Trial Coverage: Week 3

Lindemann questioned the letter's relevance to this case, suggesting that it was written specifically about HIV inmates. Dr. Patterson pointed out that many of the Department of Justice findings were consistent with his own, that there were issues across the system relating to medications management.  In reference to a portion of the Department of Justice letter that suggested the possible need for judicial intervention, Lindemann asked Dr. Patterson whether he was suggesting that Jon Ozmint, former director of the South Carolina Department of Corrections, was asking for a lawsuit.  Dr. Patterson replied that he did not know what Mr. Ozmint was asking for.

Lindemann asked a series of question related to SCDC's ability to control who is incarcerated in its prisons.  He asked, isn’t it true that “SCDC doesn’t have control over where they are sent? They can control what facility within the Department that the inmate is sent to, but my point is the judge’s orders cannot be ignored. They don’t have recourse to send them back to court, or to the Dept. of Mental Health (DMH), but must send to SCDC system. Isn’t that correct?”  Dr. Patterson agreed.

SCDC's counsel also detailed a number of funding requests that the Department has made in previous years, and asked Dr. Patterson whether he knew if any of those requests were  provided by legislature. “I don’t know that,” he said. “I do know there is not a new facility or sufficient staff. The request is to provide services needed to comply with state and federal laws to provide care for people with special needs."

When Dr. Patterson was asked whether he is an advocate for mental health care – as a medical practice, he responded “I am in favor of health care – appropriate health care – and, as a psychiatrist, I am an advocate for appropriate mental health care.”

Dr. Patterson was questioned about a general shortage of psychiatrists throughout the country, particularly in South Carolina.  Dr. Patterson disagreed that psychiatrist availability is as bad as Lindemann suggested, pointing out that he is encouraged by younger doctors’ increased interest, which is occurring because of an increase in fellowships and because they find they can treat people … long term in institutional settings.  He also explained that “the scope of what I was evaluating and the opinions I am presenting do not fall into the realm of whether there is a shortage. My opinion is that there is a need for these positions to be filled in order to meet the standards of care necessary.”

Patterson is advocating the hiring of 14.5 additional full-time equivalent positions for psychiatrists (FTEs) in South Carolina.  Lindemann asked, “have you done any assessment as to whether it is feasible for SCDC to hire that number of psychiatrists?”  Dr. Patterson explained that he did not conduct a feasibility study.

Lindemann questioned Dr. Patterson about the sudden gap in mental health coverage created by the rapid departure of a privately contracted firm that once provided mental health services at the Department.  Dr. Patterson said that departure was not the only reason that SCDC was in crisis at that time, and suggested that there are ways of planning for the pitfalls of contracting out medical services, such as including penalties for such a sudden departure.  Dr. Patterson also pointed out the value of having a mental health professional present during those contract negotiations.

Lindemann asked a series of questions that suggested difficulties in getting psychiatrists to work in a corrections environment.  Regarding pay, Dr. Patterson suggested that the pay was not necessarily better in the private sector explaining, for example,  that it used to be that psychoanalysis was one of the more lucrative areas of psychiatry.  However, since insurance often no longer covers this type of therapy, and it is often necessary for patients to attend four or five sessions a week,  you have fewer patients who are willing and capable of paying the fees. Dr. Patterson also pointed out that factoring in benefits and malpractice insurance, psychiatrists are more willing to work in the public and corrections sectors provided the pay is sufficient.

Regarding the prison work environment, Dr. Patterson stated that he feels safe providing services in a prison because patients are checked for threats and security is always near by, as opposed to his own office where someone could potentially carry a weapon and there would be no backup.

Lindemann asked about a rash of counselor terminations and resignations at Perry. Dr. Patterson described the "exodus" of counselors from Perry as more evidence of deficiencies in training, quality of staff, and appropriate supervision, explaining that to have that many people terminated for improper behavior at the same time is unusual, but "it is a system issue; it did not occur from some alignment of the stars. Where is the supervision? Where is the adherence to policy?”    

The cases of terminated counselors were explored at length. In regard to his statement about a lack of quality management, Dr. Patterson was asked to define quality assurance and quality management and how they have evolved over the years. He stated that the goal is now continuous quality improvement over time, rather than as a snapshot. He said if you are not reaching thresholds, you continue to design ways to achieve them.

