A Review of the Jail Violence Tracking and Reporting Procedures of the Los Angeles County Sheriff's Department, 2017
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Office of Inspector General County of Los Angeles Max Max Huntsman Huntsman Inspector General Inspector General A Review of the Jail Violence Tracking and Reporting Procedures of the Los Angeles County Sheriff’s Department July 2017 Contents Introduction ................................................................................................................................ 1 Comparisons of Jail Violence Data Provided by the Department............................................... 2 Tracking Use-of-Force Data ........................................................................................................ 4 Facility Trackers: ..................................................................................................................... 5 e-LOTS: .................................................................................................................................... 6 FAST:........................................................................................................................................ 6 Force Alerts: ............................................................................................................................ 7 Use-of-Force Data Compilation and Reporting .......................................................................... 7 Use-of-Force Data Reported in Monthly Books:..................................................................... 7 Use-of-Force Data Reported in Sheriff’s Critical Incident Forum (SCIF) Presentations: ......... 8 Use-of-Force Data Reported in OIG Quarterly Reports: ......................................................... 8 Tracking Inmate Assault Data ..................................................................................................... 9 Los Angeles Times Data Compared to Data Provided to the Office of Inspector General ... 14 Discrepancies between the 2007 through 2013 Totals ........................................................ 14 Discrepancies Between the 2016 Totals ............................................................................... 14 CONCLUSION ................................................................................................................................. 15 RECOMMENDATIONS ................................................................................................................... 15 Office of Inspector Generalf Introduction Pursuant to section 6.44.190 of the Los Angeles County Code, the Office of Inspector General (OIG) provides “comprehensive oversight, monitoring of, and reporting about the Sheriff's Department and its jail facilities.” The OIG monitors violence in the Los Angeles County jail system and regularly requests data from the Los Angeles County Sheriff’s Department (Department) for tracking and trend analysis. The OIG then publishes portions of this data in its quarterly report – “Reform and Oversight Efforts: Los Angeles County Sheriff's Department” (Quarterly Report). Over three quarters between June 2016 and March 2017, the OIG requested data on three types of jail violence for incorporation into its Quarterly Reports: (1) useof-force on inmates by staff, (2) inmate-on-inmate assaults, and (3) inmate assaults on staff. The Department provided the requested data and reported that the data was vetted and approved for publication. The Department also validated the draft OIG reports prior to publication. As such, the jail violence data was subsequently published in OIG Quarterly Reports dated October 2016, December 2016 and April 2017. In February of 2017, the Department released jail violence data to the Los Angeles Times (Times) which purported to show some of the same information as was published in the OIG Quarterly Reports; however, portions of the Times data was inconsistent with data published in the OIG’s reports. In April 2017, the Department notified the OIG that the data provided to both the OIG and the Times was inaccurate. The Department was not sure, however, why the data was inaccurate nor could it provide new data that it could confidently report as accurate. As a result of these and other data inconsistencies both detected by the OIG and reported to the OIG by the Department, the OIG conducted a review of the Department’s methods for tracking, compiling and reporting jail violence data. The OIG also reviewed the Custody Services Division’s (Custody) primary mechanisms for reporting jail violence data internally, including the data included in the “Monthly Books” and the data presented semi-annually at the Sheriff’s Critical Incident Forum (SCIF). The Department tracks statistics related to jail violence in a number of databases and unit-level trackers. Custody Support Services (CSS), Custody’s data unit, then aggregates the data and prepares the Monthly Books and SCIF presentations.1 The 1 See LASD, Custody Division Manual, § 4-10/000.05; and CCJV, Report of the Citizen’s Commission on Jail Violence, September 2012, pp. 80-81. http://ccjv.lacounty.gov. Page 1 Office of Inspector Generalf SCIF, in particular, is an important assessment tool used by department executives to identify and remedy systemic deficiencies related to force, violence and other jail operations. As such, the accuracy and consistency of the data presented is integral to the overall effectiveness of the SCIF process, prisoner welfare, and Departmental strategic planning. The Department’s failure to accurately track and report jail violence data was documented nearly five years ago in the Report of the Citizen’s Commission on Jail Violence which deemed the Department’s statistics on use-of-force “not reliable.” 