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DOJ Report on CRIPA Investigation of Rikers Island, 2014

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U.S. Department of Justice

[Type text]

United States Attorney
Southern District of New York
86 Chambers Street
New York, New York 10007

August 4, 2014
The Honorable Bill de Blasio
City Hall
260 Broadway
New York, NY 10007
Commissioner Joseph Ponte
New York City Department of Correction
75-20 Astoria Blvd.
East Elmhurst, NY 11370
Zachary Carter
Corporation Counsel of the City of New York
100 Church Street
New York, NY 10007

CRIPA Investigation of the New York City Department of Correction Jails on
Rikers Island

Dear Mayor de Blasio, Commissioner Ponte, and Mr. Carter:
We write to report the findings of the investigation of the United States Attorney’s Office
for the Southern District of New York into the treatment of adolescent male inmates, between the
ages of 16 and 18, at New York City Department of Correction (“DOC” or the “Department”)
jails on Rikers Island (“Rikers”).1 By letter dated January 12, 2012, we notified the City of our
intent to conduct an investigation pursuant to the Civil Rights of Institutionalized Persons Act
(“CRIPA”), 42 U.S.C. § 1997, and Section 14141 of the Violent Crime Control and Law
Enforcement Act of 1994, 42 U.S.C. § 14141 (“Section 14141”). CRIPA and Section 14141
give the United States Department of Justice the authority to seek a remedy for a pattern or
practice of conduct that violates the constitutional rights of inmates in detention and correctional
facilities. Our investigation has centered exclusively on whether DOC adequately protects
adolescents from harm. More specifically, we have focused on whether adolescents are subject
to excessive and unnecessary use of force by DOC correction officers and their supervisors,
whether DOC adequately protects adolescents from violence by other inmates, and whether
DOC’s extensive reliance on punitive segregation subjects adolescents to an excessive risk of

When we use the term “adolescents” or “adolescent inmates” in this letter, we are referring to male inmates
between the ages of 16 and 18 housed at Rikers.

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We primarily focused on practices and conduct during the period 2011 through the end of
2013. We reviewed hundreds of thousands of pages of records from both DOC and the
Department of Health and Mental Health (“DOHMH”), which is responsible for providing
medical services to inmates at Rikers.2 These records included, among other things, use of force
investigative files, inmate medical records, policies and procedures, training materials,
disciplinary records, programmatic materials related specifically to adolescent inmates, and other
data. We identified a sample of approximately 200 use of force incidents involving adolescent
inmates, and specifically requested all records related to these incidents, including use of force
reports, investigative reports and files, video surveillance, inmate medical records, and records
relating to any disciplinary action taken against involved inmates or staff.3 The Appendix to this
letter includes summaries of several of these incidents, which are intended to illustrate some of
the systemic problems we have identified through our investigation.
In addition, on January 8-11, 2013, and April 8-12, 2013, we conducted tours of those
DOC facilities that house adolescent inmates together with a consultant who is an expert in
corrections generally and use of force specifically. Together with our consultant, we interviewed
staff from DOC and DOHMH on issues related to our investigation, including use of force
policies and practices, inmate supervision, staffing, the use of punitive segregation, medical
treatment of injuries, security, investigations, training, programs specific to adolescent inmates,
and facilities management. Our consultant also interviewed 46 adolescent inmates.4
Additionally, we had discussions with former Commissioner Schriro and her senior staff in
January 2013 and December 2013.
We also conducted additional witness interviews, including interviews with staff from the
Board of Correction, an independent board established by the City Charter responsible for
ensuring DOC’s compliance with minimum correctional standards. Finally, we reviewed
materials provided to us by third parties, including the Board of Correction and the Legal Aid


We did not undertake a review of the adequacy of medical or mental health services provided to adolescent
inmates at Rikers. Our discussions with DOHMH staff and review of DOHMH records were purely in support of
our investigation into staff use of force, inmate-on-inmate violence, and the use of punitive segregation. However,
our investigation nonetheless raises serious concerns about the quality of mental health services at Rikers; this
critical issue, which warrants considerable attention and potentially raises concerns both under CRIPA and the
Americans with Disabilities Act (“ADA”), may be addressed in a future investigation by this Office.

For various reasons, including because DOC was unable to locate some videos, and because DOC did not provide
us with open DOC Investigation Division and staff disciplinary files, we did not receive all relevant records for these
sample incidents.

After City attorneys expressed their desire to sit in on these interviews, we reached an agreement with the City
whereby our consultant interviewed inmates one-on-one, outside both our presence and the presence of City
attorneys, to encourage full and candid discussion between the inmates and our consultant. We participated,
however, in the interview of one adolescent inmate—Inmate D—who was involved in a use of force that is
highlighted in the Appendix to this report.

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We thank DOC staff for their cooperation and professionalism throughout the course of
this investigation. The City has provided us with access to personnel and a large volume of
records, and we have every reason to believe that the City will be receptive to our
recommendations. Consistent with the statutory requirements of CRIPA, we now write to advise
you of the findings of our investigation and the minimum remedial steps necessary to address the
serious deficiencies we have identified. 42 U.S.C. § 1997b.
We conclude that there is a pattern and practice of conduct at Rikers that violates the
constitutional rights of adolescent inmates. In particular, we find that adolescent inmates at
Rikers are not adequately protected from harm, including serious physical harm from the
rampant use of unnecessary and excessive force by DOC staff. In addition, adolescent inmates
are not adequately protected from harm caused by violence inflicted by other inmates, including
inmate-on-inmate fights. Indeed, we find that a deep-seated culture of violence is pervasive
throughout the adolescent facilities at Rikers, and DOC staff routinely utilize force not as a last
resort, but instead as a means to control the adolescent population and punish disorderly or
disrespectful behavior. Moreover, DOC relies far too heavily on punitive segregation as a
disciplinary measure, placing adolescent inmates—many of whom are mentally ill—in what
amounts to solitary confinement at an alarming rate and for excessive periods of time.
As discussed more fully below, these conditions have resulted in serious harm to
adolescent inmates at Rikers. As a result of staff use of excessive force and inmate violence,
adolescents have sustained a striking number of serious injuries, including broken jaws, broken
orbital bones, broken noses, long bone fractures, and lacerations requiring sutures.
Our focus on the adolescent population should not be interpreted as an exoneration of
DOC practices in the jails housing adult inmates. Indeed, while we did not specifically
investigate the use of force against the adult inmate population, our investigation suggests that
the systemic deficiencies identified in this report may exist in equal measure at the other jails on
We recognize that Commissioner Ponte recently assumed the position and was not
present when the misconduct detailed in this letter occurred. We look forward to engaging in
good faith discussions with the Commissioner and all interested parties to address the issues we
have identified and implement appropriate remedial measures.


The Department is currently the subject of a class action lawsuit brought by current and former inmates at Rikers
alleging system-wide, unconstitutional use of force by staff against inmates. See Nunez v. City of New York, 11 Civ.
5845 (LTS) (THK).

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We find that the New York City Department of Correction systematically has failed to
protect adolescent inmates from harm in violation of the Eighth Amendment and the Due Process
Clause of the Fourteenth Amendment of the United States Constitution. This harm is the result
of the repeated use of excessive and unnecessary force by correction officers against adolescent
inmates, as well as high levels of inmate-on-inmate violence.
We have made the following specific factual determinations:

force is used against adolescents at an alarming rate and violent inmate-on-inmate
fights and assaults are commonplace, resulting in a striking number of serious
correction officers resort to “headshots,” or blows to an inmate’s head or facial area,
too frequently;
force is used as punishment or retribution;
force is used in response to inmates’ verbal altercations with officers;
use of force by specialized response teams within the jails is particularly brutal;
correction officers attempt to justify use of force by yelling “stop resisting” even
when the adolescent has been completely subdued or was never resisting in the first
place; and
use of force is particularly common in areas without video surveillance cameras.

Furthermore, we identified the following systemic deficiencies that contribute to,
exacerbate, and indeed are largely responsible for the excessive and unnecessary use of force by
DOC staff. Many of these systemic deficiencies also lead to the high levels of inmate violence.
These deficiencies include:

inadequate reporting by staff of the use of force, including false reporting;
inadequate investigations into the use of force;
inadequate staff discipline for inappropriate use of force;
an inadequate classification system for adolescent inmates;
an inadequate inmate grievance system;
inadequate supervision of inmates by staff;
inadequate training both on use of force and on managing adolescents; and
general failures by management to adequately address the extraordinarily high levels
of violence perpetrated against and among the adolescent population.

Finally, DOC’s use of prolonged punitive segregation for adolescent inmates is excessive
and inappropriate.

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Department of Correction Jails on Rikers Island

The Department oversees one of the largest municipal jail complexes in the country.
DOC handles over 100,000 admissions per year and manages an average daily population of
approximately 14,000 inmates,6 the vast majority of whom are held in ten facilities located on
over 400 acres on Rikers Island in the East River.7 The population consists primarily of pre-trial
detainees, although there is one facility on Rikers that houses sentenced inmates serving terms of
one year or less. Medical services are the responsibility of DOHMH, which contracts with
Corizon Correctional Health. Corizon staffs the medical clinics at each facility on Rikers, which
provide day-to-day, out-patient medical care to inmates.

Adolescent Housing Units on Rikers Island

New York is one of only two states that automatically charges all individuals aged 16 and
older as adults.8 Adolescent males are currently housed in three different jails on Rikers. Most
adolescents are placed at the Robert N. Davoren Center (“RNDC”). Recently, DOC assigned 18year olds to separate RNDC housing units so they are no longer co-mingled with the 16- and 17year olds. Sentenced adolescent males are placed at the Eric M. Taylor Center (“EMTC”), which
houses inmates sentenced to serve one year or less. Finally, up to 50 adolescents may be housed
in the Central Punitive Segregation Unit (“CPSU”) at the Otis Bantum Correctional Center
(“OBCC”), which, as its name suggests, is a central location for adult and adolescent inmates
who are placed in punitive segregation after being found guilty of an infraction or who are in
pre-hearing detention status. Until recently, up to 50 adolescents were also housed in the Mental
Health Assessment Unit for Infracted Inmates (“MHAUII”), a punitive segregation unit at the
George R. Vierno Center (“GRVC”) used to house infracted mentally ill inmates. The
Department closed MHAUII in late 2013.
Like many of the facilities on Rikers, the facilities that house adolescents are old and in
poor condition. RNDC was opened in 1972, EMTC in 1964, and OBCC in 1985. Currently, all
adolescents at RNDC are housed in cells, with the exception of newly admitted adolescents and
those in mental observation housing units, who are housed in dormitories. Adolescents in EMTC
are housed in dormitories. Adolescents in the CPSU are housed in a block of punitive
segregation cells set aside for adolescents. Over the course of our investigation, DOC increased
the number of staff assigned to RNDC, including an increase from three to five officers in
housing units during non-school hours, and added several supervisors, including a Deputy
Warden responsible for adolescents.

See Department of Correction website,


Additional facilities are located in Brooklyn, Manhattan, Queens, and a floating jail barge in the Bronx. See

North Carolina is the other state.

Page 6


Description of Adolescent Population

The average daily adolescent population at Rikers has recently deceased. The average
daily adolescent population was 489 in FY 2014, 682 in FY 2013, and 791 in FY 2012.9
The adolescent population at Rikers is a difficult one. As compared with the adult inmate
population, far more adolescents suffer from mental illness and more adolescents are awaiting
trial on felony charges. In FY 2013, approximately 51% of adolescent inmates at Rikers were
diagnosed with some form of mental illness. Inmates with mental illness are less likely to make
bail as they tend to have fewer financial resources and family members are less willing to post
their bail, so their average length of stay tends to be longer. In FY 2013, the average length of
stay on Rikers for adolescents was 74.6 days. Also in FY 2013, nearly two-thirds of all
adolescents admitted to Rikers were charged with felony crimes—almost twice the level as for
adults admitted to Rikers. The recidivism rate is also high. In FY 2013, the average number of
prior admissions into DOC custody for adolescents was 1.02. In addition, many adolescent
inmates are associated with street gangs and gang activity.


CRIPA prohibits states or their political subdivisions from engaging in a pattern or
practice of conduct that deprives persons residing in or confined to an institution of their
constitutional rights. See 42 U.S.C. § 1997a(a). Section 14141 similarly prohibits officials or
employees of any governmental agency with responsibility for the incarceration of juveniles
from engaging in a pattern or practice of conduct that deprives persons of rights, privileges, or
immunities secured or protected by the Constitution or laws of the United States. See 42 U.S.C.
§ 14141.
Prison administrators are constitutionally required “to take reasonable measures to
guarantee the safety of the inmates.” Hudson v. Palmer, 468 U.S. 517, 526-27 (1984); Hayes v.
NYC Dep’t of Corr., 84 F.3d 614, 620 (2d Cir. 1996). When a jurisdiction takes a person into
custody and holds him against his will, the Supreme Court has held that the Constitution
“imposes upon it a corresponding duty to assume some responsibility for his safety and general
well-being.” County of Sacramento v. Lewis, 523 U.S. 833, 851 (1998) (quoting DeShaney v.
Winnebago County Dept. of Social Servs., 489 U.S. 189, 199-200 (1989)); see also Randle v.
Alexander, 960 F. Supp. 2d 457, 471 (S.D.N.Y. 2013).
While the constitutional rights of convicted prisoners and pre-trial inmates are guaranteed
under different constitutional norms, courts have consistently held that pre-trial detainees “retain
at least those constitutional rights . . . enjoyed by convicted prisoners [under the Eighth
Amendment].” Bell v. Wolfish, 441 U.S. 520, 545 (1979); see also Cuoco v. Moritsugu, 222
9 These figures
include adolescent females, which represent approximately 10% of all adolescent admissions. The fiscal year runs
from July through June of the following year.

Page 7

F.3d 99, 106 (2d Cir. 2000) (noting that courts apply the “Eighth Amendment deliberate
indifference test to pre-trial detainees bringing actions under the Due Process Clause of the
Fourteenth Amendment”); Weyant v. Okst, 101 F.3d 845, 856 (2d Cir. 1996).
The Eighth and Fourteenth Amendments forbid excessive physical force against inmates
and pre-trial detainees. See Farmer v. Brennan, 511 U.S. 825, 832 (1994); see also United States
v. Walsh, 194 F.3d 37, 48 (2d Cir. 1999). In determining whether excessive force was used,
courts examine a variety of factors, including the extent of the injury suffered by the inmate, the
need for the application of force, the relationship between the need for force and the amount of
force used, the threat, if any, reasonably perceived by the responsible correction officers, and any
efforts made to temper the severity of a forceful response. See Hudson v. McMillian, 503 U.S. 1,
7 (1992).
An Eighth Amendment claim for failure to protect inmates from harm is comprised of
both a subjective and an objective component. See Farmer, 511 U.S. at 834. The subjective
component requires a showing that a prison official acted with “‘deliberate indifference’ to
inmate health or safety.” Id. This requirement is satisfied when the official “knows of and
disregards an excessive risk to inmate health or safety.” Id. at 837. “[T]he official must both be
aware of facts from which the inference could be drawn that a substantial risk of serious harm
exists, and he must also draw the inference.” Id. The objective component turns on whether the
inmate “is incarcerated under conditions posing a substantial risk of serious harm.” Id. at 834.
“Importantly, the objective prong can be satisfied even when no serious physical injury results.”
Randle, 960 F. Supp. 2d at 473.


Extraordinary Frequency of Violence

Adolescent inmates are subject to pervasive violence at Rikers. DOC staff routinely use
force unnecessarily as a means to control the adolescent population and punish disobedient or
disrespectful inmates in clear violation of DOC policy. Even when some level of force is
necessary, the force used is often disproportionate to the risk posed by the inmate, frequently
resulting in serious injuries to inmates and staff. In addition, inmate-on-inmate fights and
assaults are commonplace, in part because youth are inadequately supervised by inexperienced
and inadequately trained correction officers.
Adolescents are at constant risk of physical harm while incarcerated. The number of
injuries sustained by adolescents is staggering. For instance, during the period April 2012
through April 2013, adolescents sustained a total of 754 visible injuries, according to DOHMH
Inmates see others being beaten and attacked and are afraid that they will face the same
fate. During interviews with our consultant, many inmates expressed fear for their personal

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safety. The RNDC Ombudsman advised us that inmates have shared safety concerns with him as
well. Some inmates have even expressed a preference to be placed in punitive segregation
instead of the general RNDC population due to the high level of violence at the facility.
On a daily basis, emergency alarms sound repeatedly in adolescent housing areas
signaling some altercation or disturbance. As a result, the facility frequently is placed in locked
down status and inmates are confined to their cells. In FY 2013 alone, there were 1,118
responses to emergency alarms in the RNDC and EMTC adolescent housing areas, or on average
more than three alarms each day.
Simply put, Rikers is a dangerous place for adolescents and a pervasive climate of fear
exists. For years, DOC officials have been well aware of the frequency and severity of staff use
of force against adolescents, the high incidence of inmate-on-inmate fights, and the number of
serious injuries sustained by adolescents, but have failed to take reasonable steps to ensure
adolescents’ safety. See Farmer, 511 U.S. at 847 (“a prison official may be held liable under the
Eighth Amendment . . . only if he knows that inmates face a substantial risk of serious harm and
disregards that risk by failing to take reasonable measures to abate it”); Ayers v. Coughlin, 780
F.2d 205, 209 (2d Cir. 1986) (prison officials have a duty to “employ reasonable measures to
protect an inmate from violence by other prison residents”); Anderson v. Branen, 17 F.3d 552,
557 (2d Cir. 1994) (noting that law enforcement officers bear an affirmative duty to intercede
when they witness or have reason to know excessive force is being used or any constitutional
violation is being committed).

Frequency of Staff Use of Force

Staff use force against adolescent inmates with alarming frequency. In FY 2013, there
were 565 reported staff use of force incidents involving adolescents in RNDC and EMTC
(resulting in 1,057 injuries).10 This represented a slight increase from FY 2012, when there were
517 reported staff use of force incidents involving adolescents at these same facilities (resulting
in 1,059 injuries). These are extraordinary figures considering that the average daily adolescent
population at Rikers was only 682 in FY 2013, and 791 in FY 2012. Indeed, 308 (or 43.7%) of
the 705 adolescent males in custody as of October 30, 2012, had been subjected to the use of
force by staff on at least one occasion. Indeed, while adolescents made up only about 6% of the
average daily population at Rikers, they were involved in a disproportionate 21% of all incidents
involving use of force and/or serious injuries. Our consultant, who has observed and worked
with hundreds of correctional facilities, has never seen a higher use of force rate.
Moreover, the use of force numbers are undoubtedly even higher than DOC’s data
suggest because many incidents go unreported. As discussed infra, correction officers often do


These use of force figures exclude “use of force allegations,” which refer to instances when sources other than
DOC personnel report that force was used on an inmate. There were 56 use of force allegations at RNDC or EMTC
in FY 2013 and 45 in FY 2012.

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not accurately report incidents, and warn inmates to “hold it down” or otherwise pressure them
not to report use of force incidents.

Frequency of Inmate-on-Inmate Violence

The number of reported inmate-on-inmate fights and assaults is also striking, and further
demonstrates that DOC is not fulfilling its responsibility to ensure the safety and well-being of
adolescent inmates, resulting in grave harm to adolescents.
In FY 2013, there were 845 reported inmate-on-inmate fights involving adolescents at
RNDC and EMTC. This marked an increase from the 795 reported fights in FY 2012.11 In the
first half of FY 2014, a total of 775 infractions were issued to adolescents for fighting. Many
fights involve the use of weapons, which are widespread at Rikers. During FY 2013, 345
weapons were discovered in the RNDC and EMTC adolescent housing areas, consisting mostly
of shanks and shivs. Our consultant has never observed a system with such frequent inmate-oninmate violence.
Again, there is good reason to suspect that inmate-on-inmate fights are even more
prevalent than reflected in DOC’s data. According to the results of an internal audit completed
last year, RNDC failed to report 375 fights during calendar year 2011 alone, due in part to the
lack of a codified definition of “inmate fight,” and inconsistencies in how staff recorded and
reported inmate altercations.12 Based on our discussions with former and current Department
staff, similar reporting errors likely persisted well after 2011.
The limited programming and structured activities available at RNDC in part contribute
to the extraordinary level of inmate-on-inmate violence. We recognize that DOC has taken steps
to enhance its adolescent programming, including through the introduction of the Adolescent
Behavioral Learning Experience (“ABLE”), a privately-funded, wrap-around school program
administered by outside providers. However, adolescents remain too idle, particularly during
evenings and weekends, which increases the likelihood of altercations. Moreover, the large
number of adolescents in punitive segregation, discussed infra, are not permitted to participate in
the limited programming that is available.


From April 2012 through April 2013, adolescent fights resulted in 430 visible inmate injuries, according to
DOHMH data.


The internal report was not issued until 16 months after then-Commissioner Schriro directed the audit. RNDC
staff’s failure to accurately and consistently document inmate fights also was noted during a prior security audit in
early 2011, but little was done to address the problem.

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High Number of Serious Injuries

Staff uses of force and inmate-on-inmate fights and assaults have resulted in an alarming
number of serious injuries to adolescents, including broken jaws, broken orbital bones, broken
noses, long bone fractures, and lacerations requiring stitches. DOC too often fails to ensure that
these injured inmates receive prompt medical care.
The prevalence of head injuries is particularly striking. Adolescents suffer a
disproportionate number of the reported inmate head injuries on Rikers. From June 2012
through early July 2013, adolescents sustained a total of 239 head injuries, and were twice as
likely to sustain such injuries as was the adult population.
Bone fractures are common as well. Adolescents housed in RNDC and EMTC sustained
a total of 96 suspected fractures from September 2011 through August 2012, according to
DOHMH data.13 In addition, during FY 2013, adolescents were taken to Urgicare for emergency
medical services 459 times.
The frequency with which staff use of force results in inmate injuries, and the nature and
severity of those injuries, strongly suggest that correction officers are routinely employing
excessive levels of force against adolescent inmates. During recent years, DOHMH has tracked
the number of inmate injuries inflicted by DOC staff, and the results are disturbing. For
instance, during the first half of 2012, 55% of the inmates brought to the RNDC clinic after a use
of force incident had a verifiable injury. This represented a higher rate than any other Rikers
housing facility, taking into account inmate population. Even more concerning, 48% of those
injuries were to the inmate’s head or face, including fractures, contusions, and lacerations.14

Inappropriate Use of Force by Staff

DOC has engaged in a systemic and pervasive pattern and practice of utilizing
unnecessary and excessive force against adolescent inmates in violation of the Eighth and
Fourteenth Amendments of the Constitution. See Farmer, 511 U.S. at 832; Walsh, 194 F.3d at


RNDC inmates suffered 22 jaw fractures during the first 5 ½ months of 2012 alone.

