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RATES OF INMATE SUICIDES AND SUICIDE ATTEMPTS IN STATE PRISONS FROM 2012 THROUGH 2016
The Joint Legislative Audit Committee (Audit Committee) requested that we compare the rates of suicides and attempted suicides for male and female inmates in all state prisons from 2014 through 2016. In order to calculate these rates, we used data from Corrections’ COMPSTAT system because it is the most comprehensive source of publicly reported data for the entire correctional system. Based on our analysis of COMPSTAT data, Table A presents the rates and number of inmate suicides and suicide attempts at each state prison from 2012 through 2016. As we discuss in Chapter 3, the data from COMPSTAT on inmate suicides and attempted suicides are unreliable; however, they are also the most comprehensive, as well as being the data Corrections makes available to the public. Therefore, we present the data here but recommend in Chapter 3 that Corrections take steps to ensure its accuracy in the future.
Suicides and Suicide Attempts in Each California Prison From 2012 Through 2016
|POPULATION||ATTEMPTED SUICIDES||SUICIDES||POPULATION||ATTEMPTED SUICIDES||SUICIDES||POPULATION||ATTEMPTED SUICIDES||SUICIDES||POPULATION||ATTEMPTED SUICIDES||SUICIDES||POPULATION||ATTEMPTED SUICIDES||SUICIDES|
|TOTALS||PER 1,000||TOTALS||PER 1,000||TOTALS||PER 1,000||TOTALS||PER 1,000||TOTALS||PER 1,000||TOTALS||PER 1,000||TOTALS||PER 1,000||TOTALS||PER 1,000||TOTALS||PER 1,000||TOTALS||PER 1,000|
|Avenal State Prison||5,020||5||1.00||1||0.20||4,497||3||0.67||0||0.00||4,028||4||0.99||0||0.00||3,369||3||0.89||0||0.00||3,274||2||0.61||0||0.00|
|California City Correctional Facility||—||—||—||—||—||—||—||—||—||—||1,825||0||0.00||0||0.00||—||—||—||—||—||1,933||0||0.00||0||0.00|
|California Correctional Center||4,657||2||0.43||0||0.00||4,903||2||0.41||0||0.00||4,909||0||0.00||1||0.20||4,138||1||0.24||0||0.00||3,991||0||0.00||1||0.25|
|California Correctional Institution||4,643||5||1.08||1||0.22||4,572||5||1.09||1||0.22||4,404||3||0.68||2||0.45||3,949||11||2.79||1||0.25||3,435||17||4.95||2||0.58|
|California Health Care Facility||—||—||—||—||—||—||—||—||—||—||1,626||17||10.45||0||0.00||—||—||—||—||—||2,342||26||11.10||1||0.43|
|California Institute for Men||5,002||10||2.00||0||0.00||4,747||7||1.47||0||0.00||4,636||13||2.80||1||0.22||3,859||7||1.81||1||0.26||3,669||6||1.64||0||0.00|
|California Institute for Women||1,636||13||7.95||1||0.61||2,095||15||7.16||0||0.00||1,994||15||7.52||2||1.00||1,887||34||18.02||2||1.06||1,882||24||12.75||2||1.06|
|California Medical Facility||2,363||17||7.19||1||0.42||2,250||28||12.45||2||0.89||2,082||16||7.69||1||0.48||2,342||15||6.41||1||0.43||2,563||8||3.12||0||0.00|
|California Men’s Colony||5,368||21||3.91||0||0.00||4,983||29||5.82||0||0.00||4,368||18||4.12||0||0.00||3,910||15||3.84||2||0.51||4,101||12||2.93||3||0.73|
|California Rehabilitation Center||3,694||1||0.27||0||0.00||3,434||1||0.29||0||0.00||2,826||0||0.00||0||0.00||4,946||7||1.42||0||0.00||3,006||2||0.67||0||0.00|
|California State Prison, Corcoran||4,626||20||4.32||1||0.22||4,410||16||3.63||1||0.23||4,335||17||3.92||0||0.00||4,280||20||4.67||1||0.23||3,640||33||9.07||0||0.00|
|California State Prison, Los Angeles County||3,848||13||3.38||0||0.00||3,723||7||1.88||1||0.27||3,587||22||6.13||0||0.00||3,520||11||3.13||0||0.00||3,479||19||5.46||2||0.57|
|California State Prison, Sacramento||2,693||22||8.17||1||0.37||2,233||32||14.33||1||0.45||2,212||11||4.97||2||0.90||2,240||12||5.36||3||1.34||2,339||8||3.42||2||0.86|
