‘Thousands of Lives’ Could Have Been Saved, Expert Charges at San Quentin COVID-19 Evidentiary Hearing

By Mia Machado and Jose Medina

MARIN, CA – Even more witnesses—five of them Friday—testified in a Marin County Superior Court evidentiary hearing over the responsibility for a massive outbreak of COVID-19 in San Quentin State Prison.

Witnesses included a San Quentin incarcerated individual, a California Correctional Healthcare Services administrator, a forgetful correctional officer, an epidemiologist, and a senior safety engineer from CAL/OSHA.

The first witness called was incarcerated individual in San Quentin, (no first name available) Johnson, who spoke to his experience contracting COVID-19 in June of 2020. Attorney Matthew Stiroka questioned him on behalf of the petitioners.

Johnson testified that in July, given the poor safety conditions of the prison, he and other incarcerated individuals held a hunger strike. He explained that most of the incarcerated population involved in the hunger strike were upset about the cold food they were receiving.

Johnson explained that their food would be stored in the shower room for hours before they received it, and that it often arrived cold. He recalled one day the food sat out for three hours. Many refused to eat it for fear that it may have gone bad, or was unsanitary.

Later in July, he explained that by then he was only receiving three two-packs of saltines crackers, a block of cheese, and sunflower seeds, for all three meals. He added that the outlets in their cells did not have electricity, and that “it was very rare we got any change in linens.”

Johnson emphasized his frustration about the lack of information the men were receiving from the prison. “We felt as if they left us over there to suffer, like San Quentin’s dirty little secret or something,” he said.

He spoke to his experience contracting COVID-19 and not receiving sufficient care for the symptoms he was experiencing.

“It was terrifying for one, I felt hopeless, and it was overall very traumatic,” Johnson explained. The stress affected his ability to sleep and he admitted that he still only sleeps three hours a day now.

He also experienced emotional distress and repeatedly sought out mental health treatment. He was eventually prescribed medication for his mental health condition, in the form of a mood stabilizer for bipolar symptoms.

“I took it and it messed up my liver to the point where I had to be transferred to an outside hospital,” he said, “I almost lost my liver.”

Since his infection, he still experiences residual COVID-19 symptoms. In his limbs he experiences muscle aches and pain in his joints, and he continues to suffer from breathing problems. Though Johnson has since been offered the vaccine, he has refused to receive it.

“Like many others here, including staff, I have decided not to at this point,” Johnson said. He expressed concerns about getting sick again given the symptoms he experienced during his COVID-19 infection.

When he was brought back from the hospital he was taken to the adjustment center, he disclosed that he saw many guards moving around unmasked, even in the area where he was quarantining.

“San Quentin expects us to hold ourselves fully accountable for our actions and I think it would be quite reassuring to know that it holds itself to the exact same standard of accountability,” he said. “They don’t practice what they preach, I don’t see that happening here at all, that’s why I’m here.”

Defense Attorney John Walters took over cross-examination for Johnson and questioned his previous assertion that he had repeatedly disclosed that he was suffering COVID-19 symptoms but did not receive proper care.

Walters reviewed the San Quentin records from the quarantine and surveillance screenings that the incarcerated men received twice a day. Walters confirmed that on both June 5 and 6, Johnson was not experiencing COVID-19 symptoms. “I was fine then,” Johnson confirmed.

Walters then asserted that “every day through June 17, you reported no symptoms, no problems with COVID.” Johnson denied that being true. As they went through the reporting records of each day, Johnson denied reporting no symptoms on June 16 and 17. “That was absolutely false, I guarantee you,” he said.

“So is it your testimony that the medical staff was falsifying records?” Walters asked.

After further analysis of the surveillance and screening reports, Johnson asserted that the records were likely confused with those of his cellmate who had the same last name as him. “You know what it is, that was the other Johnson, he was reporting not having any symptoms. That was him, they confused us again, I guarantee you that’s it.”

Walters confirmed, “So is it your testimony that multiple different medical staff, every day, were confusing you and Mr. Johnson and reporting incorrectly?”

