A federal judge said this week that she will begin fining California potentially tens of thousands of dollars daily after more than 200 prison inmates killed themselves during eight years in which state corrections officials failed to complete court-ordered suicide prevention measures.

Addressing a chronic tragedy that has plagued the state for decades, Chief U.S. District Judge Kimberly Mueller said she will start the fines April 1 — $1,000 a day for each of 15 unmet safeguards until all the state’s 34 adult prisons are in full compliance.

At the same time, she will impose fines for the state’s failure to hire enough mental health professionals. And she set a hearing for August to collect more than $1.7 million in fines that have accumulated since 2017 under a previous order punishing delays in transferring inmates to state mental hospitals.

“The court is at a critical crossroads,” Mueller wrote weeks ahead of her order, which was made public Tuesday. She said inmates with serious mental disorders make up more than one-third of California’s prison population of about 96,000 and they have “waited far too long for constitutionally adequate mental health care.”

State officials said they will review the judge’s orders. California Department of Corrections and Rehabilitation spokesperson Vicky Waters said in a statement that “suicide prevention is a very important issue for us.”

In court filings, state officials objected to Mueller’s setting “an unworkable, all but impossible standard.” They pointed to lower suicide rates each of the last two years, after two decades of California consistently exceeding the national suicide rate for state prison systems. The 15 suicides in 2021 were the fewest in two decades and half the annual average over that period. Attorneys representing inmates say there were 19 deaths by suicide last year, though the official report isn’t out yet.

Those recent lower suicide rates are “significant improvements and absolute evidence of success,” Paul Mello, an attorney representing the state, told Mueller at a Feb. 10 hearing. A court-appointed suicide prevention expert, Lindsay Hayes, said the reasons for the sudden drop are unclear and the effect of the coronavirus pandemic will need to be analyzed.

Suicides in California prisons have long been seen as a key indicator that the prison system isn’t providing adequate mental health care. Mueller’s predecessor ruled in the class-action lawsuit 27 years ago that California was providing unconstitutionally poor mental health care to inmates. Yet federal judges have struggled to force improvements despite repeated orders in the case.

This time, Mueller is acting after Hayes found that the department still is failing to meet the standards despite an order dating to 2015. The safeguards include things like suicide prevention training, suicide risk evaluations, suicide-resistant cells, and checking on vulnerable inmates every 30 minutes, and often more frequently, to make sure they aren’t harming themselves.

“They’re very standard for prisons and jails around the country, and they’re not doing them,” said Michael Bien, one of the attorneys representing inmates.

Among those who corrections officials say killed themselves is 31-year-old John Pantoja. He died by hanging in June, using a ligature torn from a bedsheet, according to the Sacramento County coroner.

Pantoja was a funny, loving, caring, healthy, athletic young man until he went into California’s juvenile justice system at age 16, his sister and father told KHN in an interview Tuesday.

He emerged a changed man five years later, they said.

“He came out with his mental state just totally depleted,” with multiple mental health diagnoses, including schizophrenia, and exhibiting mood swings consistent with bipolar disorder, Elizabeth Pantoja said. “Prior to going in, we didn’t see those signs. … That was opposite of how we knew him.”

Within a few months of his release from juvenile lockup, he engaged in a robbery and shootout with Chula Vista police in 2012. His defense at the time was that he had been attempting “suicide by cop,” enticing an officer to kill him. Once in prison, Amado Pantoja said, John heard voices he blamed on the mental health medications he was prescribed. Amado and Elizabeth said John seemed to be looking forward to a birthday visit from his family and a 2026 parole hearing based on his young age at the time of his crime.

His mental health really deteriorated in the last five years, when he was repeatedly put in solitary confinement and cut off from family visits during the pandemic, they said. More recently, the television he treated like a form of therapy had been broken, although his family was sending him a new one, and he’d seen medical workers with complaints of chronic pain.

He died the next day with a half-dozen drugs in his system, including medications for depression, pain, and seizures.

In a report of prisoner suicides between January 2020 and April 2022, Hayes frequently detailed missed opportunities to prevent deaths:

• An inmate at a Sacramento County maximum security prison killed himself with punctures to his neck on Christmas Eve 2020, hours after he was seen drinking liquid cleanser in his cell. Correctional officers said he also “had been acting irrationally, stressed out, pacing back and forth, crying, distressed after a series of telephone calls with his family.” A crisis counselor talked to him at his cell door because he refused to come out, but he denied he intended to kill himself. The counselor asked no further questions, citing a lack of privacy, and the inmate killed himself several hours later.
• An inmate at the state prison in Tehachapi was found hanging from a ventilation grate by a sheet in his cell on Jan. 5, 2020. He had a years-long history of cutting his wrists and other self-destructive behavior, including repeatedly in the two days before his death. A counselor decided hours before his suicide that he wasn’t serious. But a subsequent review found his self-harm — along with his “bizarre statements and increased paranoid delusions” — should have been enough warning. He left behind a note indicating he feared other inmates were plotting his murder.
• A prisoner was found hanging by a sheet in his cell in the substance abuse treatment facility in Corcoran the day before Thanksgiving 2021. His 11 years in prison were spent mostly in mental health programs for repeatedly cutting himself and hallucinations of voices saying people were trying to kill him. A medical chart entry that he’d been seen by a counselor the day he died “was falsified by the clinician.” A department review found “a concerning pattern” of mental health providers saying they would offer him interventions but never providing them.

Mueller, who had signaled for weeks that she would impose daily fines, said during the February hearing that they were needed to “ensure that the recommendations are implemented” after the state missed repeated deadlines to comply with nearly half the court-ordered safeguards.

“The court finds further delay in the defendants’ full implementation of the required suicide prevention measures is unacceptable,” Mueller wrote in her latest order.

Mueller also ordered fines for each unfilled position exceeding a 10% vacancy rate in the required number of mental health professionals needed to care for inmates with serious mental disorders. Those fines will be based on the maximum salary for each job, including some that top out at or near $300,000 per year, and Mueller said she would schedule a hearing to find the state in contempt and order payment if the fines accumulate for three consecutive months.

The state has been out of compliance on filling the vacancies for more than four years, Mueller said, noting that more than 400 positions are vacant statewide.

Mueller imposed $1,000-a-day fines in 2017 in an attempt to end a chronic backlog in sending inmates to state mental facilities. She has never collected the money — but now she has set the August hearing to do so.

Under her current order, the fines will similarly keep accumulating as long as Hayes determines the state isn’t complying. Once his review is complete — a process that previously has taken many months — Mueller said she would schedule a hearing on the payment of fines.

This story was produced by KHN, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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