The City ofNew York Department of Investigation MARGARET GARNETT COMMISSIONER 80 MAIDEN LANE NEW YORK, NY 10038 212-825-5900 March 4, 2019 Commissioner Brann New York City Department of Correction 75-20 Astoria Boulevard, Suite 350 East Elmhurst, NY 1370 Dear Commissioner Brann: In December 2011, the New York City Department Of Correction?s (DOC) Investigation Division (ID) issued a report noting that Warden William Clemons1 and then-Deputy Warden of Security Turhan. Gumusdere2 misrepresented inmate?on-inmate ?ght statistics at the Robert N. Davoren Center (RNDC). Based on the ?ndings outlined in the 2011 report, DOC ID recommended the demotion of both Warden Clemons and Deputy Warden Gur'nusdere. However, on May 13, 2014, then-Commissioner Joseph Ponte promoted Warden Clemons to Chief of the Department, and on February 29, 2016, he'promoted Deputy Warden Gumusdere to Bureau Chief of Security for. DOC. As a result, in August 2017, the New York City Department of Investigation (DOI) commenced an investigation into violence within various DOC facilities in order to determine if publicly reported statistics truly re?ect the violence occurring in DOC. Below is a summary of DOC 2011 report, subsequent investigation, and a list of policy and procedure recommendations (PPRs) that will ensure accurate reporting of violence statistics and enhance transparency between DOC and the public. I. BACKGROUND. In response to allegations that inmate ?ghts within the RNDC were underreported, as part of its 2011 investigation, DOC ID reviewed inmate ?ght statistics. ID found that between May 1 William Clemons left DOC as-of December 1, 2014. According to Employee Look-Up System (ELS), the reason for leaving DOC is listed as ?Voluntary Retiren?ient.?5 2 Turban Gumusdere left DOC as of August 14, 2017. According to ELS, the reason for leaving DOC is listed as ?Disability Retirement.? Commissioner Brann March 4. 2019 Page 2 of 11 and November 2011, while Gumusdere was the assigned Deputy Warden of Security at RNDC and Clemons was the assigned Warden, they deliberately manipulated statistics to make it appear - as though there was a dramatic decrease in the number of inmate-on-inmate ?ghts occurring in the facility. report concluded that there was ample evidence of Gumusdere?s and Clemons? ?complete abdication of responsibility for the production of critical information that (Gumusdere and Clemons) knew was used for internal measurement and for publicly reported statistics on the performance of the department.? As a follow-up to inveStigation, DOI began an investigation into violence within several DOC facilities to determine whether there were similar patterns of underreported violence of all kinds. DOI focused on the three-month time period from February 1, 2017, through April 30, 2017, and examined 12 DOC facilities: Anna M. Kross Center (AMKC), Brooklyn Detention Complex (BKDC), Eric M. Taylor Center (EMTC), George R. Viemo Center (GRVC), George Motchan Detention Center (GMDC), Robert N. Davoren Center (RNDC), Rose M. Singer Center (RMSC), Manhattan Detention Center (MDC), Vernon C. Bain Center (VCBC), West .Facility (WP), Queens Detention Complex (QDC), and the Otis Bantum Correctional Center DOI conducted interviews with DOC staff members, reviewed DOC databases, examined DOC pelicies, collected and reviewed facility logbooks, and reviewed hundreds cf Injury to Inmate Reports. II. CURRENT REPORTING PROCESSES: CENTRAL OPERATIONS DESK AND INCIDENT REPORTING SYSTEM The Central Operations Desk?s (COD) primary mission is to accept noti?cation of, and speci?c information about, the occurrence of an unusual incident, and to disseminate the information in a prescribed manner.4 COD receives information from all DOC facilities for reportable incidents. According to COD staff, COD receives approximately 200 calls per tour, and there is one Assistant Deputy Warden (ADW) assigned per tour. Since the assigned ADW is the only staff authorized to answer the COD telephone lines, COD staff claim that calls may go unanswered while an ADW is on the telephone obtaining information about another incident. Directive de?nes an unusual incident as: ?An event or occurrence that may affect or actually does affect the safety, security, and well-being of the Department, its personnel, visitors and volunteers, as Well as the inmates over whom. it has custody and control . . . Upon the occurrence of any unusual incident, initial telephone communication to COD shall receive top priority.? ?Unusual Incidents? within Directive speci?cally includes serious injury to inmate or staff, stabbing/slashing/shooting injuries sustained by inmates, and various other inCidents not relating to interpersonal violence. 3 Unless otherwise speci?ed, the basis of all investigative steps and conclusions contained in this letter use the February 1, 2017 through April 30, 2017 time?ame and involve these 12 facilities. 