New York City Board of Correction - Serious Injury Reports in NYC Jails, 2019

• Jan. 1, 2019 • Locations: United States of America -> New York • Topics: Pain, Skeletal Injury, Injury -- Misc., Failure to Treat, Failure to Protect (General), Jail Specific, Guard Brutality/Beatings, Staff Training

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Serious Injury Reports in NYC Jails
January 2019

Table of Contents
Executive Summary ....................................................................................................................................... 3
Background ................................................................................................................................................... 6
Current Serious Injury Reporting Procedures and Policies ........................................................................... 6
Methodology ................................................................................................................................................. 8
Findings ......................................................................................................................................................... 9
Injury to Inmate Report Audit ..................................................................................................................... 12
Recommendations ...................................................................................................................................... 23
Appendix A: CHS Serious Injury Inclusion Criteria ...................................................................................... 24
Appendix B: DOC Serious Injury Categories & Policy Definitions ............................................................... 25
Appendix C: DOC Injury to Inmate Report (Form #167R‐A)........................................................................ 26
Appendix D: Injury Report Audit Template ................................................................................................. 28

Executive Summary
When serious injuries occur in New York City jails, their consequences are severe and wideranging.1 Serious injuries affect the short- and long-term physical and mental health of
individuals and have a compounding negative impact on individuals’ employment, education,
housing, and general reintegration into the community.2 These incidents also place a significant
burden on security and medical staff, as they require emergency response, follow-up medical
treatment, investigations, and reporting.
This Board of Correction staff report reviews the aggregate data on
serious injuries to people in custody over time and summarizes our
in-depth audit of three months of serious injury reports. The report
documents large discrepancies between the number of serious injuries
diagnosed by NYC Health + Hospitals’ Correctional Health Services
(CHS, the office managing health and mental health services in the
jails) and the number of serious injuries reported internally and
publicly by the Department of Correction (DOC). In 2017, DOC
reported 81% fewer serious injuries than CHS (158 v 816). This
report is also the first public accounting of serious injuries over time
and presents the number, type, cause, and facility of serious injuries
for audited months.

Serious Injury Definition
Serious injuries, as defined by
CHS, include: cuts requiring
stitches, fractures (excluding
fingers and toes), dislocations
requiring a clinical procedure,
permanent or temporary disabling
of an organ, post-concussion
syndrome, foreign object ingestion
requiring removal via procedure at
a hospital, and any injury judged
serious by medical professionals.

The City must understand the rates, types, and circumstances related
to serious injuries occurring in NYC jails in order to prevent them.
Additionally, accurate reporting is necessary to maintain public accountability and trust in and
engagement with government. When implemented, this report’s recommendations will increase
prevention
of
serious
injuries
to
incarcerated
people
and
promote problem-solving and transparency.

Key Findings:
1. From 2008 to 2017, despite a 32% decline in the DOC population, the number of Injury
to Inmate Reports (serious and non-serious) generated by DOC for people in custody
increased 101%, from 15,629 in 2008 to 31,368 in 2017.3

1
Ludwig, A., Cohen, L., Parsons, A. and Venters, H. (2012). “Injury Surveillance in New York City Jails.” Am J
Public Health, [online] 102(6), p. 1108. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3483942/.
2
Id.
3
Not all injury reports generated by DOC result in the determination of an actual injury. For example, an analysis
of injury reports coded over four months in 2010 found that 65% of the 4,695 included a detectable medical injury
based on a physical examination conducted by a clinical staff member. Ludwig, A., Cohen, L., Parsons, A. and

2. From 2016 to 2018, CHS data show the rate of serious injuries declined from an average
of 9.73 per 1,000 inmates in 2016 (Jun. – Dec.) to an average of 7.48 per 1,000 inmates in
2018 (Jan. – Sept.).
3. DOC is underreporting serious injuries, and it lacks a single metric from which to
determine the actual number of serious injuries occurring to people in its custody. DOC
consistently reports 80% fewer serious injuries than CHS.
4. Sixty-seven percent (67%, n=100) of the 149 serious injuries audited by BOC were never
reported as any type of incident by the Department.4
5. Only 31% (n=46) of audited injury reports were complete.
6. DOC’s investigation process for injuries is plagued by delays, poor accountability, and
incomplete reviews.
7. CHS staff’s requirement to document medical dispositions in injury reports is frequently
unmet.
8. The Anna M. Kross Center (AMKC) had the highest number and rate of serious injuries.
9. On average, it took approximately two hours for seriously injured incarcerated people to
receive medical attention after a DOC supervisor was notified of the injury.
10. Most serious injuries (90%) involved lacerations requiring sutures (n=79) or fractures
(n=73).Facial trauma (such as lacerations, puncture wounds, fractures and burns to the
face, as well as severe injuries to the eye) was the most common type of injury. Fiftythree percent (53%, n=79) were at least partially caused by an “inmate-on-inmate
altercation.” Additionally, 80% of serious injuries occurred in housing areasand most
events causing serious injuries were not witnessed by staff.

