Full opinion text
FINDINGS OF FACT, CONCLUSIONS OF LAW, AND ORDER THELTON E. HENDERSON, Chief Judge. TABLE OF CONTENTS Page I. Introduction.1155 II. Findings of Fact A. Excessive Force.1159 B. Medical Health Care .1200 C. Mental Health Care.1214 D. Conditions in the Security Housing Unit.1227 E. Cell Housing Practices. I> CO C<3 F. Segregation of Prison Gang Affiliates. o ^ oq III.Conclusions of Law A. Eighth Amendment Overview.1244 B. Excessive Force.1247 C. Medical and Mental Health Care.1255 D. Conditions in the Security Housing Unit.1260 E. Cell Housing Practices.1267 F. Segregation of Prison Gang Affiliates.1270 IV. Summary.1279 V. Appropriate Relief and Further Proceedings.1280 Appendix A (Glossary of Terms).1283 I. INTRODUCTION Plaintiffs represent a class of all prisoners who are, or will be, incarcerated by the State of California Department of Corrections at Pelican Bay State Prison, which is located in the remote northwest corner of California, seven miles northeast of Crescent City and 363 miles north of San Francisco. Pursuant to the civil rights statute 42 U.S.C. § 1983, plaintiffs challenge the constitutionality of a broad range of conditions and practices that intimately affect almost every facet of their prison life. They seek redress from the Court in the form of injunctive and declaratory relief. Although referred to in the singular, Pelican Bay State Prison (“Pelican Bay”) actually consists of three completely separate facilities. The first is a maximum security prison which houses approximately 2,000 “general population” maximum security inmates. The daily routine for these inmates is comparable to that in other maximum security prisons in California. The second is the Security Housing Unit, commonly referred to as the “SHU.” Located in a completely separate complex inside the security perimeter, the SHU has gained a well-deserved reputation as a place which, by design, imposes conditions far harsher than those anywhere else in the California prison system. The roughly 1,000-1,500 inmates confined in the SHU remain isolated in windowless cells for 22 and % hours each day, and are denied access to prison work programs and group exercise yards. Assignment to the SHU is not based on the inmate’s underlying offense; rather, SHU cells are reserved for those inmates in the California prison system who become affiliated with a prison gang or commit serious disciplinary infractions once in prison. They represent, according to a phrase coined by defendants, “the worst of the worst.” Finally, there is a small minimum security facility that houses approximately 200 prisoners. All in all, there are between 3,500 and 3,900 prisoners confined at Pelican Bay on any given day. Just over five years old, Pelican Bay was activated on December 1, 1989. Considered a “prison of the future,” the buildings are . modern in design, and employ cutting-edge technology and security devices. This, then, is not a case about inadequate or deteriorating physical conditions. There are no rat-infested cells, antiquated buildings, or unsanitary supplies. Rather, plaintiffs contend that behind the newly-minted walls and shiny equipment lies a prison that is coldly indifferent to the limited, but basic and elemental, rights that incarcerated persons — including “the worst of the worst” — retain under the First, Eighth, and Fourteenth amendments of our United States Constitution. In particular, plaintiffs allege that defendants (1) condone a pattern and practice of using excessive force against inmates, (2) fail to provide inmates with adequate medical care, (3) fail to provide inmates with adequate mental health care, (4) impose inhumane conditions in the Security Housing Unit, (5) utilize cell-assignment procedures that expose inmates to an unreasonable risk of assault from other inmates, (6) fail to provide adequate procedural safeguards when segregating prison gang affiliates in the Security Housing Unit, and (7) fail to provide inmates with adequate access to the courts. Named in their official capacity as defendants are Pelican Bay Warden Charles Marshall, Chief Deputy Warden Terry Peetz, Chief Medical Officer A.M. Astorga, and James Gomez, Director of the California Department of Corrections (“CDC”). They deny that any of plaintiffs’ allegations have merit, and assert that Pelican Bay operates well within constitutional limits in each of the areas outlined above. Moreover, they argue, Pelican Bay, and the SHU in particular, does exactly what it was designed to do: it isolates the most brutal and disruptive elements of the inmate population while reducing violence in California state prisons overall. The case was tried before the Court between September 14 and December 1, 1993. Immediately prior to the trial, the Court spent two days touring Pelican Bay, accompanied by counsel for both parties and prison officials. During the course of the trial, the Court heard testimony from 57 lay witnesses, including class members, defendants, and correctional employees at all levels. It also received into evidence over 6,000 exhibits, including documents, tape recordings, and photographs, as well as thousands of pages of deposition excerpts. The Court recognizes that neither the inmates at Pelican Bay nor the Department of Corrections personnel can be considered neutral witnesses. For reasons that are self-evident, class members, as well as defendants and other prison staff, are interested in the outcome of the case. We also take into account the undeniable presence of a “code of silence” at Pelican Bay. As the evidence clearly shows, this unwritten but widely understood code is designed to encourage prison employees to remain silent regarding the improper behavior of their fellow employees, particularly where excessive force has been alleged. Those who defy the code risk retaliation and harassment. We have considered all of the above, as well as the manner and demeanor of the witnesses, in assessing witness credibility and making our factual findings. The Court was also aided by the testimony of ten experts in the areas of medicine, psychiatry, psychology, and prison management and operation. With respect to the claims regarding excessive force and cell assignment practices, plaintiffs presented three experts: Charles Fenton, a former warden of two maximum security prisons, Steve Martin, who spent more than 20 years working in varying capacities for the Texas Department of Corrections, and Vince Nathan, who has worked for nearly 20 years as a court-appointed monitor and expert in prison cases. Defendants presented two experts: Daniel McCarthy, who worked for almost 40 years in varying capacities for the California Department of Corrections, most recently as its Director, and Larry DuBois, the Commissioner of the Massachusetts Department of Corrections. With respect to the claims concerning medical care, mental health care, and conditions in the SHU, plaintiffs presented Dr. Armond Start, an associate professor at the University of Wisconsin Medical School and former director of health care services for the Oklahoma and Texas prison systems, Dr. Stuart Grassian, a psychiatrist and faculty member at Harvard Medical School and expert on the effects of solitary confinement, and Dr. Craig Haney, a professor of psychology at the University of California at Santa Cruz, who has specialized in the psychological effects of incarceration. Defendants presented Dr. Jay Harness, a professor of