Coleman, et al v. Schwarzenegger, et al

Filing 4394

ORDER signed by Judge Lawrence K. Karlton on 3/15/13 ORDERING that Defendants' objections to the 2011 Suicide Report are overruled; Except as expressly provided in this order, defendants' 2/11/13 MOTION to Strike or Modify portions of the 2 011 Suicide Report 4323 is DENIED; and within five days from the date of this order defendants shall file under seal a copy of the final coroner's report of the death of Inmate HH and provide a hard copy of said report to the Special Master. (Mena-Sanchez, L)

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IN THE UNITED STATES DISTRICT COURT

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FOR THE EASTERN DISTRICT OF CALIFORNIA

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RALPH COLEMAN, et al.,
Plaintiffs,

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vs.

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No. 2:90-cv-0520 LKK JFM P

EDMUND G. BROWN, JR., et al.,
Defendants.

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ORDER
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By order filed January 17, 2013, the court directed the Special Master to file

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within fourteen days his expert’s Report on Suicides Completed in the California Department of

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Corrections and Rehabilitation (CDCR) in Calendar Year 2011 (Report or 2011 Suicide

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Report).1 Order filed January 17, 2013 (ECF No. 4297) at 2. Pursuant to that order, any

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objections to the 2011 Suicide Report were to be filed within fifteen days of its filing. Id. On

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January 25, 2013, the Special Master filed the Report (ECF No. 4308), prepared by his expert,

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Dr. Raymond Patterson. On February 11, 2013, defendants filed objections and a motion to

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strike or modify portions of the Report (Objections) (ECF No. 4326). On February 21, 2013,

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after receiving leave of court to do so (ECF No. 4337), plaintiffs filed an opposition to

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The order was precipitated by motions filed by defendants on January 7, 2013 to terminate
this action and vacate the judgment and orders of this court (termination motion), and to modify
or vacate the population reduction order of the three-judge court.
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defendants’ objections and motion to strike or modify the Report (Plaintiffs’ Opposition) (ECF

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No. 4350). Defendants’ objections and motion to strike or modify the Report are resolved

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herein.2

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As with their objections to the Special Master’s Twenty-Fifth Round Monitoring

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Report, defendants’ principal objection to the Report is that it is not focused on a constitutional

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standard. See Objections at 1. In this context, defendants assert that “[t]he Constitution requires

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that the State establish a basic program to identify, treat, and supervise inmates with suicidal

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tendencies; it does not mandate that the prisons eliminate all suicide risks.” Id. Citing to their

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termination motion, defendants contend that “California’s prison system exceeds that standard

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because the State has fully implemented and staffed a thorough, standardized suicide-prevention

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and investigation program.” Id. The termination motion is not before the court at this time. The

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court will consider defendants’ arguments and evidence in support of the termination motion

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when that motion is fully briefed and argued.

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I. Overall Objections to Statements in Report
Defendants interpose a number of specific objections to the Report. Each is

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addressed in turn.
A. Total Number of CDCR Inmate Suicides in 2011

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Defendants object to the finding that there were 34 inmate suicides in calendar

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year 2011 and, on that basis, move to strike the finding “the rate of CDCR inmates suicides in

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2011 was 21.01 per 100,000, which was essentially unchanged since 2010, when it was 21.1 per

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100,000.” Objections at 6 (quoting Report at 1.) Defendants contend that the conclusion that the

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death of inmate HH “was more likely than not to have been a suicide” is “speculative and lacks

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foundation.” Objections at 6. In support of this contention, defendants note that the case was

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On March 13, 2013, pursuant to this court’s January 20, 2013 order (ECF No. 4319),
the Special Master filed a report on inmate suicides completed in the CDCR in the first half of
2012 (ECF No. 4377). Pursuant to the January 20, 2013 order, objections to that report are due
ten days from its filing and will be resolved by separate order.
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referred to the Solano County District Attorney’s Office for criminal investigation, that the

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CDCR suicide reviewer “could not conclude that the death was a suicide” and that “additional

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information” in the case review for this inmate’s death set forth in Appendix F of the Report

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“reflects that the death may not represent a suicidal hanging.” Id.