Recommendations:
1. DOC and CHS should immediately begin jointly publishing monthly data on the number,
type, cause, and location of injuries to people in custody (serious and non-serious), as these
indicators are critical to prevention efforts.
2. Within the next three months, DOC should come into compliance with their existing policy
for reporting serious injuries. DOC should report all injuries to people in custody
determined to be serious by correctional health staff.
3. Within the next nine months, DOC and CHS should establish new protocols and take steps
to increase accountability including: assessment of which supervisory reviews are needed
and whether changes to the Injury to Inmate Report form are needed; development of an
electronic injury-tracking system; and training to ensure that injury reports are complete
and include accurate, final diagnoses and dispositions.
Venters, H. (2012). “Injury Surveillance in New York City Jails.” Am J Public Health, [online] 102(6), p. 1108.
Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3483942/.
4
None of the UOF A (Injury to Inmate), or Slashing/Stabbing incidents reported by DOC in the three-month audit
period involved multiple serious injuries.

4. DOC and CHS should immediately begin providing the Board with monthly access to all
DOC Injury Reports that CHS designates as associated with a serious injury. This will
support DOC’s and CHS’s efforts to improve their process and increase accountability.
5. Within the next three months, DOC should review the conditions leading to the high
number and rate of serious injuries at AMKC and implement a plan to reduce injuries there.
DOC should use video review to inform this injury analysis, so that the locations and causes
of serious injuries are better documented.
6. DOC should contract an independent auditor to assess reporting of serious injuries to staff.
The audit’s goals would include understanding who is getting injured (civilian v. uniform,
DOC v. DOE v. CHS v. contractors v. volunteers, etc.); how (assault v. construction-related
v. slip and fall, etc.); when and where injuries are occurring; and what types of injuries are
sustained. Ultimately, these audits must inform injury prevention planning and public
reporting.5
7. BOC should conduct an annual audit of Injury to Inmate Reports.

Currently, DOC will not share any medical information or injury diagnoses related to staff injuries with the Board.

Background
Since 2013, Correctional Health Services (CHS) has requested and the NYC Board of Correction
(BOC or Board) has granted a variance to Minimum Standard § 3-08(c)(3) on privacy and
confidentiality.6 The variance allows CHS to provide the New York City Department of Correction
(Department or DOC) with specific diagnoses related to injuries sustained by people while in
custody (the reporting of diagnoses unrelated to injuries remains prohibited). CHS and DOC report
that this communication is critical to DOC’s investigations of injuries and facilitates appropriate
follow-up care and safety measures on behalf of patients. Greater communication promotes more
effective deployment of CHS and DOC resources toward the common goal of increased safety.7
In granting this variance, the Board sought to promote stronger collaboration between CHS and
DOC in the tracking, reporting, and prevention of injuries.
At its January public meeting, the Board will again consider a variance to Minimum Standard § 308(c)(3).8 BOC staff conducted this study to understand how DOC and CHS respond to, track,
and report serious injuries, to inform the Board’s variance decision. While this study does not
investigate or audit injuries to staff, BOC has recommended that a similar study of staff injuries
be conducted.9
We must understand the rates, types, and circumstances related to serious injuries occurring in
NYC Jails in order to prevent them.

Current Serious Injury Reporting Procedures and Policies
Department policy requires that any incarcerated person who reports an injury or is suspected of
being injured be referred to the jail’s clinic for evaluation and treatment by CHS staff (regardless
of type or severity of the suspected injury).10 DOC uses an Injury to Inmate Report form to
document reported or suspected injuries.
Once the injured person’s medical evaluation is complete, CHS staff issue a medical disposition
on the Injury to Inmate Report form and return the form to DOC.11 DOC Captains are then required
6

