Preet Bharara - Rikers Report II: A Broken System lyrics

We have identified several deficiencies relating to the Department's systems, staffing, operations, and management that contribute to the excessive and inappropriate staff use of force against adolescents and the high incidence of inmate-on-inmate violence. The Department must implement corrective measures to address these deficiencies to adequately protect the adolescent population from harm. See Fisher v. Koehler, 692 F. Supp. 1519, 1564 (S.D.N.Y. 1988) (“evidence of systemic failures” in preventing improper use of force at New York City jails “supports a finding of a ‘policy of deliberate indifference' as to staff-inmate violence on the part of defendants”). A. Inadequate Reporting of Use of Force Department staff fail to adequately document use of force incidents involving adolescents. The use of force reports we have examined are almost uniformly poor and contain many significant problems, including a general lack of detail, incomplete information, and internally inconsistent information. In addition, reports frequently do not provide an accurate account of the incident or the level of force employed, and fail to specify any resulting inmate injuries. Furthermore, despite DOC policies that require a use of force report from every officer involved in a use of force, as well as from every officer who witnesses a use of force by another officer, our investigation suggests that not all uses of force are documented and violence against inmates by staff is generally underreported. Use of force reports are critically important as they form the basis for staff accountability. If a use of force is not reported, or reported inadequately or falsely, then there is no reasonable basis for review of that incident and no appropriate method to hold staff accountable for the improper use of force. Because of the poor reporting of use of force incidents at Rikers, unnecessary or excessive use of force goes undiscovered and unchallenged. This, in turn, has resulted in a culture in which staff feel empowered to use force inappropriately, in ways that go outside the bounds of written policies, because they know they are unlikely to face any meaningful consequences. 1. Failure to Report Use of Force Pursuant to DOC's Use of Force Directive, all “[s]taff who employ or witness force or have been alleged to employ or witness force . . . shall prepare a written report concerning the incident based on their own observations and written independently from other staff that were involved or alleged to have been involved in the incident.” Furthermore, staff are required to prepare these reports “prior to leaving the facility unless medically unable to do so.” Despite this clear policy requirement, this rule appears to be frequently and intentionally ignored, especially if the use of force does not result in a serious injury. There is evidence that a powerful code of silence prevents staff who witness force from reporting. For example, staff will frequently report that they witnessed an inmate using force against an officer or resisting an officer, but then fail to note or describe the force the officer employed in response to the inmate—even when the officer himself has reported that he has used force. Similarly, officers frequently affirmatively state that they did not witness any use of force despite other evidence that suggests they were at the scene where force was used. Investigators and supervisors reviewing the use of force reports consistently fail to point out these and other obvious omissions and failures to conform the reports to DOC policy, reinforcing the perception of officers that it is not important to be forthcoming or complete in their reports. For example: In April 2013, an inmate sustained facial injuries and contusions to his left shoulder after an officer struck him multiple times in the intake area of RNDC. Video of the incident shows an officer standing idly by for several minutes just a few feet away. This officer did not submit a use of force witness report, and investigators noted that they would not have known he was even in the area had they not viewed the video. In February 2012, an inmate was beaten in the head by an officer in the RNDC school area. Three months after the incident, a different officer submitted a handwritten memo to the Warden, at the request of the Deputy Warden, describing the fact that he witnessed the first officer using “control holds” to gain control of the inmate, and that he was standing by to provide a**istance if needed. The investigating Captain's report found that the use of force was justified and included no mention of this officer witness's failure to submit a use of force witness report at the time of the incident. The Tour Commander and the Warden, who concurred with the investigating Captain's conclusion, also did not reference the officer's failure to report the incident. The incident was never referred to the Department's Investigation Division, and the officer witness was not disciplined for his failure to submit a timely use of force report. We also have identified a pattern of correction officers failing to complete reports for comparatively “minor” uses of force. A correction officer a**igned to EMTC described several incidents to us that she alleged were never written up as use of force incidents, including slapping and hitting adolescent inmates to get them to stop talking or stop playing around in school. We also reviewed an incident where an officer failed to submit a use of force report after she had hit an inmate with handcuffs to wake him up while he was sleeping in cla**. The incident only came to light because the same officer similarly a**aulted another inmate, and that second a**ault led to a more serious altercation, which ultimately led to a full investigation by the Investigation Division. (This incident, referred to as involving Inmate H, is described in further detail in the Appendix.) This failure to document “minor” uses of force was also noted by the inmates themselves. During an interview with our consultant, an inmate observed that officers “slap, hit, and punch” adolescent inmates regularly, but only report a “use of force” when there is a serious beating. Additionally, in some cases, officers and supervisors pressure inmates not to report, using a phrase that is widely used and universally known at Rikers: “hold it down.” This expression is code for, “don't report what happened.” Inmates who refuse to “hold it down” risk retaliation from officers in the form of additional physical violence and disciplinary sanctions. A DOC Associate Commissioner acknowledged the underreporting of use of force by officers, noting that it would be “disingenuous” to claim that it doesn't exist. The head of the Investigation Division also acknowledged the problem. A senior DOHMH official told us that he also was very familiar with the phrase, “hold it down,” and conveyed his belief that adolescents were often instructed not to report incidents. He indicated that one of the reasons inmates might agree to “hold it down” was that if inmates do not report a use of force, they themselves were then less likely to be infracted and disciplined. The official expressed concerns that inmates might not receive needed medical treatment for injuries caused by staff uses of force if pressured not to report the incident.22 In addition, the official believed that some injuries reported to be the result of alleged slip and fall accidents in fact involved unreported use of force, based on the unusual frequency of slip and fall accidents and the serious nature of the injuries that allegedly resulted from them. For example, buried in the medical file of an inmate brought to the clinic for treatment of a one-centimeter laceration on his ear after a reported slip and fall is a note that the patient “claims he was hit in the left ear with cuffs,” although the incident was not reported as a use of force. In interviews with dozens of adolescent inmates, our consultant found that violence ranging from casual and spontaneous to premeditated and severe is often accompanied by the officers warning inmates to “hold it down.” According to our consultant, this phrase was familiar to almost every inmate he interviewed, as well as inmates he spoke with informally as he toured the jails. The warning may come from officers immediately following a beating, or sometimes days or weeks after an incident. Officers may even delay taking inmates to clinics for medical attention as they try to convince them to “hold it down.” If the inmate indeed “holds it down” and declines to report a use of force, the staff also then do not report it. The following are a few of the examples described by inmates to our consultant: An inmate reported that he was punched and stomped on by several officers in a school corridor after verbally insulting one of them during an argument. He asked to go to the medical clinic, but the officers refused to take him there, giving him tissues to clean himself up and telling him to “hold it down.” The inmate also described another incident in which officers beat him, injuring his arm. They refused to take him to the clinic for medical care until he agreed to tell the clinic that he hurt his arm playing basketball. He agreed to that story, and as far as he knows, the use of force was never reported. An inmate stated that he got into an altercation with an officer after fighting with another inmate. Although he got 70 days in punitive segregation for fighting with the other inmate, a Captain told him he would not get any additional days for fighting with the officer if he didn't report that fight or discuss the