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Luong v. Napa State Hospital

United States District Court, N.D. California

September 12, 2019

DAT THANH LUONG, et al., Plaintiffs,
v.
NAPA STATE HOSPITAL, et al., Defendants.

          ORDER GRANTING IN PART AND DENYING IN PART STATE DEFENDANTS' MOTION FOR SUMMARY JUDGMENT; AND DENYING PLAINTIFFS' MOTION FOR PARTIAL SUMMARY JUDGMENT DOCKET NOS. 183, 181

          EDWARD M. CHEN, UNITED STATES DISTRICT JUDGE

         Plaintiffs in this case are (1) the successors in interest to decedent Dat Thanh Luong (namely, his wife and minor son); (2) Mr. Luong's wife, Ai Qiong Zhong; and (3) Mr. Luong's minor son, W.L.[1] Mr. Luong was diagnosed with schizophrenia in or about 2001. See Haddad Decl., Ex. 2 (N. Luong Depo. at 27-28). In January 2016, he was arrested and booked into Alameda County's Santa Rita Jail. See Prothero Decl., Ex. A (arrest report). In July 2016, a state court ordered that Mr. Luong be committed to Napa State Hospital (“NSH”) or “any other Hospital” because he was mentally incompetent within the meaning of California Penal Code § 1368. Defs.' RJN, Ex. G (Order at 1). By September 2016, Mr. Luong still had not been transferred to NSH or any other hospital, thus prompting a state court to issue an order directing the Director of the California Department of State Hospitals (“DSH”) to transport Mr. Luong or to show cause re contempt. See Defs.' RJN, Ex. H (order). Despite the court orders, Mr. Luong was never transferred. Pending the transfer that never came, he was killed in jail in October 2016 after his cellmate strangled him.

         At this juncture, the only defendants remaining in the case are the State Defendants. They are as follows:

(1) DSH;
(2) Pam Ahlin (the Director of DSH during the relevant time);
(3) NSH;
(4) Dolly Matteucci (the Executive Director of NSH during the relevant time);
(5) Patricia Tyler (the Medical Director at NSH during the relevant time); and
(6) Cindy Black (the Clinical Administrator at NSH during the relevant time).

         Currently pending before the Court are (1) the State Defendants' motion for summary judgment or, in the alternative, summary adjudication and (2) Plaintiffs' motion for partial summary judgment. Having considered the parties' briefs and accompanying submissions, as well as the oral argument of counsel, the Court hereby GRANTS in part and DENIES in part the State Defendants' motion and DENIES Plaintiffs' motion.

         I. FACTUAL & PROCEDURAL BACKGROUND

         Both parties have submitted evidence in conjunction with their motions. The evidence reflects as follows. Where there are disputes of fact, they are so noted.

         A. General Process re Incompetent-to-Stand-Trial (“IST”) Defendants

         “DSH was created in 2012 to manage and operate the state psychiatric hospital system.” Maynard Decl. ¶ 12.[2] It is “comprised of five state hospitals, four of which serve IST defendants, ” including NSH. Maynard Decl. ¶ 12. In fiscal year 2016-17, DSH had an “average daily census of 1, 524 IST defendants.” Maynard Decl. ¶ 12.

         When a state court commits an IST defendant to the care of DSH, it does so at a hearing in which DSH is not a participant. See Black ¶ 7. “When the court orders that the defendant be committed to a State Department of State Hospitals facility or other public or private treatment facility, the court shall provide, ” inter alia, a copy of the commitment order to DSH or other facility prior to the admission of the defendant. Cal. Pen. Code § 1370(a)(3). Pursuant to California Penal Code § 1370(a)(3), the “admission packet” for an IST defendant also includes, e.g., “[c]ourt-ordered psychiatric examination or evaluation reports” and “[m]edical records.” Id. Prior to September 2016, “some counties failed to include adequate medical records or any records at all.” Black Decl. ¶ 9 (adding that this “was a factor in DSH promulgating regulations [in September 2016] requiring [that] full medical records be included in admission packets”).