|California State Prison, Solano||4,313||4||0.93||1||0.23||4,007||2||0.50||0||0.00||4,005||8||2.00||1||0.25||3,858||5||1.30||0||0.00||3,983||2||0.50||0||0.00|
|California Substance Abuse Treatment Facility and State Prison||5,683||15||2.64||0||0.00||5,603||11||1.96||0||0.00||5,435||16||2.94||1||0.18||5,489||19||3.46||0||0.00||5,296||32||6.04||0||0.00|
|California Training Facility, Soledad||5,759||4||0.69||0||0.00||5,279||3||0.57||2||0.38||4,963||5||1.01||0||0.00||2,539||1||0.39||0||0.00||5,184||5||0.96||0||0.00|
|Calipatria State Prison||3,814||0||0.00||0||0.00||3,621||12||3.31||0||0.00||3,863||5||1.29||0||0.00||3,792||2||0.53||0||0.00||3,819||0||0.00||0||0.00|
|Centinela State Prison||3,659||2||0.55||1||0.27||3,025||1||0.33||0||0.00||2,862||0||0.00||0||0.00||3,287||4||1.22||0||0.00||3,614||4||1.11||0||0.00|
|Central California Women’s Facility||2,934||5||1.70||0||0.00||3,532||8||2.27||0||0.00||3,652||6||1.64||0||0.00||3,000||11||3.67||0||0.00||2,861||25||8.74||1||0.35|
|Chuckawalla Valley State Prison||2,712||0||0.00||0||0.00||2,594||0||0.00||0||0.00||2,315||1||0.43||0||0.00||2,150||0||0.00||0||0.00||2,425||0||0.00||0||0.00|
|Deuel Vocational Institution||2,504||12||4.79||2||0.80||2,515||6||2.39||0||0.00||2,561||14||5.47||0||0.00||2,361||10||4.24||3||1.27||2,340||14||5.98||0||0.00|
|Folsom State Prison||2,840||2||0.70||3||1.06||3,017||4||1.33||3||0.99||3,100||2||0.65||0||0.00||2,913||0||0.00||1||0.34||2,979||1||0.34||1||0.34|
|High Desert State Prison||3,695||8||2.17||0||0.00||3,359||2||0.60||1||0.30||3,421||9||2.63||1||0.29||3,416||1||0.29||0||0.00||3,702||2||0.54||0||0.00|
|Ironwood State Prison||3,503||3||0.86||0||0.00||3,273||3||0.92||0||0.00||3,018||5||1.66||0||0.00||3,392||1||0.29||0||0.00||3,265||1||0.31||0||0.00|
|Kern Valley State Prison||4,108||10||2.43||0||0.00||3,728||20||5.36||1||0.27||3,804||30||7.89||1||0.26||3,759||26||6.92||0||0.00||3,910||16||4.09||3||0.77|
|Mule Creek State Prison||3,027||15||4.96||1||0.33||2,822||13||4.61||1||0.35||2,908||17||5.85||2||0.69||2,869||22||7.67||0||0.00||3,266||18||5.51||0||0.00|
|North Kern State Prison||4,680||8||1.71||0||0.00||4,761||14||2.94||1||0.21||4,591||18||3.92||0||0.00||4,243||11||2.59||0||0.00||4,381||5||1.14||1||0.23|
|Pelican Bay State Prison||3,091||11||3.56||0||0.00||2,785||17||6.10||0||0.00||2,777||4||1.44||1||0.36||2,647||11||4.16||0||0.00||2,247||15||6.67||1||0.44|
|Pleasant Valley State Prison||3,737||8||2.14||2||0.54||3,412||5||1.47||1||0.29||3,113||7||2.25||0||0.00||2,868||2||0.70||0||0.00||3,206||1||0.31||1||0.31|
|Richard J. Donovan Correctional Facility||3,537||28||7.92||0||0.00||3,355||33||9.84||3||0.89||3,076||22||7.15||1||0.33||3,114||51||16.38||1||0.32||3,112||59||18.96||0||0.00|
|Sierra Conservation Center||4,555||1||0.22||1||0.22||4,856||4||0.82||0||0.00||4,628||2||0.43||0||0.00||4,377||3||0.69||0||0.00||4,329||3||0.69||0||0.00|
|San Quentin State Prison||3,853||13||3.37||3||0.78||4,206||14||3.33||3||0.71||3,920||12||3.06||2||0.51||3,720||14||3.76||2||0.54||3,953||10||2.53||0||0.00|
|Salinas Valley State Prison||3,607||37||10.26||4||1.11||3,503||27||7.71||2||0.57||3,415||19||5.56||1||0.29||3,663||23||6.28||0||0.00||3,718||17||4.57||4||1.08|
|Valley State Prison||2,074||12||5.79||0||0.00||3,004||3||1.00||0||0.00||3,243||7||2.16||0||0.00||3,339||11||3.29||0||0.00||3,455||6||1.74||0||0.00|
|Wasco State Prison||5,043||25||4.96||1||0.20||5,134||27||5.26||1||0.19||5,154||20||3.88||0||0.00||4,897||27||5.51||0||0.00||4,983||26||5.22||0||0.00|
Source: California State Auditor’s analysis of Corrections’ COMPSTAT metrics.
