http://www.latimes.com/news/local/la-me-corcoran5feb05,0,5807439.story?coll=la-headlines-california

California Prisoner's Gruesome Death Probed
Officials want to know if Corcoran guards, who were watching the Super Bowl, were negligent.
By Mark Arax
Times Staff Writer

February 5, 2004

FRESNO — All through the night, the howls kept coming from the cell of inmate Ronald Herrera.

More than one guard at Corcoran State Prison thought something was terribly amiss. Herrera wouldn't stop screaming late Sunday, and he had covered his cell window in a curtain of toilet paper soaked in blood.

One guard had seen Herrera, a dialysis patient suffering from hepatitis, pull out the medical shunt from his arm, corrections officials said. But when the guard later tried to check on the inmate, his sergeant told him not to bother, they said. "He's not dead," the sergeant was quoted by officials as saying. "Just keep an eye on him."

The next morning, the howls had given way to silence. As a new shift made its checks, a guard saw what he said looked to be "raspberry Kool-Aid" streaming out from the cell. Inside, he found Herrera slumped over on the floor, lifeless.

Much of the blood had drained from his body, corrections officials said. Blood filled the toilet bowl and washed over the concrete floor of the 8-by-10-foot cell.

On Wednesday, Kings County and state investigators began a probe to determine if Herrera's death resulted from criminal negligence by prison staff too busy watching the Super Bowl.

The probe comes on the heels of state Senate hearings and other revelations that have shone an unflattering light on the state's vast prison system, challenging the new administration of Gov. Arnold Schwarzenegger. On Monday, he promised to make reforms and to "clean the place up."

A coroner's autopsy of Herrera had not been completed by early Wednesday, but corrections officials said there were signs that Herrera, a 60-year-old mentally ill burglar and rapist, had been trying to staunch the bleeding with a wad of toilet paper.

It was unclear if Herrera was trying to commit suicide and then changed his mind or if something more sinister happened, corrections officials said. His desperation, they said, played out for nearly 10 hours without any intervention from staff.

Of all the horrors that have taken place at Corcoran State Prison over the last decade, one official said, the death of Herrera was particularly ghastly — and preventable.

Fearing retaliation for breaking the prison system's pervasive code of silence, the officials requested anonymity. "Corcoran has seen a lot," one said, "but for an inmate to literally bleed out his body, it was one of the goriest crime scenes."

A media spokesman for the prison said he could not comment on the case because of an ongoing investigation.

Steve Fama of the watchdog Prison Law Office said he doubted whether the Kings County district attorney's office would hold staff accountable. He noted that Dist. Atty. Ron Calhoun had been elected in 1998 partly on the strength of financial support from the California Correctional Peace Officers Assn., the union representing state prison guards.

"When it's this serious, you want an aggressive, independent investigation," Fama said. "I'm not sure if the district attorney in Kings County is capable of that given the significant role that the CCPOA played in his election."

Patrick Hart, Kings County's chief deputy prosecutor, acknowledged that his office had a "fairly good working relationship" with the guards union, but he said it would not hinder the independence of the probe.

"We're not satisfied with the written reports we've gotten so far from staff," he said. "One of the things we're looking at is whether staff knew he was in trouble and failed to take the proper steps."

Herrera's case is only the latest in a series of inmate deaths at Corcoran that have raised questions about the correctional system's care of mentally ill patients and its response to suicide attempts.

In December 1998, a Corcoran inmate who had been taken off suicide watch was seen hanging in a dark corner of his cell. But rather than pop open the cell door and determine if he was alive, guards remained outside for 18 minutes while 32-year-old Michael van Straaten dangled from a noose made of bedsheets and shoelaces. When officers finally did enter and cut him loose, he was dead but his body was still warm, according to prison reports.

Two years later, on Christmas Day, an inmate with three suicide attempts succeeded in killing himself in the prison's Security Housing Unit. A lawsuit filed by the family of 26-year-old Thomas Mansfield alleged that staff negligence had allowed the suicide and that guards tried to cover up the incident by doctoring the record of cell checks. Last year, the state settled the case out of court.

And just a week before Herrera's death, corrections officials said, three inmates in the Security Housing Unit entered into a suicide pact to protest what they called brutality by Corcoran guards. One inmate, "Tiny" Walton, went through with the pact and hanged himself.

"What I've found is the so-called suicide watch is a joke," said Bob Navarro, a Fresno attorney who represented Mansfield's family and has filed suit in a recent suicide at the women's prison in Chowchilla. "The cells are not being checked according to written procedure."

A detailed account of Herrera's medical condition and death was provided by two corrections officials. Herrera was taking mood-altering medication at the time, but had not been seen by a psychiatric case manager since December. They said that violates prison policy, which dictates a one-on-one clinical evaluation every 30 days.