N.Y.C. Board of Correction, Health Care Minimum Standards § 3-08(c)(3).
7 Best practices in the areas of safety and population health within a correctional setting detailed in Macdonald, R.,
Parsons, A., and Venters, H. (2013). “The Triple Aims of Correctional Health: Patient Safety, Population Health,
and Human Rights." Journal of Health Care for the Poor and Underserved 24, no. 3 (2013): 1226-234.
https://doi.org/10.1353/hpu.2013.0142.
8
CHS Variance Renewal Request, December 26, 2018,
https://www1.nyc.gov/assets/boc/downloads/pdf/BOC_Injury_Information_Variance_Renewal_January_2019_docx
.pdf
9
The Department of Correction does not provide the Board with documentation related to staff injuries.
10
NYC DOC Directive 4516R-B (“Injury to Inmate Reports”).
11
Not all injury to inmate reports generated by DOC result in the determination of an actual injury. For example, an
analysis of injury reports coded over a four month period in 2010 found that 65% of the 4,695 included a detectable
medical injury based on a physical examination conducted by a clinical staff member. Supra, note 1.

to consult with CHS staff to confirm injury diagnoses and investigate the circumstances of the
injury. Upon completion of the Captain’s injury investigation, a Tour Commander reviews the
injury report and upgrades injuries that meet the Department’s definition of “serious injury.” DOC
defines serious injuries as: “a physical injury that creates a substantial risk of death or
disfigurement; is a loss or impairment of a bodily organ; is a fracture or break to a bone, excluding
fingers and toes; or is an injury defined as serious by a physician.”12
Per DOC policy, serious injuries are considered “unusual incidents” and are required to be reported
to the Department’s Central Operations Desk (COD).13 In practice, Serious Injury COD reports
are not generated by DOC staff when injuries are related to other reportable “unusual incidents”
such as a Use of Force or Stabbing or Slashing incidents. This means the Department does not
have a single metric from which to determine the actual number of serious injuries occurring to
people in its custody, as the number of Serious Injury CODs is an underinclusive metric.
The number of Inmate Injury Reports and Serious Injury COD reports, along with other metrics,
including Stabbings, Slashings, and Uses of Force (A, B, and C), are tracked in the Department’s
Monthly Security Report. The Department also publicly reports on rates of Serious Injury CODs
in multiple ways such as in the Mayor’s Management Report14 and at BOC Public Meetings.
Independent of DOC reporting, CHS tracks and reports monthly aggregate statistics to the Board,
including the number of serious injuries identified by CHS and the cause of injury as reported by
patients to CHS staff. CHS defines as serious: lacerations requiring suturing or stapling, fractures
(excluding fingers and toes), dislocations requiring clinical reduction, permanent or temporary
disabling of an organ, foreign body ingestion requiring removal by EGD in a hospital, any blow
to the head resulting in post-concussive syndrome diagnosis, and any injury judged to be serious
by medical professionals.15

NYC DOC Directive 5000R-A (Reporting Unusual Incidents).
DOC’s Central Operations Desk, located on Rikers Island, is a centralized unit tasked with receiving reports of
“unusual incidents” occurring in all NYC jails, as well as hospital prison wards, courtroom holding areas and
transportation buses and vans operated by the Department. The Central Operations Desk generates a 24-Hour
Report daily, which is used to track unusual incidents, such as uses of force, serious injuries to inmates or staff, and
other events that seriously affect normal operations of DOC facilities. The Department’s policy on reporting
requirements for unusual incidents defines “unusual incident” as “an event or occurrence that may affect or actually
does affect the safety, security and well-being of the Department, its personnel, visitors and volunteers, as well as
the inmates over whom it has custody and control.” NYC DOC Directive 5000R-A (Reporting Unusual Incidents).
14
https://www1.nyc.gov/assets/operations/downloads/pdf/mmr2018/2018_mmr.pdf
15
Appendix A: CHS Serious Injury Inclusion Criteria, provided to the Board via email dated April 2, 2018.
13

Methodology
Board Staff analyzed all available DOC and CHS policies relevant to serious injuries and met with
Department and CHS leaders to understand current reporting procedures and policies.
BOC staff reviewed DOC injury and incident data from 2008 to 2017 and CHS serious injury data
from June 2016 to September 2018.16 Board staff then audited DOC’s Injury to Inmate Report
forms for serious injuries from April, May, and June of 2018.
To complete the audit, Board staff requested and received a list of the 169 injuries CHS designated
as serious between April and June of 2018 and requested all DOC Injury to Inmate Report forms
associated with them., 18 The Board received 149 Injury to Inmate Report forms from DOC (88%
of the injuries designated as serious by CHS). Board staff requested these reports from facility
leadership and Bureau Chiefs and received them on a rolling basis. The first injury reports, relating
to April serious injuries, were received on June 29, 2018. The remaining injury reports were
received on October 19, 2018.
To execute the audit accurately and consistently, Board staff developed and applied an audit toolto
review each injury report.20 The tool captures relevant injury data and records the absence of
required entries. The categories found in the Board’s injury report audit tool mirror fields found in
the Injury to Inmate Report.