surgery at the University of California at Davis and former director of health care services for the Michigan prison system, and Dr. Joel Dvoskin, a clinical psychologist and director of the Bureau of Forensic Services for the New York State Office of Mental Health. We are mindful that the opinions of experts are entitled to little weight in determining whether a condition is “cruel and unusual punishment” under the Eighth Amendment. Toussaint v. McCarthy (Toussaint IV), 801 F.2d 1080, 1107 n. 28 (9th Cir.1986). As such, we have not relied upon expert opinion to make this ultimate legal determination. It is appropriate, however, for this Court to consider expert opinion in assessing subsidiary issues which inform the court’s final determination. For example, expert opinion may be properly considered in assessing the effects of challenged conditions or practices. See Helling v. McKinney, — U.S. —, —, 113 S.Ct. 2475, 2482, 125 L.Ed.2d 22 (1993) (making reference to the “scientific and statistical inquiries]” that will be used to determine the seriousness of the harm caused by challenged conditions); Jordan v. Gardner, 986 F.2d 1521, 1526 (9th Cir.1993) (en banc) (relying on expert testimony to establish psychological impact of challenged measure on inmates). See also Slakan v. Porter, 737 F.2d 368, 378 (4th Cir.1984) (correctional expert’s opinions concerning punitive nature of prison’s water hosing practices properly admitted). After the trial was completed, in December 1993, the parties filed proposed findings of fact and conclusions of law on January 28 and February 1, 1994. The case was taken under submission at that time. II. FINDINGS OF FACT A. EXCESSIVE FORCE Perhaps the paramount responsibility of prison administrators is to maintain the safety and security of both staff and inmates. Bell v. Wolfish, 441 U.S. 520, 546-47, 99 S.Ct. 1861, 1878, 60 L.Ed.2d 447 (1979). In the setting of a maximum security prison, where inmates are more likely to pose security risks, this is a remarkably difficult undertaking. As the Ninth Circuit has previously said, prison officials have the “unenviable task of keeping dangerous men in safe custody under humane conditions.” Spain v. Procunier, 600 F.2d 189, 193 (9th Cir.1979). In a place like the SHU, which houses some of the most anti-social and violence-prone prisoners in the system — including those who suffer from mental illness — the task is that much more difficult. There is no question that this demanding and often thankless undertaking will require prison staff to use force against inmates. Indeed, the responsible deployment of force is not only justifiable on many occasions, but absolutely necessary to maintain the security of the institution. As one expert at trial succinctly stated, when it comes to force, it is “as dangerous to use too little as it is to use too much.” Fenton Tr. 6-766. At the same time, the prison setting offers a tremendous potential for abuse. Custody personnel are in constant contact, day after day, with a difficult, frustrating, and sometimes openly and actively hostile inmate population. They also have powerful weapons and enormous manpower at their disposal, and exercise nearly total control over the inmates under their supervision. Adding to this volatile mix is the fact that the prison setting, and particularly the SHU, is far removed from the usual sights and sounds of everyday life. From the outside, the SHU resembles a massive concrete bunker; from the inside it is a windowless labyrinth of cells and halls, sealed off from the outside world by walls, gates, and guards. The physical environment thus reinforces a sense of isolation and detachment from the outside world, and helps create a palpable distance from ordinary compunctions, inhibitions and community norms. If, in addition to all of the above, prison administrators fail to adequately supervise and monitor the use of force, the potential that force will be misused increases significantly. See Haney Decl. at 23-24. At trial, plaintiffs sought to prove that this potential for abuse was in fact realized at Pelican Bay, leaving in its wake a pattern of excessive force against inmates. A substantial portion of the trial was devoted to this claim. The parties presented testimony from dozens of witnesses, including several inmates and CDC personnel at all levels. The documentary evidence presented included incident reports, Internal Affairs reports and investigative files and tapes. Several hundred pages of deposition testimony were also admitted into evidence. As described above, the parties also presented five experts, Charles Fenton, Vince Nathan and Steve Martin (for plaintiffs) and Daniel McCarthy and Larry DuBois (for defendants), all of whom are distinguished experts in the correctional field. There were, however, significant differences in the amount of preparation they undertook prior to testifying. On the whole, plaintiffs’ experts did substantially more to familiarize themselves with the particulars of Pelican Bay than did defendants’ experts. For example, plaintiffs’ expert Martin reviewed over one thousand documents, including all incident reports for each cell extraction and shooting that occurred at Pelican Bay through the end of discovery, all fetal restraint memoranda and Internal Affairs investigation files produced (including a number of related audio tapes), training materials, rules violations reports, grievance appeals submitted by prisoners, and 30 deposition transcripts. He also spent several days at Pelican Bay, from September 14-17, 1992, and July 7-9, 1993, during which time he toured the prison, conducted interviews with inmates, and met with correctional staff. In contrast, defendants’ expert Larry DuBois testified that he spent approximately 20 hours reading documentary evidence; in his own words, he “reviewed or cursorily reviewed” about a box and a half of documents relevant to the case (incident reports, training materials, Internal Affairs reports and policies). Tr. 29-4689. He also spent two days at Pelican Bay in October 1993, during which he met with the Warden and correctional staff, and observed demonstrations of various weapons at the prison’s firing range. After a thorough review and consideration of the testimonial and documentary evidence, the Court is compelled to conclude that the Eighth Amendment’s restraint on using excessive force has been repeatedly violated at Pelican Bay, leading to a conspicuous pattern of excessive force. In many instances, there was either no justification for the use of force, or alternately, the use of force was appropriate, but the amount of force applied was so strikingly disproportionate to the circumstances that it was imposed, more likely than not for the very purpose of causing harm, rather than in a good faith effort to restore or maintain order. Although this pattern was probably more pronounced during the initial years of the prison’s operation (and prior to the prosecution of the instant class action), the Court is satisfied that it continues to exist. Plaintiffs’ experts forcefully opined that the level of force used at Pelican Bay is well beyond the norm of any facility with which they are familiar. Nathan, for example, testified that “Pelican Bay State Prison exists in a very different universe.... [I]n 18 years of involvement with a number of the most repressive and unlawful prisons in the United States, I have never observed ... the level of officially