Review of Completed Suicides in the
California Department of Corrections
and Rehabilitation, 1999 to 2004
Raymond F. Patterson, M.D. Kerry Hughes, M.D.
ccare and to promote other constitu- tional requirements in the program.
CDCR’s mental health services de- livery system is intended to provide reasonable access to screening, as- sessment, and treatment for prisoners with serious mental illness. The men- tal health services delivery system comprises several levels of care, in- cluding the correctional clinical case management system (that is, an out- patient program for prisoners within the prison setting), the enhanced out- patient program (which consists of specialized housing units with en- hanced mental health treatments), mental health crisis bed units with 24- hour nursing care (that is, an infir- mary setting) for suicidal prisoners or prisoners in crisis, and acute and in- termediate inpatient care in pro- grams operated by the California De- partment of Mental Health located within two CDCR facilities and with- in hospitals run by the California De- partment of Mental Health that are outside CDCR.
This review is not intended to pro- vide a comprehensive analysis of the mental health services and programs provided by CDCR. Rather, it focus- es solely on the suicides that occurred in CDCR during the covered six-year span; on the recorded events before, during, and after each suicide that help facilitate an analysis of the po- tential suicide risk; and on the clinical and custodial factors relevant to each completed suicide.
Methods
The data on demographic character- istics, health care, and custody pre- sented in this study are based largely
Objective: The purpose of this extended review is to assist health care managers, clinicians, prison administrators, and custody staff in identi- fying and responding effectively to prisoners who present a substantial risk of suicide in the foreseeable future. Methods: The California De- partment of Corrections and Rehabilitation (CDCR) is the largest state- operated prison system in the country, with a census range of 155,365 to 163,346 prisoners between 1999 and 2004. The authors conducted a review of all 154 suicides that occurred in CDCR during this period and examined several factors related to the suicide, including demographic characteristics of the inmate, health care information, suicide method, custody information, and emergency response. Results: The analysis of trends in this six-year review reveals that prisoners who completed sui- cide were similar to those who took their lives in the community in age distribution and mental health factors. The analysis also found that this group of prisoners who committed suicide had other characteristics or commonalities related specifically to their incarceration. In this review 60% of the suicides were judged to have been foreseeable, preventable, or both. Conclusions: Although suicide is not predictable, the terms “foreseeable” and “preventable” are used to indicate cases in which the risk of suicide was elevated or events occurred that should have trig- gered clinical or custodial reactions that would have reduced the likeli- hood of completed suicide. This review provides clues to recognize in- mates at elevated risk and identifies some of the health care practices and conditions of confinement to consider for provision of an adequate suicide prevention program. (Psychiatric Services 59:676–682, 2008)
This review examines prisoner challenged the adequacy of mental
suicides that occurred in the
California Department of Cor- rections and Rehabilitation (CDCR) from 1999 to 2004. The review was conducted pursuant to Coleman v. Schwarzenegger, a federal district court case decided in late 1995 in which the plaintiffs, a certified class of state prison inmates, successfully
health services available to them. The litigation culminated in the appoint- ment of a special master and a deputy master to oversee the development and implementation of a constitution- ally sound mental health services pro- gram in CDCR. These persons were appointed by the court to remedy con- stitutionally inadequate mental health
Dr. Patterson is affiliated with the Department of Psychiatry, Howard University College of Medicine, Washington, D.C., and with the Department of Psychiatry, Georgetown University, Washington, D.C. Dr. Hughes is with the Department of Psychiatry, More- house School of Medicine, Atlanta, Georgia. Send correspondence to Dr. Patterson at 1904 R St., N.W., Washington, D.C. 20009 (e-mail: rpattersonmd@earthlink.net).
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on comprehensive reviews conducted at both institutional and central-office levels by CDCR mental health, cus- tody, and administrative personnel. The compilation of the data collected originally occurred as part of CDCR’s internal process for the review of in- dividual suicides. At the direction of the special master in the Coleman case in 1999, two court-appointed psychiatric experts (the authors of subsequent annual installments and this six-year study) collaborated in the generation of the first annual suicide review.
The development of a more effec- tive individual suicide review process became one of the early goals of the authors’ annual suicide reviews, and the process was influenced by the Na- tional Commission on Correctional Health Care’s standards and recom- mendations (1). Each annual review generated refinements in the compi- lation and analysis of collected data, which in turn contributed to substan- tive and procedural improvements in suicide prevention policies and prac- tices. All of this took place in a state correctional system that has a design- rated capacity of 79,477 beds and an annual population average of 159,893 for the six-year review period, ex- ceeding the rated capacity by approx- imately 200% (2).
