Houston Forensic Science Center INTER OFFICE MEMO To: Lori Wilson, Director, Quality Division ,7 {?y/7H7 From: Jerry Pe?a, Director, Crime Scene, Digital/Multi-Media Division la?bv?YIQa Peter Stout, CEO and President, Houston Forensic Science Center Cc: Lt. Chris Nettles, Deputy Director, Crime Scene, Digitai/ ulti-Media Division Date: April 4, 2017 Re: Quality Incident Report Regarding This memorandum is intended to document multiple problems with case records completed by HPD Officer?-, assigned to the Houston Forensic Science Center as a crime scene investigator. Errors were noted in approximately 88 case records dating back to November 2015, the month in which the HFSC Crime Scene Unit began using for reporting purposes. These errors included: 0 minor administrative errors, such as transposing numbers from the count of items in a report verses the count entered into the HPD Records Management System 0 the number of photographs uploaded into the HPD Dataworks system was different to the number of photographs stated in the crime scene report 0 the loss of one physical evidence item Early last year, the Harris County District Attorney's Office raised concerns about two scenes processed by HFSC then completed a review of these case records. Please note that Crime Scene SOPs currently require a technical review of at least 25% ofeach CSl?s case records. CSI Technical Supervisor? was tasked with reviewing these cases. Because problems were noted in these two cases, an additiOnal five case records were reviewed to determine if CSI - deficiencies were isolated to just the three mentioned by the office._ reported that although some errors were found, none rose to the level of requiring CSI - to be removed from casework or to undergo retraining._ reviewed with CSI- the corrections needed and offered advice on how to better process and document crime scenes to prevent a recurrence of these errors. Because ofthese on-going issues, Crime Scene Unit Supervisor Carina Haynes was assigned to work directly with CSI - to correct the errors that can be corrected. Supervisor Haynes was also tasked with writing a report that detailed specific errors made and the corrective action{s taken to address each error. The root cause of most of these errors was determined to be CSJ- lack of attention to detail, poor note taking ability, and lack of proper training. However, there were circumstances which go beyond that. There were approximately seven of CSI - case records were technicaily reviewed by as part of the required 25% review. ?rms were rarely documented or corrected during this process. There was little to no feedback during the technical review process, so CSI- was not made aware of the errors nor asked to correct those errors. Included as Appendix A is a list of case records that Supervisor Haynes worked with CSI- to correct. This Appendix includes the errors/issues noted for each case record. Officer- has been removed from casework pending correction of these case records. He must complete a compressive CSI training program and successfully complete a competency test before being authorized to return to casework status. However, I am not confident that CSI- can be trained on the basic instinctive investigative skills needed of a crime scene investigator. In several instances, he knew what and how to do things correctly but chose not to do it. Later, after being notified of errors, he responded, knew that" and forgot to do that". During the additional review conducted by Supervisor Haynes, seven case records completed by - were identified as passing a technical review conducted by_. These seven case records passed? technical review even though they contained errors that should have been documented and corrected before the technical review was dowmented as complete. Three of these were Officer invotved Shootings and four were either homicide cases or homicide follow-up cases. The HFSC Quality Manual and Crime Scene Units SOPs outline what a technical review is and what is required in case records. Thus,_ was removed from performing technical reviews and must complete training before receiving written authori7ation to resume functioning as a CSU technical reviewer. APPENDIX A Date Case Easelyes Issues Noted 10/9/2015 1302825-15 05 Evidence marker ll 12 (blood stain) omitted from report. Cartridge casing found in officer's vehicle was not mentioned in notes or report; unsure if collected. MeaSurements in notes do not match final draft. Third magazine charted and no idea where it came from. 10/15/2015 11/21/2015 1333801?15 Homicide Mase under leg of photo'd but not collected. No photos of purse that was collected. Drugs not photo'd on scene but in back of veh. No latent processing completed. No collection of cups from room or DNA swabs. Poor sequencing of photos. N10 documentation of where items collected were from the time of collection until they were submitted to Property. 