Every day they kept saying “Johnson and Johnson. They keep saying ‘which one? Which one? They didn’t even know, they never knew,” he said.

Walters later confirmed with Johnson that he is refusing to receive the vaccine. “So it’s fair to say that you are more concerned about the side effects of the COVID-19 vaccine than getting sick?”

“It’s a calculated risk,” Johnson replied.

The next testimony was from Barbara BarneyKnox, who is currently employed with the California Correctional Healthcare Services (CCHCS). She was first questioned by petitioner’s Attorney Kathleen Guinerance.

BarneyKnox is the Deputy Director of Nursing, Statewide Chief Nurse Executive for the CCHCS, the healthcare arm of CDCR. Her job includes oversight and management of the nursing department throughout California at each prison system.

The headquarters area that she oversees is responsible for program development, policies and procedures and creating the standards for nursing care.

The two discussed the May 30 transfer of approximately 122 incarcerated individuals from the California Institute for Men (CIM) to San Quentin.

BarneyKnox confirmed that there were testing guidelines that should have been in effect at the time of the transfer. She explained that guidelines required individuals to get tested seven days before their transfer, to mitigate spread of COVID-19.

BarneyKnox explained that often if a nursing staff at an institution raised safety concerns about a transfer, not all of those concerns would reach her given the “local chain of command” it goes through. However, this concern was high level enough for her to be alerted of the concerns about the transfer.

Nurses had raised concerns that the men being transferred from CIM to San Quentin had not been tested within the seven day testing window before transfer.

On May 27, three days before the transfer, BarneyKnox received an email from George Gomez, the assistant deputy director for nursing. The email raised concerns about whether the men would be re-swabbed before leaving.

BarneyKnox agreed that the email prompted her concern, given that some of the men had not been tested since May 1, and that there was a doctor there who said they weren’t going to re-test them.

She was concerned enough to start a separate conversation about it with a Dr. Tharratt. When she talked to Dr. Tharratt, she advocated the position that the guidelines be followed and that they should be tested again.

BarneyKnox was directed to a response she wrote on May 28 that said “I agree it seems counterproductive to use testing data from a month ago, especially given they are coming from CIM.

The email asks an individual named Heidi to weigh in on their opinion of whether the risk had diminished in terms of transferring them.

BarneyKnox confirmed that despite concerns, the men were still transferred without testing, and that San Quentin experienced a subsequent outbreak.

During cross-examination from Attorney Krista Pollard, she asked BarneyKnox if the protocols set in place for moving the incarcerated men allowed nurses sufficient time to perform their functions. BarneyKnox explained that “in a perfect world, yes.”

“We have standards that require movement when it’s occurring, we get a seven day buffer and if that were to happen, then yes, we would have enough time to perform our function,” she explained.

In the case of San Quentin, she explained, nurses only received 24 hour notice for when the bus was leaving and who would be on the bus. However, testing at the time required three days to get results.

Attorney Pollard later asked her to describe her role in the response to the subsequent COVID-19 outbreak at San Quentin.

BarneyKnox explained that the outbreak was manageable in the beginning, but around the beginning July, she received notice that “the numbers escalated to the point where the nursing personnel were overwhelmed and they could not manage the numbers to do screening and testing.”

They then brought in additional staff to support the nursing endeavors of taking care of the incarcerated population. On the weekend of July 4, BarneyKnox “rallied a team from headquarters,” and they set up shop in a hotel. “We basically took over the hotel,” she said.

BarneyKnox helped bring HR in to expedite onboarding of staff in four hours, a normal orientation process that usually “can take days to weeks.”

The third, though minimal, testimony came from San Quentin Employee Lee Dooley, who could not recall any of his former testimony from when he talked to a representative at Cal/OSHA named Channing Sheets, in June 2020. He was questioned by Attorney Stiroka.

Dooley has been employed full time by the CDCR at San Quentin since 2001, and works on the East block of San Quentin. Attorney Stiroka asked a series of questions about his recollections from June of 2020, that the witness could not seem to recall or confirm knowing the answer to.

