United S t a t e s District Court

Northern D i s t r i c t of California
Before The Honorable T h e l t o n E. Henderson, Judcie

Marciano Plata,

1
Plaintiff,

ORIGINAL
NO. C01-1351 TEH
Evidentiary Hearing

Arnold Schwarzenegger, et al.,

San Francisco, California Wednesday, June 1, 2005

Reporter's Transcrint Of Proceedinas

Appearances :
For P l a i n t i f f :
By:

Prison Law Office G e n e r a l Delivery San Quentin# C a l i f o r n i a Donald Specter, Esquire Alison Hardy, Esquire Steven Fama, Esquire

94964

F o r Defendants:

By:

Hanson, Bridgett, Marcus, Vlahos 333 Market Street, S u i t e 2300 San Francisco, California 94105 Jerrold C . Schaefer, Esquire Paul -110, Esquire

&

Rudy

(Appearances Continued on next page.)

Reported By:
Sahar McVickar, Official Reporter U n i t e d States D i s t r i c t Court

For the Northern D i s t r i c t of California.

{COMPUTERIZED TRANSCRIPTION BY ECLIPSE)

Aooearances, continued: - -

For Defendants:

By:

Department of Justice Office of the Attorney General 455 Golden Gate Avenue Suite 11000 San Francisco, California 94102 Jonathan L. Wolff, Esquire Maria G. Chan, Esquire

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Reporter, U.S. D. C.

I N D E X ----Plaintiff's Witnesses: Page Puisis, Dr. Michael (Previously Sworn)

Cross-Examination by Mr. Mello Redirect Examination by Mr. Specter

LaMarre, Madeline (Sworn)

226 252

Direct Examination by Ms. Hardy Cross-Examination by Mr. Schaefer

Goldenson, Dr. Joe (Sworn)

260 320

Direct Examination by Mr. Fama

334

E X H I B I T S --------

Plaintiff's Exhibits:

Evid .

None

Defendant's Exhibits:

Iden.

Evid.

None

Sahar AfcVicfcar,KPR

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Wednesday, June 1, 2005

PROCEEDINGS -----------

8:35 a . m .

THE CLERU:
THE COURT:

Court is now in session. Couldn't get rid of you, huh? No, I'm back.

THE W T E S INS:
THE COURT:

Okay, ready to proceed, counsel? Yes, Your Honor.

DIRECT EXAMINATION

MR. MELLO:

Thank you.

BY MR. MELLO:
Q.
A.

Good morning, Dr. Puisis. Good morning. Dr. Puisis, I understand at a snapshot in time, like, for

Q .

example today, there would be about 165 to 167,000 people in the California prisons, is that your understanding as well?
A.

Yes. Okay. And yesterday you testified about the intake

Q.

facility at CIM, and that approximately 100, I believe you said 100 to 180 people come in a day to that facility; is that correct?
A.

That's what we were told by

-Do you have any understanding?

Q. Okay.

Do you understand that 100 to 180 figure is five

days a week, seven days a week?

A.

My understanding was that they took intakes seven days a

week, but not the same every day.

Q.

Okay.

Do you have an understanding as to how many people

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on average were coming in to the CIM facility and intake on an average week?
A.

No, I didn't ask that question.

Q. Do you know how many people come into the California

prisons annually?

Once again, I understand that a snapshot in

time, it's 165 to 167,000, but do you know how many people come in on an annual basis?
A.

No, I don't know exactly. Do you have any idea

Q.

--

let me withdraw that.

Do you have any idea how many people leave the prison system on an annual basis?
A.

No, I don't. Okay. One of the things you testified about yesterday was,

Q.

I believe in response to a question by His Honor, was with respect to doctor quality, and I believe you testified about what you would do if the judge appointed a receiver or an interim receiver about, you know, identifying bad doctors. And I believe you testified that you said that one of the things you would do is go site to site; is that accurate, to try to identify bad doctors?
A.

Not exactly. Will you explain to me if you were appointed, if the

Q. Okay.

Court chooses to do so and you were appointed the interim receiver or the receiver, how, specifically, you would identify Sabar McVickar, RPR

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bad doctors at one facility, let's say CIM, somewhere you recently visited?
A.

Let me back up. You are assuming that I personally would review

every site, and that is -- wouldn't happen. happen.

I mean, that can't

And that's the reason why Dr. Kanan can't do, is

because she can't go site to site. You would immediately have to hire regional medical directors and require them to review every credential in a formatted fashion without waiting for a policy on it, just go and do, it and require every doctor immediately to provide material as a requirement for further employment. begin immediate review of every single physician. saying I would do that personally
Q. Of course.
A.

So you would I'm not

--

-- but you would do that as an entity.

Okay. So you would put the structure in place that

Q.

--

that

Dr. Kanan has discussed with the regional medical directors, and they would take the laboring oar of identifying the bad doctors?
A.

Yeah.

I wouldn't quite do it as Renee did it, but it would

be similar.
Q. Okay, how would you do it?
A.

I think there would be more regions with 165,000 people and Sahax McVickar, PER

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It makes sense that

facilities of five thousand each, I think you may need more than three regional medical directors.

that women's facilities be a single entity. The male facilities might then be divided into four regions, but I'm not sure about that exactly.
Q.

I think it probably would be more.

Okay. So there would be more regional medical directors,

that would be part of your plan.

And then how, then, would

those regional medical directors attack the problem at individual facilities? I understand from your testimony they would develop some credentialing guidelines?
A.

Well, the credentialing guide lines would not take long.

As I said before, it takes a couple, three days to a week to actually develop a requirement. And the first aspect is to know the players on your team. So you would do an assessment of who are the players on the team. And that would be done at the sites by regional medical directors actually going there. A major difference between the current practice and what I would propose is that staff would

--

let me back up.

Dr. Kanan does not have the ability to go to sites. In fact, she very seldom goes to sites. never seen her. Some of the sites have

But it is important that regional people be at So that would

the sites and know the physicians at the sites.

be the modus operandi, is for the regional medical directors to

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go to the sites. weeks.

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That would take, I believe, two to three

If there is thirty-three facilities, and it's divided

And six can be done in maybe three weeks.

by five, that's six.

Q.

Okay.

So they would go to each facility in those two to

three weeks, or the period of time that you have discussed, and they would, one, look at the credentials of the physicians, and they would get to know them. What else, if anything, would they do to identify the problem doctors versus the good doctors?
A.

Well, you are thinking linearly, and there are many things Number one, you have to begin

happening in parallel.

immediately hiring physicians who are of the caliber that you want. And remember that you have reviewed

--

we have already

reviewed nine sites, eight of which I think we know fairly well, and we know how many physicians are needed. There needs to be an immediate recruitment effort so that you are hiring to those positions, and that has to be extremely aggressive. And you would

--

you would

-- as an

example, you would dedicate the senior medical person to lead that, because that would be a major responsibility, let's say, of a state medical director and regional medical director, to try to find people to populate the facilities.
Q.
A.

Okay. So that would be going on simultaneously. And nine

facilities are already known, so you are dealing with

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many is that now?
Q.
A.

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22 Or 23?

22, Right.

So you have less facilities to attack. And so

I guess it would start, send a memo to all sites, physicians are to fill out this form, have all this credential information ready, within a week. And they would have to send it to their Some of

CMO which would be faxed to the person reviewing it.

it could be done remotely, but you would then go to the sites and meet the people and interview everyone. that's an unusual thing to do.
Q.

I don't think

So in addition to the hiring efforts that -- there would

also be a credentialing check and then an interview of all the physicians. And then what would happen next?
A.

In terms of what?

Q. Getting rid of good doctors

A.

-- or, bad doctors.

When you talk about a receiver, you are talking just about

what you do for the physicians.

Q. Correct.
A.

Not about anything else. Right.

Q.
A.

Okay.
Well, what I would do is establish requirements for

certain jobs, for example, the high acuity category requires a higher level of training than people who are doing sick call.
So you would establish that as a benchmark.

One could say that

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you would create another job title, call it high-acuity doctor. The high-acuity doctors would be paid at "X" rate. That would

be the entre with which one could raise salaries for physicians who were competent and provided a higher level of service. So you would create a job category to which you could recruit for. tool, vehicle. So you would have a better recruitment

And you would have to be flexible site to site.

And you would try to hire into those positions. Now, some of the existing physicians would raise to that level. salary raise. not. So some of the existing physicians would get a Those who did not have those credentials would You could go back and

And that would send two messages.

get training, or you would have to accept a lesser salary. And the group that did not have training would be subject to further scrutiny to see whether they needed to be reviewed by a program like QICM or in some other manner. So you would attack it in three or four ways. would, one, do an assessment of the team; you would do an assessment of their credentials; you would create job categories, and you would recruit aggressively to it. You You

would identify those at the facilities who are people you wanted to promote or keep in certain positions, and you would find out who they are by interview.
Q. Okay.

That process, that you have just described for me,

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can you tell me approximately how long it would take to do that at one facility? And I understand you would have five or so regional directors, and they would be doing this at more than one facility at a time, but from

--

from the day interim or not

interim receiver is appointed to the point where you finish that process that you have just discussed, how long do you think that would take?
A.

Well, I mean, I don't have a specific answer for you, but,

you could set an arbitrary deadline, but you would work toward three to six months, I think. Now, you are not, as I said yesterday, you are not going to find the entire complement of physicians you want immediately, but I think you -- you will start that task and do it.

Q. Okay.

I understand that you are saying the recruiting

aspect is definitely more difficult, and that may take longer -A.

Well, let me say this to you, though. Okay.

Q.
A.

I believe

--

my understanding of receiver is that if I find

a doctor at U.C. Davis who is finishing in July in medicine and

wants to work at SAC, I would interview that person, review their credentials and say, "How would you like a job there?" And I would negotiate a salary with that person, and it could be done in a half hour.
Sahar WVickar, RER

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bureaucracy that you have to go through now, and I think that's what you need. I'm talking here from experience. I look at the

receiver as a quasi-private sector entity that allows you to make decisions and act on them quickly. That is how it's done.

If you have someone who is good, you don't keep people on a string for six months to nine months. They quit, because if

they are good they have other opportunities. So when you find people you hire them. And July is

an important time because July is when the residency programs get out. So one of the things I personally would probably do

is I would visit all the residency programs in the state and meet physicians. And maybe get a talk at grand rounds.

And you could get some of the other people I know to do it, but go out and do that and meet the people who are possible recruits. And you have to put a face to a project. You have to be a presence, and so you would do that. And my point here is that the time from recognition of someone as a quality candidate to hire I think would be much abbreviated than what it is now.
Q. Okay.

Under the process you have described, it would be

abbreviated on the recruitment and hire side. And I'm more focused the time that you think it would take to -- from inception to dismissal or removal of a bad physician from patient care.
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Well, there is two different questions there.

The removal

of bad physicians would be much quicker because physicians, for example, who obviously from death reviews had made serious errors of omission or commission that warrant peer review or termination, would be subject to due process very quickly. The other physicians I believe need to be reviewed personally through an interview, through review of through review of their work. So there are a larger number of

physicians who are there who will be starting from scratch under a different system where their work will be subject to peer receive. Those without board section, whether QICM is

used or an alternate process, they would be subject to more critical review than is currently occurring.
Q. Okay.
A.

So to answer your question in the time frame, it's But those who are at

difficult to give you an exact timeframe.

the highest category of harm would be very quick. think

I don't

--

they would be given due process, but they might be

immediately placed administratively on leave and asked to take a review.

Q. Okay.

One of the things you spoke about yesterday was also the problem with the pharmacies that you visited. And sort of along the same lines as my last question; I mean, if you were appointed interim receiver or receiver, what steps would be

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take immediately to remedy those problems in the pharmacies?

A.

Well, right now my perception is there is a lack of And a statewide

statewide organization in pharmacies. pharmacist should be in place.

Now, I don't believe there is

one in the CDC, I've never been told, but I don't see that presence. But the

--

immediately every pharmacy must be

accountable for inventory. So I think the first thing you would do is really inventory what it is they're spending and on what. Where are

their storerooms? How are they supervised? How are they inventoried? What is their stock, etcetera.
Q.
A.

Um-hmm. That should be done by a pharmacist. Secondly, you need to determine cost data for what

is spent on pharmacy.

I have been asking for a year and a half

if anyone has data on cost for pharmaceuticals, and I'm given some aggregate costs, but if the facilities -- I think one site gave me cost data, but no one has it in the aggregate. don't see seem to use it. They

So that needs to be out there. And

they need to get control of their pharmacies. I think you would need to see some of the pharmacies to appreciate it.

I think the court and others have toured two

facilities, at least, and have looked at some of the pharmacies.

Q.

Right.
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In addition to those pharmacies, there are medication In the medication rooms there is a large amount of For example, we walked in the CIM west clinic, which is

rooms. stock.

a remote clinic. And they had thousands of pills of a medicine called Neurontin, N-e-u-r-o-n-t-i-n. Neurontin is not a

commonly used medication, but it is very expensive. And I wondered why they would have thousand of pills of Neurontin in this remote pharmacy. to that. And I don't think there is a good answer

But there are many questions like that that

pharmacists need to determine. So you would hire a statewide pharmacist. You would

have a regional pharmacist who would be responsible in the same way to visit every pharmacy and to begin a process of inventorying and inspecting every pharmacy in the system. And

I think that would take several months, maybe four months, five
months. At the conclusion of that, you would determine what systems are doing, and if it's anarchy or if there is a system to what every pharmacy is doing. And I think that it's probably a little bit of both. The Pleasant Valley pharmacy Other pharmacies had

had very low stock levels of medication.

huge quantities of stock levels and stuff sitting on the floor.

It looked very disorganized.

So you are going to identify,

very similar to the physicians, those pharmacies that are out of control and not out of control. You are going to find
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inventory problems, and you are going to identify facilities that need more attention than others. The pharmacy will develop an inspection plan. month pharmacies are inspected against a checklist. Every

You know,

problems will be identified. And at the conclusion of three or four months, you will get a general idea of how the operation of pharmacy is. I think the big question for pharmacy is that they have on-site pharmacies everywhere. And there is very few correctional systems that have on-site pharmacies. Most

correctional systems use fax-and-fill pharmacies, where they fax a prescription to a remote pharmacy, the prescription is filled and FedExed to the site the following day. The California system is very labor intensive, and
I'm not sure that it delivers a service that warrants the kinds

of monies they are spending.

I don't think it's any more But those

efficient than a fax and fill, but I'm not sure. kind of decisions would need to be made.

I believe also that at the physician side, there are

utilization issues.

Dr. Goldenson and I reviewed care at CIM,

where a physician was giving a very expensive medication to patients on a routine basis when it probably was not indicated, costing perhaps several thousand dollars a month. to be reviewed by medical people. Those need

So you would attack pharmacy

both by pharmacists and by physicians looking at utilization

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All I can tell you is in California it would take a couple of years to really get pharmacy back in shape. But I

think that the cost savings for pharmacy are perhaps, along with hospitalization, the most potentially significant benefit for the state.
Q. Okay.

And you sort of led to my next question. When you worked in with to the New Mexico prisons,

you worked for an outside entity, correct?

A.

That's correct. And

Q. Okay.

-- and you just touched upon this fax-and-fill

pharmacy program; is that one of the solutions in your mind, to contract out with the pharmacy needs?
A.

Not necessarily contract out.

The state could do it. The

state could be just as efficient as the private sector if they just do it in a different manner. The equation is, do you need pharmacists onsite, to the extent they have, or, for example, if the system uses "X" number of penicillin prescriptions on a regular basis, you would have a warehouse in Sacramento where state pharmacists fill penicillin into blister cards and send it to the sites so many a month in anticipation that that is their typical use. You could do that for many drugs. Right now, they are used to the legacy of each facility operating as an independent entity because that is how
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they grew up.

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They have not thought

The wardens ran the facilities, and each entity

was separate. There was a fee.

globally. And so each entity reproduces an entire system within itself, if you know what I mean.
Q.
A.

Um-hmm. And instead of that, it's much more efficient if you would

mass produce certain things and provide them to the facilities on a scheduled basis. When Toyota builds cars, they don't fabricate the steel bumpers at the plant where they put the car together, where they assemble them, it's fabricated somewhere else. But

the state doesn't do that, they reproduce the entire entity at the facility. And I think that's that's not just good management. So it could be farmed out.
I think those decisions, by the way, I just would

like to say that whoever the receiver is, I think it would be incumbent on them to work with the State to try to determine an exit strategy before they make decisions that the state would be encumbered with after the exit of the receiver, particularly in a temporary situation. You would not want to make a decision that the State would not be comfortable inheriting. Because that, after all, is the purpose, is to create an entity that allows for its own disillusion. And the inheriter of that is the State, the State would have to be comfortable accepting that plan.
S e -Viekart

So you would

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not really want to do something the State was vehemently opposed to.
Q. Okay.

Would one of the fixes or potential fixes of the pharmacy issue, would that involve information technology? Would that
A.

-I mean, it does now. The pharmacy does

I think it would.

have a system, and they are currently in the process of converting to software that is utilized by the VA, by the Veteran Affairs Administration. I don't know whether it's appropriate, good or bad. It may be good. But they do need an upgrade. As an example,

the pharmacies are not interconnected facility to facility. They have the thief mentality. They are just at the site. So,

for example, if someone transfers from CIM to Corcoran, the medication profile does not follow. So they have to have everything reentered. But wouldn't it be nice if you entered at CIM at an intake facility and they were sent to Corcoran that the profile was there so all someone would have to do is recognize that now they are here, and this is their profile, and it was last filled two weeks ago? That is a real possibility, but the State doesn't have

--

the health care people don't have a network, which I But it

think is an easier fix than an automated record.

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Mello

certainly is something that would be of major benefit to the Health Care Services, just to be networked.

Q. Just to be networked?
A.

Just to be networked. And then if they have a pharmacy

program, they could put that on the network. I think if you interviewed your own pharmacist, they would agree that would be a wonderful solution.
Q. Okay.

You touched upon it again; the medical persons at the individual prisons do not directly report to the warden, correct?
A.

Well, in practice or in theory or by policy?

I mean, in

practice, yeah, they do.

I mean, the wardens have changed

hiring decisions, the wardens order people to do things, the wardens send memos on TB. The wardens are involved a fair

amount in telling people what they have to do. I mean, why are people at Salinas Valley examining patients in cages? They shouldn't be doing that.

I think that

is because the warden says that is what is going to happen.

Q.

You think that's the case? You know, I'm not sure. The other examples I used I know

A.

happened, the warden making a TB policy; the warden at SAC overruling a hiring decision; the warden at -- it was either Pleasant Valley or SATF ordering that the MTAs should report to the psychologists instead of the nurses at ordered by Central
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So the wardens are making decisions like that all the

.
So, in effect, when a warden does that, staff at the

facilities know and understand that the real boss is the warden. And that has an affect on everyone.

Q. And that is based upon these anecdotal things you have just

told me?
A.

That's correct.

Q. However, if, in fact, one looked at an organizational

chart, one would see that medical people actually report up to Renee Kanan?
A

That's correct. When you talk to the physicians and you They

ask, "Who is your boss," they don't understand that.

understand a much more different and practical reality, which is their working reality. And I think that is different than what the organizational chart states.