Herrera, who was not on suicide watch, began "ranting and raving" around midday Sunday, they said, and medical personnel examined him near halftime of the Super Bowl. It is not unusual for guards and inmates to watch football on weekends. At the time, the shunt that allowed him to hook up to a dialysis machine was still in place.

But Herrera's howls continued, the officials said, and he began to cover the one window in his cell with toilet paper. He used his blood to adhere the toilet paper to the glass. That alone, corrections officials said, should have prompted a team of officers to enter his cell.

"When your view into the cell is obstructed and you don't know what's going on inside, you initiate a cell extraction," one official said. "This wasn't done. In fact, there are several notations from staff indicating concern for Herrera. But the superior officers never let them check on him."

One officer became so alarmed he called his sergeant, who took a quick look from outside the cell. "This is the same female sergeant who told the officer not to bother," the official noted.

Third watch began at 2 p.m. and ended at 10 p.m. During at least some of that time, Herrera could be heard kicking at his cell door. After the Super Bowl game ended and the first watch took over, Herrera was still making a fuss, officials said.

It wasn't until shortly after 6 a.m. the next day — when the second watch began its shift — that an officer who knew Herrera decided to check in on him.

"The closer he got to the cell, he could see this pool of 'raspberry Kool-Aid,' " said one corrections official. "They popped open the door and he was lying on the ground with the shunt on the top bunk. He was pronounced dead five minutes later."

A corrections spokesman said Herrera had a long rap sheet that included convictions for burglary and rape in San Bernardino County.

Because of his status as a sex offender, he was housed in the prison's administrative-segregation unit. In recent months, he had been the victim of an inmate assault.

That is soo sad. My fiance used to be in that prison. Makes you think.

The staff is paid again (100,000) to protect an inmate and that's how they protect them. Let them bleed to death. All the institutions need to come under investigation.

That is soo sad. My fiance used to be in that prison. Makes you think.

absolutely infuriating that a man would be screaming for hours on end, and no one even looked in on him. And how horrible for the other inmates to hear and witness that.

They are not doing their job the way the use to. Not every inmate screaming in pain is faking it in fact 99% of them are not faking it.

This is not good for Corcoran. Now it's in the paper and they just had this political arena. Oh my.....

absolutely infuriating that a man would be screaming for hours on end, and no one even looked in on him. And how horrible for the other inmates to hear and witness that.

This is inhumane.......absolutely, without a doubt, inhumane!

Kreepsgirl:

I still want that man? Maybe you need to change pictures. He is just to fine and I keep looking at him :) :fb: :ha: :ham:


That is soo sad. My fiance used to be in that prison. Makes you think.

somehow some people can just get so cold, so damn heartless. of course it could've been prevented if he got proper care. that is such a big negligence on the prison's part. I hope this will open some of the government officials' eyes , the ones that choose to keep them shut. But one day they will be judged and I hope they are prepared

I've been posting the saga of my son, Chad and life in the "Hell Hole" the call PC at Corcoran for 5+ months in Parents with Children in Prison and other Forums. He was attacked and raped in his cell by 4 Inmates when he got back from work one night. His cell-mate told him of the Guard who was in on it. He tried to just deal with it because he knows what happens to "Snitches" in Prison. But, 3 days later he lost it and spilled his guts. He was moved to PC for his own "Protection" immediately. All of his property was put in storage and he could only receive writing materials and books. The mental and physical abuse started almost a week later. He wrote to tell me what had happened and he couldn't stress enough at how ashamed he felt. I called the Prison and one kind Lt. allowed him to call me back a few hours later. He said it really helped him feel better about himself. What I didn't know at the time was that he had tried to commit suicide and was stripped of all of his clothes, put in a cold cell with a pad to sleep on for 3 days. When they let him out their comment was, "bet you don't try that again". After all "we" have been through these past 5+ months, the Super Bowl Death doesn't even surprise me. Corcoran is tied for first place as the most corrupt and charges of abuse from the Guards and "other" Personnel. 50% of all illegal drugs are brought in by the same people. My son has finally been moved to an area where he is getting mental and medical care and therapy as an outpatient in the SHU area. EOP. I talked to the Officer in charge Monday and, he obviously not only knew what Chad had been going through but, also knew who I was, and expected a call from me :~). He was very nice and Chad's property arrived as we were talking. Yes, these guys and gals are in Prison "doing the time for doing the crime" and that's the way it should be. But, something is very wrong when we have Criminals who have the title of a C/O or Guard or even Warden who are in charge of running our Prisons. If you feel your loved one is really being abused, call the Prison, the Ombudsman Office, their Counselor, write or e-mail your Senators, Congresspersons, Governors, the Warden, the Editor of the paper in the County, etc. Contact Christian Prison Organizations. A complaint to the DA's Office is a joke. Contact the PD Office. I've done it all and will continue to fight for the right for a Prisoner be treated in an humane way. Yes, there may be some "animals" in there, but treating them as such serves no purpose except making them more violent. My son and I did get some compensation through our fight and so can you. Instead of being transferred farther away from me, he is being transferred as close as they can place him and he is getting the medical treatment our family has been fighting for. Well as I always say, thank you for listening.
P.S. Thank you Kathy for keeping us informed as to what is going on inside those "Walls".