2 As discussed in detail below, OIG personnel found that the same deficiencies exist today. First, Custody has a decentralized system that includes multiple databases and processes which track jail violence data. Second, there is little standardization in data tracking processes and procedures and databases are not systematically cross-updated. Third, there is no system-wide process for data reconciliation to ensure that additions, deletions or amendments to jail violence data entries are reflected in the yearly totals, which results in reporting of some totals that are “stale” and do not reflect the most current information. Finally, there is a lack of clear accountability for the accuracy of Custody’s jail violence data. The OIG’s review consisted of four phases. First, the published yearly totals for the three data-points discussed above were compared and inconsistencies were identified. Second, a preliminary survey of the processes and procedures used for tracking jail violence was conducted to identify potential causes of inconsistencies and inaccuracies in the yearly totals. Third, a general examination of the processes of preparing the yearly totals for publication was conducted to identify issues that might contribute to inconsistencies or inaccuracies. Lastly, the OIG made recommendations aimed at improving the quality and increasing the accuracy of the Department’s jail violence data. Comparisons of Jail Violence Data Provided by the Department The OIG compared the 2016 inmate-on-inmate assault data released to the Times, reported in the Monthly Books, presented at SCIF, and reported to the OIG. The following table illustrates inconsistencies between totals for this data over the same time periods. 2 Report of the Citizen’s Commission on Jail Violence, September 2012, pp. 43-45. http://ccjv.lacounty.gov. Page 2 Office of Inspector Generalf Inmate-on-Inmate Assault Data Provided by the Department Year Total Report 2016 3354 Provided to LA Times, February 2017 2016 3371 Monthly Book, February 2017 2016 3500 SCIF, April 2017 2016 3716 OIG Quarterly Report, April 2017 The published totals for 2016 inmate-on-inmate assaults reflected substantial variances depending on their source. The Department reported 3,716 incidents of inmate-on-inmate violence to the OIG and 3,354 assaults to the Times for the same period, a difference of 362, a variation of 9.7%. The Monthly Book and SCIF presentations also reflect different totals, 3,371 and 3,500 assaults respectively. Inmate-on-Staff Assault Data Provided by the Department Year Total Report 2015 382 Monthly Book, February 2017 2015 414 SCIF, October 2016 2015 422 SCIF, April 2017 2015 464 OIG Quarterly Report, April 2017 Next, the OIG compared the 2015 inmate-on-staff assault data reported in the Monthly Books, presented at SCIF in October 2016 and April 2017, and reported to the OIG. The table above illustrates the variances between totals reported for the same reporting period. The published totals for 2015 inmate-on-staff assaults also reflected substantial variances depending on the data source. The Department reported 464 inmate-on-staff assaults to the OIG, but reported a total of 382 assaults in the February 2017 Monthly Book for the same period, reflecting a difference of 82, a variation of 17.7%. The SCIF presentations for October 2016 and April 2017 also reflect different 2015 inmate-on-staff assault totals of 414 and 422 incidents respectively. Page 3 Office of Inspector Generalf Use-of-Force Data Provided by the Department Year Total Force Reported Report 2016 1833 OIG Quarterly Report, April 2017 2016 1833 Monthly Book, February 2017 2016 3 1849 SCIF, April 2017 Lastly, the OIG compared the 2016 use-of-force data reported in the OIG’s Quarterly Report, published in the Monthly Books, and presented at SCIF in April 2017. The published 2016 totals for uses-of-force reflected a much smaller variance between totals. Initially, it appeared that the small variances indicated greater accuracy in the use-of-force totals; however, the processes used to aggregate and publish these numbers suggests that the opposite is true. The current process used by Custody to compile use-of-force totals virtually guarantees that the totals will change from month-to-month as late or outstanding reports and revisions are received and input. As a result, yearly totals that do not exhibit significant variances may indicate that those totals have not been updated and are therefore outdated. As such, the OIG focused its initial review on the processes and procedures used to compile the data-set which reflected the greatest potential inaccuracy -- use-of-force data. Tracking Use-of-Force Data When the Department is notified of a use-of-force incident, information about the incident is documented in a number of data collection systems.4 These data collection systems document, with some necessary overlap, different types of forcerelated data and are used for different purposes. The data collection systems are not linked or reconciled with each other which results in data inconsistencies between them. The flow chart below depicts the data collection systems and the processes utilized in documenting and reporting Custody use-of-force data. The red text indicates issues identified by the OIG with each data collection system that have the potential to create errors affecting the accuracy in the totals extracted from these systems. 3 The SCIF slide total as presented was 1,852; however, the slide included 3 cases from non-custody units which we excluded in order to isolate cases pertaining only to custody facilities. 4 This discussion of the force review process is limited to only those aspects pertinent to data collection and publication. Page 4 Office of Inspector Generalf Facility Trackers: Facility Trackers are spreadsheets used by individual custody facilities to track useof-force incidents. Facility Trackers are generally more detailed than the other systems listed above and give unit commanders immediate access to data regarding their facilities. However, the criteria for the data-points recorded in these trackers varies from facility to facility making it difficult to aggregate and analyze information from multiple facilities. Moreover, information is entered into Facility Trackers by employees with a wide variety of skill sets and job experiences, increasing the risk that data entry errors, accidental deletions of data, and errors during the transfer of data from one data collection system to another may occur. Page 5 Office of Inspector Generalf Lastly, the CSS unit is not always notified of updates made to facility Force Trackers and the facilities and CSS do not regularly reconcile previously reported use-offorce data with updated information. As such, the totals from Force Trackers reported to CSS quickly become outdated. e-LOTS: “e-LOTS” is an acronym for “electronic-Line Operations Tracking System.” e-LOTS is a Custody Division database used to track force-related information. The information contained in this database includes, but is not limited to the following: use-of-force incidents; inmate extractions; allegations of force by staff on inmates; prevented uses-of-force by staff; major inmate disturbances; the category of force used in an incident; and tracking force investigations.5 The CSS unit reported that in the e-LOTS (and FAST, discussed below) database, duplicate entries can occur when staff enters information under an incorrect