Q. Okay.
One of the things you testified yesterday about, I just wasn't clear what you meant, Mr. Specter asked you about whether there was enough physicians to treat high-risk patients, and you said there weren't enough in the aggregate; can you explain to me what you meant? Does that mean there are enough physicians to treat high-risk inmates at some facilities but not others?
A.

Yeah.

Maybe I was unclear, and I apologize. There are not

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enough physicians to treat high-risk patients.

Q.

Are there enough at any of the facilities that you have

visited?
A.

Perhaps at Corcoran. And I think at

--

maybe

-- I haven't

been back to SAC, but they have made some changes at SAC, and perhaps at SAC. Remember, one of the things they do which makes it difficult for us to assess it is they move people around. for example, if So,

--

Dr. Wolf has been at four or five

facilities. For a while he was at SAC, and I'm thinking well, he's at SAC so they have a high-risk doctor. And now he's at San Quentin, and he was somewhere else before. people around all the time it's not enough. But there have been three or four hires at facilities since we started the high-risk business that I know of, and that has helped. visit lack physicians. But most of the facilities that we So if they move

Q. Okay.
That's a problem that you have identified everywhere you visited, correct?
A

I think Dr. Kanan thinks it's a problem, yeah.

Q. Okay.

Yesterday you testified about peer review, I believe you testified that there is no

-- basically no peer review

process at CDC, and to the extent there is one, there is not Sahar McVickar, PER

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enough doctors to adequately do the peer review, not enough qualified doctors, I think is what you said. Did I hear you correctly, that they are sort of two problems; they don't really have a process, and they don't have a functioning process because there aren't physicians that actually do the peer review?
A.

The CTC has a requirement to do peer review, so at the

facilities where there is a requirement to do peer review, I did not see any evidence that it was done in a manner that was effective or thorough. At other facilities, I did not evidence any peer review. And even at facilities where they had CTC, they sometimes were not doing any peer review. good situation, no.
Q.

So it was not a

So in light of those two problems, one, that they don't

have a good process, and two, there aren't enough physicians to

--

qualified physicians to actually do peer review on the

others, wouldn't you agree that one would need a specialized and creative peer review process to make it work in the current system?
A.

Well, let me give a little bit of background on peer

review, because I think that you need to understand exactly what peer review is. We have talked about it quite a bit.
Q.
A.

Um-hmm. But peer review may be different in different settings. For example, in hospital settings, peer review is

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defined as someone makes a mistake, and that mistake gets raised to the level of review by a committee of peers who review whether this mistake requires a sanction or not. So

that definition of peer review has to do with the sanctioning of physicians. My perspective is somewhat different, because it comes from more of an ambulatory perspective, which is the situation of the CDC. That perspective is that peer review is

a process by which physicians1 routine care is reviewed on a regular basis to determine the adequacy of the care and the competency of the physician. things. So there are two different

One is that you are taking a sentinel event, someone

dies and then you do peer review on it; and the other one is that this is ongoing review of physician's work, almost as if it were annual review for personnel. NOW, in addition, at sites, if someone dies, there is a review of the death, and, if necessary, because of a mistake made by a physician, there would be an additional peer review of that physician. That would move into that category So I hope you are clear on the

of the sentinel event review.

kinds of perspectives on peer review. And what I'm talking about is that there is no ongoing review of the ongoing quality of physicians in CDC facilities.
Q. Okay.

With the current makeup of the CDC facilities and

based upon your testimony before, I understand that that

Puisis

- Cross /

W l o

ongoing review couldn't happen with the current circumstances; is that correct or incorrect?
A.

Well, it isn't happening.

"Couldn't" is a word that But if nothing changes,

implies that nothing will ever change. no, it couldn't happen.

Q.

And what could happen to make it change if you were the

receiver besides hiring doctors and regional medical directors? Maybe that's the answer to the question.
A.

Well, let me just give you a couple of very concrete

examples. Let's, for hypothetical purposes, assume that I became the medical director of the SAC facility, and Dr. Goldenson became the medical director at SATF, and Dr. Shansky became the medical director of Pleasant Valley; I guarantee you that at those three facilities there would be peer review. So one point I would like to make is just that if

you have people who are qualified and know what they are doing, you will review the physician staff because it's part of what you do as a physician manager or a medical director. But the second thing that could be done is as you hire regional medical directors, they would assist the sites in doing that until local chief physicians could be hired who would undertake that task. And it would be organized. would be, you know, within certain parameters. And it

It would be

done in certain parameters that are provided to staff.

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Q. Okay.

- Cross / Mello

248

Has Dr. Shansky spoken to you about his experience as the receiver in the D.C. jails?
A.

A little bit, yes.

And is it your understanding that it took several

Q. Okay.

years after he was granted the type of authority that Mr. Specter spoke about yesterday, hire, fire, contract, it took him three years to fix that facility?
A.

Yeah, I think he said it took two years before he was

minimally satisfied.
Q. Okay.

Hypothetically speaking, if the judge decides that an interim receiver or a actual receiver is appointed in this case, and assuming that that person has the same power that Dr. Shansky had in D.C., with 1700 inmates, how long would it take to bring it to the minimum levels with a system that has 165,000 inmates at one particular time?
A.

Well, let's separate that question, because I think

--

not

to cause confusion, I would like to separate it. One of the reasons that I believe the Court is looking for a receiver is because of the imminent harm to patients. So the real question is not when you could have the

entire system at a minimal standard, which I think would take a much longer period of time because you are talking about when do they get the forms, when is the automation set up, when is
Sabr BkVickar, RRR

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Puisis
-

- Cross / MeJ.10
-

the pharmacy fixed, etcetera. And that is going to, no question, take a long time. The real question is how long will it take, comparatively, to prevent the kind of deaths we are seeing and the harm to patients by getting a better cohort of physicians and fixing those things minimally enough to prevent that. So that is the question. And I think the comparison is how long would it take a receiver to do that versus any other arrangement? I think that is the question.

And I don't have a specific answer for you, although

I think, certainly, a better physician complement, which I

would be reluctant to go on the line and say how quickly you could hire a full complement or even have three doctors at each site who you trust, but I think that would reduce the death rate significantly.

If you could get two to three competent doctors and

do the scheduling at each site in such a way, you could dramatically reduce the mortality rate. And I think that is achievable within a year and a half to two years. Because that

is a minimum of 99. They already have some, so let's say you are talking about 30 to 40 people, that is not all the people you would need, but that would allow you, I think, to divert the high-risk patients to care. So that is the first objective, is to reduce that harm. Compare that to what it would take doing it in a
R

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Puisis

- Cross / Mello

different manner, and I think that is the equation. And I think there is no question that you can do it faster if you can just hire people. There is no question in my mind about that.

The second part of the answer is I'm not entirely sure but remember this, once you develop a system of peer review, whether you are developing it for 1700 patients or 165,000, you have developed a system of peer review. And if

you have five regional medical directors, when you develop policy for one, you've developed it for five. So really what

you are doing is, you are breaking the system into six to seven smaller systems, each of which, then, you would say how long will it take to get that minimally, okay? So you are really breaking it apart into smaller pieces with management. And therefore, I think, it's not --

it's not a prorated comparison, as I think you are maybe suggesting, that because it took two years for 1700, 165,000 divided by 1700 is 50, so it's going to take 100 years, that is not going to happen. You are going to break it into pieces, and you are going to attack it. And I don't have an answer for you when it

would be acceptable, because that would be the point at which you can do a final audit for Plata and exit. And I'm not sure the answer to that.
I know if you stay the same, I've heard speculation

of how long it would take to get Plata, and it's beyond my

Puisis

- Cross / Mello

lifetime. So I don't have a great answer, but I would look at it by breaking it apart and separating this protection of people from getting out.
Q.

And just so I understand your testimony, one, I'm not

trying to imply that it would take, and I think your math was off, that it would take 1700 into 165, I think it's a bigger number than the 50, but regardless, I'm not trying to imply that.

I just want to make sure I understand your answer;

you think just minimally protect

--

part A that you discussed,

two years, a year and a half to two years?

A.

I think you

--

what I said was I believe that you could get

two to three or four doctors at each site who were adequate for providing care to high-risk patients that would provide a much higher probability that you would reduce death rate as we see it now.
Q. Okay.
A.

And I think that could be done faster in a receiver than it

could be otherwise.
Q.
A.

Okay. What is that comparison? I don't know.

Q. And you don't know the answer to the second question, which
is full compliance with Plata?
A.

I think that's several years.

There is

--

I think it's

several years. Sahar MbVicfcar, PER

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Puisis
Q.

- Cross / Mello

Okay. MR. MELLO: Can I just consult with my team?

Thank you, Your Honor.

(Counsel confer

.)

BY MR. MELLO:
Q.

Thank you, Dr. Puisis.

THE COURT:

Mr. Specter?
REDIRECT EXAMINATION

BY MR. SPECTER:
Q.

Dr. Puisis, during cross-examination Mr. Mello asked you Why did you

about the prisons you've been to in some detail. pick those prisons?
A.

Well, they were the roll-out prisons. And why did you pick the roll-out prisons? And -- because this hearing is about what progress the And after all, the roll-out

Q.
A.

roll-out prisons have made.

prisons rolled out, you know, they should be

-- they should be

into the process, and they should, you know, have advanced somewhat.
Q.

You only had a limited amount of time between the time you

got notice

--

or the time of

--

strike that question.

So in terms of when you have to make a decision about which prisons to investigate, if I understand your testimony correctly, or the implications of your testimony, you picked the roll-out because they should be farther along in the
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Specter

process than the other prisons, correct?

A.

Well, yeah.

I mean, if we went to Avenal, they would say

why are you

--

of course we have problems at Avenal, it hasn't You can't expect

rolled out yet.

-- the expectation is that

So

the other facilities haven't started with this process.

they are operating under usual circumstances, which from what we have seen at the roll-out facility, usual circumstances is not very good. So we anticipated that the roll-out facilities

would be the most advanced facility, and we wanted to see how they were progressing.
Q. And if they weren't advanced, one could infer that the

others would not be advanced as well, correct?

A.

I think that's -- I think that would be correct, yes.

And that has been corroborated by your review of death

Q.

records of patients at other prisons, correct?

A.

Yeah.

As I said, we would see documentation in the death

records of what went on at other facilities, and it didn't always look good.
Q. Okay.

But we haven't been there.

Speaking about death records, you understand that 34 of the deaths that you received were sent to U.C. San Diego, the QICM program, for an intensive review, correct?
A.
Q.

Yes. And are you

--

it's true, isn't it, that the records that

were sent were more than the records that you reviewed if they
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were available. Everything the CTC had was sent to QICM?

A.

That's correct. Did you receive any information after your testimony

Q.

yesterday about whether these reviews have been completed?

A.

Yeah, Dr. Sherger sends E-mails periodically.

You may have

received it. But he sends it around on death reviews. They have done 2 3 to date. And I think of those
23,

not all of them were the deaths, but most of them were that

-- in that group of 34.

Q. 2 3 out of 34?
A
Q.
A.

Yeah, I think so, yes. And did you have an opportunity to go through any of those?

I reviewed them briefly.

I think they pretty much

corroborate our initial impressions, or even they went further and said that the care might have been worse. In some instances, they did not have the complete record, even, so even though the State is attempting to get the records, they didn't have the complete record on all of it. But they had more than we had.
Q.

And they didn't look that good.

Do you believe that that information would be helpful to

the Court in assessing the degree of danger there is to the population?

A.

Well, I would think it would

--

it would corroborate our And secondly, it would

initial impressions of those 34 deaths.

therefore solidify the estimate of probability of expected

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255

Specter

deaths that are occurring at the facilities.

Q. Okay.
Dr. Puisis, could you make those available to the Court and the parties, please?
A.

I can forward it as an E-mail to the Court, and they would

see what they did.

Q. Okay.

Forward it to the parties, and we'll get it to the

Court.
A.

Okay.

Q. Thank you.
A.

Dr. Kanan, obviously, already has it.

Q. Okay.
A.

I'll send it, anyway. Is there any question in your

Q.

--

I want to go to the last

point that you were talking about with Mr. Mello in terms of the equation you mentioned between getting things

--

making

improvements in doctor quality by specific orders or doing it by the receiver. You understand that if you do it by the specific orders you would be ordering these defendants to accomplish the tasks that you went through, correct?
A.

That's correct. Is there any question in your mind, knowing what you know

Q.

and having the experience you have had in California as compared to other jurisdictions, which would be the quickest
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way of obtaining significant relief for the patients?

A.

I think the receiver would be the quickest way to hire

people.
Q. And is that

-- is that a close calculus, or in your mind is

it
A.

-Well, I mean, there is always contingencies that are

brought up, but I think it would be

--

if it took a receiver

two days to hire somebody, it may take as long as -- I mean, we know for a fact six months currently to hire somebody, or longer. Could be shorter, but based on what we've seen, it's a So it's a fairly substantial spread.

long time.

Q. Okay.
And even if -- the plans you outlined in response to Mr. Mello's questions about what to do with physicians, what to do with pharmacies, if you took your testimony and put it into a court order and the judge signed it, would that be an adequate way to go about fixing this situation?
A.

Well, in some cases what I described would probably never

happen in the State system, because I think there is too many interests that oppose their particular self-interest. the union is the best example. I'm talking about the

I think

physician's union but also the MTA union, for an example. The State is very reluctant to

--

I don't want to

say oppose the union, but they don't move forward as quickly when there is opposition as I think a receiver might, let's

Puisis

- Redirect /

Spec*

say, in hiring somebody or in disciplining a physician.

Q. And they don't move forward as quickly, even when there is

a specific court order directing them to do certain things, correct?
A.

Well, that's been the case.

And I understand why, but I

think that some of those restrictions might not be there. And in some cases you would still do it. Let's face it, private industries of unions, and they still have agreements, and they move much quicker than states do because of the political pressures that are brought to bear. So you would have that in every area. example, I don't see them fixing pharmacy. records would be a little bit tough. I mean, remember, for the death records we thought that we couldn't get death records. And they take the whole paper record and bring it to Sacramento. And but they photocopy the death records at the facility, and then they send it to Sacramento. But because it's so cumbersome, it seldom happens. And then if ten people need that record, they would have to photocopy for ten people. And it's such a big Pharmacy, for

And even medical

requirement that it almost never gets done. We suggested sometime ago just scan it. big deal these days. file. That was It's not a

Scan it at the facility and send it as a

--

you remember the Friday meeting when that

occurred, and I think it's still

--

they are still figuring out

Puisis
a way to do that.

- Redirect /

Spec*

There is things they have to go through, I am sure, you know, requirements and this and that, but that is not a complicated issue. So I think you are going to have a lot of those types of issues that will come up that will be barriers to implementation of this. For example, the purchasing. We

are still going to have to go through the purchasing process of $2,000 limits, and all that.
Q. Well, even if we got rid of that, even if the Court ordered

them not to follow that part of State law, isn't it true that you can't anticipate, as you sit here today, or as you would draft an order or help a lawyer draft an order, all the contingencies that are going to be necessary and all the barriers that are going to

--

that one is going to face in

implementing a plan; is that correct?

A.

Yeah, I think it is. And I think what it would engender The best example is the patient So I think when I

more orders and more orders. care order.

Hire doctors at the sites.

talked to Central Office staff they said, "Well, we need a specific order because we can't hire them through the current process.'I So you would give the State an order to hire more doctors, they can't do that, they need a specific order. You

give them that order, and there might be another problem, an unforeseen event. And then you would have to give another

Puisis
order.

- Redirect /

Spec*

So in order to accomplish it, you may have series and

series of orders for one task. Now, if you

--

the attorney asked me, "How many So let's say you have

tasks do you have," you have multiple.

50 or 60 tasks to do, and each one is an order, it's going to

get complicated. I don't want to say it can't be done

--

Q. But it would be impractical, and it would be less quick?

A.

It's going to be -- yeah, yes.

MR. SPECTER:

Thank you, Your Honor. Any recross, Counsel? No, Your Honor. Okay.

THE COURT:

MR. MELLO:
THE COURT:

Sorry you had to stay over, Doctor. THE WITNESS:

THE COURT:

That's okay. Thank you for doing so.

You're excused.
THE WITNESS:
THE COURT:

Thank you. Call your next witness. Your Honor, we'll be calling

MS. HARDY:

Ms. Madie LaMarre.

THE COURT:

Okay, Ms. LaMarre, would you step

forward and be sworn in.

MADELINE LAMARRE,

called as a witness for the plaintiff, aving been duly sworn, was examined and testified as follows:
Sahar McVickar,

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Puisis

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spec-

THE WITNESS: My name is Madeline LaMarre,

M-a-d-e-1-i-n-e, L-a-, capital M-a-r-r-e.
DIRECT EXAMINATION

BY MS. HARDY:

Q. Good morning, Ms. LaMarre.

A.
Q.

Good morning. You are a nurse practitioner with over 40 years' experience

in correctional health care; isn't that right?

A.

Correct.

Q. You received your Bachelor of Nursing, or Bachelor of

Science in nursing in 1977?
A.

Correct. And your Masters of Nursing in 1982? Yes.

Q.
A.

Q. And at that point you were licensed as a nurse

practitioner; is that right?
A.

True.

Q. Can you explain for the Court the difference between a

registered nurse and a nurse practitioner?

A.

Yes. A nurse practitioner is a nurse who has received an

additional level of training whereby we are trained to diagnose and treat common occurring illnesses in the populace, like high blood pressure, bronchitis, arthritis, etcetera.
Q. And so you are able to prescribe medication for those?
A.

According to the laws in different states, they vary.

Yes.

Q. You began working for the Georgia Department of Corrections

as a family nurse practitioner part time in 1982?

A.

Yes.

Q. And two years later, you went up to management at the

Georgia Department of Corrections, and you acted in management for about 10 years until 1995; is that right?
A.

Yes, I

-- in 1995, I was promoted to another position that

had additional management responsibilities. And during the course of my years in the Department of Corrections, I also engaged in some clinical practice off and on during my tenure there.
Q. And from 1995 until December of 2004, you were the

statewide clinical services manager for the Georgia Department of Corrections; is that right?
A.

Correct.

Q. And in that position, could you describe very briefly what

you did to oversee nursing in Georgia?

A.

My responsibilities as to the clinical services manager

were broader than nursing, but I developed a health care policy related to operations, clinical operations, including nursing.

I was responsible for coordination of clinical

training, including nursing and responsible for the development of a clinical audit process that had a nursing component to it.
Q. And when you left the Department of Corrections in December

of 2004, the population of the Georgia Department of

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Corrections was about 50,000; is that right?

A.

Yes.

Q. Are you familiar with correctional health care systems in

any states other than Georgia and California?

A.

Yes, I've worked in a consulting role in Ohio, Minnesota

and Vermont and the D.C. jail.

Q.

In 2002 you were appointed as an expert in the case; is

that right?
A.

True.

Q. And you are familiar with the Court's June 2002 order in

this case?
A.