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The case review for this inmate’s death, set forth in Appendix F of the Report,

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shows that there is sufficient evidence to support the finding. See Report at 282-290. Included

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in the case review is the fact that the death was processed as a possible homicide and “a CDCR

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Form 7229-B report of inmate suicide to the suicide response coordinator at DCHCS was filed.”

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Id. at 287. Defendants have tendered no evidence of the outcome of the criminal investigation,

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nor any evidence that the death has been definitively ruled a homicide, nor any evidence that

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Inmate HH’s cellmate was prosecuted for homicide. Dr. Patterson’s finding that inmate HH’s

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death “was more likely than not to have been a suicide” is neither speculative nor without

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foundation and this objection is therefore overruled.

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Defendants’ expert, Dr. Joel Dvoskin, states in his report that this death was

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“declared a homicide by the coroner.” Dvoskin Response to 2011 Suicide Report, attached as

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Ex. 1 to Declaration of Debbie Vorous (hereafter Dvoskin Resp.), filed February 11, 2013 (ECF

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No. 4326-6), at 26. In the Report’s case review for inmate HH, Dr. Patterson noted first that the

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coroner was to make a “final determination of the manner of death” and thereafter that “the

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coroner’s report did not state a manner of death.” Report at 284. Dr. Patterson specifically

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invited any additional information in this regard. See Report at 290 (“Lastly, it is the Special

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Master’s reviewer’s analysis that the assumption by CSP/Solano clinicians that this was a suicide

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was correct. The pathologist’s report of the autopsy as this death possibly being staged left an

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open question that was never addressed by the pathologist in any of the documents that were

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presented to bring closure, other than the death was from asphyxiation. If there is additional

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information based on the investigative services report or other investigations or analysis that

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would suggest that this death was more likely a homicide or accident, that information should be
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provided or disclosed for further review.) (Emphasis added.)
The reason for the discrepancies concerning the coroner’s report for this inmate’s

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death is not clear on the record before this court. Moreover, those discrepancies must be

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resolved prior to ruling on defendants’ motion to modify the findings concerning the rate of

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CDCR inmate suicides in 2011. Good cause appearing, defendants will be directed to forthwith

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file a copy of the final coroner’s report for this inmate’s death under seal and to provide a hard

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copy to the Special Master. Ruling on defendants’ motion to modify the findings concerning the

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rate of CDCR inmate suicides in 2011 is deferred pending review of the final coroner’s report for

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inmate HH’s death.

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B. Language Concerning 2011 Suicide Rate in CDCR Prisons and Comparison to Other
Suicide Rates

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Defendants move to strike language in the Report comparing the inmate suicide

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rate in CDCR prisons unfavorably to other U.S. state prison systems and the U.S. federal prison

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system and describing the suicide rate as “growing” and “worsening.” Objections at 6-7. This

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request essentially tracks objections and a request to strike made by defendants in response to the

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Special Master’s Twenty-Fifth Round Monitoring Report and will be denied for the reasons set

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forth in this court’s February 28, 2013 order. See Order filed February 28, 2013 (ECF No. 4361),

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at 7-8.3 As set forth in that order, the question of whether defendants’ suicide prevention efforts

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are consistent with the requirements of the Eighth Amendment is reserved for hearing on

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defendants’ termination motion.

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Defendants also contend in the instant objections that there is “no evidence to support a
presumption these allegedly higher rates ‘are the result of inadequate or poor mental health
services.’” Objections at 7 (quoting Dvoskin Resp. at 5). This objection is overruled. The
Dvoskin Response does not stand for the proposition for which it is cited. Rather, Dr. Dvoskin
states that “In order to determine the causes of [the higher inmate suicide rates in California],
one must not presume that they are the result of inadequate or poor mental health services, and
consider other alternative explanations as well.” Dvoskin Resp. at 5.
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C. Language Concerning Total Number and Percentage of CDCR Inmate Suicides with
“At Least Some Degree of Inadequacy in Assessment, Treatment, or Intervention” and Total
Number of Those that Were Foreseeable and/or Preventable
Defendants next move to strike findings that in 25, or 73.5% of 34 inmate