Lindemann asked questions about the newly implemented counselor audit practice: “You didn’t have any problems with Ms. Delgado’s audits, right?”  “Wrong,” Dr. Patterson replied. “It was the methodology of the audits I had problems with. They didn’t include criteria for establishing what is satisfactory and unsatisfactory." Dr. Patterson also suggested there was a lack of directive design to remedy unsatisfactory performances. “It is not sufficient for her to say ‘follow policy.’ There must be a mechanism – a part of that is a re-audit … but the next audit period is too late. It should require ‘meet with supervisor weekly to assure you are having timely meetings with inmates.’”  When Lindemann pointed out that in one counselor termination case, dates were given for a re-audit in seven months, to which Dr. Patterson replied, “too late."

Lindemann replied, “It was certainly less than a year.” “Yes, but still too late,” Dr. Patterson reiterated. “The reason for an audit is to correct errors. You must provide training and support so they don’t keep making the same mistakes.”

Lindemann then suggested that the issue with counselor audits is a catch-22 for SCDC, suggesting that if all of the audits returned satisfactory results, Dr. Patterson would then criticize that. Dr. Patterson responded that he certainly would because his work in this case has established that would clearly not be reality.

Dr. Patterson explained: “The idea is that you want to have a meaningful audit. You want to make sure the audits are focused on performance, and then you want to translate the employee performance into the system. If the audit says everything is great, I want to know what it is based on – if you just talked to employees and looked at no records, it is flawed; if you only look at a few records, that is flawed. I need to have criteria for what is done.”

Later in the day a discussion of a Colorado study of long term segregation’s effect on inmates began.

The study had the premise that long-term segregation can exacerbate mental illness and cause mental illness where none previously existed, however the findings did not bear out the hypotheses.

Dr. Patterson expressed his concerns about the comparability of the study to SCDC, as he had in direct testimony. One such concern was that the Colorado study was limited to one year, where Dr. Patterson had testified in this case regarding stints in segregation spanning several years. He also expressed reservations because the study had not been replicated.

Lindemann also showed Dr. Patterson charts during cross examination depicting suicide rates in prisons across the country, suggesting that South Carolina has a lower rate even than New Jersey and California, two states in which Dr. Patterson has been asked to provide input into suicide prevention policies. Dr. Patterson testified that he indeed provided advice regarding suicide prevention policies, but he could not say to what extent his suggestions were applied.  

Following a brief redirect, the witness was excused.

Court will reconvene at 9 a.m. Friday, March 2, 2012, with Defendants calling their first witness, SCDC Director of Mental Health, Dr. Pamela Whitley.

The deposition of Yolanda Delgado was read, during which Delgado stated in regards to past training that a handful of lieutenants attended but suggesting that it is hard for the lower ranking corrections officers to come. When asked, Delgado could not provide the number of officers who had been trained.

Dr. Patterson explained that training corrections officers how to handle mentally ill inmates is necessary, and it should be mandatory. The department should designate time for officers to attend training. It cannot be, as Ms. Delgado stated, "optional" and "when they have time.”

He also recommended that the training not only be conducted by a mental health professional, but by someone who works in corrections, so that the corrections officers have the opportunity to ask questions and know their concerns are understood by someone who is also “on the blocks.”

As he had in earlier testimony, Dr. Patterson stressed the need for SCDC to institute a practice of effective suicide watch, which should involve constant observation. He again noted that he could recall no other state where suicide watch is limited to 15-minute checks, which he deemed “clearly inadequate,” especially since SCDC records show that the 15 minute checks, required by policy, are often not conducted. 

He noted from his review of SCDC records and his visits to South Carolina prisons over a period of more than a decade that the officers do not understand the behaviors of the mentally ill and often respond in a manner designed to control or punish the inmate, rather than enlisting the aid of a mental health staff member.

Over several objections, a letter from a former SCDC psychiatrist, written to the SCDC mental health director, was allowed into evidence. The letter expressed various concerns, including that inmates were not getting their medications in the morning because the medications were distributed at 4 a.m. The psychiatrist stated that the practice was resulting in increased psychotic behaviors. The letter suggested modifying the distribution method to reduce the risk of missed medications. This letter echoes the testimony of the majority of the inmates who testified earlier in the trial, that the early morning pill calls make it difficult to stay on their medications.

It was suggested by the defense, in their objection, that the letter was not admissible because the person who wrote it is no longer employed by SCDC, and had only been a contract worker from the Department of Mental Health. Judge Baxley admitted the letter into evidence over the objection. Dr. Patterson was asked why the letter was important. He replied, “Because of the fact that even people without a mental illness would not be motivated to get up and do anything at 4 a.m. and because this concerns a population that has illnesses that make them even less likely to comply than most. This is a situation that is not likely to encourage compliance.”

The consequences of the current pill-call policy are that it escalates problems corrections officials might have with mentally ill inmates, thus raising the risk to staff as well as inmates.