In addition to the suicide review documents prepared by CDCR per- sonnel, the authors also compiled data from prisoners’ health and classi- fication records, autopsy reports, and inmate suicide notes (when avail- able). These data were further sup- plemented by the observations and reports of the mental health experts in the Coleman case and monitors at facilities where suicides occurred, as well as by insights and information provided by counsel for plaintiffs in the Coleman case.
The sifting of the available demo- graphic data together with the cir- cumstances surrounding each death that were discernible from the atten- dant records permitted the identifica- tion of some shared characteristics that suggested a heightened potential risk of suicide for some categories of prisoners. Similarly, a close reading of the historical clinical and custody documentation surrounding each
completed suicide helped identify some common clinical failures and conditions of confinement that seemed to contribute to the transla- tion of the potential for suicide into reality.
Results
The third leading cause of death in U.S. prisons is suicide, exceeded by natural deaths and deaths from AIDS (3). At least six well-known demo- graphic characteristics of persons who commit suicide are shared by the U.S. general population and the in- carcerated subpopulation, including age, gender, ethnicity, drug and alco- hol abuse, history of psychiatric treat- ment, and prior suicide attempts (4,5). For the community, more than 90% of people who die by suicide have a combination of those risk fac- tors, such as male gender and increas- ing age (4,5). For the incarcerated population these risk factors are simi- lar with the exception of the highest rates of suicide being in the 31 to 40 age range because of fewer numbers of inmates aged 41 and older. The rates for inmates older than 50 are 9%, similar to the 14% rate in the community (4). In prisons, such as the CDCR, younger inmates com- prise the majority of inmates, with de- clines in numbers over time. The per- centage of suicide reflects these de- clining numbers by age but is consis- tent with prevalence in the communi- ty (4,5). From 2000 to 2002 state pris- oner suicide rates ranged from 13 to 14 suicides per 100,000 prisoners for every age group over 18 (6). Men are four times more likely than women to commit suicide (7). Non-Hispanic Caucasian males are the highest-risk group (7). The rate of suicide is high- est among non-Hispanic Caucasian men, regardless of whether they are inside or outside of correctional facil- ities (5,7). Family conflict, bereave- ment, and loss of support are well- known risk factors. First incarcera- tion, which usually takes place in a jail, is a widely known risk factor, as described by Metzner and Hayes (5,8) and others (6,9–11).
In contrast to society at large, where ready access to a handgun is identified as a risk factor and hand- guns are the most common method of
suicide, hanging was the most fre- quently employed method of suicide in custody found in this and other studies. This was not surprising in view of the crucial role played by a readily accessible method. In the sample presented here, hanging was employed in 85% of cases. This find- ing was consistent with the literature on incarcerated populations (5,6,8) and with the Missouri samples of completed suicides in prisons (N=37) described by Daniel and Fleming (11), who found that hanging was the most frequent method of suicide, em- ployed in 81% of cases.
Although the suicide rate in jails dropped more than 50% between 1983 and 2002 in the United States, from 129 per 100,000 down to 47 per 100,000, as described by Mumola (6), jails continue to have a much higher rate of suicide than prisons. Suicide rates in state prisons also dropped, from 34 per 100,000 in 1980 to 16 per 100,000 in 1990, with further decline to 14 per 100,000 by 2004 (5–7,9).
Recently there have been indica- tions that suicide rates among His- panics and suicide attempts among young African-American men are ris- ing nationwide (6). Regarding the in- carcerated population, non-Hispanic Caucasian inmates commit suicide at the highest rate (96 per 100,000), compared with rates of 30 per 100,000 among Hispanics in custody and rates of 16 per 100,000 among African Americans in custody (6). In the sample presented here, the num- ber of Hispanic men who committed suicide approached that of non-His- panic Caucasians, while the number of African Americans who committed suicide remained low.
The body of literature on suicide risk factors suggests hypotheses— some already codified in standards promulgated by the American Cor- rectional Association and the Na- tional Commission on Correctional Health Care (1,12)—that should elicit keen interest among those charged with the care of incarcerat- ed individuals.