Yes.

Q. Initially, one of your primary dut i e s under the court order

was perceived to be that you would be requested by the defendants to perform an audit of individual prisons when those individual prisons believed that they had come into compliance with the court order and the policies and procedures; is that correct?
A.

Yes. Have the defendants asked you to audit any of their

Q.

prisons?
A.

We participated as a group in some of the QMAT audits, some

practice audits, so to speak.

Q.

Have the defendants asked you to audit any of the prisons

to determine whether they meet compliance with the June 2002

LaMarre - Direct / Hardy

order?
A

No. In your capacity as the California expert, you visited a

Q.

number of prisons; is that right?

A.

True. And you visited all of the initial 2003 roll-oi correct?

Q.
A.

We've toured all of them, and we have visited most of the

'03 roll-out sites and '04 roll-out sites, the site tours.

Q.

Is it nine prisons that you have visited to do

--

after you

did the audit tours, did you visit nine prisons after that?
A.

Yes.

Q. Okay. And was that SAC, San Quentin, Salinas Valley, VSPW,

Pleasant Valley, SATF, Mule Creek, Corcoran and CIM?

A.

Correct. And you visited all of those in the last eight

Q. Okay.

months or so; is that right?

A.

Most since January. Okay. While you were at those institutions, did you review

Q .

unit health records for prisoners?

A.

Yes. When you reviewed those unit health records, were you

Q.

reviewing only the care that was provided at the specific prison that you were visiting?
A.

No.

In some cases, I reviewed just the care of the prison,

but often I reviewed care since the inmate had come into the

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system.
Q.

And so the unit health record is something that follows the

prisoner from prison to prison and reflects the whole history of the prisoner's health care; is that right?
A.

Correct.

Q. Okay.

You have attended meetings periodically with the parties; is that correct?
A.

True. About implementation? And I know plaintiff's counsel had sent you our

Q.

reports following our tours of the prisons, and have you read those?
A.

Most of them, yes. Okay. And you have met with the defendants, including

Q.

Kevin Carruth, Rod Hickrnan and Renee Kanan; is that right?

A.

True.

Q. And you have attended status conferences with the parties?

A.

Correct.

Q. And the Court.

And you have also discussed findings that you have found at individual prisons with your other experts; is that right?
A.

Yes.

Q. And they with you?

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A.

Correct.

Q. Okay.

In the past six months, you wrote reports on CSP, SAC, San Quentin, and Salinas Valley; is that correct?
A.

Yes.

Q. And then you also contributed to reports drafted by the

--

all of the experts on Pleasant Valley, Corcoran and SATF; is that right?
A.

Correct.

Q. And do you believe those reports to be accurate

descriptions of the status of the health care systems at those prisons?
A.

Yes. You understand that the Court ordered the defendants to

Q.

implement policies and procedures that had been approved by the experts and the parties under a prescribed schedule in the June 2002 order; is that right?
A.

Yes.

Q. Okay.
And under those policies and procedures, the correctional nurse staff plays a critical role in health care delivery to prisoners; isn't that right?
A

They do.

Q.
A.

Could you describe what that role is? Yes.

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In a correctional setting, unlike the community, Oftentimes the nurses are given the role of a

-- triaging or

conducting the initial evaluation of inmate health complaints, This is because, obviously, the inmates are locked up, they can't get to a telephone to call to make appointments. And the mechanism for accessing care for inmates with minor or serious health problems is to submit a request for services. And the nurses are the ones that do the initial triage review and conduct assessments to determine how serious those health complaints are, what the appropriate treatment might be and under what circumstances a referral to another health care professional might be indicated. So it's a very important role that they play.
Q. And would the nurse determine how urgent the complaint

would be?
A.

Yes.

Q. So they would decide the timeline if the person saw another

provider; is that right?
A.

That's correct. Do nurses also play a role in emergencies at the prison if

Q.

a prisoner, say, has a heart attack or for some reason is incapacitated?

A.

Yes.

Like accessing the routine health care -- we call it The nurses are the first ones

face-to-face triage process.

called or notified, oftentimes by correctional officers, when

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2 67

an inmate has a health complaint that he or she says cannot wait until the next day. Again, they play an important role in conducting the initial assessment in determining the potential seriousness of that complaint.

Q. Is there a serious risk to patient health if the nurse is

not doing his or her job effectively in that triage capacity?
A.

Absolutely.

Q. Could you explain that.

A.

Yes.

I an inmate is complaining of symptoms of a heart f

attack, such as chest pain, weakness, etcetera, and the nurse does not appropriately evaluate that and refers it to a physician or another provider who can appropriately address the inmate's health condition, the inmate may die.

Q.

Based on your prison visits, your chart reviews, and all of

the information that you have collected in the past two years as a court expert, have you developed, or do you believe you have sufficient information to form an opinion on how CDC has implemented the nursing policies and protocols?
A.

Yes. And what is that opinion? My opinion is that they have not adequately implemented the

Q.
A.

policies and procedures that they were required to implement, as required by the stipulation for injunctive relief in June 2002.
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Q. And the basis for your conclusion is?

A

Well, at our reviews, several of the basic policies were

either only partially implemented, in some cases, not implicated at all, such as the nursing face-to-face triage at some prisons just simply hasn't gotten off the ground. Therefore, patients' access to care was not being provided timely.
Q. Can you think of an example or two that

--

where that

happened?
A.

Yes, at several prisons.

One is Salinas Valley, where, for

example, in D Building, which was the ad seg unit, the nurses were not triaging the Health Services request forms timely. Patients were complaining of losing weight and having abdominal discomfort and not being evaluated. Patients were complaining

of using their asthma medication too much, needing renewals and not being evaluated timely. Those were just some examples.

Q. Okay.
Given your 20-plus years of experience in correctional health care, are you familiar with the elements necessary to construct a successful nursing supervision model
A.

Yes.

Q. What are those elements?

A.

In any system, you need a correctional system. At a

headquarters level, you need adequate leadership and the resources to conduct adequate supervision in the field.
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At an institutional level, there needs to be clear lines of authority, accountability, and responsibility that need to be exercised on a daily basis in the facilities to make sure that the policies that are related to nursing are being implemented.

Q.

So you are really talking about two elements. You have to

have in headquarters central leadership with the ability to then oversee what is happening in the field?
A.

Correct. And then there needs to be leadership in the field

Q.

overseeing what is happening in the clinics?

A.

That's correct. And while you were working at the Georgia Department of

Q.

Corrections, did you have that kind of model?

A.

Yes, we did.

Q. Did you have a statewide nursing director?

A.

Yes.

And let me correct that in the Georgia model, we

hired a vendor that had a, in essence, a statewide director of nurses, regional nursing directors that had clinical oversight over the institutional directors of nursing.

Q.

Do you recall how many regional directors you had in

Georgia, or the vendor had in Georgia?

A.

I believe there were three regional directors of nursing.

Q. And that was for a system of?

A

50,000 inmates.
&&ar McVickar, RPR

- Ofl5cid

&urt Rqw*, (415) 626-6060

U.S. D. C.

--D-t/Q. Okay.
In your opinion, does the Department of

-- the

California Department of Corrections have in place the elements necessary to successfully supervise and manage nursing services in the CDC?
A.

No, they do not.

Q. What is the basis for your opinion?

A.

Well, in the CTC headquarters division, there is no There are no And for all

statewide director of nurses at this time.

regional directors of nursing in the department.

intents and purposes, there is really no person in the headquarters nursing. The nurses that are there in headquarters who act as consultants assist with policy development, but they have no authority, and they really don't speak for nursing in any kind of meaningful way.
Q. And so are you referring to the Quality Management

--

at the headquarters level who speaks for

Assistant Team nurses when you say there are nurses in headquarters?
A.

They are some of the nurses.

There are others, but QMAT

nurses are the nurse consultants.

Q.

So what you are saying is in headquarters there is no one

with line authority over the nurses who are in the institutions?

A.

Correct. If nurses in the field and clinics identify problems

Q * Okay.

with policies or protocols Or implementation, what avenues are available to them to try and resolve these issues?
A.

Well, from a nursing perspective, they really have no one

that they can look to who can answer questions with real authority. The nurses in the field did tell us that they called

QMAT nurses to try to get questions answered, but in some

cases, I found that there were differences in what QMAT told the nurses and, let's say, what Dr. Kanan indicated that was the policy or the decision. So there is a lack of clarity, and

there is not a single person that the nurses can look to and say, "This is who I should call."
Q.

Did any staff tell you that they had tried to get

clarification directly from Dr. Kanan?

A.

Staff did tell us that they had contacted Dr. Kanan to

express concerns, yes.

Q. And what response did they get?

A.

Well, at several sites, they said that they had not

received a response.
Q.
A.

And that included SATF, I think you said? SATF and Pleasant Valley. Okay. Health Care Services Division has recently proposed

Q.

a reorganization that would designate both a director of nursing and three regional directors of nursing; if you have you have reviewed that proposal, have you not?
A.

--

Yes.

Q. Okay.

If that proposal were implemented, would it resolve

the supervision problem?

A.

I don't believe so.

And could you explain why? Yes. My concerns related to the proposed organizational

Q.
A.

structure is that the

-- there are two divisions, one is the

clinical policy division, and the other is the field management branch. And currently, the statewide director of nurses is

placed in the policy division reporting to a policy director, a clinical policy director, who is a physician. And the regional

directors of nurses are in another other division reporting to the regional medical directors. The statewide director of nurses has only indirect supervision of the regional directors of nurses, and this really doesn't make any sense to me, because if the regional director of nurses have another supervisor who is a nonnurse, then how can the statewide director of nurses really fully have control over the nursing program, the nursing resources and direct the activity of these regional directors of nursing? don't think it would work well.

Q. Would the statewide director of nursing under that plan

have any way of holding the directors of nursing, the regional directors, accountable for their failure to adequately implement out in the field?
A.

I don't believe so, since that person would only indirectly

supervise them.

Q. Did you advise Dr. Kanan about the problems with the
proposed nursing supervision model?
A.

I sent Dr. Kanan an E-mail, yes.

0 Do you recall when you sent that? .

A.

I think that it was approximately three weeks ago.

Did you receive any response to that memo? No, I did not.

Q.

A.

Q Okay. .

Based on your site visits at the nine prisons you've been to and your review of the unit health records, have you developed an opinion on the quality of nursing supervision that currently exists at the clinics that you have visited?
A.

Yes, I have.

Q. And what is that opinion?

A.

My opinion is that there is completely inadequate

supervision, nursing supervision, at the sites.

Q.

Is there any reason at which there is supervision of the

sort that you would expect to see in the prisons?

A.

No.

I would say that there are efforts being made by some

Sahar MeVicfcar, RPI?

- O f f c i a Coast Pepor-,
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U.S.D.C.

of the staff, but at an ultimate director of nurses level, I had not observed any institution where you see the kind of supervision that is really needed.

I think that the closest

institution that comes to what you would want to see would be Valley State.

I think that there's a nursing supervisor who is

making a good effort.

0.
A.

That's Valley State Prison for Women? Yes. Okay. So the nursing supervision at the prisons isn't

Q.

happening; what is happening at the prisons in terms of how are the nurses knowing what they are supposed to do?
A.

Well, I think that there is a real lack of direction.

For

example, in part, it's lack of nursing supervisor resources. For example, at Salinas Valley, for a prison of 4,500 inmates there is one supervising Nurse I1 position and three supervising Nurse I positions, two of which have been vacant. So there is only one supervising nurse for 4,500 inmates, and that person just can't get out to the clinics with sufficient frequency. At other prisons, such as Sacramento, they have six supervising nurses, they are all clustered in one office. And it's our impression that they don't know what is happening in the clinics because they don't visit them often enough. We realize when we would go out to the clinics with the nursing supervisors, there would be logs that weren't

filled out.

And it was a surprise to the supervisors that

these logs weren't being kept, which tells us that they weren't looking.

Q. Did you find that the supervisors that you did meet with
were documenting problems with their nursing staff?
A.

NO.

Q. Did you find that they were attempting to hold staff

accountable for their failing to implement tracking, for example?
A.

No.
Did you get a sense for why this documentation isn't

Q. Okay.
happening?
A.

Why the documentation is not happening?

Q. Why the nurses are not going through the process of holding
people accountable, giving them feedback and letting them know that they haven't implemented and aren't working to expectation.
A.

I think that there are a few reasons for that.

I think

that some nurses just have never been trained in supervision. They don't know how to supervisors.

I think that other nursing

supervisors are reluctant to supervise because of what I would call

--

there is not much of a culture of supervision in the

CDC institutions.

And what staff tells us is that if they try to document that someone is not doing their job, the employee will
--

Sabar M&Vickarf PER

- Official Court &porterf U.S.D. C. (415) 626-6060

go out

--

declare stress, go on stress leave and be gone from Or, they'll go there

the prison for months.

--

in the cases

where they have tried to document that their performance is not adequate, that the personnel board will reverse their decision, when efforts have been made in the past to terminate someone. And therefore, they were reluctant to go through the process of documenting performance, because it seemed rather futile.

Q. You visited Corcoran, in December, did you develop an

opinion about the nursing supervision that you saw in place at that institution?
A.

I think we visited Corcoran in March, I believe.

Q. Okay.
A.

Yes.

I did form an opinion.

Q. And what was that opinion?

A.

That the supervision was not adequate for the reasons that

I spoke of.

Q. And were there individuals there, specific people that you

saw that weren't doing their job and it was known to the staff?
A.

Yes.

There was a -- during tours of the yard clinics,

there was a nurse who was not triaging and documenting on the health services request forms, called the 7362s, that the inmates submit in order to access care. forms that were completely blank. counted 107 of them. There were numerous

I think the staff, we

In the course of just talking with the

supervisors, they said, "Oh, that's nurse so-and-so, he wasn't

Sahar MeVickar, SSR

- Official Court Reporter, U . S . D.C. (415) 626-6060

documenting in December." And

SO

And here it was March.

1f

We asked, "Mtall, what has been done?"

this nurse was known to have been not documenting at all, that he was seeing patients but then not documenting at so there was nothing in the health record. We askpr) what su~ervisiontmonitoring or progressive discipline had taken place, and they said none.

Q - YOU recently visited CIM clinic; is that correct?

A.

Yes. ~ n did you have a chance to talk to the supervising nurse d

Q.

at CIM?
A.

Yes, I did.

Q. And what did he or she tell you about supervising there?

A.

I asked the supervising nurse how she saw her role as a

supervisor, and she indicated that it was to supervise her supervising nurses. And then I asked how she knew that the supervising nurses were doing what they are supposed to be doing, and she indicated that she goes out to the clinics to check, but when we went out to the clinics to check, her presence didn't appear to make a difference if she did go to the clinics. For example, in the reception center, the clinics were disorganized and very messy. And she did not see it as

her role, in my discussion with her, to actually get out there and direct the staff and check and See that they are doing what

w -via=,

- Wficial
(415) 626-6060

m-,

U-S=J3-c=

they are supposed to do.

Q.

And when you went to CSP Sacramentot did the supervising

nurse there impress you as somebody who had her clinics under control?
A.

When we went to an ad seg areat the supervising nurse came with us. And there was another

NO! she didnlt.

supervising nurse with ust and when we walked into the clinict she was overheard to say, "Where is the clinic? where is the exam roomtl' which told us that she did not know where it was and thereforet wasnlt checking it to see if it had all the equipment it needed. Was it clean? Was the nurse doing what

he or she is supposed to be doing?

Q.

When you went to San Quentin! you also met with the

supervising nurse there; is that right?

A.

That's correct.

Q. And what was your impression of the supervising nurse, his

ability to supervise at San Quentin?

A.

Nonexistent. And why do you say that? Wellt 1 based it primarily on what he told met which is

Q.
A.

that his opening statement was that he was overwhelmedt disorganized and couldnlt get anything done. When I spoke with him further about his statement! I And he asked himt "Do you ever get out into the clinic^?'^ saidt "Not I never go.'' And 1 asked himt "How do you know

SO he did not see his role

as to,

A, define the

?xpectations of the supervising nurses; and B, to monitor their

~erformance to see if they were following through.

And the result was we learned that face-to-face

ursing triage was not happening, and he was not aware of it.
I.

Did you see problems at San Quentin that revealed the lack

supervision had created a health crisis at that prison?

1.

Yes.
And can you elaborate on that at all?
Yes.

2L.

At San Quentin it was really quite remarkable. When

de

arrived at the facility, the staff reported to us that every And patients Were not being brought for

system was broken.

clinic appointments. Staff were not conducting face-to-face triage. Forms of inmate health requests that very likely stacking up. contained inmates who had serious illnesses

capacities?
A.

he only time I've observed in my career nurses refusing to

carry out physician orders is when they had a belief that the order was dangeroust and then they had a responsibility to question the order. Other than that, nurses should carry out physician orders. Q * Did you see any indication that the nurses felt that the doctors were making dangerous orders?
A.

I did not have any information to suggest that. Okay. If they had been refusing to implement orders the

Q.

doctors had made because they believed they were dangeroust would you have expected to see some documentation of that?
A.

I would have expected the nurse to report it to a

supervisor and then some documentation in the record as to what alternate strategy the nurse took, who she talked to, what steps she tookt he or she tookt to address the nurse's concern that an order may have been dangerous*
Q.

Are you familiar with the policies and procedures?

THE COURT:

Excuse met Counsel.

I 1 m just curioust whatt is itt anarchy? Heck with you doctorst we do our own thing? What did you conclude?
WImSS:

Your Honort all we know is that the For example! there

nurses were refusing to carry out orders.

Sahar I k V i c k a r ,

RPR

- Official Court w t r U.S.D. C. re ,

(4l5) 626-6060

Labbrre

- Direct / Hardy

281

was a patient in the OHU at San Quentin who had dangerously high blood pressure, and the doctor ordered a STAT medicationt ordered blood pressure checkst the nurses just didn't do it.
COURT:

Okay. Sorry.

Go onf Counsel.
W . HARDY:

That's okay.

BY B S . HAIWY:
Q.

Ms. LaMarret are you familiar with the policies and

procedure requirement that requires the supervising nurses to review a certain number of unit health records to ensure that face-to-face triage is happening?
A.

Yes.

Q. Have you ever seen this provision actually implemented at

any of the institutions that you have been to?
A.

No.

Q. Okay.
A.

Most oftenl it's the supervising nurses or the nurses

themselves had not fully implemented the process in many casesl so there wasn't much to review. And in other institutionl it just wasn't happening.
Q.

When you visited the institutionst have you gotten the

sense for who is actually supervising the medical technical assistant

--

actuallyf I would like to back up.

Can you explain what a medical technical assistant

is.
Sahar &Vi&ar,

RPR

- Official Cbu~t
(415) 626-6060

U.S. D, C.

A.

A medical technical assistant is an individual who has a In other And these

license as a licensed vocational nursel an LVN.

states it is a known as a licensed practical nurse.

individuals administer medications and treatments. And the medical technical assistant is also a member of custodyl so wears a uniform and a badge and is an officer.

Q. At the prisons that you have been tol who supervises the
MTAs?
A.

Well, practically speaking

--

welll let me back up.