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suicides in 2012 there was “at least some degree of inadequacy in assessment, treatment or

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intervention” and that at least 24 of those inmate suicides were “foreseeable” or “preventable.”4

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Objections at 9. Defendants contend generally that the Report’s “resort to this classification

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system is speculative, misleading, lacks foundation, and is irrelevant to the governing legal

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standard.” Id. at 10. In support of this general contention, defendants argue that (1) causation

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for suicide should not be inferred from findings that a suicide was foreseeable or preventable; (2)

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that Dr. Patterson has included suicides “where the foundation for the conclusion is lacking or is

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speculative or subject to two reasonable clinical decisions”; and (3) that he has included

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reference to degrees of inadequacy without evidence that the inadequacy caused the suicide.5 Id.

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The first and third of these contentions raise questions concerning what evidence bears on the

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question of defendants’ compliance with the requirements of the Eighth Amendment. They are

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not bases for striking the challenged findings. The second contention is addressed infra.

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1. Motion to Strike Language that 24 Suicides were Foreseeable or Preventable

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Defendants contend that linking the two categories of analysis – suicides

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involving some degree of inadequacy in assessment, treatment, or intervention, with suicides that

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were “foreseeable” and/or “preventable” – “makes it difficult to determine whether and how the

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For the reasons set forth supra, the court leaves aside for the moment the question
whether there were 33 or 34 inmates suicides in CDCR prisons in 2012 and the related question
of the percentages of suicides in each category.
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Defendants also assert that the challenged findings “fail to recognize the State’s
systemwide attention to suicide prevention and investigation of suicides” and “draws no
established relationship between the 25 cases” and requirements of the U.S. Constitution.
Objections at 10. These arguments are for the termination motion, not the matters at bar.
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alleged failures may have contributed to the suicide” and that use of these “vague terms is

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inherently misleading.” Objections at 10. Defendants also contend that linking the findings

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concerning inadequacy in assessment, treatment or intervention with findings concerning the

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number of suicides that were foreseeable or preventable “creates an unfairly negative impression

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of the State’s mental health and suicide prevention” and “makes it difficult to determine whether

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and how the alleged failures may have contributed to the suicide.” Objections at 10 (citing

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Dvoskin Resp. at 3).6
By their contention that the terms “foreseeable” and “preventable” are “vague”,

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defendants renew an objection that was overruled by this court almost ten years ago. See Order

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filed July 25, 2003 (ECF No. 1536), at 5-6 (overruling defendants’ objection to standards used to

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monitor completed suicides); see also Fifth Suicide Report filed April 28, 2005 (ECF No. 1658),

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at 2-3 (suicide report “continues to embrace the concept of ‘foreseeable’ and ‘preventable’

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suicides, concepts that have been discussed in considerable detail, reviewed and critiqued by the

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parties and confirmed by the court as appropriate for purposes of analyzing the adequacy of the

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defendants’ suicide prevention efforts.”).7 The concepts are well-defined in this action.

