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Feb. 27 Testimony

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.