4 DOC?Directive details ?Reporting Unusual Incidents.? Some examples of unusual incidents contained in the Directive?s section include arrest of an employee, death or serious injury to inmates and staff, erroneous discharge, loss or theft of DOC property (including an employee?s ?rearm), attempted escape, sexual abuse or assault (actual and alleged), and stabbing/slashing/shooting injuries sustained by inmates. Commissioner Brann March 4, 2019 Page 3 of 11 After COD receives the noti?cations from the facilities, COD is responsible for inputting them into Incident Reporting System (IRS), which rs considered to be central database for all reportable incidents. The IRS contains various dl?Op- -down menu categories such as ?Date Occurred,? ?Primary Incident Type,? ?Location,? ?Book and Case Number,? and ?Staff Last Name,? all designed to facilitate searches of an incident. The IRS drop-down menu categories assist IRS users in narrowing down their search for a particular incident. In addition to outlining what needs to be reported, Directive sets forth timeframes within which the facility and other entities at DOC must report incidents to COD. As part of investigation, DOI reviewed multiple DOC Directives, which identify incidents that require COD noti?cation. However, given that the incidents are notconsidered an ?Unusual Incident? as outlined in DOC Directive 5000R- A, they are not noted as a ?reportable inciden in the directive. One such DOC Directive was Use of Force (UOF) Directive Directive relating to UOF, noted that UOF incidents are required to be reported to COD within two hours of occurrence. Directive de?nesa UOF incident as, ?Any instance Where staff use their hands or other parts of their body, objects, instruments, chemical agents, electronic devices, ?rearms, or any other physical method to restrain, subdue, or compel an inmate to act or stop acting in a particular way. The term Use of Force does not include moving, escorting, transporting, or applying restraints to a compliant inmate.? This directive contains an alphabetical classi?cation for UOF incidents based on the injury sustained by either the inmate(s) or staff member(s) involved in the UOF: 0 ?Class A describes incidents that require medical treatment beyond the prescription of over-the-counter analgesics or the administration of minor ?rst aid, including those resulting in one or more of the following treatments/injuries: multiple abrasions and/or contusions, chipped or cracked tooth, loss of tooth, laceration, puncture, fracture, loss of consciousness, concussion, suture, internal injuries, or admission to a hospital.? 0 ?Class describes incidents that do not require hospitalization or treatment beyond the use of over-the-counter analgesics or the administration of ?rst aid super?cial bruise, scrape, scratch, or minor swelling) or involve the forcible use of mechanical restraints in a confrontational situation that results in minor injury.? 0 ?Class describes incidents that result in no injury to staff or inmate, including, but not limited to, UOF incidents where the use of chemical agent spray resulted in no injury beyond irritation that can be addressed through decontamination.? 0 ?Class (pending) is a temporary classi?cation used to describe UOF incidents where there is not enough medical information available to classify the UOF informed that COD staff are ultimately responsible for the ?nal classi?cation of UOF incidents. Commissioner Brann March 2019 Page'4 of 11 In addition to its IRS database, DOC maintains an Inmate Fight Tracking database. The Inmate Fight Tracking Database contains information for inmate-on-inmate ?ghts that occur within DOC. DOC does not use the information contained in this database in compiling statistics it releases to the public. Inmate-on?inmate ?ghts can be searched on the database using search ?elds 'such as an inmate?s book and case number, the date of incident, and facility of occurrence. The database maintains basic information including, but not limited to: identifying information for the invOlved inmates; headshot photographs of the involved inmates; the location, date, and time of the inmate ?ght; and, if applicable, may identify the involved inmate(s) type of injury. However, review revealed that the database may not consistently list every single inmate invOlved in a ?ght, or the injury that a particular inmate sustained. INVESTIGATION 1. INMATE-ON-INMATE FIGHTS investigation involved a comprehensive review of inmate-on?ininate ?ghts, including reviewing the IRS, Inmate Fight Tracking Database, and Injury to Inmate Reports. As discussed further below, none of these sources of information could provide a complete and accurate record of inmate-on-inmate Violence within DOC. According to the Inmate Fight Tracking Database, between February 1, 2017 and April 30, 2017 there were a total of 1,434 ?ghts in the 12 facilities that serve as the basis of this investigation. When DOI cross?referenced these inmate ?ghts with the IRS, DOI discovered that only 410 ?ghts were reported in the IRS under the ?Serious Injury to Inmate? category, and 1024 inmate ?ghts were not captured in the IRS at all. Although the IRS has a category ?Inmate-on?Inmate Fights? under the ?Primary Incident Type? dropdown menu, search for inmate ?ghts under this category returned no results. Rather, the 410 ?ghts that were recorded in IRS were documented under "a ?Primary Incident Type? category entitled ?Serious Injury to Inmate.? In other words, 71% of inmate ?ghts during the study period were not documented in the IRS, and the IRS category that is supposed to be tracking inmate-on-inmate violence appears to be Wholly unutilized by DOC staff. Directive mandates that injuries to inmates must be reported to COD and documented in the IRS if there is a serious injury to the inmate. Directive 5000R-A de?nes serious injury to an inmate to be ?physical injury that creates a substantial risk of death or dis?gurement, is a 10Ss or impairment of a bodily organ, is afracture or break to a bone excluding ?ngers and toes, or is an injury de?ned as serious by a physician.? This de?nition covers injuries sustained by inmates not only during imnate ?ghts, but also sustained by Other means, such as in slip-and- fall acCidents. Inmate ?ghts that result in a non-serious injury are not required to. be documented in IRS. As such, it appears that inmate-on?inmate ?ghts are not being adequately captured, tracked, and reported in the IRS. data, at least where it is derived from the IRS, does not re?ect incidents of Violence, but rather re?ects status of injury to inmates by whatever means, including by accident. Given that the IRS maintains publicly-reported statistics, and 71% of the inmate ?ghts within the study period were not captured in IRS, statistics failed to re?ect Commissioner Brann March 4, 2019 Page 5 of 11 the overwhelming majority of inmate-on-inmate violence. This failure creates a misleading picture of the amount of intra-inmate violence and makes it more dif?cult to track progress in addressing this problem. DOI also found that while the Inmate Fight Tracking database listed some information pertaining to each ?ght (like recording identifying information for the involved inmates), it did not always document the involved inmates? injuries. In order to ensure that review of the Inmate Fight Tracking database was comprehensive and included all injuries sustained by the inmates involved in the inmate ?ghts DOI requested all Injury to Inmate Reports from General Counsel?s Of?ce. Of the approximately 7, 870 Injury to Inmate Reports DOI requested for the three-month study period DOC provided approximately 4,830, with approximately 3,040 reports outstanding. To date, the General Counsel?s Of?ce has been unable to locate or produce the missing reports. Given inability to locate almost 39% of the reports, these reports are another internal DOC data set that is not capable of generating a complete and accurate accounting of intra?inmate ?ghts and resulting inmate injuries. 2. ASSAULTS ON UNIFORMED AND NON-UNIFORMED STAFF DOI also sought to obtain and review statistics pertaining to assaults on staff. DOI reviewed the IRS to identify those incidents; however, under ?Primary Incident Type,? the IRS does not have an ?Assault on Staff? category. The IRS does have a category that captures ?Serious Injury to Staf and D01 found only two incidents reported under that category during the three-month study period, in any of the 12 facilities. According to Directive a ?Serious Injury to Staff is de?ned as ?physical injury that creates a substantial risk or death or dis?gurement or loss or impairment of a bodily organ. It also means any injury sustained as a result of a stabbing, slashing, shooting, ?re and/or explosion.? This de?nition includes not only incidents of serious staff injuries from assaults by inmates, but also other sources of serious injury, such as accidents and off-duty incidents. Additionally, this category does not account for inmate assaults on staff in which the staff member sustained an injury that DOC does not deem ?serious,? or no injury at all. As with the ?serious injury to inmate? category, because of these omissions, this category does not accurately capture and track inmate- on?staff assaults within DOC. DOI also found that some assaults on staff, mostly pertaining to Spitting and splashing incidents, are captured under the IRS ?Primary Incident Type? category entitled ?Logbook Entry.? The ?Logbook Entry? category includes not only assault-on?staff incidents, but is a catch- 6 According to DOC Directive for Injury to Inmate Reports, every inmate who requires medical attention as a result of injury shall be afforded prompt medical attention. An Injury to Inmate Report is initiated by the correction of?cer to whom the inmate ?rst reports the injury, or the ?rst of?cer who observed the act that resulted in injury. The report must document the injury, medical treatment, and any investigation into the source of the injury. Staff are required to notify the area supervisor and ensure that the inmate and report are produced in the clinic. After the inmate is examined by medical staff, they complete the report. A copy of that completed report is given to an investigating captain, and a second copy is placed 1n the inmate?s medical folder. Pending additional medical treatment beyond the initial facility clinic, Injury to Inmate Reports are updated with any additional medical diagnosis and treatment. 