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Citing to Dr. Dvoskin’s response, defendants suggest that the “findings and
recommendations” should be categorized as “institutional or systemic, based on the seriousness
of the error.” Objections at 10 (citing Dvoskin Resp. at 3). Dr. Dvoskin suggests that there is a
“much more useful” way of categorizing errors and improvements than by the findings of
whether a suicide was “foreseeable” and “preventable” as used by Dr. Patterson. Dr. Dvoskin
writes:
Specifically, I continue to believe that findings and
recommendations should be categories as institutional or systemic,
based on the seriousness of the error, and whether the error was:
1) unrelated to the death; 2) speculatively or possibly related to the
death; 3) definitely related or contributory to the death; or 4)
directly causal to the death (alleged or confirmed). An additional
category should include errors that were post-mortem, such as
documentation or notification errors.” This will clarify vague
terms such as “preventable,” making it much more clear whether
and how alleged failure may have contributed to a suicide.
Dvoskin Resp. at 2. However, Dr. Dvoskin has not used his proposed method of analysis in his
review of the individual inmate suicides in 2011. See Dvoskin Resp. at 2.
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Neither party objected to the Fifth Suicide Report, and the recommendations contained
therein were adopted by this court in an order filed June 10, 2005 (ECF No. 1668).
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The term “foreseeable” refers to those cases where information
already available about an inmate indicates the presence of a
substantial or high risk for suicide, which requires reasonable
clinical, custody and/or administrative intervention(s). Assessment
of the degree of risk, whether high, moderate or low to none, is an
important component in determining foreseeability. In contrast to
a high and immediately visible risk a “moderate” risk of suicide
involves an ambiguous set of circumstances that requires
significant clinical judgment based on adequate training and a
timely assessment to determine the level of risk and the most
appropriate and relevant interventions to prevent suicide. As
previously defined, those individuals evaluated as “low risk,” “no
risk” or “negligible risk” may require some degree of monitoring
and subsequent evaluation, with appropriate notification of clinical
and custody staff of the potential for self injury and/or suicidal
ideation or activity.

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“Preventable” applies to those situation in which, if some
additional information [had] been gathered and/or some additional
intervention(s) taken, usually as required in existing policy, the
likelihood of a completed suicide might have been reduced
substantially. These concepts of “foreseeable” and “preventable,”
in turn, reflect the adequacy of the defendants’ suicide prevention
policies and procedures, training and the implementation and
supervision of policies and procedures, as well as clinical
judgment.

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Fifth Suicide Report at 2-3; see also Eleventh Monitoring Report, filed June 10, 2003 (Doc. No.

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1519), at 286.8 These definitions are included in the 2011 Suicide Report. Report at 4-5. Dr.

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Patterson has also identified several possible interventions for inmates assessed at moderate risk

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for suicide:
Interventions may include but are not limited to changes in clinical
level of care, placement on suicide precautions or suicide watch,
and changes in housing including utilization of safe cells and
transfers to higher levels of care, as well as clinically appropriate
treatment and management services which may include but not be
limited to increased contacts/assessments by mental health
professionals, medication management review and changes, other

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In addition, plaintiffs have shown that the terms are used by experts in the field of
correctional health care, including defendants’ expert. See Plaintiffs’ Opposition at 5 (quoting
article co-authored by, inter alia, defendants’ expert Joel A. Dvoskin and Jeffrey L. Metzner, an
expert for the Special Master in this action, setting forth “overriding obligation of correctional
facilities “to protect inmates or detainees from foreseeable and preventable harm.”).
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therapeutic interventions and measure, and/or changes in level of
care, including short-term changes such as utilization of MHCBs

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and/or longer term level-of-care changes including transfer to
DSH programs.

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Id. at 4. He has also elaborated on the types of suicides that “may have been preventable.”
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include not only cases in which additional information might have
been gathered or additional interventions undertaken, but also
cases involving issues with emergency response by custody and
clinical staff. The emergency response is reviewed not only by
DCHCS mental health staff but also by DCHCS medical staff as
part of the death review summary process, as well as by this
reviewer.

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Id. at 5.9 Defendants’ suggestion that the terms “foreseeable” and “preventable” are vague is
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frivolous.
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If defendants are also contending that “inadequacy in assessment, treatment or
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intervention” is “speculative, misleading or without foundation,” Objections at 10, that
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contention too is without merit. Appendix F to the Report contains extensive and detailed case
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reviews of each inmate suicide which describe, if found, inadequacies in assessment, treatment
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or intervention in each case, as well as the basis for the determination that a suicide was
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foreseeable, preventable, both, or neither. In Section IIIC of the Report, Dr. Patterson describes
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with specificity particular types of inadequacies in assessment, treatment, or intervention, with
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citation to specific case reviews in Appendix F. Report, at 9. In Section IIID of the 2011
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Suicide Report, Dr. Patterson states that the findings summarized in Section IIIC “were based on
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the presence of information that was or should have been available to clinical staff” and that
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“[t]hese suicides were, therefore, most probably foreseeable and/or preventable.” Id. at 10.
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There is nothing “vague” or “misleading” about Dr. Patterson’s analysis or the terminology that
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As the court has previously found, the conclusion that an inmate suicide is
“foreseeable” and/or “preventable” is within the scope of Dr. Patterson’s expertise. See Order
filed November 23, 2009 (ECF No. 3731), at 12.
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he uses. The basis for these findings is neither speculative, misleading, nor without foundation.