sanctioned unnecessary and excessive force that exists at [Pelican Bay].” Nathan Deck at 12. As previously noted, the risk that force will be misused is considerably enhanced when prison administrators fail to implement adequate systems to regulate and monitor its use. Plaintiffs have demonstrated that such a failure occurred at Pelican Bay, and that it substantially contributed to the development and persistence of the pattern of excessive force. Finally, the evidence shows that the pattern of excessive force, and the lack of adequate systems to control it, are not simply the result of inadvertence, genuine mistakes in judgment, or good faith efforts gone awry. Rather, they are attributable — not only to defendants’ deliberate indifference— but also their knowing willingness that harm occur. The Court agrees with Nathan’s observation that “the use of unnecessary and excessive force at [Pelican Bay] appears to be open, acknowledged, tolerated, and sometimes expressly approved.” Nathan Deck at 12. We divide our factual findings concerning the use of force at Pelican Bay into three parts: (1) findings regarding the pattern of excessive force at Pelican Bay, (2) findings regarding the lack of adequate systems to regulate and control the use of force, and (3) findings regarding defendants’ state of mind. 1. Pattern of Excessive Force a. Sampling of Evidence of Use of Excessive Force The evidence pertaining to excessive force was not limited to one area of prison life. Rather, the record shows that excessive force was used in a variety of circumstances and settings, from staff assaults on inmates to punitive cagings under harsh conditions. Together, these strands of evidence weave a picture that reflects not just isolated indiscretions, but a pattern and practice of excessive force. The Court does not attempt to address every incident of excessive force that was raised at trial, in plaintiffs’ experts’ declarations, or in the documentary evidence; rather what follows is a sampling of the evidence concerning the use of excessive force in different contexts. (1) Staff Assaults on Inmates Inmate Castillo On January 31, 1991, Arturo Castillo refused to return his food tray in protest against a correctional officer (“officer”) who had called him and other inmates derogatory names. After leaving the tray near the front of the cell, Castillo retreated to the back and covered himself with his mattress for protection, in anticipation of a cell extraction. It is undisputed that Castillo, who is small in stature, made no verbal threats or aggressive gestures. Nor did he possess, or pretend to possess, any kind of weapon. Shortly thereafter, Sergeant Avila- warned Castillo that if he did not give up his food tray, it was going to be very painful. Castillo refused to hand Avila the tray, stating that if they wanted the tray, they would have to come and get it. The supervising lieutenant then authorized his sergeants to forcibly remove Castillo from the cell. To accomplish this removal, two rounds from a 38 millimeter gas gun were fired into the cell. A taser gun was also fired, striking Castillo in the chest and stomach. Then, without attempting to retrieve the tray (which remained near the front of the cell), some number of officers entered the cell, walked past the tray, and advanced toward Castillo. Castillo testified that one of the officers then hit him on the top of his head with the butt of the gas gun, knocking him unconscious. When he regained consciousness, he was on the floor with his face down. An officer was stepping on his hands and hitting him on his calves with a baton, at which point Castillo passed out a second time. When he regained consciousness again, he was dragged out of the cell face down; his head was bleeding, and a piece of his scalp had been detached or peeled back. At that point, it became clear that Castillo had been seriously injured, and he was taken to the infirmary and then to the hospital by ambulance. According to the incident report, Castillo sustained his head injury when he fell and accidentally hit his head on the toilet during the incident. Trial Exh. P-1100 at 4099. Lieutenant Trujillo, who was present at the time, also testified that he saw Castillo “falling forward” and heard a “loud bang” and “somebody saying that he hit the toilet.” Tr. 21-3638. We do not, however, find defendants’ explanation of the injury credible. First, Trujillo’s testimony loses much of its force since he never actually saw Castillo’s head hit the toilet even though he was “looking into the cell during the entire cell extraction.” Tr. 21-3638-41, 3667-68. Nor did he recall seeing any blood on the toilet. Second, Castillo’s credible testimony was unequivocally corroborated by Sergeant Cox, who observed the entire episode. Cox, who Trujillo admits “had a clear view” of the extraction, Tr. 21-3646, testified that he witnessed another sergeant “hit [Castillo] in the head with a 38 millimeter gun, by the butt of the gun.” Tr. 15-2330. Cox further testified that he was “basically ... ordered to keep my mouth shut and leave the area.” Tr. 15-2334. In addition, plaintiffs’ medical expert, Dr. Ar-mond Start, gave unrebutted testimony that Castillo’s head laceration was more likely the result of a high-velocity accelerated blow to the head than of a collision with a blunt, stationary object, particularly given that the injury occurred on the top of the head. Start Deel. at 242. The record contains no evidence that would support the conclusion that striking Castillo on the head with a gun, with enough force to render him unconscious, was needed to retrieve the food tray, restore order, or otherwise protect the integrity of the institutional mission. Indeed, the fact that the supervising officer made no attempt to ascertain whether the food tray could simply be taken from the front of the cell, but instead immediately resorted to gas guns and tasers, reflects a pattern of using the maximum, rather than the minimum, amount of force necessary to accomplish a goal. Finally, the fact that officers continued to beat Castillo after he was subdued and unconscious further supports the Court’s inescapable conclusion that Castillo was subjected to the use of excessive force that was imposed, not in a good faith effort to restore order or maintain security, but maliciously for the purpose of causing pain and inflicting punishment. Inmate Richard Richard, a general population prisoner, was working in the prison’s optical lab in October 1991 when a disturbance erupted between some of the other inmates in the lab. There is no dispute that Richard, of slight build, was a victim rather than an aggressor in this incident. He received some minor injuries from another inmate, including a laceration on his left cheek from a scissors, screwdriver or similar instrument. It is undisputed that Richard did not assault any staff in this incident. When he was subsequently placed in a holding cage, an officer informed him that he was rumored to have assaulted another officer during the incident. Richard denied the rumor and told him that other staff could verify that he was only defending himself from attack. Shortly thereafter, Officer Bray entered Richard’s cell, grabbed his handcuffs, and took him to an adjacent counselor’s office. There, he shoved Richard into a large table, on which Richard struck his face. Richard testified that while he was bent over the table, with his hands cuffed behind