"Across the board we see delays in diagnosis and access to care and needed tests; misfiled, incomplete or illegible medical records; lack of space, sanitation and staffing; … failures by clinicians to recognize and evaluate 'red flag' symptoms, follow published guidelines, perform basic physical examinations, or respond to patient complaints," wrote the federal receiver who conducted the investigation.
"You can't expect clinicians to practice good medicine if they don't have good medical records, if they don't have lab results to help diagnosis, if they don't have a pharmacy system to support the right order of medications, if you don't have a culture within [the state prisons] that says, 'My goodness, these are human beings and they ought to be treated as human beings,' " the receiver told the Sacramento Bee.
Topping the list was deaths from asthma, which the receiver called "unconscionable" in 21st century California.
Other causes of preventable death included:
- Acute pancreatitis - medical staff disregarded a man's nine complaints over three days of severe abdominal pain, because they thought he was lying
- Heart ailment - a man reported chest pains in the middle of the night but didn't see the doctor for eight hours
- A hernia condition – a man with recurring stomach pain, vomiting and a history of hernias had a five-week delay in a referral to a specialist (a consistent pattern found in the investigation)
Also check out the receiver’s interesting slide show on medical care at San Quentin.