Our investigation did not focus on incidents involving alleged sexual assault. However, the limited information
we obtained raises a concern that DOC may be under-reporting sexual assault allegations. In calendar years 2011
and 2012, DOC reported a total of only seven incidents of alleged sexual assault where the alleged victim was an
adolescent. (Five of these incidents were determined to be unfounded or unsubstantiated and the other two
investigations were pending at the time DOC provided the data.) This number seems extremely small given the size
of the adolescent inmate population, the frequency of inmate-on-inmate violence, and the high rate of negative
interactions between staff and inmates. Our consultant expressed concern as to whether allegations of sexual assault
are being consistently reported and investigated in compliance with the Prison Rape Elimination Act, 42 U.S.C. §
15601 et seq., and the relevant DOJ implementing regulations. We encourage the Department to examine these

Page 11

Generally accepted correctional practices require that the appropriate use of force in a
given circumstance should include a continuum of interventions, and that the amount of force
used should not be disproportionate to the threat posed by an inmate. Absent exigent
circumstances, lesser modes of intervention, such as the issuance of infractions or passive
escorts, ought to be utilized or considered before more serious and forceful interventions. When
force is necessary, correction officers generally should first apply techniques designed to
immobilize, control, and restrain an aggressive inmate. DOC routinely violates these wellaccepted contemporary correctional practices, as well as the Department’s own use of force
Rikers staff strike adolescents in the head and face at an alarming rate, and too often
employ force for the purpose of inflicting injuries and pain. Inmates are beaten as a form of
punishment, sometimes in apparent retribution for some perceived disrespectful conduct.
Correction officers improperly use injurious force in response to refusals to follow orders, verbal
taunts, or insults, even when the inmate presents no threat to the safety or security of staff or
other inmates. Adolescents have alleged that officers deliberately take them to off-camera
locations in order to beat them and inflict serious injuries that will not be captured on video.
Finally, staff frequently continue to strike inmates after they are clearly under control and
effectively restrained, often attempting to justify their actions later by reporting that the inmate
continued to resist. The Department’s failure to curb these patterns and practices that place
adolescents at ongoing risk of serious harm constitutes deliberate indifference to the adolescents’
safety while in DOC custody and violates their constitutional rights. See Farmer, 511 U.S. at
834; see also Nunez v. Goord, 172 F. Supp. 2d 417, 432 (S.D.N.Y. 2001) (“[P]rison officials’
malicious and sadistic use of force is a per se violation of the Eighth Amendment, because the
conduct, regardless of injury, ‘always’ violates contemporary standards of decency.”) (citing
Hudson, 503 U.S. at 9)).
As discussed later in this report, DOC fails to conduct rigorous and timely investigations
of use of force incidents and does not consistently hold staff accountable for their conduct. As a
result, a culture of excessive force persists, where correction officers physically abuse adolescent
inmates with the expectation that they will face little or no consequences for their unlawful

Frequency of Headshots

Headshots refer to blows to an inmate’s head or facial area, typically through a punch,
strike or a kick. Headshots are considered an excessive and unnecessary use of force, except in
the rare circumstances where an officer or some other individual is at imminent risk of serious

The Department’s Use of Force Directive directs that force may be used “only as a last alternative after all other
reasonable efforts to resolve a situation have failed.” The Directive further provides that “the amount of force used
at any time should always be proportional to the threat posed by the inmate at that time,” and “staff must start with
the minimum amount of force needed and escalate the amount of force used only if the situation requires

Page 12

bodily injury and no more reasonable method of control may be used to avoid such injury.
Headshots can cause great bodily harm, usually serve no legitimate correctional purpose, are
often retaliatory, and typically serve only to escalate incidents.
Headshots are commonplace at Rikers. We have identified numerous incidents where
correction officers struck adolescents repeatedly in the head or face, often causing significant
injuries. Based on our review of use of force incidents, inmate interviews, and other
information, it is clear that headshots are not limited to situations where staff or others face an
imminent risk of serious bodily injury. As discussed further below, staff too often strike inmates
in the head or face to punish them for their prior conduct. Staff frequently deliver closed fist
punches to an adolescent’s facial area as an initial response to a volatile situation, without first
seeking to control or neutralize the inmate through less aggressive techniques. Our consultant
reported that headshots are far more common at Rikers than at any other correctional institution
he has observed.
In many instances, correction officers readily admit hitting inmates but claim they acted
in self-defense after being punched first by the inmate. As a threshold matter, even when an
inmate strikes an officer, an immediate retaliatory strike to the head or face is inappropriate.
Moreover, there is often reason to question the credibility of the officer’s account. These
incidents also disproportionately occur in locations without video surveillance, making it
difficult to determine what transpired.
Based on a review of Department 24-hour reports16 from October 2012 through early
April 2014, we identified 64 incidents involving blows to an adolescent inmate’s head or face.17
This is undoubtedly an underestimate of the number of headshots during this period, because 24hour reports contain only initial incident summaries prepared by staff themselves. Indeed, our
review of incidents and witness interviews suggest that headshots were utilized far more
frequently during this period. However, the fact that these summaries so often openly refer to
headshots is disturbing. The following entries from 24-hour reports are representative of
instances when staff plainly admit using headshots but claim that they were provoked by inmate

On August 16, 2013, an inmate reportedly refused to comply with an order
directing him to sweep up some debris, and then allegedly spit in the face of
an officer and “took a fighting stance.” The officer “punched the inmate in
the facial area.” The inmate sustained an injury to his “right periorbital” that
required sutures. There was no video surveillance of the incident.


24-hour reports include summaries of unusual incidents that occurred during a given day, including use of force


The 64 incidents include 25 “use of force allegations.” There were 12 additional incidents that do not specifically
reference a blow to the head or face but state that the officer punched the inmate and the inmate sustained an injury
to his head or facial area.

Page 13


On August 26, 2013, an inmate reportedly spat at an officer while being
transported in a DOC vehicle. “The officer defended himself with a punch to
the inmate’s facial area.” There was no video surveillance.


On October 29, 2013, an inmate reportedly spat in the face of an officer. The
officer “punched the inmate in the face and the inmate sat on the bench
terminating the incident.”


On February 27, 2014, an inmate reportedly sat down and refused to walk
while being escorted from intake to the RNDC housing area. An officer
“approached the inmate and began hitting him in the facial area.” The inmate
sustained a superficial scalp abrasion.

In addition to the significant number of incidents where officers plainly admit delivering
headshots, as noted in further detail below, there are other occasions where staff report using
only “upper body control holds” to restrain inmates, but the evidence—such as statements in the
inmates’ medical records describing facial swelling, bruising, or lacerations—strongly suggests
that the officers in fact used headshots and submitted false reports. The following example is

In January 2013, an inmate reported that he was beaten by a correction officer
in the RNDC school area where there is no video surveillance. Despite the
fact that the inmate sustained multiple bruises to his neck and forehead, the
correction officer denied striking the inmate. The officer initially reported
that he had used an “upper body control hold” to subdue the inmate.
However, the Captain assigned to investigate the incident found that the
injuries sustained by the inmate were not consistent with staff use of force
reports and concluded that the correction officer had “falsified his use of force
report in an attempt to downplay” the incident. (This incident, referred to as
involving Inmate K, is described in further detail in the Appendix.)

Furthermore, headshots are a long-standing problem at Rikers. In 2004, Steve Martin,
the consultant retained in a then-pending class action lawsuit against DOC, issued a scathing
report decrying the frequency with which DOC staff punched inmates in the face. See Report of
Steve J. Martin submitted in Ingles v. Toro, 01 Civ. 8279 (DC). Mr. Martin wrote that “there is
utterly no question that the Department, by tolerating the routine use of blunt force headstrikes
by staff, experiences a significantly greater number of injuries to inmates than the other
metropolitan jail systems with which I am familiar.” It is troubling that, ten years later, this
practice continues.

Page 14


Use of Force as Punishment or Retribution

We found that Rikers staff utilize physical force to punish adolescent inmates for real or
perceived misconduct and as a form of retribution, in violation of the Department’s policy.18
Many of these incidents involve adolescents with significant mental health impairments who
have limited impulse control, making DOC’s punitive conduct even more troubling. Force used
for the sole purpose of punishment or retribution is always considered improper, and can result in
the most serious injuries. For example:

In December 2012, after being forcibly extracted from their cells for failure to
comply with search procedures, two inmates (mentally ill inmates placed in
the punitive segregation unit MHAUII) were taken to the GRVC clinic and
beaten in front of medical staff. Our consultant interviewed both inmates
about this incident. The New York City Department of Investigation (“DOI”)
conducted an investigation and concluded that staff had assaulted both
inmates “to punish and/or retaliate against the inmates for throwing urine on
them and for their overall refusal to comply with earlier search procedures.”
Based on inmate statements and clinic staff accounts, a Captain and multiple
officers took turns punching the inmates in the face and body while they were
restrained. One clinician reported that she observed one inmate being
punched in the head while handcuffed to a gurney for what she believed to be
five minutes. Another clinician reported that she observed DOC staff striking
the other inmate with closed fists while he screamed for them to stop hurting
him. A physician reported that when he asked what was happening,
correction officers falsely told him that the inmates were banging their heads
against the wall. A Captain later approached a senior DOHMH official and
stated, in substance, that it was good the clinical staff were present “so that
they could witness and corroborate the inmates banging their own heads into
the wall.” The correction officers’ reports did not refer to any use of force in
the clinic, and each report concluded by stating: “The inmate was escorted to
the clinic without further incident or force used.” The involved Captain did
not submit any use of force report at all. One inmate sustained a contusion to
his left shoulder and tenderness to his ribcage, and the other inmate reported
suffering several contusions and soreness to his ribs and chest. One of the
inmates told our consultant that he was still spitting up blood due to the
incident when interviewed more than a month later.19


In June 2012, in an apparent act of retribution, two correction officers forcibly
took an inmate to the ground and beat him. The officers punched the inmate


DOC’s Use of Force Directive prohibits using force “[t]o punish, discipline, assault or retaliate against an


The account of this incident is based on our consultant’s interviews of the two inmates, and DOI’s report
summarizing its investigation and findings.

Page 15

multiple times and kicked him in the head, resulting in serious injuries
including a two-centimeter laceration to his chin that required sutures, a lost
tooth, and cracking and chipping to the inmate’s other teeth. According to the
inmate, who was interviewed by our consultant, prior to the incident one of
the officers had called him a “snitch” and was under the false impression that
the inmate had previously reported that the officer had been involved in
another use of force incident. (This incident, referred to as involving Inmate
G, is described in further detail in the Appendix.)

In May 2012, an inmate was beaten near the RNDC school area where there is
no video surveillance. A correction officer punched him multiple times in the
face, and another officer allegedly kicked him while he was on the ground.
According to the inmate, the officer had gotten angry at him earlier in the day
when he did not comply with orders to stop doing pushups and report to bed.
The officer had threatened to “slap the shit out of him if he kept playing,”
according to another inmate. In his initial use of force report, the officer
asserted that the inmate had instigated the fight by punching the officer in the
face “without provocation,” and that he had responded in self-defense by
punching the inmate in the upper body. Later, the officer submitted a written
addendum to his initial report acknowledging that he had punched the inmate
in the facial area, not just the upper body. The inmate sustained a nasal
fracture and bruises to his face and head. (This incident, referred to as
involving Inmate C, is described in further detail in the Appendix.)


In January 2012, an inmate splashed a correction officer with a liquid
substance. While the inmate was flex-cuffed and being escorted away, the
correction officer approached him and started punching him in his facial area,
according to the investigating Captain’s report. The correction officer did not
stop until a probe team officer pushed her away from the inmate. The officer
then punched the wall in anger. Although the investigating Captain concluded
that the force used was “not necessary, inappropriate and excessive,” a Tour
Commander later reversed that position and concluded that the force used was
necessary and within policy.

Inmates reported to our consultant that staff have taken inmates to isolated locations with
no camera coverage to inflict beatings, and that multiple officers have teamed up to deliver these
beatings. A senior DOHMH official told us that inmates have made similar statements to him
and his staff.
Staff also regularly violate the Department’s policy prohibiting use of force against an
inmate who has ceased to resist. Correction officers often continue to hit, slap, beat, or kick
adolescents well after they have been restrained and no longer present any actual threat or safety
risk. Numerous inmates provided our consultant with specific and credible accounts of incidents

Page 16

where this occurred. Some of the most serious injuries occur when adolescents have been
already placed in flex cuffs or taken to the ground and are unable to defend themselves. 20

In August 2013, four adolescent inmates were reportedly brutally beaten by
multiple officers. Based on accounts provided by the inmates, several officers
assaulted the inmates, punching and kicking them and striking them with
radios, batons, and broomsticks. The beating continued for several minutes
after the inmates already had been subdued and handcuffed. The inmates
were then taken to holding pens near the clinic intake where they were beaten
again by several DOC Gang Intelligence Unit members, who repeatedly
punched and kicked them while the inmates were handcuffed. Two of the
inmates reported that they had lost consciousness or blacked out during the
incident. The officers’ written statements assert that the inmates instigated the
fight and they used force only to defend themselves. The Department’s
investigation of the incident was ongoing at the time this letter was prepared.
The inmates sustained multiple injuries, including a broken nose, a perforated
eardrum, head trauma, chest contusions, and contusions and injuries to the
head and facial area. (This incident, referred to as involving Inmates M, N, O,
and P, is described in further detail in the Appendix.)


In January 2013, after reportedly being disruptive while waiting to enter the
RNDC dining hall, an inmate, who was on suicide watch at the time, was
taken down by a Captain and punched repeatedly on his head and upper torso
while he lay face down on the ground covering his head with his hands. The
inmate told investigators that the Captain had “punched [him] everywhere.”
According to the Tour Commander’s report, the Captain’s use of force was
“excessive and avoidable” because the inmate presented no threat while lying
on the ground. The inmate sustained bruises to his left and right shoulders,
left and right lower arms, chest area, neck, middle back, and a finger on his
right hand, as well as an abrasion to his right elbow. (This incident, referred
to as involving Inmate L, is described in further detail in the Appendix.)

Correction officers also punish inmates through the use of painful escort techniques. For
instance, several inmates complained that staff apply flex cuffs tightly and exert intense pressure
in order to inflict extreme pain. Given that inmates in flex cuffs are restrained and pose no safety
threat, the officer’s sole purpose in these situations is to inflict needless pain.
As reflected in the below examples, adolescents have sustained serious injuries to their
wrists and hands as a result of these abusive tactics:


In late 2013, DOHMH’s Bureau of Correctional Health Services (“CHS”) analyzed serious injuries involving staff
uses of force for the entire inmate population. According to CHS’ report summarizing its review, 64 of the 80
inmates CHS interviewed reported having been struck by DOC staff after being restrained.

Page 17


An inmate told our consultant that in February 2013 a probe team Captain
lifted his hands up while he was flex-cuffed, fracturing his wrist. According
to the inmate’s statement to DOC investigators, the Captain told him and the
other inmates being escorted that “he would make them suffer,” and “cry like
babies.” Another inmate told investigators the Captain had directed the
officers to “make them scream” while the inmates were escorted through the
corridor. We reviewed video of the incident showing the inmate being
escorted down the corridor while rear-cuffed. We also reviewed medical
records confirming that the inmate broke his left wrist as a result of the
incident and required surgery. The Department’s investigation of the incident
was ongoing at the time this letter was prepared.


An inmate told our consultant that after he got into a fight with another inmate
in January 2013, the probe team arrived, placed him in flex cuffs, and applied
significant pressure. According to the inmate, after the Captain asked the
officer why he was not crying, the officer applied additional pressure. The
inmate stated that he lost feeling in his hand and was told to “hold it down”
and not report the injury. When our consultant interviewed him in April 2013,
the inmate still had no feeling in his left thumb. We reported his ongoing pain
to the Department, and the inmate was scheduled for a neurology consult

We also identified instances where staff reportedly challenged inmates to fights at
locations with no video surveillance, such as stairwells or the school area. For example:

During an interview with our consultant, an inmate reported that he got into an
altercation with a correction officer who threatened to confront him later at a
location without cameras. According to the inmate, the officer subsequently
attacked him in the school area, throwing numerous punches at his head.

Use of Force in Response to Verbal Altercations and Failure to Follow

Staff too often resort to abusive physical force when confronted with verbal taunts and
insults, noncompliant inmates, and complaints, even though no safety or security threat exists.
Although the inmate’s conduct may constitute a rule violation and warrant some form of
disciplinary action, it should not provoke an abusive physical response.

In January 2014, an inmate sustained significant facial injuries as a result of a
use of force incident that occurred in an RNDC school classroom. When
interviewed by Board of Correction staff, the inmate reported that he was
repeatedly punched and kicked in the head and face by multiple officers. The
inmate claimed that the altercation began after a civilian employee’s pen had
been taken. The inmate was still spitting up blood and having difficulty

Page 18

talking when Board of Correction staff interviewed him hours after the

In January 2013, an RNDC correction officer punched an inmate multiple
times in the face and upper body area. According to the inmate, the officer
was upset because the inmates had been playing with their food. (This
incident, referred to as involving Inmate I, is described in further detail in the


In January 2013, a Captain injured a mentally ill inmate in MHAUII by
forcefully closing the rear slide door of the cuff port of his cell on the inmate’s
left arm. In his written statement, the Captain stated that the inmate “was
holding the cuff” and did not comply with orders to remove his hand from the
slot. However, the video of the incident shows the Captain forcefully closing
the slot within just a few seconds of arriving at the inmate’s cell. (This
incident, referred to as involving Inmate J, is described in further detail in the


In August 2012, an RNDC correction officer got into a verbal confrontation
with an inmate after the inmate asked that his clothes be returned. The officer
struck the inmate in his face. In her account of the incident, the officer
claimed that she was trying to direct the inmate towards his bed, and
“inadvertently” touched his facial area. Eyewitness reports and medical
records, though, established that the officer had deliberately slapped the
inmate and then provided false statements to investigators.


In August 2012, during a cell search in MHAUII, an inmate, who was
handcuffed at the time, reportedly verbally abused a correction officer and
threatened to spit at him. The correction officer claimed he heard the inmate
collecting mucus in his mouth and responded by punching the inmate in the


In May 2012, an inmate sustained serious injuries, including a skull fracture,
as a result of a use of force incident that occurred in the RNDC search area.
The inmate claimed the beating took place after he had made a smart remark
following a strip search. An officer who admitted punching the inmate
“numerous times in his face and upper body areas” claimed that the inmate
instigated the incident by disobeying his order to comply with the search
process and punching the officer. (This incident, referred to as involving
Inmate D, is described in further detail in the Appendix.)

Staff appear to be poorly versed in conflict resolution and de-escalation skills, which are
particularly important when interacting with the volatile adolescent inmate population at Rikers.
When an inmate talks back or makes a derogatory remark, staff frequently escalate the
disagreement into a physical confrontation instead of exercising patience and seeking to de-

Page 19

escalate the situation. Staff fail to recognize the importance of using time and separation to
avoid altercations.
During our tours of the facilities, we observed some staff members’ combative approach
and tendency to aggressively push inmates for immediate compliance with directives. This
serves only to further exacerbate the hostile atmosphere that permeates the adolescent housing

Use of Force by Specialized Teams

The probe and cell extraction teams too often deploy unnecessary and excessive use of
force. These teams are the source of numerous inmate complaints.
The probe team is the group of correction officers and supervisors who respond to
disturbances and violent incidents. Each facility has its own probe team. Team members vary,
depending on who is on duty for a particular shift. Probe team members wear helmets, face
shields, and protective equipment around their torso. Inmates commonly refer to them as “the
Upon arriving at the scene of an incident, probe team members too often quickly resort to
the use of significant levels of force. As demonstrated repeatedly during inmate interviews,
adolescents fear the probe teams based on their aggressive reputation and heavy-handed tactics.
For instance, one mentally ill inmate told our consultant that a probe team member entered his
cell and struck him on the back with a baton in March 2013. The Department found that the
probe team member used the baton “in an unethical manner” based on its review of the handheld
camera recording, which was not provided to us despite our requests. The RNDC Grievance
Coordinator also advised our consultant that she has received numerous inmate complaints about
the probe team.
Cell extraction teams are called upon to remove a resistant or assaultive inmate from his
cell. Before resorting to force, staff generally ought to first try to persuade inmates to voluntarily
leave their cells through counseling. Indeed, DOC policy requires that mental health staff be
summoned to attempt to persuade an inmate to cooperate. However, these efforts rarely succeed,
and extractions too frequently lead to physical altercations and unnecessary injuries.21

Falsely Claiming that Inmate Was Resisting to Justify Use of Force

While utilizing force, staff often yell “stop resisting” even though the adolescent has been
completely subdued or, in many instances, was never resisting in the first place. This appears
intended to establish a record that the continued use of force is necessary to control the inmate.
Officers who witness the incident also frequently report that they heard the inmate was resisting,
even though that is false.

DOC does not require staff to document counseling efforts so it is difficult to assess compliance with this policy.

Page 20

During our on-site interviews, multiple inmates, without prompting, referred to the
practice. A senior DOHMH official also reported that correction officers direct inmates to stop
resisting while administering beatings. In addition, we reviewed an anticipated use of force
incident involving a cell search where the camcorder recording shows a Captain repeatedly
yelling “stop resisting” from the outset, well before she even arrived at the entrance to the cell
where she could see the inmate. At one point, the inmate responds “I’m not resisting.” We
could not determine what was happening in the cell because the camcorder was pointed at an
officer’s back and later at a polycarbonate shield.
This practice reflects a clear intent on the part of staff to cover up the use of unnecessary
and excessive force.