7 A splashing is an incident in which an inmate throws a liquid substance at a uniformed staff member. Commissioner Brann March 4, 2019 Page, 6 of 11 all that includes reports of a variety of non-assault events, such as inoperable machinery at DOC facilities, and housing areas that are on lockdown. Within the IRS ?Logbook Entry? category, there is no mechanism to ?lter reports solely related to assault-on-staff incidents. While the IRS tracks all UOF incidents that involve an. assault on staff, it does not track assaults on staff that do not involve a UOF. Through interviews with staff from Bureau Chief of Security?s Of?ce, DOI con?rmed that DOC does not have a mechanism to track assaults on Staff that do not involve a UOF. Because DOC does not have a means to adequately track and maintain all assault-on?staff incidents (whether in the IRS or elsewhere), DOI could not generate a complete and accurate accounting of assaults on uniformed staff occurring within DOC. DOI also attempted to obtain information pertaining to assaults on non-uniformed staff members occurring on DOC property. However, IRS does not have a ?Primary Incident Type? category to capture these assaults. All assaults occurring on DOC property, whether against uniformed or non-uniformed staff members, must be considered acts of violence and should be tracked by DOC. In ?scal year (FY) 2017, DOC employed 1830 non-uniformed staff who had inmate contact, comprising approximately 17% of total staff.8 Without adequate tracking of assaults on non?uniformed staff, DOC is unable to provide an accurate depiction of violent inCidents occurring within DOC. Because there is no accurate or reliable measure of assaults on either uniformed or non- uniformed staff, internal and publicly-reported statistics on violence within DOC are undercounting incidents. 3. NON-REPORTABLE LOGBOOKS DOI collected and reviewed all Non-Reportable Logbooks to ascertain the types of incidents reported in the logbooks, and to determine whether violent incidents noted in the Non- Reportable Logbooks should have been reported to COD and documented in'the IRS, but were not. In order to determine whether or not the incidents Were appropriately reported, DOI cross- referenced all violent incidents contained in Non-Reportable Logbooks (Use of Force incidents, Inmate Fights,'Assaults on Staff, and other violence related entries) with the IRS. According to Directive all facilities are required to maintain a hardcover ?Non- Reportable Incident Logbook? to record incidents that do not rise to'the level of an ?unusual incident.? Operation Order #17/99,- entitled ?Non-Reportable Incidents,? provides examples of incidents that should be maintained in the Non?Reportable Logbook, such as injuries to inmates resulting from manipulative gestures (such as suicide attempts), injuries to staff and/or inmates that do not rise to the level of an Unusual Incident (such as sprains, trauma), telephone system outages, inoperable locks, and contained ?res. 3 During that time, DOC employed 10,862 uniformed staff; for FY 2018, DOC employed 10,653 uniformed and 1,886 non-uniformed staff. Commissioner Brann March 4, 2019 Page 7 of 11 DOI found instances of UOF incidents, required to be reported to COD and documented in IRS, that were logged in the Non-Reportable Logbooks, but not documented in the IRS. . In addition, DOI discovered instances of inmate-on?inmate ?ghts and assaults on staff documented in-the Non-Reportable Logbooks, but not elsewhere. As discussed in greater detail above, under current DOC policy, inmate-on-inmate ?ghts and assault-on-staff incidents are not independently tracked in IRS and are not required to be called into COD unless there is a serious injury. Given that DOC uses IRS to track and maintain statistics, including those relating to violent incidents, Non-Reportable Logbooks should only maintain incidents pertaining to facility maintenance, either completed or requested. Despite the listed examples in Operation Order #17/99, permitting staff to document violent incidents (UOF, Assault On Staff, inmate ?ghts, etc.) in a Non-Reportable Logbook ensures that incidents of violence are not properly tracked in the IRS, leading to inaccurately reduced violence statistics. 4. INCIDENT PHOTOS MAINTAINED IN IRS Under current DOC procedure, staff are required to report ?Unusual Incidents? to COD, and COD is responsible for documenting the incidents in IRS. Each DOC facility is also required to notify COD regarding all UOF incidents When a UOF incident occurs, staff assigned to the facility where the incident occurred photographs the injuries to both staff and inmates, if any.9 DOI determined that in some instances, staff members took more than four photographs of injured inmates. However, in each UOF incident reported in IRS, DOI found only a maximum of four photographs of each involved individual Uploaded into IRS, depicting front, back, left and right views.? The DOC staff members interviewed claimed ignorance of any mechanism for storing photographs that are not uploaded into IRS. I. CONCLUSION AND RECOMMENDATIONS investigation