situation. After a severe beating by multiple officers, an inmate was taken to a holding cell in intake and told by officers to “hold it down” while medical care was delayed for more than an hour. He eventually was taken to Elmhurst Hospital for medical treatment. He refused to “hold it down,” and in fact filed a civil lawsuit against the Department, which settled before trial. (Incident is referenced supra at 18 and described in further detail in the Appendix, referred to as involving Inmate D.) An inmate stated that when he asked staff for medical attention after being raped by an officer, he was told not to say anything about the incident. He reported it anyway, and told our consultant that after doing so, staff continually hara**ed him. In fact, the inmate reported to our consultant that he was warned by two officers not to say anything about the incident as he was being taken to speak with our consultant while our investigative team was at Rikers.23 During our site visit, we observed another example of staff exerting pressure on inmates to remain silent. As an officer was bringing an inmate to our consultant for an interview, our consultant heard the officer tell him that he didn't have to tell our consultant “no damn story.” Finally, there is evidence suggesting that non-DOC staff, such as medical staff and teachers, also fail to report witnessing use of force, due in part to fear of retaliation from DOC uniformed staff, who prefer they look away when staff are using force against inmates. According to a senior DOHMH official, medical staff have faced retaliation for reporting injuries that they suspected were the result of staff uses of force. We were advised of an incident where a medical staff member reported that the reason she had witnessed an inmate being beaten was that, because she was new, she did not know she was “supposed to go to the back” of the clinic during such incidents. In addition, while DOC policy requires that mental health staff attempt to obtain inmates' cooperation to leave their cells in order to avoid forced cell extractions, mental health staff routinely leave the housing areas after doing so and before the cell extractions take place. While this is partly to avoid injuries to medical staff, a DOHMH official admitted that this practice also protects mental health staff from witnessing the actual extraction. There are also indications that teachers at the schools on Rikers, where as discussed above a disproportionate amount of violence against adolescents takes place, are told to look the other way when inmates are being beaten so as not to be a witness. During an investigation of an incident in the RNDC school area, one teacher told an investigator that when a use of force incident occurs, Department of Education staff “knows [sic] they should turn their head away, so that they don't witness anything.” In connection with the same incident, another teacher told an investigator that she tried not to watch officers beating the inmate for the same reason, despite the fact that she could hear the inmate screaming and crying for his mother. That teacher also tried to keep other inmates in the cla**room away from the window so that they would not witness anything either. The admission by two teachers that they had been instructed or trained to witness nothing did not appear to surprise the investigator who made no particular note in the investigation file. (This incident, referred to as involving Inmate H, is described in further detail in the Appendix.) Indeed, we reviewed many incidents involving use of force in the RNDC school area, but very few of the investigative files included witness statements from a teacher. In the rare instances where the file included a statement, teachers most often reported that they did not see anything. 2. Inadequate and/or Falsified Use of Force Reports Pursuant to DOC's Use of Force Directive, a written report regarding a use of force incident must include a “complete account of the events leading to the use of force,” a “precise description of the incident,” “the specific reasons” force was necessary, “the type of force” used, and a “description of any injuries sustained by inmates or staff.” Rikers staff routinely fail to meet the standards set forth in this policy when completing use of force reports. One of the many failures of the reports is a lack of detail sufficient to determine what actually happened, including why force was necessary and what injuries resulted. Reports frequently provide a generic description of the incident often using boilerplate terminology that appears designed to justify the use of force. For example, rather than providing a complete and detailed description of the events leading up to the use of force, and exactly how the encounter unfolded, staff will simply report that an inmate “failed to respond to a direct order and became aggressive,” that they “defended” themselves from the inmate, that they used “one two second burst of OC spray,”24 and that they “told the inmate several times to stop resisting.” Staff also rarely identify inmate injuries in their incident reports, and investigators and supervisors consistently fail to note this glaring and repeated omission. Furthermore, our review of use of force reports has detected certain patterns that strongly suggest staff engage in false reporting. These patterns include: Use of force reports in which staff allege that the inmate instigated the altercation by punching or hitting the officer, often allegedly in the face or head and for “no reason,” “out of nowhere,” “spontaneously,” or “without provocation.” But then the officer has no reported injuries—no lacerations or fractures or even minor bruises or swelling—that would be commensurate with such blows. While unprovoked a**aults by inmates on staff certainly may occur, according to our consultant, they are rare in other jurisdictions. This pattern of an allegation by a correction officer of an unprovoked attack by an inmate, with no commensurate officer injury, suggests that staff are justifying their own use of force by falsely accusing inmates of hitting them first.25 Use of force reports in which staff report using only limited physical force, such as control holds to subdue the inmate or “guide” him to the floor, while the inmate's injuries suggest a much greater level of force was used. For example, the inmate sustains injuries to the face and head that are consistent with blows to the head. This pattern suggests that officers are falsely reporting that the force they used was less severe than it actually was. In an interview, a senior DOHMH official noted that jail medical clinic staff have observed inmate injuries that are inconsistent with the officers' explanations of what occurred and how the inmate became injured, and our own review of medical records in conjunction with use of force reports bears this out. Use of force reports in which staff report injuries to their own hands, but do not report punching or hitting inmates, again describing the force used as something more innocuous such as “control holds” or using OC spray. Again, this pattern suggests that officers are falsely reporting that the force they used was less severe than it actually was. Use of force reports submitted by multiple officers regarding the same incident in which similar or even identical language is used to describe the incident. This similar or identical language could be a single unusual word, or an entire paragraph repeated virtually verbatim across reports. This pattern suggests collusion among officers to tell a particular story and/or to cover up the actual facts of a particular incident. In an interview, an EMTC correction officer confirmed what the pattern of similarly worded reports suggests, namely that staff work together to cover-up the facts of incidents and to ensure that they provide consistent written accounts. The officer told us that in her experience, Captains often tell officers what to write in their reports, and that officers understand that their reports must match the report of the Captain. The officer referred to one instance when she was told that someone else would write a report for her regarding a use of force that she witnessed, although she never saw or signed any such report. Use of force reports in which the description of an incident is inconsistent with the video recording, and officers later provide an addendum to their report or change their story when confronted with the video evidence. Again, this pattern suggests that officers are simply falsely reporting the force they used. The following are just a selection of the many examples of these patterns that we identified: After an incident outside the dining hall in January 2013, the Captain who repeatedly had punched an inmate reported that the inmate had “continued to resist by flailing his arm and moving his body about in [an] attempt to avoid being cuffed.” However, this was contradicted by the video surveillance. In a supplemental report prepared almost two weeks after the incident, the Captain acknowledged that the inmate “placed his hands by his head” while on the ground and explained that he had not mentioned that in his initial report “[d]ue to the inmates [sic] odd behavior and the adrenaline flowing.” (This incident is also referenced supra at 16 and described in further detail in the Appendix, referred to as involving Inmate L.) After a December 2012 incident, an officer reported that during a pat-frisk an inmate “without provocation” punched him in the face, causing him to defend himself by punching the inmate in the face. The inmate told our consultant that he never hit the officer, but instead that the officer hit