         During the relevant period, NSH had an Admissions Suite that received the commitment order and admission packet from the county/court. See Black Decl. ¶ 8. Upon receipt, the patient's name was placed on a wait list. See Black Decl. ¶ 10; Prothero Decl. ¶ 5.[3] Like all state hospitals, NSH had, during the relevant time, a wait list for admission. See Black Decl. ¶ 11. There were wait lists because “[e]ach state hospital has reached its maximum licensing, functional, or statutory capacity.” Maynard Decl. ¶ 4; see also Maynard Decl. ¶ 6 (testifying that “[a]ll State Hospitals are licensed and regulated by the California Department of Health” and “[e]ach hospital has limitations on bed space and bed usage”; NSH's “total number of beds is limited by its license” and, “until June, 2016, [NSH] was limited to 980 beds for patients whose placement was required pursuant to the Penal Code”).

         The NSH Admissions Suite had an Admissions Coordinator - at the relevant time, Dana White, a registered nurse - who would initially review the admission packet “looking for any history of escape, violence, sex offender status, or specific medical need, so that the IST defendant could be placed in the proper hospital with the proper resources available when he . . . arrived.” Prothero Decl. ¶ 3; see also Haddad Decl., Ex. 14 (White Depo. at 27) (testifying that, from 2005 to May 2019 (when she left NSH), she was the only person at NSH who reviewed the admission packets). After the Admissions Coordinator completed her review, she would “release the packet to an analyst in her office who checked the packet for completeness.” Prothero Decl. ¶ 3; see also Black Decl. ¶ 8; Haddad Decl., Ex. 13 (Black Depo. at 25) (testifying that the packet was reviewed for completeness and accuracy by an analyst and not medical staff); Haddad Decl., Ex. 14 (White Depo. at 25) (testifying that analysts do not, e.g., have a nursing license). If information was missing, either the Admissions Coordinator or an analyst would contact the county, see Prothero Decl. ¶ 3, and “facilitate the process of completing the packet with the required documents.” Black Decl. ¶ 9. After the admissions packet was complete, “the IST defendant's status on the wait list was changed to ‘ready' to schedule admission.”[4] Black Decl. ¶ 10.

         It appears that, prior to the enactment of regulations in September 2016, a defendant's place on the wait list was - as a general matter - dependent on his commitment date. See Prothero Decl. ¶ 5 (testifying that, “[i]n 2016, because of concerns arising out of the fairness of some counties in [NSH's] catchment area having standing orders, the Admissions staff continued to place all IST Defendants on the . . . wait list, once their packet was complete, according to commitment date”).[5]

         It also appears that, prior to September 2016, a defendant could be immediately placed at a hospital - i.e., in spite of the wait list - if the defendant had an acute psychiatric need. See Haddad Decl., Ex. 13 (Black Depo. at 46). Usually, NSH would be told by the county jail that the defendant had such a need (although anyone could tell NSH, including the defendant's attorney or any one concerned about the defendant), and then the referral would be reviewed by the Clinical Administrator (Ms. Black) and the Medical Director (Dr. Tyler). See Black Decl. ¶¶ 10, 12; see also Prothero Decl. ¶ 7. “Based on the review of the available records and discussion with staff treating the defendant, the Medical Director [would] determine[] if the patient needed immediate placement due to [his] psychiatric condition.” Black Decl. ¶ 10.[6]

         There is evidence that DSH/NSH did not have a practice of routinely informing the state courts issuing commitment orders, medical staff at the jails, the prosecution, or defense counsel that a psychiatric acuity review could get an IST defendant admitted on a priority basis. See, e.g., Haddad Decl., Ex. 13 (Black Depo. at 54-55) (testifying that she could not recall a specific instance of the above being told “on a routine basis”); see also Haddad Decl., Ex. 18 (Ahlin Depo. at 106) (testifying that she is “not aware of a formal notification” to county jail doctors or admissions that they can request psychiatric acuity review); Haddad Decl., Ex. 19 (Tyler Depo. at 172) (testifying that she has “never sent out a letter to jail staff saying they can ask” for a psychiatric acuity review for a patient); Blakely Decl. ¶ 7 (testifying that, while he was a public defender, he “was never informed that the Department of Mental Health or [DSH] allows for psychiatric acuity reviews upon request, to provide an IST criminal Defendant with priority admission to [NSH] based on the severity or acuity of his mental illness”).