On paperl the nurses are supposed to supervise the MTAs, but for all intents and purposesl the nurses do not supervise the MTAs. And in some cases

-- and actuallyl in some

cases the organizational structure differs institution to institution. But the bottom line is that for health care

purposes nobody supervise the MTAs.

Q. And how do you know that?
A.

Staff reports that to us, that the nurses say they have no The MTAs refuse to do

control over the performance of MTAs.

certain thingsl and then the nurses are powerless to do anything about them.
Q.

Are the MTAs primarily responsible for delivering

medications to prisoners?
A.
Q.

Yes. And so when you were in the clinics or at the institutionsl

did you observe that there were any problems with getting the

Sabr MzViekax, RRR

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U.S D. C. .

medications to prisoners who are sick?

A.

In

--

yes.

In reviewing some of the medication

administration records, we noticed that some of the spaces were blank, completely blank. So there was a lack of documentation There

as to whether or not the patient got the medication.

were problems with medication renewals, and MTAs paying attention to when this medication might expire in order to obtain a valid order from a physician, and problems with lack of documentation of signatures on medication administration records.
Q.

And so if there were someone supervising the MTAs, these

are issues that you would expect to be addressed; is that right?

A.
Q.

That's correct. But since there was no one supervising them, as far as you

know, these problems just continued?

A.

That's correct.

Q. And did you see these problems with frequency?

A.

Yes.

Q. You mentioned that some prisoners weren't able to get

renewals of medications in some of the files based on your review; is that right?
A.

Yes.

Q. And are those prisoners who had chronic illnesses?

A.

Correct.

Sahar &Vickar,

RPR

- ~~ Cbu&
(415) 626-6060

Rep*,

U.S D. C. .

IaMarre
Q-

- Direct /

Hardy

How do the policies and procedures, how are they

constructed to ensure that prisoners with chronic illnesses do get the medications as intended?
A

Well, there are several points from the time the inmate

arrives in the system in order to provide continuity of care with respect to medications. process. The first would be at the intake

Medications are identified as being prescribed for

the inmate, and at that point, a prescription should be written timely and delivered to the inmate. At the time the inmate is transferred from one point to another, a supply of medication should be sent. And then when the inmate gets to the receiving institution, there should be a review of the record to make sure that these chronic medications are continued. Once the inmate is at the prison, the inmate should be enrolled in a chronic illness program where the physician sees the patient periodically and with each clinic visit adjusts or renews the medication that he or she deems appropriate.
Q.

Based on your review files that you saw, do you believe

that the chronic care policies are functioning as they are supposed to?
A.

No.

Q. And so the chronic care policies have not been implemented

at all of the prisons?

Sahar ~ V i c k a r RPR ,

- mficial ChuA Reporter,

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U.S. D.C.

A.

That's correct.

Q * Do prisons typically have chronic care programs, or is

California on the forefront in creating the chronic care program?
A.

No, they are not on the forefront.

In the state where I

came from, Georgia, we have had a chronic illness program for over ten years. And other states have chronic illness programs that are being put into place. And these systems do have some

mechanism for seeing these patients.

Q. Let's circle back to nursing supervision issues.

You have testified that there is an absence of nursing supervision at many of the prisons that you have been to, do you believe that this lack of nursing supervision has resulted in harm or death to patients?
A.

I do believe it has resulted in harm and death to patients.

Q. And can you elaborate on that?

A.

Well, for example, the implementation of the face-to-face

and urgent care protocols is a key part of Plata and access to care. For example, at SATF there was an inmate complaining of

diarrhea, not being able to keep food down, and losing weight. And the nurse did not appropriately refer the patient, determined that there was a need to refer but scheduled it for a week ahead. And the patient came urgently two days later and was hospitalized and then later died of acute renal failure.

Sahar W V i c k a r , RPR

- Official &urt
(415) 626-6060

Reporter, U.S. D.C.

Whether or not an earlier referral could have saved the patient's life is unknown, but the fact that the nurse did not recognize the urgency of the referral meant that this patient did not get timely care. THE COURT: If there had been a referral, are you

talking about to a doctor?

THE WITNESS:
BY MS. HARDY:
Q. Are there a few prisons where the face-to-face triage

Yes.

program is starting to be initiated where nurses are actually seeing prisoners and doing assessments?
A.

Yes. And you have developed an opinion on the quality of

Q. Okay.

those assessments that you have seen?

A.

Yes.

Q. And what is your opinion?

A.

That they are not adequate.

Q. And why is that?

A.

Because in many of the prisons that the nurses are starting

to conduct the assessments, there is, for example, the inmate may complain of dizziness and headache, but the nurse doesn't take vital signs. The patient may complain of abdominal pain, but the nurse doesn't conduct an examination. So the assessment process is not adequate. And the second part of it is that the face-to-face

Sahar MbViefcar, REV.

- Official Court Seporter,

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U.S. D.C.

protocols call for the nurses to have the ability to administer over-the-counter medications, in accordance with the nurse's assessment of what the problem is. So for things like

athlete's foot or a common cold, the nurse would have the capacity to assess the patient and then administer the medication. But that component of the protocols has never been

fully implemented at any of the sites.

Q.

Do patients suffer harm if they are inadequately assessed

and they don't get these medication?

A.

If they are inadequately assessed and don't get the

appropriate treatment, they are harmed.

Q.

Okay. At the prisons you visited, you've reviewed vacancy

reports for nursing, haven't you?

A.

Yes. And do some of those prisons that you have been to have

Q.

staffing shortages for RNs and MTA positions?

A.

Yes, they do.

Q. Which prisons; do you recall?

A.

Salinas Valley is probably the most severe with th

rates. And I'll include MTAs and RNs, between 70 and 80 percent, 80 percent for the RNs, 70 percent for the MTAs. At

Pleasant Valley, approximately 50 percent vacancy rates for nurses and MTAs. At SATF, I believe the vacancy rates were in

the 40 percent range, so significant vacancy rates.

Sahar McVickar, RPR

- Official Cbu&
(415) 626-6060

Reporter, U.S. D. C.

Q.
A.

Do you have an opinion why those vacancies exist? Yes.

Q. And what is that opinion?

A.

It's not one reason, in and of itself, but a major reason Levels at the CTC are inadequate.

is compensation.

Q.

Are you familiar with a study called the CPS study that was

submitted to the CTC in November of 2004?

A.

Yes, I am. You have read that study?

Q. Okay.
A

Yes.

Q. Do you believe that that study was adequately constructed?

A.

Yes.

Q. What did that study conclude?

A.

That there were moderate to substantial compensation

issues, problems, in the CDC.

Q.
A.

Do you recall what those discrepancies were? I believe that statewide, generally, there was at least a

20 percent statewide lapse in compensation, that it was higher

in some geographic areas, up to 40 percent, and for some supervisory position even higher, 45 percent, you know, lapses in compensation.
Q.
A.

Do you know why the CDC contracted to have that study done? My understanding was that the
CDC

contracted because they

did have serious problems recruiting staff, and there was an effort to try to get

--

obtain the documentation that would

Sahar M=Vickar, RPR

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U . S . D. C.

justify to the DPA and other State organizations to increase the salaries.

Q. You mentioned the DPA, what is that?

A.

The Department of Personnel Administration. And they are the ones, if you know, they set the salaries?

Q.
A.

I'm not intimately familiar with California State

government, but it's my understanding that they bargained with the unions, and they establish the salaries.
Q.

Did DPA use that study to bargain with the unions? Not to my knowledge. We were informed that when DPA saw And they

A.

the study, they decided that it wasn't accurate. decided to conduct their own study.
Q.
A.

Do you know if they have concluded that study?

I believe they have.

Q. Do you know what their conclusions were?

A.

The conclusions were that there really was not a

significant salary discrepancy between State and community salaries, and that the State should consider other reasons why there might be recruitment problems in the CDC.

0 Do you know if the RN salaries have been raised for CDC? .

A.

To my knowledge, they have not been raised.

Q.
A.

Is it easy to hire RNs right now, anywhere?

No.

I think it's common knowledge that there is a national

nursing shortage, and competition for nurses is very high.

Q. So if the CDC is paying, based on the CPS study, which you

competitors, depending on geographic areas, they are probably not competitive in the hiring game, are they?
A.

No, they are not.

Okay.

Q.
A.

And as Dr. Puisis mentioned yesterday, the result is that

the CDC has to hire registry staff, paying a lot more money than they would pay if they had a State employee that they hired on staff.

Q.

When you talk to staff out in the field, do they believe

that they are getting paid adequately?

a.
2.

No. What have you heard from staff in the field?

1 Well, just that .

--

their frustration at not being

adequately compensated, and their desire to be adequately compensated, because some nurses really like their job, want to stay, but it's frustrating.

Q. And for those nurses who are charged with hiring other
Turses, have they told you how sncountered?
A.

--

the obstacles they have

Yes.

Q. And those obstacles have to do with pay?

A.

Absolutely. Does the CDC have the flexibility to increase pay for R N s

Q.

at those prisons where the vacancy rate is highest, for

Sabar MBVickar, SER

- Official Qmct Reporter, (415) 626-6060

U.S.D.C.

example, at Salinas Valley?

A.

Would you repeat that? Did the CDC have the flexibility to increase pay at

Q.

specific institutions where the vacancy rates are particularly high?

A.

I don't believe they do.

I think there is a mechanism

called "Recruitment and Retention Bonuses," but I think there is a bureaucratic process that has to be gone through and approved before that can take place. consider that flexibility.
Q.

So it's

-- I would not

In terms of other things that contribute to the nursing

shortage for the CDC, do you believe that their hiring process impacts their ability to hire and retain RNs?
A.

Yes.

Q. And why is that?

A.

Well, as with the physicians, the hiring process needs to When staff or nurses in the community are

be very efficient.

interested in a position, when they call or try to contact the CDC, that someone responds timely to them, demonstrates that, yes, we are interested in hiring you and that, you know, that it's a fairy rapid process because the competition is so great.
Q. And what about promoting within the CDC?

Are there

barriers to getting nurses placed in supervisory positions?

A.

Yes, there are. At many of the prisons we visited, staff are in an

Sabr

McVickar, R

- Official Cburt Reporter,

(415) 626-6060

U.S D.C. .

--

acting capacity.

In some prisons, everybody is the acting And the

nurse, the acting senior MTA. those capacities for months.

--

and they will be in

And what we learned is that in order to get promoted, the staff member has to get put on a list. order to get on that list, they have to take a test. But in But the

test may not be offered but every six months or every year, so they remain in the acting capacity. Which I think the staff, in fact, expressed to us, they said, "At Pleasant Valley, someone doesn't want to be listening to us, they say, 'Well, you are going to be leaving. You are not permanently in that position, so I don't really have to listen to you.'" And it's

demoralizing to staff who are staying at the prison, this inability to promote in a timely manner.
Q.

If you can't promote within the institution you are in and

you are gaining skills, are you likely to stay, stick around?
A.

It definitely negatively affects retention.

Q. Okay.

You said that the prison does backfill some of these positions with registry nurses, isn't that good enough to have a body in those positions?
A.

No, it's not good enough to have a body.

One needs to have

someone who is trained in the policies, invested in the success of the institution. And staff reported to us the difficulty with trying

~-

to conduct and keep the registry staff trained in the nursing policies and protocols, particularly the face-to-face protocols, and the difficulty in sort of engendering their support for compliance with the policies, because the nurses can just go from one prison to another, or one facility to another.
THE COURT:

Let's find a convenient spot. This is actually fine. Is this okay? Yeah. Okay. Let's take our first recess for

MS. HARDY:

THE COURT:
MS. HARDY:
THE COURT:

15 minutes. The Court is adjourned.

(Recess taken at 10:18 a.m.) (Proceedings resumed at 10:39 a.m.)
THE COURT:

You may proceed when you are ready,

Counsel.
MS. HARDY:

Thank you, Your Honor.

DIRECT EXAMINATION, CONTINUED

BY

MS. HARDY:

Q. Ms. LaMarre, under the policies and procedures, primary

duties of the RN are to do face-to-face triage and provide nursing care according to the nursing care protocols; is that right?
A.

Correct.

Sahar M k V i c b r , RER

- Of..icial

Court Reporter, U.S.D. C.

(415) 626-6060

LaMarre

- Direct /

Q. What type of exam area does a nurse require in order to

perform those duties competently?

A.

A nurse, like any health care provider that is conducting

an assessment, physical assessment, needs a room of adequate size, and lighting, adequate lighting; that is private, that has auditory and visual privacy, and it is adequately equipped and supplied and that is kept clean.
Q.
A.

So you need to have hand-washing access? Yes.

Q. Okay. And have you observed the areas in which nurses are
doing face-to-face triage at the nine prisons that you've visited?
A.

Yes.

Q. And in your opinion, has the CTC ensured that the nurses
are afforded exam areas that are adequate to permit them to fulfill their duties under the policies and procedures?
A.

No.

Q. What is the basis for that opinion?

A.

Our tours of the prisons in which nurses are provided

anything from a broom closet to conduct their assessments to conducting assessments out in the hallway without visual or auditory privacy, without access to medical equipment and supplies, without ready access to hand washing. And in some

prisons where they have been given a room to conduct it, they're not adequately equipped and supplied.
Sahar

mvickar, RER

- O f f i c i a l Court Reporter,
(415) 626-6060

U.S.D.C.

LaMarre

- Direct /
-

Q - Could You describe some of the problems you saw at

San Quentin?
A.

Yes. The nurse was in the Donner unit -- I think the

Donner unit was most disturbing

-- where this is a five-tier

cell block, and the area that was designated for the nurse to conduct sick call was at the end of a long tier, through locked gates, through the men's showers. And there was a room that

was designated as a clinic that did not have an examination table. The furniture was broken. There was no sink, not a

shred of medical equipment or supplies. And the nurse did not have access to the health record. This is the area where the nurse was expected to conduct sick call. And on the day that we toured, as I went with a group of people down this tier, there were 20 naked men, at least 20, I didn't count them all, showering as we moved through to get to the clinic. And it was just a humiliating and degrading situation for any health care professional, much less not being able to have the equipment and supplies that you need to conduct the examination.
Q.

So working conditions that will require you to walk through

a shower while it's being used by a bunch of naked men would

probably make it harder to hire nurses, wouldn't it?

A.

No question. Okay.
&hr MkVickar, RPR

Q.

- O f f i c i a l C b u r t -, (415) 626-6060

U.S D. C. .

UMarm
-

- Direct

Pleasant Valley, can you describe the facilities that were used by the nurses to do face-to-face triage at that prison?
A.

The nurses were conducting face-to-face triage in the

hallway at a small desk, out in the middle of the

-- in the

hallway where officers and inmates trafficked back and forth.

Q.

Is it possible to get an accurate patient assessment when

you don't have any privacy?

A.

The likelihood of getting it is extremely low, you are not

going to be able to get a thorough history, you are not going to be able to conduct an adequate examination. possible. It's really not

Q. In your experience in correctional medicine, do you think

it's likely that a prisoner who has HIV is going to disclose that kind of information in a nonprivate setting?
A.
Q.

Probably not. Okay. Is it possible to do an adequate exam of a prisoner

if you are doing it in a hallway without an exam table?

A.

I don't believe so.

Okay. What did you see at Salinas Valley? What conditions

Q,

did the nurses have to deal with at Salinas Valley?

A.

The rooms were

--

the sanitation was striking at how, you Staff reported they had
The

know, how poor the sanitation.

difficulty getting inmate porters to clean the clinics.

Sahar McVickar, RPR

- O f f i 626-6060 Reporter, c i a l Court (415)

U.S D. C. .

rooms were not adequately equipped and supplied.

Q. You have described that some of the facilities, including

San Quentin and Salinas Valley, were dirty; is that an aesthetic problem?
A.

It's not just an aesthetic problem.

It's certainly not

conditions you want to work in, but in addition to that, it presents an infection control threat, threat of transmission of communicable diseases, when the clinics are not cleaned, the countertops are not disinfected. You have inmates with infections, such as methicillin resistant staph aureus, MRSA, coming into the prisons. And if the exam tables and the

countertops are not properly sanitized, it increases the risk of transmission to other patients and staff.
Q.

In your review of the clinics that you went to and the

prisons that you went to, did you see that MRSA is a problem at some of the prisons?
A.

Yes.

Q. Okay.

Did any of the clinics that you visited have any schedules for doing cleaning or sanitation?
A.

None that we visited.

Q. And so to the extent that they are clean, who is keeping

them clean, do you know?

A.

The institutions have inmate porters which are inmates --

this is their job, to clean the clinics, but, unfortunately,

Sabr W V i c k a r , RPR

- ~~ &urt
(415) 626-6060

Rqwrter, U.S.D.C.

the frequency of the inmate porter cleanings vary greatly. At institutions that had frequent lockdowns like Salinas Valley the inmate porters might not be there for weeks. At Corcoran because the inmate porter, through lack of correctional officer supervision, got into trouble and was taking things, they

--

the custody just took the porter away

from the clinic, said, okay, he's gotten into trouble, we're going to take him away. no one to clean. He wasn't replaced, and so there was

Q. You've visited a lot of prisons outside of California and

in the Georgia prisons, is it a common problem to have dirty clinics?
A.

Not in my experience. And to the extent that there are

unsanitary conditions, it's a problem that should be addressed.

Q.

Did you find that the clinics that you went to had the

supplies necessary for the nurses to do adequate treatment or to even wash their hands?
A.

No.

Q. And can you explain that?

A.

We observed and staff reported great difficulty in

obtaining basic supplies. And in some prisons -- such as hand towels, and soap. SATF would be an example where the staff

reported they couldn't get paper towels to alcohol swabs and gauze.
At our most recent visit to CIM, staff reported that

Sahr B&Vi&arf

RPR

- CEfZcial Cburt Rqporterf

(415) 626-6060

U.S.D.C.

the business -- the business office was calling them, asking them why they needed to have these Foley catheters and shower chairs.
Q .
A.

Is there something you can substitute for a Foley catheter? No, no. So the clinics did not have what they need to

provide basic medical treatments. And it was a great concern to the court experts that staff reported that there was delays by the business office in obtaining supply requests.
Q. Who's in charge of these clinics when you are out there?

Who should be making sure that these supplies are there and that exam tables are there, for example?
A.

Well, in my opinion, my observation, there is really no one

in charge.

I mean, I know what would happen in other systems,

I think the nurse would be in charge of most clinic operations, but there really is no one in charge. Everybody who works in

the clinic, the MTA, the office technician, the nurse, all have different lines of authority, they report to different people, and if something

-- if the

OT, the office technician, doesn't

want to do something, the nurse is not empowered, really, to say, "You will do that," and so it didn't get done. And staff reported to us frequently infighting and conflict about who will do this or do that, including ordering the supplies.
Q. And so there was no person that everyone recognized was the

Sahar McVickar, SPR

- 0 Court -rter,
(415) 626-6060

U.S. D. C.

person that could delegate authority to make sure things were done?
A.

Correct.

Q. Was that just a problem at SATF?

A.