Dr. Patterson discussed several examples of Medication Administration Records (MARs), a monthly tally of which medications have been prescribed and taken by an inmate.

“They (the records) are crucial to mental health care management because they give practitioners the opportunity to determine whether or not the inmate is compliant with medications,” he said. “It is troubling because there is no documentation of the meds being given. You cannot make out what is in the columns.”

Partial dosing and intermittent administration of medications not in accordance with the doctor’s orders can cause more medical problems for the mentally ill, according to Dr. Patterson, who said that following doctor’s orders and completing the MAR “is a must.”

Dr. Patterson continued to stress that “The Special Management Unit (SMU) is not a treatment environment – it is a disciplinary environment. Inmates might be sick, might want to hurt themselves – they are locked in isolation for 23 hours a day, with very little contact with people, receiving essentially no treatment. A counselor comes by at the cell block and asks through the door with no confidentiality, ‘Are you thinking about hurting yourself? Are you ready to come off CI?’ Or, ‘How are you doing?’" He said inmates will not confide in the counselor because “It is, after all, a prison. They don’t want other inmates to think they are weak, so there is very little likelihood they will share how they are feeling in that environment.”

Dr. Patterson was asked about the practice of putting the inmate into Crisis Intervention (CI), which a layperson might interpret as a supportive environment where an inmate who has threatened self-harm can be counseled and treated in order to help the inmate resolve the issues s/he is having.

However, numerous witnesses have described the CI experience as a painful, humiliating ordeal where the inmate is put in a cold, cement cell with no clothing, blanket or mattress, often for days or weeks.

Dr. Patterson said that SCDC staff members say the reason for not providing clothing or bedding is because of the risk that those items might be used by the inmate to attempt suicide. Dr. Patterson testified that inmates on crisis intervention should be provided at least a suicide blanket, which is designed to be tear resistant. “What is important in S.C. is that there is no constant watch. It takes time to pull a thread and unravel something – the inmates know the 15-minute check policy, so in ‘real time observation’ that can be prevented; when the room is vacated, you check the blanket; you check the mattress… if you find evidence of attempts to unravel, then you take that piece out of commission… it’s that simple.”

In one of the more shocking revelations in the trial so far, Dr. Patterson spoke about the inappropriate use of shower stalls, interview booths, and rec/shake-down cages for CI purposes. He described the rec/shake-down cages as “runs” used for searching inmates returning from the yard.

He mentioned that two of these alternate CI areas provide a blocked view of the inmate, which seemed to be at odds against the need to observe them because they are moved there “ostensibly on CI status because of decompensation and increased risk of harm to selves,” he said. “You want to be able to see them and neither provides that option. The spaces are not designed for suicide prevention.”

Dr. Patterson cited example after example from the SCDC’s own logs that showed inmates being placed in those alternate areas, not only when the designated CI cells are full, but as a primary choice despite there being few or no inmates occupying the CI cells.

Dr. Patterson testified that inmates are stripped and put in these spaces, sometimes open to view of anyone (inmates or officers) walking by. There are no bathrooms in these spaces.  They must ask permission to go to a bathroom, or else go where they are with no provisions to clean up. They are given finger foods but no sink, so they cannot wash their hands or maintain any hygiene.

Dr. Patterson said that none of those areas are appropriate for suicide prevention and outlined some cases he said were most concerning to him. One example involved an inmate who was placed in a shower for 72 hours with no place to lie down and the only means to relieve himself was to go in the shower drain.

Several inmates were kept in the rec cage for four or more days with no clothing, no bathroom, and without being transported to a bathroom, which Dr. Patterson said would be humiliating for anyone, but when the person is mentally ill it can increase their risk of decompensating significantly.

A clear pattern emerged whereby inmates on CI are put in inappropriate areas as a primary choice, not for reasons of unavailability of regular CI cells. Dr. Patterson said, “Even though containment in a segregated unit is contraindicated for the mentally ill inmates, a CI cell would be better than the cage.”

Dr. Patterson, discussing incidents in which SCDC employees were terminated because an inmate was placed in a shower stall on crisis intervention, and the 15 minute cell check log had been falsified, said, “That shows a continued pattern of disregard.”

When asked “In what cases would it be appropriate to place inmates in shower stalls or other places not designed for CI?” He answered, “None. This reinforces my opinion that the system is broken."

He emphasized, “Mental illness is not improved by taking someone’s dignity and by putting them naked out in front of anyone – inmates or others.”

Dr. Patterson was asked to describe his extensive experience in suicide prevention programs in prisons.