         In addition, there is evidence that DSH/NSH did not have a practice of automatically subjecting IST defendants to psychiatric acuity reviews before they were placed on the wait list - i.e., there was no attempt to “triage.” See, e.g., Haddad Decl., Ex. 13 (Black Depo. at 48, 58) (testifying that “[w]e do not do a triage for admission” - i.e., NSH does “not triage patients to determine their psychiatric acuity before putting them on the waiting list”); Haddad Decl., Ex. 17 (Maynard Depo. at 63) (testifying that “[t]here is not a standard that I am aware of while I have been with DSH to triage and evaluate every patient prior to placement on the wait list”). However, there is some evidence indicating that the Admissions Suite nurse of a state hospital would do a limited kind of psychiatric acuity review at or about the time that the admission packet was sent to the hospital. See, e.g., Haddad Decl., Ex. 17 (Maynard Depo. at 39-40) (testifying that, at the time of referral, “[t]he patient referral information provided by the county is reviewed by a nurse in each of the hospitals, or the patient management unit, for specific placement issues which could be related to psychiatric acuity” or other matters such as “the type of offense” and “medical conditions”); Haddad Decl., Ex. 14 (White Depo. at 39, 41) (testifying that “[w]e have medical records before they go on the waiting list” such that, “if anything sticks out in those medical records that call to us to ask the jail for further information, we do call the jail”; “sometimes, to me, I'll read something and think: Wow, this person needs to get in a hospital now” so “I'll ask the [Admissions] [S]uite to make a phone call to the jail to see if they are suicidal right now or if things have changed or how the person's doing now, right that moment”). According to Plaintiffs, it was feasible to do a more systematic psychiatric acuity review for all IST defendants because there is evidence that “it takes Dr. Tyler only about an hour to do one on an ad hoc basis.” Pls.' Opp'n at 8; see also Haddad Decl., Ex. 19 (Tyler Depo. at 171-72) (stating that the time to do a psychiatric acuity review “can vary, but I would say less than an hour”; this includes reviewing available medical records).

         The State Defendants, however, note that “the numbers of IST defendants that counties [have] referred to DSH . . . have experienced tremendous growth over the last several years. For example, the number of county IST referrals to DSH systemwide increased from 1, 859 in Fiscal year (FY) 2013-14 to over 3, 400 in FY 2016-17.” Maynard Decl. ¶ 10. Although DSH has been able “to increase admissions and numbers of IST defendants served, ” Black Decl. ¶ 11; see also Maynard Decl. ¶ 12 (testifying that, in “the last four years, DSH has added 970 new beds to its overall treatment system of state hospital beds and Jail Based Competency (JBCT) Program beds”[7]), “the number of county referrals continue to outpace the rate of admissions.” Maynard Decl. ¶ 10; see also Maynard Decl. ¶ 13.

         Given the above, it is not surprising that state courts often had to issue orders to show cause (“OSCs”) because an IST defendant had not been transferred to a hospital as required by a court commitment order. When a state court issues an OSC “for disobeying a court order of commitment, it may be directed to the Director of DSH [e.g., Ms. Ahlin] in [her] official capacity.” Maynard Decl. ¶ 8. The OSC, however, “does not [actually] go to the Director of DSH and instead [is] routed directly to the DSH legal department for handling.” Maynard Decl. ¶ 8; see also Carson Dec., Ex. A (Ahlin Depo. at 42); Ahlin Decl. ¶ 4. “[I]n fiscal year 2016, DSH received 1, 975 OSCs.” Maynard Decl. ¶ 8.

         B. Process Specific to Mr. Luong as an IST Defendant

         On January 26, 2016, Mr. Luong was arrested for assault after he allegedly attacked a person with a mallet. See Prothero Decl., Ex. A (arrest report). Mr. Luong was eventually placed in custody in the Santa Rita Jail in Alameda County.

