NO SAFE PLACE: A Troubling Suicide at a California Women’s Prison & a Report Pointing to Chronic Failures in the Facility’s Suicide Prevention PracticesApril 29th, 2016 by Celeste Fremon
Erica Rocha was 35 years old when she committed suicide on April 14 of this year, in the mental health unit of the California Institution for Women (CIW).
Rocha had been locked up for 21 years, since she was 14 years old. But there was a real possibility that her life was on the verge of a large change for the better.
The day after she killed herself, Rocha had been scheduled to attend what is called an SB 260 parole hearing, a special kind of legal procedure for people who were given lengthy sentences in adult court when they were juveniles. Rocha was serving a sentence of 19-to-life for an incident that occurred in a Los Angeles foster care group home, involving a group of kids who hurt another kid. Rocha was the youngest of the group, but reportedly was also the one whom the police and prosecutor were able to most successfully lean on to take a deal.
Rocha’s friends at the prison said she was optimistic about the hearing. But she was also scared. “She talked about whether she could do it,” said Colby Lenz, who is a legal advocate with the California Coalition for Women Prisoners. “She was nervous about whether she could make it on the outside.”
In the weeks before Rocha’s death, she had been on and off suicide watch multiple times. And she had made at least one serious attempt at suicide in the past, when another potential parole hearing loomed. So the risk was very real. Still, the day immediately before her death, when her feelings about the upcoming hearing would be running particularly high, Rocha was unaccountably transferred off suicide watch and into a mental health unit where she managed to hang herself.
“It makes me very angry,” said Lenz, who had gotten to know Rocha in the year she’d been working with her on her case. “She was actively suicidal. She’d just been released from suicide watch. It sounds like they didn’t do what they were supposed to do to prevent her death.”
“A PROBLEMATIC INSTITUTION”
Lenz is not the only person to express serious concern about whether or not the suicide prevention practices at CIW are adequate.
In January 2014, suicide expert Lindsey M. Hayes delivered a report that was the result of Hayes’ eight-month examination of suicide prevention practices at all 34 prisons of the California Department of Corrections and Rehabilitation. He found CIW, in particular, to be “a problematic institution that exhibited numerous poor practices in the area of suicide prevention.”
Hayes’ report, which was court ordered in response to a massive class action lawsuit (Coleman v. Brown) in behalf of the state’s mentally ill inmates, contained lengthy and detailed descriptions of the ways in which CIW was failing to keep its most vulnerable women safe.
It also came after 4 women at CIW had killed themselves in an 18 month period, along with a rash of 20 suicide attempts in addition, according to state records, giving CIW by far the highest suicide rate in the CDCR. Specifically, in 2015, the suicide rate at CIW was more than eight times the national rate for women’s prisons, and more than five times the rate for all California prisons.
The list of issues Hayes found were many and varied. For instance, according to the report, the agreed upon practice when someone is put into a “crisis bed,” for suicidality is for those crisis bed inmates to be checked either on an ongoing basis, or every 15 minutes.
At CIW, however, according to Hayes, inmates were being observed at 30 minute or 60 minute intervals, which was asking for trouble.
And when he toured the solitary confinement units, where the observations are less frequent, but still rigorous, Hayes found that even the supervising lieutenant was “unaware” that the inmates were supposed to be subject to 30 minute welfare checks—in other words, they were supposed to be eyeballed every half hour to make sure they weren’t harming themselves.
Hayes also found that many staff thought that women were faking when they claimed to be considering suicide, and their actions reflected that belief.
In response to Hayes’ report, and the court’s concern, the CIW administration agreed to make specific improvements.
Hayes returned to CIW in 2015 for a re-audit, to see what improvements had been made. He presented the court with the results of his re-audit in January of this year. Some issues had gotten marginally better, according to Hayes’s second report. For example, a grand total of 49 percent of the mental health staff had completed suicide training—as opposed to zero, which was the case the last time. However, 49 percent was nothing close to compliance.
In other categories he audited, Hayes found that the CIW staff had either not improved or they had lost ground.
In addition to looking at the institution’s general practices, Hayes reviewed two suicides in particular as part of his report, and was particularly alarmed by the second of the two.
Dismayed, he wrote in his conclusion, “As perhaps best symbolized by the…inmate suicide on March 6, 2015, this reviewer found that CIW continued to be a problematic institution that exhibited numerous poor practices in the area of suicide prevention, including extremely low completion of required SREs [suicide risk evaluations] based upon emergency mental health referrals for SI [suicidal ideation], several cases in which inmates were discharged from alternative housing without completion of suicide risk evaluations, inadequate treatment planning, low compliance rates for annual suicide prevention training, and multiple inmate suicides during the calendar year.”
“Some of this is extremely, extremely concerning,” said Jane Kahn, a lead attorney for the Coleman lawsuit. “For instance,” Kahn said, “at one point in the report he said that CIW’s compliance is the worst of any of the CDCR’s facilities.”
Kahn then noted various specifics in the body of Hayes report, like the fact Hayes reviewed 38 health records “in which a suicide risk evaluation should have been done because the client said, ‘I’m thinking about suicide.’” said Kahn. “But the mental health clinicians completed a suicide risk evaluation in only 68 percent of the cases. And when Hayes was there the year before, he found the clinicians did them in 76 percent of the cases. So it got worse. It actually got worse.”
Then, of course, as if in tragic illustration of his points, on April 14, a few months after Hayes delivered his second report, Erika Rocha killed herself. Then, less than a week after that, another CIW woman made a serious suicide attempt that reportedly landed her in a coma.
Last week’s suicide attempt is its own disturbing story…
We’ll have more on Erika Rochas’ suicide and the serious problems with inmate safety at CIR in Part 2 of NO SAFE PLACE.
So stay tuned.
Photograph of Erika Rocha courtesy of Linda Reza.