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The primary basis for defendants’ motion to strike these findings is their

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contention that the grouping together of all suicides that involved “at least some degree of

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inadequacy in assessment, treatment, or intervention” and all the suicides that were “foreseeable”

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or “preventable” is misleading. See Objections at 10-11. This argument goes to the weight to be

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given particular findings in the Report in connection with this court’s assessment of the

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adequacy of defendants’ suicide prevention program which, as discussed above, will be before

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the court on defendants’ termination motion. It is not a basis for striking the challenged findings.
Finally, defendants contend that “the statistics lump together alleged errors by

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CDCR personnel with those under the control of the Plata receiver” and that it “seems unfair” to

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blame CDCR for things done by staff they have no control over. Objections at 11 (citing

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Dvoskin Resp. at 3.) Elsewhere in the objections, defendants cite to two suicides, those of

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inmates identified as J and S, in which they contend “the error in care was not under the control

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of the State.” Objections at 21.
The case review for Inmate J in Appendix F of the Report includes three problems

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identified by the CDCR suicide report for this inmate: (1) the evening before Inmate J’s suicide

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a licensed psychiatric technician (LPT or psych tech) failed to follow through with necessary

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contacts after Inmate J threatened self-harm; (2) “[t]he primary clinician missed weekly contacts,

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including one due the week of the suicide”; and (3) intake information when Inmate J threatened

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self-harm was not documented in the record, no suicide risk evaluation was completed “despite

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the history of suicide attempts and ideation,” and followup did not show that the inmate’s

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records from another prison had been reviewed. Report at 121. Defendants’ contention that the

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error in Inmate J’s case was not made by staff in CDCR control is based on the error by the

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psych tech. See Objections at 15. As noted above, the error by the psych tech was not the only

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problem
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identified by CDCR in connection with this suicide. Even if psych techs were completely

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outside defendants’ control,10 the other two problems certainly involved CDCR staff.
Defendants’ assertion that Inmate S’s suicide should not be attributed to

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defendants is frivolous. The objection, in its entirety, reads:

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This inmate suffered from a deteriorating medical condition
including pain, serious weight loss, and inability to eat and
maintain hydration. (ECF No. 4308 at 199.) The report states that
this suicide ‘appears to have been possibly foreseeable and highly
likely preventable” had mental health clinicians deemed this
inmate’s medical condition a “risk factor” and had measure been
taken by medical clinicians to collaborate with mental health
clinicians. (Id.) Thus, it appears that “pain was the likely cause of
his suicide,” and that “more successful medical care may have
likely prevented this man’s suicide.” (Dvoskin Resp. to 2011
Suicide Rep. at 19).

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Objections at 18. As defendants’ objections describe, it is plain that the findings concerning this

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inmate’s suicide implicate both mental health staff under CDCR’s control as well as medical

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staff. See also Appendix F at 199.

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Neither suicide cited by defendants involved inadequacies in assessment,

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treatment, or intervention, or circumstances which rendered the suicide foreseeable or

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preventable, that were attributable solely to staff over which CDCR had no control. This

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contention is without merit.
For all of the foregoing reasons, defendants’ motion to strike the Report’s finding

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that 24 suicides were “foreseeable” or “preventable” will be denied.
2. Inadequate Assessment in Clinical Assessment, Evaluation, and Treatment

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It is not at all clear from the record that this assertion is true. At a minimum,
defendants’ suggestion that they have no control over the psych tech is called into question by
the fact that an Investigative Services Unit has referred the matter to CDCR’s Office of Internal
Affairs. Appendix F at 121. However, the court need not resolve this question in order to
dispose of the objection at bar.
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Defendants object and request to strike or modify the report’s finding that “in 50

