Court Hearing Examines Whether San Quentin’s Deadly COVID-19 Outbreak Could Have Been Prevented

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San Quentin seen from the San Francisco bay
San Quentin State Prison, which overlooks the San Francisco Bay, was the site of a massive COVID-19 outbreak which infected about 75% of the incarcerated population and led to 28 deaths. (Julie Small/KQED)

“I feared for my life,” said Ellis Hollis, who testified from inside San Quentin State Prison, where he is currently incarcerated. “Our lives was in jeopardy.”

Hollis is one of hundreds of men who are suing over the conditions inside San Quentin during the height of the COVID-19 outbreak there last summer and afterward. About 75% of the prison’s population caught the virus and 28 prisoners and one staff member died.

At issue is whether prison officials did enough to protect the health of people incarcerated there.

The men incarcerated at the prison say that the crowded conditions and lack of adequate isolation and quarantining, among other prison health care policies, amounted to cruel and unusual punishment — a violation of the Eighth Amendment.

In a hearing in Marin County Superior Court that began in late May, a roster of witnesses were called to the stand by attorneys representing the incarcerated petitioners. Hollis and other men testified to feelings of fear and anxiety and a deep sense of helplessness.


One prisoner, Demetris McGee, talked about being locked up in the same cell as a man who had tested positive for COVID-19.

“You guys are cellies, so you have to stay together,” McGee said he was told, using a common nickname for cellmates.

Attorneys representing McGee demonstrated through photos and other exhibits just how small many of the cells are at San Quentin: 11 feet, 1 inch deep by 4 feet, 5 inches wide, with a distance of 3 feet, 2 inches between the upper and lower bunk beds. That’s about the size of a walk-in closet.

When McGee asked to be moved out of his cell so he wouldn’t get infected by his cellmate, he said he was told, “no can do.”

Several other prisoners also testified to being confined in the same cell as sick people while they were still healthy.

The testimony comes after a year of ongoing litigation involving hundreds of medically vulnerable men incarcerated at San Quentin, who began petitioning for release when the COVID-19 pandemic began sweeping through California's state prison system.

The judge denied KQED’s request to record video, audio or images of the proceedings, but the hearing is accessible to the public. The inmates participating in the case both testified and watched the hearing over Zoom, from inside the prison chapel.

Many men described harrowing COVID-19 symptoms. For Jesse Johnson, the illness was made worse by the condition of his cell. He said he experienced diarrhea, but had a toilet that didn’t work.

“I put a towel over the toilet to cover my excrement, you know, because the toilet wouldn't flush,” Johnson said. “It was just terrible.”

When asked whether he received medical care, Johnson said, “Not a single cough drop.”

“Eventually people just started dropping like flies,” Johnson said. “You heard, ‘Man down! Man down!' ”

One person incarcerated at San Quentin, Michael France, became visibly distressed when he described watching another prisoner die.

“He sounded critical,” France said. “He couldn't breathe. He belonged in the hospital for sure.”

France sobbed for several minutes, asking the court to “hold on” so he could compose himself.

When asked how the treatment his friend received made him feel, France replied, “Like trash. Cattle. Definitely not human.”

As he described watching correctional staff try to revive his friend, he said he could see everything that was happening through the bars of his cell door.

France’s testimony was a reminder of one way in which San Quentin’s design contributed to the rapid spread of the virus. Many have said the lack of solid cell doors at the prison, which is the oldest in the state, allowed respiratory droplets to drift freely — not just between cells, but also to different floors of the prison.

San Quentin tiers with open bars
San Quentin is the oldest state prison in California. In some parts of the prison, cell doors are bars, not solid, and five floors share an open atrium. (Monica Lam/KQED)

“Right from the very beginning, when COVID-19 hit, as an epidemiologist and a physician, I had my eyes on San Quentin, knowing that it was a high-risk setting,” said Dr. Matt Willis, public health officer of Marin County, where San Quentin is located. “A prison, like San Quentin, where you have large numbers of individuals gathered close together, it's very challenging to manage when an outbreak occurs.”

Willis, who testified during the second day of the hearing, said he reached out to San Quentin officials to offer public health guidance and to help them manage their response to the pandemic. But he said his recommendations — which included putting in place a mask-wearing mandate, halting all transfers of prisoners between different housing units and weekly testing of staff for COVID-19 — were not followed.

Willis also said he strongly urged the prison to reduce its inmate population, because there was not enough room to adequately isolate and quarantine individuals.

“We were told that [the California Department of Corrections and Rehabilitation] had made a ruling that ... local health officers’ orders don't apply,” Willis said.

Through the Eyes of the Warden

Some of the most revealing testimony came from acting San Quentin Warden Ron Broomfield, who took the stand on the fourth day of the hearing and talked in frank and simple terms about events at the prison, which ignited the outbreak.

On May 30 of last year, San Quentin had recorded zero cases of COVID-19 among the incarcerated population. It was on that day, however, that a busload of prisoners were transferred from a Southern California prison with an active outbreak. At least two passengers already showed symptoms of the virus, according to the warden’s testimony and a report by the Office of the Inspector General.