High Levels of Use of Force in Areas Without Cameras

The most egregious inmate beatings frequently occur in locations without video
surveillance. To its credit, DOC has installed hundreds of surveillance cameras in RNDC in
response to the unacceptable levels of violence in the facility. However, a number of areas with
no video surveillance still remain. A disproportionate number of the most disturbing use of force
incidents occur in these areas, including several incidents cited in this letter and discussed at
greater length in the Appendix. In particular, an astonishing number of incidents take place in
the RNDC school areas, including classrooms and hallways. It is unclear why the Department
has not installed additional cameras in these areas. Other locations that did not have security
cameras during the time period of our investigation include some search locations, the clinics,
intake holding pens, and individual cells.
Inmates, correction officers, and supervisors are well aware of these locations. Some
even have names. For instance, the RNDC intake cells are reportedly known as “forget about
me” cells.


We have identified several deficiencies relating to the Department’s systems, staffing,
operations, and management that contribute to the excessive and inappropriate staff use of force
against adolescents and the high incidence of inmate-on-inmate violence. The Department must
implement corrective measures to address these deficiencies to adequately protect the adolescent
population from harm. See Fisher v. Koehler, 692 F. Supp. 1519, 1564 (S.D.N.Y. 1988)
(“evidence of systemic failures” in preventing improper use of force at New York City jails
“supports a finding of a ‘policy of deliberate indifference’ as to staff-inmate violence on the part
of defendants”).

Page 21


Inadequate Reporting of Use of Force

Department staff fail to adequately document use of force incidents involving
adolescents. The use of force reports we have examined are almost uniformly poor and contain
many significant problems, including a general lack of detail, incomplete information, and
internally inconsistent information. In addition, reports frequently do not provide an accurate
account of the incident or the level of force employed, and fail to specify any resulting inmate
injuries. Furthermore, despite DOC policies that require a use of force report from every officer
involved in a use of force, as well as from every officer who witnesses a use of force by another
officer, our investigation suggests that not all uses of force are documented and violence against
inmates by staff is generally underreported.
Use of force reports are critically important as they form the basis for staff accountability.
If a use of force is not reported, or reported inadequately or falsely, then there is no reasonable
basis for review of that incident and no appropriate method to hold staff accountable for the
improper use of force. Because of the poor reporting of use of force incidents at Rikers,
unnecessary or excessive use of force goes undiscovered and unchallenged. This, in turn, has
resulted in a culture in which staff feel empowered to use force inappropriately, in ways that go
outside the bounds of written policies, because they know they are unlikely to face any
meaningful consequences.

Failure to Report Use of Force

Pursuant to DOC’s Use of Force Directive, all “[s]taff who employ or witness force or
have been alleged to employ or witness force . . . shall prepare a written report concerning the
incident based on their own observations and written independently from other staff that were
involved or alleged to have been involved in the incident.” Furthermore, staff are required to
prepare these reports “prior to leaving the facility unless medically unable to do so.” Despite this
clear policy requirement, this rule appears to be frequently and intentionally ignored, especially
if the use of force does not result in a serious injury.
There is evidence that a powerful code of silence prevents staff who witness force from
reporting. For example, staff will frequently report that they witnessed an inmate using force
against an officer or resisting an officer, but then fail to note or describe the force the officer
employed in response to the inmate—even when the officer himself has reported that he has used
force. Similarly, officers frequently affirmatively state that they did not witness any use of force
despite other evidence that suggests they were at the scene where force was used. Investigators
and supervisors reviewing the use of force reports consistently fail to point out these and other
obvious omissions and failures to conform the reports to DOC policy, reinforcing the perception
of officers that it is not important to be forthcoming or complete in their reports. For example:

In April 2013, an inmate sustained facial injuries and contusions to his left
shoulder after an officer struck him multiple times in the intake area of
RNDC. Video of the incident shows an officer standing idly by for several
minutes just a few feet away. This officer did not submit a use of force

Page 22

witness report, and investigators noted that they would not have known he
was even in the area had they not viewed the video.

In February 2012, an inmate was beaten in the head by an officer in the
RNDC school area. Three months after the incident, a different officer
submitted a handwritten memo to the Warden, at the request of the Deputy
Warden, describing the fact that he witnessed the first officer using “control
holds” to gain control of the inmate, and that he was standing by to provide
assistance if needed. The investigating Captain’s report found that the use of
force was justified and included no mention of this officer witness’s failure to
submit a use of force witness report at the time of the incident. The Tour
Commander and the Warden, who concurred with the investigating Captain’s
conclusion, also did not reference the officer’s failure to report the incident.
The incident was never referred to the Department’s Investigation Division,
and the officer witness was not disciplined for his failure to submit a timely
use of force report.

We also have identified a pattern of correction officers failing to complete reports for
comparatively “minor” uses of force. A correction officer assigned to EMTC described several
incidents to us that she alleged were never written up as use of force incidents, including
slapping and hitting adolescent inmates to get them to stop talking or stop playing around in
school. We also reviewed an incident where an officer failed to submit a use of force report after
she had hit an inmate with handcuffs to wake him up while he was sleeping in class. The
incident only came to light because the same officer similarly assaulted another inmate, and that
second assault led to a more serious altercation, which ultimately led to a full investigation by
the Investigation Division. (This incident, referred to as involving Inmate H, is described in
further detail in the Appendix.) This failure to document “minor” uses of force was also noted
by the inmates themselves. During an interview with our consultant, an inmate observed that
officers “slap, hit, and punch” adolescent inmates regularly, but only report a “use of force”
when there is a serious beating.
Additionally, in some cases, officers and supervisors pressure inmates not to report, using
a phrase that is widely used and universally known at Rikers: “hold it down.” This expression is
code for, “don’t report what happened.” Inmates who refuse to “hold it down” risk retaliation
from officers in the form of additional physical violence and disciplinary sanctions. A DOC
Associate Commissioner acknowledged the underreporting of use of force by officers, noting
that it would be “disingenuous” to claim that it doesn’t exist. The head of the Investigation
Division also acknowledged the problem.
A senior DOHMH official told us that he also was very familiar with the phrase, “hold it
down,” and conveyed his belief that adolescents were often instructed not to report incidents. He
indicated that one of the reasons inmates might agree to “hold it down” was that if inmates do
not report a use of force, they themselves were then less likely to be infracted and disciplined.

Page 23

The official expressed concerns that inmates might not receive needed medical treatment for
injuries caused by staff uses of force if pressured not to report the incident.22 In addition, the
official believed that some injuries reported to be the result of alleged slip and fall accidents in
fact involved unreported use of force, based on the unusual frequency of slip and fall accidents
and the serious nature of the injuries that allegedly resulted from them. For example, buried in
the medical file of an inmate brought to the clinic for treatment of a one-centimeter laceration on
his ear after a reported slip and fall is a note that the patient “claims he was hit in the left ear with
cuffs,” although the incident was not reported as a use of force.
In interviews with dozens of adolescent inmates, our consultant found that violence
ranging from casual and spontaneous to premeditated and severe is often accompanied by the
officers warning inmates to “hold it down.” According to our consultant, this phrase was
familiar to almost every inmate he interviewed, as well as inmates he spoke with informally as
he toured the jails. The warning may come from officers immediately following a beating, or
sometimes days or weeks after an incident. Officers may even delay taking inmates to clinics for
medical attention as they try to convince them to “hold it down.” If the inmate indeed “holds it
down” and declines to report a use of force, the staff also then do not report it.
The following are a few of the examples described by inmates to our consultant:

An inmate reported that he was punched and stomped on by several officers in
a school corridor after verbally insulting one of them during an argument. He
asked to go to the medical clinic, but the officers refused to take him there,
giving him tissues to clean himself up and telling him to “hold it down.” The
inmate also described another incident in which officers beat him, injuring his
arm. They refused to take him to the clinic for medical care until he agreed to
tell the clinic that he hurt his arm playing basketball. He agreed to that story,
and as far as he knows, the use of force was never reported.


An inmate stated that he got into an altercation with an officer after fighting
with another inmate. Although he got 70 days in punitive segregation for
fighting with the other inmate, a Captain told him he would not get any
additional days for fighting with the officer if he didn’t report that fight or
discuss the situation.



After a severe beating by multiple officers, an inmate was taken to a holding
cell in intake and told by officers to “hold it down” while medical care was
delayed for more than an hour. He eventually was taken to Elmhurst Hospital

According to the report prepared by DOHMH’s Bureau of Correctional Health Services (discussed supra at n.20),
45 inmates (including adult inmates) reported in interviews that DOC staff interfered with their effort to seek
medical treatment or otherwise retaliated against them after a use of force incident by, among other things,
threatening inmates with violence or infractions unless they declined medical care or stated that the injures were due
to something other than staff use of force.

Page 24

for medical treatment. He refused to “hold it down,” and in fact filed a civil
lawsuit against the Department, which settled before trial. (Incident is
referenced supra at 18 and described in further detail in the Appendix,
referred to as involving Inmate D.)

An inmate stated that when he asked staff for medical attention after being
raped by an officer, he was told not to say anything about the incident. He
reported it anyway, and told our consultant that after doing so, staff
continually harassed him. In fact, the inmate reported to our consultant that
he was warned by two officers not to say anything about the incident as he
was being taken to speak with our consultant while our investigative team was
at Rikers.23

During our site visit, we observed another example of staff exerting pressure on inmates
to remain silent. As an officer was bringing an inmate to our consultant for an interview, our
consultant heard the officer tell him that he didn’t have to tell our consultant “no damn story.”
Finally, there is evidence suggesting that non-DOC staff, such as medical staff and
teachers, also fail to report witnessing use of force, due in part to fear of retaliation from DOC
uniformed staff, who prefer they look away when staff are using force against inmates.
According to a senior DOHMH official, medical staff have faced retaliation for reporting injuries
that they suspected were the result of staff uses of force. We were advised of an incident where a
medical staff member reported that the reason she had witnessed an inmate being beaten was
that, because she was new, she did not know she was “supposed to go to the back” of the clinic
during such incidents. In addition, while DOC policy requires that mental health staff attempt to
obtain inmates’ cooperation to leave their cells in order to avoid forced cell extractions, mental
health staff routinely leave the housing areas after doing so and before the cell extractions take
place. While this is partly to avoid injuries to medical staff, a DOHMH official admitted that
this practice also protects mental health staff from witnessing the actual extraction.
There are also indications that teachers at the schools on Rikers, where as discussed
above a disproportionate amount of violence against adolescents takes place, are told to look the
other way when inmates are being beaten so as not to be a witness. During an investigation of an
incident in the RNDC school area, one teacher told an investigator that when a use of force
incident occurs, Department of Education staff “knows [sic] they should turn their head away,
so that they don’t witness anything.” In connection with the same incident, another teacher told
an investigator that she tried not to watch officers beating the inmate for the same reason, despite
the fact that she could hear the inmate screaming and crying for his mother. That teacher also
tried to keep other inmates in the classroom away from the window so that they would not
witness anything either. The admission by two teachers that they had been instructed or trained
to witness nothing did not appear to surprise the investigator who made no particular note in the

The inmate’s allegation that he was pressured not to report this incident also raises concerns under the Prison
Rape Elimination Act, 42 U.S.C. § 15601 et seq., and the relevant DOJ implementing regulations.

Page 25

investigation file. (This incident, referred to as involving Inmate H, is described in further detail
in the Appendix.) Indeed, we reviewed many incidents involving use of force in the RNDC
school area, but very few of the investigative files included witness statements from a teacher. In
the rare instances where the file included a statement, teachers most often reported that they did
not see anything.

Inadequate and/or Falsified Use of Force Reports

Pursuant to DOC’s Use of Force Directive, a written report regarding a use of force
incident must include a “complete account of the events leading to the use of force,” a “precise
description of the incident,” “the specific reasons” force was necessary, “the type of force” used,
and a “description of any injuries sustained by inmates or staff.”
Rikers staff routinely fail to meet the standards set forth in this policy when completing
use of force reports. One of the many failures of the reports is a lack of detail sufficient to
determine what actually happened, including why force was necessary and what injuries resulted.
Reports frequently provide a generic description of the incident often using boilerplate
terminology that appears designed to justify the use of force. For example, rather than providing
a complete and detailed description of the events leading up to the use of force, and exactly how
the encounter unfolded, staff will simply report that an inmate “failed to respond to a direct order
and became aggressive,” that they “defended” themselves from the inmate, that they used “one
two second burst of OC spray,”24 and that they “told the inmate several times to stop resisting.”
Staff also rarely identify inmate injuries in their incident reports, and investigators and
supervisors consistently fail to note this glaring and repeated omission.
Furthermore, our review of use of force reports has detected certain patterns that strongly
suggest staff engage in false reporting. These patterns include:

Use of force reports in which staff allege that the inmate instigated the altercation
by punching or hitting the officer, often allegedly in the face or head and for “no
reason,” “out of nowhere,” “spontaneously,” or “without provocation.” But then
the officer has no reported injuries—no lacerations or fractures or even minor
bruises or swelling—that would be commensurate with such blows. While
unprovoked assaults by inmates on staff certainly may occur, according to our
consultant, they are rare in other jurisdictions. This pattern of an allegation by a
correction officer of an unprovoked attack by an inmate, with no commensurate
officer injury, suggests that staff are justifying their own use of force by falsely
accusing inmates of hitting them first.25


Oleoresin Capsicum (“OC”) spray, commonly known as pepper spray, is a chemical agent that irritates the eyes
and respiratory system of a target.


In July 2014, criminal charges were brought by the Bronx District Attorney’s Office against a Captain and two
correction officers for beating an adult inmate unconscious. The DOC staff members were charged both with felony
assault and with felony charges in connection with preparing and submitting false “use of force” reports. In June

Page 26


Use of force reports in which staff report using only limited physical force, such
as control holds to subdue the inmate or “guide” him to the floor, while the
inmate’s injuries suggest a much greater level of force was used. For example,
the inmate sustains injuries to the face and head that are consistent with blows to
the head. This pattern suggests that officers are falsely reporting that the force
they used was less severe than it actually was.
In an interview, a senior DOHMH official noted that jail medical clinic staff have
observed inmate injuries that are inconsistent with the officers’ explanations of
what occurred and how the inmate became injured, and our own review of
medical records in conjunction with use of force reports bears this out.


Use of force reports in which staff report injuries to their own hands, but do not
report punching or hitting inmates, again describing the force used as something
more innocuous such as “control holds” or using OC spray. Again, this pattern
suggests that officers are falsely reporting that the force they used was less severe
than it actually was.


Use of force reports submitted by multiple officers regarding the same incident in
which similar or even identical language is used to describe the incident. This
similar or identical language could be a single unusual word, or an entire
paragraph repeated virtually verbatim across reports. This pattern suggests
collusion among officers to tell a particular story and/or to cover up the actual
facts of a particular incident.
In an interview, an EMTC correction officer confirmed what the pattern of
similarly worded reports suggests, namely that staff work together to cover-up the
facts of incidents and to ensure that they provide consistent written accounts. The
officer told us that in her experience, Captains often tell officers what to write in
their reports, and that officers understand that their reports must match the report
of the Captain. The officer referred to one instance when she was told that
someone else would write a report for her regarding a use of force that she
witnessed, although she never saw or signed any such report.


Use of force reports in which the description of an incident is inconsistent with
the video recording, and officers later provide an addendum to their report or

2013, criminal charges were brought against ten DOC staff members, including the former Assistant Chief of
Security, two Captains, and seven correction officers, in connection with a severe assault on an adult inmate that
resulted in multiple facial fractures. These DOC staff members also were charged with not only felony assault, but
with felony charges related to their attempts to cover-up the attack by submitting false use of force reports and false
use of force witness reports, in which DOC staff claimed the inmate attacked an officer first. While the inmates
involved in these particular assaults were not adolescents, the allegedly false information in the use of force reports
in these criminal incidents is similar to the patterns suggesting false reporting that we found in our investigation.

Page 27

change their story when confronted with the video evidence. Again, this pattern
suggests that officers are simply falsely reporting the force they used.
The following are just a selection of the many examples of these patterns that we

After an incident outside the dining hall in January 2013, the Captain who
repeatedly had punched an inmate reported that the inmate had “continued to
resist by flailing his arm and moving his body about in [an] attempt to avoid
being cuffed.” However, this was contradicted by the video surveillance. In a
supplemental report prepared almost two weeks after the incident, the Captain
acknowledged that the inmate “placed his hands by his head” while on the
ground and explained that he had not mentioned that in his initial report
“[d]ue to the inmates [sic] odd behavior and the adrenaline flowing.” (This
incident is also referenced supra at 16 and described in further detail in the
Appendix, referred to as involving Inmate L.)


After a December 2012 incident, an officer reported that during a pat-frisk an
inmate “without provocation” punched him in the face, causing him to defend
himself by punching the inmate in the face. The inmate told our consultant
that he never hit the officer, but instead that the officer hit him after he made a
snide remark. Although the officer went to the hospital for treatment, medical
notes indicate that his face appeared normal with no swelling or bruising.


After an incident in November 2012 in the RNDC school area, officers
reported only guiding an inmate to the floor and using a “one two second burst
of OC.” However, the inmate sustained facial bruising and swelling on the
nasal bridge. Ten days later, the inmate was still complaining of pain, and
medical staff recommended an x-ray to rule out a nasal bone fracture.


After a cell extraction in September 2012, officers reported only that they had
pinned an inmate to the wall and applied force to his upper torso and legs.
However, medical reports show that the inmate had pain in his right and left
jaw, swelling of his right jaw, as well as swelling and pain behind his left ear
and redness of the left ear canal. Such injuries cannot be explained by the
force the officers reported using. In this same incident, multiple officers used
a nearly identical phrase in their use of force reports, describing the way the
inmate “twisted and turned away from the bed.” Other officers used an
identical sentence to explain why force was used, citing the use of force policy
regarding the need to “defend oneself or another from a physical attack.”


After a May 2012 incident in the EMTC school area, an officer reported that
an inmate threw several punches to the officer’s face and neck area without
warning. Although the officer claimed injuries to his hand and shoulder, he

Page 28

had no injuries to his facial area. (This incident, referred to as involving
Inmate E, is described in detail in the Appendix.)

Failure to Use Video to Augment Use of Force Reporting: Loss of
Video and Poor Video Recordings of Anticipated Use of Force

Video recordings are extremely useful tools for reviewing use of force incidents,
evaluating staff and inmate statements, and determining whether the use of force was
appropriate. Indeed, the Department relies heavily on video recordings in those instances where
correction officers are actually charged and disciplined for excessive or inappropriate force. The
head of the Investigation Division noted, for example, that video evidence is critical in cases of
excessive or inappropriate force because that is the evidence that is most clear cut.
As discussed above, several areas in the jails where adolescents are housed have no
camera coverage whatsoever. Additionally, critical videotapes frequently go missing. As noted
above, we requested all relevant records, including video surveillance, for approximately 200 use
of force incidents. Of the incidents in our sample that were captured by the video surveillance,
the Department advised us that it had lost or was otherwise unable to locate over 35% of those
video recordings. Many investigative reports also note that although video was recorded, the
video evidence cannot be located.
The missing video surveillance is alarming, given that the Department has a specific
policy requiring any video recording of a use of force or alleged use of force to be retained in the
office of the Deputy Warden for Security for no less than four years, as well as detailed
procedures for documenting the chain of custody for any such recordings. The frequency with
which video evidence disappears either indicates an unacceptably blatant disregard for the
Department’s policies regarding the safeguarding of video evidence, or even more disturbingly,
possible tampering with important evidence.
Another concern is the poor quality of some of the video recordings that do exist. By
policy, staff are required to film cell extractions, probe teams deployments, and other situations
where use of force is anticipated. There is a detailed policy requiring the videotaping of all cell
extractions, from start to finish, including a requirement that the videotape show the extraction
team’s attempts to gain the inmate’s compliance before force is used. However, based on our
review of incidents involving anticipated uses of force, the videotape is often shot poorly such
that the use of force is not clearly visible and other important information is not captured. The
failure to properly videotape these incidents is particularly concerning given the frequency with
which probe teams and cell extraction teams are involved in incidents where excessive and
unnecessary force is allegedly used.

Inadequate Investigations into Use of Force

The Department’s investigations into use of force by staff against adolescent inmates are
inadequate at both the facility level and the Investigation Division (“ID”). Pursuant to
Department policy, the facility (e.g., RNDC) is generally responsible for conducting an initial

Page 29

investigation into use of force incidents, and most incidents are not subject to any further review.
Certain incidents, such as those involving serious injuries, may trigger a full investigation by the
ID. As discussed below, the criteria for when the ID must investigate an incident appears
unclear, and less than one-fifth of the adolescent use of force incidents and allegations in 2012
were subject to a full ID investigation. In addition to performing full investigations, the ID also
conducts a limited review of a sample of facility-level investigations to assess their quality.
Finally, use of force incidents of particular concern may be referred for an investigation by New
York City’s Department of Investigation, a separate city agency.
Reviews and investigations of use of force incidents are critically important because
they are the means by which the Department is able to determine whether its own use of force
policies are being followed and to evaluate the adequacy of staff reporting of incidents.
Rigorous investigations, conducted with integrity, are a key part of any system that intends to
hold staff accountable for their actions, and thus prevent future abuses. Our investigation has
found the systemic failure of the investigative process at Rikers to be one of the central reasons
for the widespread use of excessive and unnecessary force against adolescent inmates. The
Department’s failure to conduct thorough and comprehensive use of force investigations has
resulted in a system where staff are frequently not held accountable for policy violations, and
expect that their version of events will be accepted at face value with little scrutiny.

