Feb. 29, 2012, Testimony

Dr. Raymond Patterson, forensic psychiatrist, continued his direct testimony for the Plaintiffs on Wednesday, Feb. 29, 2012.

Dr. Patterson detailed many of what he called “the failings” of the Department of Corrections in South Carolina (SCDC).

Among them were deficiencies in how corrections officers are trained to treat and handle mentally ill inmates. As referenced by one of the SCDC trainers, training for that purpose is sometimes offered, but appears to be voluntary and sparsely attended, mostly by upper echelon officers, not those who most often come into contact with the inmates. 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.