During his testimony, Broomfield said he had not inquired when — or whether — the passengers on that bus had been tested for the coronavirus. He also said he did not inquire about what kind of social distancing was practiced on the bus.

“I had no participation in the scheduling, cohorting or transferring of those inmates,” Broomfield said.

While the symptomatic transferees were isolated right away, he said, their fellow passengers were not immediately quarantined. Instead, they were allowed to move about and use showers and other facilities shared by the rest of the housing unit for several days.

It was only after tests confirmed that some passengers were indeed infected with COVID-19 that the group was moved into isolation, Broomfield said. But by then, the virus had had the opportunity to spread within the prison.

Broomfield said he was “focused on keeping San Quentin safe,” but added that he could not have refused the additional prisoners.

“It is obvious to me that the population at San Quentin was horribly impacted by this pandemic. I'm also aware that the neighboring communities were horribly impacted by this pandemic,” Broomfield said towards the end of his testimony. “So my opinion is that anywhere in the world where there's dense populations, there's an increased risk of the spread of this pandemic.”

Doctors Disagree

The director of health care for the California prison system, Dr. Joseph Bick, testified that prison policies on social distancing, mask-wearing and quarantining not only met but exceeded public health and other state guidelines. Lawyers for the prison system have also pointed out that early in the pandemic, much less was known about how the virus is transmitted and about best practices.

In these portions of the hearing, all the witnesses, including the warden and representatives of prison medical services, have been called to the stand by attorneys representing the incarcerated petitioners. In the coming days, the attorney general’s office will call their experts and witnesses to build their side of the case.

Doctors and nurses who toured the prison during the outbreak or assisted with its medical response said they saw inconsistent mask-wearing and noted that in many situations, people did not maintain a 6-foot distance from others. UCSF infectious disease physician Dr. David Sears toured the prison last June and said he was concerned about the level of sanitation.

" 'Clean' is not the word that I would use,” Sears said. “I had a sense of foreboding for both the residents and the staff of the prison.”

Sears was one of several authors of a June 2020 memo addressed to San Quentin officials urging several changes, including improving testing turnaround times, expanding space for quarantine and isolation — and probably most controversially, reducing the prisoner population by “50% of current capacity.”

Other public health experts said their offers of assistance also went unheeded. In April of last year, when access to COVID-19 testing was in high demand but difficult to obtain, one UC Berkeley professor who ran a lab with specialized testing capability, Fyodor Urnov, reached out to the prison’s chief medical executive, Dr. Alison Pachynski.

“We immediately, as far as the leadership of the lab, made the executive decision that we will make available our nonprofit [testing] capacity to San Quentin,” Urnov said.

Urnov said Pachynski thanked him, but did not follow up to take advantage of his offer. Later, in June, when news of the outbreak at the prison began breaking, he said he renewed his offer of assistance, but did not hear back.


UCSF epidemiology professor Meghan Morris called the actions of prison officials “reckless.”

“There was enough evidence within the scientific community — and policies being implemented in non-custodial settings — that we knew how transmission occurred,” Morris said. “And we also knew how to implement policies to prevent the transmission within a custodial setting.”

Morris also said that one of the most powerful tools for combating the spread of COVID-19 is to “reduce population density,” which remains at the heart of the current court case.

During cross-examination, attorneys for the prison system suggested that many of the experts who testified were not necessarily qualified to offer their expert opinion on prison policies. Prison officials have also argued that they face the unique challenge of juggling the health of inmates with the demands of maintaining public safety.

“The court failed to give 'due regard for prison officials’ unenviable task of keeping dangerous men in safe custody under humane conditions,' ” attorneys for the prison system wrote in a November court filing.

Early Petition for Release

The first person to petition the court for release from San Quentin, Ivan Von Staich, submitted his plea before there were any known cases of COVID-19 at that lockup. Von Staich said his medical conditions put him at higher risk of dying from the coronavirus, and he contended that prison officials would not be able to prevent the spread of the virus when it hit San Quentin. Von Staich’s initial request was rejected, but he won on appeal.

The case had gone up to the California Supreme Court and is now back in the Marin County Superior Court, where Judge Geoffrey Howard convened an evidentiary hearing that began on May 20.

The state’s attorneys have argued that the current hearing is altogether unnecessary because the outbreak is over. They say that conditions at San Quentin are greatly improved — about 70% of those incarcerated there have been vaccinated, and about 53% of the staff as well.

Additionally, corrections officials say the population at San Quentin has already been reduced significantly — it’s now down to 2,411 people as of late May, compared to 3,508 a year ago.

But the petitioners say the treatment they experienced during the height of the COVID-19 outbreak reflects an overall indifference to their health and welfare that continues.

“San Quentin demonstrated a lack of value for the lives of those who are incarcerated within San Quentin,” said Morris, the UCSF epidemiologist. “And I believe that the lack of value for the lives of people incarcerated still remains.”

The hearing is expected to wrap up this week or early next week.


KQED's Julie Small contributed to this story.