The accompanying tables provide graphic representation of the demo- graphic data collected during each of the six years covered in the study.
The number of annual suicides oc-
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Table 1 California Department of Corrections and Rehabilitation population, suicide rate, and housing and location of suicide
Total Population (at suicides
Variable end of year) (N=154)
Single-cell Suicide housing
rate per 100,000 N %
Administrative segregation or secure housing unit
N %
Mental health crisis bed unit
N %
Year 1999 160,970 2000 160,855 2001 155,365 2002 158,099 2003 160,722 2004 163,346
25 15.5 15 9.3 30 19.3 22 13.9 36 23.1 26 15.9 26 16.2
20 80 9 12 80 8 25 83 12 15 68 6 22 61 20 22 85 19 19 73 12
36 2 8 53 0 — 40 6 20 27 1 5 56 3 8 73 3 12 46 3 12
Average
159,893
curring during the covered period ranged from a low of 15 in 2000 to a high of 36 in 2003. On the basis of the institutional population of CDCR at the end of each of these respective years, the suicide rate ranged from 9.3 per 100,000 to 23.1 per 100,000. The variability in the annual rate of suicides is tracked for each of the cov- ered years in Table 1.
The wide range of variability illus- trates the pitfalls of comparing annu- al rates of an event with a low base rate event in a small, fluctuating pop- ulation. Even with large samples, a minimum of five years of data are needed for meaningful analysis be- cause of year-to-year variability and other factors affecting mental health resources (10,11,13).
Table 1 also provides a breakdown of the annual end-of-year overall CDCR population and the annual number of suicides per year in each type of housing unit where prisoners resided at the time of their deaths. Three different types of housing units were examined: single cell, adminis- trative segregation or secure housing, or mental health crisis bed. Single- cell units are defined as one inmate per cell and can be for the general population or for inmates with spe- cialized needs. Administrative segre- gation and secure housing units can have one or two persons in a cell. Ad- ministrative segregation consists of housing units where inmates are gen- erally locked in their cells 23 hours per day, for days to months at a time, and secure housing units are a “super maximum” security setting where in- mates are typically locked in their
cells for 23 hours per day for one to many years. Mental health crisis bed units or outpatient housing units have one person in a cell and have nursing and clinical staff on the units 24 hours per day. The breakdown of suicides occurring in single-cell housing in ad- ministrative segregation or secure housing units and in the general pop- ulation (that is, nonspecialized hous- ing units) is also included in Table 1. The data indicate that 73% of all sui- cides were completed in single cells, while 46% of completed suicides oc- curred in single cells in administrative segregation or secure housing units and 12% occurred in mental health crisis beds.
These findings regarding the im- portance of environmental stressors unique to prison conditions, such as isolation, punitive sanctions, severely restricted living conditions, and ac- quisition of new charges or imposi- tion of an unexpected sentence were consistent with previous reports (11,14,15). We found that the condi- tions of deprivation in locked units and higher-security housing were a common stressor shared by many of the prisoners who committed sui- cide. Liebling (16) found that recent punishment, segregation, long or un- expected sentences, and high levels of reported distress, including symp- toms of depression and anxiety, were reported by a sample of men who at- tempted suicide. In Liebling’s (16) sample of 50 cases, 24% had recent- ly experienced punishment or were in segregation and 22% had recently received a long or an unexpected sentence.
Among the 154 prisoners who com- mitted suicide during the six-year pe- riod, 149 (97%) were male, and four (3%) were female. Sixty-two (40%) were Caucasian, 55 (36%) were His- panic, 25 (16%) were African Ameri- can, four (3%) were Asian, and eight (5%) were of another race or ethnici- ty. Seventy-three (47%) of the prison- ers who completed suicide were aged 31–40 years, 42 (27%) were 18–30 years, 24 (16%) were 41–50 years, 14 (9%) were older than 50 years, and one (1%) was younger than 18 years.
The methods utilized by prisoners who completed suicide included hanging (N=131, or 85%), lacerations or exsanguinations (N=9, or 6%), overdose (N=5, or 3%), and other (N=9, or 6%).
Among prisoners who completed suicide during the six-year period, 73% had a history of mental health treatment, and 62% had a history of suicidal behavior or statements. The breakdown of these numbers for each year is provided in Table 2.