Jenjenson:

Your right God is going to judge them and it isn't going to be very pretty once "HE" steps in.



I've been posting the saga of my son, Chad and life in the "Hell Hole" the call PC at Corcoran for 5+ months in Parents with Children in Prison and other Forums. He was attacked and raped in his cell by 4 Inmates when he got back from work one night. His cell-mate told him of the Guard who was in on it. He tried to just deal with it because he knows what happens to "Snitches" in Prison. But, 3 days later he lost it and spilled his guts. He was moved to PC for his own "Protection" immediately. All of his property was put in storage and he could only receive writing materials and books. The mental and physical abuse started almost a week later. He wrote to tell me what had happened and he couldn't stress enough at how ashamed he felt. I called the Prison and one kind Lt. allowed him to call me back a few hours later. He said it really helped him feel better about himself. What I didn't know at the time was that he had tried to commit suicide and was stripped of all of his clothes, put in a cold cell with a pad to sleep on for 3 days. When they let him out their comment was, "bet you don't try that again". After all "we" have been through these past 5+ months, the Super Bowl Death doesn't even surprise me. Corcoran is tied for first place as the most corrupt and charges of abuse from the Guards and "other" Personnel. 50% of all illegal drugs are brought in by the same people. My son has finally been moved to an area where he is getting mental and medical care and therapy as an outpatient in the SHU area. EOP. I talked to the Officer in charge Monday and, he obviously not only knew what Chad had been going through but, also knew who I was, and expected a call from me :~). He was very nice and Chad's property arrived as we were talking. Yes, these guys and gals are in Prison "doing the time for doing the crime" and that's the way it should be. But, something is very wrong when we have Criminals who have the title of a C/O or Guard or even Warden who are in charge of running our Prisons. If you feel your loved one is really being abused, call the Prison, the Ombudsman Office, their Counselor, write or e-mail your Senators, Congresspersons, Governors, the Warden, the Editor of the paper in the County, etc. Contact Christian Prison Organizations. A complaint to the DA's Office is a joke. Contact the PD Office. I've done it all and will continue to fight for the right for a Prisoner be treated in an humane way. Yes, there may be some "animals" in there, but treating them as such serves no purpose except making them more violent. My son and I did get some compensation through our fight and so can you. Instead of being transferred farther away from me, he is being transferred as close as they can place him and he is getting the medical treatment our family has been fighting for. Well as I always say, thank you for listening.
P.S. Thank you Kathy for keeping us informed as to what is going on inside those "Walls".

Thanks for posting this Kathy.

How sad. This just breaks my heart. My thoughts are with the family, friends, and fellow inmates of this unfortunate man.
I am impressed anew that all inmates need our prayers, not just our own loved one who is incarcerated.

Kathy, did you send a copy to Arnie? I'm sure he knows, but it would be nice if he knew that others knew and are watching what he is going to do about it....
Yes, maybe he has vowed to clean house, but you know what? Even one death is unacceptable and there isn't time to "clean the place up" slowly. How many more will die before the job is done, if it is done, if it even can be done? The whole system is nothing but a rats nest. I hope he knows that and makes some swift moves....this is just too much.

This is the type of inofrmation that needs to be sent to a federal regulation office. The Feds need to step in at this point. Lawsuits need to be filed. Bankrupt the CCPOa. That sergant needs to be relieved of her duties. Why was he in Ad-seg if he was mentally ill?

[QUOTE]pool of 'raspberry Kool-Aid

am i the only one who thinks congealed blood doesn't resemble Kool-Aid of any flavor?

Editorial: Another report? No need
Existing reports tell the tale about prisons

Published 2:15 a.m. PST Friday, February 6, 2004
Memo to: Governor Schwarzenegger
Subject: Reports, old and new

Another day, yet another prison horror story. This time, it involves an inmate who bled to death in his cell at Corcoran State Prison on Super Bowl Sunday. Although he howled through the night and one guard asked a superior if he should check on the inmate, apparently no one bothered until the next morning. The inmate was found dead, in a pool of blood that had drained out of his body and seeped onto the floor outside his cell. The death is yet another graphic example of lethal incompetence and neglect in California's prisons.