Inadequate Investigations at the Facility Level

Facility-level investigations are conducted initially by one of the Captains within the
facility where the incident took place, then reviewed by a Tour Commander and an Assistant
Deputy Warden and/or Deputy Warden for Security, and ultimately approved by the Warden.
The assigned investigating Captain cannot be the Captain who was supervising the officers
involved in the use of force at the time of the incident. Because the majority of use of force
incidents will never be reviewed by the ID or the DOI, this investigation by the facility is the
sole Departmental review for most use of force incidents. These investigations are grossly
The facility rarely finds that force has been used inappropriately, and nearly always
concludes that force was justified and in accordance with Departmental policy—often despite
evidence to the contrary. Based on our review of facility investigation files, we found the
investigations to be cursory and identified the following common and systemic deficiencies:

A general bias toward accepting staff’s version of an event at face value, even
where there is medical or other evidence to the contrary, and discrediting the
inmate’s account.


Failure to consistently follow up with staff regarding obvious deficiencies in
their use of force reports. As discussed above, these deficiencies may include
accounts that are inconsistent with reported injuries to the inmate or the
involved officers, accounts that fail to explain why officers did not or could

Page 30

not have used a lesser level of force, and suspiciously similar statements and
language in descriptions of incidents.

Failure to identify and reconcile material discrepancies between statements
from involved officers, staff witnesses, reported injuries, and video
surveillance (when available).


Failure to make sufficient efforts to obtain statements from inmates, including
the inmates subject to the use of force and inmate witnesses. Although we
realize that inmates may be reluctant to talk to uniformed officers due to fear
of retaliation, we were struck by the frequency with which facility
investigative packages state that inmates refused to provide statements,
especially given how openly inmates have discussed incidents with our
consultant, medical staff, and even ID investigators.


Where video exists, failure to describe the events on the video. Often there is
just a summary statement that the video was reviewed and consistent with
officers’ use of force reports. Because video recordings so frequently go
missing, as described above, without an accurate and detailed description of
the video recording, there is no longer any objective record of the incident.

The Captains assigned to investigate incidents at the facility level do not receive
specialized training in investigative techniques, and show little familiarity with basic
investigative skills or procedures. In most investigations, Captains and Tour Commanders
simply summarize the use of force reports provided by the officers involved, and the witness
statements provided by other correction officers and inmates (if any). Finally, due in part to an
antiquated system that relies on handwritten statements and the physical transfer of paper folders
and files from one desk to another, there is often a backlog of use of force packages awaiting
final approval, notwithstanding Departmental policy that use of force investigations be
completed within 15 days of the incident. This almost inevitably contributes to pressure on a
facility’s top management to give each use of force package little more than a cursory review,
making it easier for correction officers to conceal misconduct.

Lack of Clarity Concerning What Triggers ID Investigation

It is unclear what criteria are used for referring an incident to the ID for a full
investigation—both in terms of how a determination is made as to which cases merit further
investigation and who makes those determinations. The criteria for involvement by the DOI in
any particular incident are also ambiguous. The lack of transparent lines of responsibility for
investigations undermines the effectiveness of the investigative process, and creates the risk that
particularly troubling incidents may escape the rigorous and comprehensive review they merit.
The policies regarding when the ID investigates an incident, as well as key officials’
understanding of these policies, are inconsistent and contradictory. According to the Use of
Force Directive, “the facility is responsible in the first instance for investigating all uses of

Page 31

force.” This suggests that the ID becomes involved only after the facility has completed its own
investigation of a use of force. But other Departmental policies, as described in the ID Training
Manual and in interviews with Department officials, specify that ID investigates in the first
instance all Class A uses of force, and allegations of Class A uses of force.26 Written policies
also specify other situations in which an ID investigation is mandatory, such as allegations that
inmates were dissuaded from reporting force. The ID also appears to have the authority to open
a full investigation whenever it deems it appropriate to do so. The facility officials we
interviewed, including RNDC Deputy Wardens and the now former RNDC Warden, indicated
they also have the discretion to refer any use of force to the ID, which may then “take over” an
investigation. Responsibility for investigation of headshots illustrates some of the confusion in
this area: although the head of the ID told us that her division handles investigations involving
alleged headshots, it is clear that many such incidents are subject only to facility-level
Further complicating matters, the Department operates an Intelligence Unit (“IU”) that
also conducts investigations into matters such as inmate-on-inmate fights and violence.
Although these incidents often lead to use of force by staff, and thus could have overlapping
witnesses and evidence, the extent to which IU investigations are coordinated with facility
investigations or ID investigations is unclear.
Finally, some incidents are referred to the DOI, or the DOI may on its own “take over” an
investigation. According to written policies, the DOI broadly investigates “corruption or other
criminal activity . . . or other misconduct within the Department of Correction.” Although we
believe it is important to have a watchdog agency outside the Department review use of force
incidents that are of particular concern, there do not appear to be clearly established criteria
concerning the types of investigations that require external review, nor is it clear how incidents
are brought to the attention of the DOI.
The ambiguity surrounding when incidents are subject to investigations by the ID and/or
the DOI is magnified by the Department’s failure to implement an effective case management
tool to track all pending and completed use of force investigations. The Department does not
appear to have a single centralized system for tracking information on all use of force
investigations and findings, including whether the facility, the ID, or the DOI (or some
combination of these entities) investigated an incident, the date the investigation was
commenced and completed, whether the investigating entity ultimately determined that force was
used appropriately, and any resulting discipline of the correction officers involved.


According to the Department’s Use of Force Directive, a Class A use of force is one which requires “medical
treatment beyond the prescription of over-the-counter analgesics or the administration of minor first aid,” including
lacerations, fractures, sutures, chipped or cracked teeth, or multiple abrasions and/or contusions.

Page 32


Inadequate Investigations by the ID

While we found ID investigations to be marginally more professional and sometimes of
better quality than facility-level investigations, we nonetheless found that they suffer generally
from the same bias in favor of correction officers and against inmates. The extraordinarily high
number of use of force incidents appears to overwhelm the review and investigative capacities of
the ID. The unit has an insufficient number of investigators to effectively review and investigate
the use of force incidents at over a dozen DOC jails, especially given that these same individuals
are also responsible for investigating other types of alleged staff misconduct and policy
violations, including inmate disturbances, discovery of dangerous contraband, erroneous
discharges, and serious injuries. During an interview, the head of ID acknowledged that her
front line investigators have extremely high caseloads that impeded their ability to conduct
expeditious investigations. Because the Department’s investigative functions are overwhelmed
in this way, they have become largely ineffectual and staff accountability for excessive or
inappropriate use of force is greatly diminished.27

Poor Quality of ID Investigations

The ID investigations suffer from numerous problems. We found several instances
where the ID concluded that staff’s use of force was appropriate despite evidence suggesting
otherwise or without conducting a comprehensive and rigorous investigation. Although ID
investigations are conducted by trained investigators and are superficially more thorough than
facility investigations, as noted above, they nonetheless are plagued by the same biases as the
facility investigations, which affect the entire investigative process. Despite lengthy
investigations, ID investigators frequently fail to reconcile contradictory statements or reports,
usually defaulting to the staff version of events. While the ID has the ability to compel
interviews of DOC staff, and usually does so, investigators often fail to ask obvious questions
about deficiencies in staff reports or inconsistencies in their accounts. Additionally, investigators
often fail to interview all the relevant witnesses, especially inmate witnesses. When they do
interview inmates, ID investigators too frequently fail to credit their version of events, even
when the inmate’s account is more consistent with the medical records or other evidence.
Finally, the ID disregards or is selective about the policy violations that it chooses to note in its
reports—from failure to safeguard video and failure to submit timely use of force reports, to false
reporting and excessive use of force—sometimes recommending no charges at all despite
substantial evidence of one or more policy violations.
The following are just a few examples of some of these common problems:


The ID conducted a full investigation of an incident in April 2012 in which an
inmate alleged that he was beaten in the head by multiple correction officers
at the behest of a female Captain in the RNDC school area after a heated

In early 2014, DOC announced that the ID was going to add 26 staff positions.

Page 33

argument with the Captain earlier that day. The inmate provided a detailed
account to the ID, describing two officers and the Captain by name. The
Captain who the inmate alleged ordered the beating claimed she was not in the
area during the incident. However, a preliminary ID report describes video
showing a female Captain going up to the school area before the incident and
then coming down from the school area with the probe team that removed the
inmate from the area. The final ID report includes a much shortened
description of this video and omits the fact that a female Captain went either
into or out of the school area. The ID apparently made no attempt to find out
where the Captain was at the time of the incident or who was with her. The
ID also did not interview or otherwise obtain a statement from one of the
officers named by the inmate as participating in the beating, nor did the ID
interview the probe team members to ask whether the Captain was present
when they arrived. Additionally, the one officer who admitted using force
made inconsistent statements in his use of force report and to ID investigators,
which he explained away by saying he had been “dazed” by the incident and
thus forgot to include certain details, although he never submitted a
supplemental report. The ID nonetheless credited that officer’s account that
the inmate had punched him first, and concluded that the use of force was
appropriate. No charges were recommended and the case was closed. (This
incident, referred to as involving Inmate A, is described in further detail in the

The ID conducted a full investigation of an incident in February 2012 in
which it concluded that an officer had inappropriately sprayed an inmate with
OC spray during an argument, when the inmate was clearly not a threat to the
officer at the time. The officer had stated in both her written use of force
report and during her interview that the inmate had threatened her with a
weapon, but the video showed that the inmate was actually turned away from
the officer and in the process of putting on a sweatshirt when he was sprayed.
Another officer witness also submitted a use of force witness report
containing information that the video showed was false, but the ID did not
interview that officer. While the ID recommended that charges be brought for
unnecessary use of force, the ID did not recommend that any charges be
brought for submitting false use of force reports or making false statements to


The ID conducted a full investigation into a May 2011 incident in which an
inmate was beaten by officers in the RNDC school area and suffered two
broken front teeth, a lip laceration that required sutures, and additional facial
swelling, contusions and abrasions. Despite the fact that the officer
previously had been involved in 45 separate use of force incidents, two of
which resulted in charges, the ID investigators credited the officer’s report
that the inmate had struck the officer in the face with a closed fist “without
any warning,” requiring him to defend himself by striking the inmate in the

Page 34

face and upper torso. During an interview, the officer later added the fact that
when he brought the inmate to the floor he brought him down face first and
fell down on top of him, which the ID investigator believed was a possible
cause of the broken teeth. The ID investigator also failed to obtain written
statements from or interview any of the probe team members who responded
to the incident, and did not interview the one other officer who submitted a
use of force witness statement, whom the inmate had alleged joined the first
officer in beating him and kicking him in the mouth. Although the incident
took place in school during school hours, there is also nothing in the file that
suggests that any inmates or teachers were interviewed about the incident. No
charges were recommended and the case was closed.

Untimeliness of Investigations

ID investigations are not completed in a timely manner. Written policies state that DOC
must maintain an eight-month average for completion of ID investigations of Class “A” uses of
force, but that every effort must be made to complete investigations within five months.
However, according to the Department, in the first part of 2013, the average completion time for
Class A use of force incidents was just over 9 months (278 days). In addition, as of October 31,
2012, 11 percent of ID’s cases had been open for more than 350 days, and 42 percent of ID’s
cases had been open for between 151-350 days. We also found several examples of ID
investigations into particularly serious incidents that took well over a year to complete.

The ID’s investigation into an incident involving an inmate who suffered a
nasal fracture when an officer punched him in the face was not completed
until 14 months after the incident. (This incident is also referenced supra at
15 and described in further detail in the Appendix, referred to as involving
Inmate C.)


The ID’s investigation into the use of force following an inmate fight—in
which inmates alleged that a correction officer had hit them with a baton
while they were lying handcuffed on the ground and one inmate suffered a
laceration that required eight sutures on the back of his head—was not
completed until 15 months after the incident. The ID did not request the use
of force package from the facility until more than two months after the
incident, and did not even interview the officer involved until nine months
after the incident.


The ID’s investigation into an incident involving an inmate who was beaten
by multiple officers in the RNDC school area was not completed until 16
months after the incident. (This incident is also referenced supra at 22 and 24
and described in further detail in the Appendix, referred to as involving
Inmate H.)

Page 35


The ID’s investigation into an incident involving an inmate who suffered
lacerations to the face and head after an encounter with officers was not
completed until 18 months after the incident.


The ID’s investigation into an incident involving an inmate who suffered a
broken tooth and laceration of the lip when an officer punched him in the face
was not completed until 20 months after the incident. The two key officers
involved in the incident were not interviewed by the ID until 16 months after
the incident. (Incident is also referenced supra at 27-28 and described in
detail in The Appendix, referred to as involving Inmate E.)

This undue delay diminishes the quality of the investigations because, as time passes,
witness memories fade and evidence becomes less available. This is especially true at Rikers
where the inmate population is transient, and witnesses may in fact be released or transferred to
the state prison system long before an investigation is completed. Moreover, in the relatively
few instances where officers are found to have violated policy, they are not subject to any
disciplinary measures until long after the misconduct.

Superficial Review of Facility-Level Investigations

As discussed above, in addition to conducting full investigations of certain incidents, the
ID is responsible for performing limited reviews of some facility-level investigations to ensure
the facility has conducted an adequate investigation and reached appropriate conclusions
regarding the use of force. The ID claims that it conducts this type of “facility-review” for all
Class B28 use of force allegations, all Class B and Class C29 incidents involving headshots,
instances where “substantive or procedural issues” have been detected, and/or when litigation is
anticipated. And yet despite the serious and widespread problems with the facility investigations
identified by our consultant, the ID frequently concurs with the facility’s findings without noting
deficiencies that should be obvious to trained investigators. Accordingly, while ID’s facility
review process should be playing a critical oversight role, there is minimal accountability for the
poor quality of the facility-level investigations.
The ID’s insufficient review of a deeply flawed facility-level investigation into an
incident in January 2012 is particularly illustrative. This incident, briefly referenced above,
supra at 15, occurred after an inmate splashed an officer in a housing area. The officer activated
her alarm, and the probe team arrived, secured the inmate, and put him in restraints. After the

According to the Department’s Use of Force Directive, a Class B use of force is one “which does not require
hospitalization or medical treatment beyond prescription of over-the-counter analgesics or the administration of
minor first aid.” The “forcible use of mechanical restraints in a confrontational situation that results in no or minor
injury” is also a Class B use of force.

According to the Department’s Use of Force Directive, a Class C use of force is one that results in “no injury” to
the staff member or inmate involved, and includes incidents where “use of OC-spray results in no injury, beyond
irritation that can be addressed through decontamination.”

Page 36

inmate had been handcuffed, the officer approached the inmate and began to punch him in the
face. The probe team Captain ordered the officer to stop punching the inmate, and another
correction officer needed to physically pull the officer off the inmate, at which point she punched
that officer and also punched the wall in anger. Another officer submitted a witness report
alleging that the officer’s punches did not actually connect with the inmate. The investigating
Captain submitted a report the next day concluding that the officer’s use of force was
“unjustified,” and submitted another, more detailed report a few days later noting that the
officer’s use of force was “not necessary, inappropriate, and excessive.” However, the Tour
Commander ultimately concluded that the use of force was necessary, noting that the video was
consistent with that finding. When the ID reviewed the facility investigation and requested to
view the video, the facility reported that the video had been lost. Although the ID reminded the
facility that it must retain video of critical incidents for four years, the ID concluded that the
facility’s investigation was satisfactory. Our consultant found the ID’s conclusion to be
astonishing, given that the facility had concluded that the use of force was “necessary” and
“within policy” despite the fact that two officers (including the probe team Captain) had
submitted reports stating that the officer had punched an inmate who was in handcuffs, and was
so out of control that she also had hit a fellow officer.

Inadequate Staff Discipline

The Department fails to adequately discipline staff for using unnecessary or excessive
force against adolescents. Because most investigations conclude that staff have not violated
DOC policies, often despite evidence to the contrary as discussed above, staff are rarely
disciplined for using unnecessary or excessive force. And in those relatively rare cases where a
facility or ID investigation results in a determination that staff used inappropriate force, the
disciplinary sanctions are minimal. As a general matter, we found that the most frequent
disciplinary response by the Department is to “counsel” a correction officer or send him or her
for “re-training.” Between January 1, 2011, and May 23, 2013, a total of 356 staff from RNDC
underwent a 3-hour use of force re-training course.
Sometimes when initial investigations do find violations of policy, charges are
recommended, but not brought, and therefore never result in any actual disciplinary action.
Some examples of this include the following:

The Tour Commander who conducted a facility investigation recommended,
based on his review of the video and medical evidence, that a correction
officer be charged with excessive force for striking an inmate on the head, and
failing to report a use of force. However, the Deputy Warden and Warden did
not concur with the Tour Commander’s recommendation, finding that the
force used was minimal and within Departmental guidelines. It is unclear
whether the incident was ever passed on to the ID for further review.


Similarly, in the incident described supra at 15 and 35-36 in which an officer
struck an inmate in the face while he was in handcuffs (and then struck
another officer), the investigating Captain found the use of force to be

Page 37

unnecessary and excessive. However, the Tour Commander and Warden
disagreed, the ID declined to open a full investigation, and the officer was
thus not subject to any disciplinary action.
In other instances where the Department found clear violations of use of force policies,
the sanctions were not at all proportionate to the seriousness of the offense. We found instances
where staff misconduct was so egregious that, according to our consultant, in many correctional
systems it would have warranted immediate termination—such as beating an inmate who was
already restrained or using force and failing to report it—and yet significantly lesser sanctions
were imposed. Examples of staff discipline that was not proportionate to the offense include the

An investigation into an August 2012 incident found that the officer threw a
closed fist punch to the inmate’s facial area while the inmate was in handcuffs
and another officer had him in control holds. The facility Warden
recommended that the assaulting officer forfeit 20 vacation days. The
supervising Captain, who watched the entire incident, was “counseled” for
“fail[ing] to be proactive with regard to his supervisory duties.” (This
incident is also referenced supra at 18.)


An investigation into a May 2012 incident found that the inmate’s allegations
that the officer slapped him on the head were correct. Review of video
showed one officer slapping the inmate’s head as he stuck it out of a food slot,
with another officer watching. The officer who slapped the inmate submitted
a false report in which he said he guided the inmate’s head back into his cell.
The other officer submitted a report in which he said he did not witness any
use of force. The Department accepted negotiated plea agreements from both
officers for loss of 18 vacation days and loss of 20 vacation days, respectively.


An investigation into an April 2012 incident found that although the inmate
was being disruptive, he posed no immediate threat. The officer nonetheless
struck the inmate in the head to gain control of him. The officer was charged
with failing to use conflict resolution skills and failing to notify a supervisor
before using force. The officer was sent for re-training.


An investigation, including a review of video, into a February 2012 incident
found that a correction officer “without provocation” pushed an adolescent
inmate into a wall, and then pushed him into his cell. The officer failed to
report the use of force, falsely reporting that his feet became tangled with the
inmate’s feet and they both tripped. He was charged with using force and
failing to report it. He was counseled and penalized one “owe[d] comp day.”

As noted in the first example cited above, while Captains or other supervisors are
sometimes cited for ineffective or inadequate supervision, they do not appear to be held
accountable in any real way for the actions of the correction officers under their command. In

Page 38

his review of use of force incidents and disciplinary records, our consultant found no instances
where Captains or other supervising officers were held accountable for the actions of the officers
they supervised with sanctions equal to or more severe than those received by the officers.
Additionally, some officers with histories of involvement in staggering numbers of use of
force incidents have remained at RNDC for years, in continuing close contact with adolescents.
Rather than intervene in any meaningful way and consider transferring the officer to nonadolescent housing, the Department’s practice is too often to “counsel” such officers in an
Based on our review of DOC records, we identified four officers who had been involved
in between 50 – 76 use of force incidents at RNDC over the six-year period from 2007 – 2012,
and another seven officers who had been involved in between 20 – 35 use of force incidents at
RNDC over the same six-year period.31 The officer with the highest number of uses of force
during the six-year period (76) was disciplined only once during this time; most of the others
were disciplined once or twice, and some never.
Finally, the Department does not appear to have a functioning early warning system for
identifying and intervening with those officers involved in critical incidents with unusual
frequency. An appropriate early warning system is an important management and accountability
tool that allows for early intervention by alerting a facility to a need for additional training,
insufficient policies, supervision lapses, or possible bad actors.

Inadequate Classification System for Adolescents

An adequate and effective inmate classification system is a fundamental management
tool to ensure reasonably safe conditions in a correctional facility. The primary purpose of a
classification system is to house inmates based on their different levels of need and security risk.
Inmates should be classified promptly after their admission into the facility, and then reclassified as necessary during their incarceration. A classification system utilizes various
objective factors to determine the appropriate custody level for an inmate. The Department,
which revised its classification system in 2012, now uses three custody levels—minimum,
medium, and maximum.
The Department utilizes the same classification system for adolescents and adults. A
classification tool designed for adults can lead to inappropriate results when applied to youth.
The system may not be “sensitive to the unique attributes and behaviors of youthful
populations.” Department of Justice, Bureau of Justice Assistance, Juveniles in Adult Prisons
and Jails: A National Assessment at 65 (Oct. 2000), For instance, the maturity levels of 16- and 1730

One officer was identified as having been “counseled” on October 18, 2012, then again on November 29, 2012,
and yet a third time on December 12, 2012, with no escalating response from the Department.


During calendar year 2012 alone, one officer was involved in 16 reported uses of force.