Among the 154 suicides completed during the covered period, 87 (56%) involved prisoners on the mental health caseload. Table 3 provides the breakdown. One caveat: prisoners housed in a mental health crisis bed unit or a Department of Mental Health inpatient program may have been at any level of care before their placement in those beds, including “none.” The level of mental health care for the 87 prisoners included in the CDCR mental health caseload at the time of their suicides was as fol- lows: five (3%) were at the Depart- ment of Mental Health inpatient
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(hospital) level of care; two (1%) were at a crisis level of CDCR care (in a mental health crisis bed unit, outpa- tient housing unit, or transitional care unit); 27 (18%) were in the enhanced outpatient program; and 53 (34%) were in the correctional clinical case management system program.
These findings are consistent with Daniel and Fleming’s ten-year re- view (11) of prison suicides in Mis- souri. These findings point to the need for thorough suicide risk as- sessment of prisoners who appear to be relatively high functioning or who are found not to be in need of ongo- ing mental health treatment. In the group of suicides presented here, 59 (38%) were not in need of mental health treatment (as determined by the CDCR clinical treatment staff), a percentage that was higher than Daniel and Fleming’s finding that nearly 30% of the prisoners who committed suicide over a ten-year period in Missouri presented with no mental health problems (11). For eight (5%) inmates, mental health treatment status was unknown be- cause of missing data. In our Califor- nia sample, like the Missouri sample, the prevalence of prior treatment was higher than current need for treatment. Both findings reflect a well-known indicator of elevated sui- cide risk in society at large—that is, history of psychiatric treatment. A total of 112 of 154 (73%) of the per- sons who committed suicide in our sample had a history of psychiatric
treatment; however, 101 of the 112 (90%) had axis I diagnoses. Seventy- three percent of the total Missouri sample had been diagnosed as hav- ing an axis I disorder at some point in the past, and 66% of our total sample had a diagnosis of an axis I disorder at some point in the past (11).
Also reviewed were emergency re- sponses to inmates who were unre- sponsive when they were discovered and who subsequently were deter- mined to have committed suicide. The reviews focused on the timely initiation and continuation of car- diopulmonary resuscitation (CPR) by first responders. Policy requires that CPR be initiated and continued with very few exceptions, exceptions such as the presence of rigor mortis, lividi- ty, or obvious trauma, such as severe head injury or decapitation. For the
six-year review period, CPR was per- formed in a timely and appropriate manner on 107 inmates who commit- ted suicide (69%), CPR was not per- formed in a timely and appropriate manner on 42 inmates (27%), and it could not be determined on the basis of the available documentation wheth- er CPR was performed in a timely or appropriate manner on five inmates (3%). These results are presented by year in Table 4.
Sixty percent of all the suicides cov- ered in this six-year period were ei- ther foreseeable or preventable, and some were both. The term “foresee- able” refers to cases in which already known and reasonably available infor- mation about an inmate indicates the presence of a substantial or high risk of suicide that requires responsive clinical, custody, or administrative in-
Table 2
Mental health history of persons who committed suicide in the California
Department of Corrections and Rehabilitation
Mental health case- Total load at time of death
suicides Variable (N=154) N %
Previous mental health treatment
N %
Previous suicidal activity
N %
Year 1999 25 16 64 18 72 17 68 2000 15 8 53 11 73 11 73 2001 30 16 53 22 73 19 63 2002 22 10 45 14 64 12 55 2003 36 23 64 27 75 18 50 2004 26 13 50 20 77 15 58
Average 26 14 54 19 73 15 58
Table 3 Level of care received by persons who committed suicide in the California Department of Corrections and Rehabilitation
Correctional clinical case management system
Enhanced outpatient program
Mental health cri- sis bed, outpatient housing unit, tran- Department of sitional care unit Mental Health None Unknowna
N % N % N % N %
Total Variable suicides
N % N %
Year 1999 25 10 40 6 24 0 — 0 — 8 32 1 4 2000 15 4 27 3 20 0 — 1 7 0 — 7 47 2001 30 7 23 6 20 0 — 3 10 14 47 0 — 2002 22 9 41 0 — 0 — 1 5 12 55 0 — 2003 36 16 44 6 17 2 6 0 — 12 33 0 — 2004 26 7 27 6 23 0 — 0 — 13 50 0 —
Total 154 53 34 27 18 2 1 5 3 59 38 8 5
a Unknown because of missing data.