Dooley could not recall when staff first received N95 masks, other than knowing they received them “later in the pandemic.” Attorney Stiroka attempted to get him to quantify the date, asking if it was “July, August…” but Dooley maintained that he did not know.

Attorney Stiroka then asked if he received any instruction on how to properly put on personal protective equipment (PPE) in June. “We received instructions, yeah. I don’t remember the time,” Dooley said.

Attorney Stiroka asked if at any point he had to escort witnesses in the East bloc. Dooley explained there were minimal interactions with escorts because things were closed at the time. When Stiroka asked if he had done any escorting, he said he couldn’t recall.

To assist in refreshing the witness’ recollection, Attorney Stiroka displayed notes from his previous interview with CAL/OSHA.

After asking if Dooley could see the exhibit, he responded “I can see it, it’s kinda messy writing.” Attorney Stiroka asked if it refreshed his memory about when he received PPE training. Dooley said it did not.

Attorney Stiroka showed a separate page that revealed his former comments, where Dooley wrote “in my unit they have to be handcuffed, we have to hand their stuff, it’s a lot of contact, we’re very hands on.”

Stiroka asked again if this helped recollect his memory for if he remembers escorting anyone in June of 2020. Dooley provided few comments, asserting “I don’t do it, there’s other people that do it.”

After a series of questions about his former statements that Dooley allegedly could not remember, Stiroka asked if any of Dooley’s supervisors talked to him about testifying in this preceding. “No, um, they didn’t know what it was about,” Dooley said.

“So none of your supervisors are aware that you’re testifying in this proceeding?” Stiroka asked.

“They know because I had to leave my post to come here, but they don’t know what it’s about, they just know it’s a court call,” responded Dooley.

They moved on.

Attorney Taylor Reeves took over questioning of the next witness, Dr. Daniel Parker, an infectious disease epidemiologist and an assistant professor in public health and epidemiology at the University of California in Irvine.

His work consists of creating maps of infectious diseases to track their spread and find ways to disrupt that. He has a BA in anthropology with a certificate in global health, Masters and PHD in anthropology and demography.

As a designated expert witness in the field of infectious diseases epidemiology for the case, Dr. Parker’s job was to provide expert opinion with respect to infectious disease epidemiology given the COVID-19 outbreak that was happening in San Quentin.

He reviewed peer review scientific literature, documents from the CDC on guidance for incarceral settings, visited SQ twice, and analyzed data on the CDCR website.

Considering the scientific literature on COVID-19, and the epidemiological trends in San Quentin, Dr. Parker concluded that characteristics of this prison, it is “a place that is just primed for the spread of a respiratory virus like COVID-19.”

As a result of the practices of the individuals in charge of the prison, “we saw a failure to prevent the importation of the disease into the prison, and then after it was imported, we saw a failure to control the spread of the disease within the prison,” he explained.

As a result, he added, “We saw unnecessary illnesses and deaths.”

Dr. Parker explained that correctional facilities are exceptionally susceptible to the spread of COVID-19 given the crowding in indoor spaces. One of the biggest risk factors is being indoors in enclosed settings with infected individuals.

He determined that the transmission rate within San Quentin, given the opened barred cells that are stacked on top of each other with individuals sharing cells, there is a higher transmission rates than the general public.

Dr. Parkers said that he visited San Quentin twice in October in 2020 and in April 2020, and through both of his visits saw the entirety of the prison. He described there being five stories of 4.5 feet and 11 ft long cells–with many of the cells with double occupancy– and the “the ventilation seem[ing] poor.”

He compared these to the cells he observed through his visits in Orange County (OC), explaining OC has a bit more variety with cell types, with many completely sealed off instead of open bars. He pointed out that San Quentin’s cells are “smaller, and generally more cramped” than OC, and that the “West block was particularly filthy.”

Dr. Parker pointed out that having cells stacked on top of each other, like they are in San Quentin, “is a major problem.”

