Murder by Medical Neglect
February 5, 2004
FRESNO — All through the night, the howls kept coming from the cell of inmate Ronald Herrera.
More than one guard at Corcoran State Prison thought something was terribly amiss. Herrera wouldn't stop screaming late Sunday, and he had covered his cell window in a curtain of toilet paper soaked in blood.
One guard had seen Herrera, a dialysis patient suffering from hepatitis, pull out the medical shunt from his arm, corrections officials said. But when the guard later tried to check on the inmate, his sergeant told him not to bother, they said. "He's not dead," the sergeant was quoted by officials as saying. "Just keep an eye on him."
The next morning, the howls had given way to silence. As a new shift made its checks, a guard saw what he said looked to be "raspberry Kool-Aid" streaming out from the cell. Inside, he found Herrera slumped over on the floor, lifeless.
Much of the blood had drained from his body, corrections officials said. Blood filled the toilet bowl and washed over the concrete floor of the 8-by-10-foot cell.
On Wednesday, Kings County and state investigators began a probe to determine if Herrera's death resulted from criminal negligence by prison staff too busy watching the Super Bowl.
The probe comes on the heels of state Senate hearings and other revelations that have shone an unflattering light on the state's vast prison system, challenging the new administration of Gov. Arnold Schwarzenegger. On Monday, he promised to make reforms and to "clean the place up."
A coroner's autopsy of Herrera had not been completed by early Wednesday, but corrections officials said there were signs that Herrera, a 60-year-old mentally ill burglar and rapist, had been trying to staunch the bleeding with a wad of toilet paper.
It was unclear if Herrera was trying to commit suicide and then changed his mind or if something more sinister happened, corrections officials said. His desperation, they said, played out for nearly 10 hours without any intervention from staff.
Of all the horrors that have taken place at Corcoran State Prison over the last decade, one official said, the death of Herrera was particularly ghastly — and preventable.
Fearing retaliation for breaking the prison system's pervasive code of silence, the officials requested anonymity. "Corcoran has seen a lot," one said, "but for an inmate to literally bleed out his body, it was one of the goriest crime scenes."
A media spokesman for the prison said he could not comment on the case because of an ongoing investigation.
Steve Fama of the watchdog Prison Law Office said he doubted whether the Kings County district attorney's office would hold staff accountable. He noted that Dist. Atty. Ron Calhoun had been elected in 1998 partly on the strength of financial support from the California Correctional Peace Officers Assn., the union representing state prison guards.
"When it's this serious, you want an aggressive, independent investigation," Fama said. "I'm not sure if the district attorney in Kings County is capable of that given the significant role that the CCPOA played in his election."
Patrick Hart, Kings County's chief deputy prosecutor, acknowledged that his office had a "fairly good working relationship" with the guards union, but he said it would not hinder the independence of the probe.
"We're not satisfied with the written reports we've gotten so far from staff," he said. "One of the things we're looking at is whether staff knew he was in trouble and failed to take the proper steps."
Herrera's case is only the latest in a series of inmate deaths at Corcoran that have raised questions about the correctional system's care of mentally ill patients and its response to suicide attempts.
In December 1998, a Corcoran inmate who had been taken off suicide watch was seen hanging in a dark corner of his cell. But rather than pop open the cell door and determine if he was alive, guards remained outside for 18 minutes while 32-year-old Michael van Straaten dangled from a noose made of bedsheets and shoelaces. When officers finally did enter and cut him loose, he was dead but his body was still warm, according to prison reports.
Two years later, on Christmas Day, an inmate with three suicide attempts succeeded in killing himself in the prison's Security Housing Unit. A lawsuit filed by the family of 26-year-old Thomas Mansfield alleged that staff negligence had allowed the suicide and that guards tried to cover up the incident by doctoring the record of cell checks. Last year, the state settled the case out of court.
And just a week before Herrera's death, corrections officials said, three inmates in the Security Housing Unit entered into a suicide pact to protest what they called brutality by Corcoran guards. One inmate, "Tiny" Walton, went through with the pact and hanged himself.
"What I've found is the so-called suicide watch is a joke," said Bob Navarro, a Fresno attorney who represented Mansfield's family and has filed suit in a recent suicide at the women's prison in Chowchilla. "The cells are not being checked according to written procedure."
A detailed account of Herrera's medical condition and death was provided by two corrections officials. Herrera was taking mood-altering medication at the time, but had not been seen by a psychiatric case manager since December. They said that violates prison policy, which dictates a one-on-one clinical evaluation every 30 days.
Herrera, who was not on suicide watch, began "ranting and raving" around midday Sunday, they said, and medical personnel examined him near halftime of the Super Bowl. It is not unusual for guards and inmates to watch football on weekends. At the time, the shunt that allowed him to hook up to a dialysis machine was still in place.
But Herrera's howls continued, the officials said, and he began to cover the one window in his cell with toilet paper. He used his blood to adhere the toilet paper to the glass. That alone, corrections officials said, should have prompted a team of officers to enter his cell.
"When your view into the cell is obstructed and you don't know what's going on inside, you initiate a cell extraction," one official said. "This wasn't done. In fact, there are several notations from staff indicating concern for Herrera. But the superior officers never let them check on him."
One officer became so alarmed he called his sergeant, who took a quick look from outside the cell. "This is the same female sergeant who told the officer not to bother," the official noted.
Third watch began at 2 p.m. and ended at 10 p.m. During at least some of that time, Herrera could be heard kicking at his cell door. After the Super Bowl game ended and the first watch took over, Herrera was still making a fuss, officials said.
It wasn't until shortly after 6 a.m. the next day — when the second watch began its shift — that an officer who knew Herrera decided to check in on him.
"The closer he got to the cell, he could see this pool of 'raspberry Kool-Aid,' " said one corrections official. "They popped open the door and he was lying on the ground with the shunt on the top bunk. He was pronounced dead five minutes later."
A corrections spokesman said Herrera had a long rap sheet that included convictions for burglary and rape in San Bernardino County.
Because of his status as a sex offender, he was housed in the prison's
administrative-segregation unit. In recent months, he had been the victim
of an inmate assault.
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