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Furthermore, the BOP failed to inform complainants of the status of investigations into their allegations, despite being required to do so both by its own policy and the Consent Decree.

The report also found that “staff were not properly trained on what constitutes sexually abusive behavior” and that “staff are not equipped to provide trauma-informed care to sexual abuse survivors.”

The report found ongoing, widespread retaliation against class members. During the reporting period, there were 17 complaints of staff retaliation. In a troubling pattern, the report noted a “noticeable trend of Class Member complaints regarding staff member retaliation and subsequent receipt of disciplinary incident reports, followed by extremely harsh penalties.”

It further found that many individuals who reported misconduct faced harsh discipline in return, with little transparency or due process. Some of the harshest consequences included isolation, loss of good time credit, and transfers far from family and legal support.

Class members also continued to face serious barriers to accessing medical and mental health care. The monitor reported that “Class Members experienced significant delays in accessing care, in part due to systemic understaffing,” and that “BOP also has no system currently for recording, tracking, and auditing the requests for medical care, or for monitoring the provision and quality of care, leaving Class Members extremely vulnerable.”

Among the findings were delays in treatment for chronic illnesses, failures to follow up on changes to prescriptions, limited access to specialty care, and an “overreliance on commissary medications and unwillingness to utilize prescription medications.” For indigent individuals, this meant going without basic over-the-counter medications, such as pain relievers, if they could not afford them.

In several cases, the report identified retaliatory and discriminatory behavior by medical providers. Class members reported being told by healthcare staff that they “should feel lucky they are getting care since they are illegal aliens or criminals,” or that they “should not expect special care because they are from Dublin, and no amount of ‘whining to lawyers’ will get them care.”

In assessing this issue, the Monitor found that “it is not clear that front line providers have retained professional independence, and there appear to be instances when facility protocols or directives outweigh clinical professional judgment.”

The report described “widespread, long wait times for essential medical devices, including, but not limited to prescription glasses and dentures,” with an average wait time of nine to ten months for glasses—“which is both unacceptable and does not meet community standards.”

Mental health care services were similarly deficient. Although the report acknowledged “substantial compliance” with initial mental health screening alerts, it noted that those screenings often failed to result in effective or timely care.

In particular, class members in need of individual therapy “are not receiving this care and instead are in group programming even when clinically indicated,” which the Monitor noted “can be threatening and re-traumatizing” for survivors of sexual abuse or those with serious mental illness.

Translation services are also rarely utilized, resulting in inadequate care for class members who do not speak English. The report observed that “mental healthcare is not consistently performed in the patient’s primary language.”

In an especially troubling practice, the report noted that BOP uses incarcerated people to monitor other incarcerated individuals on suicide watch. The Monitor found this “problematic due to the lack of confidentiality,” a concern long raised by advocates and mental health professionals.

The Bureau also failed to fully comply with requirements surrounding the use of solitary confinement, known as Special Housing Units (SHU). The report found that in April alone, ten class members were placed in isolation, many of them in violation of the Consent Decree’s due process safeguards.

In multiple cases, individuals were placed in SHU without proper medical or mental health screenings, and without being given necessary medication or assistive devices. In several instances, their charges were later expunged. The Monitor’s team was often unable to evaluate compliance because BOP failed to provide required documentation.

Disciplinary practices were a particular area of concern. The monitoring team reviewed 965 disciplinary incident reports issued at FCI Dublin between January 2020 and May 2024. Of those, 571—or 59 percent—were found to have such serious errors that they had to be expunged.

“Class Members were subjected to disciplinary segregation, credit losses, and loss of privileges,” the report found, all of which affected their security classifications and eligibility for early release. “There appears to be a systemic failure, by BOP, to ensure that imposed discipline is applied consistent with BOP policy and within constitutional mandates.”

The consequences of these erroneous reports have been significant. As one advocate from the California Coalition for Women Prisoners noted in a statement, “In addition to unwarranted punishments and solitary confinements, these expunged charges represent weeks and months of improperly extended incarceration for each affected person. In the aggregate this adds up to more than 10 years of freedom stolen from the class members by prison staff.”

The Monitor also found that BOP had failed to comply with key provisions of the Consent Decree related to the release and transfer of class members. Many individuals continue to be held far from their families.

One class member was kept at a transfer center for over a month, despite federal statutes and decree provisions requiring timely placement. Other class members lost time credits due to transfers from Dublin—credits that BOP was required to restore. The report noted that “BOP staff inappropriately den[ied]” community placements for noncitizen class members with immigration detainers, in clear violation of federal law and the Consent Decree.

The findings confirm what many advocates and survivors have long insisted: that the abuse at FCI Dublin was not an isolated breakdown, but a symptom of broader institutional dysfunction and neglect. The report makes clear that the Bureau of Prisons continues to fall short of meeting even basic constitutional and statutory obligations toward the people in its custody.

Senior Monitor Wendy Still is expected to issue additional monthly and quarterly reports over the next two years, until the Consent Decree’s enforcement period expires. The full April 2025 report is available to the public and can be accessed on the court docket in California Coalition for Women Prisoners et al. v. United States Bureau of Prisons et al., Case No. 4:23-cv-04155-YGR.