacancies in its mental health treatment programs, including its efforts to hire and retain psychiatrists.

This bill requires that the report be posted on CDCR’s website in an easily accessible format.

This bill requires CDCR to notify the contact person of an inmate, if one is listed on record, within 24 hours by telephone in the event of the inmate’s serious illness, serious injury, or death.

This bill provides that “serious injury” includes attempted suicide, and “serious illness” includes a new mental health diagnosis.

COMMENTS

1. Need for This Bill

According to the author:

SB 960 imposes efforts to prevent and respond to inmate suicides at state prisons in California. High suicides rates at the California Institution for Women prompted an audit by the State Auditor which concluded that the California Department of Corrections and Rehabilitation (CDCR) needs to report annually to the legislature about their efforts to improve its suicide response and prevention programs. Inmate suicides in California’s prisons have been higher, on average, than those of all U.S. state prisons for several years. From 2005 through 2013, the average suicide rate in California’s prisons was 22 per 100,000 inmates compared to the average 15.66 per 100,000 in state prisons in the United States.

SB 960 also establishes a notification timeline requiring CDCR’s prisons to contact the next of kin of an inmate, within 24 hours, when that inmate commits suicide or attempts suicide. Reports have included long delays of notification or no notification at all following an inmate suicide or suicide attempt.

1. Background

CDCR has a long history of inmate suicides. In 1995, the U.S. District Court for the Eastern District of California ruled that CDCR was not providing adequate mental health care in violation of inmates’ Eighth and Fourteenth Amendment rights. (Coleman v. Wilson (1995) 912 F. Supp. 1282 (now Coleman v. Brown).) As part of that ruling, the court identified six areas where CDCR needed to make improvements, including suicide prevention. The court appointed a Special Master to monitor and report on CDCR’s progress toward providing an adequate level of mental health care. That remedial process has been ongoing.

CDCR’s continued difficulty in remedying the deficiencies of its mental health care system is well documented. A 2013 report to the court by the Special Master criticized CDCR for failing to follow many of the recommendations he had made to the department over a 14-year period. (https://rbgg.com/wp-content/uploads/Coleman-Report-on-Suicides-Completed-in-the-CDCR-in-Calendar-Year-20111.pdf ; <http://articles.latimes.com/2013/mar/13/local/la-me-ff-court-expert-prison-suicide-rate-20130313> [as of Apr. 17, 2018].) In recent years, an increase in the number of inmate suicides led the Joint Legislative Audit Committee (JLAC) to request that the California State Auditor prepare an audit report concerning CDCR’s policies, procedures, and practices for suicide prevention and reduction, with a particular emphasis on the recently elevated suicide rate at the California Institution for Women. (See <http://www.sacbee.com/news/local/crime/article41246670.html>; <https://www.theguardian.com/us-news/2016/may/10/suicide-california-womens-prison-mental-health> [as of Apr. 17, 2018].) The findings and recommendations of that report are summarized in Comment 4.

1. CDCR Policies

Mental Health Generally

CDCR regulations require the department to provide a broad range of mental health services to inmates by assessing the needs of its population and developing specialized programs of mental health care, to the extent resources are available for that purpose. (Cal. Code of Regs., tit. 15, § 3360, subd. (a).) Necessary and appropriate mental health services must be provided to inmates, and adequate staff and facilities must be maintained for the delivery of such services. (Id.) When an inmate is found to require mental health care that is not available within those resources, but which is available in the Department of Mental Health, the case will be referred to the director for consideration of temporary transfer to that department pursuant to Penal Code section 2684. (Cal. Code of Regs., tit. 15, § 3360, subd. (b).)

All required mental health treatment or diagnostic services must be provided under the supervision of a psychiatrist licensed to practice in the state, or a psychologist licensed to practice in the state and who holds a doctoral degree and has at least two years of experience in the diagnosis and treatment of emotional and mental disorders. (Cal. Code of Regs., tit. 15, § 3361, subd. (a).) When an inmate or an inmate’s guardian or relative, or an attorney or other interested party desires to have an inmate examined by a private psychiatrist or other mental health professional, a request must be submitted in writing to the warden. (Cal. Code of Regs., tit. 15, § 3361, subd. (b).) The warden will grant the request after consulting with the institution’s chief psychiatrist or, in his or her absence, the chief medical officer, unless there are specific case factors which, in the judgment of the warden, warrant denial. (Id.) Private consultants are not permitted to order mental health treatment for any inmate, but may be asked to make a report of findings and recommendations to the warden. (Id.) All persons committed to CDCR must be informed that mental health services are available to them, and that, upon an inmate’s request, an evaluative interview will be provided within a reasonable period of time by a licensed practitioner, or a specially trained counselor supervised by a licensed practitioner. (Cal. Code of Regs., tit. 15, § 3362.) Upon request, an inmate will be provided with information as to what specialized treatment programs may be available in the department and how such treatment may be obtained. (Id.)