         In February 2016, medical staff at the jail assessed Mr. Luong with schizophrenia and/or psychosis. See, e.g., Haddad Decl., Ex. 6 (PLF 617, 620). He was prescribed the antipsychotic drug Risperdal. See Haddad Decl., Ex. 6 (PLF 627).

         On March 7, 2016, the state court in the criminal proceeding related to the assault appointed an alienist (Victoria Campagna) pursuant to California Penal Code § 1368 to assess Mr. Luong's competency. See Defs.' RJN, Ex. A (order).

         Shortly thereafter, medical staff at the Santa Rita Jail made note that Mr. Luong was refusing to take his medication. See, e.g., Haddad Decl., Ex. 6 (PLF 629-31). Risperdal continued to be prescribed. See, e.g., Haddad Decl., Ex. 6 (PLF 634, 636, 638).

         On April 5, 2016, Dr. Campagna (the court-appointed alienist) opined that Mr. Luong was competent to stand trial. This was based on, inter alia, an interview with Mr. Luong on the preceding day. See Prothero Decl., Ex. A (Campagna report).

         On April 6, 2016, the state court appointed another alienist (Martin Blinder) to assess Mr. Luong's competency. See Defs.' RJN, Ex. C (order).

         On May 7, 2016, Dr. Blinder (the court-appointed alienist) opined that Mr. Luong was not competent to stand trial. This was based, inter alia, on an interview with Mr. Luong on May 3, 2016. See Prothero Decl., Ex. A (Blinder report).

         In mid- to late May 2016, Mr. Luong's condition began to deteriorate, with medical records indicating, e.g., that he had been refusing to eat and drink and that he was delusional. See, e.g., Haddad Decl., Ex. 6 (PLF 639, 641, 643).

         On June 1, 2016, medical staff at the Santa Rita Jail noted that Mr. Luong refused to take his anti-psychotic medication and determined that Mr. Luong's condition had deteriorated to the point where he was a danger to self and had a grave disability, thus prompting a detention for evaluation and treatment at the John George Psychiatric Pavilion pursuant to California Welfare & Institutions Code § 5150.[8] See Haddad Decl., Ex. 6 (PLF 646).

         On June 2, 2016, the state court appointed another alienist (David Echeandia) to assess Mr. Luong's competency. See Defs.' RJN, Ex. E (order).

         On or about June 10, 2016, Mr. Luong returned to the jail from the John George Psychiatric Pavilion. See Haddad Decl., Ex. 6 (PLF 649); see also Haddad Decl., Ex. 7 (hospital records from the John George Psychiatric Pavilion).

         Beginning in late June 2016 and continuing into July 2016, Mr. Luong began to refuse to take his anti-psychotic medication again. See, e.g., Haddad Decl., Ex. 6 (PLF 656, 660).

         On July 5, 2016, Dr. Echeandia (the court-appointed alienist) opined that Mr. Luong was not competent to stand trial. This was based, inter alia, on an interview on July 1, 2016. See Prothero Decl., Ex. A (Echeandia report).

         On July 8, 2016, the state court found Mr. Luong mentally incompetent within the meaning of § 1368. The court ordered Mr. Luong to be referred to the Conditional Release Program (also known as “CONREP”) for an examination and a recommendation for placement pursuant to California Penal Code § 1370. See Defs.' RJN, Ex. F (order). CONREP is a program overseen/administered by DHS. See Cal. Wel. & Inst. Code § 4360(a) (providing that DSH “shall provide mental health treatment and supervision in the community for judicially committed persons” and that “[t]he program established and administered by [DSH] under this chapter to provide these services shall be known as the Forensic Conditional Release Program [or CONREP]”).

         On or about July 29, 2016, Alameda County, with whom DSH had contracted to provide CONREP services, see Id. § 4360(b) (providing that DSH “may provide directly, or through contract with private providers or counties, for these services”), recommended to the state court (via a letter) that the court place Mr. Luong at NSH and that the court authorize the use of involuntary medication. See Prothero Decl., Ex. 1 (CONREP letter).