He asserted that the horizontal six foot rule to prevent spread does not take into account the vertical aspect of a tier system prison. Most of the droplets can fall much further than six feet given gravity, arguing, “That six foot rule no longer applies to cells stacked on top of each other,” he said.

He explained that in addition to the stacked architecture, most cells had multiple occupancy when he visited. He explained that if you had one person who was infected, the other person “is highly likely to become infected.”

He also asserted that there is likely less than six feet between the adjacent cells, so “if you’re laying in one of these beds for example, the distance between you and the person in the cell next to you is likely smaller than six feet/”

Dr. Parker pointed out that he noticed the air quality was very poor. He explained that as you climb up to the fifth tier in several of the units, “it was hot and stuffy and the smell was bad. I could smell body odor, I would smell a bad smell that emanated from the place.”

“It was obvious to me that I wasn’t breathing outside air,” he added.

Speaking to the Adjustment Center (AC), where COVID-19 positive individuals were put in isolation, he pointed out that the cells held one person and had a sealed door.

Dr. Parker raised concerns that using the AC for isolation may act as a deterrent, and that it could delay how long an individual waited before confessing that they were sick.

Dr. Parker asserted that the CDCR and San Quentin did not comply with the CDC’s recommendations for carceral settings. Dr. Parker explained that the first fault was the importation of inmates from CIM in the first place, being mixed in with people with unknown status, when moved into the South block.

Likewise, after a known outbreak going on in a specific block, “it should have been treated as a single unit with proper spacing” to prevent the spread to other blocks.

Dr. Parker discussed the data on the transmission of COVID-19 in San Quentin prison, and pointed to the trend of exponential growth that was observed. But a closer look, he explained, one could see “stutter steps” in that growth, “almost like it’s trying to plateau,” but then it “takes off” in an exponential curve again.

“It looks to me like after these cases were imported into that facility, you had an essentially uncontrolled epidemic in one of those blocks. It essentially spread throughout the entire block, around 500 people,” he explained. “It could have leveled off at that point, but then it takes off again.”

He believes that at that point, that is when the virus jumped to other blocks. To him, it suggests that this was a series of epidemic curves stacked on top of each other, and that if an intervention to stop the spread between the blocks was implemented, it would have prevented the subsequent exponential spikes.

After showing Dr. Parker a graph of the transmission trends, attorney Reeves asked “what would you expect to see on this chart if San Quentin had done nothing at all to prevent the spread of COVID-19.

“This is exactly what I would expect to see,” he said. Dr. Parker assured that if the prison had rapidly decarcerated by at least 50 percent and spread people out, they would have been able to successfully mitigate the spread

Defense Attorney John Walters responded with his own questioning.

After confirming with Dr. Parker that the period of exponential growth started and ended within a short period of about 30 days, Attorney Walters questioned his assertion about rapid decarceration as the a “only way to stop this exponential growth.”

He asked Dr. Parker if he knew if the warden would have the power or authority to do that, or how much notice it would take to do that. Dr. Parker asserted that it was outside of his expertise.

After having Dr. Parker confirm that San Quentin was not the only prison to experience an outbreak, citing CIM as an example, he asked if Dr. Parker agreed that those outbreaks “occurred regardless of the physical designs of those prisons.”

Walters asked Dr. Parker a series of measures taken by CDCR and asked if each one was “reasonable.”

Dr. Parker repeated that they sound reasonable, “of course I agree with that,” but that his expertise is about what is going to stop transmission, which is different than asking what is reasonable to ask people to do.

“Well, do you agree that everything that I mentioned so far is at least a piece of an attempt to stop transmission?” Walters asked. Dr. Parker confirmed. “Okay, that’s all we’re doing. That’s how simple the exercise is,” Walters said.

Walters then asked him if he thinks it’s important to that before coming to speak to have known all the past and present practices and policies at San Quentin that were used to mitigate or battle COVID-19

“Information is good, yeah, but to be honest I can look at the epidemic curves and tell you that the public interventions didn’t work, regardless of what policies were put in place,” Dr. Parker replied.

