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Overview

CCWF Deaths

"I watched two women die on my yard that I was very close to...if I could see that the whites of their eyes were as yellow as a caution sign, why couldn't somebody else? Every day she asked me: 'Am I gonna die here? Am I gonna die here? Do you think that's what's gonna happen to me?' And there was nothing I could do about it. And I know that something could be done" - Beverly Henry, incarcerated at CCWF, testifying before the California State Legislature, October 11, 2000.

Waves of grief and anxiety have swept through Central California Women's Facility (CCWF), as women prisoners witnessed the ninth death of a fellow prisoner within a period of eight weeks. At least three of the nine women died suddenly and unexpectedly. A team of doctors from nearby universities appointed to investigate the three "unexpected" deaths concluded that two of them could have been prevented. These deaths are unconscionable, coming as they do in the wake of the dismissal of the Shumate lawsuit and the historic two-day long legislative hearings held in October addressing the conditions inside the women's prisons.

Jody Fitzgerald, 31 years old, died on November 11, 2000 after having been very ill for weeks, complaining of extreme fatigue, loss of vision, weight loss, and inability to eat. As her health steadily declined, she was bathed and fed and assisted in the toilet by her cellmates. She was unable to walk without their help. Her cellmates repeatedly asked that she be seen by the medical department, but were told by staff that "it's all in her head". Both custody and medical staff believed she was faking and sent her for psychological evaluation. Instead of being taken to the medical unit, she was sent to the mental health unit, where she died a week later. One of her cellmates, Maria, wrote to outside advocates: "It took her [Jody Fitzgerald's] death to let them believe she was ill...if they took time to treat her, she may have had a chance, but instead they neglected medical treatment..her life is valued just as any other human's, and she should have been treated like one."

Pamela Coffey, 46, died on December 2, collapsed on the bathroom floor of her cell, about three hours after her cellmates had called for medical help for her. Ms. Coffey had unsuccessfully sought treatment for a mass on her side; her abdomen was reportedly so swollen that she looked nine months pregnant. On the evening of her death, she complained of terrible abdominal pain and numbness in her legs; her tongue was so swollen she could barely speak. According to eyewitness testimony, a Medical Technical Assistant (MTA) -- a guard with low-level medical training-- arrived on the scene but did not examine her. Rhonda Smith, who witnessed Ms. Coffey's death, told investigators:" When he [the MTA} came out of the room, he was laughing. He said ' I can't understand a word she's saying - you can do more for her than I can'. I was like, 'This isn't funny.'" Ms. Coffey's condition worsened; she lost control of her bowels and began vomiting blood. Her cellmates cleaned her up, and comforted her, and called desperately for help.The MTA was again summoned, and arrived about 30 minutes later. By then, Ms. Coffey was dead. Her body was left in the cell for over an hour, further traumatizing her cellmates, who had been forced to witness her death.

The medical investigators reviewing the circumstances surrounding Ms. Coffey's death concluded that "there were significant problems with Ms. Coffey's medical care that might have contributed to her death". The report notes that abnormal blood tests were not followed up in the days prior to her death, and one of the investigators, Dr. Kathleen Clanon of University of California at San Francisco, determined that the MTA who examined her should have sought more help.

Eva Vallario, 33, died in a holding cell in back of the visiting room on December 15 after undergoing a strip-search following her visit. Ms. Vallario had a history of asthma that appeared to have been poorly managed by prison medical staff. The report by outside investigators concluded that Ms. Vallario apparently died after choking on her vomit, and that "there is a substantial likelihood that she could have been resuscitated if she had been ventilated earlier". Ms. Vallario's sister, Misty Miller, testified at her sister's funeral about the loss to her and her family: " I feel that my sister has passed the most important test of all. She was born into a difficult life, with a fierce personality and a spirit full of fire. She took everything that was thrown at her with a strong heart and mind. My sister has always been my protector, my shield, my friend...it is my turn to be her protector. So, as I create my own shield and prepare to face this life without her, I let you all know that she will never be forgotten or disregarded... Do not forget her, because I never will."

Stephanie Hardie, 34, died December 9 at CCWF. The investigation by Dr. Clanon found that Ms. Hardie never received proper treatment for her complaints of shortness of breath and chest pain.

Other women who died in this time period include Leila Peyton, believed to have been co-infected with HIV and Hepatitis C, Carolina Paredes, who suffered from long delays in medical treatment for her cancer , and Michelle Wilson, who had a brain tumor and apparently died of complications following long delays in treatment, including a brain infection secondary to the treatment and a punctured lung.

Prison officials have responded to this crisis with internal memos and press releases suggesting that the women who died probably were using "bad drugs", ( a theory disproved by each autopsy report) or from sharing their medications with each other. They have punished the women by searching and upending their cells, confiscating medications, and threatening to break up the living arrangements of any women who ask for medical assistance in the middle of the night. One woman wrote: "Our administration has elected to punish us because our peers are dying...these ladies died due to uncompassionate and incompetent medical staff. Nothing else. Not only were those women abused by this system, so were those of us who survived their deaths... a team was assembled and thrashed our cells withing 1-2 hours of the last death...but not one inmate has been afforded grief counseling."