No, that was virtually at all the sites. Did the nurses have the tools that they needed to assess,

Q.

such as otoscopes and ophthalmoscopes?

A.

Those often they did not. Did they talk to you about why that was and what efforts

Q.

they made to get these tools?

A.

In some cases, they reported that it had been requested but In other cases, they reported that they had ordered

denied.

it, but it hadn't come yet. At Salinas Valley, that was an '03 rollout site. When we were there in January of this year, they had only the last month ordered the equipment. I mean, they were supposed

to have rolled out the policies in '03, and here it was December of '03, and they hadn't even ordered the equipment for the nurses to do their job. So there were a variety of

reasons, including delays, modification, cancellation of purchase orders by the business office in getting what they needed.
Q.

Is it possible for the nurses to follow the nursing

protocols that they are supposed to follow if they don't have basic tools, such as an otoscope and ophthalmoscope?
Sahar MzVickar, RRR

- OBZcial

C w Reprter, U . S . D.C. b A (415) 626-6060

A.
Q.

No. Could you describe for me the purpose of screening, health

screening at the reception center?

A.

The purpose is to identify health care problems and develop

an appropriate treatment plan that hopefully would serve as a blueprint for the inmate's stay in CTC. That is the place

where you would want to identify the existing problems and also identify risks of other problems that you would want to prevent.

Q. So it also has a public health component?

A.

Yes, it does.

Screening for tuberculosis would be one

aspect.

Q. Okay.
How many reception centers have you visited?
A.

Three.

Q. And those are?

A.

San Quentin, CIM and Valley State Prison for Women.

Q. Did you have an opinion as to the adequacy of the reception

screening as it exists at those reception centers that you visited?

A.

Ido. What is your opinion? That it's completely inadequate to identify and treat the

Q.
A.

health care problems of newly arriving inmates.

Q.

Could you describe why at CIM the process isn't working to

Sahar MbVickar, RRR

- Official Court Reporter,

(415) 626-6060

--

U.S. D.C.

---

--

--

-- -

do what it's supposed to do?

A.

I think that it begins with the MTA, the process at CIM

begins in a security, a controlled area, it's called reception and release. And in this area, an MTA has a desk that is right next to a holding tank for inmates. And at this desk, the MTA obtains a set of vital signs. There is an inmate who fills out a TB screening form, the identifying information, but also asks the newly arriving inmate, "Have you ever tested positive before?" So

you have an inmate asking another inmate confidential medical information, which should not be. If the inmate discloses any

information to the MTA, it can be overheard by all these other inmates in the holding tank.
Q.

So yesterday Dr. Puisis described sort of a confessional

booth where the nurse and the prisoner meet at the reception center at the CIM and the nurse does an assessment; is that before that process begins?
A.

That's correct.

Q. Okay.
A.

Then the inmate moves on to the booth where he is As Dr. Puisis has described, it's

interviewed by the nurse.

not optimal, because one of the things the nurse is supposed to do is observe to the inmate for any signs of illness, diaphoresis, or sweating

--

Q. Could you define diaphoresis?

S a b r &Vi&ar,

RPR

- Official C W r t Reporter,
(415) 626- 6060

U.S. D.C.

A.

Sweating.

Q. Okay.
A

Is he underweight? A general observation, did he look So that that nurse might ask a few more probing

depressed. questions.

But there is a metal grate and a Plexiglas scree between the nurse and the patient that I think discourages that observation process. And it's

--

I find it really

depersonalizing and not a process that would elicit information. And given the volume of patients coming through

--

and I was told by the senior MTA that there are approximately 2500 inmates a month who come through CIM, about 125 inmates a day on average. As Dr. Puisis has said, it can be more or less. And this occurs over a 16-hour period. And when the bus

loads come in, it's very rushed. And, therefore, it does not encourage an adequate screen. Following that, again they go to a mental health area for a mental
Q.
A.

--

Can I stop you for a second? Yes. Have you seen that kind of setup at any other prison

Q.

systems that you have ever worked in?

A.

No, including at other CDC facilities. We do not see this

booth arrangement. We were told that it was for two reasons.

Initially, we were told it was for security reasons because the nurses were apprehensive, and they didn't know who was coming in the front door. Later we were told it was part of the Coleman settlement to provide confidentiality. But that could easily be done across the hall in offices like where the mental health staff are, which are very neat, clean, confidential. And, as a matter of fact, the inmates go right across the hall minutes later to meet with the mental health staff. And there is no screen. It's not the same arrangement.

It's more professional, more humane, and I think designed to more likely get true information.
Q. Okay.

And then after they finish with the nurse in the

booth, they move on to see the physician, in most cases?

A.

I think they have a two-minute dental screen, first, is

what was reported to me, and then they have the exam with the physician.
Q. Given that they are getting 125, sometimes 180, I think we

have heard, prisoners a day, are they able to get through all the physicals in one day?
A.

At the time of our visit, they reported they were not able

to get through most of the physicals each day.

Q. And did you hear that custody sometimes moves prisoners out

of the reception center before the screening physical process is completed?

--

A.

Correct. Can you tell me what the impact would be on that screening

Q.

physical process?
A.

Yes.

I mean, it's a problem because the point of the

reception process is to identify medical problems, including diseases like

--

diseases that are communicable like If the inmate is

tuberculosis and syphilis and other diseases.

transported to another area of the facility, that inmate may expose other inmates and staff to a communicable disease. What we observed also, though, is that when custody was moving inmates to other parts of the institution, they were lost to follow-up. For example, I looked a chart of an inmate

with medical problems that didn't have his intake physical for five weeks after arrival. Jackie Clark, the other nurse

accompanying us, found other charts where inmates were not getting their intake physicals for several weeks. So inmates are not receiving timely evaluations. And if they need care, they are not receiving timely care.

Q. Do you recall whether any of those that you and

Jackie Clark found that had not had timely physicals were on medications when they came into the
A.

--

Yes, the chart I reviewed, the inmate gave a history of

high blood pressure and high cholesterol. And his high cholesterol medication was not renewed at that time.
Q.

What is

--

is that likely to have harm or cause him harm?

Sahar McVickar,

PER

- Official Coast Reporter, U.S.D.C.

(415) 626-6060

--

A.

Untreated high cholesterol, untreated high blood pressure

can cause harm, can lead to heart disease.

Q.

Do you think that the assessments that are done on the

prisoners are catching the people who have very serious illnesses and require immediate attention?
A.

I don't believe that the evaluations are adequate.

Did you find any cases where prisoners with serious

Q. Okay.

conditions were not detected in the screening processes as you would expect them to be?
A.

Yes.

Well, what I detected was that there was a case of an

inmate who was evaluated at intake, the physician identified medical problems, but did not prescribe any -- and he had serious medical problems, such as cirrhosis. And, obviously, from the notation on the record, had swelling of his ankles. There was no further test ordered, no further treatment ordered, no further medical appointments or follow-up ordered, and three days later the inmate collapsed in his cell block

-So

collapsed in his housing area and was hospitalized in the acute care hospital, where he remained at the time of our visit. he had been there about three weeks. So he had a serious

medical problem upon arrival for which there was no plans for follow-up made at that time.
Q.

And you would have expected to see that the inmate was

referred to the physician fairly expeditiously given his symptoms?

Sahar WVickar, SPR

- Official Coast &porter,

(415) 626-6060

U.S. D.C.

IaMarre
A.

- Direct /

Hardy

Given his disease, yes.

Q. Okay.
A.

Particularly given that CIM does not have a chronic illness So the question is how would he

program in place at this time.

have been followed up if the physician made no other orders for him to be followed up? Incidentally, another physician I spoke to, I actually discussed this case with the emergency room physician about the fact that there were no orders or lab tests, and he told me, "I never order lab tests when I'm doing physicals, because they won't get done." And he said, "If they get done, we won't get the lab results back because of the filing problems, " etcetera.
Q. So what is the point of the physical, if you can't provide

any treatment?
A.

Well

--

Q. Okay, it's rhetorical.

A.

It's important that the CDC develop a process by which

there is an adequate history, an adequate examination, that an appropriate treatment plan is developed, and that there is adequate follow-up in a timely manner.
Q. Okay.
T H E COURT:

Can you define or describe an adequate If you were to control

examination intake in terms of time?

this, would you be able to say it has to take at least 10

Sahar -Vi&ar,

RPR

- ~ f i c i a &urt l
(415) 626-6060

Rqporter, U . S . D . C .

minutes, 20 minutes, half an hour, and it has to incorporate these elements? Is that doable?

THE WITNESS:

Your Honor, I think the length of time

that it takes to do an adequate history and physical in part depends on the complexity of the medical condition of the patient.
THE COURT:
THE WITNESS:

Urn-hmm. As with a very young population, an

adolescent population, the history physical might take 15 to 20 on a young healthy person. But in the prison system we

estimate, you know, 20 to 30 percent, at least, of inmates have serious medical illnesses. And in Georgia, our experience at the diagnostic center is our staff take 30 to 45 minutes with inmates who have complicated medical problems. And they are expected to take a history. a medical history form. The CDC has a medical history form that they are not using, so if you don't inquire about, you know, risk factors for heart disease, presence or absence of chest pain, you are not going to get
I mean, they are not even filling

--

you are not going to be told that.

So I would expect for complicated patients, 30 to 40 minutes on the first encounter. And if the volume were such that you couldn't get it all done in a single day, you schedule a follow-up, a follow-up visit.
THE COURT:

But that is not taking place.

You mentioned a moment ago that they see

Sahar MsVickar, RPR

- O f f i c i a l Court Peporter,
(415) 626-6060

U.S.D.C.

2500, roughly, a month. THE W I T N E S S :

THE COURT:

That's what was reported to me. Do they do this every day, so that if I

divide 30 into 2500 that comes out to be about 83; would that be the average per day?
THE W I T N E S S :

Your Honor, I ' m not sure

-- I

understood it was reported that they take people in seven days a week, but that was not my understanding.
I was sort of

basing it on sort of five days a week so I cannot speak to that. But the staff reported to us that they get anywhere

from, let's say, 80 to 90 to 150, that it varies because they have buses that come in at varying points throughout the day. And the process is a 16-hour period from 8:00 in the morning till 10:OO o'clock at night, they don't receive inmates from 10:OO at night till 6:00 in the morning. throughout the day they receive inmates.
THE COURT:

So it's

Okay.

Sorry for that interruption.

B Y M S . HARDY:

0. Okay, at San Quentin you also observed the intake process

in the reception center?
A.

Correct.

0. Could you describe that process for us.

A.

At San Quentin, the reception process took place in a large

- - D h t / w

room that had several stations and cubicles. And it began with nurses who did do an initial interview to take vital signs from the inmate. They sat at two separate desks in close proximity Following

to one another, so there was no auditory privacy. that, the inmates were

--

had their physicals in one of a

series of cubicles where the physicians conducted physical exams. The cubicles were approximately four feet by five feet. They were extremely small, barely enough room for an

exam table and to be able to turn around in the room, and were not well equipped or supplied. There was no access to hand-washing in these cubicles. And I saw no sanitizing gel in them. And the dentist had a chair in the -- immediately adjacent to the inmate waiting room where the inmates got into the chair and the dentist had a light and a tongue blade, and he did his oral examination right there in the middle of the inmate waiting room, for all intents and purposes. And he was gowned and gloved but did not wash his hands between -- change his gloves or wash his hands between patients.
Q.

And again, the nurse had absolutely no privacy to ask

sensitive, confidential medical information; is that right?

A.

Correct. Okay. And so did the prisoners who are getting exams in

Q.

these cubicles have sound privacy?

Sahar MbVickar, PER

- Official Court importer, U.S.D.C.

(415) 626-6060

Qe

Okay. Are you familiar with the policies and procedures as

they set forth a process for physician referral to specialty care that requires utilization management nurse?
A.

Yes. And in your understanding, the referrals have to be

Q.

reviewed by the UM nurse?

A.

Correct. What is his or her role in that process? To determine whether all the appropriate information is

2.
1.

here, whether there is adequate clinical information contained

3n

the referral request, and to basically approve it, so to

speak, and schedule it, and then pass it on for scheduling.

3.

Okay.

And so, typically, at the institutions you've been

to, does the UM nurse work fairly closely with the scheduler?
A.

Yes.

Q. And is it your understanding that UM nurses are supervised

by Central Office?
A.

That's my understanding.

Q. Okay.
And under the policies and procedures there are prescribed timelines for when referrals need to be accomplished; is that correct?
A.

That's correct.

s&ar MzVidcar, RE?R

-(415)

R e p o m , U*S*D-C.

626-6060

Q.

You recently visited Pleasant Valley and evaluated the

specialty refer process at that prison?

A.

Yes.

Q. Could you describe what you found?

A.

I found serious problems with the

--

with access, timely

access to consultations.

The problem was that there had been

scheduling clerk prior to our visit who apparently just allowed the scheduling process to fall apart. disorganized. It was very

And there was a new scheduling person appointed

that was trying very hard to get caught up and schedule things, appointments timely. The problem was that I found a series, through chart review, a series of charts in which there was greatly extended delays for very serious medical problems that were not being attended to.
Q. Could you describe some of those problems?
A.

Yes. There was one patient who had chronic ear infections

and also had mastoiditis, which is an infection of the bone that could lead to a possible brain abscess. When the patient was initially seen, I think two and a half years ago, the ENT doctor requested follow-up in three weeks, and then the patient was lost to follow-up for two years. There was another patient with abdominal pain who lost 30 pounds who was to be evaluated by a GI specialist for a
Sabr MkVickar, RPR

- Official &u&
(415) 626-6060

w t r U.S. D.C. re ,

potential malignancyl it had been over six months and he had not been evaluated yet. There was a case that Dr. Puisis described yesterday that I found in which an inmate had reported abdominal pain for which a colonoscopy was requested in June of I03

--

I'm sorryl

in August of '031 and that colonoscopy was not performed until June of '04. By the time the colonoscopy was performedl the mass in his colon was so large that the scope could not be passed through and it turned out to be cancerl and he had to have surgery and a colostomy. So there are some very, very serious

problems for which patients were not being followed up.

Q.

Based on your reviewl did it appear that this was a problem

of recent origin or that it had actually been a problem for some time?
A.

It had been going on for some time because there were

consultation requests that were requested as far back as December of '03 and in the early part of ' 0 4 for which appointmentsl to this dayl had not been scheduled*
Q.

Did you see any indication there that the prison

--

at the

prison or did anyone communicate to you that this problem had been communicated to Central Office?
A.

No. Okay. Have you ever

Q.

--

since you made your reportl which I

believe was filed in April with the Court

S a b r WVickar,

--

RPR

- CEficial &urt
( 4 s ) 626-6060

Zkporter, U.S. D.C.

A.

Yes.

Q.

-- have you received any response about those problems from

Health Care Services Division?

A.

No.

Q. The failure to provide that kind of specialty care could

have resulted in harm or death to those patients; is that right?

A.

Yes.

Q. Okay.

Do you have an opinion as to whether the CTC adequately ensures that medical care is provided to inmates without interference from nonmedical custody officers?
A.

Do I have an opinion? Yes. Yes, I do.

Q.
A.

Q. And whatls your opinion?

A.

That there are a number of occasions in which medical is

interfered with by custody.

Q. What do you base that on?
A.

During our visits to the prisons! staff reports! personal

observations.
Q. Can you recall any instances?
A.

When we visited San Quentin, and this was included in

Jackie Clarkls report! there was a patient in the OHU that was suicidal and under suicide precautions.
Sabr &Vicbr,

And there was a

Reporter, U.S D. C. .

RPR

- Official &urt
( 4 s ) 626-6060

sergeant who apparently determined who came in and out of the OHU and made a decision that this patient, who was under suicide watchl would be sent back to his housing unit. And it was reported to Jackie that the physician came in the next day and was furious because this patient was under the physicianls care and had been discharged without the physicianls approval or knowledge.
Q.
A.

Is it your understanding that that was an anomalous event?

Not that was reported to have been a common occurrence,

that custody decided who went in and out of the OHU at San Quentin. Other examples aret that were reported at San Quentinl is that the officers that were designated to assist with implementation of Plata policies were redirected to other functions.
Q. By who?
A.

By the custody staff.

Q. Okay.

Did you hear stories about correctional officers searching prisoners1 cells at San Quentin?
A.

Yes. What stories were those? It was reported to us by a correctional officer and an MTAt

Q .
A.

that when the officers do cell searches at San Quentin that they confiscate all the inmates1 property and then determine

whether there is any contraband. But in the process, they discard the inmates1 prescribed medication that has been given to the inmate to keep on his person. So the MTA reported that it was very frustrating, because then the MTA had to figure out whose medication was thrown away and make arrangements to get it refilled by the pharmacy.
Q.

Did the custody officer who related this to you have an

explanation for why they do this?

A.

I wasnlt a direct party to that conversation, it was

reported to me by Jackie Clark, but there was no explanation that I recall given to her as to why this was done, but that it had been ongoing.
Q.

Okay. We have talked a little bit about medical technical

assistants already, these are CDC employees who are both health care workers and custody workers?
A.
Q.

Yes. Is that the kind of job designation or job description that

you have seen in other systems?

A.

Not in most state systems.

I do understand in the federal

system that there may be a dual custody medical role but not in most systems that I 1 m familiar with.
Q.

Do you have an opinion as to whether itls appropriate to

have nurses act in a custodial capacity?

A.

I do have an opinion.

Q. And what's your opinion?

A.

My opinion is that it's a conflict of roles, and that it's

really almost impossible for a custody officer to serve as a nurse. You could have an MTA take an inmate down in a use of force and then a minute later have to treat the inmate. And to me that presents a conflict of role. And it's very difficult to maintain any kind of objectivity if you are having to serve in both roles.
Q.

Doesn't the nursing role sort of -- isn't it predicated? to

some extent? on a certain amount of trust between the health care provider and the patient?
A.

Yes. You can imagine that it's difficult to engender that kind

Q.

of trust if the person also acts as custody?

A.

Yes? it is.

Q. Okay.

In February, you submitted a report about Salinas

Valley State Prison to the Department of Corrections, and broadly speaking, you described problems with implementation of the face-to-face triage, lack of equipment and nursing shortages; do you recall that?
A.

Yes. And did you receive a response from the Department

Q. Okay.

Sa&r B&Vickar, RPR

- ~i~

C h a r t Rqwrter, U.S.D.C. (415) 626-6060

of Corrections to that report?

A.

NO, I did not.

Q. And then later, in February, you filed a report on

Sacramento in which you described serious problems with face-to-face triage and absence of nursing leadership and a lack of adequate equipment; is that right?
A.

Yes.

Q. And then in April you submitted a report about San Quentin

that describes serious problems with face-to-face triage and RN1s not following medical orders?
A.

Yes. Did you receive any response from Health Care Services on

Q.

those reports?
A.

No, I did not receive a formal response.

I will say that

we learned about some of the responses through our 30-day meetings, but I did not receive a formal response.
Q.

Since you filed those reports, you have attended 30-day

meetings with the plaintiffs and defendants, correct?

A.

Yes.

Q. And you have also attended some of the status conferences

with the Court; isn't that right?