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Table 4
Cardiopulmonary resuscitation (CPR) performed on persons who committed
suicide in the California Department of Corrections and Rehabilitation
CPR performed CPR not performed Unknown
Total Variable suicides N % N % N %
Year 1999 25 15 60 8 32 2 8 2000 15 11 73 4 27 0 — 2001 30 20 67 9 30 1 3 2002 22 16 73 6 27 0 — 2003 36 29 81 5 14 2 6 2004 26 16 62 10 38 0 —
Total 154 107 69 42 27 5 3
terventions to prevent self-harm. The term foreseeable is not to imply “pre- dictable,” because suicide is not pre- dictable, but rather to refer to the presence of an elevated risk to sub- stantial or high risk, which requires appropriate clinical or custodial inter- vention or monitoring.
The term “preventable” applies to situations where if some additional information had been gathered or some additional interventions had been undertaken, usually as required in existing policies and procedures, the likelihood of a completed suicide might have been substantially re- duced. The concept includes, but is not limited to, situations where in- mates report self-injurious behaviors or threats but do not receive appro- priate evaluation or treatment, are not transferred to a more clinically appropriate or safe environment, or fail to receive appropriate lifesaving procedures, such as timely CPR.
Table 5 shows the breakdown of fore- seeable and preventable suicides by year. Major contributing factors in foreseeable or preventable deaths in- cluded inadequate clinical assess- ments, inappropriate interventions, incomplete referrals, missed appoint- ments and appointments that were not rescheduled, unsupported diag- noses, failure to review records, as- signments to inappropriate levels of mental health care, failure to provide protective housing, and the provision of inadequate or untimely resuscita- tion efforts. In numerous cases, mul- tiple such factors contributed to the outcome.
Discussion
During the period covered by this re- view, both the scope and quality of CDCR’s review process improved sig- nificantly. In 1999 psychological au- topsies were rarely included in re- views, and many of the psychological
autopsies were conducted by person- nel who were clinically involved di- rectly or indirectly with the specific inmate who committed suicide. By 2004 clinicians not involved in specif- ic inmates’ care and treatment had performed psychological autopsies for all inmates who had committed suicide. In 1999 the special master’s reports recommended improvements in the review process that included clarification of the duties of local re- viewers, mandated time frames for completion of reviews, and the devel- opment of corrective action plans. Subsequent procedural recommen- dations focused on specific timelines for the preparation of responsive cor- rective action plans by institutions.
The review process did not focus solely on procedural elements. From the beginning of the study period the annual review helped prompt sub- stantive changes and improvements in suicide prevention policy and prac- tices, including, for example, require- ments for increased clinical monitor- ing of prisoners in high-security units, both for those who were and for those who were not on the mental health caseload; the development of clinical and custody follow-up monitoring regimens for suicidal prisoners dis- charged from mental health crisis beds and their alternatives; the effec- tive provision of group therapy for prisoners on the mental health case- load in administrative segregation units; the development of routinely administered suicide risk assess- ments; efforts to keep suicidal prison- ers out of cells with heating, ventilat- ing, and air conditioning vents with large-mesh screens to facilitate hang- ing; a ban on the substitution of video monitoring for the personal observa- tion of prisoners on suicide watch; and the development and implemen- tation of improved CPR policies and practices.
The suicides by four female in- mates and the sharp rise in the num- ber of suicides in locked units, partic- ularly administrative segregation, led to greater attention to both areas. Failure to use a suicide risk assess- ment instrument as required by de- partmental policy was a factor in the female suicides, and corrective meas- ures were taken. The rising rate of
Table 5
Foreseeable or preventable suicides in the California Department of
Corrections and Rehabilitation
Foreseeable or preventable
Total Variable suicides N %
Not foreseeable or preventable
N %
Unable to determine
N %
Year 1999 25 2000 15 2001 30 2002 22 2003 36 2004 26
Total 154
8 32 6 11 73 3 14 47 13 10 45 12 29 81 7 21 81 5 93 60 46
24 11 44 20 1 7 43 3 10 55 0 — 19 0 — 19 0 — 30 15 10
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suicide in administrative segregation initiated a two-year effort to analyze the causes and prescribe remedies. The latter have included, among oth- er initiatives, custody monitoring of new arrivals at 30-minute intervals, preplacement mental health screen- ings, better tracking of history of sui- cidal behavior, easing of property re- strictions for protective custody pris- oners, and improved physical safety in cells for newly arrived prisoners. Several of these remedies were based upon data indicating that suicides oc- curred most often within three weeks of a prisoner’s placement in an ad- ministrative segregation unit. In the California cases, 39 of 74 (53%) of the suicides that occurred in administra- tive segregation or secure housing units occurred within three weeks of placement. Individuals housed in ad- ministrative segregation and secure housing units are more isolated than those in the general prison popula- tion, and these housing changes may represent a very different and stress- ful environment for inmates as they are placed in these environments be- cause they incurred charges or for safety and protective custody reasons (typically these environments involve 23 hours per day in cell confinement with some exceptions for out-of-cell time for yard activities and showers).