Page 39

year olds will vary more than adults, and can be a significant factor in properly classifying
adolescent offenders. The Department’s classification system does not take into account certain
factors that may be particularly relevant when assessing the security risk or vulnerability of
youth, such as the inmate’s cognitive and emotional development and physical stature.
Moreover, as further discussed below, a significant percentage of adolescents are assigned to
punitive segregation housing where inmates with different classification levels are co-mingled.
Finally, the Department does not make sufficient use of protective custody to ensure the safety of
vulnerable adolescents. The deficiencies in the Department’s classification system contribute to
the unsafe conditions in adolescent housing areas and increase the risk of inmate-on-inmate

Inadequate Inmate Grievance System

The inmate grievance system is deficient, and may discourage adolescent inmates from
reporting inappropriate use of force by staff. An inmate grievance system is an important
element of a functional jail system, intended to provide a mechanism for allowing inmates to
raise concerns or issues related to conditions of confinement to the administration. If viewed as
credible by inmates, it can also serve as a source of intelligence regarding potential security
breaches, including excessive force or other misconduct.
At Rikers, inmate complaints regarding staff-on-inmate assaults and staff-on-inmate
verbal harassment are non-grievable by policy. This is quite unusual. In most correctional
systems, such grievances, including complaints about lack of professionalism, are viewed as
among the highest priority grievances by administrators, according to our consultant. Although
the Department has assured us that inmate allegations of staff use of force are reported and
investigated, the process for reporting such incidents, as well as to whom they should be
reported, are unclear.
The grievance system is also deficient in the way it handles emergency grievances where
an immediate response is necessary, such as when inmates face an imminent threat to their safety
or well-being—a common scenario for adolescents at Rikers. The grievance policy states that
inmates with grievances requiring immediate attention should submit a regular grievance form to
the Captain or Tour Commander, who is then supposed to forward the form to the grievance
coordinator within one day. In some instances, one day may be too long for the inmate to wait.
In other instances, there could be further delays because the grievance coordinator is unavailable
or on leave.

Page 40


Inadequate Inmate Supervision

The high rates of staff use of force and inmate-on-inmate violence are attributable in part
to inadequate inmate supervision. The problem is not a lack of resources or too few staff.
RNDC has a relatively high staff-to-inmate ratio when compared to other jails. As of early 2013,
778 correction officers were assigned to RNDC, resulting in almost a one-to-one staff-to-inmate
ratio. Instead, the problem is that many frontline RNDC staff have minimal corrections
experience, fail to interact with inmates in a professional manner, and fail to adequately monitor
the conduct of the challenging adolescent population.

Inexperienced Staff and Excessive Turnover

RNDC is the first assignment for most new officers after they complete their initial
training at the Academy. Indeed, 220 (or 90.9%) of the 242 correction officers who started
working at RNDC during calendar year 2012 came directly from the training Academy. In
addition, approximately 35% of RNDC correction officers had fewer than two years of
experience in the Department as of early 2013. These green officers are placed into one of the
most combustible environments at Rikers, ill-equipped to cope with adolescents who are often
belligerent and suffer from a wide range of mental illnesses and behavioral disorders. As a
result, inexperienced officers quickly resort to using violence as a means to control the inmates.
Others may be intimidated and reluctant to assert their authority, which reportedly has resulted in
instances where older and more dominant adolescents exercise significant control over
adolescent housing areas. In short, the least experienced staff at Rikers are paired with arguably
the most difficult inmate population to manage.
Furthermore, and also not surprisingly, RNDC suffers from an unusually high rate of
staff turnover. Correction officers are eager to escape the turbulent environment for a more
tranquil facility. From January 2011 through April 4, 2013, 282 correction officers transferred
out of RNDC, while 401 new correction officers were assigned to the facility. The turnover level
at the Captain level is similarly high. Thus, just as staff members may be developing some of the
necessary conflict resolution techniques and interpersonal skills to effectively manage the
adolescent population and curb violence, they leave for another facility.
In June 2012, DOC instituted modest special assignment pay to attract and retain more
experienced staff at RNDC. But this has made little difference, and RNDC continues to be
plagued by excessive staff turnover.32


The incentive pay offered to correction officers willing to work in adolescent housing areas is equal to a 3%
increase for the first year, and can reach up to 12% over a 4-year period. As of January 14, 2014, only 38 staff
members had received “specialty pay” since it was introduced at RNDC.

Page 41


Lack of Continuity in Facility Management

An analogous lack of continuity among facility management also contributes to a
cumulative leadership vacuum, making it difficult to institute and implement any meaningful
reforms. One top administrator told us there had been eight Wardens over the past eight years at
RNDC.33 The Warden is the most important leadership figure for staff in any jail.
A Warden who is in place for only a short time may be less inclined to take responsibility for any
past problems related to violence among or against inmates, including use of force, in his or her
jail. The lack of continuity was also reflected in the RNDC Deputy Wardens, some of whom
changed even between the dates of our two visits.
The constantly changing leadership is exacerbated by inadequate supervisory continuity
for frontline officers. Correction officers are supervised by different Captains depending on their
shift assignment and schedules, as opposed to working a constant shift under the same Captain
for an extended period of time.

Lack of Staff Professionalism

A lack of staff professionalism exacerbates the volatile atmosphere in adolescent housing
areas and contributes to the high level of violence. Although there are exceptions, the
unprofessional demeanor of staff and supervisors is widespread and readily apparent.
During our tours, we observed and heard staff yelling unnecessarily at inmates and using
obscenities and abusive language. Supervisors did not react or reprimand the officers in any
way. Numerous inmates told our consultant that staff are disrespectful and regularly scream,
threaten, berate, and curse at them. Inmates noted that staff frequently insult them and use racial
epithets, such as “nigger.” The RNDC Grievance Coordinator described the facility as simply a
very “hostile” place.
Staff also humiliate and antagonize inmates, which provokes physical altercations. For
instance, one EMTC correction officer reported that staff have ordered adolescents to strip down
to their underpants and walk down the dormitory hallway (referred to as “walking down
Broadway”) when they misbehave. Inmates also complain that staff retaliate against them by
spitting in their food, tossing their belongings, and depriving them of food, commissary, and
recreational privileges.

Failure to Monitor Inmate Conduct

The pervasive inmate-on-inmate violence is largely due to DOC’s failure to adequately
supervise adolescents. Staff cluster together on living units instead of interacting with inmates,
and too often leave their assigned posts. They frequently fail to closely monitor inmate conduct,

In early 2014, after our on-site tours of the facilities and staff interviews, the Department once again appointed a
new RNDC Warden.

Page 42

and often do not intervene as necessary in order to prevent verbal disagreements from escalating.
When physical altercations do occur, staff sometimes fail to intervene in a timely manner,
exposing inmates to a significant risk of serious injuries. Several inmates informed our
consultant that they were attacked when staff were not properly overseeing the area. One inmate
told our consultant that he had witnessed multiple instances where officers allowed inmate fights
to escalate by failing to intervene.34
Management has acknowledged deficiencies in staff supervision. For instance, after
touring RNDC in January 2013, the RNDC Integrity Control Officer35 noted in a report that staff
were “ignoring the obvious potential security issues.” She further noted that dayroom officers
often stand in the entrance so that they can talk to the “B” post officer, rather than assuming a
position where they can better observe the inmates. Not surprisingly, dayrooms are a common
site for inmate-on-inmate fights.
The following examples illustrate how DOC staff fail to meet their obligation to protect
youth from assaults:

In May 2012, an inmate was attacked by two other inmates while on his way
back to the housing area from the RNDC school. According to staff who
observed video surveillance of the incident, one inmate approached the other
inmate from behind and punched him in the face. The first inmate threw the
second to the ground and repeatedly punched him in the face and head. A
third inmate then kicked the second inmate several times on his body, and he
lost consciousness. According to the investigation file, no staff witnessed the
assault even though it occurred during inmate movement. The correction
officer on duty was counseled regarding the proper procedure for escorting
inmates from school to the housing area. During an interview with medical
staff, the inmate who was beaten stated that he had requested medical
treatment after waking up, but was not taken to the clinic until about three
hours later. The inmate sustained a broken tooth and a fractured jaw.


In March 2012, an inmate was assaulted by another inmate in an RNDC
dayroom and sustained a broken jaw. The Incident Report makes no mention
of any staff who observed or responded to the incident, although it was
captured on video. The inmate who was attacked claimed that he previously
had advised DOC staff that he felt unsafe and wanted to be transferred but his


In August 2013, 11 inmates and one correction officer reportedly sustained injuries during a large fight involving
adult inmates in GRVC. This incident was captured on video that was obtained by ABC News and posted on its
website. ( Although
there were numerous staff members at the scene, none intervened while inmates fought and threw chairs and other
objects at each other. According to ABC, the incident continued for more than one hour.

The Integrity Control Officer is charged with overseeing the extent to which staff comply with Department
policies and procedures.

Page 43

requests were ignored. The inmate required two surgeries and his jaw was
wired shut.

Inadequate Staff Training

The training offered by the Department to correction officers assigned to adolescent
housing areas is deficient in several respects.

Use of Force Training

Although the use of force training covers the basic components of the Department’s
policy, the curriculum is poorly designed and repetitive. The training is conveyed via a scripted
lecture format, and lacks sufficient demonstrations, discussions, and role playing. A training
program with more interactive exercises and examples of realistic scenarios presented through
video training films would be far more effective and likely to better engage correction officers.
Moreover, the training does not sufficiently focus on some of the most troubling practices at
Rikers, such as headshots, false reporting, and painful escort techniques.36 Given the longstanding use of force problems at Rikers, we expected that the Department would have
developed a more innovative and interactive training program by now.
The remedial training for officers who violate the Department’s use of force policies and
procedures is the same as the standard in-service training. Such “re-training” is less likely to
have a positive impact than a more specialized, focused, and rigorous program designed
specifically for officers who already have engaged in improper conduct.

Training on Managing Adolescents

The vast majority of RNDC staff, including supervisors, have no prior professional
experience working with adolescents. However, until recently, DOC offered no comprehensive
training on how to interact with and manage incarcerated youth, despite the dire need for such
specialized training. Indeed, after reviewing an incident in late 2012 where an officer improperly
utilized force against an inmate in response to a verbal disagreement, the RNDC Integrity
Control Officer recommended that the officer receive counseling and wrote: “We have to set up
some type of training to enforce to staff how to effectively deal with the adolescent population.
Staff cannot continuously respond to the kids like they do their own. If this were an
In 2013, DOC finally introduced a 12-hour in-service training program on adolescent
development principles and practices, which was developed by the Youth Development Institute.
Although a significant improvement, this training focuses too much on theory and adolescent

The use of force training materials include an example that offers troublesome guidance to officers. In the
example, an inmate is seated in an unauthorized area and refuses to comply with an order to return to his housing
area. The inmate spits at the officer and states: “It will take more than you to move me.” The materials incorrectly
indicate that these circumstances justify the use of chemical agents against the inmate. However, in such a situation,
best practices require the officer to first seek to control the situation verbally by applying appropriate conflict
resolution skills, according to our consultant.

Page 44

research, as opposed to teaching appropriate responses to the challenging behavior of
incarcerated youth. The materials do not adequately address the practical skills needed to
manage the Rikers adolescent population or handle the serious challenges RNDC staff actually
face. The training also offers few realistic examples.

Management Deficiencies

The Department’s top management has failed to meaningfully address an organizational
culture that tolerates unnecessary and excessive force, which has resulted in an environment in
which adolescent inmates are at constant risk of serious harm. There is a fundamental disconnect
between the Department’s top administrators, who operate in a high-end corporate environment
off Rikers, and the Department’s uniformed staff, who spend their days interacting with a
difficult inmate population in aging, decrepit, and grim jail facilities on Rikers. One result of
this disconnect is widespread frontline noncompliance with use of force policies, and top
administrators who appear, with some exceptions, to be out of touch with the systemic
deficiencies in inmate oversight and management. Despite several well-intentioned and useful
reforms implemented over the past two years, the Department has not initiated any
comprehensive and effective efforts to address the key factors driving the high incidence of staff
violence against adolescent inmates, including a general inclination to use force as a tool to
control adolescents, a tendency to escalate rather than de-escalate potential incidents, an
environment premised on fear and intimidation, a widespread and tolerated code of silence
among staff, and inexperienced frontline staff inadequately trained to manage the challenging
adolescent population.
There is no question that the Department has a long and troubled history of staff use of
force against inmates, which reinforces our finding of a deeply entrenched organizational culture
that accepts violence as an inherent part of a jail environment. The Department has been the
subject of six use-of-force related class action lawsuits brought by inmates and their advocates,
starting back in the 1980s and continuing today with Nunez v. the City of New York, 11 Civ. 5845
(LTS)(THK), a class action alleging system-wide violations of inmates’ constitutional rights.
Four of the previous class actions focused on specific facilities, including the jail currently
known as EMTC (Fisher v. Koehler, 83 Civ. 2128), the Bellevue Prison Psychiatric Ward
(Reynolds v. Ward, 81 Civ. 101), the Brooklyn House of Detention (Jackson v. Montemango, 85
Civ. 2384), and the CPSU (Sheppard v. Phoenix, 91 Civ. 4148). The fifth class action, like
Nunez, alleged system-wide constitutional violations (Ingles v. Toro, 01 Civ. 8279). All of these
cases settled by either court-ordered or private settlement, instituting limited injunctive relief and
certain reforms related to use of force practices and policies. In Nunez, which is currently in
discovery, plaintiffs allege that any reforms that were instituted as a result of these cases were
not sustained once those settlements and court orders terminated.
In addition to these court cases, there have been several criminal prosecutions of
correction officers, including those referenced supra at note 25, and a case in which two officers
pled guilty in connection with events that led to the death of an adolescent inmate, Christopher
Robinson, in October 2008. Robinson died from a punctured lung after he allegedly was beaten
by other inmates for refusing to participate in “the Program,” a system of extortion among

Page 45

adolescent inmates that was reportedly operating at Rikers with the approval of correction
officers. In an indictment unsealed on January 22, 2009, two officers were accused of enterprise
corruption regarding the events that lead to Robinson=s death. At their arraignment, the assistant
district attorney reportedly told the court that there were “scores” of victims, and that “[the
accused] turned the jail into almost a nightmare environment.”37 Bronx District Attorney Robert
Johnson characterized the situation at the time as “turn[ing] a detention facility for adolescents
into an incubator for violent criminal activity sanctioned by adults in positions of authority.”38
The officers were sentenced to two years in prison, and one year in jail, respectively.39
DOC management has had little success grappling with this violent legacy. During
interviews and meetings both at the Department’s Bulova headquarters and at the jails on Rikers
and during tours of adolescent areas, our consultant was struck by the noticeable lack of presence
of Departmental administrators and top managers in the facilities themselves. This lack of
presence, including management’s physical separation from the jails themselves, contributes to a
broken organizational culture within the facilities that is largely defined by anti-inmate attitudes
and a powerful code of silence. It also may contribute to a perception among uniformed staff,
often repeated in statements made by the head of the correction officers’ union, that civilian
administrators don’t understand how difficult their jobs are because they don’t understand the
reality of the situation on the ground in the facilities. Based on his years of experience working
with and observing correctional facilities around the country, our consultant believes that this
disconnect, in turn, may contribute to a culture among uniformed staff that both tolerates blatant
violations of the Department’s use of force policies and attempts to shield its rank and file from
discipline for violations of those policies, based in part on a belief that they were crafted by
people who do not understand what they deal with every day.


Graham Rayman, Rikers Fight Club, The Village Voice, Feb. 4, 2009.


Press Release, Bronx District Attorney=s Office, Death of an 18-Year Old Inmate on Rikers Island Last October
Leads to Numerous Charges, Jan. 22, 2009,

Elizabeth A. Harris, Corrections Officers Plead Guilty in Assault Case, N.Y. Times, Oct. 21, 2011.

Page 46



Adolescents involved in use of force incidents and inmate-on-inmate fights, as well as
adolescents charged with committing non-violent rule violations, are placed in punitive
segregation for extended periods of time. The Department improperly relies on punitive
segregation as a way to manage and control disruptive adolescents, placing them in what
amounts to solitary confinement at an alarming rate and for excessive periods of time. The
Department’s extensive use of prolonged punitive segregation for adolescents, including inmates
with mental illnesses, exposes them to a risk of serious harm. The manner in which DOC uses
segregation to punish adolescents and the conditions of that segregation raise constitutional
concerns, as well as concerns under Title II of the Americans with Disabilities Act, which
prohibits under certain circumstances isolating adolescents with mental impairments in punitive
segregation due to disability-related behaviors, and thereby denying them the opportunity to
participate in correctional services, programs, and activities.40
On any given day in 2013, approximately 15-25 percent of the adolescent population was
in punitive segregation, with sentences ranging up to several months. For instance, on July 23,
2013, 140 adolescents (or 25.7% of the adolescent population) were in some form of punitive
segregation housing, and 102 (or 73%) of those inmates were diagnosed as seriously or
moderately mentally ill. James Gilligan, M.D et al., Report to the New York City Board of
Correction (“Gilligan Report”), at 3 (Sept. 5, 2013).
The excessive use of punitive segregation can cause significant, psychological, physical,
and developmental harm to adolescents. Solitary confinement can have a particularly profound
impact on youth due to their stage of growth and development. The American Academy of
Child and Adolescent Psychiatry has found that “[d]ue to their developmental vulnerability
juvenile offenders are at particular risk” of possible adverse psychiatric consequences from
“prolonged solitary confinement.”
s.aspx). Youth may experience symptoms such as paranoia, anxiety, and depression after being
isolated for only a fairly short period. This potential harm can be even greater for youth with
disabilities or histories of trauma and abuse, which constitute a significant portion of the Rikers
adolescent population. Solitary confinement may have a long-lasting impact on adolescents who
suffer from mental illnesses, and could result in self-harm or even suicide. The Attorney
General’s National Task Force on Children Exposed to Violence recently concluded that
“[n]owhere is the damaging impact of incarceration on vulnerable children more obvious than
when it involves solitary confinement.” Robert L. Listenbee, Jr., Report of the Attorney
General’s National Task Force on Children Exposed to Violence at 178 (Dec. 12, 2012), In addition, under the juvenile detention
facility standards issued by the Juvenile Detention Alternatives Initiative of The Annie E. Casey

Title II of the ADA provides that “no qualified individual with a disability shall, by reason of such disability, be
excluded from participation in or be denied the benefits of services, programs, or activities of a public entity, or be
subjected to discrimination by any such entity.” 42 U.S.C. § 12132.

Page 47

Foundation, room or cell confinement may be used only as “a temporary response to behavior
that threatens immediate harm to the youth or others” and may never be used as a form of
discipline or punishment. See A Guide to Juvenile Detention Reform: Juvenile Facility
Assessment at 177 (2014),
Our consultant has concluded that the Department has created a vicious cycle that serves
to perpetuate rather than curb adolescent violence. Troubled youth who exhibit violent or
disruptive behavior are placed in punitive segregation for clearly excessive periods, where they
reportedly too often do not receive the mental health services they need. Adolescents have a
greater tendency to react to adverse conditions with anger and violence, and often act out, as
illustrated by the high frequency of reported uses of force in punitive segregation areas. Facing
weeks and often months of segregation time, they have little incentive to modify their behavior
because the chance of returning to the general population prior to their release or transfer to
another correctional facility is minimal. They often receive additional infractions while in
punitive segregation, which further extends their time there. The effects of solitary confinement
also may make these adolescents more prone to unstable and violent behavior, and exacerbate
the mental health issues prevalent among the Rikers adolescent population.

Adolescent Punitive Segregation Units41

Youth in punitive segregation are confined in six-by-eight-foot single cells for 23 hours
each day, with one hour of recreation and access to a daily shower.42 Recreational time is spent
in individual chain-link cages, and many inmates choose to remain in their cells due to
depression or because they do not want to submit to being searched and shackled just to be
outside in a cage. Inmates are denied access to most programming and privileges available to the
general adolescent population, and receive meals through slots on the cell doors. They are not
allowed to attend school, and are instead given schoolwork on worksheets and are offered
educational services telephonically.43 The majority of male adolescent inmates who commit

Shortly after our second site visit in April 2013, DOC made the long overdue decision to stop placing infracted
mentally ill adolescents in MHAUII. MHAUII was an inappropriate setting for any inmate suffering from mental
illness, particularly adolescents. The conditions were deplorable, the physical facilities were in disrepair, and
adolescents were not separated by sight and sound from adult offenders as required by correctional standards. It was
evident that the adolescents were at risk of psychologically decompensating due to the corrosive environment.
Several of the most egregious use of force incidents occurred at MHAUII. At the end of 2013, DOC finally closed
the entire unit.


Inmates may be permitted to attend visits, the law library, or religious services in addition to the one out-of-cell
hour permitted for recreation. In addition, as discussed below, certain infracted inmates with mental illnesses are
placed in RNDC’s restrictive housing unit where they may earn additional out-of-cell time as they reach various


During our investigation, we did not focus on the nature or quality of the educational services delivered to
adolescents, including adolescents placed in segregation units. However, we are concerned that the educational
services offered to youth in punitive segregation units may not comply with the requirements of the Individuals with
Disabilities Education Act, 20 U.S.C. §§ 1400 et seq. (“IDEA”), and may look more closely at this issue in the

Page 48

infractions are placed in the general population punitive segregation units at RNDC (“RNDC
Bing”), which have 64 beds, or the CPSU, which has 50 adolescent beds.
In 2012, the Department began assigning certain infracted adolescents with mental health
needs to the RNDC Restrictive Housing Unit (“RHU”) (30 beds), a program jointly administered
by DOC and DOHMH that offers individual behavioral and group therapy. The RHU utilizes a
three-tiered reward system designed to create incentives for good behavior. Upon being
admitted to RHU, inmates start at level zero and are locked in their cells 23 hours a day. As
inmates move towards achieving the program’s goals, including good behavior and active
participation in therapy sessions, they may earn additional out-of-cell time for programming and
leisure activities. Inmates with non-violent Grade II and III infractions who successfully
complete the program—which takes approximately eight weeks—can earn up to a 50% reduction
in their segregation time. Those who do not comply with the program or engage in violence or
anti-social behavior may be transferred out of the RHU into the general population punitive
segregation units.
Although DOC executive staff are quick to point to the RHU as a significant
accomplishment, the program has met with little success. As of October 1, 2013, only 29 of the
hundreds of inmates placed at the RHU had “graduated” from the program and received a
sentence reduction. DOC transfers adolescents out of the program well before it has any realistic
chance of having a substantial positive impact. Commonly identified reasons for discharge
include that the inmate was “clinically inappropriate,” engaged in “excessive misbehavior,” or
was “deemed inappropriate.” The correction officers assigned to the RHU lack sufficient
training in mental health issues, such as suicide watch, according to the DOHMH doctor who
oversees the program. The now former RNDC Warden noted that the program was not working
when interviewed by our consultant.
During our tour of the RHU, we encountered an extremely troubling incident. We
observed what appeared to be a suicide attempt by an inmate who had tied a ligature around his
neck. The inmate was on the floor and unresponsive. Staff did not immediately enter the cell to
cut the ligature and determine whether CPR was necessary, and it took an unreasonable amount
of time for an emergency response team to arrive with a gurney and provide treatment to the
inmate. During his tours, our consultant heard a number of comments from uniformed staff
about inmates using suicide attempts to manipulate the officers and that the attempts therefore
did not need to be taken seriously.
Although DOC’s effort to offer some alternative for infracted adolescents with mental
health needs may be well-intentioned, at its core, the RHU is still a punitive segregation setting
where inmates are confined in single-occupancy cells for prolonged periods. Even inmates who
progress to Level 3 of the program can earn only up to three hours of lock-out time. While our
investigation did not focus on mental health care provided to adolescent inmates, we note that the
authors of a report to the Board of Correction recently concluded that the RHU “should be
eliminated because it is a punitive rather than a therapeutic setting for people with mental
illness.” Gilligan Report, at 10.

