San Quentin Warden Grilled on Deadly Prison Transfer during COVID-19 Pandemic

By Priana Aquino, Michael Wheeler, Koda Slingluff and Leah Timmerman

MARIN, CA— The evidentiary hearing over responsibility for a devastating COVID-19 outbreak in San Quentin State Prison continued Tuesday here in Marin County Superior Court with testimonies from incarcerated individuals, doctors and the warden overseeing the prison.

The first witness present on Tuesday morning was Demitrius McGee. McGee had been living in the West Block of San Quentin for eight years and shared a space with fellow inmate, Kevin Sample, for three years.

When Sample started showing symptoms of having the virus, McGee requested to be moved to another cell to reduce his chances for catching it as well. However, his requests were denied, and he remained in the same cell even after Sample tested positive on June 29.

When asked by plaintiffs’ attorney Kathleen Boyle about how he felt at the time, McGee said “It was a feeling of frustration, fear, anxiety. And after a day or so, it was all right because there was nothing I could do.”

McGee told the court that he was tested for COVID multiple times and was unsurprised when one taken on July 5 came back positive.

When asked about his symptoms, McGee described having headaches and loss of both taste and smell. He also mentioned that he still has headaches he believes are from having had COVID.

Attorney Boyle showed the court a picture of the bars that act as doors to the cells in San Quentin. This, along with the proximity of McGee’s cell to the open and shared showers were highlighted in her questioning as factors leading to a rapid spread of COVID in West Block.

The second witness that was called to testify was Fyodor Urnov, Professor of Genetics, Genomics and Development at UC Berkeley.

Urnov was assigned by Berkeley to oversee a lab focused on COVID-19 testing, and was contacted by two staff members at San Quentin for the possibility of providing tests to inmates.

Urnov’s correspondence with staff at San Quentin was not followed up until June when he learned of the COVID outbreak in the prison.

He reached out again and offered to provide free testing for inmates. However, Dr. Alison Pachynski, who was working at San Quentin, declined his offer and did not email back again. This online correspondence was corroborated by screenshots of their email chain.

Urnov recalled learning about the massive outbreak and feeling as if there was something that could have been done earlier to mitigate the impact.

Boyle next questioned Ellis Hollis, an inmate at San Quentin housed in the bay side cell block. Beginning in June, he noticed that a lot of inmates were coughing and not wearing masks while waiting in line for the showers.

He did not observe staff telling people to put their masks on, saying, “They didn’t ask, not one time.”

Because of a past case of valley fever that left him with damaged lungs and reliant upon a CPAP machine to sleep, Hollis expressed fears for himself if he were to contract the virus.

“If you don’t mind me saying, I share a cell with a 79-year-old man… as I was feared for my life I was more fearful of his life…everyday was a challenge for us,” he admitted.

As a kitchen worker at San Quentin until the kitchen was shut down in the middle of July, he came into contact with staff from many different buildings, not all of whom wore masks.

Hollis never tested positive, but believed that he had contracted COVID-19 at one point, as there was a brief period of slowed testing beginning around June 24, during which he felt that he had lost his sense of smell.

His cellmate also had symptoms, demonstrating difficulty breathing and complications with his heart.

San Quentin interim warden Ron Broomfield next took the stand, after difficulty tracking him down amid miscommunication on the part of the respondents as to when he was to appear.

Under subpoena to appear at 9 a.m., Broomfield eventually appeared after the court moved up its morning break and was questioned by Charles Carbone, representing the petitioners.

Prior to the transfer of California Institute for Men (CIM), Broomfield testified that while he had access to information that inmates at CIM were dying, he was not focused on it. Instead, his focus was on ensuring that his own facility managed the pandemic situation.

He had daily conversations about his healthcare colleagues regarding the virus, but did not remember specific conversations concerning CIM. Broomfield stated, however, that he had concerns prior to May 30 that cells without block doors would be more susceptible to the spread of COVID-19.

The housing situation was a matter of particular concern for Broomfield.

Despite San Quentin being at 110 percent of design capacity, he did not believe that the prison was overcrowded. In order to ensure that his large population could avoid the virus, “We were… trying to social distance our population in our dorms by reducing the numbers in our dorms so we could achieve more social distancing.”

If one inmate demonstrated flu-like symptoms, the entire housing unit would be put into quarantine. Deflecting questioning from Carbone, Broomfield stated that administrators would not question the needs of medical staff regarding inmate housing transfers within the prison.

Inmates who were exposed were to be housed separately from the general population, with the expectation also being that any staff who tested positive or were exposed were to quarantine at home for two weeks following the positive test or exposure.

Prison protocols were also substantially modified to protect inmates from COVID-19.

As examples, he described changes to the yard schedule, changes to the feeding process, and reduced interactions between housing units. The more restrictive policy of cohorting was limited to H Unit and the gymnasium, however.

In another step taken to reduce the spread of the virus, on April 22 prison staff had begun providing cloth masks to inmates. They were required to wear these masks when in common rooms and in the yard, and, in addition, in person social and attorney visits were halted.

