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Family of Coalinga State Hospital Resident Says They Weren't Told He Died—Or That He Had COVID-19

Department of State Hospitals
Coalinga State Hospital

In late December, Clementine Sanders called her son at Coalinga State Hospital to make sure he had received her Christmas card. That’s when his bunkmates informed her that her son, 58-year-old Shannon Starr, had died three weeks earlier. “I was just totally shocked,” she says. “Nobody called me.”

Since then, she says, none of her messages to staff or reception have been returned. “I still wasn’t notified and I still haven’t heard from the [hospital],” she says.

When Sanders and her daughter instead sought out information from the Fresno County Coroner’s Office, they learned that Starr’s body had already been cremated and his ashes disposed of off the coast of San Luis Obispo County. “I’m just numb. I don’t know what to do,” Sanders says. “I’m upset. I don’t know exactly who to be upset with, except for them, and I can’t talk with them.”

No one told Sanders that Starr had tested positive for COVID-19. According to the Fresno County Coroner’s Office, Starr’s official causes of death include cardiac arrest, a pulmonary embolism, and kidney failure, but he did test positive for the virus a month earlier. It’s unclear if the virus played a role in his death.

Starr was one of more than 350 patients at Coalinga, or about a quarter of the hospital’s population, to have contracted the virus. Nearly 80 of those cases were reported in just the last two weeks. Patients there complain of unsafe living conditions, including cramped living quarters and staff being allowed to float freely between quarantined and non-quarantined units, and at least one resident is so concerned for his health he’s said he’d rather be deported than remain at the facility. What’s more, the full impact of the virus may be obscured by reports that the institution does not consistently inform families when their loved ones inside the hospital die.

Coalinga State Hospital is not a prison, but it’s not a typical hospital either. It’s a state-run facility that houses felons, most of whom are sexually violent predators. They’ve served their prison sentences, but a court has determined they’re not yet fit for a life of freedom. Like many other patients and advocates, James Hydrick, who’s been a patient at Coalinga for 14 years, calls it a shadow prison. “When patients die from Coalinga they die being handcuffed to a bed,” he says. “They’re not allowed to see their families, receive phone calls or anything.”

At least twelve residents have died of COVID-19 since May. Hydrick, however, suspects the death toll is higher, claiming that many of the men who died in recent months were never tested for COVID-19. He also says that in a few cases, when he’s reached out to the loved ones of those who’ve died, he’s discovered the hospital had never informed them. “They simply feel that they have no obligation to notify family members of their loved ones’ passing,” he says.

In an email, Angela Bass, a public information officer with the Department of State Hospitals (DSH), says that when a patient dies, the hospital will make every effort to reach out to loved ones. “If they cannot be reached by phone, a letter is mailed to any address we have on file for the next of kin or emergency contact,” she says. “If the information DSH was provided is either inaccurate or outdated, this may contribute to the delay or inability to contact the next of kin or emergency contact.”

When asked why Shannon Starr's family had not been informed of his death, Bass says the department cannot legally comment on specific patients' cases.

Kerry Klein is an award-winning reporter whose coverage of public health, air pollution, drinking water access and wildfires in the San Joaquin Valley has been featured on NPR, KQED, Science Friday and Kaiser Health News. Her work has earned numerous regional Edward R. Murrow and Golden Mike Awards and has been recognized by the Association of Health Care Journalists and Society of Environmental Journalists. Her podcast Escape From Mammoth Pool was named a podcast “listeners couldn’t get enough of in 2021” by the radio aggregator NPR One.
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