The question, governor, is what do you plan to do about it?

Earlier this week, you told a radio interviewer that you wanted to name another panel to examine prisons. You now appear to be backing way from that idea. That's good. Frankly, governor, you don't need a new report on the subject.

In the past decade, plenty of reports have been written. Those reports, now gathering dust in government offices around the state, document waste, fraud, abuse and outright criminal conduct in the prison system.

Before you order up any new reports, here's a suggestion: Check out the list of suggested readings below. Then, settle into a comfortable chair this weekend for some extended reading.

You should begin with the recent report by John Hagar. He's the special master appointed by a federal judge. His report depicts a prison system dominated by the prison guards union and alleges criminal acts by some of the Department of Corrections' highest officials.

That report should make it clear why the state simply can't afford to wait for you to assemble another team of "experts." As Steve White, the former inspector general for the Department of Corrections and now a Sacramento Superior Court judge, says, a new "commission will simply delay action already long overdue."

After you finish reading, you might want to spend a bit of time considering who advised you to form an "independent commission" on prisons. Was it the same advisers who counseled you to dismantle the Office of Inspector General? If so, you should get yourself some new advisers.

The Office of Inspector General has consistently investigated and reported wrongdoing within Corrections. Anyone who counsels you to shut it down wants to stall reform in the hope that the prison scandals will fade from the headlines, and that the public will forget.

If your advice came from legislators, check out who contributed to their election campaigns. Chances are the contributors included the California Correctional Peace Officers Association, the prison guards union whose members have benefited handsomely from the status quo.

Corrections is bleeding money that the state doesn't have. Inmates and correctional officers alike are in danger. There is no shortage of information about these problems. What's lacking is the political will to fix them.

You say, governor, that you want to stop "the corruption going on ... the overspending ... the code of silence." If you really want to do that, stop dismantling the Office of Inspector General and ask the federal courts for help. Ask the courts to send in a monitor with wide authority to help honest and capable prison administrators take control of a prison system that has gone badly awry.

But first, take a few hours and do some reading. You won't find the subject matter entertaining, but it certainly will be enlightening.



--------------------------------------------------------------------------------

California's prison crisis: Recommended reading
Governor:

This list includes investigative reports and audits compiled by various agencies and institutions since 1994. It does not include more than two dozen investigative reports by the state Office of the Inspector General, many of which include allegations of criminal misconduct. Some of those reports have not been made public, but you and your staff have access to them.

* Draft Report Re: Departments of Corrections Investigations and Employee Discipline; Federal Special Master, January 2004.

* Back to the Community, Safe and Sound Parole Policies; Little Hoover Commission, November 2003.

* Survey of Educational Programs at California Department of Corrections Level IV Institutions; Office of the Inspector General, July 2003.

* Management Review Audit: California Substance Abuse Treatment Facility and State Prison Corcoran, California; Office of the Inspector General, January 2003.

* California Department of Corrections: A shortage of Correctional Officers, Along With Costly Agreement Provisions, Raises both Fiscal and Safety Concerns and Limits Management's Control; State Auditor, July 2002.

* California Department of Corrections: Its Fiscal Practices and Internal Controls are Inadequate to Ensure Fiscal Responsibility; State Auditor, November 2001.

* Department of Corrections: Though Improving, the Department Still Does not Identify and Serve All Parolees Needing Outpatient Clinic Program Services, but Increased Caseloads Might Strain Clinic Resources; State Auditor, August 2001.

* California Department of Corrections: Poor Management Practices have Resulted in Excessive Personnel Costs; State Auditor, January 2000.

* Wasco State Prison: Its failure to Proactively Address Problems in Critical Equipment, Emergency Procedures and Staff Vigilance Raises Concerns About Institutional Safety and Security; State Auditor, October 1999.

* Prisons Industry Authority: Its outside Purchase of Goods and Services is Neither Well Planned nor Cost Effective; State Auditor, September 1998.

* California Department of Corrections: The Cost of Incarcerating Inmates in State Run Prisons is Higher Than the Department's Published Cost; State Auditor, September 1998.

* Early Intervention Program: Flaws found in the 1997 Report On the Benefits of Early Intervention; State Auditor, April 1998.

* Beyond Bars, Correctional Reforms to Lower Prison Cost and Reduce Crime; Little Hoover Commission, January 1998.

* Prison Industry Authority: Has Failed to Take Significant Corrective Action on Many State Auditor Recommendations; State Auditor, August 1997.

* Prison Industry Authority: Statutory and Cost Control Problems Adversely Affect the State; State Auditor, April 1996.

* Boot Camps: An Evolving Alternative to Traditional Prisons; Little Hoover Commission, January 1995.

* Putting Violence Behind Bars: Redefining the Role of California Prisons; Little Hoover Commission, January 1994.