Despite the steps that prison authorities had taken to mitigate the spread of the virus, by May 30 the inmate positivity rate was six times greater than that among the free population.

Furthermore, Broomfield could not recall having read a set of guidelines distributed by the federal Centers for Disease Control and Prevention that laid out suggested guidelines for prisons to follow for dealing with the pandemic.

Under additional questioning from Carbone, Broomfield stated that he had only been informed of the transfer three days in advance.

No inquiries were made about whether the inmates being transferred from CIM had been tested recently, their most recent tests having been three to four weeks prior to the transfer date. Nor had anyone inquired into the manner of social distancing that the prisoners had utilized during the transfer.

Broomfield stated that, should he have wanted to, he had no authority to refuse the transfer, and deflected the responsibility for the transfer policies to CIM, saying, “I had no participation in the scheduling, cohorting, or transferring of those inmates.”

Upon arrival, the transferees were housed in the Badger unit, and their entry to the prison brought the San Quentin population to 116 percent of design policy.

Following the lunch break, Carbone’s questioning of Broomfield returned to the CIM inmates that were transferred. Broomfield said they would only quarantine the inmates if they showed symptoms or tested positive once they arrived at San Quentin State Prison.

Medical personnel were in charge of testing the symptomatic patients and the warden did not know the timing of the testing in regard to when they arrived at the facility, he said.

Broomfield said that if the CIM inmates had no symptoms or had a negative test result they were placed in tier 4 or 5 in Badger Section. The cells in this section were open door with a safety mesh over the bars.

When asked about the timing of the testing, Broomfield was asked if he agreed that the longest wait for a test was three days. He disagreed with that statement and said it would be shorter than three days, but the longest wait for test results would be five days.

There were two inmates who tested positive for COVID-19 that arrived at San Quentin on the buses from CIM. It took three to five days to get these results before they were removed from the population and the rest of the inmates in the Badger Section were placed in precautionary quarantine, he said.

In a series of questions by Carbone, Broomfield showed with his answers that the inmates were not really in actual quarantine.

Inmates, he said, could walk between tiers in Badger unit with no threat of rules violation. They could use the same showers, sick call lines, and pill lines as the other inmates. When inmates were in close contact with the two COVID cases there was also no threat of a rules violation.

Carbone went back to when the buses arrived at San Quentin and asked if the prison was able to determine which bus had the two positive cases on it. The warden said yes they could, they isolated bus number one on June 5, 2020 and they isolated buses two and four on June 6, 2020.

Carbone then brought up a report done by the Office of the Inspector General that came out in February 2021 and was part three of a COVID Review Series. The second paragraph on page six of the report was highlighted.

They found that “once staff at Corcoran and San Quentin received the positive COVID-19 test results for some of the arriving incarcerated persons, we found that both prisons failed to properly follow CCHCS’ COVID-19 contact tracing policy.

“In response to our request for all contact tracing documentation related to the first positive COVID-19 results at San Quentin, the prison responded that there were too many positive cases over a short period of time to conduct contact tracing.”

When asked his opinion of the report, the warden gave no opinion but did not doubt the validity of the report. Carbone asked if the prison had changed its policy regarding contract tracing after the report came out, and the warden said they did not.

Contact investigation was done by an outside entity, Candace Murch from the CCHCS. Contact tracing of prison staff was done by the office of employee health and, for the inmates, it was done by the local nurse.

Carbone then asked questions regarding the policies around staff completing shifts in different parts of the prison. Broomfield stated there was no prohibition on the custody staff or the medical staff from working in other housing units or areas of the prison while also working in the area with the CIM transfers.

In October of 2020, there was no mechanism to cohort staff and it was also stated that there continues to be no mechanism to cohort staff at San Quentin. 15-20 percent of staff work in multiple housing units or facilities in the same time period.

Broomfield had no knowledge of any CDC recommendations for staff cohorts but did state that the California Department of Public Health advised the prison to cohort staff.

Broomfield admitted that the prison is not in conformity with that recommendation and also allows for unvaccinated staff to work in multiple areas of the prison.

Broomfield, when asked about the essential inmate workers, stated that there was no policy to place them in cohorts until September of 2020.

Food service and hospital maintenance workers were considered to be essential and mixed with inmates from other parts of the prison on a daily basis before the policy was put in place.

When asked about a surge plan, Broomfield stated that there was no surge plan for the prison prior to July 7, 2020 after the incident command center was created. At the time there were 1,131 COVID cases in San Quentin.

Moving on to masks, Carbone asked when they were required by staff and when they started offering both staff and inmates N-95 masks. The warden stated that masks became mandatory for staff on either April 21 or 24. Staff received N-95s July 8 and inmates received them from July 14 to July 19. An eight-day difference existed between when staff and inmates had access to the N-95 masks.

Required disciplinary actions were put in place for staff and inmates violating mask-wearing policies in the prison. Broomfield could not say the total number of reprimands, and acknowledged that failure to wear or to incorrectly wear a mask undermined the health and safety of individuals in the prison.

When asked about social distancing, Broomfield stated that, under modified programming, social distancing could be accomplished—but areas like stairs, stairwells, walkways, and the law library could not accomplish social distancing.