Since April 2016, CHS has sent monthly reports containing the number of serious injuries sustained by people in
custody by facility and cause. In March 2018, CHS started including injury types in this monthly serious injury
reporting.
18
See Appendix C, which shows the Injury to Inmate Report format.
20
See Appendix D.

Findings
From 2008 to 2017, despite a 32% decline in the DOC population, the number of Injury to
Inmate Reports (serious and non-serious) generated by DOC for people in custody increased
101%, from 15,629 in 2008 to 31,368 in 2017.21
The Department’s Monthly Security Reports classify injuries according to the following six “types
of injuries”: Use of Force (Excluding Allegations), Use of Force Allegations, Inmate on Inmate
Incidents, Self-Inflicted Injuries, Accidents, and “Other.” In general, most injuries were related to
inmate on inmate fights, followed by uses of force (excluding allegations), accidents, and “other.”
Over the 2008 to 2017 period, injuries resulting from “Inmate on Inmate Incidents” grew by 71%
(from 7,405 to 12,656). Injuries related to staff use of force (excluding allegations) grew by 260%
(from 1,981 to 7,139), and injuries designated as being caused by “Other” increased by 527%
(from 796 to 4,985).
Figure 1.

DOC Injury to Inmate Reports
(Serious and Non‐Serious)
Number of Injury to Inmate Reports

2008 ‐ 2017
35,000

30,564

30,000

31,368

25,724

25,000
20,000

32,183

19,603
15,629

16,558

21,523

16,250

From 2008 to 2017, the
Department saw a 101% increase
in injury to inmate reports.

13,213

15,000
10,000
5,000
0
2008

2009

2010

2011

2012

2013

2014

2015

2016

2017

Year
Source: DOC Monthly Security Reports.

Not all injury reports generated by DOC result in the determination of an actual injury. For example, an analysis
of injury reports coded over four months in 2010 found that 65% of the 4,695 included a detectable medical injury
based on a physical examination conducted by a clinical staff member. Ludwig, A., Cohen, L., Parsons, A. and
Venters, H. (2012). “Injury Surveillance in New York City Jails.” Am J Public Health, [online] 102(6), p. 1108.
Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3483942/.

From 2016 to 2018, CHS data show the rate of serious injuries declined from an average of
9.73 per 1,000 inmates in 2016 (Jun. – Dec.) to an average of 7.48 per 1,000 inmates in 2018
(Jan. – Sept.).

Figure 2.

Rate of Serious Injuries per 1,000 People in DOC Custody
June 2016‐September 2018

12.00

10.00

10.85
10.49
10.37

9.43

9.14

9.27

8.23

8.54

8.00

8.99

8.74
7.59

7.46

7.40

6.96

6.00

7.43 7.31
7.66
6.49

7.16

8.96

6.07

6.22

6.05

7.42 8.01

6.64

6.44

8.76

4.00

2.00

Sep

Aug

Jul

Jun

May

Apr

Mar

Feb

Jan

Dec

Nov

Oct

Sep

Jul

2017

Aug

Jun

May

Apr

Mar

Jan

2016

Feb

Dec

Nov

Oct

Sep

Jul

Aug

Jun

0.00

2018

Source: BOC calculation of Serious Injury Rate using CHS monthly Serious Injury Numbers and average daily
population (ADP) calculated from the DOC daily census.

DOC is underreporting serious injuries. There is a significant disparity between the number of
serious injuries reported by CHS and the number of serious injury incidents (Serious Injury CODs)
reported by DOC. DOC’s definition of serious injury outlined in policy appropriately includes “an
injury defined as serious by a physician,”22 yet DOC consistently reports ~80% fewer serious
injuries than CHS. This discrepancy is not accounted for by including other DOC reportable
incidents that may, but do not always, include serious injuries such as Stabbings or Slashings or
Use of Force A (Injury to Inmate). For example, in 2017, even after accounting for all DOC
reportable incidents potentially involving serious injuries (Serious Injury CODs, Stabbing and
Slashings, and Use of Force A), DOC still reported 55% fewer serious injuries than CHS. Figure
3 and Table 1 compare serious injuries reported by CHS and DOC and highlight the disparities in
reporting.23

22
23

NYC DOC Directive 5000R-A (Reporting Unusual Incidents).
See Appendix B for complete definitions of Serious Injury to Inmate, Slashing/Stabbing, and Use of Force A.