WOW! I'm speechless! How absolutely horrible!

Great job Kathy! I've been thinking all day long about how the TV Media jumps all over the story of the 2 guards kidnapped by 2 Inmates at the Arizona State Prison Complex-Lewis, and the like. But, you never hear them report on stories like you have just posted? At least I never see them. I am a Cable News Junkie and Fox prides itself on being Fair and Balanced. I have already e-mailed these past 2 post about Corcoran and Salinas to all of them. I have been sending them copies of many posts of corruption and abuse at the hands of the Guards and other Personnel, as well as my own Saga of the abuse my son has suffered, begging them to investigate and report the other side of what goes on inside the "walls". Maybe one day a Staffer will read and take enough interest on the subject to bring it to the attention of the Producers and those they work for. Again, thank you Kathy for bringing the information to us and a great outline of what everyone can say and flood into the office of the Governor.

Kathy:

You did a great job at expressing yourself. Again, I am beginning to wonder about Arnold. Does CCPOA have their money involved or is Arnold being led around by a bunch of legislatures who owe CCPOA.

HELLO....IT REALLY DOSEN'T TAKE A ROCKET SCIENTIST TO SEE WHAT IS TAKING PLACE.

IS ARNOLD AFRAID TO CONFRONT THE DEPARTMENT. EVEN THOUGH IT WAS A POLITICAL ARENA AT LEAST ROMERO AND SPRIERS CONFRONTED IT.

I guess I am still watching and examining it. I could hardly wait to get out of the Department. They are very corrupt. To let a man bleed to death. Now, that should be investigated but let me guess, the Department will say they didn't hear him screaming for help and laid their in his bed and bleed to death in his sleep.


Great job Kathy! I've been thinking all day long about how the TV Media jumps all over the story of the 2 guards kidnapped by 2 Inmates at the Arizona State Prison Complex-Lewis, and the like. But, you never hear them report on stories like you have just posted? At least I never see them. I am a Cable News Junkie and Fox prides itself on being Fair and Balanced. I have already e-mailed these past 2 post about Corcoran and Salinas to all of them. I have been sending them copies of many posts of corruption and abuse at the hands of the Guards and other Personnel, as well as my own Saga of the abuse my son has suffered, begging them to investigate and report the other side of what goes on inside the "walls". Maybe one day a Staffer will read and take enough interest on the subject to bring it to the attention of the Producers and those they work for. Again, thank you Kathy for bringing the information to us and a great outline of what everyone can say and flood into the office of the Governor.

February 7, 2004

Inmate's Open Shunt Led to Bleeding Death
The device was not fully closed, letting blood flow out of the
prisoner's jugular vein at Corcoran State Prison, coroner says.

By Mark Arax, Times Staff Writer

FRESNO — An autopsy of a Corcoran State Prison inmate who bled to death
in his cell overnight on Super Bowl Sunday showed that his medical
shunt was not fully closed, allowing blood to flow out of his jugular
vein, authorities said.
The autopsy Thursday could not determine whether inmate Ronald Herrera,
a 58-year-old dialysis patient, had opened the shunt's clamp in a fit
of anger, or if the medical staff responding to his screams
administered a sedative through the shunt and had failed to close the
device.