concluded that current practices in reporting and recording violence incidents against inmates or staff result in unreliable statistics and, in general, underreporting of the amount and frequency of violent interactions, whether between inmates or between inmates and staff. The lack of adequate or reliable tracking inhibits oversight investigations, makes it more dif?cult for DOC to assess and address violence and devise effective measures to reduce it, and results in inaccurate reporting to the public and to other government of?cials and entities. The recommendations below are intended to address these concerns. i. All inmate-on?inmate ?ghts must be reported to COD and captured in IRS as an independent ?Primary Incident Type? category. DOC should document and track all inmate-on?inmate ?ghts in IRS. Because IRS is the central database used by DOC to maintain statistics that are publicly reported, tracking inmate-on-inmate ?ghts is essential to ensure those statistics are accurate. DOC should create reporting rules that would require all intra-inmate ?ghts, regardless 9 DOI found that in some photos, inmates covered their faces or gave their backs to the camera, appearing uncooperative. Commissioner Brann March 4, 2019 Page 8 of 11 ii. iv. of resulting injury, to be reported to COD and captured in the existing (but apparently unutilized) IRS category for ?Inmate-on?Inmate Fights.? Under current practice, only inmate ?ghts resulting in a serious injury to an inmate are reported to COD and tracked in IRS. Reporting all inmate ?ghts to COD and accurately capturing these incidents in IRS as an independent category would create an accurate depiction of the amount of intra-inmate violence occurring within DOC. . All assault-on?staff incidents must be reported to COD and captured in IRS as an independent ?Primary Incident Type? category. DOC should create a ?Primary Incident Type? category in IRS to track assault-on?staff incidents as its own independent category. Currently, IRS only tracks assault-on?staff incidents that result in serious physical injury. While D01 is aware that some assault- on?staff incidents are captured in IRS as a UOF, or a ?Logbook Entry? for spitting/splashing incidents, neither is a "reliable way to capture assault-on-staff incidents that do not result in a serious injury or that result in no injury, even though any assault on staff is clearly an act of violence. DOC should create a sub category in IRS that would ?lter assault-on-staff incidents to identify a distinction between physical force assault on staff and spitting/splashing incidents. DOC should create a ?eld within IRS that would permit an IRS user to be able to ?lter between assaults on staff that are physical assaults, and those that involve an inmate spitting on or splashing a staff member. Assaults involving non-uniformed staff members occurring on DOC pmperty should be reported to COD and captured in IRS as an independent ?Primary Incident Type? category. Similar to assault-on-staff incidents, assaults involving non-uniformed staff occurring on DOC property are not currently captured in IRS. All assaults on DOC employees, whether uniformed or non-uniform, are ?violent incidents? and should be tracked as such within DOC systems to ensure accurate reporting. DOC should create a uniform classification system for all ?violent incidents that occur within DOC. Under current Use of Force Directive (5006R4D), use of force incidents are classi?depending on the type of injury sustained and treatment received. However, assaults on staff that do not involve a UOF are not reported in IRS, unless the staff member sustains a serious injury. Similarly, inmate-on?inmate ?ghts are not reported in IRS, unless the inmate sustains a serious injury. According to Directive the de?nition of a serious injury varies arbitrarily, depending on Whether a staff member or an inmate sustains the injury. Therefore, in order to Commissioner Brann March 4, 2019 Page 9 of 11 vi. vii. accurately depict violence within DOC and create a consistent reporting system, DOC should create a uniform classi?cation system under which all violent incidents are classi?ed in the same manner. DOC should create a complete, uniform list of all incidents that are required to be reported to COD and documented in IRS, which shall be distributed to all COD staff and maintained in all DOC facilities. While Directive identi?es various incidents that require COD noti?cation this list IS not all- inclusive. After a review of other directives such as Directive 5006R- D, DOI discovered that there are various other incidents that also require a COD noti?cation, although it appears that compliance with these noti?cation protocols is not uniform. Given this, DOI recommends that DOC create a centralized document that contains a list of all incidents requiring COD noti?cation and any supplemental reporting requirements associated with those incidents. This centralized document should be distributed to all staff within DOC facilities and to COD. A clear and concise list of all reportable incidents will reduce confusion among staff members about the