A.
Q.

Yes. Has the information that you have received through those

reports led you to believe that the problems that you have identified in those reports have been adequately remedied?
S a b r MkVickar, RER

- Official Court R q o r t e r ,
(415) 626-6060

U.S D. C. .

A.

NO.

Q. Okay.

Based on all that you have learned about the Department of Corrections since your appointment in 2002, do you believe that the Department of Corrections can remedy the problems that they face currently with the health care department delivery system without additional assistance from the Court?
A.

I don't believe that they can do it without additional

assistance from the Court.

Q.

If the Court were to issue additional orders to the

Department of Corrections and expect them to implement them, do you believe that the Department of Corrections has the capacity to implement them?
A.

No. Okay. And that's based on all that you have said? Yeah. It's based on our previous experience with court I

Q.
A.

orders and the difficulty implementing current court orders. have no reason to believe that the Department could implement new orders.
Q. Okay.
MS. HARDY:

I don't have anything further.

Thank you, Your Honor.

THE COURT:

Thank you, Counsel.

Cross-examination?
Sahar MkViekar, RPR

- Official C b u &
(415) 626-6060

w t r U . S . D. C. re ,

IaMarre
MR. SCHAEFER:

- cross /

schaefer

Your Honor, can we have a brief

recess?
THE COURT:

Sure.

How long do you want?

MR. SCHAEFER: THE COURT:

Ten minutes-. Court is adjourned for ten

Okay.

minutes.
( R e c e s s taken a t 11:20 a.m. )

(Proceedings resumed a t 11:32 a.m.)

THE COURT:

Okay, you can proceed when you are

ready, Counsel.

BY MR. SCHAEFER:

Q. Ms. LaMarre, you testified earlier that there is a national

shortage of nurses, registered nurses; is that correct?

A.

Yes.

Q. And would that be equally true of nurse practitioners?

A.

Not as severe.

In some areas there may be.

Q.

Do nurse practitioners receive greater compensation than

registered nurses?
A.

Yes.

Q. Okay.
A.

Generally, speaking, yes. And by how much? What percentage?

Q. Okay.
A.

I couldn't specify, depends on the geographic area. Are you familiar with the compensation of nurses in

Q. Okay.

S a h r =Vickar,

Rm

- O f E c i a l Cbzzrt Reporter,
(415) 626-6060

U.S. D. C.

the State of California that are employed by the State of California?

A.

I'm sorry, would you repeat the question?

Q. Sure.

With respect to registered nurses who were employed by the State of California, are you familiar with what their compensation is?
A.

Not per class. Do you know whether nurses employed by the

Q. Okay.

California Department of Corrections is the same or different than nurses employed by other state agencies in California?
A.

I don't know. And so you wouldn't know whether or not the State

Q. Okay.

has classes of nurses that establish common compensation rates; is that correct, for nurses?
A.

I'm sorry, say that again.

Q. Sure.

Is it your testimony that you don't know whether or not the State has common classifications for nurses employed throughout the State at similar compensation levels?
A.

My understanding is they do have common classifications.

Q. Okay. And with respect to those common classifications, do

you know whether nurses in a particular classification at the California Department of Corrections are paid the same or differently than nurses in a similar classification employed at

IaMarre
another state agency?
A.

- cross /

SChaEfer

I don't know whether they are or not.

Q. Okay.
A.

What I do know, though, is that regardless of the

compensation levels, it's

--

the State compensation levels are

not competitive enough to hire nurses into the California Department of Corrections.
Q. Okay.

And do you know whether or not the State of California has difficulty recruiting nurses for employment with other state agencies than the California Department of Corrections?
A.

I don't know that for a fact, but based on the national

shortage, I would presume that they would have similar challenges.

Q. Okay.

And it's true, also, that private health care

institutions have difficulties in recruiting nurses today; isn't that correct?

A.

That 's correct.

Q. Okay.

Now, the

--

if we look at the prison at Mule Creek,

isn't it correct that there is a full nursing staff at that facility?

A.

I do believe that Mule Creek does not have a problem with

recruitment and retention.

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RPR

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IaMarre
Q.
A.

- cross /

S M e r

Okay.

And do you understand why that is the fact?

What I presume is that it's in a geographically more It's near Sacramento and probably easier

desirable location.

to recruit for those purposes.

Q.

Is there any other factors that you are aware of that make

recruiting easier at Mule Creek, other than geography?

A.

I will say that the conditions at the prison are much more

pleasant to work in because the environment is clean, as opposed to some of the other facilities that we visited. So I

think that the work environment at Mule Creek is a little bit better.
Q.

Okay.

So you would describe the area as being sanitary and

clean and orderly?

A.

Yes. Okay.
THE
COURT:

Q.

Excuse me a minute.

Is that because the warden there is doing something the other wardens aren't or because it's a newer prison, or what? THE WITNESS: That facility has a history, I'm told,

of support for the medical program from the warden, that the warden at that prison, and they have had several, but there is
a culture at that prison of supporting the medical program.

I will add because of that the sanitation in the medical area is really very, very good and should serve as a
Sabr MkVickar, RPR

- Official C b u r t Reporter,
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U.S.D. C.

UMarre

- cross /

s-er

model for the rest of the CDC facilities. BY MS. HARDY:

Q.

NOW, you talked about regional support staff for nurses,

and is there a statewide directory of nursing for the California Department of Corrections at this time?
A.

No. Does such a position exist?

Q.
A.

I think it's in the process of being created.

Okay. And do you know whether recruiting has started for

Q.

that position?
A.
Q.

I don't know whether it has or not.

Okay. And with respect to regional nursing administrators,

do you know if such positions exist within the California Department of Corrections?
A.

I believe they are in the process of being established.

Q. Okay.

And do you know whether recruiting has started for those positions?
A.

I do not know. kay. 0 And directing your attention to your comments

Q.

earlier about the use of health care vendors or vendor at the State of Georgia, would you explain what you were referring to.
A.

In Georgia -- in the Georgia Department of Corrections, we

have an interagency agreement with the Medical College of Georgia. They are our vendor, so to speak, of health services.

Sahar MsVickar, KPR

- Official Court Reporter, U . S . D . C . (415) 626-6060

LaMarre

- cross /

s-er

It's a not-for-profit arrangement basically between two state agencies. So the Medical College of Georgia hires all the doctors and the nurses, and they implement the policies that are developed by the Office of Health Services, which is the Georgia Department of Corrections. That is the office in which

I worked. Our office is responsible for policy development,

coordination of training and clinical and administrative oversight.
Q. Okay.
A.

And who is the actual employer of those physicians?

The Medical College of Georgia.

Q. Okay.

And does the Medical College of Georgia establish

the salary and compensation for physicians that are employed by

A.

--

in the corrections end?

Yes. And do you know whether that compensation is the

Q. Okay.

same or different than other physician positions within the State of Georgia?
A.

Sorry, would you Sure.

--

0.
A.

--

repeat that?

Q. The compensation levels for physicians established by the

College of Medicine at Georgia, do you know whether the compensation levels that they establish for physicians is the same for physicians employed outside of the correctional

institution?
A.

If the question is are the salaries competitive enough for

us

--

for the Department of Corrections or Medical College to

be able to hire, the answer is yes, the salaries are competitive.

Q. Okay.

I was going to get to that with you, but I first

wanted to know whether the College of Georgia established separate compensation levels for physicians that it recruited that were different than compensation levels for physicians employed by the State of Georgia?
A.

By the medical college, or --

Q. No, by other governmental entities within the State of

Georgia.
A.

Okay. Well, the Medical College of Georgia is part of the

university system, the State university system. And therefore, their salary structure is different than the salary structure as a State employee, okay? So it is a different salary

structure and it is more competitive, which is part of the reason the Department decided to engage into this interagency agreement.
Q.

Okay. And did the College of Medicine also hire nursing

staff for the institution?

A.

Yes.

Q. And did they employ both registered nurses and nurse

practitioners?
A.

Registered nurses, nurse practitioners and licensed

practical nurses, which is equivalent to the MTA's here.

Q. Okay.

Now, with respect to the nursing supervision, were

the nursing supervisors employed by the College of Medicine or by the correctional institution?
A.

The Medical College of Georgia. And with respect to nursing management, were the

Q. Okay.

nursing managers employed by the College of Medicine or by the correctional institution?

A.

The Medical College of Georgia. And who was the highest health care official

Q. Okay.

employed by the College of Medicine to perform services for the correctional institution?
A.

Who is the

--

would you repeat the question?

Q What was the position of the highest level health care .

practitioner who was employed by the College of Medicine to provide services for the correctional institution?
A.

I'm not sure I understand your question, but I will say

that there is a managing director who is an administrator. An( then there is a statewide medical director for the Medical College of Georgia and a director of patient care services that is the equivalent of a director of nurses for the Medical College of Georgia. So they have their own management

structure for the employees that they hire and supervise.

IaMarre
Q. Okay.

- cress / schaefer
-or, were they fully

And to whom did they report

responsible for the supervision of the health care professionals that they employed who were assigned to the correctional institution?
A.

Yes. Did the correctional institution provide any

Q. Okay.

supervision or direction over those health care practitioners who are hired and employed by the College of Medicine?
A.

The

--

is the question did the custody staff provide --

Q. Yes.
A.

--

supervision? Only administratively in the sense that the warden

was held accountable for all the programs at his or her facility. But the health care staff had their own chain of

command that went up through the institutional director of nurses up to the health care staff chain of command up to that top office at the medical college.
Q.

Okay. What officials at the College of Medicine reported

directly or indirectly to the correctional institution?

A.

Sorry, I don't understand.

Q. Well, withdraw that.

Did any health care manager at the College of Medicine report directly or indirectly to the correctional institution?
Sabr

McVickar, RER

- OiTicial CbmA Reporter, (415) 626-6060

U.S. D. C.

--

- -

-- -

---

A.

Well, the health care team at the prison were a part of the In a sense, they were part of the team even And as such, they

prison staff.

though they had a different employer.

participated in meetings, and cooperated with custody, and coordinated the medical and securities operations together. But as I mention earlier, they

--

and to the extent

that they obeyed the security rules and regulations, they did their jobs, but they had another supervisor and only administratively came under the supervision of the warden, not direct, direct supervision.

Q. Okay.
Who was responsible for the facilities management of the health care facility utilized by the College of Medicine personnel at the correctional institution?
A.

I'm sorry. I don't understand your question.

Q. Okay.

Let me direct your attention to this:

Did the

College of Medicine work in clinical areas at the prisons to provide Health Care Services?
A.

Yes. And who was responsible for the maintenance of those

Q. Okay.

clinical areas?
A

The security staff made arrangements to provide sanitation

in all areas of the prison, including the medical area.

Q.

And with respect to the supplies and equipment that were Sabar WVickar, RER

- OIXicial C h n A w t r U.S.D.C. re ,
(415) 626-6060

used in the clinical areas of the correctional institution, who was responsible for obtaining or providing those supplies and equipment?
A.

Custody staff.

Q. Okay.

And did you have any hospitals within the correctional institutions?
A.

No licensed hospitals. And for prisoners who required acute hospital care,

Q. Okay.

how were those cases managed?

A.

If they required acute hospital care that was beyond, let's

say, an infirmary requirement, they were sent to an outside hospital.

Q. Okay.

And what if they required only infirmary care? How would that be handled?
A.

There were

--

we had 40 prisons in Georgia and there are

about 15 or so that have infirmaries, they would be placed in an infirmary bed.

Q. Okay.

Who was responsible for the management of the

infirmary from a facilities standpoint?

A.

Correctional staff. Okay. And who was responsible for supplies and equipment

Q.

in the infirmary in the correctional institution?

A.

Custody staff.

Q. Okay.
In your testimony you identified certain vacancy rates at some of the prisons with respect to the nursing staff; with the use of registry or registry nurses, what were the -what is the existing vacancy rate in the prisons in CDC with respect to nursing staff?
A.

I can't say specifically prison to prison, it varied.

Sometimes the staff could get the registry staff, sometimes they couldn't. So it improved the vacancy rates over the State

vacancy rates, but I couldn't say exactly what the vacancy rate was.
Q.

Now, you testified quite a bit with respect to the intake

of new prisoners and establishing their health needs, medical history, and all, aren't there situations where you have new prisoners who do not have current health care needs?
A.

There are some inmates that would enter, I would presume,

that have no significant medical problems, yes.

Q.
A.

What percentage would that be? Well, I don't think I could give an exact percentage. We

know generally speaking that, you know, approximately

30 percent of inmates in our correctional facilities have

chronic illnesses, but in addition to that, some inmates have acute illnesses and some inmates have mental health problems on top of that, so I don't think I can give you a figure of percentage of inmates have no medical problems.

Sahar McVickar, RPR

- Official Court Reporter,

-

U.S. D.C.

(415) 626-6060

LaMarre - cross / s u e r
Q. Okay.

Ms. LaMarre, you also testified about when a prisoner transfers from one location to another that there is a process where a nurse completes a form and that follows the prisoner to the new location; is that correct?
A.

Yes. And then there would be a nurse that would receive the form

Q.

at that institution. Is that process working?

A.

The process has begun at a number of prisons.

There are

some significant problems with the process so that it doesn't

--

while it has gotten started and that is a good

thing, staff are using forms, they are completing forms, the problems relate to the institutions not always getting the health record at the time of transfer. For example, at

Sacramento one day five inmates came, no health records arrived at Sacramento. Another day, 24 inmates came, 25 percent of the records did not come. The other issues are that the medications that are supposed to be transferred with the inmates do not always come. And for example, at Sacramento, inmates often arrived after the pharmacy had closed, so if their medications didn't come with them, then the nurses couldn't order them the same day. And other problems were that inmates with medical problems that should have been addressed the day of arrival, such as inmates with blood pressure that was out of control

Sahar MaVickar, RPR

- Official Court Reporter, U.S.D.C. (415) 626-6060

- -

would not be referred and referrals or follow-up appointments didn't consistently take place. So while the process has begun in that staff are using the forms, all the mechanisms that should take place accompanying that are not.
Q. Okay.

Is it your testimony, nevertheless, that the forms

are being used and also that the forms are being used correctly?
A.

Not always, but

--

Q.
A.

In those instances? In those cases, they are making an effort to fill them out

correctly.

MR. SCHKEFER:
witness.
THE COURT:

I have no further questions of the

Thank you, Counsel.

Redirect?
MS. HKRDY:

I have nothing further, Your Honor. Okay. Thank you.

THE COURT:

Thank you for testifying.

THE WITNESS:
MR. FAMA.:
Dr. Joe Goldenson.

Thank you, Your Honor.

Plaintiffs will next call

If we could go off the record for a scheduling

matter?
THE COURT:

Okay.

Goldenson

- Direct /

Fama

Dr. JOE GOLDENSON.

called as a witness for theplaintiff, having been duly sworn, was examined and testified as follows:
THE CLERK:

Please state and spell your name for the

record. THE W T E S INS: Joe Goldenson, G-o-1-d-e-n-s-o-n.

DIRECT EXAMINATION
B Y M R . FAMA:

Good morning, Doctor. Good morning. You are a medical doctor? Yes, I am. You've been appointed as a cou: Yes, I have. You obtained your medical degree in 1975, right? Correct. And shortly thereafter, you began and completed a three-year residency in family practice at the University of California San Francisco Medical School and then an additional year of a fellowship in family practice, right?
A.

ixpert in this case?

No.

Actually, it was six months of a fellowship.

Q. Thank you for the clarification.

And so you are board eligible in family practice medicine?

A

Correct.

Goldenson

- Direct

/ Fama

Q. And family practice medicine is the medical specialty that

provides continuing comprehensive care to individuals and families?

A.

Correct.

Q. And family practice medicine encompasses all ages, both

sexes, each organ system and every disease entity?

A.

Correct.

Q. Can you please describe your experience in providing or

managing medical services in a correctional setting.

A.

Since 1987 I have worked in the San Francisco County jails.

I worked for the Public Health Department providing health care

to prisoners in the county jail. Since 1993

--

I started out as a staff physician.

And around 1995, I

In 1993, I became a medical director.

became the program director and the medical director.

Q. So if my math is right, you have worked about 18 years in

the county jail here in San Francisco?

A.

Correct.

Q. And for much of that time you have managed the system?
A.

Correct.

Q. And your system at the county jail delivers medical care at

multiple jail buildings?

A.

Correct. We have six facilities.

Q. And you manage the full range of medical staff, including

primary care providers and nurses?

Goldenson
A.

- Direct /

Fama

Including primary care and mental health, the whole range

of health services.

Q. And other than the fact that the jail population by

definition is short term, and thus you don't have an opportunity to see medical conditions run a course for much more than a year in most cases, you provide the full range o medical service at your jail?
A.

We provide the full range except for acute hospitalization,

and then those folks would be admitted to San Francisco General Hospital where there is a jail ward at the hospital that I oversee also.
Q.

And you are appointed by this Court as the medical expert

in the litigation known as, originally, Madrid versus Gomez, correct?

A.

Correct.

Q. And been doing that for almost a decade now?

A.

Correct.

Q. And you have any other experience evaluating or monitoring

medical services in jails or prisons other than your work in the present case here in Plata and that Pelican Bay case?
A.

Yes.

I'm also the medical expert in a case in Ohio at the

Ohio State Penitentiary, which is their super maximum security prison.

Q.

And in that Ohio case, were you initially hired by counsel

that represented prison officials?

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- -

A.

Yes, I was hired through the Attorney General's office.

Q. And do you have a continuing role in that case?

A.

Yes, I do.

Q. And in connection with your work at Pelican Bay and in

Ohio, you review the care provided to patients and the adequacy of and compliance with policies and procedures?
A.

Correct. Considering your 18 years here in San Francisco at the jail

Q.

and your monitoring work at the other prisons, is it true that you have either directly provided or closely reviewed the medical care provided to thousands of inmates?
A.

Correct.

Q. You are familiar with the stipulation for injunctive

relief, Doctor, that was filed in the case in June 20027
A.

Yes, I am.

Q. You are familiar with the requirement that the defendants

implement specific policies, medical policies, at certain prisons during each calendar year beginning in 2003?
A.

Yes, I am.

Q. And more specifically, you know, don't you, that the

injunction calls for implementation of those policies on a phase basis, seven prisons in calendar year 2003 and five each of the subsequent years up to 2008?
A.

Correct.

Q. And that those prisons, Doctor, that have been required to

Goldenson

- Direct /

Fama

or are required to implement the medical policies required by the injunction are referred to by the parties and others sometimes as the roll-out prisons?
A.

Yes, I am.

Q. And you are familiar, I assume, with the medical policies

required to be implemented under the Court's order?
A.

Yes, I am.

Q. And you are familiar also with the injunction's provisions

regarding how compliance with implementation is to be achieved and the Court expert's role in that process?
A.

Yes, I am.

Q. And you know that pursuant to the Court order there is a

standardized audit instrument that measures, through chart reviews and other information, whether a prison is in substantial compliance with the major requirements of the required policies?
A.

Yes, I am.