Page 49

In addition, DOC has not developed an effective strategy for how to manage the
adolescent population previously placed in MHAUII—inmates with mental illnesses who
commit serious rule infractions and are not eligible for the RHU, such as adolescents who assault
correction officers.44

Excessive Punitive Segregation Periods

Based on our review of Department data, it is clear that adolescents at Rikers receive
infractions at an extraordinarily high rate and spend an exorbitant amount of time in punitive
During the 21-month period from March 2012 through November 2013, a total of 3,158
adolescent inmates were infracted, or an average of more than 150 inmates each month. These
3,158 inmates received a total of 8,130 infractions, resulting in a total of 143,823 sentence days.
Several of the most common infractions were for non-violent conduct, such as failure to obey
orders from staff (1,671 infractions), verbally harassing or abusing staff (561 infractions), failure
to obey orders promptly and entirely (713 infractions), and shouting abusive-offensive words
(392 infractions). Outside of a correctional facility, such conduct is often viewed as
characteristic adolescent behavior. At Rikers, this behavior can lead to substantial time in
solitary confinement.45
Census data for adolescent punitive segregation units reveal that adolescents are routinely
placed in punitive segregation for months at a time.

Of the 57 adolescents assigned to the RNDC Bing on February 1, 2013, 36
had punitive segregation sentences of 60 or more days. (12 had sentences
between 60 and 89 days, 22 had sentences between 90 and 188 days, and two
had sentences exceeding 200 days.)


Of the 26 adolescents assigned to RHU on March 1, 2013, 22 had punitive
segregation sentences of 60 or more days. (Six had sentences between 60 and
89 days, 10 had sentences between 90 and 197 days, and six had sentences
exceeding 200 days.)


In late 2013, DOC opened the Clinical Alternative to Punitive Segregation (“CAPS”) unit as an alternative to
punitive segregation for inmates deemed to be seriously mentally ill. When placed at CAPS, the inmate’s infraction
is set aside and he is assigned to a secure setting for treatment for a period of time determined by clinical staff.
Unfortunately, the unit has only 60 beds for adult and adolescent male inmates combined, far fewer than is needed to
accommodate the high number of seriously mentally ill inmates who commit infractions. Very few adolescents have
been placed in CAPS. Gilligan Report, at 8.


Our investigation has not focused on the quality or adequacy of the inmate disciplinary system. However, based
on the volume of infractions, the pattern and practice of false use of force reporting, and inmate reports of staff
pressuring them not to report incidents, we believe the Department should take steps to ensure the integrity of the
disciplinary process.

Page 50


Of the 25 adolescents assigned to MHAUII on April 3, 2013, 23 had punitive
segregation sentences (including time accrued while in segregation) of 90 or
more days (15 had between 90 and 194 days still owed, and eight had more
than 200 days still owed.)

Inmates accrue additional segregation time for offenses committed while in punitive
segregation. For instance, one mentally ill adolescent our consultant interviewed owed 374 days
upon his admission to MHAUII, and then accrued an additional 1,002 days for infractions
committed while there.
During our meetings, Department management highlighted its effort to address the
overuse of punitive segregation through the use of the “temporary cell restriction” (“TCR”)
option, which was introduced in October 2012. Unfortunately, this initiative had a minimal
impact and was short-lived. TCR was supposed to be used as an alternative to more formalized
discipline. Correction officers could confine adolescents to their cells for up to two hours when
they engaged in certain non-violent infractions, such as using obscene language or engaging in
horseplay. However, staff were reluctant to use TCRs in lieu of the more formal disciplinary
process. The TCR program was abandoned altogether in early 2014.
In response to the recent increased scrutiny of its inmate disciplinary system, DOC
implemented sentencing reforms in late 2013 that apply to the adult and adolescent population.
First, sentences for multiple non-violent infractions are now generally supposed to run
concurrently, as opposed to consecutively. Second, under the prior system inmates would “carry
over” previously accumulated punitive segregation time upon their re-incarceration, but now
such historical time may be expunged. Specifically, DOC expunges time owed for infractions
committed after one year has elapsed, with the exception of assaults on staff, inmate-on-inmate
assaults resulting in serious injuries, and incidents involving the use of weapons, which will be
expunged only after two years. Third, inmates in general population punitive segregation units
for non-violent infractions may earn a conditional discharge after completing 66% of their
sentence if they commit no violations while in segregation. Fourth, the Department implemented
certain changes to its sentencing guidelines in an attempt to reduce the amount of time inmates
spend in punitive segregation.46
Although these reforms are positive steps, it is too early to assess their impact. As
recently as December 5, 2013, 105 adolescents remained in punitive segregation. There
continues to be a punitive segregation backlog due to the lack of available beds. In addition,
adolescents are still subject to the same sentencing guidelines as adults, and receive lengthy
sentences for rule violations. In November 2013 alone, 160 adolescents were served with a total
of 406 infractions that resulted in punitive segregation sentences totaling 6,024 days. Despite the
revisions to the sentencing guidelines, the most serious infractions can still result in up to 90
days in punitive segregation. In addition, adolescents who “verbally abuse or harass staff
members,” do not “obey” certain orders, or do not “follow facility rules and staff orders relating

DOC has indicated that it plans to implement additional reforms, including the use of intermediate sanctions in
lieu of punitive segregation (e.g., in-school detention, probation).

Page 51

to movement inside and outside the facility,” can receive up to a 20-day sentence, and those who
threaten staff members can receive up to a 30-day sentence. Notwithstanding DOC’s claim that
the sentencing changes have substantially reduced average sentences, as of December 16, 2013,
11 of the 27 inmates assigned to one of the RNDC punitive segregation units had sentences of 60
or more days, 19 of the 27 inmates housed in the CPSU had sentences of 60 or more days, and 14
of the 22 inmates housed in the RHU had sentences of 60 or more days.47


We recognize that the Department has instituted several new initiatives in recent years,
some of which are specifically designed to better manage the adolescent inmate population.
Some of these, such as the RHU, focus on alternatives to traditional punitive segregation for
disciplining adolescent inmates. Others are designed to more productively fill the time for
adolescent inmates, such as the ABLE program, also discussed above. Still other measures aim
to reduce conflict between adolescent inmates, including by moving adolescents out of dormitory
housing and requiring them to wear institutional garb and footwear. Additional staff have been
added to adolescent housing areas, as noted above, as well as additional management positions,
including a newly created position of Deputy Warden for Adolescents. Although these
initiatives are laudable, they have thus far done little to meaningfully reduce violence among the
adolescent inmate population. Indeed, at least one relatively new initiative, the use of TCR, has
already been abandoned by the Department.
The larger problem, however, is that by and large these reforms do not address—or even
attempt to address—the core problem and the heart of our findings: use of excessive and
unnecessary force by correction officers against adolescent inmates and the lack of
accountability for such conduct. The few reforms that arguably go to this issue—such as the
installation of additional cameras, the addition of a DIAL hotline that allows inmates to
anonymously report abuse, including by staff, and the addition of an Integrity Control Officer
located within RNDC—do not go nearly far enough. As noted above, for example, there are still
many areas throughout RNDC and EMTC with no camera coverage, including the school areas,
where adolescent inmates spend a significant portion of their waking hours. Fundamentally,
these few changes alone—while certainly important—cannot and will not fix a system where
officers regularly use excessive and unnecessary force with minimal consequences.
Accordingly, in order to address the constitutional deficiencies identified in this letter and
protect the constitutional rights of adolescent inmates, the Department should implement, at a
minimum, the following measures:


Ten of the inmates housed in the RHU had sentences exceeding 100 days.

Page 52



House Adolescent Inmates at a DOC Jail Not Located on Rikers Island that
Will Utilize “Direct Supervision” Management Model

The Department should develop a plan to house adolescents at a DOC jail
not located on Rikers Island that will be staffed by experienced, competent
officers and supervisors who will receive specialized training in managing
youth with behavioral problems and mental health needs. The Department
should incentivize well-qualified staff to volunteer for assignment to this
facility by offering significant pay increases, preferred schedules, and
other benefits.


The Department should employ a “direct supervision” management style
in the adolescent facility. Direct supervision refers to an inmate
management strategy in which, among other things, staff continuously
interact with and actively supervise inmates from posts within housing
areas, as opposed to being stationed in isolated offices. Direct supervision
has been shown to reduce rates of violence, lead to better inmate behavior,
lower operating costs, and improve staff confidence and morale. Frontline
housing officers and first line supervisors are afforded substantial
decision-making authority so that they feel empowered and responsible for
the effective management and supervision of the unit. To effectively
employ the direct supervision approach, the jail should be designed to
reduce the physical barriers between inmates and staff, and ensure clear
sightlines to all housing areas. It would be difficult to implement direct
supervision at RNDC due to its linear design and layout. Housing
adolescent inmates at an alternative facility located off Rikers Island will
put DOC in a better position to develop a new paradigm for effectively
managing the adolescent inmate population.

Increase Number of Cameras in Adolescent Areas of Jails

Install additional video surveillance cameras in all adolescent areas,
including but not limited to housing areas, school/classroom areas, intake,
search locations, and clinics.


Enhance and ensure compliance with procedures for maintaining video
surveillance of use of force incidents and inmate-on-inmate fights or
assaults, and sanction staff for failure to comply with these procedures. If,
upon preliminary review, a particular portion of the video footage appears
crucial, that portion of the video should be copied and maintained
separately from the original.

Page 53


Strengthen the Department’s Use of Force Directive

Develop and implement the following clarifications and changes to the
Use of Force Directive, and related policies and procedures:

Clarify the definition of “use of force” to provide better guidance
on the conduct that triggers reporting and investigation
requirements. The definition should include any instance where
staff use their hands or other parts of their body, objects,
instruments, chemical agents, electric devices, fire arms or any
other physical method to restrain, subdue, intimidate, or compel an
inmate to act in a particular way, or stop acting in a particular way.


Clarify that headshots are considered an excessive and unnecessary
use of force, except in the rare circumstances where an officer or
some other individual is at imminent risk of serious bodily injury
and no more reasonable method of control may be used to avoid
such injury.


Explicitly prohibit, or further highlight and emphasize the
prohibition on, the following:

The use of unnecessarily painful escort or restraint


The use of force as a response to inmate verbal insults or


The use of force against inmates in restraints, unless the
inmate presents an imminent threat to the safety of staff or
others in which case the force must be proportionate to the


The use of force as corporal punishment, emphasizing the
principle that force can be used only to stop or control what
an inmate is currently doing, not in response to what he
previously did.


The use of force as a response to inmates’ failure to follow
instructions where there is no immediate threat to the safety
of the institution, inmates, or staff, unless staff has
attempted a hierarchy of nonphysical alternatives that are
documented, including the use of time as circumstances

Page 54




Harassing or verbally provoking inmates.


Retaliation against inmates, Departmental staff, medical
staff, or teachers for reporting a use of force incident or
providing information in connection with a use of force


Pressuring or coercing inmates, Departmental staff, medical
staff, or teachers not to report a use of force incident.


In situations involving cell extractions or other planned uses of
forces, require the following additional reporting: (i) the name of
the mental health care professional who attempted to resolve the
incident without the use of force; (ii) a written report prepared by
the mental health care professional setting forth his or her efforts to
attempt to resolve the situation and why those attempts were not
successful; and (iii) the length of time spent trying to resolve the
situation without the use of force.


Require staff in planned use of force situations to wait a minimum
of 90 seconds after application of chemical agents before
proceeding with a physical use of force so the chemical agent can
take effect. Staff should be required to document compliance with
this procedure. This requirement would not apply if an inmate’s
conduct changes a planned use of force into a reactive use of force.


Specify requirements for training on the Use of Force Directive
specifically, including which staff must complete the training,
when they must be trained (including regular refresher courses),
and the length of the training.

Reorganize the Use of Force Directive to make it more accessible to front
line correction officers, clarifying key requirements and prohibitions. In
addition, prepare a separate, short summary of the key requirements and
prohibitions that are included in the Use of Force Directive. The summary
should be designed specifically for use and quick reference by correction
officers. A separate summary could be prepared for supervisors, outlining
the key responsibilities for Captains and Tour Commanders.

Use of Force Reporting

Ensure that all staff who are involved in or witness a use of force incident
submit complete, accurate, and prompt reports. The Department should
institute a zero tolerance policy for failure to submit complete, accurate,
and prompt reports—both by involved officers or by witnesses—with

Page 55

serious consequence for failure to do so. Supervisors must also be held
accountable for the failure of officers under their command to satisfy this

In the event staff report that force was necessary due to an inmate’s
alleged resistance, require staff written reports to provide a specific and
detailed description of the inmate’s alleged resistance and conduct.


Ensure that staff do not review video footage prior to completing their
written reports or being interviewed, and prohibit staff from changing their
written reports after reviewing video footage.


To the extent possible, segregate staff involved in a use of force incident
until they have submitted their written reports to ensure that they submit
independent reports.


Clarify the definitions of the categories of institutional violence data
maintained by the Department (e.g., “use of force allegations,” inmate-oninmate “fight” vs. “assault”) to ensure the collection and reporting of
reliable and accurate data.


Ensure that adequate systems are in place to accurately track information
on use of force incidents and inmate-on-inmate fights and assaults,
including the inmate(s) and/or staff involved, the location of the incident,
the nature of any injuries, medical care provided, the investigation and
findings, and any corrective, disciplinary, or prosecution actions taken
against inmates or staff.


Ensure that medical staff advise the ID whenever they have reason to
suspect that inmates have sustained injuries due to staff use of force so
that such incidents are identified and properly investigated. Train medical
staff on how to report incidents where inmate mistreatment is suspected.


Ensure that the camcorder operator assigned to search teams follows an
established and approved video protocol and films any conflicts or
incidents arising out of the search.


In the event a camcorder operator fails to properly record a planned use of
force, conduct an investigation and, when appropriate, take appropriate
disciplinary actions.


Expand the video recording protocol used for cell extractions or other
planned uses of force to include the recording of: (a) attempts made to
obtain the inmate’s compliance before force is used; (b) a statement from
the team leader summarizing the situation and the plan for resolution; and

Page 56

(c) a statement from the camcorder operator explaining any impediments
to obtaining a clear video recording of the incident.



Revise the grievance policy so that inmate complaints concerning staff use
of force or staff verbal harassment are grievable, and ensure that such
complaints are promptly referred for investigation.


Develop and implement a reliable procedure for identifying and timely
addressing emergency grievances involving inmate safety issues.


Ensure that non-DOC staff, such as medical personnel and teachers, report
any use of force that they witness. Clearly communicate this requirement
to all non-DOC staff, emphasizing that failure to report such incidents, or
false reporting related to such incidents, may lead to administrative or
legal sanctions.

Use of Force Investigations

Ensure that all use of force incidents are thoroughly and timely
investigated, and that complete and detailed reports are prepared
summarizing the findings and any recommended corrective actions. Each
person investigating an incident, whether for a preliminary investigation or
a final investigation, should be required to make recommendations based
on his or her findings. Staff shall be accountable for biased, incomplete,
or otherwise inappropriate investigations, reports, and recommendations.


Ensure that every reasonable effort is made to obtain the involved
inmate’s account of a use of force incident, as well as the accounts of any
key inmate witnesses, even if that requires making multiple interview
attempts. Assure inmate witnesses that they will not be subject to any
form of retaliation for providing information in connection with an
investigation. Requests for interviews with inmates shall not be made at
cell fronts or within sight or hearing of other inmates. Generally such
requests shall be made one-on-one and off the living unit. Offer inmates
the opportunity to be interviewed in a private and confidential setting.


Require in-person interviews of any staff member who submits a written
report stating that he or she did not observe any use of force where there is
reason to believe that the staff member was in close proximity to the
location of the incident and should have observed what occurred.


Where video surveillance is available, require staff responsible for
investigating the incident to summarize the video footage and explain
whether the footage is consistent with witness reports.

Page 57


Ensure that use of force investigations are completed in a reasonable
amount of time. Require ID investigations to be completed within 60
days, absent unusual and documented circumstances. If necessary,
increase the staff and resources of the ID to ensure that each investigator is
assigned a manageable caseload.


Address the current backlog of pending ID investigations. Complete
investigations of any incident that occurred during the last three months
within 60 days of the date of this report. If necessary, allocate additional
staff and resources to meet this deadline.


Ensure that investigation of the most serious use of force incidents are
prioritized to ensure that they are investigated in an expedited manner.


Clarify the criteria used to determine whether use of force incidents must
be investigated by the ID. At a minimum, the ID should investigate any
incident involving: (a) an alleged headshot by staff; (b) a serious injury to
an inmate or staff member; (c) a staff member who has been involved in
three or more use of force incidents within the last 12 months; or (d) a
staff member previously disciplined for violation of the use of force
policies and procedures within the prior 18 months.


Clarify the criteria used to determine whether a use of force incident
should be referred to law enforcement for further investigation, and
establish a mechanism for then promptly referring relevant incidents to
outside investigative and law enforcement agencies, including the United
States Attorney’s Office for the Southern District of New York.


Develop and implement a standardized system for the organization and
contents of investigation files to facilitate review and oversight.


Ensure that facility-level investigations are appropriate, thorough, and
timely. In addition to the currently required reviews of certain facilitylevel investigations by ID line investigators, require senior ID managers
and Department managers to periodically review a sample of
investigations conducted at the facility level as well. The results of these
reviews should be documented and any appropriate remedial actions
should be taken.


Develop and implement a quality control process to ensure that ID
investigations are appropriate, thorough, and timely. Senior Department
managers should review a sample of investigations performed by the ID.
The results of these reviews should be documented and any appropriate
remedial actions should be taken. In addition, an external entity should
conduct periodic audits of the ID’s operations and investigations.

Page 58


Safety and Supervision

Ensure that inmates are adequately supervised at all times.


Ensure that staff intervene in a timely manner to prevent inmate-on-inmate
fights and assaults and de-escalate inmate-on-inmate altercations.


Ensure that injured inmates receive prompt medical care after a use of
force incident or inmate-on-inmate fight or assault. Ensure that staff
document the time and date an inmate is taken to receive medical care
after a fight, assault, or staff use of force, and the time and date the inmate
is initially assessed by medical staff.


Develop and implement an age-appropriate classification system for
adolescent inmates that incorporates factors that are particularly relevant
to assessing the needs of adolescents and the security risks they pose.


Promptly place adolescents who express concerns for their personal safety
in temporary protective custody housing, pending evaluation of the risk to
the inmate’s safety and a final determination as to whether the inmate
should remain in protective custody housing, whether the inmate should
be transferred to another housing unit, or whether other precautions should
be taken. The Department should follow the same protocol when a family
member, lawyer, or other individual expresses credible concerns on behalf
of an adolescent inmate.


Transfer any inmates deemed to be particularly vulnerable or otherwise at
risk to an alternative housing unit.


Redefine expectations regarding staff professionalism and staff-inmate
communications, and implement a zero-tolerance policy towards verbally
harassing or humiliating inmates. This prohibition should include
homophobic slurs, racial epithets, and obscenities. The Department
should document the new expectations and clearly convey them to staff,
and hold non-compliant staff accountable.


Offer adolescents enhanced programming and activities, especially in the
evenings and on weekends, to engage them and reduce idleness.


To the extent possible, adopt a team staffing structure where a group of
officers and a supervisor are consistently assigned to the same adolescent
housing area and same tour to facilitate staffing continuity and improve
staff-inmate relations.

Page 59



Limit the practice of assigning recently hired correction officers to
adolescent housing areas immediately upon their graduation from the


Develop and implement measures to reduce staff turnover at adolescent
housing facilities.


Adopt incentives, including greater financial incentives, to persuade
experienced and qualified officers to work in adolescent housing facilities.


Ensure that specialized teams, such as the probe and cell extraction teams,
are staffed with officers with superior skills and extensive experience. To
the extent possible, the staffing of these teams should remain constant for
stability and continuity purposes.


Require the Wardens and Deputy Wardens to tour adolescent housing
units for at least one hour each day, making themselves available to
respond to questions and concerns.


Ensure that all allegations of sexual assault involving adolescents are
properly and timely reported and thoroughly investigated, whether those
allegations are from an inmate, a family member, an inmate advocate, a
grievance, or some other source.


Develop more comprehensive and effective competency-based training
programs on use of force policies and force and defensive tactics. The
trainings should be largely scenario-based and involve significant roleplaying, demonstrations, and/or videotape reflecting realistic situations.
The training should emphasize, among other things, techniques to avoid
the use of force when possible, the importance of using time and distance
to de-escalate, the general prohibition against headshots, the utilization of
control techniques designed to minimize injuries to inmates and staff, the
need to cooperate with use of force investigations, and the array of
disciplinary actions that will be taken for violations of use of force policies
and procedures.


Develop a remedial training program specifically designed for officers
found to have violated use of force policies and procedures. This program
shall be separate and different from the general in-service use of force
training program, and shall focus in large part on the more frequent types
of use of force violations.