1-495880- 15 Homicide No latent processing of the scene was completed despite the fact that the scene clearly extended from in the interior to the exterior. Victim is deceased inside the residence and one size cartridge case is on the floor; outside a different size cartridge case is located. No processing of bloody shoeprints (The victim is wearing only socks) The report talks about a bent screen on a in notes or photos. Need to change pistol to cartridge case in RMS corrected 1/ 19/ 2016 81510-16 OIS Scene description in report is not an accurate representation of the scene--> Interior of business described as white tiles/white walls; scene included brown tiled floored and brown walls. A bullet hole was in a store sign; same was briefly documented with photos but there is no mention of the damage in the report or notes. Damage to truck is not described correctly in report (bullet holes noted in incorrect locations) Need to change pistol to cartridge case in RMS corrected APPENDIX A 3/20/2016 356909-16 Incorrect count on cartridge cases with one left behind on scene. Measurements are in ?nal sketch but not in notes. Admits to leaving behind cart case be "appeared to be unrelated". This info was not in notes. Still don?t know where measurements came from. 6/13/2016 368640-16 Agg Assault 5 N0 LIMS or RMS report; Photos not uploaded. Inv requested DNA from vehicle and - did not collect. RMS report generated and photos uploaded 6/18/2016 782674-16 Death Shirt is was not collected and therefore not turned into evidence as stated in report. Correction made in report stating shirt left 7/6/2016 869067-16 Bank Robbery .stated that "he could not discern any visible ridge patterns? and did not process for Iatents. He also stated that he submitted DNA swabs collected from the counter. Latent cards and swabs were submitted to Property by the investigator on scene. It appears that .did process for prints and turn both the swabs i and prints over to the investigator. We aren't sure that?s what happened because there are SPARCE notes with the case file but that's what can be assumed. Correction to report that he turned over latent cards and swabs to investigator. 10/3/2016 1162209-16 VEB Report said he collected 8 swabs but only 6 submitted to Property. He said he remembers only collecting 6 swabs so he changed it in report; no notes to support. 10/10/2016 1167943-16 VEB No notes taken. Possible blood stain lnv. requested to be tested was not photographed. lnv. requested latent print processing- only steering wheel, seatbelt latch and rear view mirror. All other viable surfaces omitted Unable to correct 11/8/2016 1425587-16 Homicide Parent admitting to hitting deceased with belt before death and pointed it out in scene video; belt not collected. Possible blood on master bedroom light switch not noted in report or notes. TR by CH on 3.6.17 possible blood on light switch added to report. APPENDIX A 11/12/2016 1443685-16 Homicide Shoe/foot imprints in blood throughout scene; not documented with scale. No latent processing done. Measurements in report do not match notes. Says 10 swabs were collected, only 8 submitted to Property. TR by CH on 3.8.17 Measurements corrected. He changed the it of swabs in the repart but there is no documentation to know if he actually collected 10. 2/8/2017 0148566-17 Agg Assault (VEB) No notes regarding scene processing. No photos of clothing, center console, glove box or documents despite request. TR by CH on 3.9.17 grammar mistakes corrected other items cannot be fixed. MINOR 11/5/2015 1419998-15 OIS Measurements on final draft do not match notes. Some measurements not recorded in notes. Report needed to be restructured to make sense. Measurements corrected and report amended. 12/25/2015 1650956- 15 Sparse notes. Of?cer's serial ti on weapon recorded incorrectly. Measurements in ?nal sketch do not match notes. Need to change pistol to cartridge case in Serial it, measurements and RMS corrected 2/ 10/ 2016 175457-16 Child Abuse Initially wrote no LIMS report or RMS report. Omitted BB gun info from report (suspect weapon) Bath LIMS and RMS reports written. BB gun info added. 3/5/2016 287828-16 Child Death Towel on bed with possible blood omitted from report. Sparse notes. Towel added to report. 5/1 1/2016 749013-16 Homicide Shoeprints in blood not documented with scale. Blood trail and cartridge case not measured into scene. Injuries to victim not in notes or report. Injuries to victim added to report. 14/ 2016 616168-16 Homicide Measurements on ?nal draft do not match notes. Some measurements not recorded in notes. Measurements corrected. 5/ 15/2016 62024 1-16 Child Death Rough sketch is not legible. Measurements in notes are different from draft. Claims spiders throughout residence and rat poison under sink, not in notes or photos. Measurements corrected 3 1/ 2016 694234-16 Death No LIMS report even though RMS says see LIMS. Multiple incorrect dates listed. -->Correction to dates made 7/16/2016 888762-16 Homicide Negative results not reported after metal detector was used for almost 2 hours. Quality incident generated. LIMS report written after prompting. APPENDIX A 8/7/2016 100998446 Homicide Final diagrams in packet but no draft sketches cempleted on scene. Measurements in report but not in notes. No latent processing of the residence attempted. Property submitted on 8/8 when report indicates in was submitted the same day. 8/ 15/2016 1008562-16 VEB -L No photos were taken (didn't want to contaminate his camera equipment, per report). Measurements of bullet holes were mentioned in report but no notes. VIN number listed incorrectly. Property description doesn't match what was collected. VIN corrected. Property corrected. 