Q. And you also know, don1t you, that under the Court1s
injunction, in addition to a passing score on the standardized audit instrument, a prison, to be in compliance, must also have certain other procedures in place, including an adequate death review process?
A.

Yes.

Q. And that under the injunction, prison officials first audit

themselves, and then once they determine they are ready to be

Goldenson

- Direct /

Fama

audited for compliance, they tell you, the Court experts, that they are ready, and you then perform an audit?
A.

Correct. And have prison officials notified you that any of the

Q.

roll-out prisons from 2003 or the calendar year 2004 are ready for a compliance audit?
A.

No, they have not.

Q. And, Doctor, you visited some of the prisons covered by the

injunction in this case, haven't you?

A.

Yes, I have.

Q. And you have, for example, been to Salinas Valley State

Prison?
A.

Yes.

Q. And the California State Prison in Sacramento?

A.

Yes.

Q. Corcoran State Prison?

A.

Yes.

Q. The substance abuse and treatment facility across the

street, so to speak, from Corcoran?
A.

Yes.

Q. The Valley State Prison for Women?

A.

Yes. California Institution for Men? Yes.

0.
A.

Q. San Quentin Prison?

Sahar McVickar, RPR

- Official Court Reporter,

(415) 626-6060

U.S.D.C.

Goldenson
A.

- Direct

/ Fama

Yes. In fact, you've been to San Quentin

Q.

--

well, how many times

have you been to San Quentin, Dr. Goldenson?

A.

I think I was there in January, then in February, and then

again recently, within the last couple of weeks.

Q. Have you been to Pleasant Valley State Prison?

A.

Yes.

Q. And any other prisons that you have been to, Doctor?
A.

Did you mention Sacramento?

Q.
A.

I believe I did.
We were also to some of the other prisons just for tours

when they first rolled out, but we didn't really look at the medical care that closely.
Q.

And when you go to a prison to look at the medical care

closely, what methods do you use, Doctor?

A.

I primarily do chart reviews. We look at chart reviews of

patients that have died recently, people with chronic illnesses, people who put in sick-call requests, people who have specialty appointments. I also

--

if I see a chart that is of some concern,

sometimes I will see the patient and interview them and examine them myself. Also visit, sometimes, the patients who are

either in the infirmary or in the hospital depending depending on what is set up at that prison.
Q.

--

or CTC,

Would it be also accurate to say that you will talk to

Goldenson

- Direct / Fama

medical and other staff at the institution?

A.

Yes.

Q. And in addition to the prison visits and the work that you

have described, you have also reviewed a few completed Internal Affairs investigations conducted by the Department of Corrections related to inmate patient medical care?
A.

I've reviewed or completed ones that I think were not quite

completed, yeah.
Q. And you have also, consistent with what the other experts

have testified to, participated in status conferences, with the Court in this case?
A.

Correct.

Q. You've also attended and participated in meetings with the

lawyers and health care services division staff representing the Department of Corrections?
A.

Correct.

Q. Based on your visits to the prisons and other information,

do you have an opinion as to whether defendants at any of the prisons you've seen have substantially implemented the required medical policies?
A.

Yes, I have an opinion. All right. Thank you. And

Q.
A.

-- and what is that?

That in the prisons I have looked at they have not

substantially implemented the policies.

Q.

Based on your visits to the prisons, Doctor, and the other

Sahar McVickar, KPR

- Official Court Reporter,

(415) 626-6060

U.S.D.C.

Goldenson

- Direct /

Fama
--

information that you received, do you have concerns related to the adequacy of patient care that are different than a simple failure to implement the required medical policies?
A.

Yes, I do. I'm extremely concerned that in a number of the

cases that I have looked at that people have been dying unnecessarily, that their deaths could have been prevented. So

that the question here is a lot bigger than just saying whether it's a constitutional system in terms of providing constitutional health care, because I've seen systems where constitutional health care is the issue, but people aren't dying in the numbers they are dying in the systems in terms of preventible deaths.
0.

Doctor, when you look at a unit health record of an inmate

who dies, what sort of issues do you attempt to evaluate?

A.

Well, I look at the care that is provided prior to the

final event.

I look at the care that is provided in the

emergency treatment of whatever actually happens in the final event. And then review the hospital records, if there are any,

to get a better sense of exactly what the health problems were that the patient presented with. So that I try to evaluate both the care that was provided in the preceding period for chronic illnesses, or whatever problem the person might have, to see if that contributed to the death and whether there are things that
Sabr McVickarf RER

- Official Cburt Reporterf U.S.D.C.

(415) 626-6060

Goldanson

- Direct

/ Fama

could have been done at an earlier point that would have prevented the death from happening. And then I look at the care that is provided when the person shows up at the emergency room, if they end up there, in the facility or at the housing unit, or whenever they are identified as having an emerging problem, to see if the care there is appropriate, also to see if there are any things that could have been done that, again, would have prevented the death.

Q. So one thing a death review could show is whether the death

itself was preventible?
A.

Correct.

Q.

Is another thing that a death review can show, even in a

case where the death may not have been preventible, whether or not there were significant clinical problems with the care provided?
A.

Yes.

In a number of cases I've seen, the person was

ultimately diagnosed with a terminal illness so that, you know, whatever would have been done wouldn't necessarily have saved their life in the long run, but there are two issues. One is that you want to evaluate the care and how, basically, how a doctor and a nurse approach a patient with certain symptoms to the point where you don't really know what is going on. If they mismanage the person, then you are aware that there is a possibility that if this person didn't have a
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terminal illness, but say, some other form of life-threatening illness and presented in the same manner that that would have been a preventible death they would have missed, and the person would have probably died if treated in the same way. So this provides you information about what kind of needs the staff have for training, what kind of system problems need to be addressed, or if it's just a question that the doctor and the nurse really are incompetent and shouldn't be practicing. So we look at those issues also, not only to

determine if it's preventible, but whether there were any gross deviations from the standard of care that need to be addressed.
Q. And would you also try to determine in those cases, I

suppose especially those in which there was a terminal illness, whether or not adequate care would have prolonged the life of the patient?
A.

That's correct also, whether -- even though someone has a

terminal illness, they might not have been ready to die the day they died if they had gotten appropriate care. So that is

another issue, that whether the person is treated appropriately when they are finally diagnosed with a terminal illness.

Q.

Doctor, you told the Court that you believed that inmate

patients are dying unnecessarily; is this a continuing risk to the plaintiff class in this case?
A.

I believe it is. Doctor, do you recall reviewing a case in which an inmate

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Fauna

at the California State Prison went to the emergency treatment area of that institution and presented with, among other symptoms, fingertips that had turned blue?
A

Ido.

Q. Could you tell the Court, please, the facts of that case,

as you understand them from your review?

A.

I have some notes here that I brought from my reports.

The problem here is that a lot of these cases are very similar, unfortunately, from different prisons so that I want to make sure I get things exactly right on the specific cases.
Q. And, Doctor, when you say, "very similar," what do you

mean?
A.

What I mean is that in a number of the cases I reviewed

from different prisons, patients would show up in the emergency room with vital signs or other symptoms, that just jumped out at you that this was a very serious problem, and that the doctor would not respond appropriately. And he would not send the person to the hospital or wait too long to send the person to the hospital to the point where when they were finally sent, or in some cases weren't sent, it was too late to treat it where it was a treatable problem initially.
Q.

Thank you, Doctor, I apologize for the interruption. I had asked you about the case with the inmate who

presented with the fingertips that had turned blue.

Goldenson
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Which prison was that, again?

Q. At Sacramento.
A.

All right. There was a case -- this was one of the Internal

Affairs investigations that I reviewed. And it was an especially concerning case, both because of what happened to the patient, but also the review that was done by the medical staff. This was a patient who initially presented to the doctor with about two- or three-week history of fever, chills. The doctor, from what I could tell, did a fairly adequate exam, including an exam of his heart, where he specifically noted the patient did not have a heart murmur and sent the patient back with some treatment. Patient came back a month later, was feeling worse, still having fevers. This time when the doctor examined him,

he noted that the patient had what he called a 5 over 6 heart murmur. Heart murmurs are sounds that you can hear when you

listen with a stethoscope to the blood flowing through the valves. If there is an abnormality of the valve, you will hear

certain sounds. And they can be graded from 1 to 6, 1 being you have to listen very hard to hear it, 6 you could almost hear it without a stethoscope. So 5 over 6 is a very loud murmur, which indicates there is a significant problem with the person's heart valve.
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-

The doctor noted that the patient probably had vegetations. Vegetations are there is a condition called One

endocarditis, which is an infection of the heart valves.

of the things that happens is you get growths on the heart valve that are related to the infection, and they are what causes part of the heart murmur. Endocarditis is an emergency where someone needs to be admitted to the hospital immediately for intravenous therapy. Because if it's allowed to go on, the person could die from it. Well, even though the doctor noted that that was the problem, he

--

and said that, "We would have to get some tests

at some point," he sent the person back to the housing unit. The patient was then seen two weeks later and two weeks after that, each time saying he was feeling worse. At

one of those times, the doctor actually said that the patient had endocarditis, so he actually wrote the diagnosis, but again, didn't treat the patient appropriately and sent him back to his housing unit. About two weeks after that, the patient showed up in the emergency room and was feeling very sick. indicated that he was going into shock. pressure, high fever. he had the flu. His vital signs

He had very low blood

The doctor evaluated him and said that

The nurse said, "Wait a minute"

--

and wanted

to send him back to his housing unit.

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The nurse said, "Wait a minute, Doctor, this patient has endocarditis. He is very sick. He needs to go to the

hospital." And the doctor basically responded that he is the doctor, and he doesn't listen to nurses, and sent the patient

--

and so the nurse called her supervisor because she was so

concerned. And somehow the decision was made to admit the patient to the OHU so he could be watched but still not instituting appropriate treatment, which at that point clearly would have been to send him to the emergency room and started the appropriate therapy. cardiac arrest and died. When I say that the review was very concerning, this case was reported to Internal Affairs, and they did an investigation. One of the doctors from Health Care Services interviewed the physician who was responsible for the care and also reviewed the medical records, wrote what I considered to be a very good report basically saying what I just said, that the patient was totally mismanaged, and that it was a preventible death. And there was another physician in Central Office at the time who, at that point, agreed with the assessment of the physician. And then somehow once the Internal Affairs -- I'm Shorty thereafter, the person had a

sorry, the second physician, who was above the first one who wrote the report, interviews the doctor, and he subsequently

Goldenson

- D i r e c t / Fcona

writes a memo saying that initially he had thought the doctor was at fault, but that after he interviewed the doctor, he realized that when the doctor saw the patient in the emergency room

--

now, remember, when he saw him in the emergency room,

that is after about six weeks of mismanaging a very serious medical problem, when the person is in shock at the time. And the physician says that the doctor didn't have medical records when he saw the patient in the emergency room, so you really can't evaluate his care. THE COURT: Can't evaluate what? His care.

TSE WITNESS:

And the conclusion of the IA report, Internal Affairs report, was that basically nothing could be done. NOW, I was asked to review the case, and I wrote a memo to Dr. Kanan. And subsequent to my report, the doctor was

put on administrative leave. But he was practicing from the time this happened, which I think was a year, year and a half before I actually reviewed it, until I wrote my report. Again, it was extremely concerning, both based on the lack of care provided by the physician, but also what I considered to be a coverup of a very serious medical error, a series of them, medical errors.
BY MR. FAMA:
Q.

Thank you, Doctor. And let me ask one follow-up question

on the facts.

Goldenson

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I had alluded to the presentation of the fingertips;

was that something that had happened in the case, please?

A.

Yes.

When the patient was

--

I think it was

--

when he was

in the emergency room, along with the abnormal vital signs, the doctor did note, or the nurse, I forget who noted it, that his fingers were cyanotic. And cyanosis is a blue discoloration, which indicates a lack of blood flow, which in this case is further evidence that the patient was either going into or was in shock and wasn't getting blood to the organs that he needed to get them to.

Q. Dr. Goldenson, you have been here earlier today and

yesterday and heard, did you not, the testimony of Dr. Puisis and Nurse Practitioner LaMarre?
A.

Yes, I heard most of it,

Q. And the case that you have just described was not one that

they discussed, was it?

A.

NO, it was not.

Q. And, Doctor, you wrote a memo in approximately October 2004

regarding the case that you have just described, correct?

A.

Yes, I did.

Q. And in that memo you wrote that, "This was the most

reckless and grossly negligent behavior I have seen by a physician"; do you recall that?
A.

Yes, I do.

Q. And in the months since, have you seen other cases

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involving members of the plaintiff class that rivaled the inappropriateness of care that you observed in the case just described?
A.

Unfortunately, yes, I have.

Q. And, Doctor, do you recall reviewing the unit health

records of three inmates who died in San Quentin from 2002 through January 2005 while under the care of a particular physician at that facility?
A.

Yes, I do.

Q. And could you describe to the Court what your review of the

charts in those cases showed?

A.

Yes. When I was at San Quentin, I think it was in

January, a patient had just died the week before. And I was reviewing his chart, which I'll talk about in a minute, but I think once I discussed it with one of the physicians who was there from QMAT and talking about the circumstances of the death, he gave me two other Internal Affairs reports concerning the same physician that were still active, one from 2002, one from 2003, where patients had died, and the care was suspect enough that these cases had been referred to Internal Affairs for more review. And it was

--

I looked at the details, and I just

want to say that, again, it was a situation where it was extremely concerning to me that here was a physician where

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there had been two prior cases where his mismanagement had resulted in the death of a patient, and he was still practicing. And, unfortunately, another patient died who probably wouldn't have died if he had gotten appropriate care. So, again, it was another example, not only of bad medical care, but information was known about a physician who was dangerous and responsible for patients dying who was still practicing. The case of the patient who died a week prior to my visit, he was a 48-year-old man with really no significant medical problems who showed up in the

--

it's called the TTA, I

think it's called the treatment and triage area, for San Quentin, which is their emergency room. And at the time of his presentation, he had a high fever. And vital signs, again, a low blood pressure, a high pulse, a fast respiratory rate, which was indicative of a very serious medical problem. The physician examined the patient and basically decided, I think, that he had bronchitis, or something, some minor upper respiratory problem, and sent him back to his cell. Again, the vital signs that this patient presented with and his symptoms, it was very clear that he needed emergency medical care. When I say very clear, I think a

fourth-year medical student, in this case, the nurses, were aware of it.
I think even the custody staff knew that this guy

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was very sick. What happened was he got sent back to his housing unit. As custody staff was taking him back, the man collapsed,

and he either fainted or almost fainted. Custody staff brought him back to the medical facility saying, "This guy is really sick." And the doctor did a very superficial assessment and sent him back to his housing unit. afternoon.
Q.

This was on a Friday

Doctor, excuse me, sent him back a second time to his

housing unit?
A.

Yes.

Second time after he had collapsed on his way back

the first time. So this was on a Friday evening. Saturday

afternoon, he presented again to the TTA, this time a different physician saw him, sent him to the hospital, but he died at the hospital. And, again, this was totally mistreated. When I reviewed the other two Internal Affairs reports, now I didn't have the complete medical records, I was just reading the reports at that time, which included a lot of medical records and also interviews with staff, there were two other cases, as I said, one in 2002, one in 2003, where again the same physician had shown extremely poor judgment to the point of negligence. One case was someone who was in their cell, fell down and hit their head.
Sahar MbVickar, RPR

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think around 4:00 in the morning, the patient's blood pressure was very low, he had some bleeding from where he hit his head, and the physician said, "Put him in the OHU and we'll see him in the morning."Again, this is a case where at that point, given that the patient's blood pressure was extremely low, had a head injury, he should have been sent to the hospital immediately.

A physician came in in the morning, evaluated him

and decided that he would send him to the emergency room. Called Novato Hospital, which is one of the hospitals that San Quentin contracts with. He was going to send them Code 2,

which when you send people via ambulance, there is Code 1, 2, and 3, indicating how fast you want someone to go out; code 1 being, I think, it's just regular, code 2 would be lights, and Code 3 would be lights and sirens. So it indicates how He was

important you think it is that they get out there. going to send him Code 2.

When he talked to the doctor at emergency room in Novato, he said, "First of all, I think this guy need to go to Marin General because they have more"

-- they have a

neurosurgeon available, and it sounded like the guy need a neurosurgeon.

So he changed his order to send him to Marin

General Code 3. But while he was waiting for the ambulance, instead of keeping him in the medical area, and monitoring him, he sent
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him back into a cell in the OHU, where, when the nurse went back 15 minutes later to check on him, he had had a cardiac arrest and died. So that was the second case.

The third case was a patient who came into the TTA, and was demented. He wasn't a demented patient, but he was

showing signs of dementia. He was very confused, disoriented. His physician said, "This is obviously a psychiatric problem. He needs to get admitted to the Psych Unit." The psychiatrist who was there refused to admit him to the Psych Unit saying, "He needs to be medically cleared before I'm going to put him in the Psych Unit." The story goes

on from there, but basically, the guy ended up dying of an overwhelming infection that, again, this doctor didn't pick up on the clues, didn't manage it correctly, and the patient died. So, again, three cases, 2002, 2003, 2005, where the same doctor made very significant medical errors, and to the point where I almost feel like it was negligence, just not caring.

I mean, it was so obvious that these folks were sick.

That he didn't send them out, it's hard to even fathom why someone would do that. In the first case I described, even the

custody staff was saying this guy needed to go to the hospital.

Q.

And, Doctor, you wrote up your conclusions in this case,

and they were included in a report that was sent to defendants, right?
A.

Correct.

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Q. And, in fact, you made your concerns known at the time,

shortly after your initial visit to San Quentin when you first discovered these facts, correct?
A.

That's correct. And with respect to the cases, three cases that you

Q. Okay.

discussed at San Quentin, or the case of the inmate at the California State Prison at Sacramento, has any clinician or other representative of the defendants taken issue with any of your conclusions regarding the adequacy of care?
A.

No.

They have agreed with me.

And, in fact, the

--

I just

received last night an E-mail from Dr. Sherger, who is one of the U.C. San Diego doctors who is doing the death reviews down there, and he sent copies of 23 of their death reviews. And these three cases that I just described from San Quentin were in there, and they agreed with everything I said.
Q. And, in fact, Doctor, it's been your practice at Pelican

Bay to share your conclusions and observations regarding the adequacy of care with clinicians both at the prison and at Central Office and for those clinicians to provide you with any feedback or concerns regarding your conclusions, correct?
A.

Mostly at Pelican Bay I've dealt with the health care

I haven't dealt with the Central Office that much in

manager.

terms of the Pelican Bay cases.

Q.

I'm thinking, Doctor, of your review of the audits of the You do those more or less every

physicians at Pelican Bay.

Goldenson
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Em ' a

Correct.

Q. You review the audits that the Department of Corrections

does of the physicians at Pelican Bay?

A.

But I send those reports to the special master.

I don't

deal directly with Central Office on those.

Q.

I see. Well, at Pelican Bay and with your review of the

physicians, is it correct that the Department of Corrections only rarely, if ever, takes issues with the conclusions and opinions that you give?
A.

