An inspector generals report skewered the California Department of Corrections and Rehabilitation for its role in creating a coronavirus outbreak at San Quentin State Prison in which over 2,000 incarcerated people got the virus and over two dozen died.

The report released Monday said the California corrections department and its health care services caused a public health disaster when they transferred medically vulnerable incarcerated persons without proper safeguards.

In late May, after the California Institution for Men in Chino experienced a COVID-19 outbreak, the states corrections department decided to transfer out incarcerated people with health issues that could make them more susceptible to severe coronavirus cases. From May 28-30, California Correctional Health Care Services transferred 189 people to San Quentin prison and Corcoran prison. But in making those transfers, staff at the prison, pressured by health care services leadership, inadequately screened the transferees for the coronavirus, including not testing 172 out of 189 transferees for the virus for at least two weeks prior, per the report. Then they put them on buses that didnt allow for safe distancing.

Once at San Quentin, 119 of those transferred were placed in a unit with open bar cells where air could move and circulate without quarantining them from the rest of the prison population. Staff were also circulating throughout the prison, likely transmitting the virus from location to location, per the report.

Before the transfer, no one at San Quentin had tested positive for the virus. Within a few weeks, over a dozen transferees tested positive for COVID-19. By mid-July, over half of the 3,100 or so people incarcerated at San Quentin were infected and 11 people died. By the end of August, 2,237 incarcerated people and 277 staff had COVID-19, and over two dozen incarcerated people had died .

The report said it found the corrections departments actions were deeply flawed and risked the health and lives of the medically vulnerable incarcerated persons.