report number. If the record cannot be found using the correct report number, a new entry is made which results in multiple entries for the same incident. Additionally, the databases do not validate data entry fields; therefore, incomplete and incorrect entries can be saved. FAST: “FAST” is an acronym for “Facility Automated Statistical Tracking.” FAST is a Custody Division database which is also used to track incidents involving the useof-force by jail staff, but collects different data points than e-LOTS. The information contained in FAST includes, but is not limited to the following: date/time/work shift of the incident, location of the use-of-force, specific type of force used (OC Spray, Taser, etc.), inmate’s mental history, weapons used, body part injured, and identifying information related to the staff members and inmates involved in the incident. Although FAST is still being used at facilities to record force-related data, department employees reported that the FAST system is unreliable and should not be used. Specifically, database queries in FAST are downloaded to a Corel Paradox table which must then be converted into Microsoft Excel spreadsheets. Paradox is a relational database software package that is no longer supported by the company that published the software. Department staff reported that the conversion process between Paradox and Excel produces inaccurate results and that data corruption may also occur when multiple people are using FAST at the same time. 5 See MPP 4-01/025.05 Electronic Line Operations. Page 6 Office of Inspector Generalf Force Alerts: A Force Alert is used to quickly notify department management of a use-of-force incident. The Force Alert contains a synopsis of the incident along with other information relating to the incident. After a use-of-force is reported, facility staff emails the Force Alert to all concerned departmental personnel and units, including CSS. Each facility uses its own Force Alert form and the format and contents of the alert forms vary between facilities.6 Use-of-Force Data Compilation and Reporting As each reportable use-of-force is tracked by e-LOTS, FAST, Force Alerts, and Facility Trackers, the use-of-force totals from these data collection systems should be identical. Therefore, the published yearly totals for uses-of-force which are compiled from these data collection systems should likewise be identical. However, the OIG noted variances between the use-of-force totals published in the Monthly Books, SCIF presentations, and OIG Quarterly Reports. As such, OIG personnel reviewed the Custody Division’s processes of compiling and reporting yearly force totals for each of these publications and discovered problematic issues unique to each publication. Use-of-Force Data Reported in Monthly Books: The Department has suspended the publication of the Monthly Books pending an internal review of its data tracking and reporting processes. The process of tracking use-of-force data in the Monthly Books began with a Force Alert. When the Department learned of a reportable use-of-force, the involved facility sent a Force Alert via e-mail to the CSS unit. The CSS unit entered preliminary data from the Force Alert into a tracking spreadsheet and produced a daily use-of-force report reflecting all uses-of-force from the previous day. At the end of each month, the daily use-of-force totals were aggregated and published in the Monthly Books. At year end, the December Monthly Book contained the yearly use-of-force totals. OIG personnel reviewed the methodology used in producing the use-of-force totals and determined that the totals published in the Monthly Books were rarely updated. The actual use-of-force totals often changed for one or more the following reasons: allegations of force which are later substantiated and documented as a use-of-force (increasing the total); force incidents being deleted because they were reported in error or there was a duplicate report number (decreasing the total); and late 6 Although Force Alerts work well in notifying management when incidents happen, their inconsistent formats and inconsistent data points make their use as a statistical tool problematic. Page 7 Office of Inspector Generalf reporting or discovery of a use-of-force (increasing the total). However, the CSS unit rarely updated previously published use-of-force totals with this subsequent information. As such, the use-of-force totals reported in the Monthly Books became “static” and inaccurate.7 In recognition of this and other issues, the Department suspended the publication of the Monthly Books pending its internal review. Use-of-Force Data Reported in Sheriff’s Critical Incident Forum (SCIF) Presentations: The Sheriff’s Critical Incident Forum (SCIF) is a semi-annual meeting of department executives and facility/unit commanders held to review statistical data and issues pertaining to the function of the L.A. County jail system. Custody Support Services (CSS) collects data from all Custody Services Division facilities for presentation at the SCIF.8 None of the information contained in the Monthly Books is used in SCIF presentations. Instead, SCIF presentations are based on use-of-force data from eLOTS, FAST and the Facility Trackers. At the outset, department staff reported to OIG personnel that the e-LOTS and FAST databases frequently produced different use-of-force totals and were thus unreliable sources of information for statistical analysis. This uncertainty regarding the e-LOTS and FAST totals has caused CSS to rely more heavily on the totals obtained from the individual Facility Trackers for incorporation into SCIF presentations. As such, the individual Facility Trackers have become the default source for the use-of-force totals presented during SCIF . This reliance on the individual Facility Trackers has created additional accuracy problems as the Facility Trackers are not standardized, do not track the same data points, and do not employ a consistent tracking methodology. It is also uncertain, given the different levels of training and expertise possessed by the employees charged with maintaining the Force Trackers at each facility, that facility Force Tracker data is free from calculation or input error. Use-of-Force Data Reported in OIG Quarterly Reports: The processes used by the Department to report and then validate use-of-force totals to the OIG also appear to be problematic. During this review, OIG personnel requested information regarding the Department-validated use-of-force totals published in the OIG’s Quarterly Report in April 2017 (a total of 1,833 force 7 Department personnel indicated that the Monthly Book was initially meant to provide departmental command staff a “snap shot” of the most immediate information available at the time. It was never meant to be a definitive statistical resource. Nevertheless, the Department released use-of-force totals from the Monthly Books for publication without qualification or caveat. 