Figure 3.

Serious Injury Monthly Reporting: CHS vs. DOC
(June 2016‐September 2018)
120
100
80
60
40
20

Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep

2016

2017

2018

CHS Serious Injuries
DOC Total Combined: Serious Injury CODs, Slashing/Stabbing CODs, UOF A
DOC Serious Injury CODs

Source: CHS Monthly Serious Injury Reports, DOC Monthly Security Reports.

Table 1.
Serious Injuries Reported by DOC & CHS
June 2016 ‐September 2018
Jun – Dec
2016

Jan – Dec
2017

DOC
Serious Injuries
Slashings/Stabbings
Use of Force A
Total Combined
Serious Injuries
Slashings/Stabbings
Use of Force A
Total Combined
Serious Injuries
Slashings/Stabbings
Use of Force A
Total Combined

CHS
132
99
24
255
158
131
64
353
113
60
60
233

Difference

660

From June through December 2016,
DOC reported 80% (528) fewer
serious injuries than CHS, 61% (405)
fewer when including all reportable
incidents.

816

In 2017, DOC reported 81% (658)
fewer serious injuries than CHS, 57%
(463) fewer when including all
reportable incidents.

From January through September
2018, DOC reported 80% (459) fewer
Jan – Sep
serious injuries than CHS, 59% (339)
572
2018
fewer when including all reportable
incidents.
Source: CHS Monthly Serious Injury Reports, DOC Monthly Security Reports.

Injury to Inmate Report Audit
To investigate discrepancies in the aggregate data reported by DOC and CHS and better understand
DOC and CHS responses to serious injuries, BOC audited Injury to Inmate Reports for April, May,
and June 2018. CHS identified 169 serious injuries to people in custody during these three months.
By contrast, during the same period, DOC reported a total of 38 Serious Injury CODs to people in
custody,24 16 UOF A (Injury to Inmate) incidents,25 and 18 slashing/stabbing incidents during the
same period.26 The following reflects findings from the BOC’s audit.
Due to missing or incomplete documentation, only 149 (88%) of the 169 serious injuries
identified by CHS in the audit period could be audited by BOC. BOC staff attempted to obtain
all injury reports corresponding to the 169 serious injuries reported by CHS for April, May and
June of 2018, but received only 157 forms from the Department. DOC confirmed that staff did not
generate Injury to Inmate Report forms for 7% (n=12) of the serious injuries identified by CHS.
In nine (9) of those cases no reason was specified, for two (2) DOC reported that the individual
was seen at sick call, and for one (1) DOC reported the injury was related to a medical emergency.
BOC received eight (8) injury reports from DOC related to individuals identified by CHS, but
BOC could not conclusively confirm DOC provided the correct corresponding Injury to Inmate
Report for these individuals.27 Therefore, BOC staff could only audit 149 Injury to Inmate Report
forms.
Sixty-seven percent (n=100) of the 149 serious injuries audited by BOC were never reported
by the Department. Board staff reviewed each of the 149 Injury to Inmate reports associated
with CHS designated serious injuries in the audit period. Board staff searched manually and
reviewed all DOC data on reportable incidents occurring in the audit period and found only 32
reported by DOC as serious injuries, 11 reported as stabbing or slashings, and six reported as Use
of Force A (Injury to Inmate).

For the purposes of this audit, BOC recalculated the April, May and June Serious injury COD totals based upon
incident date rather than the date the injury was upgraded by the Department and reported to the Central Operations
Desk. DOC reported that 42 Serious Injury CODs took place during the three-month period, but only 38 of those
injuries occurred within this period.
25
Of the 16 UOF A (Serious Injury to Inmate) events reported by DOC during the audit period, CHS designated eight
serious injuries relating to those events. DOC’s UOF A injury criteria is more inclusive than CHS’s serious injury
criteria, including injuries such as chipped or cracked teeth and multiple abrasions/contusions (for a full definition of
UOF A, see Appendix B.) Based on an audit of injury reports, of the eight CHS designated serious injuries resulting
from UOF A events, the injuries included five lacerations, one puncture wound, one fracture of the wrist and one
unknown injury. UOF A injuries not resulting in a CHS designated serious injury include superficial lacerations,
contusions, abrasions, and swelling.
26
Of the 18 slashing/stabbing events reported by DOC, CHS designated 11 serious injuries. This indicates that 11 of
the 18 slashing events occurring during the audit period resulted in a laceration to an individual that required sutures
to repair.
27
Either because the report indicated that the incarcerated person refused treatment or the injury was superficial in
nature.