reporting requirements, which should result in more complete and accurate records. DOC should enter reports electronically. DOC should also transition to utilizing databases in which forms such as Injury-to Inmate Reports, UOF documents, Incident Reports, and inmate statements, are entered directly into a database. DOC should implement an electronic ?ling system for DOC Records, including ix. Injury to Inmate Reports, Use of Force Reports, and Incident Reports. DOC could not locate and produce 39% of its Injury to Inmate Reports for the study period. DOI experienced similar dif?culties in trying to obtain various logbooks for this investigation. DOI recommends that DOC implement an electronic ?ling system for Injury to Inmate Reports, Use of Force Reports, Incident Reports, and other documents DOC maintains. To prevent unacceptable loss of business records, all DOC staff-generated reports should be uploaded into a central database and stored electronically. Non-Reportable Logbooks should be used only for facility maintenance. review of Non-Reportable Logbooks revealed that ?Unusual Incidents? (Directive were logged in Non?Reportable Logbooks and not reported to COD or documented in IRS. DOI also uncovered UOF incidents in Non-Reportable Logbooks that were not reported to COD or documented in the IRS, as required. DOI further found that Non-Reportable Logbooks often contained information about inmate-on-inmate ?ghts and assault-on-staff incidents that were not found in IRS, as required. Given these ?ndings, DOI recommends that DOC restrict the use of Non- Commissioner Brann March 4, 2019 Page 10 of 11 Reportable Logbooks to issues pertaining to maintenance of DOC properties. Non- Reportable Logbooks should not Contain, under any Circumstance, any violence?related incidents or any incident that involves inmates, uniformed and non-uniformed staff, volunteers, or visitors, all of which should be reported to COD and logged in the IRS. x. COD staff must review associated medical records before ?nalizing classi?cation Of violence (force, assault on Staff, and inmate?on-inmate ?ght incidents. COD is responsible for the ?nal classi?cation of UOF incidents as either Class A, B, or C, based on information received from the facility regarding injuries sustained by the involved inmates or staff members. UOF incidents are also. temporarily classified as Class when there is not enough medical infermation available to otherwise classify the injuries. These classi?cations are based objectively on injuries sustained and medical treatment received by the involved staff members and inmates. DOI recommends that COD classify UOF incidents only after reviewing associated paperwork. This. will also reduce incident .misclassi?cation, which DOI observed throughout the course of its investigation. xi. Terminate the use of unrecorded phone lines xii. COD receives the information for incidents that occur within DOC via telephone, and has both recorded and un-recorded telephone lines. Staff interviews revealed that un-' recorded lines were used for ?coaching? purposes for COD staff to inform facilities? staff the information that is needed to be reported. After speaking on un-recorded lines, COD staff directed facility staff to call the recorded telephone lines. In order to capture all information conveyed and to protect the integrity of the report, DOC should terminate unrecorded lines. COD should be staffed with a minimum of two Assistant Deputy Warden (ADW) staff members per tour. COD is responsible for taking DOC facilities? reports regarding incidents and is also responsible for entering all reported incidents into the IRS. In order to accomplish this task in a timely fashion with optimal accuracy, and to prevent incidents from being unreported, DOI recommends that DOC assign, at minimum, two ADWS per tour. Recommendations relating to IRS Incident Photos DOI used the IRS to obtain information regarding incidents occurring within DOC, and found that DOC uploaded incident photos for UOF incidents. However, DOC did not upload?photos uniformly: it was not done for all violent incidents; photos of some involved parties were often missing; inmates often gave theirback in photos, which were titled ?refused? and; not all photos taken were always uploaded. As a result, DOI recommends: Commissioner Brann March 4, 2019 Page 11 of 11 a. Incident photographs should be taken for every violent incident (UOF, inmate-on-inmate ?ghts, AOS). b. Incident photographs should be taken of all involved parties. 0. All photographs taken of an involved parties? injuries should be uploaded into IRS, not just four or fewer. d. All photographs should be immediately uploaded into IRS. e. If someone refuses to have photographs taken of their injury, that person must sign a re?isal form. Please contact me if you have any questions or wish to discuss this further. Please notify this of?ce of response to the above described recommendations within 30 days. Sincerely, Margaret (lamett BY: Dana A. Roth Inspector General cc: Angel Villalona, Acting First Deputy Commissioner Brenda Cooke, Chief of Staff Heidi Grossman, General Counsel