Suicide Prevention and Response

Each institution head is required to ensure that all employees whose assignments routinely involve inmate contact are trained to recognize signs and symptoms associated with suicide risk, the appropriate procedures for staff intervention, and the appropriate procedures to be followed in response to emergency situations resulting from self-injurious or suicidal actions. (Cal. Code of Regs., tit. 15, § 3365, subd. (a).) Specifically, peace officer classifications are required to complete annual training on suicide prevention. (Department Operations Manual (DOM) § 32010.15)

Each institution head is required to implement a Suicide Prevention Program for inmates who display self-injurious or suicidal behavior or symptoms. These programs must include the following components:

• Suicide Watch. When medical staff determine that an inmate is actively suicidal, a licensed physician or psychologist must order placement of the inmate on suicide watch in a General Acute Care Hospital (GACH), Correctional Treatment Center (CTC), Skilled Nursing Facility (SNF), Outpatient Housing Unit (OHU), or other appropriate health care facility, for continual observation.
• Suicide Precaution. When medical staff determine that an inmate is at high risk of attempting self-injurious behavior, a licensed physician or psychologist shall order placement of the inmate on suicide precaution in a GACH, CTC, SNF, OHU, or other appropriate health care facility, for periodic monitoring.
• Follow-up Treatment. Discharge from suicide watch or suicide precaution must occur when an interdisciplinary team of clinicians determines that the inmate no longer presents a suicide risk. A written treatment plan and follow-up outpatient treatment must be provided by a mental health clinician. (Cal. Code of Regs., tit. 15, § 3365, subd. (b).)

When a suicide attempt is discovered in progress, medical assistance must be summoned immediately to provide emergency medical care. (Cal. Code of Regs., tit. 15, § 3365, subd. (c).) Security and safety procedures must be followed, including the use of required equipment and procedures to deal with bodily fluids. (Id.) A cut-down kit must be immediately accessible on each unit and must be used by staff in case of an attempted suicide by hanging. (Id.) All subsequent activities and procedures must comply with local institutional emergency plans. (Id.) Additional protocols regarding suicide prevention and response are detailed in Chapter 10 of the Mental Health Program Services Delivery System Program Guide. (https://www.cdcr.ca.gov/DHCS/docs/Mental%20Health%20Program%20Guide.pdf)

Finally, the DOM requires that “incidents, events and activities that occur within the jurisdiction of institutions of immediate interest to the Department, other governmental agencies or the news media” be reported to the Director or the departmental Officer-of -the-Day, or the Deputy Director, DAPO. (DOM § 51030.1.) Certain incidents are required to be reported, including attempted suicides. (DOM § 51030.3.)

Inmate Death, Serious Injury, or Serious Illness: Notification Requirements

The DOM provides that CDCR must treat the death, serious injury, or serious illness of an inmate with dignity and respect as is regularly accorded persons who are not incarcerated. (DOM § 51070.2.) The procedures to be followed after death, serious injury, or illness must comply with the requirements of all applicable laws. (Id.) The DOM includes detailed protocols for prison staff after an inmate’s death. Among the responsibilities and duties for prison staff following an inmate’s death, include pronouncement of death, preparing a written summary of the circumstances surrounding the inmate’s death, signing the death certificate, and identifying the decedent. (DOM §§ 51070.4-51070.8.)

The DOM also provides the notification requirements following an inmate’s death. For example, an inmate’s death must be reported to the county sheriff and coroner within two hours of the death. (DOM § 51070.9.) The inmate’s death must be reported to the district attorney in the county in which the prison as well as specified CDCR officials within 24 hours. The DOM specifies that Receiving and Release staff in Reception Centers obtain primary and alternate emergency contact information for each incoming inmate. (DOM § 51070.10.) This information is stored in two CDCR databases and is required to be updated:

• Annually as part of the classification review process.
• Upon recommendation of transfer by a classification.
• Whenever an inmate advises his or her correctional counselor of a desire to change the information.