Figure 4.

Serious Injuries Reported by CHS v. Reporting by DOC
April ‐ June 2018 Audit Findings
n=149

Stabbing/Slashing
11
Not Reported by
DOC
100
67%

Reported by DOC
49
33%

Serious Injury COD
32

UOF A
(Injury to Inmate)
6

Source: BOC review of Injury to Inmate Reports and DOC Reportable Incident Data (COD 24 Hour
Reports).

None of the UOF A (Injury to Inmate) or Slashing/Stabbing incidents reported by DOC in
the three-month audit period involved multiple serious injuries. Per DOC policy, serious
injuries are considered “unusual incidents” and are required to be reported to the Department’s
Central Operations Desk (COD).28 In practice, Serious Injury COD reports are not generated by
DOC staff when injuries are related to other reportable “unusual incidents” such as a Use of Force
or Stabbing or Slashing incidents. This means the Department does not have a single metric from
which to determine the actual number of serious injuries occurring to people in its custody, and
the number of Serious Injury CODs is an underinclusive metric. While use of force incidents and
stabbing or slashing incidents could involve multiple injuries, none of the incidents reported by
DOC in the audit period did.
Only 31% (n=46) of audited injury reports were complete.29 Board staff reviewed each of the
149 audited injury reports for content and completeness. Among the sections that are completed
28

DOC’s Central Operations Desk, located on Rikers Island, is a centralized unit tasked with receiving reports of
“unusual incidents” occurring in all NYC jails, as well as hospital prison wards, courtroom holding areas and
transportation buses and vans operated by the Department. The Central Operations Desk generates a 24-Hour
Report daily, which is used to track unusual incidents, such as uses of force, serious injuries to inmates or staff, and
other events that seriously affect normal operations of DOC facilities. The Department’s policy on reporting
requirements for unusual incidents defines “unusual incident” as “an event or occurrence that may affect or actually
does affect the safety, security and well-being of the Department, its personnel, visitors and volunteers, as well as
the inmates over whom it has custody and control.” NYC DOC Directive 5000R-A (Reporting Unusual Incidents).
29
An “incomplete” injury report is here defined as lacking the completion of an essential, required component of the
Injury to Inmate report form. For DOC, this might include critical missing information such as the time of injury,

by DOC, the most common cause of incomplete injury reports was lack of review by Deputy
Wardens (n=27) or Commanding Officers (n=34). Among the sections to be completed by CHS,
the most common causes of incomplete reports were failures by clinicians to indicate a final
disposition (n=69) or indicate the time (n=20) or date (n=15) of medical disposition.
Figure 5.

Injury to Inmate Report Documentation
April ‐ June 2018 Audit Findings
n=149

31%

69%

Complete

Missing Required Information

Source: BOC review of 149 Injury to Inmate Reports.

Missing Information from Injury to Inmate Reports
Table 2.
CHS
Missing Information
No Medical Disposition
No Time of Medical Disposition
No Date of Medical Disposition
No Time Entry for "Reported For
Medical Attention"
No "Visible Injury" Entry
No Date of Injury
Source: BOC Review of 149 Injury to
Inmate Reports.

Table 3.
Total
69
20
15
12
5
4

DOC
Missing Information
No Commanding Officer's Review
No Deputy Warden's Review
No Tour Commander's Review

Total
34
27
9

No Time of Supervisor Notification

9
7
6

No Witness Entry

No Injury Time
Missing Investigation/Review Date

indication whether the injury was witnessed by a staff person, or the failure of a captain to complete an
investigation. For CHS, this might include the absence of an entry indicating the time the incarcerated person was
presented for medical treatment, failure to indicate a final disposition on the form, as well as the date and time of the
disposition.

4
No "Injuries Resulted From" Entry
3
No Captain's Investigation
Injury Investigation Completed Prior to
2
Medical Disposition
Source: BOC Review of 149 Injury to Inmate Reports.

The Eric M. Taylor Center was the facility with the highest percentage of fully completed injury
reports (83%, n=15). The Robert N. Davoren Complex (11%, n=1), the Brooklyn Detention
Complex (11%, n=1), and the Otis Bantum Correctional Center (14%, n=3) had the lowest rate
of fully completed injury reports.
Figure 6.

Incomplete Reports - Responsible Party
n=103

CHS
39%

DOC & CHS
40%

DOC
21%

Source: BOC Review of 149 Injury to Inmate Reports.

DOC’s investigation process for injuries is plagued by delays, poor accountability, and
incomplete reviews. Department policy requires that all reported or suspected injuries be
investigated promptly, and that each injury investigation be completed by a Captain and then
reviewed by three levels of facility leadership, under specific timelines.