8/20/ 2016 1067154-16 Homicide Omission of keys and wallet from LIMS report. Incorrect number of photos listed. No documentation of where items collected were after collection until they were submitted to Property (9 days). Measurements in final sketch are not found in notes. Vomit on ?oor omitted from report. 10/3/2016 1191945-16 VEB No overall photos taken of vehicle before trajectory rod used. No measurements in notes but in final report. Remove measurements 1 1/15/2016 1052250-16 Homicide LIMS report is uploaded under correct case ll. Property and photos are uploaded under incorrect case number of 1052557-16. Dates are not consistent through report. No notes regarding veh condition or processing- ->Report uploaded under correct case Dates changed to become consistent throughout 11/15/2016 1353409-16 Agg Robbery LIMS says ?ngerprint cards were tagged but none in RMS. No RMS report written. Fingerprints photographed (improperly) but not collected. 12/31/2016 165882346 Death Inv No LIMS report even though RMS says see LIMS. No notes. Blurry photos not recaptured. Mention of white shorts but not photographed, noted or collected. (After correction. he removed from report.) Property submission date is incorrect. Where was it? 2/6/2017 0153954-17 Homicide No measurements in notes but listed in final report. A lot of extraneous info in report. Poor ?ow of photos Don?t know where measurements came from; extraneous info removed. 2/8/2017 172898-17 Homicide Minimal notes. No measurements recorded in notes but present on final sketch. Pillow and towel near body omitted from report later added to repon. Still don?t know where measurements came from. 2/9/2017 0172898-17 Homicide Add towel and pillow near body. Measurements omitted from report all items added A Measurements in final draft did not match notes. 2/11/2017 0185513-17 Homicide Headphones left off evidence list. Measurements corrected and headphones added to evidence list. NO RMS PHOTOS UPLOADED 11/6/2015 142907845 Homicide Needs to change pistol to cartridge case in RMS. Poor photo progressuon. RMS corrected 15/2015 1400901-15 Homicide Needs to change clothing description in 12/17/2015 1611221_15 Death my (child) Clari?cation needed about paper towel being packaged With children clothes 12/29/2015 166779845 Homicide Need to change pistol to cartridge case in corrected Re ort loaded un er wron case number. 5 arse 1/ 17/ 2016 152324945 Agg Rabbery nofes ??>pReport refploadedgunder correct car: Report placed under wrong case number. No RMS 4/5/2016 432825-16 Suicide report generated. Minimal notes. Case moved to correct case number and RMS report generated. . Minimal notes. No overalls of residence. No RMS 4/24/2016 520191-16 Ch'ld Death report generated. RMS report written 5/18/2016 634542-16 Death Inv. Incorrect number of photos listed--> corrected 7/7/2016 871609-16 Robbery No LIMS or RMS repert; Photos not uploaded 7/7/2016 872548?16 Burglary No LIMS or RMS report; Photos not uploaded No LIMS or RMS re ort; Photos not loaded No 7/8/2016 868242-16 Agg Robbery photos done 9 7/9/2016 881316-16 Homicide No description how many photos taken Corrected 7/27/2016 929343-16 VEB Photos not uploaded to DW. Photos uploaded 7/30/2016 973851-16 Child Death Minimal notes. No RMS report. 3 RMS report written 8/6/2016 984697-16 Agg Robbery No @tes. No RMS report. RMS report written . . . No LIMS or RMS re ort; Photos not loaded Case 8/22/2016 105225045 Homlc'de file completed and Iphotos uploaded. 8/28/2016 1102239-16 Homicide Casings and fragment called pistol in RMS 9/6/2016 1070840-16 FSRA Case still pending. ne_ed notes/case file. 9/10/2016 115994846 Homicide Money- and box in report but not listed in Evid. 7H Disposmon 10/3/2016 I 104373446 VEB Minimal notes. No RMS report. RMS repert written 10/18/2016 1330573-16 Child Death Minimal notes. report. RMS report written Ma azines ta ed as rifles. Wron make on ammo. 11/2/2016 134850546 Hom'c'de i STILL coanecrnog 11/14/2016 . 137903446 VEB i Photos not uploaded to DW. Photos uploaded 12/11/2016 1569052-16 Homicide No LIMS report even though RMS says see LIMS 12/13/2016 1578999-16 Death Minimal notes. No RMS report. RMS report written 12/18/2016 1602874-16 Homicide Minimal notes. No RMS report. RMS report written 12/21/2016 917804-16 Agg Robbery lncOrrect number of photos isted-?> corrected 12/21/2016 1616061-16 Child Death Minimal notes. No RMS report. RMS report written APPENDIX A No LIMS or RMS report; Photos not uploaded--> No 12/28/2016 164600446 Hom'C'de photos done. Case uploaded under- 1/7/2017 27621-17 Death Inv Minimal notes. No RMS report. RMS report written 1/15/2017 62702-17 Homicide incorrect number of socks tagged in RMS 1/28/2017 122426-17 Death Inv No RMS report generated.--> RMS report generated