Notes: As we note in Chapter 3 of the audit report, our review of various records from individual prisons revealed that COMPSTAT has consistently underreported the number of suicides in California prisons. The numbers in this table are not adjusted; we present them as they appear in COMPSTAT.
Italicized rows represent the four prisons reviewed in this audit.
* Because we calculated populations based on a 12‑month average, annual population amounts may differ from the total prison populations due to rounding.
SCOPE AND METHODOLOGY
The Audit Committee directed the California State Auditor to perform an audit of Corrections’ policies, procedures, and practices related to suicide prevention and reduction. We were directed to review the suicide and attempted suicide rates for male and female inmates in all state prisons; Corrections’ policies and procedures for inmate suicide prevention and response, as well as their implementation; and CIW’s implementation of Corrections’ policies. We were also asked to determine areas in which Corrections could improve its mental health services, causes for CIW’s high suicide rates, and the adequacy of mental health and suicide prevention training for CIW staff. Table B lists the objectives that the Audit Committee approved and summarizes the methods we used to address those objectives.
|1||Review and evaluate the laws, rules, and regulations significant to the audit objectives.||Reviewed relevant state laws and regulations.|
|2||Evaluate Corrections’ policies and procedures for inmate suicide prevention and response, including those related to instances when an inmate exhibits suicidal behavior. Determine whether such policies and procedures are implemented consistently throughout California’s state prisons.||
|3||For the most recent three‑year period, compare the suicide and attempted suicide rates for male and female inmates in all state prisons.||
|4||Identify areas where Corrections can improve its mental health services, particularly with respect to the safety and care for inmates needing mental health treatment.||
|5||In reviewing the CIW do the following:
a.) Evaluate whether CIW appropriately implemented Corrections’ suicide prevention policies.
|The procedures we performed in Objective 2 also addressed this objective.|
|b.) Identify and analyze CIW’s policies and procedures in the event of a suicide, including any ensuing investigation and communication with the deceased inmate’s family during and after such investigation.||
|c.) To the extent possible, identify the causes or factors contributing to the higher rates of suicide and suicide attempts at CIW, including any systemic problems or failures.||
|d.) Identify and analyze CIW’s policies and practices in the event that an inmate displays suicidal behavior. Evaluate CIW’s ability to appropriately house and treat inmates identified as suicidal and determine whether CIW allows access to inmate program activities or movements such as yard time.||
|e.) Evaluate the adequacy of the mental health and suicide prevention training for CIW staff.||
|6||Review and assess any other issues that are significant to the audit.||
Sources: California State Auditor's analysis of the Audit Committee's audit request number 2016‑131, planning documents, and analysis of information and documentation identified in the table column titled Method.
Assessment of Data Reliability
In performing this audit, we obtained data from Corrections’ COMPSTAT organizational management tool. The U.S. Government Accountability Office, whose standards we are statutorily required to follow, requires us to assess the sufficiency and appropriateness of computer‑processed information that we use to support findings, conclusions, or recommendations. Corrections’ COMPSTAT tool provides monthly data to stakeholders and the public on a variety of measures at each of Corrections’ prisons and other institutions. We used COMPSTAT data to report on the number of suicides and attempted suicides throughout California’s adult prisons. We performed data‑set verification procedures and found no errors. Further, as reported in Chapter 3, we assessed the accuracy and completeness of COMPSTAT data by comparing the data on suicides and attempted suicides for selected months to incident logs from the four prisons we visited and identified several errors. We also compared the number of suicides reported in COMPSTAT to those in reports from the special master’s suicide experts and found they did not agree. Finally, during the course of our audit work, we identified one suicide each at three of the four prisons we visited that was not included in COMPSTAT. As a result, we determined that COMPSTAT data are not sufficiently reliable for the purposes of this audit. Nevertheless, we present these data in the report because COMPSTAT is Corrections’ comprehensive source of data available on suicides and attempted suicides for each of its prisons, and it contains data Corrections makes publicly available. We discuss our findings in more detail in Chapter 3 and make a recommendation for improving the data.
We also obtained summary data from Corrections on the rates at which its employees attend various trainings. We tested selected employees at CIW and determined they did not all attend required trainings. We requested self‑reported summary data from Corrections for each of the four prisons we visited to determine whether there was evidence at each prison to corroborate our findings at CIW. Because the data corroborated our findings, we determined it would be too resource‑intensive to further test the accuracy and completeness of the prisons’ self‑reported data. Instead, we clearly attribute the data in the report to Corrections.