"That is one of the questions investigators will look at," said Rene
Hanavan, chief deputy coroner for Kings County. "The bleeding from the
open dialysis shunt caused him to go into shock, and that shock caused
his heart to beat in an irregular rhythm."
On Friday, state Sen. Gloria Romero (D-Los Angeles), who recently
co-chaired a series of legislative hearings critical of the prison
system, called on Atty. Gen. Bill Lockyer to take over the
investigation into what she called a "gruesome and completely
avoidable" death.
Guards could be found criminally negligent if they were too busy
watching the Super Bowl game to respond to Herrera's repeated screams.
Romero questioned whether Kings County Dist. Atty. Ron Calhoun, who was
elected in 1998 on the strength of financial backing from the state
prison guards' union, could conduct an independent probe of the local
prison.
"A matter this serious demands an aggressive, independent investigation
that will rise above political concerns or other factors that might
compromise probes conducted at the local level," Romero wrote to
Lockyer.
A press spokesman for the attorney general said Romero's letter had not
crossed Lockyer's desk, but "when it does, we'll review it."
Patrick Hart, Kings County's chief deputy prosecutor, said a story on
Herrera's death in The Times on Thursday has complicated the
investigation. He said correctional officers at Corcoran might use the
story to claim facts about the incident that they did not observe. Hart
would not give further details of the investigation.
The story appeared on the fourth day of the probe, after written
reports and logs had been examined by county investigators and word had
spread throughout the prison.
Two corrections officials provided The Times with an account of
Herrera's death on the condition that they not be named for fear of
retaliation by superiors.
They said Herrera, a mentally ill burglar and rapist from Ventura
County, began "ranting and raving" about midday Sunday. Prison medical
staff members examined Herrera near halftime of the Super Bowl and may
have given him medication to calm him, they said. But Herrera kept
howling and kicking at the door throughout the evening.
At one point, they said, he began to cover the window in his cell with
toilet paper soaked in his blood. More than one guard thought something
was terribly wrong, the officials said, but Herrera was not checked
again that night. Prison policy, they said, required that the cell door
be opened as soon as Herrera blocked the view with the toilet paper.
"There are several notations from staff indicating concern for
Herrera," one official said. "But the superior officers never let them
check on him."
A female sergeant did check from outside the cell, but she told
subordinates not to bother doing anything more, they said. "He's not
dead," the sergeant was quoted by the officials as saying. "Just keep
an eye on him."
From one watch to the next, over a 10-hour period, Herrera continued to
bleed from an opening in his shunt. It wasn't until shortly after 6
a.m. that a guard who knew Herrera decided to check on him. A large
pool that looked to the guard like "raspberry Kool-Aid" was streaming
out of the cell. Inside, he found Herrera slumped over on the floor,
the blood drained from his body.
At least one guard reported that the cap of the shunt was sitting on
Herrera's bunk, an official said. The chief deputy coroner said the
rest of the shunt was attached to Herrera's upper chest at the time of
the autopsy.
"Nothing appeared to be malfunctioning with the shunt itself," said
Hanavan, the chief deputy coroner.
"But for whatever reason, the cap had been taken off one of the tubes
and the clamp wasn't squeezed shut. The opening allowed him to bleed.
Right now, there's not enough information to say whether it's suicide
or not."
Judy Greenspan of California Prison Focus, a watchdog group based in
San Francisco, said she has visited dozens of Corcoran inmates who were
receiving dialysis treatment in recent years. Often, she said, the
shunts put in by outside dialysis centers that contract with the state
are defective.
"Most of the men I visited complained of having shunts that didn't
work. They had multiple operations to install new shunts, many of which
still failed," Greenspan said. "To me, it represented the continuing
abysmal medical care at Corcoran."

Copyright 2004 Los Angeles Times

http://www.latimes.com/news/local/la-me-
corcoran7feb07,1,5758056.story?coll=la-headlines-california

i feel bad for the AOD, I wonder who it was and can only imagine the hell they are going threw right about now.

For those who do not know, the AOD is the Administrative Officer of the Day. They are an executive staff member in charge of runing the prison at night and during the weekends. They run the gambit from, Community Resource Managers, Chief of Plants, Supervisors of Vocational and Academic Instruction. Correctional Counselors, Captains and even Associate Wardens. They are the ones that are supose to get the calls when things go wrong at a prison. As you might imagine some classifications are not prepared to deal with something of this magnitude

I am not envying the AOD right about now. He/she has alot of questions they are going to have to answer to along with the Sgts and officers. Again, I am not feeling sorry for any of them. When you have an inmate screaming for help someone should of been paying attention.


i feel bad for the AOD, I wonder who it was and can only imagine the hell they are going threw right about now.

For those who do not know, the AOD is the Administrative Officer of the Day. They are an executive staff member in charge of runing the prison at night and during the weekends. They run the gambit from, Community Resource Managers, Chief of Plants, Supervisors of Vocational and Academic Instruction. Correctional Counselors, Captains and even Associate Wardens. They are the ones that are supose to get the calls when things go wrong at a prison. As you might imagine some classifications are not prepared to deal with something of this magnitude

How sad and horrible, that we as human beings live amongst others that
don't give a damn about human life. And that female SGT, that said "don't bother" how disgusting... She should be heldaccountable for this inmate's
death! What a great system we have, NOT!!!!!!!!! Our prisons all need serious
housecleaning, and the ones that promote death to inmates, should be
sentenced to life in prison without parole. :pissed:

You know, I realize that this thread is about neglect on the part of the CO's and rightly so.
But as a nurse I see some big questions about medical malpractice/neglect as well.

From the medical aspect, a true "shunt" for dialysis is placed in the forearm of a dialysis client, under the skin. It does not have tubes or caps.
I wondered at the comments in the first article about it being found on the top bunk. I just couldn't picture an entire shunt removed from an arm and sitting on a bunk. Not an option. A shunt for dialysis is surgically placed in the artery in the arm to give access without having to poke into the artery each time. Kind of like splicing in a piece of garden hose. It will handle the large bore needle, necessary for dialysis.