He also stated that if inmates wanted to socially distance they could, but if they just open the doors to the cells prison staff can’t enforce it.

Carbone showed another report to Broomfield, this one submitted by various physicians from UC Berkeley and UC San Francisco. The report, dated June 13, 2020, recommended that the prison reduce capacity by 50 percent.

It emphasized San Quentin’s potential to become a “full-blown local epidemic and health care crisis in the prison and surrounding communities.”

The report stated, “San Quentin is an extremely dangerous place for an outbreak, everything should be done to decrease the number of people exposed to this environment as quickly as possible.”

Broomfield said he did not recall reading the report, despite the fact that it was sent to San Quentin as an urgent memo.

He said he was aware of “a lot of the recommendations” from the memo. When prompted, he said that he did not have any conversations with staff about the recommendations, and never considered the feasibility of reducing the population by 50 percent.

Carbone finished his questioning by asking about a specific transfer from San Quentin to the California Correctional Center (CCC) in Susanville, CA. Upon arrival at CCC, three inmates tested positive for coronavirus. Broomfield confirmed that he was aware of the situation at CCC.

“Are you aware that that outbreak led to a state of emergency being declared in Lassen county [the county where CCC is located]?” Carbone asked. Broomfield replied, “No.”

Michael Lagrama then examined the witness. His inquiry focused on responsibility, emphasizing the organizations outside of San Quentin’s control that could be seen as responsible for the outbreak. To begin, Lagrama asked whom Broomfield reports to as warden.

“Associate Director Ron Davis,” Broomfield responded. “We both work for DAI, the Department of Adult Institutions, which is within CDCR. Highest official of CDCR is secretary Kathleen Allison.”

Broomfield went on to talk about California Correctional Health Care Services, CCHCS. CCHCS is responsible for the healthcare of inmates statewide, including at San Quentin. While CCHCS staff works closely with the warden, they are separate entities from the prison itself.

The witness stated that CCHCS handles “[n]ursing, rounding, diagnosing, testing, treating,” as well as Covid testing and contact tracing.

Notably, CCHCS was referred to as ‘CCHS’ and variations like ‘CHCS’ by both the attorneys and the witness. This was likely accidental, given the department is called CCHCS on its own website.

Broomfield continued that he had very little notice beforehand about the CIM transfer to San Quentin. He spoke briefly to his superior Ron Davis, and did not believe he had the authority to overturn the decision to transfer.

“Those instructions were coming down from headquarters, my leadership. So I would have to usurp their authority, which in a chain of command you don’t do,” Broomfield said.

Lagrama then shifted to asking logistical questions about the prison. He asked where they planned to house the CIM transfers.

The warden replied that his preferred plan was to use the prison’s adjustment center. The adjustment center is used for disciplinary cases, however, and its fullness forced him to consider other options. They ended up in Badger Section, the reception center that he had testified earlier did not have solid doors.

Broomfield described the prison layout, saying, “We have two facilities, A and B. A consists of West Block, North Block, and now South Block. East Block is our condemned population and they are on A facility. And at the top of North Block is North seg, and that’s also condemned. And our gym, when we were using that, is also in A facility. Our chapels, too.”

The gym and the four on-sight chapels were used as housing during the outbreak. When these sites reached capacity, San Quentin brought in tents.

To finish up the day, Lagrama asked some questions about current testing protocols.

Broomfield elaborated that inmates are tested every day by CCHCS nursing staff. The test results are recorded onto an electronic healthcare system.

Additionally, staff is required to test for coronavirus weekly. Masks are required for staff and inmates, though the types of masks and situations for masking have shifted with new guidelines.

“During the height of the pandemic, all inmates and staff were placed in N95 masks. As we moved out of our outbreak status, guidance changed to allow cloth,” Broomfield stated.

San Quentin has been requiring masks for inmates since approximately May 5, 2020. Staff started masking slightly earlier, sometime between April 21 and April 24. For staff that do not comply with mask-wearing, the policy is “progressive punishment,” according to Broomfield.

Judge Geoffrey Howard ended the day’s proceedings at 4:31 pm. The hearing   will reconvene Wednesday morning. The petitioners hope to conclude with their 14 additional witnesses by Thursday or Friday this week.

Michael Wheeler is a junior at UC Davis, where he studies History and Economics. He is from Walnut Creek, California.

Priana Aquino is an incoming 4th year at the University of San Francisco, majoring in Business and Minoring in Legal Studies. Upon graduation, she hopes to attend law school and continue her work in uplifting and advocating for communities of color.

Koda is a junior at UC Berkeley, majoring in Philosophy and minoring in Rhetoric. He is from Ventura, CA.

Leah Timmerman is a 4th year Political Science and American Studies major at UC Davis. She is originally from Los Angeles, California.

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About The Author

The Vanguard Court Watch operates in Yolo, Sacramento and Sacramento Counties with a mission to monitor and report on court cases. Anyone interested in interning at the Courthouse or volunteering to monitor cases should contact the Vanguard at info(at)davisvanguard(dot)org - please email info(at)davisvanguard(dot)org if you find inaccuracies in this report.

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