When asked if SCDC has a good suicide prevention program based on a lower rate of suicides in prisons than other states, Dr. Patterson explained that it is necessary to evaluate the circumstances surrounding the suicides themselves within a system, as well as the attempts and other types of self-harm. He said it is important to look at the successful suicides to see whether it was foreseeable and preventable.

He discussed several suicides at SCDC that he considered foreseeable and preventable. The records Dr. Patterson reviewed indicated a disregard for warning signs that could have averted the death. Others he attributed to a lack of constant observation. Dr. Patterson outlined some of the key aspects of quality management: “Suicide prevention systems; medication management; adequate mental health staff to inmate ratios; informed assessments of mentally ill inmates; and medication compliance monitoring (ways to make the determinations coincide – matching Rx with caseload numbers, and more). You need an accurate count of those on the caseload; services to be provided; ratios necessary to provide those services – or you must augment or modify; you must evaluate the efficacy of psychiatric clinics to determine whether sufficient for inmates to be seen during the required time periods. Over numerous objections, Judge Baxley allowed the deposition testimony of Ms. Whitley, SCDC Director of Mental Health, to be read, including an admission that she shredded hard copies of statistical documents related to the treatment of mentally ill inmates sent to her from the regional managers. Whitley changed her testimony at a later deposition, claiming that she was wrong about shredding the documents. The defense informed Judge Baxley that they had in fact produced those documents, which Plaintiffs' counsel pointed out was yesterday, three weeks into trial.

Dr. Patterson was asked his expert opinion on that practice of shredding the only copies of mental health statistics. He said, “Quality management is a dynamic process – you don’t shred or get rid of reports – you need to know where you are; you measure; if you are not where you need to be you make assessments and corrections; then you determine how you can get it up to the accepted threshold of compliance with a specific performance indicator. You want to keep that information and build on it; you want to be able to show how you are doing – you want to reach a 90 percent standard – and 100 percent on critical items, the things you cannot afford to miss. You have to have (the data reports).”

The next area covered involved audits of SCDC mental health counselors. Testimony cited multiple failures to conduct patient assessments in keeping with SCDC policy. Dr. Patterson cited widespread policy violations including: inconsistencies in the diagnosis listed in records; therapy not being provided or documented; psychiatric visits not held when required – if at all; treatment plans not completed; and treatment notes that were documented in the automated medical record prior to treatment team meeting.

Pointing out more concerns about the trustworthiness of staff entries in medical records, Dr. Patterson said, “Other than ‘treatment team has not yet met’ there is no reason for a note to be in the file about treatment team findings prior to their having met.”

He said many of the counselors, about half at some locations, were recently rated unsatisfactory or satisfactory with major deficiencies. He said the audit findings raise questions about the methodology used to audit counselors. He explained that although he often found similar deficiencies when comparing audits, he could not discern why one would be unsatisfactory when the other would be “satisfactory but with major deficiencies.” Dr. Patterson stated he has never seen such audit findings before coming to S.C. He offered this as additional evidence that the quality management program in SC is not adequate.

Dr. Patterson's knowledge of the mental health system at SCDC predates this lawsuit. In 1999 – 2000, Dr. Patterson was invited by SCDC to be a technical advisor to review the system. In that role, Dr. Patterson and others found that “the behavioral medicine program at SCDC was in crisis – interventions were necessary for improvement.” A supplemental report (March 2000), found that the department was “woefully inadequate in its training, procedures and medical services.”

That document was admitted into evidence over objection, as was a joint legislative proviso from October 2000, written in part by one of the SCDC psychiatrists, Richard Ellison, and a letter from the United States Justice Department, all of which pointed out the inadequacies in SCDC's mental health program.

One report said that “The public is being shortchanged because they (the mentally ill inmates) are eventually going to be released to commit crimes against the public and/or be returned to incarceration at the public’s expense.”

Another said, “It actively impacts the citizens throughout the state and throughout the communities when inmates are not given the care they need and then are returned in worse shape. They should be in better shape so they can make the adjustments necessary to living in the community.”

Dr. Patterson noted that “Clinicians and advocates wrote one report and the other report committee was comprised of movers and shakers – legislators and directors and former directors of SCDC, but both were very consistent with the conclusions I made.”

Dr. Patterson had informed SCDC at the time about a lack of adequate resources and a serious problem with delivery of services. He stated today that he was disappointed to have been invited to be a technical assistant at SCDCs request without his recommendations being taken into account. Despite the numerous notices and warnings to the department, the mental health program remains inadequate.

He said, “The mentally ill as a group don’t have – either outside or inside prisons – many advocates; but those inside the walls need those who are outside to take up their cause and help with their needs.”