What this guy must have had placed was a "central line", a catheter that is surgically placed in the chest and going directly into the arch of the aorta, just outside the heart chamber. It is something generally used for administration of caustic antibiotics or chemo or for transfusions and is of a more temporary nature where you need something more than small peripheral vein but you don’t plan for the patient to have it the rest of their life.
It is not used for dialysis, unless the patient is in ICU and only getting dialysis on a temporary basis (like for OD's for instance that temporarily shut down their kidney function). Most people receiving dialysis in an outpatient setting (not hospitalized) need to receive it for the rest of their lives and so they place a permanent device for that purpose--the shunt in the arm.
Sometimes an outpatient will start out with a central line and then have the shunt placed down the road a few weeks once insurance/ MediCal pays for it because it becomes clear that it is going to be a long term situation. But basically, the shunt in the arm is used for outpatient dialysis.

Furthermore, a central line should never be used in a psych patient for the very reason of what happened. Leaving it unclamped is routine (you don't want a clot to form in the line from stationary blood), and the caps are checked to be sure that they are on tight, but the patient is always taught how to do emergency measures so they don't bleed to death should a cap come lose, a tube break, or something of that nature. They are taught to clamp the clamp and call for help immediately. And if a patient cannot understand the emergency measures or successfully demonstrate emergency measures or might do something to compromise the line and their life because of their mental status or for whatever reason, then this device is not placed in that patient.

So my questions are: 1) Why did a psych patient have a central line?
It says RISK all by itself.
2) Is it customary for CDC medical people to chose central lines
for things such as dialysis because it is cheaper than a
shunt?
3) Why was that line not immediately checked by medical
personnel when the patient became agitated and was
yelling?
4) Is there a protocol for calling medical personnel when an
inmate has this device?
4) Were staff trained in emergency measures to deal with
a bleed out (in 2-3 minutes) if the line became compromised?
If a nurse couldn't get there in under a minute and a half,
they should have been.

Looks to me like a lot more than neglect on the part of a Sargent here....looks like some bad medical decision making as well. Just a bad system overall, from all involved.

What a mess. And how sad for this man and his family, that he bled out unnecessarily from a device that could have and should have preserved his life. A tragedy.

I bet that the medical aspect never comes out in public....he was just a crazy man who chose to unscrew his cap and bleed to death...you know? And the guards aren't nurses so, hey, they don't know about this stuff, right? Yep, everyone is going to point the finger at everyone else, but nothing is going to change.

crstdrvn:

Your right the C/O's are not trained in medical procedures but they are trained to contact someone in the hospital at the institution if an inmate is having problems. You don't put it off until the morning.

So, I guess, now they have to get rid of some bad Administrators, C/O's and medical staff. What a mess???????


You know, I realize that this thread is about neglect on the part of the CO's and rightly so.
But as a nurse I see some big questions about medical malpractice/neglect as well.

From the medical aspect, a true "shunt" for dialysis is placed in the forearm of a dialysis client, under the skin. It does not have tubes or caps.
I wondered at the comments in the first article about it being found on the top bunk. I just couldn't picture an entire shunt removed from an arm and sitting on a bunk. Not an option. A shunt for dialysis is surgically placed in the artery in the arm to give access without having to poke into the artery each time. Kind of like splicing in a piece of garden hose. It will handle the large bore needle, necessary for dialysis.

What this guy must have had placed was a "central line", a catheter that is surgically placed in the chest and going directly into the arch of the aorta, just outside the heart chamber. It is something generally used for administration of caustic antibiotics or chemo or for transfusions and is of a more temporary nature where you need something more than small peripheral vein but you don’t plan for the patient to have it the rest of their life.
It is not used for dialysis, unless the patient is in ICU and only getting dialysis on a temporary basis (like for OD's for instance that temporarily shut down their kidney function). Most people receiving dialysis in an outpatient setting (not hospitalized) need to receive it for the rest of their lives and so they place a permanent device for that purpose--the shunt in the arm.
Sometimes an outpatient will start out with a central line and then have the shunt placed down the road a few weeks once insurance/ MediCal pays for it because it becomes clear that it is going to be a long term situation. But basically, the shunt in the arm is used for outpatient dialysis.

Furthermore, a central line should never be used in a psych patient for the very reason of what happened. Leaving it unclamped is routine (you don't want a clot to form in the line from stationary blood), and the caps are checked to be sure that they are on tight, but the patient is always taught how to do emergency measures so they don't bleed to death should a cap come lose, a tube break, or something of that nature. They are taught to clamp the clamp and call for help immediately. And if a patient cannot understand the emergency measures or successfully demonstrate emergency measures or might do something to compromise the line and their life because of their mental status or for whatever reason, then this device is not placed in that patient.