         On July 22, 2016, the state court ordered Mr. Luong to be committed to NSH “or any other Hospital” pursuant to § 1370.[9] Defs.' RJN, Ex. G (Order at 1). The court also ordered that “the treatment facility may administer antipsychotic medication to [Mr. Luong] involuntarily when and as prescribed by a treating physician.”[10] Defs.' RJN, Ex. G (Order at 2). (The local jail did not have the authority to administer medication involuntarily. See Hayward Rpt. at 6 (noting that “the Alameda County jail had no statutory authorization to involuntarily treat Mr. Luong even after the court had issued an involuntary medication order”).) Finally, the court ordered that, “within ninety (90) days of this commitment and thereafter at no less than six months intervals, the Executive Director of the Hospital or facility where [Mr. Luong] is housed shall make a written report to this Court . . . concerning [his] progress toward recover of . . . mental competence.” Defs.' RJN, Ex. G (Order at 1).

         In late July 2016, medical staff at the Santa Rita Jail described Mr. Luong as “catatonic, ” Haddad Decl., Ex. 6 (PLF 664, 666), noted that he was refusing to take his medication, and indicated that he would be detained again for a § 5150 evaluation at the John George Psychiatric Pavilion. See Haddad Decl., Ex. 6 (PLF 666, 668) (indicating that Mr. Luong had been “decompensating since clinician last saw him on 7/7/16”).

         On or about August 3, 2016, Mr. Luong was returned to the jail from the John George Psychiatric Pavilion. See Haddad Decl., Ex. 6 (PLF 669-70).

         On August 22, 2016 - approximately a month after the state court issued the order placing Mr. Luong at NSH - Alameda County transmitted the commitment order and admission packet for Mr. Luong to NSH.[11] See Prothero Decl. ¶ 10; see also Haddad Decl., Ex. 14 (White Depo. at 24) (testifying that, although the commitment order issued in late July 2016, it took time for NSH to approve Mr. Luong for admission because it took time for the court to generate the admission packet and send it to NSH). “The [admission] packet was reviewed and completed on August 26, 2016.” Prothero Decl. ¶ 10. Because no beds for IST defendants were available at that time, “Mr. Luong was placed on the waiting list according to his date of [c]ommitment.” Prothero Decl. ¶ 12.

         Mr. Luong's admission packet included (1) three psychological and psychiatric reports regarding competency to stand trial (as ordered by the state court); (2) a letter from CONREP regarding placement (as ordered by the state court); and (3) medical records. More specifically, these documents indicated as follows:

Psychological report by Dr. Campagna, dated April 5, 2016. Dr. Campagna opined that, “at the present time, Mr. Luong is competent to stand trial.” Prothero Decl., Ex. A (Campagna Rpt. at 1) (emphasis omitted). She noted, however, that, according to Mr. Luong's sister, he “functions well when he takes his medication” but not when he does not take his medication, and “[t]his is what appears to have happened in this instance.” Prothero Decl., Ex. A (Campagna Rpt. at 2). She recommended that, when Mr. Luong “is released to the community, . . . he be ordered to investigate the appropriateness of a long-lasting injectable psychiatric medication to treat his schizophrenia, and if his physicians feel this is an option for him, that he be court-ordered to avail himself of this treatment.” Prothero Decl., Ex. A (Campagna Rpt. at 2) (emphasis omitted).
Psychiatric report of Dr. Blinder, dated May 7, 2016. Dr. Blinder opined that Mr. Luong has “[i]ntermittent psychosis, etiology to be determined.” Prothero Decl., Ex. A (Blinder Rpt. at 3). He also opined that Mr. Luong was not competent to stand trial: “I find this gentleman's commerce with reality impaired sufficient[ly] to negate any likelihood of rational participation in forthcoming legal proceedings.” Prothero Decl., Ex. A (Blinder Rpt. at 3). Dr. Blinder added that Mr. Luong was “currently receiving appropriate medications which, though thus far not curative, have doubtless brought him closer to remission, ” and “it is entirely possible that several months hence he may be psychiatrically equal to his day in court. . . . [¶] [S]o long as he continues to take his medication he constitutes little danger to self or others.” Prothero Decl., Ex. A (Blinder Rpt. at 3).
Psychological report of Dr. Echeandia, dated July 5, 2016. Notably, Dr. Echeandia stated that, during his interview with Mr. Luong, Mr. Luong's “mental state appeared to deteriorate more and more” and “[t]oward the end of the interview, [he] decompensated to an acute psychotic state.” Prothero Decl., Ex. A (Echeandia Rpt. at 3). Dr. Echeandia also took note that medical records “revealed that [Mr. Luong] had been treated with antipsychotic drugs for psychotic symptoms . . . over a period spanning the past 15 years or so. Other medical records provided diagnoses of Schizophrenia, Paranoid Type and/or Psychotic Disorder NOS, and described treatment with antipsychotic medications, as well as several psychiatric hospitalizations, the most recent in 2015. During his current incarceration, he was also transported to John George [Psychiatric Pavilion] for psychiatric reasons.” Prothero Decl., Ex. A (Echeandia Rpt. at 5). Dr. Echeandia opined that Mr. Luong was not competent to stand trial and that “treatment with antipsychotic medications both medically appropriate and necessary to restore [his] mental competence, given the evidence of his acutely psychotic behavior during the interview.” Prothero Decl., Ex. A (Echeandia Rpt. at 5). Dr. Echeandia stated that, based on the assault that resulted in Mr. Luong's arrest, he was “inclined to believe that Mr. Luong may continue to represent a danger to others unless adequate treatment in the form of more effective psychiatric medication and therapy is provided.” Prothero Decl., Ex. A (Echeandia Rpt. at 6).
CONREP letter, dated July 19, 2016. CONREP stated that it was evaluating Mr. Luong for placement as ordered by the state court. CONREP noted that Mr. Luong has a serious mental illness, Schizophrenia”; that, pursuant to California Welfare & Institutions Code § 5150, he had been detained for evaluation and treatment at John George Psychiatric Pavilion (“JGPP”) in October 2015 (i.e., a few months before his arrest in January 2016); and that he had been hospitalized for nine days at JGPP in June 2016 (i.e., several months after his arrest). Prothero Decl., Ex. A (CONREP Letter at 1). (CONREP did not mention the second hospitalization at JGPP in late July/early August 2016 because that hospitalization took place after the date of the CONREP letter.) CONREP also stated that it appeared Mr. Luong “generally does well when he takes his anti-psychotic medications” but that he “was not taking his medications at the time of the alleged offenses”; that he “is currently refusing to take” an anti-psychotic drug prescribed at the jail; and that, without “consistent treatment to keep his psychotic symptoms under control, ” he “is at high risk for deterioration.” Prothero Decl., Ex. A (CONREP Letter at 1). CONREP recommended to the state court that it place Mr. Luong at NSH and that it authorize the use of involuntarily medication.
Medical records. The medical records consisted of two pages. The first page was a “Medical Information Transfer Form” from the Alameda County Sheriff's Office. It indicated that Mr. Luong had a “mental disorder” for which he was being prescribed, inter alia, Risperdal (which is an antipsychotic drug) as of August 2016. Prothero Decl., Ex. A (Medical Information Transfer Form). The second page was a form from the Santa Rita Jail indicating that a skin test for tuberculosis had been applied to Mr. Luong in February 2016. See Prothero Decl., Ex. A (PPD Skin Test). Alameda County did not transfer the full medical records from the Santa Rita Jail, nor did it transfer the medical records from Mr. Luong's two hospitalizations at the John George Psychiatric Pavilion (i.e., while he was in custody in June and late July/early August 2016). See Defs.' Mot. at 11.

         In late August 2016, medical staff at the Santa Rita Jail noted that Mr. Luong was once again not compliant with his medication. See Haddad Decl., Ex. 6 (PLF 678).

