In 2021, a KVPR investigation revealed thatpatients at Coalinga State Hospital (CSH) were dying at a higher rate than at any other state hospital or prison. Only one state-run facility reported a higher death rate: the California Medical Facility, which cares for California’s sickest prison inmates.
Now, an analysis of state data reveals that the state-run psychiatric hospital earned that grim distinction for a second year in a row. In 2021, 21 patients died while in custody of CSH, a sum that equates to 1.6% of the hospital’s population. That death rate was 60 percent higher than the average across all state hospitals, and nearly five times the average within the entire state prison system.
Patient Michael St. Martin says little has changed from year to year. “The only thing that surprised me is there wasn’t more” deaths, he said.
In the past, patients have pointed to inadequate preventive care as one culprit for their high death rate. With the help of medical records and state documents, KVPR confirmed last year that CSH doctors had in at least a handful of cases skipped patients’ quarterly and annual physical exams.
Since then, St. Martin claims the problem has not improved, and that he spends an inordinate amount of time advocating for his fellow patients to be seen by a doctor. “I've had to get on the phone, call the head doctor, call the chief physician and surgeon, call the doctor on the unit, and have to force them to do it,” he said. In some cases, in which a routine problem evolved into an emergency, “they spend thousands and thousands of dollars on something that they could have solved for a lot less money,” he said.
The facility’s ultimate purpose is to treat and rehabilitate men who have been determined by a judge or jury to be mentally unfit to live in free society. Nearly all of them have been charged with a crime, and three-quarters have been designated sexually violent predators. However, St. Martin and many other patients also claim the men are not receiving the psychiatric care required by law, which KVPR has not independently confirmed.
Regardless of the care that is or is not being provided, nearly 1,300 men are confined there at a cost approaching $300,000 per patient per year – a price tag that is footed by taxpayers.
In an email statement, the California Department of State Hospitals, which oversees the facility, cited patient age and high rates of psychiatric and chronic diseases as risk factors for death.
“As acute psychiatric hospitals, DSH hospitals, including Coalinga State Hospital, have a higher concentration of patients with these medical and behavioral health challenges than would be represented in the overall inmate population within non-DSH state operated facilities. At Coalinga State Hospital, 67.9 percent of the patients had at least one COVID-19 medical risk factor (age over 60 years, Blood, BMI>30, Bowel/GI, Cancer, Circulatory, Diabetes, Immune, Renal, Respiratory),” reads the statement. In addition, “age should not be discarded or ignored when evaluating death rates. DSH-Coalinga has a much older population compared to both other state hospitals and the average prison population in California. Individuals housed at DSH-Coalinga arrive after serving long prison sentences and they generally remain in this facility for many years.”
The agency also wrote that the hospital has taken corrective action in response to a citation from the state Department of Public Health in 2021 related to the hospital’s medical care. “A few examples of actions taken include but are not limited to the following: hospital-wide patient charts were reviewed to ensure compliance with history and physical completion per hospital policy. DSH-Coalinga now generates a monthly list of patients who are due for their annual and quarterly visits. Additionally, patient chart audits are performed to monitor compliance.”
Meanwhile, St. Martin and other patients continue to call for a state audit of the hospital, which can be requested by legislators.
This story was updated to include comment from the Department of State Hospitals.