his back, Bray repeatedly struck his head, particularly on the side of the face where he already had the laceration. It is undisputed that Richard was not resisting at this time. Bray then dragged Richard onto the floor where Bray continued the assault while another officer held Richard’s legs. Richard testified that, despite his repeated denials that he had attacked anyone, Bray continued punching him about the head and neck, and continued to assert that Richard had assaulted another officer (who also happened to be a friend of Bray’s). At one point, blood started shooting out of Richard’s mouth, but the punches continued. He was then taken back to the holding cell, after the blood was washed from his face. During this incident, other officers watched but made no effort to intervene. After experiencing two days of intense pain and inability to chew, Richard was allowed to go to the infirmary, and he was subsequently informed that he had a fractured jaw. Five days later, he was taken to a hospital, and he spent the next six weeks with a wired jaw in the Pelican Bay infirmary. Prison officials later suggested that Richard had fractured his jaw in the optical lab incident and not at the hands of Officer Bray. The Court again finds that this version of events entirely lacks credibility. First, immediately following the lab incident, Richard was taken to the infirmary and given an entire body check for wounds, which included an examination of the inside of his mouth; however, the medical report indicates only that Richard sustained a laceration on his cheek, a scrape on the top of his left thigh and a small abrasion on his right elbow. Trial Exh. P-3084 at 79958. Second, the prison’s Chief Medical Officer later expressed the opinion to investigators that an attack with scissors or other similar instrument, like the one suffered by Richard in the optical lab, would not likely have caused a fractured jaw. Trial Exh. P-3084 at 79885. Further, Captain Jenkins testified that, in the course of investigating the incident, the officers involved made inconsistent statements which led him to believe that they were not being truthful about the incident. Tr. 3-360-61. He expressed concern that he was facing a “code of silence” problem, particularly because he felt that the correctional officers’ union was suggesting that the officers “play their cards pretty close to the vest.” Tr. 3-361-2. Based on the above, the Court finds that Richard was beaten about his head and neck, and suffered a broken jaw, as punishment for an officer’s belief that Richard had assaulted another member of the staff. Given the severity of the injury, and the undisputed evidence that Richard neither provoked nor resisted Bray, the Court finds that Bray’s use of force was not only excessive, but also completely unnecessary and inflicted for the purpose of causing pain rather than in a good faith effort to restore order or maintain security. Inmate Martinez This incident was precipitated when Martinez spit at Officer Parson and threw his meal tray through the narrow food port, striking Parson. A short time later, correctional officers returned and ordered Martinez to submit to mechanical restraints before being removed from his cell. When Martinez refused, and shielded himself with a mattress and/or blanket, the officers fired tear gas and nine 38 millimeter gas gun rounds. When this did not subdue Martinez because of the shields, a team of officers, including Parson, then entered the cell. Although Martinez was combative, kicking and striking with fists, he was ultimately subdued. Louie Lopez, another inmate, was able to observe subsequent events. He credibly testified that he observed Martinez, then handcuffed, emerging from the cell and being thrown against the wall. At that point, “he was out [i.e. seemingly unconscious]. He wasn’t moving.” Tr. 1-68. Lopez then observed officers kicking Martinez’ head, face, neck and shoulders, and saw a lot of blood. One of the control booth officers on duty also told the investigating officer that once Martinez was out of the cell, he was restrained and under control, yet an officer whom the booth officer could not identify had kicked Martinez in his upper shoulder or lower head area, after which someone said, “that’s enough, knock it off!” Trial Exh. P-8083 at 79053. He also confirmed that other inmates on the tier could see what was happening and that they were yelling, “you can’t kick a guy in the head like that.” Trial Exh. P-3083 at 79052. As a result of this incident, Martinez lost four teeth, received a 1.5 inch laceration to the back of his head, and suffered abrasions to the head, face, back, neck, chest and both legs. The Court finds that the level of force used against Martinez was not motivated by a good faith effort to restore order or maintain the security of the prison. Rather, the extraction was prompted by the desire to punish or retaliate against Martinez for spitting on an officer and striking him with a food tray. Moreover, even assuming that Martinez strenuously resisted during the initial part of the extraction, this furnishes no justification for the continued use of force after Martinez was subdued and no longer resisting. Such use of completely gratuitous force evidences a malicious intent to inflict injury rather than a good faith effort to restore order. Inmate Ward Kenneth Ward testified that one morning he refused lunch, which led to a heated verbal exchange with a female correctional officer (Officer Reynoso). Ward, who used profanity during the exchange, continued to be verbally abusive to Reynoso at other points during the day. The next morning, Ward was awakened by Officer Kelly who had returned with Reynoso. Kelly told Ward he was being moved. Ward did not at first understand what Kelly had said, so he stood up. He saw Kelly standing with a “smile on his face, and [saying] ‘you like disrespecting my old lady, huh?”’ Ward swore at both officers. Kelly responded that he would move Ward to a cell “in [Kelly’s] block” with “somebody your [own] size.” Ward Tr. 2-219. When Ward protested, Kelly returned with Sergeant Rowland and three other officers. Rowland threatened Ward with a cell extraction and ordered him to “cuff up.” Ward Tr. 2-220. Ward eventually turned his back to the cell door and put his hands through the small food slot (approximately four to five inches high and 12 inches long) to be cuffed up. Ward’s trial testimony and the officers’ deposition testimony about what happened next dramatically conflict. According to Ward, one of the officers grabbed his arm and twisted his wrist upward, causing Ward enormous pain. When he couldn’t take the pain any longer, he jerked his hands back inside the cell and accused them of trying to break his wrist, to which an officer again responded with a threat of a cell extraction. Ward then again placed his hands through the food port, at which point Kelly immediately jerked his left arm through the small slot all the way up to his tricep while Rowland grabbed the other arm. Ward then pulled his right hand back into the cell and bent down to try ,and ease the pain. At this point, Kelly repeatedly threw his body weight against Ward’s left arm. It is undisputed that as a result, Ward’s upper left arm snapped and broke. Ward immediately became lightheaded and he felt a lot of pain. He recalls that he felt as if he were in shock and was unable to move. As a result of this injury, Ward has suffered