Dr. Patterson will be cross-examined by defense counsel for SCDC Thursday, March 1, 2012, at 8:30 a.m.

He testified about a census decline in the numbers of inmates reported to need ICS (Intermediate Care) saying that the numbers no longer reflect normal percentages of ICS patients, which gives the false appearance that a lower number of mental health staff is needed.

Dr. Patterson reported on a large discrepancy between the numbers of female inmates at one prison reported with mental illness (46) versus the number being treated (5). Dr. Patterson explained that mental health care for women at SCDC is inadequate based upon these numbers and his interviews with women at Graham. He also identified a lack of inpatient resources for women, explaining that a lack of available services at the highest level of care is a sign of an inadequate mental health system that that places women in SCDC at substantial risk.

Dr. Patterson also described the environment at SCDC as one where segregation is commonly utilized instead of treatment. He testified that the mentally ill are over-represented in the Special Management Units (SMUs), where mentally ill inmates do not get appropriate care.  “What this means is that we are not putting mentally ill inmates in treatment programs, we are locking them in SMUs.  Special Management Units that are essentially segregated 23-hour lockdown units,” Dr. Patterson said.  Dr. Patterson expressed concern that segregation often contributes to a decline in mental health.

Despite the overwhelming need for better mental health treatment, there is no movement at SCDC toward providing better care.

A former SCDC task force comprised of former and present SCDC heads, Jon Ozmint and Dr. William Byars, among others, stated in 2003 that Gilliam Psychiatric Hospital was in need of replacement: “The current facility is clearly inadequate.” However, instead of moving forward with much-needed services for the mentally ill, plans that SCDC had for new facilities are “on hold.”

In a written statement, Dr. Woolery, a SCDC psychiatrist, said that 40 to 50 percent of the inmates she sees in SMU are actively psychotic and exhibiting symptoms of their illnesses. 

In his testimony, Dr. Patterson said, “The major question is: why are they still in SMU? Why are they not in a place where their illness and symptoms can be treated?”

Dr. Patterson believes that psychiatrists should be monitoring all SMU inmates – not just those that are actively psychotic, to observe them for onset of symptoms. He explained that it is important to check on the quiet inmates – those that staff sometimes calls ‘cell dwellers’ – because those are the ones most at risk of decompensating while in segregation. Isolation is an undisputable risk factor for suicide.

Dr. Patterson does not believe SCDC counselors are qualified to make high-level determinations or recommendations regarding inmates who are decompensating. He said, “There is a mechanism where mental health workers can help corrections officers.  If there is a way to intervene and stop disruptions, you can help corrections manage difficult-to-manage people – we can address the behavior, which can help all.”

He also said that long-term segregation is common for mentally ill inmates at SCDC – one inmate had been in continuously for 2565 consecutive days of segregation - about seven years; another openly psychotic patient (who testified about being able to “see” fire in the room) has been in segregated lockdown for the past twelve years.

Patterson said such long-term segregation can contribute to psychotic disorders, aggression, and suicide. Regardless whether inmates are mentally ill prior to going into segregation, Dr. Patterson testified, segregation complicates their mental condition.

Dr. Patterson described a case in which a schizophrenic inmate's placement in the Supermax Unit resulted in his death.

Dr. Patterson said that communication between security and mental health staff was non-existent in that case. Prior to being placed in Supermax, officials had reported that the inmate was trashing his cell, being loud, and running around naked. Dr. Patterson said he could find no clear reference why the inmate was given no clothing or sheets in Supermax, or why he had not seen his counselor or a psychiatrist in the 11 days he was there, despite policy that requires a counselor assess the inmate under those circumstances daily. The counselor that should have been assessing the inmate stated in a deposition that he had not known his client was in Supermax. The counselor also said that he had never known that inmate to be violent.

Photos were shown of the conditions of the room, which showed blood and dirt throughout it.  Dr. Patterson described the conditions as bleak, filthy and detrimental to anyone’s well-being.

“This is a very tragic example of the serious harm that inmates with mental illness are subjected to,” Dr. Patterson said. “This inmate was transferred to an environment that was bleak and depressing for reasons that were unclear; he was stripped of his basic needs; his mental health counselor was not aware he was there; the SCDC psychiatrists do not go into Supermax."

Dr. Patterson explained that the inmate was still alive when the officers found him, but medical responders waited for inmate workers to come and remove him from the cell before providing medical attention. Several hours passed before he was transferred to an outside hospital, where he died, from a heart attack.

"As a physician, you respond and render service to people in distress… I don’t believe that was done,” Dr. Patterson said.