On the Plata cases, I don't think they've ever taken issue On the QMAT, there is, like, lots of cases, and there

with.

are some minor disagreements, but on the major issues they have never disagreed with anything I've said.
Q. Thank you, Doctor.

Do you recall reviewing a case that took place at the Substance Abuse and Treatment Facility in the city of Corcoran in which an inmate presented with symptoms of low blood pressure and complaining that he hadn't urinated in two or three days?
A.

Yes.

Q. And it seems obvious, but let me ask you, but is

complaining of not urinating in two or three days a medically significant fact?

A.

It's a medically significant fact. And in this case, this

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So the fact that he

patient had chronic renal failure. He was on dialysis and also had diabetes and congestive heart failure.

hadn't urinated in two or three days was extremely significant, and as an indication that his renal failure could be worse or his congestive heart failure. medical problems. He had a number of serious

The fact that he had low blood pressure and

hasn't urinated was extremely concerning, again.

Q. And what happened

-- well, did this particular patient see

a physician at the Substance Abuse and Treatment Facility when he presented with those symptoms?
A.

Yes.

He came over to the emergency -- the MTA who

--

when

I say extremely low blood pressure, for example, in this case,

the man's blood pressure was 70 over 50. And normal would be 120 over 80, 115 over 70. So it was extremely low.

He was sent over to the emergency treatment at the prison. It's not clear that anything was really done at that The doctor wanted to get

time except for some blood tests.

blood tests, which in this case, as far as I'm concerned, was a total waste of time. It was very clear that this person had a significant problem with his vital signs and the fact that he wasn't urinating. And he should have been sent immediately to an emergency room of an acute care hospital where he could have been adequately treated. Instead, he spent seven-and-a-half

hours in the emergency room at the prison, where according to Sahar MzVickar, RPR

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the records, nothing was done. They finally called for paramedics to take him to the hospital. oxygen. When the paramedics got there, they checked his

There's something called a pulse oximeter rating,

where you put a little device on someone's finger and it checks out what their oxygen saturation is, and his was low, it was
92 percent.

A normal person's would be 98.

95 is sort of a

cutoff where you start worrying. And the paramedic immediately put oxygen on him. Here he had been in the emergency room at the prison for over seven hours and they certainly hadn't given him oxygen as he needed. And, again, unfortunately, by the time he got to the hospital, he had a cardiac arrest and died.
Q. And, is it your opinion, Doctor, that it's very possible

that with timely and appropriate care that death could have been prevented in that case?
A.

Yes.

I think in all the cases we discussed so far this

morning that is the case.

Q.

Was there any other case involving the physician who

provided or failed to provide the care in the case you just described that was brought to your attention?
A.

Yes.

When I returned from SATF, I realized I didn't have

all the information I needed to address this case and in the report I wanted to write. So I wrote an E-mail to Central

Office asking for copies of the medical records, and I got a

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response back from one of the physicians in Central Office saying that she had arranged for me to have the files but that she was also going to send me the file on another patient that she thought I should look at. When I reviewed that case, it was a patient where the physician had ordered a chest x-ray, and the chest x-ray came back, and -- I'm just going to read it, because it's a very abnormal chest x-ray. Basically, it said that the findings on the chest x-ray could be from a "pleural effusion, neoplastic disease, inflammatory disease, or a combination of these. CT," which is

a computerized tomography, a special kind of x-ray, "of the chest would be helpful." So, basically, it was a very abnormal chest x-ray that could signify a number of very serious medical problems. And they were recommending further studies. What happened was when the same physician got the x-ray report, he filled out a form that he sent back to the patient saying, "We have your x-ray results, and they are normal," so that he didn't do anything to follow up on it. And a month later, the patient was found unresponsive in his cell. clear what he died from. There was no autopsy, so it's not So I can't say for sure that if they

had responded to the x-ray appropriately that his life would have been saved or not.
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But what is clear is, again, it's not a question of medical judgment at this point, it's just total negligence. It's lack of caring, which is to me as concerning, if not more so, of lack of judgment. you just ignore it. And, again, this is something that I saw over and over again in the charts I read. Luckily not

I mean, you have the information and

--

people weren't

dying all the time when it happened, but there would be abnormal lab values, abnormal x-rays that the doctors just didn't respond to.
Q. And, Doctor, I think it was

--

well, you went to Pleasant

Valley State Prison sometime in the last 30 days or so, correct?

A.

Thirty

--

yeah, something like that.

Recently.

Q. And was there a case that you reviewed while at Pleasant

Valley State Prison that involved an x-ray report that suggested the possibility of tuberculosis?
A.

Yes.

Q. Excuse me, Doctor.

If you were able to rate the public health threat posed by tuberculosis in a correctional setting on a ranking of
1 through 10, where would you place tuberculosis?
A

I also tell my staff that tuberculosis is number 1, 2, and It's such an important public health issues in corrections,

3.

because not only does it involve the health of the patient, but

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it involves the health of the other people in the jail, the staff, and then people in the community. In the early '90s, when there was a TB epidemic in the prisons back east, the correctional officers were infected, and they would bring that infection back to the community when they got home. So that tuberculosis really is an incredibly

serious problem in correctional institutions.

Q. Thank you, Doctor, for that information.

I had asked you, and let me ask you again, about a

case that you reviewed at Pleasant Valley State Prison involving an x-ray and tuberculosis?
A.

Yes. It was a patient who was housed in their CTC. And I

had actually gone into the CTC to review the care of another patient. I was informed that there was a patient there with

TB. And because it's such an important public health issue, I

always review cases of tuberculosis. And what I found was that in either December, I think it was, December 2002, January 2003, this physician had seen the patient because he had a positive skin test for tuberculosis in the past, and he was doing the yearly screening to make sure that

--

generally, in the prison system, you will

do the skin test on a yearly basis to make sure that people aren't developing tuberculosis. If someone has already had a positive skin test,

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it's always going to be positive, so you don't repeat the tests, but you want to make sure to check them for symptoms. And if there is any reason to be suspicious, you'll get a chest x-ray just to make sure that they haven't developed tuberculosis in that year. So the physician ordered a chest x-ray, which came back, and as I remember, had an abnormal finding, I think it was the right upper lobe infiltrate, which meant that they looked at the x-ray, and it looked like there was something that shouldn't be there in the right upper lobe. And it's incumbent upon a physician, once you learn about something like that, to determine what it's from.
It

could be pneumonia, it could be another kind of infection. In this case, where you are concerned about TB, TB is definitely a possibility, so you want to follow up, isolate that person, basically, until you figured out what was the cause of the infiltrate. In this case, the only action the physician took was he wrote a note in the patient's chart that said "abnormal chest x-ray, right upper lobe infiltrate," and signed his name. He didn't call the patient back to check him out. He didn't do

anything. Again, this was in 2002/2003 -- I'm sorry, 2003/2004. In 2005, the physician saw the patient again and wrote that he had had an abnormal chest x-ray the year before,
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so we should repeat it. So he gets another x-ray, this time it comes back and the radiologist says basically the same kind

of findings and says, "Rule out tuberculosis." Now, again, this should have been reported to the physician immediately. I don't know if it was the physician's fault or radiology, but it took, I think, about three weeks before the physician actually responded to the chest x-ray. And at that point, he took the appropriate action of putting the patient in respiratory isolation and starting treatment.
Q.
A.

Starting treatment for what? For tuberculosis. We were told that at the time we were there, there

were two other prisoners who were being evaluated for possible tuberculosis from exposure to this case, and in addition, that there were two custody officers who were being evaluated. And

I haven't heard what the results of those investigations were,

or if there were more patients or staff who possibly could have been exposed. time
Q.

They were doing a contact investigation at the

Do you have an opinion, Doctor, about the adequacy of care

provided by the doctor who reviewed the initial x-ray in the case, noted the results and took no further action?
A.

Again, I just don't understand how a physician could do You are presented with this information,

something like that.

which is a very significant abnormality which is indicative of

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It's I

a significant problem, and he just doesn't do anything.

beyond incompetence to me, it's total lack of caring, again.

mean, I can't even begin to understand how a physician would do that.

Q. And thank you, Doctor.

You also reviewed cases at the prison in, it's called Corcoran State Prison, correct?
A.

Correct. Do you recall a case in which a patient who needed

Q.

emergency hospitalization had that hospitalization delayed because he was made to go back to his housing unit to change his shoes?
A.

Yeah. It was a patient

--

as I remember, he was a patient

with HIV infection who had had significant viral infection a month or so before and presented with changes in mental status, confusion, difficulty walking. It turned out that he had

meningitis and, unfortunately, ultimately died from that. The case was mismanaged all along in terms of delays in the diagnosis. And, again, this was a case where the

physicians at QICM felt that he had not received appropriate care leading up to his death. But what was even more -- not more

--

disturbing to

me was there was a note in the chart that at this point where they decide to send the patient to the hospital where they have
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noted he is very confused and disoriented and can't walk, he gets sent back to his cell because custody staff said he needed to change his shoes before he could go through work change. And work change is one of the gates you go through. So here is this guy they are in the process of sending to the emergency room who ends up having meningitis who is very sick, and they make him go back to his cell to get his shoes. And then there is another note that the medical staff recommended to custody staff that they give him a wheelchair because he was having so much trouble walking, and the custody staff didn't do that.
Q. And, Doctor, you have reviewed other cases in addition to

the ones that you have described to the Court in which you have concluded that the adequacy of care was very poor, correct?
A.

Correct.

Q. And you have reviewed other cases in which you identified

significant clinical issues in instances where inmates died?

A.

Correct.

Q. And cases where adequate care would have prolonged life,

even in cases where there were

A.
Q.

--

was a terminal condition?

Correct. Do you have an opinion about the general level of

incompetence that you have seen in these and the other cases that you have reviewed?
A.

Well, as I've said, it's

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and it also goes beyond a question of competence to just gross negligence, lack of concern, lack of caring, that is extremely disturbing that I really have not seen anywhere else when I've reviewed records to the extent that it is happening here.
Q. And, Doctor, have you had an opportunity to

--

well, let me

ask you this:

You told me that the injunction, you understand

the injunction requires that there be an adequate death review process, correct?
A.

Correct.

Q. And is it fair to say that an adequate death review process

is essential because through such reviews individual and systemic problems can be identified and, if necessary, corrective action taken?
A.

Yes.

Death reviews are a critical piece of a quality

improvement program where you look at what you are doing and try to discover if there are problems that can be addressed so that you don't repeat the same errors.
Q.

Have you formed an opinion about the Department of

Corrections' current process for reviewing deaths?

A.

Well, at the moment, there is really no process.

The death

reviews aren't occurring.

Q. Are they done at the individual prisons by the physicians

and others involved in care?

A

I think occasionally they are. And when they are done,

it's extremely superficial. And in most cases, they aren't

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How about at the Central Office's Health Care Services

Division, Doctor, are they doing reviews of these deaths there?

A.

They hadn't, and then there was a plan to start doing them.

I don't think they have started, but they may have started
recently doing them.

Q.

Is it your understanding that the Central Office death

review process is way behind?

A.

Yes.

Q. And from what facts do you draw that understanding, please?

A.

I've been told that by Central Office staff, including

Dr. Kanan.
Q.

And November and December of that last year, that is 2004,

Doctor, did the Department of Corrections approach you and Dr. Puisis and ask for help with the death reviews?
A.

Yes, they did.

They wanted us to basically triage a Since they were so far behind they --

certain number of them.

they felt to do full death reviews on all of them was beyond their capacity, and they wanted to triage them to try to pick out the ones that were most important to review. So we went through the information they had, which were -- some of the medical records, some reports, we didn't have the complete information. And in cases where it was clear that it was a terminal event and it was an expected death, we decided that those wouldn't be reviewed.

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But, as I said earlier, that is really not an optimal system because you want to look at all the deaths, because, like I said, in some of the cases of terminal illness that we found, if the patients had received the appropriate care earlier on, they might not have died from their terminal disease. In addition, even in those cases where people would die, no matter what you did, you can learn information sometimes that would help you in other situations respond more appropriately to patients presenting with similar problems.
Q. But their backlog was so great you and the other experts,

Dr. Puisis and Dr. Shansky, decided that those cases, this instance could be put to the side?
A.

The decision was made.

I don't remember if I had input

into that or not.

Q.

Thank you, Doctor. Go ahead, what other cases did you look at, or

groups of cases?
A.

I'm sorry.

In addition to the

-do you remember about how

Q.

Well, I'm sorry, Doctor, let me try this question: You

have just told us that among the

--

many cases the Department of Corrections presented to you and Dr. Puisis and Dr. Shansky?
A.

As I remember there were around 200, but I'm not sure of

that.
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Q. And was it your understanding that was all the cases that

were backlogged, that is all the deaths that were waiting for review up at Central Office?
A.

NO, my understanding was there were a lot more, but that

was the initial group that they were going to go through.

Q. All right.

And then you just have explained that some of

those cases involved events or circumstances where it was determined that no further review would be done, correct?
A.

Correct.

Q. And were there other categories of cases that you and the
other experts determined that this group of almost or approximately 200 fell into?
A.

There was a group where we felt we just didn't have enough

information to make a determination, and that they needed to be read with more information, when we got more of the medical records. And there was a group where we felt that even though we didn't have all the information, there was enough information that they were extremely concerning and felt that there were definitely problems and needed a more intense review.
Q. All right.

And are you aware of what the Department of

Corrections did with that latter group of cases?

A.

Yes.

I think there were about 34 of those cases, and they

were sent down to U.C. San Diego for the physician at QICM to

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Are you aware of whether the physicians at UC San Diego

have completed their review of any of those cases?

A.

I think they have completed all of them.

I got an E-mail

last night from Dr. Sherger that I mentioned before --

Q. Excuse me, who is Dr. Sherger?

A.

Dr. Sherger is one of the physicians on the staff of the

San Diego

-- the family practice program which is coordinating

all of this, who is coordinating the death reviews. So he has a group of physicians, I think it's three or four physicians, who are reviewing these death records and then writing reports. And he sent 23 of them last night in an E-mail to Dr. Kanan and to Dr. Puisis and I and some other people that were on the E-mail.
Q.
A.

Did you have an opportunity to review the E-mail? Yes, I did.

Q. And did you review the approximately two dozen reviews that
Dr. Sherger forwarded?
A.

Yes, I did.

Q. And what did those reviews conclude?

A.

Of the 23 cases

--

one actually was a patient who didn't

die, so I don't know why it was included in that. One was a patient who swallowed a bag of methamphetamine, and the bag dissolved and he died from that. So that was really an

unpreventable death, and there was no preceding history that

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would have helped you at all. But of the other 21, as I remember there were words like "gross deviation from standard of care," "egregious," 'multiple deviations." Basically, there was one patient where

they felt was a gross deviation of care who had a terminal illness where it might not have made a difference. But of the

other cases, as I remember, the other 20 they felt they all contributed

--

all the errors contributed to the eventual death

of the patient.
Q.

Doctor, the deaths and other inappropriate care that you

have described and the conclusions that you characterized having seen that have been reached by the University of California San Diego physicians, does that information suggest to you

--

what kind of risk do the inmate patients in the

Department of Corrections face given that kind of information?

A.

I think they face risk of significant morbidity and

mortality that they shouldn't be facing with appropriate medical care. unnecessarily. I mean, people, as I said, are dying People's health is deteriorating.

I mean, we are just talking here about the deaths. I mean, what

--

those are sort of the tip of the iceberg. What

you have below the surface are all the people with chronic illnesses, what we are calling high-risk problems, whose health status is just getting worse because they are not being appropriately treated.
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lives are going to be shortened because they are not getting appropriate medical care.

Q. Thank you, Doctor.

Have you had an opportunity

--

let me just ask you

more directly, have you formed an opinion regarding the management structure in the Department of Corrections as it relates to the delivery of medical services?
A.

Yes, I have, but before that, there is one more case I

would like to just mention.

Q. Well, Doctor, that is not responsive, but let me ask you a

question:

Is there another case

(Laughter. )

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BY MR. FAMA:

Q.

--

that you have looked at that concerns you such that you

would like to bring it to attention of the Court?

A.
Q.

Yes, there is. Could you please tell us about that. Yes. The reason is -- it was just in the report I sent

A.

out, and I don't know if you have had a chance to read it. just gave it to the Court yesterday.

Q. I'm sorry to interrupt.

Just so that we are clear here on the record, what does that report concern?
A.

That is what I was getting to.

My recent visits to

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San Quentin where one of the major things I did was I spent a lot of time reviewing OHU records and looking at people in the
OHU wing.

This is especially concerning because when we were in

--

at San Quentin in February, I spent some time, but And one of the

Dr. Puisis spent a lot of time in the OHU.

cases that he described was an elderly gentleman who had some dementia who

--

I think he had renal failure. And Dr. Puisis

describes his condition such that he was having trouble walking. There were times where he was described as lying in This

his own feces and just, basically, was being neglected. was on February 7th that Dr. Puisis was there.

When I read the death record, the gentleman was sent to the emergency room on February 8th, so somehow because

--

can only assume that as a result of our visit someone finally took the time to look at this man and decided, yeah, he really is sick and needs to go to the hospital. When he got to the hospital, they found that he was what is called pancytopenic, p-a-n-c-y-t-o-p-e-n-i-c, which means that all of his blood cells were low, so that his red blood cells, white blood cells and his platelets

--

his

hematocrit, I forget exactly, it was extremely low, very low. He was extreme anemic. They did a bone marrow, which is where they stick a needle into the bone so you can look at what is going on with
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the blood because that is where the blood is produced, and they found that he had no iron. Okay? So he was more than He also was

extremely iron deficient, he had no iron.

dehydrated and was in mild renal failure from being dehydrated. So it was clear that this man had just been totally neglected. There was evidence in Dr. Puisisl report that they had ordered blood tests to see his condition like two months before, but either it hadn't been done or the results weren't there and no one followed up on it, but these are

--

this was

condition that took a long time to develop. Given the descriptions of how medical staff was seeing this, the fact that no one took the time to really evaluate him and see if there was an underlying medical problem that could be treated, this was just criminal, as far as I'm concerned. disturbing.
Q.

It was very

And Doctor, am I assuming correctly that the facts of the

case you just described informed your opinions previously given regarding the adequacy of care and risk to inmate patients?
A.

Correct.
MR. FSMA:

Your Honor, instead of launching into a

new area, I think this might, if the Court would permit, would be a good time to recess for today.
THE COURT: Okay, we will.

We will recess for the day and continue with this testimony tomorrow, beginning at 8:30.

MR. FSMA:

Thank you, Your Honor.

The C o u r t i s a d j o u r n e d .

THE COURT:

(Proceedings adjourned at 1:00 p.m.)

CERTIFICATE OF REPORTER

I, Sahar McVickar, Official Court Reporter for the United States Court, Northern District of California, hereby certify that the foregoing proceedings were reported by me, a certified shorthand reporter, and were thereafter transcribed under my direction into typewriting; that the foregoing is a full, complete and true record of said proceedings as bound by me at the time of filing. The validity of the reporter's certification of said transcript may be void upon disassembly and/or removal from the court file.

Sahar McVickar, Official Court Reporter June 1, 2005