BOC found that 6% (n=9) of Tour Commander Reviews, 18% (n=27) of Deputy Warden
Reviews, and 23% (n=34) of Commanding Officer Reviews were not completed.
Despite a requirement that Captains submit their injury investigation to Tour Commanders
within 72 hours of the medical disposition, Captain’s investigations were completed after
18 days, on average.
Tour Commanders must review completed injury investigations within 72 hours of the
medical disposition, yet they took, on average, 31 days from the date of medical disposition
to complete their reviews.
15



Deputy Wardens for Security must complete their reviews within five business days of the
incident, yet they took, on average, 41 business days from the incident date to complete
their reviews.
DOC policy does not provide a timeline for the final review by the Commanding Officer
(facility warden). These reviews were completed, on average, 46 business days from the
incident date.

Finally, the Board found that 26% of Deputy Warden’s Reviews (n=38) and 28% of
Commanding Officer’s Reviews (n=42) were only completed after the Board requested the
injury reports for the audit, months after the date of injury.
Table 4.

Source: BOC Review of 149 Injury to Inmate Reports.
CHS staff’s requirement to document medical dispositions in the Injury to Inmate Report is
frequently unmet. Board staff found 59 reports (40%) in which the clinician signed and entered
the date of medical disposition without providing a disposition. An additional 10 injury reports
(7%) contained no disposition and no date of disposition.
The Injury to Inmate Report contains an area, designated specifically for CHS clinicians, that
serves three distinct functions. The first section asks clinicians to record their initial patient

encounter. The second section requires them to document medical findings from any medical
referrals, if the injured patient requires a higher level of diagnostic or treatment care than can be
afforded in the jail’s medical clinic. The third section asks clinicians to indicate the final
disposition of the patient, as CHS policy also requires.30 The Board’s variance allows CHS to share
these sections of the Injury to Inmate Report with DOC.

Figure 7.

For the vast majority of injuries occurring in jails, which are non-serious in nature,31 the second
section of the injury report form is not utilized, and the initial treating clinician also marks the
disposition upon completion of the initial encounter.
30

CHS Policy #Med 7, Procedure 8 (April 1, 2008): “Upon completion of the evaluation, the practitioner will make
a determination as to the disposition of the patient and notify DOC by checking the appropriate box on the bottom of
Form 167R.”
31
In 2017, DOC generated 31,368 Injury to Inmate Reports and CHS designated a total of 816 serious injuries, an
approximate serious injury rate per report of 2.6%.

However, because nearly all serious injuries result in referrals to either the West Facility (where
urgent care and radiology services are available) or Bellevue and East Elmhurst Hospitals,32 the
second section is typically required in cases of serious injury.
The audit found that CHS clinicians frequently (n=88, 59%) signed off on the initial patient
encounter (section 1) and then signed off on the final disposition (section 3) during the same
initial encounter, even if urgent medical referral services were ordered and still pending. In those
88 cases, the final medical disposition was signed within one hour of the initial evaluation. In 64
cases (42%), the final medical disposition was signed within 30 minutes of the initial evaluation.
In 79 of 149 (53%) audited injury reports, DOC indicated in the injury investigation that
the cause was at least partially due to an “inmate-on-inmate altercation.” Similarly, 54% of
serious injuries (91/169) occurring during April, May, and June 2017 were caused by fights
between incarcerated people, as reported by CHS.33 Accidents were the next common cause of
serious injury (28%, n=42), as reported in DOC injury investigations.
Figure 8.

DOC - Causes of Serious Injury - April, May, June 2018
n=149
70
40

Source: BOC Review of 149 Injury to Inmate Reports.

In its review of 149 injury reports relating to serious injury, BOC found that 98% (n=146) resulted in referrals to
medical services outside of the jail’s clinic.
33
CHS data tracks causes of injury based on CHS clinical staff’s encounter with the patient, a determination made
independently from the Department’s injury investigation.

CHS data over the three-month audit period show 90% of all serious injuries involved
lacerations requiring sutures (n=79) or fractures (n=73).
Figure 9.

CHS - Types of Serious Injuries* - April, May & June 2018
n=169
Blow to Head
2%
Injury Judged Serious by
a Medical Professional
Involved
1%

Disabling of an Organ
2%
Dislocation
4%
Foreign Body Ingestion
1%

Laceration
47%
Fracture
43%

Source: CHS Monthly Serious Injury Reports.
* Types of serious injuries as reported by CHS.