Another aspect that Dr. Patterson testified was problematic is the disproportionate application of disciplinary sanctions to mentally ill inmates. Despite an available verdict of “Guilty but not Accountable” or GBNA, he said, “It appears there is no impact on the sentencing when the verdict of GBNA is recommended by counselors. The full disciplinary sentence, oftentime in segregation, is commonly imposed regardless. Inmates are sent to lock up even when counselors assess them as not accountable." Dr. Patterson said that although it is unusual in most states to use restraints to prevent self-harm, it is standard practice at SCDC. He also said SCDC does not require staff to get a doctor’s order to use what are essentially medical restraints, which he said is “very concerning to mental health professionals because restraints can do considerable harm and use of them is not considered the ‘least restrictive’ way, in order to reduce the risk of harm.”

“However, at SCDC, the restraint chair is sometimes ordered by counselors and sometimes by corrections staff,” Dr. Patterson said. “This violates the standards because it is not an in-person order, not a doctor’s order, or a written order. SCDC policy allows corrections officials to place inmates in restraints for four hours; then another four hours without evaluation of the behavior.”

Comparing the national standards to SCDC policies, Dr. Patterson said, “Doctor’s orders must contain orders for release, and no specific amount of time is ever ordered. It is always ‘up to’ a limit of time.”

According to Dr. Patterson, once you are in the restraint chair at SCDC – even if you are calm, you remain in the restraints for at least four hours and in some cases up to 12. He said these should be medical decisions, not custody decisions. Later in his testimony, Dr. Patterson was asked, “Are psychiatrists involved in approval of restraint devices?”

“I have seen no evidence of that,” he answered, testifying under oath that one SCDC psychiatrist had told him, “They (security) are running the place. I just get out of the way.”

Three videos involving the use of the restraint chair were then shown.

Two of them were quite graphic and involved cases of inmates being severely injured, one from a self-inflicted cut to a vein in his arm that was bleeding profusely and caused the inmate to go in and out of consciousness; while the other inmate had eviscerated himself, with his intestines bulging outside his abdominal wall. In both cases, the inmates were shown in great distress, but were still strapped down in the restraint chair in ways that made their injuries worse. There were no immediate attempts to administer medical aid. In one case, corrective action was later taken against the staff involved for failing to transport the inmate to a hospital. In the latter case, the forceful tightening of the restraint straps had pushed the inmate’s intestines further out.  A nurse entered and attempted to push the intestines back into his abdomen, without benefit of painkillers or a sterile environment.

Dr. Patterson expressed great concern over the treatment in the videos, pointing out that no medical staff was on duty, the inmate was trembling, which is potentially a sign that he was going into shock. However, no one checked his blood pressure or pulse. Dr. Patterson also pointed out that the bandage, applied by non-medical staff long after the wound was inflicted, had soaked through with blood, and that while there was a great deal of effort to put restraints on the inmate, who was not moving or resisting, there was no effort to stop the bleeding. Instead, his arm was extended downward with restraints, which is the opposite of what should be done to stop bleeding. The inmate was in the chair in this condition for four hours.

Dr. Patterson said, “I have seen a lot of things in 30 years of practice but this is the worst, most outrageous, horrific response … it is the a sign of a broken system.”

The officers in the video could be heard saying that the captain authorized it. When the inmate asks to go over his head, they said there was nothing they could do, that they were "just a first responder."  

When a nurse finally came to check on the inmate, she talked to him through the cell door.  She did not take vital signs or try to determine whether he needed to be sent to a hospital.

Dr. Patterson explained that the memo promising corrective action shows an awareness of what is wrong in this case; but corrective action against one officer does not address the systemic issues. He emphasized that this incident is evidence that the mental health system at SCDC is broken.

“The officers were following instructions of what they are told to do… my opinion is that this is coming from a level much higher up,” he said.

Dr. Patterson described SCDC's mental health program as “crisis reactive."   

“The system is broken,” Dr. Patterson concluded.

Court will resume Wednesday morning at 9 a.m.

After a week in recess, testimony resumed Monday, Feb. 27, 2012, with Plaintiffs calling Dr. Raymond Patterson, a forensic psychiatrist from Washington, D.C., with more than 30 years of experience in his field. Dr. Patterson first inspected the S.C. Department of Corrections in 1999 on a grant from the United States Justice Department. Dr. Patterson has monitored prison mental health systems throughout the United States. Dr. Patterson has conducted numerous inspections at South Carolina prisons, and he has interviewed dozens of inmates and staff in his review of the S.C. Department of Corrections' mental health system.

Dr. Patterson has served as Commissioner of Mental Health for Washington, D.C., and as an associate professor of psychiatry at Howard University as well as at Georgetown University.