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percent [or 17] of the suicide cases in 2011, inmate suicide risk evaluations were either not done,

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or found levels of ‘low’ or ‘no appreciable’ risk of suicide, without adequate consideration of

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risk factors, past history, and/or review of medical records.” Objections at 12. Defendants

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contend that “the analysis lacks foundation, is speculative (not judged by what was known at the

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time of the decision), fails to connect the inadequacy to the suicide, blames the State for suicides

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outside of its control, and disregards the State’s systemwide attention to suicide prevention and

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investigation of suicides.” Id. Defendants interpose objections and requests to strike specific

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findings in each of the seventeen cases. Id.
First, the court here will only address defendants’ contentions that Dr. Patterson’s

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analysis lacks foundation or is speculative. The last three of defendants’ five contentions go to

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issues directly related to the pending termination motion. As already discussed, those

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contentions are not a basis for striking or modifying the Report, and nothing in this order affects

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defendants’ right to make all appropriate arguments of fact and law in connection with their

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termination motion.
Second, the court observes that defendants’ request to strike statements from

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individual case reviews goes far beyond the challenged finding: that in each case a suicide risk

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evaluation was “either not done, or found levels of ‘low’ or ‘no appreciable risk of suicide,

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without adequate consideration of risk factors, past history, and/or review of medical records.”

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Instead, defendants challenge a variety of conclusions drawn by Dr. Patterson, primarily whether

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a suicide was foreseeable or preventable. See Objections at 12-21.11 As noted above, Dr.

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Patterson is well-qualified to opine about whether a suicide was foreseeable or preventable.

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In some instances, defendants also seek an additional finding that there can be no
finding that the State was “deliberately indifferent” with respect to a particular suicide. See, e.g.,
Objections at 13 (Inmate E), 14-15 (Inmates I and K), 16 (Inmate O). Dr. Patterson was not
required to make determinations concerning deliberate indifference in the Report and
defendants’ request for such modifications is denied.
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In addition, defendants’ expert, Dr. Dvoskin, stated in his response that “in

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reviewing the individual cases, I agree with many of Dr. Patterson’s findings, . . . [and] [e]ven

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where we disagreed, in most cases there were simply two alternative and equally reasonable

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ways to look at the case.” Dvoskin Resp. at 2. Unless defendants are also contending that their

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own expert’s analysis of individual cases “lacks foundation”, the objection is belied by

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defendants’

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own evidence and is frivolous. For that reason, and to the extent that this objection is different

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from defendants’ legal argument in support of their termination motion, it is overruled.

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3. Non-Completion of Timely Custody Welfare Checks
Defendants’ next objection and request to strike or modify findings concerns non-

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completion of timely custody welfare checks. It is also frivolous. The challenged finding reads

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in its entirety:
In five of the suicide cases in 2011, identified as inmates G, R, X,
AA, and EE, rigor mortis had already begun prior to discovery of
the inmate’s body.12 In three of the five cases, the inmate was
housed in administrative segregation at the time of the suicide.
The onset of rigor mortis indicates that in these five cases at least
two to four hours had passed since the time of death before the
bodies were discovered, underscoring the importance of timely
welfare and custodial checks.

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Report at 2-3 (footnote in original). Defendants contend inmate EE should not be included in

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this group because his suicide was “not found to be foreseeable or preventable”, that inmate X

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should not be included in this group because he was not housed in a place where hourly custody

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security checks or welfare checks were required, that the conclusions concerning inmates G and

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R must be stricken because the State has corrected any errors in connection with those two

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suicides, and the conclusion concerning inmate AA must be stricken because “any assertion that

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Rigor mortis is defined as “the stiffness of joints and muscular rigidity of a dead body,
caused by depletion of ATP in the tissues. It begins two to four hours after death and lasts up to
about four days, after which the muscles and joints relax.” COLLINS ENGLISH
DICTIONARY (2003 ed.)
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errors may have contributed to this inmate’s death are speculative.” Objections at 23. None of

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the objections raised are responsive to the facts reported by the Special Master’s expert: all five

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of these inmates were dead in their cells, undiscovered, for at least two to four hours. Nor do

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defendants’ objections undermine Dr. Patterson’s conclusion that these facts “underscore” the

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need for “timely welfare and custodial checks.” Report at 3. The objection is overruled and the

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request to strike the findings will be denied.