8 See, LASD, Custody Division Manual, 4-10/000.05 Sheriff’s Critical Issues Forum (Emphasis added). Page 8 Office of Inspector Generalf incidents) and the totals from the “Force by Facility” report presented in the April 18, 2017 SCIF (a total of 1,849 force incidents). After reviewing the Department’s response, OIG personnel asked if work papers were kept memorializing the processes used to calculate the Quarterly Report totals and the totals presented at the SCIF. OIG personnel stated that work papers would include any printouts from data collection systems used to arrive at the published totals and any supporting documents related to the process of calculating those totals. Work papers would also include the documentation necessary for a reviewer to reconstruct the totals that were published in the Quarterly Report and SCIF presentations. Department staff reported that they do not keep work papers for use-of-force totals and have never been instructed to keep such documentation. Tracking Inmate Assault Data OIG personnel reviewed the methods used to track “Inmate-on-Inmate” and “Inmate-on-Staff” violence (collectively “Inmate Assaults”). The Department begins tracking an Inmate Assault as soon as it is reported and a Uniform Report Number (URN)9 is generated. Each URN is a unique number that is used to identify the incident and is entered on all crime reports and supplemental reports and forms concerning that incident. All information relating to the initial incident is filed under the URN. Involved personnel forward their completed Crime Report (SH-R-49) and related Custody Services Division Crime Analysis Supplemental Form (SH-R-49C)10 documenting the incident to Operations staff for processing. Each morning, operations staff generates a “URN Log” from the Los Angeles Regional Crime Information System (LARCIS)11 database which lists all report numbers generated for incidents from the previous day. Operations staff then 9 See MPP 4-02/010.00 Uniform Report Number. A “Uniform Report Number” (URN) is a 15-digit number used to classify and compile statistical information. 10 Manual of Policy and Procedures 4-01/020.40, Supplemental Reports, requires that line personnel complete the Custody Services Division’s Crime Analysis Supplemental form (SH-R-49C). OIG personnel noted that certain custody facilities were not aware of or utilizing form SH-R-49C. 11 LARCIS shows a summary of all pertinent information contained within a report including but not limited to the following: crimes committed; involved people (suspect, victim, witness, informant, etc.); vehicles involved in an incident; property mentioned in reports (e.g. stolen, recovered, or damaged property); crime analysis and modus operandi information; and case management/assignment information. Immediately following an Inmate Assault, facility line staff obtain a Uniform Report Number (URN) from LARCIS and completes a crime report (SH-R-49) and related supplemental form (SH-R-49C). By the end of their shift or the following shift if deferred, the deputy forwards the Crime Report to Operations for processing. The unit initiating a first report where an URN is issued is responsible for making the necessary data entries into the LARCIS database. Additional information from subsequent supplemental reports must also be entered in LARCIS. This information is typically entered and updated at the unit level by supervising sergeants and administrative staff. (See MPP 401/140.00-140). Page 9 Office of Inspector Generalf review the URN Log to ensure that they have received completed crime reports for every report number listed. Missing or late reports are noted by staff. Operations staff then process the crime reports and forward them to the Custody Division’s Jail Investigations Unit (JIU) for investigation.12 Once the JIU receives a crime report, a staff member will review the report and enter the details of the assault into an incident tracking spreadsheet (JIU Tracker). The JIU Tracker is the data collection system used to produce Inmate Assault data for the Custody Division. The Inmate Assault totals presented to Department command staff at the Sheriff’s Critical Issues Forum (SCIF) are compiled by JIU. JIU also compiles the Inmate Assault totals for the Monthly Books as wells as any other data requests related to Inmate Assaults. When compiling Inmate Assault totals, the JIU only counts Inmate Assaults which have been entered into the JIU Tracker. If the JIU does not receive a completed crime report, then that incident will not be entered into the JIU Tracker and will not be included in the total number of Inmate Assaults reported for that time period. As such, missing and/or delayed reports result in an underreporting of Inmate Assault data in both the Monthly Books and SCIF presentations.13 The flow chart below depicts the processes utilized in documenting and reporting Inmate Assault data. The red text indicates issues identified by the OIG with each data collection system that may impact the accuracy in the totals extracted from these systems. 12 JIU begins the Department’s criminal investigation process that is not the subject of this review; therefore, discussion of this investigation process is limited to only those aspects pertinent to data collection and publication. 13 Custody Support Services (CSS) reported that the Inmate Assault data used for the Monthly Books and SCIF presentations is prepared and provided solely by JIU. CSS does not verify or modify the Inmate Assault data provided by the JIU.OIG compared 6 months of JIU data from 2016 and traced them to the monthly reports issued by CSS and concluded that CSS reported the JIU numbers without modification. Page 10 Office of Inspector Generalf The OIG has identified three significant issues affecting the accuracy of Inmate Assault data reported in the Monthly Books and SCIF presentations: (1) custody facilities are not submitting their crime reports in a timely manner; (2) multiple assaults in one incident are not always tracked; (3) and previously published Inmate Assault totals are not updated. Facilities are not Sending Crime reports to the Jail Investigative Unit in a Timely Manner Generally, the Department mandates that all written reports should be completed at the end of the handling