DOM section 51070.10 lays out the protocol that CDCR staff must follow with respect to notifying an inmate’s emergency contact in the event of the inmate’s death, serious injury, or serious illness. In the event of a death, serious injury, or serious illness, the Warden or designee at the level of Correctional Lieutenant or Correctional Counselor II or above is required to use all reasonable means to contact the person identified on the notification form. CDCR is required to notify the emergency contact person as soon as possible. Notification via phone must be used whenever possible. If notification cannot be immediately made, the Warden or designee at the level of Correctional Lieutenant or Correctional Counselor II or above must use all reasonable means to make contact with family members, including but not limited to: assigning Investigative Services Unit staff to utilize telephone signup sheets, Inmate Monitoring and Recording Systems, searching the inmate’s personal property, reviewing the inmate’s visiting file, contacting the previous parole agent, if any, contacting the local coroner’s office, contacting the arresting agency, reviewing social media, or contacting the Office of Correctional Safety (OCS) to locate contact information. All efforts made to notify the next of kin must be documented on a specified form.

The DOM further provides that if notification with the contact listed cannot be made within 72 hours, the Warden must notify their respective Associate Director that all reasonable means for obtaining contact information have been exhausted. The Associate Director is then required to make contact with the OCS for any additional assistance in locating the next of kin.

In addition to the notification requirements described above, CDCR is required to report inmate suicides and other critical incidents within a specified timeframe to the Office of the Inspector General, the agency tasked with providing oversight to California’s correctional system.

1. Audit on CDCR Inmate Suicides

Pursuant to its duty to complete an audit requested by JLAC, the State Auditor conducted an audit of CDCR’s policies, procedures, and practices for suicide prevention and reduction. The audit included visits to four state prisons, including two women’s prisons and two men’s prisons. The report was released in August 2017 and concluded:

We identified significant weaknesses in prisons’ suicide prevention and response practices at the four prisons we reviewed. Specifically, we found that the prisons failed to complete some required evaluations to assess inmates’ risk for suicide and those that the prisons did complete were often inadequate. The inadequacies included leaving sections of the risk evaluations blank, failing to appropriately justify the determinations of risk, failing to develop adequate plans for treatment to reduce the inmates’ risk, and relying on inconsistent information about inmates to determine risk. Also, the prisons we reviewed did not properly monitor inmates who were at risk of committing suicide. For example, we found that staff were not staggering behavior checks or conducting checks in the required 15-minute intervals. Finally, we found that some staff members at the prisons we visited had not completed required trainings related to suicide prevention and response. These conditions may have contributed to elevated suicide and attempted suicide rates at California prisons.

Corrections also lacks assurance that prisons are implementing its policies to address serious issues. For many years, a court-appointed special master, working with Corrections to address inmate mental health care, identified many of the same issues we discuss in this report. In 2013 Corrections began developing an audit process to review prisons’ compliance with its policies and procedures, including those it issued in response to the special master’s reports; however, that process is still in development. In addition, Corrections could provide additional leadership to prisons regarding the communication of best practices related to suicide prevention efforts. Finally, Corrections’ policies require it to complete a thorough review of a prison’s compliance with policies and procedures following an inmate’s suicide, but Corrections does not complete such reviews for suicide attempts. This hinders Corrections’ ability to identify problems with a prison’s compliance with crucial policies and procedures until after an inmate dies. (https://www.auditor.ca.gov/pdfs/reports/2016-131.pdf)

In order to provide additional accountability for CDCR’s efforts to respond to and prevent inmate suicides and attempted suicides, the Auditor recommended that the Legislature require that CDCR report to it annually on the following issues:

• Its progress toward meeting its goals related to the completion of suicide risk evaluations in a sufficient manner.
• Its progress toward meeting its goals related to the completion of 72‑hour treatment plans in a sufficient manner.
• The status of its efforts to ensure that all staff receive training related to suicide prevention and response.
• Its progress in implementing the recommendations made by the special master regarding inmate suicides and attempts, as well as the results of any audits CDCR conducts as part of its planned audit process to measure the success of changes it implements as a result of these recommendations.
• Its progress in identifying and implementing mental health programs at the prisons that may ameliorate risk factors associated with suicide.

In order to remedy CDCR’s deficiencies, the Auditor recommended:

• CDCR should immediately require mental health staff to score 100 percent on risk evaluation audits in order to pass. If a staff member does not pass, CDCR should require the prison to follow its current policies by reviewing additional risk evaluations to determine whether the staff member needs to undergo additional mentoring.
• To ensure that prison staff conduct required checks of inmates on suicide precaution in a timely manner, CDCR should implement its automated process to monitor these checks in its electronic health record system by October 2017.
• To address the unique circumstances that may increase its female inmates’ rates of suicide and suicide attempts, CDCR should continue to explore programs that could address the suicide risk factors for female inmates.
• To ensure that all prison staff receive required training related to suicide prevention and response, CDCR should immediately implement a process for identifying prisons where staff are not attending required trainings and for working with the prisons to solve the issues preventing attendance.
• To ensure that prisons comply with its policies related to suicide prevention and response, CDCR should continue to develop its audit process and implement it at all prisons by February 2018. The process should include, but not be limited to, audits of the quality of prisons’ risk evaluations and treatment plans.
• To ensure that all its prisons provide inmates with effective mental health care, CDCR should continue to take a role in coordinating and disseminating best practices related to mental health treatment by conducting a best practices summit at least annually. The summits should focus on all aspects of suicide prevention and response, including programs that seek to improve inmate mental health and treatment of and response to suicide attempts. Corrections should document and disseminate this information among the prisons, assist prisons in implementing the best practices through training and communication when needed, and monitor and report publicly on the successes and challenges of adopted practices.
• In an effort to prevent future inmate suicide attempts, CDCR should implement its plan to review attempts with the same level of scrutiny that it uses during its suicide reviews. CDCR should require each prison to identify for review at least one suicide attempt per year that occurred at that prison. To ensure that the reviews include critical and unbiased feedback, CDCR should either conduct these reviews itself or require the prisons to review each other. These reviews should start in September 2017 and follow the same timelines as the suicide reviews, with the timeline beginning once the team identifies a suicide attempt for review.

This bill adopts several of the Auditor’s recommendations. This bill requires CDCR to submit an annual report to the Legislature on CDCR’s efforts to respond to and prevent inmate suicides and attempted suicides. The report must identify:

• All recommendations that, if implemented, would affect CDCR’s efforts to respond to and prevent suicides and attempted suicides among inmates and that were made to CDCR or to a prison or institution as the result of an audit, assessment, or other review, whether internally or externally conducted, mandated, or court-ordered.
• A description of CDCR’s progress in implementing each recommendation identified in an audit or other review, as described above, including the expected timeline for full implementation for each recommendation and the activities undertaken to address each recommendation. If CDCR does not intend to fully implement a recommendation, the CDCR must describe in sufficient detail its reasons for not fully implementing the recommendation.
• A description of the results of any audit or review CDCR conducts that measure the success of changes it implements as a result of the recommendations made by an audit or other review.
• A description of the CDCR’s progress in identifying and implementing mental health programs that may ameliorate risk factors associated with suicides at the prisons and institutions.
• A description of CDCR’s progress in meeting its goals for completing suicide risk evaluations and comprehensive mental health treatment plans in a sufficient manner, including identifying the number of suicide risk evaluations and comprehensive mental health treatment plans completed, describing the criteria CDCR uses to assess the quality of the suicide risk evaluations and comprehensive mental health treatment plans, and reporting on the results of its assessments of the suicide risk evaluations and comprehensive mental health treatment plans. CDCR must present the information regarding its progress in meeting its goals for completing suicide risk evaluations separately from the information regarding the department’s progress in meeting its goals for completing comprehensive mental health treatment plans.
• A description of CDCR’s efforts to ensure that all mental health staff receive required training and mentoring related to suicide prevention and response, including describing the trainings and mentoring required and identifying the number of individuals required to take each training or to participate in mentoring, and the number of individuals who completed each required training or participating in required mentoring.
• A description of CDCR’s efforts to fill vacancies in its mental health treatment programs, including its efforts to hire and retain psychiatrists.

The bill additionally requires that this report be posted on the department’s website, and requires CDCR to notify an inmate’s emergency contact person by phone within 24 hours of an inmate’s serious illness, serious injury (including attempted suicide), or death.

1. Argument in Support

According to the National Association of Social Workers, California Chapter:

In response to an unusually high number of suicides in recent years, the Joint Legislative Audit Committee approved an audit of the prison suicide crisis in California state prisons. CDCR establishes its own policies in responding to, planning treatment for, and observing suicidal inmates. However, the State Auditor revealed in an audit released in August 2017, that the CDCR knowingly did not consistently follow their established procedures and practices for years. As a result, state prisons have failed to adequately complete required behavioral risk evaluations for inmates, inmates have been insufficiently monitored, and some mental health staff did not complete required training related to suicide prevention and response.

SB 960 would enact the State Auditor’s recommendations to require CDCR to issue an annual report to the Legislature with the Department’s progress related to:

• Implementation of recommendations made by internal and external audits
• Meeting its goals for completing suicide risk evaluations and mental health treatment plans
• Ensuring that vacancies in mental health treatment programs are filled, and that staff is adequately trained in suicide prevention and reporting

…NASW-CA advocates…for the implementation and improvement of programs and policies designed to enhance human well-being and help meet the basic needs of all people.

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