him after he made a snide remark. Although the officer went to the hospital for treatment, medical notes indicate that his face appeared normal with no swelling or bruising. After an incident in November 2012 in the RNDC school area, officers reported only guiding an inmate to the floor and using a “one two second burst of OC.” However, the inmate sustained facial bruising and swelling on the nasal bridge. Ten days later, the inmate was still complaining of pain, and medical staff recommended an x-ray to rule out a nasal bone fracture. After a cell extraction in September 2012, officers reported only that they had pinned an inmate to the wall and applied force to his upper torso and legs. However, medical reports show that the inmate had pain in his right and left jaw, swelling of his right jaw, as well as swelling and pain behind his left ear and redness of the left ear can*l. Such injuries cannot be explained by the force the officers reported using. In this same incident, multiple officers used a nearly identical phrase in their use of force reports, describing the way the inmate “twisted and turned away from the bed.” Other officers used an identical sentence to explain why force was used, citing the use of force policy regarding the need to “defend oneself or another from a physical attack.” After a May 2012 incident in the EMTC school area, an officer reported that an inmate threw several punches to the officer's face and neck area without warning. Although the officer claimed injuries to his hand and shoulder, he had no injuries to his facial area. (This incident, referred to as involving Inmate E, is described in detail in the Appendix.) 3. Failure to Use Video to Augment Use of Force Reporting: Loss of Video and Poor Video Recordings of Anticipated Use of Force Video recordings are extremely useful tools for reviewing use of force incidents, evaluating staff and inmate statements, and determining whether the use of force was appropriate. Indeed, the Department relies heavily on video recordings in those instances where correction officers are actually charged and disciplined for excessive or inappropriate force. The head of the Investigation Division noted, for example, that video evidence is critical in cases of excessive or inappropriate force because that is the evidence that is most clear cut. As discussed above, several areas in the jails where adolescents are housed have no camera coverage whatsoever. Additionally, critical videotapes frequently go missing. As noted above, we requested all relevant records, including video surveillance, for approximately 200 use of force incidents. Of the incidents in our sample that were captured by the video surveillance, the Department advised us that it had lost or was otherwise unable to locate over 35% of those video recordings. Many investigative reports also note that although video was recorded, the video evidence cannot be located. The missing video surveillance is alarming, given that the Department has a specific policy requiring any video recording of a use of force or alleged use of force to be retained in the office of the Deputy Warden for Security for no less than four years, as well as detailed procedures for documenting the chain of custody for any such recordings. The frequency with which video evidence disappears either indicates an unacceptably blatant disregard for the Department's policies regarding the safeguarding of video evidence, or even more disturbingly, possible tampering with important evidence. Another concern is the poor quality of some of the video recordings that do exist. By policy, staff are required to film cell extractions, probe teams deployments, and other situations where use of force is anticipated. There is a detailed policy requiring the videotaping of all cell extractions, from start to finish, including a requirement that the videotape show the extraction team's attempts to gain the inmate's compliance before force is used. However, based on our review of incidents involving anticipated uses of force, the videotape is often shot poorly such that the use of force is not clearly visible and other important information is not captured. The failure to properly videotape these incidents is particularly concerning given the frequency with which probe teams and cell extraction teams are involved in incidents where excessive and unnecessary force is allegedly used. B. Inadequate Investigations into Use of Force The Department's investigations into use of force by staff against adolescent inmates are inadequate at both the facility level and the Investigation Division (“ID”). Pursuant to Department policy, the facility (e.g., RNDC) is generally responsible for conducting an initial investigation into use of force incidents, and most incidents are not subject to any further review. Certain incidents, such as those involving serious injuries, may trigger a full investigation by the ID. As discussed below, the criteria for when the ID must investigate an incident appears unclear, and less than one-fifth of the adolescent use of force incidents and allegations in 2012 were subject to a full ID investigation. In addition to performing full investigations, the ID also conducts a limited review of a sample of facility-level investigations to a**ess their quality. Finally, use of force incidents of particular concern may be referred for an investigation by New York City's Department of Investigation, a separate city agency. Reviews and investigations of use of force incidents are critically important because they are the means by which the Department is able to determine whether its own use of force policies are being followed and to evaluate the adequacy of staff reporting of incidents. Rigorous investigations, conducted with integrity, are a key part of any system that intends to hold staff accountable for their actions, and thus prevent future abuses. Our investigation has found the systemic failure of the investigative process at Rikers to be one of the central reasons for the widespread use of excessive and unnecessary force against adolescent inmates. The Department's failure to conduct thorough and comprehensive use of force investigations has resulted in a system where staff are frequently not held accountable for policy violations, and expect that their version of events will be accepted at face value with little scrutiny. 1. Inadequate Investigations at the Facility Level Facility-level investigations are conducted initially by one of the Captains within the facility where the incident took place, then reviewed by a Tour Commander and an Assistant Deputy Warden and/or Deputy Warden for Security, and ultimately approved by the Warden. The a**igned investigating Captain cannot be the Captain who was supervising the officers involved in the use of force at the time of the incident. Because the majority of use of force incidents will never be reviewed by the ID or the DOI, this investigation by the facility is the sole Departmental review for most use of force incidents. These investigations are grossly inadequate. The facility rarely finds that force has been used inappropriately, and nearly always concludes that force was justified and in accordance with Departmental policy—often despite evidence to the contrary. Based on our review of facility investigation files, we found the investigations to be cursory and identified the following common and systemic deficiencies: A general bias toward accepting staff's version of an event at face value, even where there is medical or other evidence to the contrary, and discrediting the inmate's account. Failure to consistently follow up with staff regarding obvious deficiencies in their use of force reports. As discussed above, these deficiencies may include accounts that are inconsistent with reported injuries to the inmate or the involved officers, accounts that fail to explain why officers did not or could not have used a lesser level of force, and suspiciously similar statements and language in descriptions of incidents. Failure to identify and reconcile material discrepancies between statements from involved officers, staff witnesses, reported injuries, and video surveillance (when available). Failure to make sufficient efforts to obtain statements from inmates, including the inmates subject to the use of force and inmate witnesses. Although we realize that inmates may be reluctant to talk to uniformed officers due to fear of retaliation, we were struck by the frequency with which facility investigative packages state that inmates refused to provide statements, especially given how openly inmates have discussed incidents with our consultant, medical staff, and even ID investigators. Where video exists, failure to describe the events on the video. Often there is just a summary statement that the video was reviewed and consistent with officers' use of force reports. Because video recordings so frequently go missing, as described above, without an accurate and detailed description of the video recording, there is no longer any objective record of the incident. The Captains a**igned to investigate incidents at the facility level do not receive specialized training in investigative techniques, and show little familiarity with basic investigative sk**s or procedures. In most investigations, Captains and Tour Commanders simply summarize the use of force reports provided by the officers involved, and the witness statements provided by other correction officers and inmates (if any). Finally, due in part to an antiquated system that relies on handwritten statements and the physical transfer of paper folders and files from one desk to another, there is often a backlog of use of force packages awaiting final approval, notwithstanding Departmental policy that use of force investigations be completed within 15 days of the incident. This almost inevitably contributes to pressure on a facility's top management to give each use of force package little more than a cursory review, making it easier for correction officers to conceal misconduct. 