In a scathing report issued Thursday, the California State Auditor blamed high suicide rates in the state's prisons on a failure of leadership and oversight at the California Department of Corrections and Rehabilitation.
From 2005-2013, California's prisons had an average suicide rate of 22 per 100,000 inmates, compared to 15.66 per 100,000 in state prison systems nationwide. Over the past couple years, the report said, suicide amongst female inmates has soared.
While women make up 4 percent of the prison population, they now account for 11 percent of prison suicides, according to the auditor.
"These statistics, combined with the significant deficiencies we identified when we reviewed suicide prevention and response practices at four prisons, raise questions regarding Corrections’ leadership on this critical issue," the report said.
In a written response, CDCR Secretary Scott Kernan said the department "takes its responsibility to prevent inmate deaths by suicide very seriously and reviews each case carefully to allow it to continue to refine the suicide prevention program."
He also pointed to recent improvements in CDCR's suicide prevention programs, such as coming investments in substance abuse counseling and domestic violence counseling, a new program to offer discreet mental health services to female inmates, as well as updated suicide suicide assessment tools and protocols.
In an email, CDCR Press Secretary Vicky Waters said the number of suicides has dropped since 2013, with California now seeing 20 per 100,0000 inmates. So far in 2017, the system has had 17 suicides.
In 2016, there were 26 suicides in California prisons, according to the auditor, compared to 19 the year before.
Auditors who visited four prisons, however, found staff in some cases were not properly following protocols, improperly completing suicide risk screenings of inmates in 26 of 36 cases reviewed.
The prisons were California Institution for Women, California State Prison, Sacramento, Central California Women's Facility, and Richard J. Donovan Correctional Facility.
"The inadequacies we noted included leaving sections of the risk evaluations blank, failing to appropriately justify the determinations of risk, failing to develop adequate plans for treatment to reduce the inmates’ risk, and relying on inconsistent or incomplete information about the inmates to determine risk," the report said.
Staff at the prisons also were not always completing required 15-minute checks on suicidal inmates, auditors found. Some staff hadn't received proper training in suicide prevention protocols.
The audit recommended a set of changes in CDCR, including stricter training requirements for staff, an accelerated implementation of electronic monitoring of suicide checks, a beefed up internal auditing process, and periodic reports to the legislature on progress.
CDCR, in a statement, said it had already complied with some of the auditor's recommendations. Kernan also expressed a continuing commitment to improve suicide protocols.