Page 60


Develop a more comprehensive and effective competency-based training
program on conflict resolution and crises intervention skills for frontline
officers and first line supervisors. The training should be realistic,
corrections-specific, and skill-based.


Revise the recently implemented adolescent training program so that it
focuses less on theoretical principles and more on techniques to manage
the challenging adolescent behaviors that staff routinely encounter.
Require all staff assigned to adolescent facilities to successfully complete
this training.


Develop stand-alone required training on the importance of submitting
prompt, complete, and accurate use of force reports, and the serious
potential consequences (including criminal consequences) for falsifying
use of force reports and/or failing to report a use of force, including as a
witness. The training should be offered at the Academy for new recruits,
and refresher courses should be required annually. Some version of this
training should also be required for all non-DOC staff who work on Rikers


Develop and implement an effective and comprehensive competencybased training program for all staff responsible for reviewing or
investigating use of force incidents (e.g., ID staff, Wardens, Assistant
Deputy Wardens, Captains, Tour Commanders) that covers investigation
methods and skills, including conducting effective witness and victim
interviews, reviewing video surveillance for consistency with policy
requirements and inmate statements, and identifying and resolving areas of


Ensure that staff are adequately trained on how to interact and manage
adolescents with mental illnesses and/or suicidal tendencies.

Page 61



Ensure that staff are subject to appropriate and meaningful discipline for
any violation of use of force policies and procedures, including but not
limited to: (a) using unnecessary or excessive force; (b) failing to submit
prompt, complete, and accurate use of force reports; (c) encouraging,
pressuring, or coercing inmates or DOC and non-DOC staff members not
to report uses of force; and (d) failing to intervene as soon as practical
when inmate-on-inmate violence occurs.


Develop categories of officer misconduct that warrant termination,
including but not limited to: (a) hitting an inmate who is in restraints;
(b) kicking an inmate who is on the ground; (c) striking an inmate in the
head except in situations where an officer or some other individual is at
imminent risk of serious bodily injury and no more reasonable method of
control may be used to avoid such injury; (d) providing an intentionally
false use of force report or interview; and (e) intentionally failing to report
staff use of force resulting in serious bodily injury.


In the event that a staff member is found to have utilized excessive or
unnecessary force or otherwise violated the Department’s use of force
policies, assess the fitness of the staff member for continued assignment to
an adolescent housing area.


Develop and implement a formalized progressive disciplinary process for
violations of use of force policies and procedures.


Develop and implement an early warning system (“EWS”) designed to
effectively identify potentially problematic staff as early as possible.

The EWS should track the frequency with which staff are involved
in uses of force, are the subject of a complaint or grievance, engage
in unprofessional conduct, are subject to disciplinary action, and
are involved in other incidents that may serve as predictors of
future misconduct. The EWS should be triggered when officers
reach a threshold developed and determined by the Department.


Staff identified by the EWS should be subject to an appropriate
corrective action plan (at least one year in duration), and should be
deemed ineligible for promotion or special assignments, including
the probe or cell extraction teams, until the corrective action plan
has been successfully completed. The corrective action plan shall
not substitute for, or mitigate, administrative disciplinary action in
any incident.

Page 62



Require that a supervisor above the rank of Captain interview any staff
member who: (a) utilizes a headshot; (b) uses restraints or escort
techniques that result in an inmate injury; or (c) strikes an inmate without
first applying OC spray. The interviewer should document the interview
and attempt to ascertain whether the conduct violated Department policy
and procedures.


Ensure that ID staff and other staff responsible for investigating the use of
force are appropriately disciplined for any failure to conduct a thorough,
timely, and unbiased investigation.


Ensure that DOC supervisors and managers are held accountable for the
performance of their subordinates, including by being subject to
appropriate disciplinary measures when staff under their supervision
improperly use force or fail to adequately report the use of force.


Develop a strategic plan to create and maintain a culture of accountability
at all levels of the Department.

Inmate Discipline

Develop and implement an adequate continuum of alternative disciplinary
sanctions for rule violations that do not involve lengthy isolation, as well
as systems to reward and incentivize good behavior.


Develop and implement an alternative housing strategy for chronically
disruptive adolescents that does not deny them the programming and
privileges afforded to the general population and does not compromise the
safety of other inmates or staff.


Prohibit placing adolescents with mental health disorders in solitary
confinement for punitive purposes. Ensure that a mental health care
professional is consulted prior to the imposition of any disciplinary
sanction on adolescents with mental health disorders.


Establish an appropriate therapeutic secure setting to house adolescents
with serious mental illnesses who commit infractions, which should be
staffed by well-trained and qualified personnel and operated jointly by


To the extent any adolescents without mental health disorders are placed
in punitive segregation, monitor their medical and mental health status on
a daily basis to ensure that their health is not deteriorating.

Page 63



Ensure that the conditions of the housing areas for infracted inmates,
including individual cells, are sanitary, safe, adequately ventilated, and
properly maintained.


Retain an outside consultant to conduct an independent review of
Department infraction processes and procedures to ensure that: (a) they
are fair and reasonable; (b) inmates are afforded due process; and
(c) infractions are imposed on adolescents only where there is sufficient
evidence of a rule violation. The consultant should document the results of
the review and make any appropriate recommendations, which DOC
should implement.

Management and Leadership

Develop and implement a comprehensive strategic plan for altering the
institutional culture to one that does not tolerate violence, and holds staff
accountable for using excessive or unnecessary force.


Enhance management continuity at adolescent housing facilities, and limit,
to the extent possible, the rate of turnover among Wardens and Deputy


Develop and implement procedures to identify systemic patterns
associated with uses of force and inmate-on-inmate fights and assaults,
and take appropriate steps to address these patterns.


Require DOC’s top operational administrators to conduct periodic
unannounced tours (including evening and weekend tours) of adolescent
housing areas.

Page 64

We hope to contim1e working with the Department in an amicable and cooperative
fashion to address our outstanding concerns, and to develop specific policies and procedures that
will implement the remedial meas~1res discussed above. We are obligated to advise you thEJt. in
the event that we m·e unable to reach a resolution regarding our concerns, tbe Attorney General
may initiate a lawsuit pm·s\.mnt to CR[PA to conect deficiencies oftbe kind identified in this
letier 49 days aftet· appropriate officials have been notified of them. See 42 U.S.C.
§ l997b(a)(1 ). We would prefet•, however, to resolve this matter by wol'ldng cooperatively with
you and are hopef1.1l that we will be able to do so in this case. We will he contacting you to
discuss this matter in further detail.
Finally, please note that this findings letter is a public document. It will be posted on the
website of the Civil Rights Divisio11 ofthe United Stotes Depa1'tment of Justice. We will also
pmvide a copy of this letter to any individual or entity upon request.

Acting Assistant Attorney General
Civil Rights Division


United States Attorney for the
Southern District ofNcw York

Nh IMJ)_
Jeffrey K. Powell
Assistant United States Attomey





Assistant Unitmcl
States At

Page 65

In connection with our investigation, we identified a sample of approximately 200 use of
force incidents involving adolescent male inmates and requested all records related to these
incidents. Among other things, we requested use of force reports, investigative reports and files,
video surveillance, inmate medical records, and records relating to any disciplinary action taken
against involved inmates or staff. In addition, our consultant interviewed the adolescents
involved in some of these incidents. As noted in the body of our letter, in many cases, we were
not provided with video surveillance that existed at one time, because the Department claimed
that it could no longer locate the footage.
We have compiled the below summaries based on our review of the materials provided
and our consultant’s interviews.48 With the exception of the final incident referenced in the
Appendix, we have not included incidents where there was an ongoing DOC investigation at the
time this letter was prepared. These incident summaries are intended to illustrate several of the
serious, systemic deficiencies we have identified in the body of our letter, which we have
concluded violate the constitutional rights of adolescent inmates and expose them to an ongoing
substantial risk of harm during their confinement at Rikers. These incidents are just some of the
incidents that we have found to be problematic; they are in no way intended to serve as a
complete list of all instances in which DOC staff have used unnecessary or excessive force
against adolescents.
*Inmate A
In April 2012, DOC staff repeatedly punched Inmate A in the face near the RNDC school
security gate, allegedly with the approval of a Captain who had previously gotten into a verbal
altercation with the inmate. There is no video of the incident because there are no cameras in the
school area.
During an interview with investigators the day following the incident, Inmate A provided the
following detailed account: After leaving the school area to go to lunch, he set off the
magnometer and a Captain told him to empty his pockets. He and the Captain had a heated
argument and the Captain tossed Inmate A’s chips into the garbage. Inmate A called the Captain
a “bitch,” and the Captain responded by saying, “all right, wait until you come back up.”
Another correction officer, who was also present, warned him to “watch when you come back.”
When Inmate A returned from lunch, the correction officer instructed him to wait at the security
gate while the other inmates entered the classrooms. The officer asked the Captain what he and
two other officers should do with Inmate A, and the Captain directed him to mace Inmate A,

An asterisk indicates that our consultant interviewed the inmate involved in the incident during our on-site tours.

Page 66

which he did. The officer then punched Inmate A on the right side of his face. After this initial
blow, this same officer and the two other officers punched Inmate A approximately ten times in
the face and ribs. When Inmate A fell to the ground, the officers began kicking him, and one of
the kicks to the inmate’s face cut his lip.
The ID inexplicably did not complete its investigation until June 2013, 14 months after the
incident took place. The officer who maced and initially punched inmate A told the ID
investigators that when he instructed Inmate A to place his hands on the wall after Inmate A did
not clear the magnometer, Inmate A punched him in the face and body. The officer stated that he
had neglected to mention in his initial written report that Inmate A had punched him in the body
as well as the facial area because he was “dazed” after the incident. According to the officer, he
used the OC spray but it did not achieve the desired effect, so he punched Inmate A in the body
and face. The officer claimed he and Inmate A were the only ones in the area at the time of the
incident. When interviewed by ID investigators in January 2013, the Captain denied being in the
area when the use of force occurred.
According to a logbook, Inmate A was not seen in the RNDC clinic until more than three hours
after the incident. Inmate A sustained a laceration to his upper lip and was transferred to
Urgicare where he received three sutures. Inmate A also suffered contusions to his right orbital
and rib areas. The officer sustained injuries to his left thumb and knee, but there is no indication
in the record of any facial injuries, which is inconsistent with the officer’s assertion that Inmate
A punched him in the face.
Notwithstanding the officer’s admission that he had repeatedly punched Inmate A in the body
and face and the fact that the officer’s injuries were inconsistent with his account, the ID
concluded that the use of force was within the use of force guidelines. According to DOC
records, the officer was involved in a total of 13 use of force incidents at RNDC from 2010
through early 2013.
Inmate B
In April 2012, Inmate B, who was in the adolescent punitive segregation unit of MHAUII due to
mental health needs, was repeatedly punched in the head and upper body by an officer while two
other officers stood idly by. The incident was captured on video, which we reviewed.
Several inmates in the MHAUII multi-purpose room got into a disagreement and began throwing
a storage bin at each other. One officer entered the room and approached Inmate B, whose
handcuffs apparently had been removed. According to the infraction report later prepared by the
officer, when he tried to re-apply the mechanical restraints, Inmate B stood up and pushed him,
and the officer defended himself by “applying a combination of blows and strikes to the subject
inmate’s upper torso and took Inmate B down to the ground.” However, the video of the
incident shows that the officer actually delivered multiple roundhouse punches to Inmate B’s
head, while at least two officers in the room stood by and made no attempt to intervene. It is
unclear from the video whether Inmate B actually pushed the officer as the officer contends.

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Inmate B sustained multiple abrasions to the right and left side of his face, his right wrist, and his
left elbow. The officer suffered trauma to his right thumb, presumably from punching Inmate B.
Notwithstanding the video surveillance, the facility concluded that the force was minimal and
necessary. The other officers in the multi-purpose room who witnessed the use of force
inexplicably did not provide written reports as required by policy.
Inmate C
In May 2012, in an apparent act of retribution, Inmate C was beaten near the RNDC school, an
area that does not have security cameras. Inmate C was punched several times in the face by an
officer, and was allegedly kicked by a second officer after falling to the ground.
During his interview with investigators, Inmate C stated that an officer got angry at him one
morning when he did not follow the officer’s order to stop doing pushups and report to his bed.
The officer threatened Inmate C and told him that he would “slap the shit out of him if he kept
playing,” according to a statement provided by another inmate. According to Inmate C, in the
afternoon, while inmates were lining up to enter the RNDC classroom, the officer ordered Inmate
C to stay behind. Inmate C reported that the officer then put on a pair of gloves, assumed a
fighting stance, and punched Inmate C in the face approximately 15 times, causing him to fall to
the floor. Inmate C reported that he felt a second officer kick him while he was bleeding on the
In his use of force report, the first officer asserted that Inmate C instigated the fight by punching
him in the face “without provocation,” and that the officer punched Inmate C in his upper body
only in self-defense. The officer claimed that he repeatedly used OC spray to subdue Inmate C
and gave him several verbal commands to stop his aggression. However, several inmate
witnesses confirmed many aspects of Inmate C’s account, including that the officer instigated the
incident, that Inmate C was hit repeatedly, and that other officers joined in the beating. The
officer later submitted a written addendum to his initial report acknowledging that his punches
were to Inmate C’s facial area, not just to his upper body.
Inmate C sustained a nasal fracture and bruises to his face and head, which is consistent with
being punched in the face. The first officer also sustained injuries and was transported to Booth
Memorial Hospital for treatment. The ID, which did not complete its investigation until 14
months after the incident, concluded that the use of force was appropriate and that the facial
blows delivered by the officer were used as self-defense. The officer was not disciplined, even
though he indisputably filed a false use of force report that did not mention the punches to
Inmate C’s face.
*Inmate D
In May 2012, Inmate D sustained serious injuries, including a skull fracture, as a result of a use
of force incident that occurred in an RNDC search area, where there is no video surveillance.

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Inmate D provided the following account: When he entered the RNDC visit search area after a
visit with his girlfriend, DOC staff ordered him to remove his clothing, squat, and cough. Inmate
D complained about the strip search but eventually complied. After Inmate D made a smart
remark to one officer, multiple officers proceeded to repeatedly punch and kick him in the chest,
face, and head while he tried to protect himself. He was then ordered to remove his clothes
again, which he did (other than his socks). Additional officers then joined in the beating and
repeatedly punched and kicked Inmate D while he was on the ground. A large metal fan was
thrown on top of him multiple times. Inmate D reported that at least five correction officers
participated in the assault, and that the beating continued until one officer stated that he thought
Inmate D was dead. He was then handcuffed and kicked in the face a few more times.
Inmate D bled heavily, was taken to an intake pen, and did not receive medical treatment until
more than an hour after the incident. He was eventually taken to Elmhurst Hospital.
In statements to investigators, according to the officer to whom Inmate D initially made a smart
remark, Inmate D instigated the altercation by disobeying his order to comply with the search
process, throwing his underwear at the officer, and punching him in the face. In his written
report, the officer reported that he “defended [himself] punching [Inmate D] numerous times in
his face and upper body area.” The officer claimed he did not observe any other staff member
punch or kick Inmate D. The other officers involved denied using any force themselves and
claimed they did not see the first officer use any force either.
Inmate D sustained a skull fracture, bruises to his back and shoulders, and multiple lacerations to
his forehead and inner lip requiring stitches. The first officer sustained mild tenderness to his
left anterior shoulder and left anterior knee, as well as mild swelling to the left side of his face.
The ID concluded that Inmate D’s allegations that he was beaten by numerous officers were
unsubstantiated. Based on our review, the staff reports in this case raise credibility issues that
should have been addressed during the investigation. Most importantly, Inmate D’s severe
injuries are inconsistent with the accounts provided by the officers. In addition, the Captain who
arrived on the scene claimed he did not recall seeing any blood, which is inconceivable given
Inmate D’s injures. Furthermore, the same initial officer asserted that a patterned contusion on
Inmate D’s upper back might have been caused by his watch when he pressed his forearm
against Inmate D’s back (as opposed to being a “boot print”), but medical personnel disagreed.
No effort was made to compare the officers’ boots to the bruise pattern to determine whether an
officer had in fact stomped on Inmate D.
The description of the incident Inmate D provided to our consultant in January 2013 is
substantially consistent with the accounts he provided in May 2012 to the ID investigators, DOC
medical staff, and the Legal Aid Society. Inmate D received a sentence of 75 days in punitive
segregation for not following orders and assaulting an officer. Inmate D filed a lawsuit based on
this incident, which settled before trial.

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Inmate E
In May 2012, Inmate E was ordered out of his classroom and beaten by officers in the EMTC
school area after an officer perceived that Inmate E was challenging his authority by allegedly
disregarding his order to pull up his ill-fitting and overly large institutional pants. Inmate E
suffered multiple injuries to his head and face, including a broken tooth. One year and eight
months after opening its investigation, the ID concluded that there was insufficient evidence to
conclude that inappropriate and excessive force was used, no charges were recommended against
the officers involved, and the case was closed. There is no video surveillance in the ETMC
school area.
In an interview with investigators, Inmate E explained that the day before the incident he had
been issued institutional pants that were too big for him. On the day of the incident, an officer
looked into a classroom, saw that Inmate E’s pants were falling down, and ordered him to pull
them up. Inmate E did so, but the officer ordered him out of the classroom and told him that he
had to comply when given an order. When Inmate E explained that his pants were too big, the
officer told him not to question his authority, and pushed his head so that the back of his head hit
the wall. Inmate E became angry and “flinched” at the officer, but did not actually hit him. The
officer then started punching Inmate E. A second officer then came out from the A post, and
started punching him as well. Together the two officers punched him in the ribs, right eye, left
side of his forehead, and right side of his jaw. Inmate E estimated that four or five punches
landed on his jaw. A third officer also joined in and began beating Inmate E as well. Once the
Captain arrived, she ordered Inmate E to put his hands on the wall, which he did. The second
officer then punched Inmate E again. Inmate E denied hitting any of the officers, and said he was
just trying to block punches. DOHMH records also indicate that Inmate E told medical staff that
he was “jumped” and “punched all over his body” for “no apparent reason.”
The officers’ statements regarding the incident were not consistent with Inmate E’s and not
entirely consistent with each other. In his use of force report and interview, the second officer
said he saw Inmate E swing at the first officer, and that he came to his aid and together he and
the first officer were able to restrain Inmate E against the wall. The second officer said he did
not see the first officer punching Inmate E and did not report taking part in or witnessing any
force other than “restraining” Inmate E and “gaining control” over him. The Captain reported
that she saw Inmate E “strike [the first officer] in the face with a closed fist,” when she arrived in
the area, although the second officer reported that they had already gained control of him by the
time the Captain arrived. The first officer, who did not submit a use of force report until two
days after the incident, reported that Inmate E first punched him three or four times on his face
and neck, and that the punches were so powerful, they caused the officer’s legs to “buckle.” He
then punched Inmate E approximately three times; one punch inadvertently hit Inmate E in the
face, and the others landed on his arms and torso. The officer did not report any further strikes to
Inmate E’s head or torso, and only described putting Inmate E in a rear arm lock against the wall.
The first and second officers claimed torn rotator cuffs to the shoulders, although both refused to
sign HIPAA forms for the release of medical records. The first officer also claimed pain to his

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left wrist, left shoulder, neck, and lower back. Such injuries are more consistent with throwing
punches than being punched “three or four times” in the face and neck.
Although the ID’s case closing report states that “[Inmate E]’s version [of events] was not
supported by other testimony,” in fact six inmates provided statements substantially consistent
with Inmate E’s, including detailed statements regarding the fact that the first officer pushed
Inmate E’s head against the wall, that three officers were beating him, that Inmate E was trying
to block the punches, and that the Captain watched the fight but did not intervene.
Inmate E sustained “multiple injuries to face, and head and mouth,” including bruises to his right
eye and lip, and injuries to the left side of his head, nose, and mouth. He was sent to Urgicare
for x-rays, where it was determined that he had a broken tooth. In addition, photographs
documented blood stains on his shirt. Although the ID concluded that these injuries “can be
accounted for by the officers’ account of the force used,” it is not credible that one inadvertent
punch to the face and control holds could result in multiple bruises and injuries to the opposite
sides of his head, a broken tooth, and leave blood stains on his shirt.
The ID took one year and eight months to complete this investigation, and recommended that the
case be closed without charges. The length of the investigation is particularly striking, given that
a preliminary investigative case report was written up by the ID just five days after the incident,
including summaries of all the statements inmate witnesses made to ID investigators. At that
time, the ID did not yet have the first officer’s use of force report, and the preliminary report
noted that the case should remain open in order for the first officer and other staff to “explain
how [Inmate E] sustained a chipped tooth and multiple injuries to face, head and mouth.” It then
took nearly nine months before the ID conducted an interview of the Captain, and then still
another eight months before the ID conducted interviews of the first and second officers. In
total, the first and second officers were interviewed one year and five months after the incident
took place.
*Inmate F
In June 2012, Inmate F, a mentally impaired inmate, was repeatedly punched in the face by an
officer who has been involved in well over 20 other RNDC use of force incidents. Although the
officer admitted that he delivered multiple blows to the inmate’s face, the Department concluded
that the force used was appropriate based on the officer’s contention that he was acting in selfdefense and responding to an unprovoked blow from the inmate. There is no video of the
incident because it occurred in the school area.
During an interview with our consultant, Inmate F reported that the officer challenged him to a
one-on-one fight after they had gotten into a verbal confrontation in the RNDC school area.
Inmate F reported that the officer punched him in the face, injuring his nose. Inmate F told our
consultant that the officer kept on punching him, and he eventually punched the officer back and
then ran into the corridor where he knew there was video surveillance and assumed a “surrender”
position. According to DOC records, the officer was involved in a total of 24 use of force