employee’s shift unless the report is deferred. Deferred reports should be completed within 24 hours unless otherwise approved by a watch commander.14 However, custody facilities do not always submit crime reports to 14 LASD, Custody Division Manual, 4-01/000.00, et seq. Page 11 Office of Inspector Generalf the JIU within that period. The OIG noted that certain custody facilities were not aware of or utilizing form SH-R-49C. As depicted in the table below, the OIG reviewed six months of Inmate Assault reports (July through December 2016) and determined there were a total of 103 assault incidents noted in the LARCIS database in which late reports were submitted to the JIU. Reports Incident Month Outstanding as of July 9/4/2016 August 10/5/2016 September 11/4/2016 October 12/6/2016 November 1/5/2017 December 2/8/2017 TOTAL LATE REPORTS CRDF IRC MCJ NCCF 0 0 3 5 1 1 2 4 2 0 4 3 1 0 19 5 1 0 12 4 1 0 5 3 6 1 45 24 North 7 5 0 1 0 0 13 South 1 1 0 1 0 0 3 TTCF 1 0 3 2 5 0 11 Totals 17 14 12 29 22 9 103 According to the JIU, when reports are not submitted to JIU in a timely manner, this results in the incidents not being input into the JIU Tracker. As a result of outstanding reports, the JIU tracker likely underreports Inmate Assault totals for both the Monthly Books and the SCIF presentations. Multiple Inmate Assaults in One Incident. Another identified accuracy issue is the potential underreporting of Inmate Assault data in the JIU Tracker when there are multiple inmate assaults in one incident. An assault is an attempt to commit a battery against a single victim. Multiple assaults against both inmates and staff can occur within a single incident of jail violence. According to the JIU staff, Inmate Assault totals do not necessarily include all the assaults in an incident of jail violence in which there were multiple assaults reported under the same report number. For example, if a single incident involves three “Inmate-on-Inmate” assaults and two “Inmate-on-Staff” assaults, the numbers reflected in the JIU tracker will be one “Inmate-on-Inmate” assault and one “Inmate-on-Staff” assault. The JIU Tracker documents the types of jail violence that occur in each incident. It does not track the number of incidents of jail violence or individual assaults. The OIG recognizes that the JIU Tracker was not designed to track the number of incidents of jail violence or individual inmate assaults. However, it is important to recognize that one “incident” of jail violence can involve numerous individual inmate assaults, both on other inmates and on staff, and that these two concepts should not be conflated. Page 12 Office of Inspector Generalf Previously Published Inmate Assault Totals were not Updated Once the JIU Tracker totals had been reported in the Monthly Books, they were generally not updated to reflect additional data later input from missing or outstanding reports. For example, OIG personnel discovered that “Inmate-onStaff” assaults for 2015 as reported in the February 2017 Monthly Book still displayed the same total that was first published at the end of 2015 (382). OIG personnel then verified that a subsequent SCIF presentation reflected an updated total of 414 for 2015 “Inmate-on-Staff” assaults, a 7.7% increase. The lack of subsequent updates to the published totals in the Monthly Books results in the permanent underreporting of Inmate Assault data. Inmate Assault Totals Should Vary Depending on the Date They are Generated. Inmate Assault totals in the Monthly Books present another example of how consistency in reported totals in all reports may actually indicate that the reported data is stale or less accurate. Depending upon when the report is created, inconsistent totals that change over time may indicate greater accuracy as totals are updated. Indeed, Inmate Assault totals should change over time as the JIU Tracker is updated. As such, totals that are generated at a later date for the same year will usually yield different results. The table below reflects three different reported totals for 2015 “Inmate-on-Staff” assaults. The variation is as much as 40 between two reports that were generated approximately 14 months apart. Inmate-on-Staff Assaults for 2015 YEAR REPORT 2015 2015 2015 February 2016 Monthly Book SCIF SCIF Inmate-on-Staff Assaults Date Issued 382 414 422 2/16/2016 10/27/2016 4/18/2017 The table below reflects variances in 2016 “Inmate-on-Inmate” assaults. The variance is as much as 396 between the February 2017 and April 2017 reports. Though such high variation is troubling, it suggests that the “Inmate-on-Inmate” assault totals are being updated with new data. Inmate-on-Inmate Assaults for 2016 as Reported in 2017 YEAR REPORT 2016 2016 2016 February 2017 Monthly Book Provided to LA TIMES SCIF Inmate-on-Inmate Totals Date Issued 3104 3354 3500 2/1/2017 2/14/2017 4/18/2017 Page 13 Office of Inspector Generalf Los Angeles Times Data Compared to Data Provided to the Office of Inspector General When the Los Angeles Times inquired about the total number of “Inmate-onInmate” assaults, the Department provided totals that differed from the totals previously published by the OIG. OIG personnel compared the two sets of totals and found significant differences in the totals for each year from 2007 through 2013 and for 2016. 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 Totals Provided to LA Times 2,496 2,393 2,235 2,124 1,880 2,621 3,076 2,849 3,104 3,354 26,132 Provided to OIG 1,804 1,494 1,370 1,395 1,302 1,682 2,746 2,849 3,104 3,716 21,462 Difference 692 899 865 729 578 939 330 - - (362) 4,670 Percent Difference 27.7% 37.6% 38.7% 34.3% 30.7% 35.8% 10.7% 0.0% 0.0% 10.8% 17.9% Discrepancies between the 2007 through 2013 Totals The Department’s explanation for the different 2007 through 2013 totals is that the totals were generated by the FAST database. At the time, the Department did not realize that the FAST database limited the number of assaults that could be transferred from its Paradox software into the Excel spreadsheet that was used to tabulate the results. Consequently, the Department acknowledged, the numbers provided to the OIG for 2007 through 2013 underreported the totals due to this software issue. This problem was identified by department staff and a “work around” was used to produce the totals for the Los Angeles Times, which may be more accurate – or at least not definitively incorrect. The OIG was not provided work papers and therefore this error cannot be replicated. Discrepancies Between the 2016 Totals The JIU staff reported that the 2016 total reported to the OIG was incorrect and was issued in error. The JIU staff explained