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4. Timely and Appropriate Performance of Emergency Response Procedures

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Defendants object and move to strike inclusion of eleven of the sixteen suicide

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cases identified by the Special Master’s expert as cases in which “cardiopulmonary resuscitation,

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including availability or use of the Automated External Defibrillator (AED) and/or use of first

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aid, were not performed in a timely and/or appropriate manner.” Objections at 23 (quoting

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Report at 3). Defendants contend that three of the cases were suicides that were neither

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“foreseeable” nor “preventable” so that inclusion of the cases as examples of untimely

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emergency response is “unfair and misleading” and that in the other eight cases the report “fails

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to relate – or inaccurately relates – the allegation of an untimely emergency response to any

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finding of preventability.” Id. To the extent that this objection is different from defendants’

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legal arguments it is frivolous. Defendants tender no evidence that calls into question the facts

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reported by the Special Master’s expert concerning the untimely and/or inappropriate use of CPR

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and/or first aid in these cases. The objection is overruled and the motion to strike or modify this

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portion of the report will be denied.

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D. Compliance with Reporting Requirements
Defendants move to strike the finding that “CDCR failed to comply with post-

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suicide review and reporting timeframes in seven . . . cases in 2011” on the ground that there is

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no evidence to support it. Objections at 25. Appendices A and B to the Report are charts which

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show that in at least seven instances the Program Guide timeframes for suicide reports and/or
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quality improvement plans were not met. See Appendices A and B to Report (suicide reports for

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Inmates B, D, G, H, L, N, O, P, Q, R, S, and U completed after sixty day period; quality

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improvement plans for Inmates B, G, H, L, and Q completed after one hundred fifty day period).

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Defendants acknowledge that they did not meet Program Guide timelines for quality

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improvement plans for three of the suicides on three occasions when quality improvement plans

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were required. Objections at 26. The motion to strike will be denied.
Defendants also object to what they characterize as a complaint in the Report

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“that CDCR’s failure to timely upload suicide review materials is the root cause of his inability

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to submit a comprehensive report on 33 suicides in 2011 until January 2013.” Objections at 27.

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This objection mischaracterizes an extended discussion at pages 12-16 of the Report and is

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overruled.

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II. Recommendations
Finally, in spite of the fact that their own expert concurs with the

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recommendations in the Report, see Dvoskin Resp. at 2, defendants object to those

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recommendations. Defendants’ objection is to continued federal court supervision and is

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predicated entirely on arguments raised in their termination motion. As an objection to the

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Report itself it is overruled. As the court has already noted, nothing in this court’s orders

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reviewing objections to the Special Master’s Reports should be construed to preclude arguments

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raised by defendants in their termination motion, which is not before the court at this time.

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Whether the recommendations will become the subject of a further order of this court is deferred

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pending resolution of the termination motion.13

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In his response, defendants’ expert Dr. Dvoskin states that “[t]he systemic
recommendations in Dr. Patterson’s report at pages 16-18 are reasonable and should assist the
California Department of Corrections and Rehabilitation in its essential goal of preventing
suicides in the future.” Dvoskin Resp. at 2. The court emphasizes that nothing in this order
should preclude defendants from moving forward with action consistent with those
recommendations.
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In accordance with the above, IT IS HEREBY ORDERED that:

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1. Defendants’ objections to the 2011 Suicide Report are overruled;

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2. Except as expressly provided in this order, defendants’ February 11, 2013

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motion to strike or modify portions of the 2011 Suicide Report is denied; and

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3. Within five days from the date of this order defendants shall file under seal a

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copy of the final coroner’s report of the death of Inmate HH and provide a hard copy of said

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report to the Special Master.

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DATED: March 15, 2013.

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