2. Lack of Clarity Concerning What Triggers ID Investigation It is unclear what criteria are used for referring an incident to the ID for a full investigation—both in terms of how a determination is made as to which cases merit further investigation and who makes those determinations. The criteria for involvement by the DOI in any particular incident are also ambiguous. The lack of transparent lines of responsibility for investigations undermines the effectiveness of the investigative process, and creates the risk that particularly troubling incidents may escape the rigorous and comprehensive review they merit. The policies regarding when the ID investigates an incident, as well as key officials' understanding of these policies, are inconsistent and contradictory. According to the Use of Force Directive, “the facility is responsible in the first instance for investigating all uses of force.” This suggests that the ID becomes involved only after the facility has completed its own investigation of a use of force. But other Departmental policies, as described in the ID Training Manual and in interviews with Department officials, specify that ID investigates in the first instance all Cla** A uses of force, and allegations of Cla** A uses of force.26 Written policies also specify other situations in which an ID investigation is mandatory, such as allegations that inmates were dissuaded from reporting force. The ID also appears to have the authority to open a full investigation whenever it deems it appropriate to do so. The facility officials we interviewed, including RNDC Deputy Wardens and the now former RNDC Warden, indicated they also have the discretion to refer any use of force to the ID, which may then “take over” an investigation. Responsibility for investigation of headshots illustrates some of the confusion in this area: although the head of the ID told us that her division handles investigations involving alleged headshots, it is clear that many such incidents are subject only to facility-level investigations. Further complicating matters, the Department operates an Intelligence Unit (“IU”) that also conducts investigations into matters such as inmate-on-inmate fights and violence. Although these incidents often lead to use of force by staff, and thus could have overlapping witnesses and evidence, the extent to which IU investigations are coordinated with facility investigations or ID investigations is unclear. Finally, some incidents are referred to the DOI, or the DOI may on its own “take over” an investigation. According to written policies, the DOI broadly investigates “corruption or other criminal activity . . . or other misconduct within the Department of Correction.” Although we believe it is important to have a watchdog agency outside the Department review use of force incidents that are of particular concern, there do not appear to be clearly established criteria concerning the types of investigations that require external review, nor is it clear how incidents are brought to the attention of the DOI. The ambiguity surrounding when incidents are subject to investigations by the ID and/or the DOI is magnified by the Department's failure to implement an effective case management tool to track all pending and completed use of force investigations. The Department does not appear to have a single centralized system for tracking information on all use of force investigations and findings, including whether the facility, the ID, or the DOI (or some combination of these entities) investigated an incident, the date the investigation was commenced and completed, whether the investigating entity ultimately determined that force was used appropriately, and any resulting discipline of the correction officers involved. 3.Inadequate Investigations by the ID While we found ID investigations to be marginally more professional and sometimes of better quality than facility-level investigations, we nonetheless found that they suffer generally from the same bias in favor of correction officers and against inmates. The extraordinarily high number of use of force incidents appears to overwhelm the review and investigative capacities of the ID. The unit has an insufficient number of investigators to effectively review and investigate the use of force incidents at over a dozen DOC jails, especially given that these same individuals are also responsible for investigating other types of alleged staff misconduct and policy violations, including inmate disturbances, discovery of dangerous contraband, erroneous discharges, and serious injuries. During an interview, the head of ID acknowledged that her front line investigators have extremely high caseloads that impeded their ability to conduct expeditious investigations. Because the Department's investigative functions are overwhelmed in this way, they have become largely ineffectual and staff accountability for excessive or inappropriate use of force is greatly diminished. a. Poor Quality of ID Investigations The ID investigations suffer from numerous problems. We found several instances where the ID concluded that staff's use of force was appropriate despite evidence suggesting otherwise or without conducting a comprehensive and rigorous investigation. Although ID investigations are conducted by trained investigators and are superficially more thorough than facility investigations, as noted above, they nonetheless are plagued by the same biases as the facility investigations, which affect the entire investigative process. Despite lengthy investigations, ID investigators frequently fail to reconcile contradictory statements or reports, usually defaulting to the staff version of events. While the ID has the ability to compel interviews of DOC staff, and usually does so, investigators often fail to ask obvious questions about deficiencies in staff reports or inconsistencies in their accounts. Additionally, investigators often fail to interview all the relevant witnesses, especially inmate witnesses. When they do interview inmates, ID investigators too frequently fail to credit their version of events, even when the inmate's account is more consistent with the medical records or other evidence. Finally, the ID disregards or is selective about the policy violations that it chooses to note in its reports—from failure to safeguard video and failure to submit timely use of force reports, to false reporting and excessive use of force—sometimes recommending no charges at all despite substantial evidence of one or more policy violations. The following are just a few examples of some of these common problems: The ID conducted a full investigation of an incident in April 2012 in which an inmate alleged that he was beaten in the head by multiple correction officers at the behest of a female Captain in the RNDC school area after a heated argument with the Captain earlier that day. The inmate provided a detailed account to the ID, describing two officers and the Captain by name. The Captain who the inmate alleged ordered the beating claimed she was not in the area during the incident. However, a preliminary ID report describes video showing a female Captain going up to the school area before the incident and then coming down from the school area with the probe team that removed the inmate from the area. The final ID report includes a much shortened description of this video and omits the fact that a female Captain went either into or out of the school area. The ID apparently made no attempt to find out where the Captain was at the time of the incident or who was with her. The ID also did not interview or otherwise obtain a statement from one of the officers named by the inmate as participating in the beating, nor did the ID interview the probe team members to ask whether the Captain was present when they arrived. Additionally, the one officer who admitted using force made inconsistent statements in his use of force report and to ID investigators, which he explained away by saying he had been “dazed” by the incident and thus forgot to include certain details, although he never submitted a supplemental report. The ID nonetheless credited that officer's account that the inmate had punched him first, and concluded that the use of force was appropriate. No charges were recommended and the case was closed. (This incident, referred to as involving Inmate A, is described in further detail in the Appendix.) The ID conducted a full investigation of an incident in February 2012 in which it concluded that an officer had inappropriately sprayed an inmate with OC spray during an argument, when the inmate was clearly not a threat to the officer at the time. The officer had stated in both her written use of force report and during her interview that the inmate had threatened her with a weapon, but the video showed that the inmate was actually turned away from the officer and in the process of putting on a sweatshirt when he was sprayed. Another officer witness also submitted a use of force witness report containing information that the video showed was false, but the ID did not interview that officer. While the ID recommended that charges be brought for unnecessary use of force, the ID did not recommend that any charges be brought for submitting false use of force reports or making false statements to investigators. The ID conducted