Dr. Patterson, who has visited and assessed over 100 prisons as a psychiatric consultant, spoke about symptoms, standards of care and treatment as well as the conditions he found at S.C. Department of Corrections (SCDC).

Dr. Patterson estimated that he has spent around 500 hours working on this case since he was retainined in 2005. Many of those hours were spent visiting S.C. prisons.

He explained that his opinions are based on interviews with inmates and staff and his review of policies, procedures, practices, quality management information and personnel files.  He said that he would have preferred to see quality management files over time, explaining that it is better to focus first on quality assurance and then quality improvement and corrective actions. Then, the entity can turn to quality management, including assessing individual staff member performance, to determine whether procedures are being followed and whether those procedures are effective.

He stated that his medical opinion is that the SCDC system is “inadequate and insufficient for the medical health needs of the inmates.”

When asked to describe SCDC’s psychiatrists’ involvement, he said, “It’s minimal.”

Dr. Patterson described a lack of awareness and involvement on the part of the mental health staff.  One example concerned a psychiatrist who stated in her deposition that she was not aware of what the acronym CI stood for (crisis intervention).  Dr. Patterson explained that crisis intervention and the role of counselors in the mental health program are essential areas about which a psychiatrist should have knowledge.  Depositions excerpts were read into the record in which one SCDC psychiatrist was quoted as saying, “I have very little knowledge” [of the different mental health classifications for inmate patients]… “Maybe they don’t wash as well; I cannot tell a difference… I don’t know about it and really don’t understand area mental health… a guy comes to me with a problem and I deal w/the problem… not the categories.”

Dr. Patterson emphasized that “Psychiatrists are the most responsible highest-trained individuals and are responsible for patient care. They must know the categories in order to assign them correctly to the level of service and areas with more mental health services. When you are in a system you must know what the system is capable of providing.”

One SCDC psychiatrist, in a deposition, reportedly described a confusing schedule of visits between three prisons, one of which he never went to, but used video conferencing instead. He was spread so thinly, he only got to one prison two days a month.

Dr. Patterson emphasized the need for consistency in counseling. “If done properly it leads to a level of continuity – those who need more care should be at a level 2 area mental health facility and need to be seen frequently; those who are more stable – they need less.”

Another mental health provider from SCDC could not provide the number of patients at a particular institution when asked during a deposition:

“What percentage of your patients is in SMU at Perry?”

“In what? SMU…?”

“Do you know how many?”

“No… how would I know? How would I tell? I don’t know… I don’t know anything about Perry… I also don’t know about prisons or anything…”

“Do you know what SMU stands for?”

“Not really.”

Dr. Patterson testified that SMU stands for “Special Management Unit, which is a 23-hour lockdown; conditions are markedly different from normal prison conditions and it is absolutely essential for mental health staff to know. It is very disappointing for the psychiatrist not to know the difference between someone who can go to chow, go to the yard outside versus someone on 23-hour lockdown who is segregated from the community.”

He stated that thisprovider should inquire into a patient's housing because that is part of the due diligence required in providing adequate services.

Dr. Patterson said, “He should know what they do there… even if by telemedicine; but he should take a trip… I certainly have and I came from much further away to find out how the inmates with mental illness are treated, are they provided confidential contacts? What are the conditions in CI? Are the inmates stripped out? What is their food like? Are they able to exercise? How is their toileting? All those factors are important for inmates… the conditions are extreme.”

Dr. Crawford, a SCDC psychiatrist, was asked in her deposition:

“I asked you about ICS… “

“Yeah, I’m not sure how that works…”

“Do you know what it stands for?”

“No.”

“Is there a distinction between ICS …”

“This is how I think of it… they need more treatment, they need less treatment, and I’m not sure which is which.”

Dr. Patterson described Dr. Crawford’s lack of awareness about  ICS as “appalling.” He said, “Dr. Crawford is the psychiatrist at Graham, the area for women with mental health issues, so how can she not know the distinctions in levels of care; how can she not know what ICS stands for? She has a responsibility to provide adequate treatment of care. She must be the mover and shaker to determine what and how frequent the treatment should be.”

Dr. Patterson testified for nearly eight hours about that and several other demonstrations of mental health staff’s lack of involvement regarding what happens to their patients, and about how the conditions of their confinement illustrates that these individuals are not getting the help they need.

One psychiatrist admitted during deposition that he had no administrative or supervisory duties in regard to patients or their treatment plans.

Dr. Patterson gave his medical opinion and said “to have the psychiatrist have no knowledge about treatment plans and to use the counselors as gatekeepers is absolutely unacceptable.”