and provided work papers which showed that the numbers provided to the OIG reflected assaults that occurred in non-jail units such as Transportation and Court Services while inmates were enroute to or present in courts for their case appearances. As such, the JIU reported Page 14 Office of Inspector Generalf the number provided to the OIG over-stated the number of “Inmate-on-Inmate” assaults. OIG personnel reviewed the work papers and verified the Department’s explanation accounted for the differences in the 2016 totals. However, to exclude inmate-oninmate assaults because those assaults do not occur within the jails is misrepresentative of the true number of in-custody inmate-on-inmate assaults. CONCLUSION There is no single unit in the Department that is responsible for reconciling, verifying and validating the accuracy of jail violence statistics. The Department has acknowledged that this absence of centralized accountability allowed for inaccurate data to be generated and, if continued, would impede the Department’s ability to correct the problem. The Department maintains that it has not intentionally misled stakeholders in releasing inaccurate data, and the OIG review did not reveal information to suggest otherwise. However, on May 24, 2017, after the inaccuracies were discovered, department executives and the Custody Compliance and Sustainability Bureau again presented jail violence data at a Public Safety Cluster Agenda Review Meeting (CAR). This data was generated in the same manner, using the same databases and may reasonably be expected to contain similar errors. The Department’s system of tracking jail violence is comprised of a confusing collection of databases and processes. Each database is stand alone and there is no uniform procedure for reconciliation to ensure that subsequent additions, deletions or amendments are input to each database and are tracked consistently. Because these data are used by the Department to identify systemic deficiencies that impact safety and jail operations, report information to the OIG and other stakeholders, and for strategic planning purposes, it must be accurate if they are expected to be useful. RECOMMENDATIONS 1. A single unit should be responsible for compiling, reconciling, verifying, and validating the accuracy of all jail violence data. Any future statistical methods and data reconciliation should adhere to generally accepted record keeping standards. The responsible unit should keep organized work papers for later evaluation and replication of its work, and data generated by this unit should be periodically audited and/or overseen by the AAB. 2. The Department should not release any data unless it is sure of its accuracy within a certain and identified margin of error. Any margins of error, Page 15 Office of Inspector Generalf qualifying variables, or potential discrepancies must be clearly identified and reported with the data. 3. The Custody Services Division should ensure that any future Monthly Books or reports that contain data include the most current data available. Monthly Books or other reports which include data previously reported should be updated with the most current data. 4. The Department should identify which data collection system it will utilize for tracking and reporting each data set, and the single and centralized unit discussed in recommendation 1 above should be responsible for immediately reconciling and updating each dataset across all data collection systems. 5. The Department should create a standardized Facility Tracker template for use by all custody facilities to ensure consistency. This template could be modified to include the particular data requirements of each unit, but a baseline set of tracked data elements should be standardized across all facilities for ease and accuracy of compilation and analysis. 6. The Department should create a standardized Force Alert form for use by all custody facilities to ensure consistency. Although Force Alerts work well in notifying management when incidents happen, their inconsistent formats and inconsistent data points make their use as a statistical tool problematic. Standardized Force Alert forms should reduce error in the reporting and tracking of use-of-force incidents and create a more useful data set for future analysis. 7. Clear data collection and entry guidelines should be established and manuals and training provided to ensure that data is entered into all databases in a consistent manner at all custody facilities. 8. Custody facilities should conduct monthly reconciliations between incident alerts, databases (e-LOTS and FAST) and trackers to ensure consistency of the total number of force incidents. These reconciliations should then be verified for accuracy by the single and centralized unit discussed in recommendation 1 above. 9. All positions tasked with compiling statistical data should be staffed with qualified civilian personnel with an appropriate level of education, training and expertise in data collection/reporting and database management. All personnel should be trained in a single and consistent data entry method by qualified personnel. 10. The Department should re-evaluate the methodology used for compiling Inmate Assault data and develop a more accurate reporting mechanism for incidents which include multiple assaults against inmates and/or staff within a single incident of jail violence. Page 16 Office of Inspector Generalf 11. The Department should implement an Inmate Assault Alert system similar to the one used for Force Alerts to quickly inform the Jail Investigations Unit of inmate-on-inmate or inmate-on-staff incidents. Inmate Assault Alert details could then be reconciled with LARCIS to ensure that every assault is tracked. 