recurring problems with nerves in arms, including numbness and spasms. Officers Rowland and Kelly did not testify at trial, but the Court has been provided with their deposition transcripts. Officer Rowland does not dispute that he heard a loud snap, after which Ward stopped struggling immediately, although Officer Kelly, who actually broke Ward’s arm, denies hearing any snap. Both officers do, however, state that the amount of force used was necessary and appropriate because Ward was resisting being cuffed up, and was attempting to pull an officers’ arm into the cell. Officer Kelly testified that when he tried to cuff Ward up the first time, Ward pulled on his thumb, which resulted in a sprain to his thumb and his wrist and some abrasions. Officer Rowland stated that it was better to gain control of the inmate in the manner they did than to have to send in a cell extraction team. Even assuming that Ward was resisting in some fashion, we are convinced, by the weight of the evidence, that the force used was employed, at least in substantial part, for the purpose of inflicting pain and not for good faith security-related reasons. Several factors inform this finding. First, it is un-contradicted that the sheer amount of force required to break Ward’s arm was “enormous,” in the words of plaintiffs medical expert Dr. Armond Start. The Court itself observed that Ward has a well-developed physique. The sheer amount of force that would be needed to break Ward’s arm suggests that excessive force was used. The context also suggests that such force was probably unnecessary. The officers were not facing the threat of any immediate, serious injury, given that Ward was confined inside his cell, with his back to the cell door and his hands through a narrow food port. Even if Ward offered some struggle, there is no indication that the officers made any effort to end the incident by less violent means. In short, there is no convincing basis for concluding that the degree of force used was necessary to protect either the officers involved or any other person. There are certainly instances where, in the heat of the moment, officers may use more force than intended. Such a case would suggest that the officers did not act with punishment in mind. Here, however, the manner in which Kelly and Rowland executed the cuff-up procedure — severely twisting Ward’s arm and using enormous pressure — and their openly hostile attitude demonstrate an intent to do Ward some harm. Thus, although they may not have known that the precise level of force used would be sufficient to break Ward’s arm, they clearly used unnecessary force with a knowing willingness that harm occur. It is also significant that the circumstances leading up to the incident provided Kelly with a motive for retaliating against Ward. All too often, the evidence showed that inmates suffered serious injuries after providing an officer with some provocation, such as spitting, name calling, or refusal to obey a minor order. Inmate Cooper In this incident, an officer struck inmate Cooper twice with a closed fist in the head at a time when he was offering no resistance. Cooper was being escorted, in handcuffs and leg irons, by several officers from the Facility D Program hallway. When Cooper began resisting and kicking, Officers Plumlee and Bettencourt leaned against Cooper’s legs and forced him against the wall. At this point, two other officers both observed that Cooper was under control and unable to kick, but that Officer Plumlee nonetheless proceeded to punch Cooper twice in the face with a closed fist. An internal investigation concluded that Plumlee had hit Cooper twice on the left side of his face with a closed fist, which is also consistent with a subsequent medical report, which indicated contusions to the left chin, left cheek, and mid forehead, a black eye and a small cut above the eye. Trial Exh. P-3087 at 77542. Although Officer Plumlee defended his punches as being simply “reflexive,” the Court finds that the record, overall, does not support his position, given the eyewitness reports of the other officers and the fact that there were two punches thrown. We further find that punching Cooper at a time when he was restrained and under control constituted a gratuitous and unnecessary use of force that was imposed not for any security related purpose but for the purpose of inflicting pain. Inmate Dortch Vaughn Dortch, a mentally ill inmate, suffered second-and third-degree burns over one-third of his body when he was given a bath in scalding water in the prison infirmary. The week before the incident Dortch bit an officer. Dortch had also created a nuisance by smearing himself and his cell with his own fecal matter. Although there was a shower near Dortch’s cell, which would have provided a more efficient method of cleaning Dortch than a bath (even assuming Dortch was uncooperative), the officers instead forcibly escorted Dortch to a bathtub in the SHU infirmary, located some distance away in another complex. According to Barbara Kuroda, the nurse on duty at the infirmary, a Medical Technical Assistant arrived shortly before Dortch, and was asked if he “want[ed] part of this bath,” to which he responded, yes, he would take some of the “brush end,” referring to a hard-bristle brush which is wrapped in a towel and used to clean an inmate. Tr. 1-144. Five or six correctional officers then arrived with Dortch. Although a nurse would normally run the water for a therapeutic bath, Dortch’s bath was managed solely by correctional staff. Kuroda later observed, from her nurse’s station, that Dortch was in the bathtub with his hands cuffed behind his back, with an officer pushing down on his shoulder and holding his arms in place. Subsequently, another officer came into the nurse’s station and made a call. Kuroda’s unrebutted testimony is that she overheard the officer say about Dortch, who is African-American, that it “looks like we’re going to have a white boy before this is through, that his skin is so dirty and so rotten, it’s all fallen off.” Tr. 1-154. Concerned by this .remark, Kuroda walked over toward the tub, and saw Dortch standing with his back to her. She testified that, from just below the buttocks down, his skin had peeled off and was hanging in large clumps around his legs, which had turned white with some redness. Even then, in a shocking show of indifference, the officers made no effort to seek any medical assistance or advice. Instead, it appeared to Kuroda that the officers were simply dressing Dortch to return him to his cell. When Kuroda told them they could not return him in that condition, Officer Williams responded, in a manner described by Kuroda as disparaging and challenging, that Dortch had been living in his own feces and urine for three months, and if he was going to get infected, he would have been already. Williams added, however, that if Kuroda wanted to admit him, she could do the paperwork. Dortch then either fell, or began falling, to the floor from weakness, at which point Kuroda had Dortch taken to the emergency room. Although Dortch was not evidencing any pain at this point, Kuroda testified that this did not surprise her. Because severe burns destroy the surrounding nerve endings, the victim does not experience any pain until the nerves began to mend. Dortch was ultimately transported to a hospital bum center for treatment. Based on the record before us, we can not say that any of the