A Multi-leveled Community Response

On January 11, a community meeting was held at the San Francisco Women's Building about the urgent situation at the prison. What was initially scheduled to be a report back on the historic legislative hearings held at the women's prisons in October became a speak-out on yet another wave of prisoner deaths. Family members from all over the state spoke to a packed audience about the loss of their loved ones. They demand that prison officials answer for the deaths, and implement changes in the medical system so that women would not continue to die behind the walls.

The public outcry over the deaths led to a second legislative hearing, held on January 17 in Sacramento at the insistence of prisoner rights advocates. This hearing was attended by many family members who had lost a loved one to the state's negligent medical care, as well as many concerned members of the community. After a press conference on the steps of the Capitol, family members testified about the circumstances surrounding the death of their loved ones, spoke of their grief and loss, and demanded that the California Department of Corrections (CDC) take responsibility for letting their mothers and daughters and sisters die unnecessarily. The CDC's official response was predictably evasive and defensive of their medical department. They found no wrongdoing by anyone in their department, and took no official responsibility for the deaths. When family members asked for a response, the CDC's Deputy Director of Health Services, Dr. Susann Steinberg, beat a hasty retreat and refused to speak to family members. Dr. Steinberg has day-to day responsibility for the administration of healthcare in the prisons, and has consistently side-stepped charges of substandard care with comments about the "human failings" of any medical system. Within days of this "whitewash" hearing, the report by outside doctors found the CDC culpable in two of the three deaths investigated.

The mobilization of people committed to ending the deaths continued with a dramatic demonstration at the gates of the prison on January 27. Over 100 people from all over California held a memorial/protest at CCWF, to honor and remember the women who died, and to demand that measures be taken to stop the deaths. Relatives of women who died again spoke out, as well as many formerly incarcerated people, demanding that the CDC take responsibility for the deaths. "My mother was sentenced to a prison term, she wasn't sentenced to death", said the daughter of deceased prisoner Pamela Coffey. Protesters demanded a thorough investigation into the deaths, an end to the use of MTAs, and the most comprehensive demand, that the medical care delivery system for prisoners be taken out of the hands of the CDC and assigned to an entity such as the state university system, where outside oversight and a higher degree of professionalism could save prisoners lives.

Health care for women prisoners -- a long battle

The recent deaths at CCWF do not come in a vacuum.The battle over medical care has been fought by women prisoners for at least seven years. The Shumate lawsuit challenged several aspects of negligent care: the lack of access to doctors, the failure to provide follow-up care to chronically ill women, constant interruption of medications such as insulin, hypertension medications, and protease inhibitors, and the failure to provide consistent preventative care such as paps and mammograms. Investigative reporters have written several major articles about medical neglect, Ted Koppel's Nightline series exposed the horrendous conditions for California's women prisoners.

After the Shumate suit was settled and the prisons found to be in compliance with all provisions of that settlement (a finding disputed by the women and their attorneys), there were several meetings, letters and phone calls between legal advocates and the CDC 's medical representatives, notifying them of the names and critical condition of several of the seriously ill prisoners. The California State Legislature held unprecedented hearings, listening to at least five hours of testimony of death and needless suffering by women prisoners. Yet women continue to die, and the deaths are dismissed as "natural causes". Prisoner rights advocates are concentrating on a some key demands now to focus the next phase of the fight: abolishing the MTA position, granting compassionate release to women who are dying in prison, abolishing the $5.00 payment required of prisoners for medical visits, removing the healthcare system from control of the CDC, and an independent investigation of the ongoing medical crisis in women's prisons.

MTA s: cops and caregivers all in one?

One of the critical issues being taken up by the legislature is the use of MTAs, guards who perform a dual role of guard and provider of medical care. Prisoner rights advocates have long argued that an MTA cannot reasonably function in both roles, because the first priority will always be "security" and control over the provision of medical care. Several of the women who died in the recent rash of deaths had been "treated" by an MTA within hours of their death. The MTAs appear to have made assessments of the severity of a woman's illness, and denied them access to a doctor based on their evaluation.This evaluation process, known as triaging, is inappropriate for someone with only basic medical training.

The Shumate lawsuit reaffirmed that MTAs are not supposed to triage, only to take vital signs, yet the numerous accounts of the death of Pamela Coffey indicate that the standard of care agreed to in Shumate was not followed. Some of the efforts to bring about change are beginning to be reflected in the legislature. State Senator Sheila Kuehl has drafted legislation to end the use of MTAs in the California prison system, a move that is being vigorously opposed by the prison guard's union. She is also sponsoring a bill to abolish the $5.00 fee for treatment, as well as a bill to require that the CDC seek accreditation from the National Commission on Correctional Health Care in order to raise the standard of care.

The Struggle Continues

The urgency of the situation faced by women prisoners demands an all-out effort to stop the deaths and change the health care system. The passion for justice is driven by the women prisoners themselves, who, at great risk to themselves, come forward to let the world know about what goes on behind the walls. Their demands are being taken up by their family members, their advocates and a growing community of people who support them. Amnesty International has joined the fight; in a press release last December, they stated: "What is clear is that there continues to be serious question about the delivery of healthcare and the ability of the MTAs to respond in crisis situations. The time has come for medical standards to be independently-and regularly- monitored". As advocates, we will continue to use everything at our disposal -legislative work, media advocacy, community mobilizing, and legal action- to win justice for women prisoners.