Conclusions
Over the six years of the study, the suicide review process has identified characteristics that ought to draw the attention of staff to certain categories of prisoners, including the following:
' Prisoners with a history of seri- ous mental illness
' Prisoners with a history of sui- cide attempts
' Prisoners housed in a single cell, particularly in administrative segrega- tion or a secure housing unit
' Prisoners expressing safety concerns with associated anxiety and agitation
' Prisoners with serious medical concerns
' Prisoners with both severe per- sonality disorders and coexisting mental illness
' Prisoners whose legal status has undergone significant change—for
example, individuals returning from court after denial of appeals and those receiving third-strike determi- nations or other additions to their sentences
' Caucasian prisoners, although the number of suicides among His- panic prisoners increased rapidly dur- ing the six-year period.
The above categories may help identify prisoners who might warrant focused attention. CDCR’s experi- ence with completed suicides over the study period highlights both clin- ical practices and physical conditions that ought to be addressed, including the following:
' The failure of clinical staff to re- fer potentially suicidal prisoners to programs with more intensive moni- toring and care
' The provision of prompt and ad- equate access to higher levels of mon- itoring and care to prisoners identi- fied as potentially suicidal
' The elimination of physical safe- ty deficiencies in cells and other housing for prisoners most at risk of suicide—for example, large mesh vents or other protuberances regular- ly used for hanging
' The lack of adequate confiden- tial interviewing space in most high- custody housing units, which inhibits the ability and willingness of poten- tially suicidal prisoners to communi- cate effectively with clinicians about their risk of suicide
' Clinicians’ failure to review fully and carefully available documenta- tion, such as health and classification records, for indices of prior suicidal activity or ideation
' The timely completion of all of the documentation associated with the institutional or departmental ele- ments of the suicide review process, including the documentation of im- plemented remedies and adverse per- sonnel actions.
This review suggests the following recommendations and considerations for correctional administrative, clini- cal, and custody staff members to as- sist in their efforts to establish and manage an effective suicide preven- tion program:
' The development and timely im-
plementation of effective policies and procedures
' Training and supervision of all staff regarding adherence to policies and procedures
' Development and implementa- tion of a systematic quality manage- ment process with review of all com- pleted suicides
' Use of screening criteria, clinical rounds, and timely access to care for inmates in isolated conditions of con- finement, especially administrative segregation
' Access and timely transfers to higher levels of care when indicated
' Provision of a timely and com- plete emergency response system, in- cluding CPR, first aid, and transfer to medical units or facilities
' Consideration of the impact of overcrowding and staffing deficiencies.
Prisons and prison life create enormous stress, even for individu- als who are mentally healthy. The strain for offenders with mental ill- ness, who are often both fragile and intensely vulnerable, sometimes ex- ceeds their ability to cope. One sur- passingly critical purpose of mental health services in prisons is to help identify such individuals for inter- vention and provide the monitoring, treatment, and physical safety need- ed for their survival. This review at- tempts to provide some clues about recognizing prisoners most at risk of suicide and to identify some of the failed practices and inadequate con- ditions that often combine to pre- vent the provision of adequate pro- tection and treatment. This review identifies several risk factors, as well as necessary administrative, clinical, and custody staff involvements and responsibilities for an effective sui- cide prevention program.
Acknowledgments and disclosures
The authors thank J. Michael Keating, Jr., J.D., special master appointed through Coleman v. Schwarzenegger, Matthew A. Lopes, Jr., J.D., deputy special master appointed through Cole- man v. Schwarzenegger, and the other team ex- perts and monitors also appointed through the case. The authors also thank the California De- partment of Corrections and Rehabilitation and plaintiffs counsel for their diligence and as- sistance.
The authors report no competing interests.
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