a full investigation into a May 2011 incident in which an inmate was beaten by officers in the RNDC school area and suffered two broken front teeth, a lip laceration that required sutures, and additional facial swelling, contusions and abrasions. Despite the fact that the officer previously had been involved in 45 separate use of force incidents, two of which resulted in charges, the ID investigators credited the officer's report that the inmate had struck the officer in the face with a closed fist “without any warning,” requiring him to defend himself by striking the inmate in the face and upper torso. During an interview, the officer later added the fact that when he brought the inmate to the floor he brought him down face first and fell down on top of him, which the ID investigator believed was a possible cause of the broken teeth. The ID investigator also failed to obtain written statements from or interview any of the probe team members who responded to the incident, and did not interview the one other officer who submitted a use of force witness statement, whom the inmate had alleged joined the first officer in beating him and kicking him in the mouth. Although the incident took place in school during school hours, there is also nothing in the file that suggests that any inmates or teachers were interviewed about the incident. No charges were recommended and the case was closed. b. Untimeliness of Investigations ID investigations are not completed in a timely manner. Written policies state that DOC must maintain an eight-month average for completion of ID investigations of Cla** “A” uses of force, but that every effort must be made to complete investigations within five months. However, according to the Department, in the first part of 2013, the average completion time for Cla** A use of force incidents was just over 9 months (278 days). In addition, as of October 31, 2012, 11 percent of ID's cases had been open for more than 350 days, and 42 percent of ID's cases had been open for between 151-350 days. We also found several examples of ID investigations into particularly serious incidents that took well over a year to complete. The ID's investigation into an incident involving an inmate who suffered a nasal fracture when an officer punched him in the face was not completed until 14 months after the incident. (This incident is also referenced supra at 15 and described in further detail in the Appendix, referred to as involving Inmate C.) The ID's investigation into the use of force following an inmate fight—in which inmates alleged that a correction officer had hit them with a baton while they were lying handcuffed on the ground and one inmate suffered a laceration that required eight sutures on the back of his head—was not completed until 15 months after the incident. The ID did not request the use of force package from the facility until more than two months after the incident, and did not even interview the officer involved until nine months after the incident. The ID's investigation into an incident involving an inmate who was beaten by multiple officers in the RNDC school area was not completed until 16 months after the incident. (This incident is also referenced supra at 22 and 24 and described in further detail in the Appendix, referred to as involving Inmate H.) The ID's investigation into an incident involving an inmate who suffered lacerations to the face and head after an encounter with officers was not completed until 18 months after the incident. The ID's investigation into an incident involving an inmate who suffered a broken tooth and laceration of the lip when an officer punched him in the face was not completed until 20 months after the incident. The two key officers involved in the incident were not interviewed by the ID until 16 months after the incident. (Incident is also referenced supra at 27-28 and described in detail in The Appendix, referred to as involving Inmate E.) This undue delay diminishes the quality of the investigations because, as time pa**es, witness memories fade and evidence becomes less available. This is especially true at Rikers where the inmate population is transient, and witnesses may in fact be released or transferred to the state prison system long before an investigation is completed. Moreover, in the relatively few instances where officers are found to have violated policy, they are not subject to any disciplinary measures until long after the misconduct. c. Superficial Review of Facility-Level Investigations As discussed above, in addition to conducting full investigations of certain incidents, the ID is responsible for performing limited reviews of some facility-level investigations to ensure the facility has conducted an adequate investigation and reached appropriate conclusions regarding the use of force. The ID claims that it conducts this type of “facility-review” for all Cla** B28 use of force allegations, all Cla** B and Cla** C29 incidents involving headshots, instances where “substantive or procedural issues” have been detected, and/or when litigation is anticipated. And yet despite the serious and widespread problems with the facility investigations identified by our consultant, the ID frequently concurs with the facility's findings without noting deficiencies that should be obvious to trained investigators. Accordingly, while ID's facility review process should be playing a critical oversight role, there is minimal accountability for the poor quality of the facility-level investigations. The ID's insufficient review of a deeply flawed facility-level investigation into an incident in January 2012 is particularly illustrative. This incident, briefly referenced above, supra at 15, occurred after an inmate splashed an officer in a housing area. The officer activated her alarm, and the probe team arrived, secured the inmate, and put him in restraints. After the inmate had been handcuffed, the officer approached the inmate and began to punch him in the face. The probe team Captain ordered the officer to stop punching the inmate, and another correction officer needed to physically pull the officer off the inmate, at which point she punched that officer and also punched the wall in anger. Another officer submitted a witness report alleging that the officer's punches did not actually connect with the inmate. The investigating Captain submitted a report the next day concluding that the officer's use of force was “unjustified,” and submitted another, more detailed report a few days later noting that the officer's use of force was “not necessary, inappropriate, and excessive.” However, the Tour Commander ultimately concluded that the use of force was necessary, noting that the video was consistent with that finding. When the ID reviewed the facility investigation and requested to view the video, the facility reported that the video had been lost. Although the ID reminded the facility that it must retain video of critical incidents for four years, the ID concluded that the facility's investigation was satisfactory. Our consultant found the ID's conclusion to be astonishing, given that the facility had concluded that the use of force was “necessary” and “within policy” despite the fact that two officers (including the probe team Captain) had submitted reports stating that the officer had punched an inmate who was in handcuffs, and was so out of control that she also had hit a fellow officer. C. Inadequate Staff Discipline The Department fails to adequately discipline staff for using unnecessary or excessive force against adolescents. Because most investigations conclude that staff have not violated DOC policies, often despite evidence to the contrary as discussed above, staff are rarely disciplined for using unnecessary or excessive force. And in those relatively rare cases where a facility or ID investigation results in a determination that staff used inappropriate force, the disciplinary sanctions are minimal. As a general matter, we found that the most frequent disciplinary response by the Department is to “counsel” a correction officer or send him or her for “re-training.” Between January 1, 2011, and May 23, 2013, a total of 356 staff from RNDC underwent a 3-hour use of force re-training course. Sometimes when initial investigations do find violations of policy, charges are recommended, but not brought, and therefore never result in any actual disciplinary action. Some examples of this include the following: The Tour Commander who conducted a facility investigation recommended, based on his review of the video and medical evidence, that a correction officer be charged with excessive force for striking an inmate on the head, and failing to report a use of force. However, the Deputy Warden and Warden did not concur with the Tour Commander's recommendation, finding that the force used was minimal and within Departmental guidelines. It is unclear whether the incident was ever pa**ed on to the ID for further review. Similarly, in the incident described supra at 15 and 35-36 in which an officer struck an inmate in the face while he was in handcuffs (and then struck another officer), the investigating Captain found the use of force to be unnecessary and excessive. However, the Tour Commander and Warden disagreed, the ID declined to open a full investigation, and the officer was thus not subject to any disciplinary action. In other instances where the Department found clear violations of use of force policies, the sanctions were not at all proportionate to the seriousness of the offense. We found instances where staff misconduct was so egregious that, according to our consultant, in many correctional systems it would have warranted immediate