FCI Dublin: Special master finds 'cascade of failures' at women's prison

DUBLIN, Calif. - A federal court-appointed "special master" found that the medical care, investigations into sex abuse reports, unnecessary disciplinary measures, lack of programming and classes, as well as the hasty transfer of 605 incarcerated women at FCI Dublin were a "cascade of failures." 

"The cascade of failures in operational practice has led staff and AICs (Adults in Custody) becoming discouraged and to lose confidence in the BOP (Bureau of Prisons) to lose confidence to protect/support them," the report states.

Those were the much-anticipated and unprecedented findings by Special Master Wendy Still in a 100-page report to U.S. District Court Judge Gonzalez Rogers, unsealed on Friday.

On the one hand, nothing substantively new was revealed in the report, which focuses on the now-closed all-women’s prison, shuttered in mid-April, 10 days after Still was named in her position to oversee reforms there.

Still and her all-female team of medical and data experts methodically documented findings that revealed the incarcerated women were not given medical and mental health treatment promptly and there was no safe or consistent path women could take to file sex abuse complaints in a prison where seven correctional officers, including the warden, have been sentenced to prison for sex crimes. An eighth officer is headed to trial on similar charges. 

But what the report does do for the first time is codify and corroborate what more than 100 women have told KTVU anecdotally over the last 2/12 years, as well as what they have told their attorneys, who filed a class-action lawsuit on their behalf in August 2023.

And Still’s report does unearth some new details about the "failures" she witnessed at FCI Dublin, including the fact that, because of severe understaffing levels, cooks, teachers and nurses were often tasked with correctional officer duties, and female prisoners were asked to observe their colleagues on suicide watch. 

FCI Dublin has the second-highest staff vacancy rate in the western region of the BOP; 51% when factoring in the 27 staff on administrative leave, Still wrote. Many of those absences are because of sexual abuse allegations on the job or other improper behavior.

Because there weren’t enough staff, officers couldn’t provide enough classes at the prison so that incarcerated women could earn time off for good behavior, check for drugs that were smuggled into the prison, and complete reports promptly, in order to release women from the Special Housing Unit, or the SHU, according to the report. 

"The consequences of these circumstances at FCI-Dublin have been dire," Still wrote. "The negative consequences associated with these staffing shortages are numerous." 

Perhaps even more importantly, now that FCI Dublin is closed, Still’s report highlights the fact that the problems are not unique to this low-security prison in the East Bay hills.

This finding is even more relevant as the 605 women who were housed at FCI Dublin were taken by bus to prisons across the country, where many of them have been complaining about similar issues.

"It is critical to note that some of the deficiencies and issues exposed within this report are likely an indication of systemwide issues with the BOP," Still wrote, "rather than simply within FCI Dublin." 

In an email, BOP spokeswoman Randilee Giamusso wrote: "The FBOP welcomes the additional oversight at FCI Dublin and looks forward to working with the Special Master on the findings and recommendations in the report."

She declined to comment on any other aspect of the report as they related to "pending litigation or ongoing legal proceedings." 

The document is historic because there has never been a special master placed over a federal prison before and because the majority of reports looking into life at a BOP prison are commissioned by the BOP.

The failures that Still said she saw include previously unknown details such as the number of women suffering substance abuse problems and who were not given methadone and "denied treatment by the physician despite the fact that illegal drug usage was rampant throughout the facility." 

"An alarming number of patients voiced concerns about their MAT medication being reduced by one-third without reason or explanation," Still wrote.

In another case, Still said the mental health care is so poor that two women placed on suicide watch were placed on the administrative side of the medical building or in five-point restraints "while another inmate performs the watch," according to the report. "Having other inmates perform clinical functions is against every acceptable standard." 

Still also found that FCI Dublin’s investigations into sexual abuse allegations were haphazard, and she cited U.S. Sen. Jon Ossoff’s research that found women prisoners at 19 out of 29 federal prisons had been sexually abused by BOP male employees. 

At FCI Dublin specifically, Still found that there was no computer tracking system for when a woman complained of abuse and no time frame in which an investigation had to be closed.

For example, the chief psychologist at FCI Dublin acknowledged that she kept no Prison Rape Elimination Act files on any of the women.

"There was no mechanism in place to ensure PREA administrative remedies that were granted were sent to the PREA compliance manager for appropriate follow-up," Still wrote.

She also noted that FCI Dublin and the BOP used "boilerplate" responses after women filed formal complaints, which she said was indicative of a dismissive attitude toward its incarcerated population. 

Still’s recommendations in her report are generally for the BOP to conduct better training, fix systemic tracking issues, hire more people and conduct exit interviews to find out why staff are leaving the agency.

In the meantime, Kara Janssen, an attorney representing the incarcerated women in the class action suit called Coalition for California Women Prisoners, said she’s heartened that Still’s report addresses what her clients have already said for years, and also looks at problems within the higher levels of the BOP.

"The failure of regional and central BOP leadership to address these types of issues is key to how this happened in Dublin and continues to happen elsewhere. There will always be bad apples and it is the job of BOP leadership to catch and address those bad apples. But BOP has done nothing to fix their broken systems or address the underlying issue." 

Lisa Fernandez is a reporter for KTVU. Email Lisa at lisa.fernandez@fox.com or call her at 510-874-0139. Or follow her on Twitter @ljfernandez