staff involved in the incident specifically intended the severity of the burns inflicted upon Dortch. It is unclear whether the officers knew the actual temperature of the water or the full extent of the burns that were being inflicted. Nor did Dortch yell out in pain to alert the officers. On the other hand, officers were observed holding Dortch down in the tub, and the burns he was experiencing must have been visible. Although we assume, for purposes of this ease, that those involved did not intend to inflict third-degree burns, it is nonetheless clear, from all of the surrounding circumstances, that Dortch was given the bath primarily as a punitive measure and for the purpose of inflicting some degree of pain, in retaliation for, and perhaps out of frustration with, his prior offensive conduct. Inmate Brown In this incident, John Brown was taken from his cell in full restraints when a staff member observed, and later reported to internal investigators, that Brown was kicked in the face by another officer in the presence of a Lieutenant, Sergeant, and acting Program Administrator. There is no evidence that he was struggling or resisting at the time. In an interview with investigators, Brown also stated that he had been kicked in the head three or four times while being carried in restraints. Trial Exh. P-3085 at 776601-02. The medical report, which is consistent with being kicked in the face, notes an abrasion on the right side of his face and a % inch cut on his chin. Id. at 77638. The fact that Brown was kicked in the face for no apparent reason, while he was fully restrained, leads us to conclude that this force was applied maliciously for the purpose of causing harm rather than to restore or maintain security. (2) Use of Fetal Restraints The fetal restraint, also known as “restraint control status” or “hog-tying,” is a particular type of in-cell restraint. Utilized numerous times until late 1991 or mid 1992, the fetal restraint procedure involves handcuffing an inmate’s hands at the front of his body, placing him in leg irons, and then drawing a chain between the handcuffs and legs until only a few inches separate the bound wrists and ankles. At least one officer, however, handcuffed inmates in the back, so that the inmate’s arms were behind his back and his ankles were up around his handcuffs. The fetal restraint was applied most commonly in response to an inmate kicking his cell door, although it was utilized on other occasions as well. Plaintiffs’ medical expert confirmed inmate testimony that being in this position without the ability to stretch one’s legs or arms would, over time, likely cause considerable pain, and could pose a serious health risk to inmates with respiratory ailments. Thus, unlike four- or five-point restraints, which completely prevent any disruptive movement without imposing pain or health risks, fetal restraints can inflict significant pain and yet not fully secure the inmate. Notably, no expert at trial defended the use of fetal restraints. Plaintiffs’ expert described such restraints as a painful, repugnant, humiliating punishment, and termed their level of use at Pelican Bay “unprecedented” in modem corrections. Martin Tr. 18-1351 Defendants’ expert Daniel McCarthy testified that he had never previously used or seen anyone use a fetal restraint in his forty years in the California Department of Corrections, and did not believe that it would be an acceptable technique. Defendants’ other expert, Larry DuBois, also stated that he had never used a fetal restraint and that he had not been asked to express an opinion regarding its use. The testimony of Mark Jones, which was not refuted at trial, provides but one example of an inmate’s experience with fetal restraints at Pelican Bay. On one occasion, Jones repeatedly kicked his cell door to get the attention of the control booth officer, in an effort to get him to close the door to the exercise pod, which was letting in cold air. In response, he was put in fetal restraints for five hours. Another time, Jones attempted to call up to the control booth officer to find out why the television in his cell was not working, but was ignored. When he tried again later that day, and was still ignored, he started kicking the cell door to get attention. About 10 or 15 minutes later, a sergeant and a few more officers went to his cell. Upon admitting that he had been kicking the door, he was put in his bunk in fetal restraint chains for approximately nine hours, from 1:00 p.m. to about 10:00 p.m. He was in pain after a while but eventually fell asleep. When he awoke, parts of his body were asleep. He attempted to spin around, but, unable to control his movements, fell off his bunk, hitting his back, head and shoulder on the floor. Officers who later' arrived to deliver Jones his regularly-scheduled medicine refused to remove the restraints, instead taunting him that he should “get up and get [his medicine].” In response, Jones got “kind of verbal.” Jones Tr. 3-521. Approximately one hour later, the fetal restraints were removed by another officer. On another occasion, following a verbal altercation between Jones and an officer over a book that had been confiscated, two officers handcuffed Jones and escorted him down the hallway, pulling him sideways at times. When Jones complained, one of the officers slammed Jones’ head into the wall, chipping his teeth. Jones was then taken to a holding cell where he was put in fetal restraints for four horn’s. In none of these instances is there any evidence that the fetal restraints, particularly for periods of four to nine hours, were necessary for security reasons. Rather, their usage evinces an intent to punish and inflict pain. Inmates restrained in fetal restraints were at times also chained to toilets or other fixed objects, particularly during program administrator Rippetoe’s tenure in the SHU. Although there is directly conflicting testimony regarding the extent of this practice, the Court finds that it was more than merely an occasional occurrence. Sergeant Cox testified credibly that during the limited period that he was working overtime in the SHU, he personally observed, over the course of different shifts, ten to twelve inmates who were in fetal restraints and chained to stationary objects. Some staff, including Sergeant Cox, objected to this practice, and one SHU program administrator testified that he “never ha[s] and never would” authorize such a practice. Lopez Tr. 14-2196. Sergeant Cox testified, however, that his objections were dismissed out of hand. When he asked Rip-petoe why they were engaging in this practice, he responded “because we can do it.” Tr. 15-2345. When he raised the issue with Associate Warden Garcia, he was told “this is Pelican Bay State Prison, and if you don’t like it, get out '... [W]e’re going to do it our way.” Tr. 15-2347. Prison records indicate that fetal restraints were used in dozens of instances between January 1990 and August 1992. Such restraints were imposed from anywhere between a few minutes to 24 hours, -with most instances falling in the three to six hour range. Current written SHU policies permit use of fetal restraints for up to 12.hours without obtaining consent of the Warden. Whether an inmate would be freed from the restraints in order to eat or use the toilet was left to the discretion of individual staff. At trial, defendants did not attempt to justify the fetal restraint as an appropriate response