termination—such as beating an inmate who was already restrained or using force and failing to report it—and yet significantly lesser sanctions were imposed. Examples of staff discipline that was not proportionate to the offense include the following: An investigation into an August 2012 incident found that the officer threw a closed fist punch to the inmate's facial area while the inmate was in handcuffs and another officer had him in control holds. The facility Warden recommended that the a**aulting officer forfeit 20 vacation days. The supervising Captain, who watched the entire incident, was “counseled” for “fail[ing] to be proactive with regard to his supervisory duties.” (This incident is also referenced supra at 18.) An investigation into a May 2012 incident found that the inmate's allegations that the officer slapped him on the head were correct. Review of video showed one officer slapping the inmate's head as he stuck it out of a food slot, with another officer watching. The officer who slapped the inmate submitted a false report in which he said he guided the inmate's head back into his cell. The other officer submitted a report in which he said he did not witness any use of force. The Department accepted negotiated plea agreements from both officers for loss of 18 vacation days and loss of 20 vacation days, respectively. An investigation into an April 2012 incident found that although the inmate was being disruptive, he posed no immediate threat. The officer nonetheless struck the inmate in the head to gain control of him. The officer was charged with failing to use conflict resolution sk**s and failing to notify a supervisor before using force. The officer was sent for re-training. An investigation, including a review of video, into a February 2012 incident found that a correction officer “without provocation” pushed an adolescent inmate into a wall, and then pushed him into his cell. The officer failed to report the use of force, falsely reporting that his feet became tangled with the inmate's feet and they both tripped. He was charged with using force and failing to report it. He was counseled and penalized one “owe[d] comp day.” As noted in the first example cited above, while Captains or other supervisors are sometimes cited for ineffective or inadequate supervision, they do not appear to be held accountable in any real way for the actions of the correction officers under their command. In his review of use of force incidents and disciplinary records, our consultant found no instances where Captains or other supervising officers were held accountable for the actions of the officers they supervised with sanctions equal to or more severe than those received by the officers. Additionally, some officers with histories of involvement in staggering numbers of use of force incidents have remained at RNDC for years, in continuing close contact with adolescents. Rather than intervene in any meaningful way and consider transferring the officer to non- adolescent housing, the Department's practice is too often to “counsel” such officers in an interview.30 Based on our review of DOC records, we identified four officers who had been involved in between 50 – 76 use of force incidents at RNDC over the six-year period from 2007 – 2012, and another seven officers who had been involved in between 20 – 35 use of force incidents at RNDC over the same six-year period.31 The officer with the highest number of uses of force during the six-year period (76) was disciplined only once during this time; most of the others were disciplined once or twice, and some never. Finally, the Department does not appear to have a functioning early warning system for identifying and intervening with those officers involved in critical incidents with unusual frequency. An appropriate early warning system is an important management and accountability tool that allows for early intervention by alerting a facility to a need for additional training, insufficient policies, supervision lapses, or possible bad actors. D. Inadequate Cla**ification System for Adolescents An adequate and effective inmate cla**ification system is a fundamental management tool to ensure reasonably safe conditions in a correctional facility. The primary purpose of a cla**ification system is to house inmates based on their different levels of need and security risk. Inmates should be cla**ified promptly after their admission into the facility, and then re- cla**ified as necessary during their incarceration. A cla**ification system utilizes various objective factors to determine the appropriate custody level for an inmate. The Department, which revised its cla**ification system in 2012, now uses three custody levels—minimum, medium, and maximum. The Department utilizes the same cla**ification system for adolescents and adults. A cla**ification tool designed for adults can lead to inappropriate results when applied to youth. The system may not be “sensitive to the unique attributes and behaviors of youthful populations.” Department of Justice, Bureau of Justice Assistance, Juveniles in Adult Prisons and Jails: A National Assessment at 65 (Oct. 2000). For instance, the maturity levels of 16- and 17-year olds will vary more than adults, and can be a significant factor in properly cla**ifying adolescent offenders. The Department's cla**ification system does not take into account certain factors that may be particularly relevant when a**essing the security risk or vulnerability of youth, such as the inmate's cognitive and emotional development and physical stature. Moreover, as further discussed below, a significant percentage of adolescents are a**igned to punitive segregation housing where inmates with different cla**ification levels are co-mingled. Finally, the Department does not make sufficient use of protective custody to ensure the safety of vulnerable adolescents. The deficiencies in the Department's cla**ification system contribute to the unsafe conditions in adolescent housing areas and increase the risk of inmate-on-inmate violence. E. Inadequate Inmate Grievance System The inmate grievance system is deficient, and may discourage adolescent inmates from reporting inappropriate use of force by staff. An inmate grievance system is an important element of a functional jail system, intended to provide a mechanism for allowing inmates to raise concerns or issues related to conditions of confinement to the administration. If viewed as credible by inmates, it can also serve as a source of intelligence regarding potential security breaches, including excessive force or other misconduct. At Rikers, inmate complaints regarding staff-on-inmate a**aults and staff-on-inmate verbal hara**ment are non-grievable by policy. This is quite unusual. In most correctional systems, such grievances, including complaints about lack of professionalism, are viewed as among the highest priority grievances by administrators, according to our consultant. Although the Department has a**ured us that inmate allegations of staff use of force are reported and investigated, the process for reporting such incidents, as well as to whom they should be reported, are unclear. The grievance system is also deficient in the way it handles emergency grievances where an immediate response is necessary, such as when inmates face an imminent threat to their safety or well-being—a common scenario for adolescents at Rikers. The grievance policy states that inmates with grievances requiring immediate attention should submit a regular grievance form to the Captain or Tour Commander, who is then supposed to forward the form to the grievance coordinator within one day. In some instances, one day may be too long for the inmate to wait. In other instances, there could be further delays because the grievance coordinator is unavailable or on leave. F. Inadequate Inmate Supervision The high rates of staff use of force and inmate-on-inmate violence are attributable in part to inadequate inmate supervision. The problem is not a lack of resources or too few staff. RNDC has a relatively high staff-to-inmate ratio when compared to other jails. As of early 2013, 778 correction officers were a**igned to RNDC, resulting in almost a one-to-one staff-to-inmate ratio. Instead, the problem is that many frontline RNDC staff have minimal corrections experience, fail to interact with inmates in a professional manner, and fail to adequately monitor the conduct of the challenging adolescent population. 