Inspector General: California prison transfers during coronavirus caused public health disaster at San Quentin

The Office of the Inspector General, which is the independent oversight body over the California prison system, issued a scathing report Monday on how officials handled coronavirus transfers, saying that the preparation and execution of the transfers were "deeply flawed and risked the health and lives of thousands of incarcerated persons and staff."

In fact, the OIG went a step further, saying that the California Correctional Health Care Services and the California Department of Corrections and Rehabilitation caused a "public health disaster" at San Quentin when they transferred medically vulnerable incarcerated people from the California Institute for Men in Chino to the Marin County prison "without taking the proper safeguards" roughly seven months ago.

Investigators also found that there were similar problems with the transfer of people to the state prison in Corcoran but that outbreak was much smaller mostly because of the architecture of the prison. 

The OIG even put together a timelapse video to show how quickly the virus spread.

Their report, signed by Inspector General Roy Wesley, was ordered at the behest of Speaker of the California Assembly Anthony Rendon this spring. The oversight body cannot fine the prison system and has the power only to make recommendations. In this case, the findings were made public for transparency's sake, said OIG spokesman Shaun Spillane. It is up to lawmakers and key stakeholders to decide what to do about it. 

To date, 192 incarcerated people have died in California prisons since March. San Quentin had the most deaths: 28. At the height of the outbreak in August, 2,237 people at San Quentin had tested positive for the virus. 

In a joint statement, the prison and prison healthcare system explained what happened from their point of view. They said they appreciated the review, but noted there were "many factors that contributed to the need to move medically high-risk individuals from CIM last May that are not reflected in the report."

Prison authorities said that the transfers were done with the intent to mitigate potential harm and were based on a "thoughtful risk analysis using scientific information available" in May.

"We have acknowledged some mistakes were made in the process of these transfers, and both CCHCS and CDCR have made appropriate changes to patient movement since that time," the prison statement said. 

Some of these changes include increased testing, designated isolation and quarantine spaces, and better personal protective equipment.

The prison authorities said that "it is important to note" that since the changes were implemented, there have been no outbreaks attributed to institution transfers.

However, the state oversight inspectors have a different view of what transpired. 

The OIG investigators said that the prison system was insisting that they had to meet a tight deadline for the transfers to occur from Chino to San Quentin and Corcoran in May, even though the vast majority had not been recently tested for COVID-19.

According to email conversations that the OIG reviewed, a California Institution for Men health care executive "explicitly ordered that the incarcerated persons not be retested the day before the transfers began," and multiple prison health executives were aware of the outdated nature of the tests before the transfers occurred.

"With outdated test results, the prison had no way to know whether any of the incarcerated persons were currently infected with the virus," the OIG found.

Plus, prison health care staff conducted verbal and temperature screenings on many people about to be transferred, but those screenings were conducted too early to determine whether they had symptoms of COVID-19 when they boarded the buses, the OIG's report found. 

As a result, some of the incarcerated people may have been experiencing COVID-19 symptoms when they left the prison. And then, the OIG found, prison authorities still packed the transfer busses, not allowing enough room for physical distancing. The state investigators called this an "inexplicable decision." 

Looking back to the origins of the spread, the state investigators said that nurses at San Quentin immediately noted that two people from Chino had COVID-19.

Nonetheless, the prison housed almost all of the incarcerated persons who arrived from the California Institution for Men in a housing unit without solid doors, allowing air to flow in and out of the cells, the report found.

By the time the prison tested the incarcerated persons for COVID-19, many of those who tested positive had been housed in the unit for at least six days.

The virus then spread quickly through the housing unit and to multiple areas throughout the prison. After the transfers were botched, the OIG review also found that San Quentin and CIM  failed to properly conduct contact tracing investigations. According to San Quentin, there were too many positive cases over a short period of time to conduct contact tracing.

To conduct this report, OIG investigators reviewed records from the California Institution for Men—the sending prison—and Corcoran and San Quentin—the two receiving prisons. 

A team of OIG staff visited the three prisons, where they interviewed managers and at least 56 incarcerated people, and also directly observed prison operations.

In addition, the OIG investigators read class-action lawsuits that name the department as a party, as well as published articles and reports related to outbreaks in the prison environment. 

This third OIG report confirms CDCR violated the 8th Amendment when it transferred people from CIM to San Quentin. CDCR officials were advised by medical staff in writing the dangers transfers presented, and medical staff advised the transfer should be slowed down. CDCR  proceeded anyway stating the benefits outweighed the risks.  CDCR should not be entrusted with conducting transfers.

To Marin County Deputy Public Defender Kathleen Boyle, the findings were neither new nor surprising. She and other lawyers have sued the Attorney General and the prison system to release about 300 incarcerated people from San Quentin, citing just these conditions.

And nothing, she said, has changed.

In the north and west blocked, the cells remain open and there are no solid doors. Cells are 4 feet by 9 feet and most contain two people, meaning social distancing is impossible, she said. Plus, she noted, there is poor ventilation. And while people wear masks during the day, most everyone takes them off when they sleep.

"Those who have not contracted the virus are understandably terrified about doing so; those who did get sick during the outbreak are very concerned about reinfection, particularly considering the arrival of new variants," Boyle said. 

The coronavirus outbreak in the prison has also become the subject of an investigation by the State Senate and is a rallying cry for many civil rights activists who even held a car caravan rally on the Bay Bridge this weekend. They openly called on Gov. Gavin Newsom to authorize the release of thousands of more people from the state prison system.

They asked what the point of ending the death penalty was if the governor is just allowing incarcerated people to die of a deadly disease behind bars? 

"He put a moratorium on the death penalty, and is now subjecting people to the death of COVID-19," said Nube Brown, managing editor of San Francisco BayView, who was one of the dozens gathered at Middle Harbor Shoreline Park in Oakland. "He needs to release our people and release them now."


KTVU photography Jacy Lockhart contributed to this report. Lisa Fernandez is a reporter for KTVU. Email Lisa at or call her at (510) 874-0139. Or follow her on Twitter @ljfernandez.