to the kicking of cell doors per se, although current SHU policy permits the use of fetal restraints for cell door kicking. Trial Exh. D-49 at 18307. Indeed, although cell door kicking is a common occurrence, no lay or expert witness was able to identify any other prison that resorted to fetal restraints in response. Rather, defendants testified that the use of fetal restraints for kicking doors was necessary because a weakness in the metal in the door retainer at the bottom of each cell made cell doors vulnerable to metal fatigue in the event of continued kicking. Various prison officials testified that they became aware of this problem when the prison opened (in December 1989), and that the practice of using fetal restraints stopped once the doors were fixed in December 1991. Integrity of cell doors is, of course, a critical security concern. However, we are not persuaded by the record that repairs to address the metal fatigue problem were not undertaken until late 1991. Although defendant Peetz testified that repair work on the cell doors occurred between approximately June and December 1991, it appears that these repairs primarily concerned another door problem involving the pneumatic locking mechanism, which was not discovered until sometime in 1991. Prison officials were extremely vague as to what was done and when to respond specifically ' to the metal fatigue problem. One SHU program administrator testified that work was done to reinforce the holding cells in the SHU (where inmates kicking their cells could be placed), and that this work probably took a “week or so.” Lopez Tr. 14-2199. He did not identify any time frame for this work. It is highly unlikely, however, that it was not done until 1991. As stated above, prison officials discovered the metal fatigue problem as early as December 1989 or January 1990. It is not credible that they would have waited until December 1991, two years later, to reinforce the holding cells, if in fact, metal fatigue presented a serious security concern. More fundamentally, however, we are not persuaded that the use of fetal restraints was necessary or primarily prompted by legitimate penological purposes. The “D” wing of the SHU and the “C” wing of - the SHU suffered from the same metal defect, and housed roughly the same number of inmates (physically the two wings are mirror images of each other). Yet, during the period that inmates in C-SHU were fetally restrained on dozens of occasions, fetal restraints were used in D-SHU less than 5 times. Given that defendants offered no basis for concluding that the inmates in D-SHU would be less likely to kick their cell doors than in C-SHU, this discrepancy in numbers is a compelling indication that the utilization" of fetal restraints was not necessary to maintain security. Moreover, fetal restraints did not even effectively prevent continued kicking of cell doors. As Captain Scribner agreed, it was “clear that if an inmate wanted to kick the door while he had his [fetal restraint] chains on ... he could do so,” and in fact it appeared to him that an inmate might end up kicking the door even harder after he was restrained. Scribner also testified that such an inmate could still get “enough of a kick” that he could compromise the integrity of the door. Scribner Tr. 7-1241, 6-1120. Indeed, it is clear that the continued ability to kick only escalated the need for more restraints, such that there was a practice, albeit relatively short-lived, of locking an already fetally-restrained inmate to his toilet — a practice which Lieutenant Carl agreed was in violation of governing California regulations. Carl Depo. at 291-92. The use of fetal restraints in response to the kicking of doors becomes particularly suspect when it is considered that a far more effective, yet less painful, alternative was available. As plaintiffs’ expert Steve Martin emphasized without contradiction, from a custody standpoint, the most effective means of preventing an inmate from kicking a cell door is to place him in full restraints: “you put a man in a four-point, five-point restraint, he’s not going to kick a door.” Tr. 8-1350. And, as noted above, full restraints accomplish this result without inflicting discomfort and pain. Nonetheless, there is no indication in the record that defendants ever considered full restraints as an alternative at any point between December 1989 and December 1991. In short, it is undisputed that the fetal restraint, which requires an obvious eontortion of normal body position, can cause considerable pain over time. It is also undisputed that this restraint failed to effectively prevent the kicking of doors, and that other more effective and less painful alternatives were available and known to defendants. Nonetheless, in one section of the SHU, fetal restraints were often the response of first resort to cell door kicking for a period of at least two years. We do not, and need not, find that every application of the fetal restraint at Pelican Bay was punitive in nature. Nor do we address the facial validity of the prison’s fetal restraint rule. However, the record and particular circumstances presented here convince us that there was a practice of using fetal restraints at Pelican Bay for solely punitive rather than good faith security purposes. (3) Cagings Another use of force at Pelican Bay that is punitive in character is the confinement of naked or partially dressed inmates in outdoor holding cages during inclement weather. These cages, approximately the size of a telephone booth, and constructed of weave mesh metal, are designed to provide a temporary holding place for an inmate, and are positioned at various locations around the prison. Inmates confined in the cages are exposed to the elements as well as public view. Violet Baker, a former educational program supervisor at Pelican Bay, gave a frank and credible account of one such incident. She testified that one day in late January or early February, she was walking from her office toward another facility. It was very cold (she was wearing gloves and a heavy jacket), and it was pouring rain. She observed two African-American inmates being held naked in two cages. When she passed by again one hour later, one inmate was still there, and she observed that he was covered with goose bumps. He said he was freezing, and asked her to request a pair of shorts and a T-shirt. She then saw an officer coming in her direction. When she looked at him, he looked back and just shrugged his shoulders, saying it was “Lieutenant’s order.” When she determined that it was Lieutenant Slay-ton on duty, she let the matter drop. Although the incident upset her, Slayton had a reputation for causing problems if crossed, and she did not want her educational program or teachers to suffer by her interference in this matter. In another such incident, inmate Johnny Barnes testified credibly that he was caged naked in one of the outdoor holding cages on a “misty” day. Although he was bleeding from his nose and mouth after a physical altercation with several correctional officers, Barnes was held in the outdoor cage for an hour and a half without receiving medical attention. In public view of whoever passed by, Barnes recalled that he felt like he was “just a[n] animal or something.” Tr. 10-1529. Lieutenant Slayton at first denied that there was “ever any occasion” when an inmate was held in a holding cell completely nude. Tr. 20-3363. However, he later