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incidents at RNDC from 2007 through early 2013, including eight incidents in 2012 alone. He
also has been subject to repeated disciplinary actions.
In his written report, the officer claimed that Inmate F initiated the altercation by punching him
in the facial area after the officer found him in an unauthorized area (the teacher’s lounge) and
attempted to escort him to the school entrance. The officer openly acknowledged in his written
report that that he “responded by throwing several punches striking [Inmate F] in the facial area.”
The officer also admitted that he did not attempt to use OC spray to subdue Inmate F before
hitting him. Another officer who allegedly witnessed the event submitted a written report stating
that Inmate F “spontaneously” punched the officer in his facial area and then the officer
“retaliated by striking said inmate with a closed fist to his facial area.” The officer witness did
not mention that the officer involved in the incident actually delivered several punches, as that
officer himself conceded. Inmate F denied assaulting the officer during his interview with
The Captain who investigated the matter and the Tour Commander concluded that the use of
force was within the Department’s guidelines, and the RNDC Warden and Deputy Warden for
Security concurred with this finding. There is nothing in the record to suggest that the facility
interviewed any potential inmate witnesses as part of its investigation, took into account the
officer’s use of force history, or explored why the only officer who admitted to witnessing the
incident failed to mention that the officer involved in the incident delivered several punches as
opposed to just one. In addition, although this incident involved multiple head blows, it was not
referred to the ID for a more thorough investigation.
Inmate F sustained nasal and upper lip contusions and the officer suffered a contusion to his jaw.
Inmate F’s medical records note that he scratched his left arm “after the incident because he did
not want to go to [the] box.” Nonetheless, Inmate F was transferred to the RHU and placed on
suicide watch. A few days after the incident, Inmate F’s attorney advised DOC that Inmate F
suffered from a lifelong condition of claustrophobia and that being housed in isolation could lead
to a mental breakdown.
DOC pursued criminal charges against Inmate F based on the officer’s allegation that Inmate F
had assaulted him, but these charges were dismissed in December 2012.
*Inmate G
In June 2012, in an apparent act of retribution, two officers forcibly took inmate Inmate G to the
ground and beat him. Inmate G was punched multiple times and kicked in the head, resulting in
serious injuries including a lost tooth.
During his interview with investigators, Inmate G reported that he walked into the pantry area in
RNDC 3 Central North to get some water, and an officer told him he could not have any water
because he was “a snitch.” According to Inmate G, the officer was under the false impression
that Inmate G had previously reported that the officer had been involved in another use of force
incident. The officer grabbed Inmate G around the waist and threw him out of the pantry,

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according to notes of the investigator who reviewed the video of the incident. Inmate G reported
that a second officer then grabbed him by the waist, threw him toward a supply closet, and said:
“Oh what you doing? You must want to get fucked up today? You know who I am?”
Several minutes later, Inmate G had another confrontation in the vestibule area with both
officers. Inmate G told investigators that the two officers tried to restrain his arms, and
eventually forcibly took him to the ground. Inmate G stated that the second officer put his knee
into Inmate G’s back, making it hard for him to breathe, and then banged his face into the floor.
According to the ID report, the video revealed that Inmate G and the two officers struggled for
several minutes. After Inmate G was placed in flex cuffs and a Captain arrived, the second
officer stomped on Inmate G’s head, causing his chin to hit the floor and his upper front tooth to
fall out. Inmate G reported that a staff member told the first officer: “Yo, if anyone comes to
you tell them this is what happened. The inmate was being aggressive, he wasn’t cooperating,
and he was refusing to put his hands behind his back.” Inmate G was then taken to the clinic
where he alleged he was further assaulted and pressured to prepare a false written statement
about the incident, which he refused to do.
During interviews with investigators, the two officers claimed they used force only in response
to Inmate G’s aggression and repeated refusal to obey orders. The first officer claimed that he
had ordered Inmate G “to stop resisting” but he did not. However, the written statements
provided by both officers contained inaccuracies and were found to be inconsistent with the
video surveillance. For instance, in his written statement, the first officer falsely stated that he
had guided Inmate G out of the pantry, while the video surveillance showed that he used physical
force to remove him. In addition, the second officer initially stated in his written report that he
had “lost [his] balance causing [his] foot to momentarily and inadvertently make contact with
[Inmate G’s] head.” However, the second officer later admitted that he intentionally kicked
Inmate G in the head “in the heat of the moment.” Neither officer used OC spray to subdue
Inmate G before resorting to physical force.
Inmate G suffered a two-centimeter laceration to his chin that required sutures, lost a tooth, and
sustained cracking and chipping to other teeth. Although the ID investigation report repeatedly
refers to video surveillance of the incident, DOC claimed the video could not be located and did
not provide it to us. The ID found that the first officer violated the use of force policy by
utilizing physical force to remove Inmate G from the pantry when Inmate G did not pose a direct
threat to him and recommended that charges be brought, although it does not appear from the
records provided that the first officer was subject to formal discipline. The second officer was
suspended after the incident, but the length of his suspension is unclear.
Inmate H
In September 2012, after shouting obscenities at an officer who had hit him in the ribcage with
handcuffs while he was sleeping in class, Inmate H was pulled out of a classroom in the RNDC
school area by a second officer and severely beaten in the corridor. Two teachers in the area
reported hearing Inmate H screaming and crying for his mother while being beaten. Inmate H,
who was not seen by medical clinic staff for more than four hours after the incident took place,

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suffered pain and contusions to the left cheek, lower lip, and left upper ribcage. There is no
video surveillance in the RNDC school area.
In an interview with ID investigators on the day of the incident, Inmate H explained that he was
sleeping with his head on his desk in the early afternoon, when he felt something hit him on the
left side of his ribs. Another inmate told him that an officer had hit him in the ribs. The teacher
in the classroom confirmed to ID that an officer had wrapped metal handcuffs around her hand
and used them to hit him in the ribs in order to wake him up. Inmate H then walked to the
classroom door, and yelled obscenities at the officer. According to Inmate H and as reported in
the ID investigation report, a tall muscular officer then grabbed him, saying “yo get the fuck over
here,” and punched him in the left eye causing him to fall on the floor. Inmate H told the ID that
other officers then joined in, kicking him while he was on the floor on the face, head and back.
When he thought the beating was over, the first officer who had hit him in the ribs said, as
reported by ID, “Oh just because I’m a female that don’t mean nothing cause I can still fuck you
up. Next time watch your fucking mouth.” She then hit him and kicked him, after which
another officer came over and asked if he could hit Inmate H as well. Again according to Inmate
H, the other officers in the area said, “sure, why not,” after which the officer proceeded to kick
him in the mouth. Another officer asked if anyone had pepper sprayed him yet, and then
proceeded to spray him directly in the eye, one inch from his eye. According to Inmate H, he did
not fight back while the officers were beating him.
The use of force reports submitted by three officers told a different story, but also contradicted
each other in part. The first officer initially reported Inmate H came off the wall during a pat
frisk, grabbing her collar and ripping it. She then claimed to defend herself from this assault by
using closed hand strikes to Inmate H’s “facial and upper body areas.” In an addendum
submitted later, she noted that the pat frisk she reported earlier took place after Inmate H
followed her into the corridor because he was angry that she had “tapped” him on the shoulder to
wake him up while he was sleeping in class. A second officer reported that he arrived on the
scene while Inmate H was assaulting the first officer, at which point he sprayed Inmate H with
OC. But a third officer reported that the second officer appeared at the door of the classroom
and ordered Inmate H into the corridor after Inmate H shouted obscenities at the first officer.
The Captain assigned to the facility investigation acknowledged that the stories of the three
officers were somewhat contradictory, but concluded that the use of force was appropriate and
the case should be closed without further investigation.
Several other statements, however, tend to confirm Inmate H’s version of events. A different
inmate (the “inmate witness”) stated to the ID that the same initial officer who woke up Inmate
H by hitting him with handcuffs had also woken him up in the classroom by hitting him with
handcuffs, but that the inmate witness didn’t say anything because, as reported by the ID, “if you
start to argue, they would say that you hit them first and you will catch a new charge.” Two
teachers confirmed that the first officer hit the inmate witness with handcuffs in their classroom
earlier in the day. The inmate witness said that he saw the female officer hit Inmate H with
handcuffs as well, but that when Inmate H started cursing, the officers “took him into the
hallway and knocked him out.” The inmate witness said that he and several other inmates
watched through the window of the classroom as three or four officers began to punch Inmate H.

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In a follow-up interview with the ID several months later, the inmate witness said he didn’t
remember anything and didn’t want to cooperate.
Three teachers also reported seeing Inmate H pulled by officers from the classroom into the
corridor. One teacher reported that after seeing Inmate H pulled from the class she heard him
being beaten, but “tried not to look in the direction of where the CO and inmate were because
she didn’t want to see the inmate beat.” Once it appeared to be over, she looked out in the
corridor and saw him lying on the floor, looking dazed. According to handwritten notes in the
ID file, she tried to keep her students away from the window. She told her students that Inmate
H was OK, but then heard the officer shouting at him again, loud thuds, and then the inmate’s
cries for his mother. She described how she started to shake because she was so upset. Another
teacher gave a similar description, and said he heard “thumping” and “screaming,” and that he
“knew” that the inmate was being assaulted. That teacher also stated that “when an incident
occurs, [Board of Education] staff knows they should turn their heads so they don’t witness
anything.” He also stated that he heard the inmate “crying and screaming for his mother,” and
that the other inmates in his class were trying to see what was happening through the window
“because they were upset.” After Inmate H was removed from the corridor, the teacher “saw
blood and saliva on the floor.”
While the first officer was treated at the on-site clinic for “shoulder pain” within minutes, Inmate
H was not seen at the clinic until after 6pm that evening. His injuries were described as “left
upper rib cage pain (contusion),” “left cheek contusion,” and “lower lip contusion,” and he was
treated with an ice pack and Tylenol for pain.
The ID investigation, which was not completed until January 2014—one year and four months
after the incident occurred—recommended that charges be brought against the first officer for
seven separate violations of DOC policies, including for using unnecessary force (including
using force as retaliation), using blows to the head, striking an inmate with institutional
equipment, failing to report a use of force, and providing false and misleading MEO-16
testimony, among other violations. In addition, the ID investigation recommended charges
against the second and third officers in connection with submitting false or inaccurate use of
force reports and knowingly providing false and misleading statements during their MEO-16
interviews. The first and second officers were later charged, and those charges are still pending,
according to documents provided by DOC.
*Inmate I
In January 2013, Inmate I was hit several times in the RNDC school area where there are no
security cameras. An officer admitted that he punched Inmate I multiple times in the face and
upper body area, but was not subject to any formal disciplinary action.
During his interview with Department investigators, Inmate I stated that the officer was upset
because some of Inmate I’s friends were playing with their food in the mess hall. Once the

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inmates were back in the classroom, the officer ordered Inmate I and another inmate to stand up
and face the wall. Inmate I claimed that at some point he laughed and the officer responded by
punching Inmate I with a closed fist about ten times to the head and face. Inmate I stated that he
was able to block some of the punches, but then an unknown officer grabbed Inmate I, pulled
him to the floor, and then took him into the bathroom. The description Inmate I provided to our
consultant is substantially similar to the account he provided to the Department investigators,
except he told our consultant that another officer was also involved in punching him. His
account to the Legal Aid Society was substantially similar to the description of the incident he
provided to our consultant.
According to an inmate witness, after Inmate I refused to comply with the officer’s direction to
put his hands on his head, the officer punched Inmate I one time on the side of his mouth causing
Inmate I to fall to the floor. The inmate further stated that the officer then punched Inmate I two
times in the chest area and kicked him four times to the rib area. The inmate claimed that the
officer continued to hit Inmate I while another officer held Inmate I’s arms behind his back.
The officer stated that he punched Inmate I in the face and upper body area only after Inmate I
hit him in the face. According to the officer, after bringing Inmate I down to the floor, he hit
Inmate I again in response to Inmate I continuing to punch the officer. The officer claimed that
he gave Inmate I several verbal orders to cease his aggression before Inmate I finally complied.
The officer later amended his written report to add that he could not use chemical agents to
subdue Inmate I because of the close proximity between himself and Inmate I.
Although other correction officers were in the vicinity at the time of the incident, none admitted
to witnessing any use of force against Inmate I.
Inmate I sustained contusions on his lip and scalp consistent with being hit in the face. The
officer suffered a contusion on his right hand, but no injuries to his face, which is inconsistent
with the officer’s claim that Inmate I hit him in the face.
The ID concurred with the facility investigation’s determination that the use of force “was
appropriate and necessary” for the officer to defend himself. The ID did not conduct an
independent investigation, even though its report acknowledges that “[i]t is undisputable that [the
officer] punched Inmate [I] in the facial area multiple times.” The facility recommended that the
officer attend use of force re-training and subjected him to “a corrective interview” for violating
the rule to avoid striking inmates in the head and facial areas when possible, but no formal
disciplinary action was taken against the officer. Inmate I was charged in criminal court (charges
that were ultimately dismissed) and received 90 days of punitive segregation as a result of this
*Inmate J
In January 2013, Inmate J, a mentally ill inmate housed in MHAUII at the time, extended his
forearm through the small cuffing port of his cell to get staff’s attention because he wanted a
shower and to use the telephone. A Captain, accompanied by another officer, approached the

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inmate’s cell and, within seconds, forcibly closed the rear slide door of the cuff port on Inmate
J’s left arm and walked away. The incident was captured on video.
After the incident, Inmate J told clinic staff that the Captain approached his cell and “slammed
the slot forcefully” on his arm without any warning, resulting in “shocking pain . . . like I got hit
with a hammer or something.” In his written statement, the Captain stated that he responded
after being told that Inmate J “was holding the cuff” and gave Inmate J “several direct orders to
remove his hand” before closing the slot. The Captain claimed that as he began to close the slot,
Inmate J “simultaneously removed his hand swiftly… causing him to brush his arm against the
closing slot.” The officer who accompanied the Captain reported that the Captain asked Inmate J
“numerous times” to remove his hand before closing the port. In contrast to the Captain, the
officer claimed that the injury occurred because Inmate J “spontaneously stuck his arm back
through the cuffing port at the same time” as the port was closed.
The video surveillance contradicts the written statements from both the Captain and the officer.
The Captain slammed the slide door of the cuff port on Inmate J’s arm within approximately ten
seconds of arriving at Inmate J’s cell, making it highly unlikely that he had repeatedly ordered
Inmate J to remove his hand before inflicting the injury as the Captain and the officer claim. The
video also shows the Captain closing the door while Inmate J’s arm was still extended, further
contradicting the Captain’s account. When interviewed by our consultant, Inmate J stated that
the Captain threw out the written statement he provided after the incident.
The Captain who investigated the matter and the Tour Commander concluded that the force was
inappropriate but not excessive, and the GRVC Warden concurred. This finding demonstrates a
fundamental and concerning misunderstanding of the definition of excessive force. Since it was
not necessary to use force under these circumstances, any force used was excessive. Moreover,
neither the Tour Commander nor the investigating Captain noted that both staff members had
submitted false reports, or the inconsistencies between their reports.
The Tour Commander recommended command discipline for the Captain involved in the
incident for violation of the Use of Force Directive, and the Warden subsequently recommended
a 4-day penalty. This was at least the third time that the Captain had been subject to disciplinary
action in connection with a use of force incident.
The ID reviewed the facility’s investigation and found that it was “satisfactory” and no
independent investigation was necessary.
Inmate J sustained trauma to his upper left arm, swelling, and a mild decrease in motion. The
Tour Commander recommended that Inmate J receive “the maximum punitive segregation time
Inmate K
In January 2013, an officer hit Inmate K in the school area where there are no security cameras.
Inmate K told medical staff that he was “beaten” by the officer. Despite the fact that Inmate K

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had multiple visible injuries on his face and neck, the officer denied striking Inmate K. Based on
the extent of the injuries suffered by Inmate K, the Captain assigned to investigate the incident
found that the officer had falsified his report and that the use of force was excessive.
The officer told investigators he approached Inmate K and asked him to hand over playing cards,
and when Inmate K refused to do so, the officer instructed Inmate K to go against the wall.
According to the officer, Inmate K attempted to grab the officer’s shirt and the officer used a
“swiping motion” to release Inmate K’s grip on his shirt and to gain distance. Inmate K then
kneeled down and placed his hands on his head. The officer initially indicated in his report that
he had used an “upper body control hold” to subdue Inmate K, but then amended his report to
say that he had not used such a hold. None of the inmates or correction officers in the area at the
time of the incident admitted to witnessing any use of force.
Inmate K sustained multiple bruises to his forehead, neck and back, as well as pain in his wrist.
The officer had swelling and bruising on his right thumb.
The Captain assigned to investigate the incident concluded that the use of force was “excessive
and not proportionate to the threat presented.” The Captain further found that the injuries
suffered by Inmate K were not consistent with staff reports and that the officer had “falsified his
use of force report in an attempt to downplay” the incident. Despite the Captain’s
recommendation that the ID investigate the matter, there is no record that such an investigation
took place. There is also no record of the officer being formally disciplined or subjected to any
corrective action for either the use of excessive force or the submission of a false report.
Inmate K received 60 days of punitive segregation as a result of the incident even though there
was evidence that the charges against Inmate K were based, at least in part, on a false report by
the officer.
Inmate L
In January 2013, after reportedly being disruptive while waiting to enter the RNDC dining hall,
Inmate L (who was on suicide watch at the time) was taken down by a Captain and punched
repeatedly on his head and upper torso while he lay face down on the ground covering his head
with his hands. Inmate L sustained multiple bruises and abrasions to his shoulders, arms, back,
and neck.
Officers reported that Inmate L became disruptive while inmates lined up to enter the dining hall
and did not comply with orders to cease his behavior. According to the Tour Commander’s
report, when Inmate L refused to comply with the Captain’s order to place his hands on the wall,
the Captain “guided [the] subject to the wall then took him to the ground.” The Captain
proceeded to punch Inmate L “twice in the head and upper torso,” while the inmate was face
down on the ground with his hands over his head, as confirmed by video surveillance. The Tour
Commander concluded that the Captain’s use of force was “excessive and avoidable” since
Inmate L presented no threat while on the ground. Although the Tour Commander
recommended command discipline, the Department did not provide any records showing that the

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Captain was formally disciplined for his use of excessive force. Inmate L, however, was
infracted for disorderly conduct.
Other evidence suggests that the level of force utilized was more severe than the facility found.
Inmate L told investigators that the Captain “punched [him] everywhere.” In addition, according
to medical records, Inmate L sustained bruises to his left and right shoulders, left and right lower
arms, chest area, neck, back, and a finger on his right hand, as well as an abrasion to his right
elbow. It is unlikely that all of these injuries would result from just two punches. The Captain
sustained mild swelling of his right wrist, possibly due to the punches he threw.
This is also another instance when staff submitted clearly false reports. In his initial written
statement after the incident, the Captain falsely claimed that Inmate L “continued to resist by
flailing his arm and moving his body about in [an] attempt to avoid being cuffed.” This was
contradicted by the video surveillance reviewed. In a supplemental report prepared almost two
weeks after the incident, the Captain acknowledged that the inmate “placed his hands by his
head” while on the ground and explained that he had not mentioned that in his initial report
“[d]ue to the inmates [sic] odd behavior and the adrenaline flowing.” Moreover, only one of the
many staff members who submitted written reports acknowledged that the Captain punched
Inmate L, and that officer stated that the blows were necessary due to Inmate L’s “apparent
assault” and “constant violent resistance.” Notwithstanding these false reports, the clearly
excessive force applied, and Inmate L’s extensive injuries, this matter was not referred to the ID
for a more extensive investigation.
Inmates M, N, O, P
In August 2013, four RNDC inmates were seriously injured during a brutal use of force incident
involving multiple officers in a trailer that contains classrooms. The incident was referred to the
ID for investigation, but we did not receive the ID file because the investigation was still pending
at the time this letter was prepared. The four inmates each provided substantially consistent
accounts of the incident to the Legal Aid Society and a senior DOHMH official. The inmates all
sustained serious injuries, including fractures. There is no video of this incident because there
are no cameras in the RNDC school area.
The following is a general summary of the accounts the four inmates provided: The inmates and
one officer were working in the trailer and got into a verbal confrontation. The officer grabbed
Inmate M by his neck, slammed his face into a concrete wall, and then began to repeatedly punch
him. The officer reported that he had been jumped and called for backup. Soon thereafter,
several other officers, including probe team members, arrived and brutally assaulted the four
inmates, punching and kicking them and striking them with radios, batons, and broomsticks.
This continued for several minutes after the inmates had been subdued and handcuffed. The
probe team then took the inmates to holding pens in the clinic intake area where they were
handcuffed and beaten again by several DOC Gang Intelligence Unit members, who repeatedly
punched and kicked them while they were handcuffed and slammed them against cell walls.
Two of the inmates reported that they thought they had lost consciousness or blacked out for
some period of time.

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According to written staff reports, the inmates instigated the confrontation by attacking the
officer who was working in the trailer. Staff claimed that Inmate M pulled that officer off a
ladder and started to kick and punch him, and then the other inmates joined in the assault,
beating the officer with broken mop sticks and a metal rod. According to staff, when other
officers arrived to provide assistance, the inmates attacked them as well and fights ensued, with
officers acting in self-defense. Several officers stated that they punched the inmates in the upper
torso and facial area to protect themselves. According to the officers, the probe team eventually
arrived and took the inmates away in restraints. We did not receive any statements from the
involved probe team officers or the Gang Intelligence Unit officers.
Several officers utilized similar phrasing and language in their written use of force reports,
suggesting that the officers may have colluded with each other to ensure their reports were
consistent. For instance, one officer wrote that an inmate was “able to break this writer’s hold
and subsequently turned his aggression toward this writer.” Another officer noted that an inmate
“broke from the control hold and then directed his aggression to this writer.” A third officer
wrote that an inmate “was able to break this writer’s control hold turning his aggression towards
this writer.”
The inmates sustained a wide array of serious injuries, including a broken nose, a perforated
eardrum, head trauma, chest contusions, and other head and facial injuries. Although clinic
medical staff quickly determined that the inmates all needed hospital care, it took an
unreasonably long time to secure escorts to transfer the inmates from the jail. In an email shortly
after the incident, a senior DOHMH official stated that “this type of delay could have proved
fatal” and requested an investigation of why it took so long to take the inmates to the hospital.