1. Inexperienced Staff and Excessive Turnover RNDC is the first a**ignment for most new officers after they complete their initial training at the Academy. Indeed, 220 (or 90.9%) of the 242 correction officers who started working at RNDC during calendar year 2012 came directly from the training Academy. In addition, approximately 35% of RNDC correction officers had fewer than two years of experience in the Department as of early 2013. These green officers are placed into one of the most combustible environments at Rikers, ill-equipped to cope with adolescents who are often belligerent and suffer from a wide range of mental illnesses and behavioral disorders. As a result, inexperienced officers quickly resort to using violence as a means to control the inmates. Others may be intimidated and reluctant to a**ert their authority, which reportedly has resulted in instances where older and more dominant adolescents exercise significant control over adolescent housing areas. In short, the least experienced staff at Rikers are paired with arguably the most difficult inmate population to manage. Furthermore, and also not surprisingly, RNDC suffers from an unusually high rate of staff turnover. Correction officers are eager to escape the turbulent environment for a more tranquil facility. From January 2011 through April 4, 2013, 282 correction officers transferred out of RNDC, while 401 new correction officers were a**igned to the facility. The turnover level at the Captain level is similarly high. Thus, just as staff members may be developing some of the necessary conflict resolution techniques and interpersonal sk**s to effectively manage the adolescent population and curb violence, they leave for another facility. In June 2012, DOC instituted modest special a**ignment pay to attract and retain more experienced staff at RNDC. But this has made little difference, and RNDC continues to be plagued by excessive staff turnover.32 2. Lack of Continuity in Facility Management An an*logous lack of continuity among facility management also contributes to a cumulative leadership vacuum, making it difficult to institute and implement any meaningful reforms. One top administrator told us there had been eight Wardens over the past eight years at RNDC.33 The Warden is the most important leadership figure for staff in any jail. A Warden who is in place for only a short time may be less inclined to take responsibility for any past problems related to violence among or against inmates, including use of force, in his or her jail. The lack of continuity was also reflected in the RNDC Deputy Wardens, some of whom changed even between the dates of our two visits. The constantly changing leadership is exacerbated by inadequate supervisory continuity for frontline officers. Correction officers are supervised by different Captains depending on their shift a**ignment and schedules, as opposed to working a constant shift under the same Captain for an extended period of time. 3. Lack of Staff Professionalism A lack of staff professionalism exacerbates the volatile atmosphere in adolescent housing areas and contributes to the high level of violence. Although there are exceptions, the unprofessional demeanor of staff and supervisors is widespread and readily apparent. During our tours, we observed and heard staff yelling unnecessarily at inmates and using obscenities and abusive language. Supervisors did not react or reprimand the officers in any way. Numerous inmates told our consultant that staff are disrespectful and regularly scream, threaten, berate, and curse at them. Inmates noted that staff frequently insult them and use racial epithets, such as “n******g.” The RNDC Grievance Coordinator described the facility as simply a very “hostile” place. Staff also humiliate and antagonize inmates, which provokes physical altercations. For instance, one EMTC correction officer reported that staff have ordered adolescents to strip down to their underpants and walk down the dormitory hallway (referred to as “walking down Broadway”) when they misbehave. Inmates also complain that staff retaliate against them by spitting in their food, tossing their belongings, and depriving them of food, commissary, and recreational privileges. 4.Failure to Monitor Inmate Conduct The pervasive inmate-on-inmate violence is largely due to DOC's failure to adequately supervise adolescents. Staff cluster together on living units instead of interacting with inmates, and too often leave their a**igned posts. They frequently fail to closely monitor inmate conduct, and often do not intervene as necessary in order to prevent verbal disagreements from escalating. When physical altercations do occur, staff sometimes fail to intervene in a timely manner, exposing inmates to a significant risk of serious injuries. Several inmates informed our consultant that they were attacked when staff were not properly overseeing the area. One inmate told our consultant that he had witnessed multiple instances where officers allowed inmate fights to escalate by failing to intervene.34 Management has acknowledged deficiencies in staff supervision. For instance, after touring RNDC in January 2013, the RNDC Integrity Control Officer35 noted in a report that staff were “ignoring the obvious potential security issues.” She further noted that dayroom officers often stand in the entrance so that they can talk to the “B” post officer, rather than a**uming a position where they can better observe the inmates. Not surprisingly, dayrooms are a common site for inmate-on-inmate fights. The following examples illustrate how DOC staff fail to meet their obligation to protect youth from a**aults: In May 2012, an inmate was attacked by two other inmates while on his way back to the housing area from the RNDC school. According to staff who observed video surveillance of the incident, one inmate approached the other inmate from behind and punched him in the face. The first inmate threw the second to the ground and repeatedly punched him in the face and head. A third inmate then kicked the second inmate several times on his body, and he lost consciousness. According to the investigation file, no staff witnessed the a**ault even though it occurred during inmate movement. The correction officer on duty was counseled regarding the proper procedure for escorting inmates from school to the housing area. During an interview with medical staff, the inmate who was beaten stated that he had requested medical treatment after waking up, but was not taken to the clinic until about three hours later. The inmate sustained a broken tooth and a fractured jaw. In March 2012, an inmate was a**aulted by another inmate in an RNDC dayroom and sustained a broken jaw. The Incident Report makes no mention of any staff who observed or responded to the incident, although it was captured on video. The inmate who was attacked claimed that he previously had advised DOC staff that he felt unsafe and wanted to be transferred but his requests were ignored. The inmate required two surgeries and his jaw was wired shut. G. Inadequate Staff Training The training offered by the Department to correction officers a**igned to adolescent housing areas is deficient in several respects. 1. Use of Force Training Although the use of force training covers the basic components of the Department's policy, the curriculum is poorly designed and repetitive. The training is conveyed via a scripted lecture format, and lacks sufficient demonstrations, discussions, and role playing. A training program with more interactive exercises and examples of realistic scenarios presented through video training films would be far more effective and likely to better engage correction officers. Moreover, the training does not sufficiently focus on some of the most troubling practices at Rikers, such as headshots, false reporting, and painful escort techniques.36 Given the long- standing use of force problems at Rikers, we expected that the Department would have developed a more innovative and interactive training program by now. The remedial training for officers who violate the Department's use of force policies and procedures is the same as the standard in-service training. Such “re-training” is less likely to have a positive impact than a more specialized, focused, and rigorous program designed specifically for officers who already have engaged in improper conduct. 2. Training on Managing Adolescents The vast majority of RNDC staff, including supervisors, have no prior professional experience working with adolescents. However, until recently, DOC offered no comprehensive training on how to interact with and manage incarcerated youth, despite the dire need for such specialized training. Indeed, after reviewing an incident in late 2012 where an officer improperly utilized force against an inmate in response to a verbal disagreement, the RNDC Integrity Control Officer recommended that the officer receive counseling and wrote: “We have to set up some type of training to enforce to staff how to effectively deal with the adolescent population. Staff cannot continuously respond to the kids like they do their own. If this were an adult???????????” In 2013, DOC finally introduced a 12-hour in-service training program on adolescent development principles and practices, which was developed by the Youth Development Institute. Although a significant improvement, this training focuses too much on theory and adolescent research, as opposed to teaching appropriate responses to the challenging behavior of incarcerated youth. The materials do not adequately address the practical sk**s needed to manage the Rikers adolescent population or handle the serious challenges RNDC staff actually face. The training also offers few realistic examples. H. Management Deficiencies The Department's top management has failed to meaningfully address an organizational culture that tolerates unnecessary and excessive force, which has resulted in an environment in which adolescent inmates are at constant risk of serious harm. There is a fundamental disconnect between the Department's top administrators, who operate in a high-end corporate environment off Rikers, and the Department's uniformed staff, who spend their days interacting with a difficult inmate population in aging, decrepit, and grim jail facilities on Rikers. One result of this disconnect is widespread frontline noncompliance with use of force policies, and top administrators who appear, with some exceptions, to be out of touch with the systemic deficiencies in inmate oversight and management. Despite several well-intentioned and useful reforms implemented over the past two years, the Department has not initiated any comprehensive and effective efforts to address the key factors driving the high incidence of staff violence against adolescent inmates, including a general inclination to use force as a tool to control adolescents, a tendency to escalate rather