12. Manual of Policy and Procedures 4-01/020.40, Supplemental Reports, requires that line personnel complete the Custody Services Division’s Crime Analysis Supplemental form (SH-R-49C). Custody should ensure the appropriate data is memorialized and the correct forms are utilized by line staff. In addition, the Department should enforce the time deadline for the submission of crime reports and related crime analysis supplemental forms to the Jail Investigations Unit. 13. The Department should consider discontinuing its use of the FAST database altogether. The OIG will continue to monitor this issue and any corrective action taken. Page 17 (71 - iCE CFJ-HE Sfl[EREFE 1054 COUNTY OF LOS ANGELES C4LIroR4L JD’i MCDONXELL, ShERIFF August 22, 2017 Max Huntsman, Inspector General Los Angeles County Office of Inspector General 312 South Hill Street, 3rd Floor Los Angeles, California 90013 Dear Mr. Huntsman: RESPONSE TO THE LOS ANGELES CO!Th[TY OFFICE OF INSPECTOR GENRLAL REPORT ON A REVIEW OF THE JAIL VIOLENCE, TELA.CKING, ATD REPORTING PROCEDURES OF THE LOS ANGELES COTXNTY SHERIFF’S DEPARTIvtENT Attached is the Los Angeles County Sheriff’s Department’s (Department) response to the Los Angeles County Office of Inspector General’s (OIG) final report entitled, “A Review of the Jail Violence Tracking and Reporting Procedures of the Los Angeles County Sheriff’s Department.” As I believe you are aware, this past spring, prior to the release of the aboveentitled report, I directed our internal Audit and Accountabifity Bureau (AAB) to conduct a Department-wide examination of our Information and Technology (IT) Systems. The examination was conducted in accordance with Generally Accepted Government Auditing Standards. The results of the examination were presented to me on July 11, 201%, and identified deficiencies in internal controls governing the collection, storage, and dissemination of data. In addition, AAE identified the use of antiquated and obsolete IT systems which need to be reconciled with other IT systems to obtain accurate information. The examination also identified root causes related to data inconsistencies as a Department-wide issue rather than a singular issue isolated to Custody Operations. AAE recommended that deficiencies with the IT systems be addressed and solved as a Department-wide effort. Consequently, the Technology and Support Division, as the governing body for the Department’s 211 WEST TENPLE Siiii, Los ANGELES, CMIFo1uA 90012 Aadin o/ Peice — nce 1850 —‘ Mr. Huntsman -2- August 22, 2017 IT systems, will be included as part of any corrective action, as well as Custody Operations. We thank you and your staff for your efforts in reviewing the Jail Violence and Reporting Procedures in Custody Operations and your specific recommendations are addressed in the attached document. As you may note, the reforms identified by our internal examination are generally in line with recommendations in your report. We are confident that the implementation of such reforms will bring progress toward our goal of a comprehensive data solution. In the meantime, as we carry on our day-to-day work amongst the challenges of legacy systems, we respectfu]ly disagree with any assertion that there exists a lack of control, a manipulation of data, or any intent to mislead or provide false fliformation to the public. The examination we conducted, as well as all of the underlying documentation, recommendations, and processes, is available for your review should you wish to see it. The Audit and Accountability Bureau has the responsibifity to monitor and document the Department’s response related to this review. Should you have any questions regarding the Department’s response, please contact Captain Steven E. Gross at (323) 307-8302. Sincerel I JI McDONNELL SHERIFF RESPONSE TO THE LOS ANGELES COUNTY OFFICE OF INSPECTOR GENERAL REPORT COUNTY OF LOS ANGELES — SHERtFF SUBJECT: A REVIEW OF THE JAIL VIOLENCE TRACKING AND REPORTING PROCEDURES OF THE LOS ANGELES COUNTY SHERIFF’S DEPARTMENT Response of Recommendations by the OIG 1. A single unit should be responsible for compiling, reconciling, verifying, and validating the accuracy of all jail violence data. Any future statistical methods and data reconciliation should adhere to generally accepted record keeping standards. The responsible unit should keep organized work papers for later evaluation and replication of its work, and data generated by this unit should be periodically audited and/or overseen by the AAB. Response: Concur. A standardized methodology for data collection and verification reduces the likelihood of inconsistent data. A centralized unit adhering to a standardized data governance process increases accuracy and ensures accountability. The AAB is an independent audit organization and has authority to audit, but no authority to oversee another unit as indicated in the recommendation. The OIG’s report references the Generally Accepted Recordkeeping Principles (the Principles) established the Association of Records Managers and Administrators (ARMA). The Principles create a high-level framework of good practice which would include the maintenance of all work papers related to these processes for accountability and validation purposes. The Department will identify the appropriate positions as stated in recommendation 9, and identify if a funding request is warranted. However, in the meantime, training will be sought to educate the current Custody staff responsible for these tasks. 2. The Department should not release any data unless it is sure of its accuracy within a certain and identified margin of error. Any margins of error, qualifying variables, or potential discrepancies must be clearly identified and reported with the data. Response: Concur. The data should be cited and sourced to indicate the origin of the data, as well as the time period, the unit responsible for releasing the data, and any variables or disclaimers known in advance. If data is preliminary, the release of that data should be contingent on whether the need for the data outweighs the delay for its validation. 1 3. The Custody Services Division (CSD) should ensure that any future Monthly Books or reports that contain data include the most current data available. Monthly Books or other reports which include data previously reported should be updated with the most current data. Response: Concur. Adhering to a standardized data governance process increases accuracy and ensures accountability. The Custody Services Division (CSD) have discontinued the Monthly Books, but will ensure that any future reports that contain data include the most current data available and that reports which include data previously reported are updated with the most current data. 4. The Department should identify which data collection system it will utilize for tracking and reporting each data set, and the single and centralized unit discussed in Recommendation No. I should be responsible for immediately reconciling and updating each dataset across all data collection systems. Response: Concur. A standardized methodology for data collection and verification reduces the likelihood of inconsistent data. 5. The Department should create a standardized Facility Tracker template for use by all custody facilities to ensure consistency. This template could be modified to include the particular data requirement of each unit, but a baseline set of tracked data elements should be standardized across all facilities for ease and accuracy of compilation and analysis. Response: Concur in part. Facility Trackers should only be employed as a subset of a centralized database. Relying on these independent trackers as the source of data undermines the Department’s goal of consistency, transparency, and accountability. Independent trackers do not employ the same security as Department databases which require a login by specified personnel. 