testified that there were instances where inmates were briefly held naked in cages, but insisted that they were dressed as soon as possible. Providing inmates with clothes was a priority, he testified, because of the inclement weather, and because “it’s just a common dignity.” Tr. 20-3364. Clearly, there are times when prison officials will need to take an inmate’s clothes, as potential evidence after an incident, or for other justifiable purposes. And we agree with Lieutenant Slayton that providing substitute clothes is not only a matter of health and safety in inclement weather, but a matter of common dignity, given the public placement of the cages and the routine presence of female staff. However, his testimony that the inmates were never caged naked for more than brief periods lacks credibility in light of his inconsistent testimony on this point, as well as the credible testimony of Violet Baker and Johnny Barnes. Moreover, some of these cages are visible from the main administrative offices for the yard (including the Lieutenant’s office), and are in full view of anyone who crosses the yard. Thus, it is apparent that such naked cagings would be known to, and thus implicitly, if not explicitly, condoned by supervisory staff. Indeed, the incident to which Violet Baker testified was clearly ordered by mid-level supervisory staff, as opposed to a renegade officer. Such incidents may be relatively infrequent. Baker testified that she had never seen anyone naked in the cages except for that one day. However, as Martin observed, this is the type of incident that is not typically memorialized in reports, making it difficult to determine how often it occurs. Notably, neither of the above incidents were documented, which leads the Court to conclude that there likely have been other undocumented instances as well. The reaction of the correctional officer to Baker’s inquiry suggests that this was not considered an extraordinary or unique event. Leaving inmates in outdoor cages for any significant period — as if animals in a zoo — offends even the most elementary notions of common decency and dignity. It also fails to serve any legitimate penological purpose in any kind of weather, much less cold and rainy weather. The fact that it occurred at all exhibits a callous and malicious intent to inflict gratuitous humiliation and punishment. (4) Cell Extractions (i) Overview The forcible removal of an inmate from his cell — also known as a “cell extraction” — is indisputably an essential tool in maintaining security in any prison. There will clearly be occasions when security concerns mandate that an inmate be removed from his cell against his will, such as where the inmate is suspected of harboring contraband, or has had an altercation with a cellmate. Such a forcible removal can be accomplished by various means. Staff who are completely unarmed, or armed only with a mattress or shield, can use sheer weight and numbers to overwhelm the inmate. At the other extreme, staff can be highly armed, even during routine extractions, as is the case at Pelican Bay. Indeed, the cell extraction process at Pelican Bay is an undeniably violent maneuver which can involve several weapons, including 38 millimeter gas guns, tasers, short metal batons, and mace. It also results in frequent injuries and infliction of pain. As Chief Deputy Warden Peetz summed it up, “cell extractions are a very, very violent maneuver ... Inmates get hurt and staff get hurt, and it’s just the nature of the thing.” Tr. 20-3316. As such, witnesses for both sides agree that cell extractions should be performed only when necessary. Indeed, under normal circumstances, an inmate should not be extracted absent an imminent risk to the safety and security of the institution. Scribner Tr. 7-1211. (ii) Unnecessary use of cell extractions Notwithstanding the above, for over two years (until February 1992), the number of extractions at Pelican Bay prison was clearly greater than necessary to meet safety or security needs. Prison records show that for the period through February 1992, 205 inmates were eell extracted in 26 months, at a rate of approximately 94.5 per year. Fenton viewed such numbers as “seriously excessive,” Fenton Tr. 5-792, while defendants’ experts also acknowledged that the number of extractions the first two years was “relatively high,” DuBois Deck at 4-5, or “a little on the high side.” McCarthy Tr. 15-2472. A comparison with practices at the prison since February 1992 is particularly revealing. From that date through May 1993, a period of 16 months, only 26 extractions were performed, at a rate of approximately 1.6 per month or 19.5 per year. This constitutes a drop of almost 500 percent from the previous 16 months (October of 1990 through January of 1992), when 120 inmates were cell extracted at a rate of 7.5 per month or 90 per year. Defendants’ experts testified that the high rate of cell extractions prior to February 1992 simply reflected the normal starting pains of a new prison, as well as the need to remove inmates who were kicking their doors, given the security concerns regarding cell doors. If the number of cell extractions had declined gradually between January 1990 and May 1993, this first explanation would carry significant weight; the record, however, demonstrates that the number of cell extractions was fairly consistent over 1990 and 1991 and then dropped off significantly in February 1992. Nor are we persuaded that the door problems explain the high frequency of cell extractions. Only a small number of the total extractions were reportedly door-related, and defendants testified that door kicking was often addressed through the use of fetal restraints. Rather, the substantial reduction in extractions after February 1992 more likely reflected a change in policy. The Court further finds no indication that the safety or security of the institution was compromised by this change. As such, we agree with plaintiffs’ experts that the previous volume of extractions was unnecessarily high. This conclusion is confirmed by the fact that prior to February 1992, cell extractions — using the full arsenal of force described below — were frequently employed, not to address imminent threats to security, but to respond to relatively minor infractions. For example, inmates were subjected to full scale cell extractions, often resulting in significant injuries, for not promptly giving up a meal tray, a jumpsuit, a pair of tennis shoes, or a skull cap. Martin Decl. at 40-57. Many of these cell extractions were performed without any indication that the situation presented an imminent security risk. Clearly, defendants are entitled to enforce prison rules through normal disciplinary channels; inmates must be made to know that prison rules can not be ignored without consequence. However, in this case, it is clear that minor infractions were used as a pretextual justification for inflicting physical, and often brutal, punishment. (iii) High degree of force The mere fact that staff employs a procedure more often than necessary, may not, in and of itself, warrant serious concern. In this case, however, the unnecessarily high number of cell extractions in 1990 and 1991 takes on a much more troubling and ominous character given that these extractions routinely involved a strikingly high degree of force, and resulted in numerous injuries that were too often left unexplained by official incident reports. Based on the evid