         On September 7, 2016 - after receiving notice from the public defender that Mr. Luong was still at Santa Rita Jail and had not been transferred to NSH - the state court issued an order to Ms. Ahlin, the Director of DSH, instructing her to comply with the order to transport Mr. Luong or to show cause why she should not be held in contempt. A hearing was set for September 12, 2016. See Defs.' RJN, Ex. H (order).

         It appears that a hearing was held on September 12, 2016, as reflected by a state court minute order. The minute order indicates that, at the hearing, a September 20, 2016, progress report was canceled. See Defs.' RJN, Ex. I (order).

         On or about October 7, 2016, the Santa Rita Jail staff assigned Aref Popal to be Mr. Luong's cellmate. See SAC ¶ 81.

         On October 11, 2016, NSH's Admissions Suite “was notified that a bed would become available for the next IST Defendant on the wait list, ” which was Mr. Luong. Prothero Decl. ¶ 13.

         The Admissions Suite called the Santa Rita Jail to arrange for Mr. Luong's transport and was subsequently told that Mr. Luong had died. See Prothero Decl. ¶¶ 13-14. Mr. Luong had been killed by his cellmate on the same date. See Haddad Decl., Ex. 4 (autopsy report for Mr. Luong) (indicating death from asphyxiation/strangulation).

         According to Plaintiffs, at least twelve inmates have died awaiting transfer to a state hospital.[12] See Pls.' Opp'n at 11-12. Plaintiffs also maintain that multiple inmates have waited for as long as 100-300 days for transfer to a state hospital. See Pls.' Opp'n at 12; Haddad Decl., Ex. 32 (Plaintiffs' chart on “Longest Waits on Direct Admission Wait List”). But see Defs.' Opp'n at 22-23 (asserting that there were reasons for these wait times).

         C. Plaintiffs' Experts

         Plaintiffs have provided expert evidence in support of their opposition to the State Defendants' summary judgment motion. There are four experts in total:

(1) Dr. Terry Kupers. The expert report from Dr. Kupers was technically submitted in a different case, Stiavetti v. Ahlin, No. RG15779731 (Alameda Superior Court). However, Plaintiffs indicate that they will be using Dr. Kupers as an expert in their case as well. In his report, Dr. Kupers states, inter alia, as follows.
a. “Adequate competency restoration treatment can only occur in a setting conducive to mental health treatment.” Kupers Rpt. at 31.
b. “Jail is not a setting conducive to mental health treatment nor to competency restoration treatment, absent major alterations in milieu, staffing, and programming. Jail crowding, the threat of violence, the culture of punishment that permeates the facilities, and the relative inadequacy of programs and treatments have a very detrimental effect on the mental status of incompetent prisoners, and on the ability to participate effectively in competency restoration.” Kupers Rpt. at 31-32.
c. “Jails are violent places. Prisoners with serious mental illness are disproportionately victims of violence, or lose control of their temper and get involved in altercations.” Kupers Rpt. at 32.
d. “[S]ixty days is far too long for incompetent individuals to remain in harmful jail conditions with limited mental health treatment.” Kupers Rpt. at 33.
(2) Dr. Bruce Gage. The expert report from Dr. Gage was also technically submitted in a different case, Stiavetti v. Ahlin, No. RG15779731 (Alameda Superior Court). However, as above, Plaintiffs indicate that they will be using Dr. Gage as an expert in their case as well. In his report, Dr. Gage states, inter alia, as follows.
a. DSH has an “unwieldy admissions process[] that demand[s] excessive information from the counties and other local entities.” Gate Rpt. at 1.
b. The process is “not currently causing delay in DSH” but “only because DSH capacity to treat this population is so limited that the delays caused by lack of capacity mask the inefficiencies of the admission process.” Gage Rpt. at 1.
c. “Once placement is determined, two weeks gives ample time to conduct medical and short-term risk assessment, communicate with the jails for clarification of packet information, identify the appropriate facility, provide the information to the receiving facility, and arrange transportation. To accomplish this most efficiently, central control of the admissions process is ...

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