Dr. Patterson says all inmates on segregation should be seen frequently to be sure they are not decompensating and should be monitored to be sure they are remaining stable; it is important for the psychiatrist to know if the inmate cannot tolerate segregation.  They must figure out how to have a safe environment for both inmate and staff. The role of psychiatrist, according to the American Psychiatric Association, is they should be an advocate for good mental health care in service of the patient.

When asked how he would assess the adequacy of the psychiatric staff, Dr. Patterson answered, “Woefully inadequate,” Dr. Patterson said, “I thought so since my first visit in 2000, and my opinion has been reinforced. Since 2005, the staff increased to 5.5 FTEs, which is still woefully inadequate.”          

Dr. Patterson said that the normal percentage of inmates on  a prison mental health caseload is about 15-20 percent; however, SCDC says their caseload is 12-13 percent, which he stated was a very low estimate.

National data shows that 80 percent of mentally ill inmates are on psychotropic drugs; however, SCDC reports 90 percent.

The ratio of full time psychiatrists to patients Dr. Patterson said was “so far out of acceptable standards it is difficult to describe.”

He stated his concerns also centered on the number of inmates in a particular facility; staff in place; and staff vacancies; as well as the ratio of staff to inmates, which at Perry was 1-89, despite a form that misrepresented the numbers based on a typographical error as 1-58, which is still well over the national recommendations.

Dr. Patterson said, “The ratio is approximately twice what I’d consider adequate.”

He outlined the “very troubling number of psych clinics,” saying that the minimum standard in SC is to have inmates seen by a prescribing psychiatrist a minimum of every 90 days.

“… To have three of every seven canceled means inmates are not being seen whether or not their meds are lapsing, or if they are being renewed without them being seen,” Dr. Patterson said.

Another area of concern was the lack of group therapy. Dr. Patterson repeated the concern throughout his testimony that group therapy has a positive effect and can prevent “devolving,” which can keep the inmates and staff safer.

A theme continued to recur as Dr. Patterson reviewed staff records – “staff are not performing their duties.”

Improper behavior was cited in numerous cases, multiple issues of inmates not being seen when they were supposed to be seen, groups were canceled, and what Dr. Patterson said was worst were incidents of failure to respond to crisis calls. He said that SCDC is behind the rest of the nation in their suicide watch system, and that 15-minute checks were not being conducted as required. He detailed a case where 15-minute cell check logs were falsified. In that instance, security video proved that the checks were not conducted, yet the cell check logs reflected the checks having been made. He said the corrections officer had been sleeping.

Dr. Patterson recommended the following:

Adequate staffing for the treatment of the mental health population as a service delivery system

Quality management staff – needs to be a manager at each of the four regional area mental health components and one at Kirkland centrally

Suicide prevention staff

Policy development for suicide watch

Recreational therapy

Regional Mental Health directors (minimum 5) to make it a system.

An additional 20 counselors and more full time psychiatrists
Dr. Patterson spent several hours going over particular issues with a lack of treatment plans. Treatment plans are a key element of the psychiatric profession. According to him, “If we are not meeting the requirements of the treatment plan, it doesn’t matter what else we are doing. This treatment plan is the main document we need to be using; that information must be there for us to make comparisons… we cannot use it if it is not there.”

The examples he gave were, he said, “Significant as they illustrate the inadequacy of the SCDC mental health delivery system; they are incomplete; the practice is to return on the minimal 30 day cling schedule, which is frequently not met; and the minimum 90 days for psychiatric evaluations, which is not met.”

He also spoke of his “concerns that inmates are not being assessed within 48 hours of arrival.”

His next concern is that they are not being seen within 30 days by a psychiatrist. Inmates are being transferred prior to being assessed so that when they arrive at a housing facility they may be assigned to a counselor without having been assessed.
He also stated that inmates on CI (crisis intervention) are not being assessed daily as required.

“These inmates have been identified for self-harm risks, and they are placed in CI in lockdown, but are not being seen by counselor, the policy only requires a Monday through Friday schedule, as if Saturdays and Sundays are not critical to someone in CI status.”
He also testified that medications are being changed by medical, but non-psychiatric, physicians without consulting the psychiatrist. A non-psychiatrist might not be very familiar with symptoms, diagnoses and how to assign coding.

Before court was dismissed for the day he said the “deficiencies at SCDC were significant.
These are substantial risks that can result in serious harm.”

He recommended a study to find out “what happened to these inmates to determine how many devolved to go on CI or segregation and how many escalated to higher level mental illnesses.”

Dr. Patterson will take the stand for more direct testimony at 9 a.m. Tuesday, Feb. 28, 2012.