than de-escalate potential incidents, an environment premised on fear and intimidation, a widespread and tolerated code of silence among staff, and inexperienced frontline staff inadequately trained to manage the challenging adolescent population. There is no question that the Department has a long and troubled history of staff use of force against inmates, which reinforces our finding of a deeply entrenched organizational culture that accepts violence as an inherent part of a jail environment. The Department has been the subject of six use-of-force related cla** action lawsuits brought by inmates and their advocates, starting back in the 1980s and continuing today with Nunez v. the City of New York, 11 Civ. 5845 (LTS)(THK), a cla** action alleging system-wide violations of inmates' constitutional rights. Four of the previous cla** actions focused on specific facilities, including the jail currently known as EMTC (Fisher v. Koehler, 83 Civ. 2128), the Bellevue Prison Psychiatric Ward (Reynolds v. Ward, 81 Civ. 101), the Brooklyn House of Detention (Jackson v. Montemango, 85 Civ. 2384), and the CPSU (Sheppard v. Phoenix, 91 Civ. 4148). The fifth cla** action, like Nunez, alleged system-wide constitutional violations (Ingles v. Toro, 01 Civ. 8279). All of these cases settled by either court-ordered or private settlement, instituting limited injunctive relief and certain reforms related to use of force practices and policies. In Nunez, which is currently in discovery, plaintiffs allege that any reforms that were instituted as a result of these cases were not sustained once those settlements and court orders terminated. In addition to these court cases, there have been several criminal prosecutions of correction officers, including those referenced supra at note 25, and a case in which two officers pled guilty in connection with events that led to the d**h of an adolescent inmate, Christopher Robinson, in October 2008. Robinson died from a punctured lung after he allegedly was beaten by other inmates for refusing to participate in “the Program,” a system of extortion among adolescent inmates that was reportedly operating at Rikers with the approval of correction officers. In an indictment unsealed on January 22, 2009, two officers were accused of enterprise corruption regarding the events that lead to Robinson=s d**h. At their arraignment, the a**istant district attorney reportedly told the court that there were “scores” of victims, and that “[the accused] turned the jail into almost a nightmare environment.”37 Bronx District Attorney Robert Johnson characterized the situation at the time as “turn[ing] a detention facility for adolescents into an incubator for violent criminal activity sanctioned by adults in positions of authority.”38 The officers were sentenced to two years in prison, and one year in jail, respectively.39 DOC management has had little success grappling with this violent legacy. During interviews and meetings both at the Department's Bulova headquarters and at the jails on Rikers and during tours of adolescent areas, our consultant was struck by the noticeable lack of presence of Departmental administrators and top managers in the facilities themselves. This lack of presence, including management's physical separation from the jails themselves, contributes to a broken organizational culture within the facilities that is largely defined by anti-inmate attitudes and a powerful code of silence. It also may contribute to a perception among uniformed staff, often repeated in statements made by the head of the correction officers' union, that civilian administrators don't understand how difficult their jobs are because they don't understand the reality of the situation on the ground in the facilities. Based on his years of experience working with and observing correctional facilities around the country, our consultant believes that this disconnect, in turn, may contribute to a culture among uniformed staff that both tolerates blatant violations of the Department's use of force policies and attempts to shield its rank and file from discipline for violations of those policies, based in part on a belief that they were crafted by people who do not understand what they deal with every day. ------------- Footnotes 22 According to the report prepared by DOHMH's Bureau of Correctional Health Services (discussed supra at n.20), 45 inmates (including adult inmates) reported in interviews that DOC staff interfered with their effort to seek medical treatment or otherwise retaliated against them after a use of force incident by, among other things, threatening inmates with violence or infractions unless they declined medical care or stated that the injures were due to something other than staff use of force. 23 The inmate's allegation that he was pressured not to report this incident also raises concerns under the Prison Rape Elimination Act, 42 U.S.C. § 15601 et seq., and the relevant DOJ implementing regulations. 24 Oleoresin Capsicum (“OC”) spray, commonly known as pepper spray, is a chemical agent that irritates the eyes and respiratory system of a target. 25 In July 2014, criminal charges were brought by the Bronx District Attorney's Office against a Captain and two correction officers for beating an adult inmate unconscious. The DOC staff members were charged both with felony a**ault and with felony charges in connection with preparing and submitting false “use of force” reports. In June 2013, criminal charges were brought against ten DOC staff members, including the former Assistant Chief of Security, two Captains, and seven correction officers, in connection with a severe a**ault on an adult inmate that resulted in multiple facial fractures. These DOC staff members also were charged with not only felony a**ault, but with felony charges related to their attempts to cover-up the attack by submitting false use of force reports and false use of force witness reports, in which DOC staff claimed the inmate attacked an officer first. While the inmates involved in these particular a**aults were not adolescents, the allegedly false information in the use of force reports in these criminal incidents is similar to the patterns suggesting false reporting that we found in our investigation. 26 According to the Department's Use of Force Directive, a Cla** A use of force is one which requires “medical treatment beyond the prescription of over-the-counter an*lgesics or the administration of minor first aid,” including lacerations, fractures, sutures, chipped or cracked teeth, or multiple abrasions and/or contusions. 27 In early 2014, DOC announced that the ID was going to add 26 staff positions. 28 According to the Department's Use of Force Directive, a Cla** B use of force is one “which does not require hospitalization or medical treatment beyond prescription of over-the-counter an*lgesics or the administration of minor first aid.” The “forcible use of mechanical restraints in a confrontational situation that results in no or minor injury” is also a Cla** B use of force. 29 According to the Department's Use of Force Directive, a Cla** C use of force is one that results in “no injury” to the staff member or inmate involved, and includes incidents where “use of OC-spray results in no injury, beyond irritation that can be addressed through decontamination.” 30 One officer was identified as having been “counseled” on October 18, 2012, then again on November 29, 2012, and yet a third time on December 12, 2012, with no escalating response from the Department. 31During calendar year 2012 alone, one officer was involved in 16 reported uses of force. 32 The incentive pay offered to correction officers willing to work in adolescent housing areas is equal to a 3% increase for the first year, and can reach up to 12% over a 4-year period. As of January 14, 2014, only 38 staff members had received “specialty pay” since it was introduced at RNDC. 33 In early 2014, after our on-site tours of the facilities and staff interviews, the Department once again appointed a new RNDC Warden. 34 In August 2013, 11 inmates and one correction officer reportedly sustained injuries during a large fight involving adult inmates in GRVC. This incident was captured on video that was obtained by ABC News and posted on its website. (http://www.huffingtonpost.com/2013/08/22/rikers-island-prison-fight-video_n_3799160.html). Although there were numerous staff members at the scene, none intervened while inmates fought and threw chairs and other objects at each other. According to ABC, the incident continued for more than one hour. 35 The Integrity Control Officer is charged with overseeing the extent to which staff comply with Department policies and procedures. 36 The use of force training materials include an example that offers troublesome guidance to officers. In the example, an inmate is seated in an unauthorized area and refuses to comply with an order to return to his housing area. The inmate spits at the officer and states: “It will take more than you to move me.” The materials incorrectly indicate that these circumstances justify the use of chemical agents against the inmate. However, in such a situation, best practices require the officer to first seek to control the situation verbally by applying appropriate conflict resolution sk**s, according to our consultant. 37 Graham Rayman, Rikers Fight Club, The Village Voice, Feb. 4, 2009. 38 Press Release, Bronx District Attorney=s Office, d**h of an 18-Year Old Inmate on Rikers Island Last October Leads to Numerous Charges, Jan. 22, 2009, http://bronxda.nyc.gov/information/2009/case3.htm. 39 Elizabeth A. Harris, Corrections Officers Plead Guilty in Assault Case, N.Y. Times, Oct. 21, 2011.