In California, mental health care in state prisons is designed so that incarcerated people transfer to appropriate levels of care as their needs change. Treatments range from outpatient therapy in the general prisoner population to long-term hospitalization in treatment facilities within the correctional system.

Prisoners needing the highest level of care could be sent to state hospitals, which are separate facilities that also house people who are not in the criminal justice system.

But the system doesn’t always work perfectly. In several investigations, the Inspector General has determined that people who need it sometimes aren’t referred to a higher level of care.

In other cases, experts say, multiple transfers can mean the system is working and people are getting the care they need.

Department spokesperson Dana Simas wrote in an emailed statement that the state transfers prisoners for a variety of reasons, including court hearings, medical treatment, mental health treatment, changes in security level, patient safety, staff conflicts, misconduct allegations or parole.

In California, prison mental health treatment policies are governed by a federal class-action lawsuit — known asColeman— on behalf of prisoners with serious mental illness.

In 1995, a federal court ruled that the department was not providing adequate mental health care to prisoners. The court eventuallyapproved the Corrections Department’splan for providing mental health care and appointed a special master to monitor and report on the state’s compliance.

“The department works closely with the Coleman special master and others on these matters, and always strives for what is in the best interest of the patient’s individual needs,” Simas wrote in an email to CalMatters.

Special master Matthew A. Lopes Jr. did not respond to CalMatters’ request for comment.

In Collier’s case, he moved so frequently that his mother, Susan Ottele of McMinnville, Ore., started “every single, solitary day” checking online to see which prison was holding Collier and why.

When the pandemic hit, the prisons went on lockdown, and Collier sat inside Kern Valley State Prison for seven months. It was his longest stay at any prison since 2016.

“With all these transfers, I’m fucking dizzy,” Collier wrote in a letter to Ottele in March 2020. Months later, at age 43, Collier killed himself.

The Office of the Inspector General investigated Collier’s suicide and found that the department had “poorly handled” Collier’s case. The inspector general’s March 2021 report describedan array of internal problems,including clinicians improperly delaying Collier’s referral to a higher level of care and failing to adequately document his history of self-harm.

Earlier this year, Ottele fileda wrongful death complaintin federal court, alleging that prison guards failed to monitor her son and acted with deliberate indifference.

In court documents, state attorneys deny these claims, saying the guards were not aware of Collier’s history of suicide attempts. The Department of Corrections and Rehabilitation declined to comment on the lawsuit, citing pending litigation. Lisieski, Ottele’s attorney, said the case likely won’t be resolved for years.