So my questions are: 1) Why did a psych patient have a central line?
It says RISK all by itself.
2) Is it customary for CDC medical people to chose central lines
for things such as dialysis because it is cheaper than a
shunt?
3) Why was that line not immediately checked by medical
personnel when the patient became agitated and was
yelling?
4) Is there a protocol for calling medical personnel when an
inmate has this device?
4) Were staff trained in emergency measures to deal with
a bleed out (in 2-3 minutes) if the line became compromised?
If a nurse couldn't get there in under a minute and a half,
they should have been.

Looks to me like a lot more than neglect on the part of a Sargent here....looks like some bad medical decision making as well. Just a bad system overall, from all involved.

What a mess. And how sad for this man and his family, that he bled out unnecessarily from a device that could have and should have preserved his life. A tragedy.

I bet that the medical aspect never comes out in public....he was just a crazy man who chose to unscrew his cap and bleed to death...you know? And the guards aren't nurses so, hey, they don't know about this stuff, right? Yep, everyone is going to point the finger at everyone else, but nothing is going to change.

crstdrvn:

You made some very valid, important, and insightful points. This situation is about a lot more than neglect by CO's. I do not know who this poor man was, or if he had family and friends who were concerned about him. I pray that someone takes up his cause and fights for the inhumane, cruel, and malicious way he was allowed to die. I am almost overwhelmed by all of it. Life is precious and god-given and what happened in this situation is tantamount to murder. Who is on the wrong side of the bars here?

Kittie:

Bad CO's, adminstrators and medical stafff within the CDC?????????? As usual, girl, you are so right!!!!!!

Having witnessed end stage Hep C with my husband, I can give you a little info as to what happened to this inmate. I am operating on the assumption that the guards were aware that he was in end stage and that is why they chose to ignore along with the parallel timing of The Game (the CO's have established their priorities there on many occasions). They probably had no clue how ugly it could be though. In reading the article I also didn't note anyone attempting to call in the doctor or nurse which I found peculiar.

Hep C and the resulting scirrosis of the liver and related organs finally ruptures the scar tissue (thick) and overstressed layers (thin) and the bleeding begins. It frequently starts with the esophagus and works on down to and through the related organs literally popping a hole here or there along the way. Ultimately the ruptures allow bile to comingle and create a poison that causes more pain and suffering. These ruptures and the bleeding CAN be stopped with shunts and meds. My husband bled out and flatlined twice before receiving a liver transplant that saved his life literally with only a few days to go. He described a feeling of wanting to rip his skin off his body during those events and was given large doses of Morph to help him deal with the pain. I suspect this inmate had reached that state. The shunts although being used fairly routinely now, are a tricky business. My educated guess is that someone, somewhere had made an executive decision that this would be a wasted procedure as transplant was out of the question and that is why no medical staff was called on behalf of the inmate. I do know that his pain could have been lessened and he probably could have been made comfortable and treated with some dignity in hisfinal hours regardless of his crime, his status, his mental level or imminent death. This gross insensitivity and failure to act is unacceptable under any conditions. It sounds like at least one CO had enough compassion and concern to act and then buckled and was quelled by the others. I feel so badly for this man and can't even fathom what a horrible end it must have been for him in pain and alone in a cold little cubicle.

My husband has one year left to survive his term which the transplant team had told me was highly unlikely. I thank God every night for two doctors at
CMC who haven taken a personal interest as well as extra time to give my husband every chance to survive against all odds. How lucky we are and we know it. He is lucky to have made it to CMC at all as Orange County Central jail denied and/or ignored his requests to see a Dr. immediately for the 14 or so different drugs he takes daily to fight off rejection and provide what little immunity he has to disease. On day thirteen he called me and told me the pain was so unbarable he was going to kill himself or someone else if it continued. I took action in no uncertain terms. He was transported to UCI where he spent the next four months in the ICU with full Hepatitis back and ravaging his new liver, etc. I went to the sentencing judge who told me because his crime was drug related, tough luck - don't even think about suing the system. What a sad state of affairs this socalled "correctional" system is in. I wonder how many more will die from medical neglect or suicide before changes take place. So much forTitle 15 and prisoners rights at Corcoran. Thank God for a more caring and sensitive staff at CMC.

SO SAD AND UNNECESSARY...my husband has had now TWICE, in about 3 months, a syst the size of a 50cent piece on his back pop and CDC has nothing to help him. Their Doctor told him, "Can't you do something that will get you written up so you'll get more time added on and then maybe you'll be able to go to CTC to get it lanced and cleaned out?" Can You Imagine The Nerve? But if it were one of their damn family members theyD be pulling out all the stops...F***IN ANIMALS!

This is just Herendous. makes me sick to think this would hsppen and most likely nothing will be done

Absolutely disgusting!!! I'm lost for words. Makes me glad I fell in love with my inmate instead of hurting him! I'm glad I don't work for DOC anymore.