The final witness was Channing Sheets, a senior safety engineer for the San Francisco and Foster City districts of CAL/OSHA, since sept of 2014 who investigated San Quentin last year for COVID-19 as part of a communicable disease emergency response.

Sheets explained that he interviewed “anyone that walked.” He interviewed 117-120 correctional officers, but revealed that some were not completed because they were having issues such as trouble breathing. He also interviewed a number of lieutenants and sergeants, even the warden.

Sheets asserted that the situation at San Quentin was “dire.”

“I’ve investigated a lot of outbreaks in the past 25, 30 years or so, and it had to be hands down one of the worst to deal with I’ve ever encountered,” he maintained.

After touring the San Quentin prison on June 24, 2020 Sheets sent an email to the California Department of Public Health where he shared his concerns about the way the facility was managing the COVID pandemic.

In the email, Sheets confessed “honestly, this is the worst outbreak in a correctional setting I have ever seen.”

The email also detailed what he learned during his tour of San Quentin stating, “when I went there last Wednesday there were 445 cases, 69 employees were positive, 45 on precautionary removal, with another 45 that called sick that day.”

While sending this email, Sheets wanted to make it clear that his goal was to “prevent the introduction of the virus into the housing unit without cases which, but in order to do so the issues that he noticed at San Quentin needed to be addressed.

He told the court that the issues that needed to be addressed were the movements of staff within the prison. Sheets iterated that the problem was that “you have staff take shifts in a positive unit and then they take shifts in a negative unit” causing the employees to transfer the virus around the prison as well.

Aside from staff transferring COVID throughout the prison, Sheets revealed that they had the yard open to every incarcerated person regardless if they tested positive or negative for the virus.

He lectured “you don’t take positive and negative inmates from different tiers and mix them together, that’s a recipe for disaster that should never have been done.”

Sheets also criticized San Quentin’s insufficient COVID testing practices. Despite the outbreak picking up full speed in the prison, he was notified that not every employee had been tested for the virus.

Additionally, Sheets revealed that San Quentin’s screening practice was just as inefficient as its testing practices. He recalled being both appalled and confused by certain staff bypassing screening procedures.

During his tour he observed “the people who worked the wall post in custody staff, people who worked inside the admin building outside of the main compound didn’t have to go to the gate to be screened.”

Sheets also observed that an “employee can come to work and say they didn’t feel well or be symptomatic and then they can be sent home, they can come back the next day and say they were feeling fine because they didn’t want to go on doc in terms of pay and walk right into the complex” instead of quarantining or taking the time to isolate.

These practices made the COVID outbreak worse and caused the number of infected people to rise, he opined.

While conducting his investigation of San Quentin he interviewed correctional officers, one of them being Officer Lee Dooley.

During the interview with Officer Dooley, Sheets learned that the prison did not have a donning procedure for the PPE gear and thus putting more people in danger through the improper use of PPE.

Sheets made various site visits after his initial tours. In one of those visits he observed the facility’s employee gym not following any safety protocols in a time when gyms across California were mandated to shut down.

He found a staff member using the cardio equipment without a mask, the windows were closed when they should have been opened to create ventilation, and the lack of disinfection procedures for the gym equipment.

Sheets recalled that changes were made weeks after he raised his concerns through his emails. From boarding up the employee gym to keep people out to contracting out people to be in charge of the screening procedure to make it consistent.

However, by the time these changes were made the COVID outbreak in San Quentin had already been massive.

Sheets stressed that these changes should have happened much earlier into the pandemic and “could potentially have saved over a thousand lives.”

The hearing will reconvene on Tuesday morning.

Mia Machado is a junior at UC Davis, currently majoring in Political Science-Public Service and minoring in Luso-Brazilian studies. She is originally from Berkeley, California. She is a team member on the Chesa Boudin Recall – Changing the Narrative Project.

Jose graduated from UC Davis with a BA in Political Science and has interned for the California State Legislature. He is from Rocklin, CA.

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