6. The Department should create a standardized Force Alert form for use by all custody facilities to ensure consistency. Although Force Alerts work well in notifying management when incidents happen, their inconsistent formats and inconsistent data points make their use as a statistical tool problematic. Standardized Force Alert forms should reduce error in the reporting and tracking of use-of-force incidents and create a more useful dataset for future analysis. 2 Response: Concur in part. Force Alerts are internal notifications to management that a force incident occurred, and as such, should only be used for that purpose. Force Alerts should not be used for statistical data tracking. Utilizing Force Alerts for data tracking further exacerbates the issue of having multiple points of data entry, requiring a greater need for reconciling data. 7. Clear data collection and entry guidelines should be established and manuals and training provided to ensure that data is entered into all databases in a consistent manner at all custody facilities. Response: Concur. This issue is prudent for the Department as a whole to increase accuracy and ensures accountability. 8. Custody facilities should conduct monthly reconciliations between incident alerts, databases (e-LOTS and FAST), and trackers to ensure consistency of the total number of force incidents. These reconciliations should then be verified for accuracy by the single and centralized unit discussed in Recommendation No. 1 above. Response: Concur in part. Incident alerts should not be used for statistical tracking. The Department plans to sunset FAST as it is an antiquated IT system which has been shown to be historically unreliable. The database e-LOTS was created for Custody with the intent of providing management with the progress of a force investigation. The goal is to reconcile FAST and e-LOTS into one system called CARTS, a project already underway. 9. All positions tasked with compiling statistical data should be staffed with qualified civilian personnel with an appropriate level of education, training, and expertise in data collection/reporting and database management. All personnel should be trained in a single and consistent data entry method by qualified personnel. Response: Concur. In 2015, the Department created the Chief Data Officer position in order to make sure that information is accessible, properly managed, secured and disseminated in a consistent manner. Custody concurs that each custody facility should have a professional staff position with the responsibility of maintaining and tracking data. The position should be part of the Chief Data Office for data dissemination, which is then responsible for any public data sharing responsibilities. 3 10.The Department should re-evaluate the methodology used for compiling Inmate Assault data and develop a mote accurate reporting mechanism for incidents which include multiple assaults against inmates and/or staff within a single incident of jail violence. Response: Concur. The current method of relying on the Jail Investigations Unit (JIU) to track assault incidents is ineffective. The Custody Division is currently implementing protocols so that jail violence is tracked by incident as well as by victims, as often there are more victims involved in a single incident. LARCIS currently provides reports with these totals and will be utilized as the sole source. Additionally, the Department will evaluate whether force incidents should be tracked by individual incidents, or by victim as is currently the standard used in Patrol Operations. That standard is defined by the Criminal Justice Information Services (CJIS) Division Uniform Crime Reporting (UCR) Program. II. The Department should implement an Inmate Assault Alert system similar to the one used for Force Alerts to quickly inform the Jail Investigations Unit of inmate-on-inmate, or inmate-on-staff incidents. Inmate Assault Alert details could then be reconciled with LARCIS to ensure that every assault is tracked. Response: Concur in part. Alerting management and investigators of an assault incident is a necessity. This is not unique to Custody Operations. Patrol Operations documents these incidents in the shift Watch Commander Logs where any type of notifications can be delivered through the Station/Bureau Administration Portal to concerned parties. Currently, the policies within the Custody Division Manual requires watch commanders to initiate an “Incident Alert,” for all significant issues including serious assaults, riots, significant injuries, and/or assaults against staff. The County jails average about 300 to 400 assaults on a monthly basis. Initiating an additional “Incident Alert” specifically for all assaults will result in an additional tracking mechanism, which would require staff to manually track these incidents. The results of another “tracker” could easily cause unreliable statistics. The Department currently utilizes LARCIS and will discontinue the use of the Jail Investigation Unit tracker as a tool to cross reference completed assault reports. The Department concurs that utilizing a single source to track all crimes is more efficient. 12. Manual of Policy and Procedures, Section 4-01/020.40; Supplemental Reports, requires that line personnel complete the Custody Services Division’s Crime Analysis Supplemental form (SH-R-49C). Custody should ensure the appropriate data is memorialized and the correct forms are utilized by line staff In addition, the Department should enforce the time deadline for the submission of crime reports and related crime analysis supplemental forms to the Jail Investigations Unit. 4 Response: Concur. The JIU acts as the detective bureau for Custody. Similar processes with the submission, approval, and tracking of crime reports as used in Patrol Operations should be applied to Custody for overall consistency throughout the Department. 13.The Department should consider discontinuing its use of the FAST database altogether. Response: Concur. As mentioned above, the Department plans to sunset FAST as it is an antiquated IT system. Any future IT system changes should be done in collaboration with the governance policies created and set forth by the Technology and Support Division. 5