Facial trauma (such as lacerations, puncture wounds, fractures and burns to the face, as well
severe injuries to the eye) was the most common type of serious injury. Board staff review of
Injury to Inmate Reports identified 76 CHS-designated serious injuries associated with the facial
area during the audit period. These represented 51% of all Board-audited serious injury reports. In
its review of injury reports, the Board noted ten nasal fractures, six mandible fractures and three
orbital fractures. Top facial laceration sites included the lip (n=19) and the eyebrow (n=9).
Metacarpal fractures34 (n=10) and ankle fractures related to slip-and-falls and basketball (n=6)
were also prevalent.

Metacarpal fractures are frequently associated with closed-fist strikes:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3088367/.

The Anna M. Kross Center (AMKC) had the highest number and rate of serious injuries.35
AMKC confines 25% of the City’s incarcerated people and is the largest jail in the City. CHS
reported 34% of all serious injuries systemwide occurred to people incarcerated at AMKC during
the audit period. This amounts to the highest number of injuries (n=58) and the highest monthly
rate of serious injuries per 1000 incarcerated people (9.45). West Facility (9.01) and Robert N.
Davoren Center (RNDC, 8.58) had the next highest rates.
The rates of serious injuries were lowest at the Rose M. Singer Center (RMSC, .66) and the Vernon
C. Bain Center (VCBC, 3.05). Only one serious injury (fractured nose) occurred at RMSC during
the three-month period.

Figure 10.
CHS ‐ Serious Injuries By Facility ‐ April, May, June 2018
n=169

VCBC
3%

NIC
3%

WF
1%

GMDC
2%

RMSC
1%

MDC
7%

AMKC
34%

BKDC
8%

RNDC
8%

GRVC
10%

EMTC
11%

Source: CHS Monthly Serious Injury Reports.

Monthly rate per 1,000 incarcerated people.

OBCC
12%

Table 5.
Serious Injuries by Facility (April - June 2018)
Facility

Number of
Serious
Injuries

% of Average
Monthly
Census

% of Serious
Injuries

Monthly Rate per
1,000
Incarcerated
People

AMKC
EMTC
OBCC
MDC
GRVC
VCBC
BKDC
RNDC
RMSC
NIC
GMDC
WF
TOTAL

58
18
21
12
17
6
13
13
1
6
3
1
169

25%
14%
11%
9%
8%
8%
7%
6%
6%
3%
3%
0%
100%

34%
11%
12%
7%
10%
3%
8%
8%
1%
3%
2%
1%
100%

9.45
5.41
7.84
5.65
8.50
3.05
7.59
8.58
0.66
7.35
3.70
9.01
6.71

Source: CHS Monthly Serious Injury Reports, DOC Facility Census Data.

Close to 80% (n=114) of serious injuries occurred in housing areas. In 53% (n=60) of the
reports of serious injuries that occurred in a housing area, it was not possible to tell, based on the
narrative details available in the report, where in the housing area the injury occurred—i.e.,
whether it occurred in the dayroom, bathroom, or cell.
Figure 11.

Top Five Locations of Serious Injuries
n=138

Recreation Yard
14
Main Intake
10%
4
3%
Clinic
3
2%

Housing Area
114
83%

Mess Hall
3
2%

Source: BOC Review of 149 Injury to Inmate Reports.

Most events causing serious injuries were not witnessed by staff. Thirty-two percent (32%
n=48) of all serious injuries were witnessed by staff, as indicated in the injury reports. Among
serious injuries stemming from violent encounters, officers witnessed 45% (n=43) of the incidents.
On average, it took approximately two hours for seriously injured incarcerated people to
receive medical attention after a DOC supervisor was notified of the injury. BOC found 13
UOF/fight-related serious injuries for which a four-plus-hour lapse occurred between time of
injury and the time the injured individual was presented for medical attention.36
Table 6.

Source: BOC Review of 149 Injury to Inmate Reports.

DOC Directive 4516R-B was updated with new requirements on 6/22/2018, including one that orders: “Inmates
must be afforded medical attention by medical staff as soon as practicable, but no more than four (4) hours following
a Use of Force incident or inmate-on-inmate fight, barring certain circumstances.” The Sixth Report of the Nunez
Independent Monitor, filed on October 17, 2018, analyzed medical wait times experienced by incarcerated people
following use of force incidents. The Nunez Compliance Unit (NCU) found significant improvements in this area. In
January 2018, 57% of incarcerated people included in their audit waited less than four hours for medical treatment
following a use of force. By June 2018, 79% were afforded medical treatment within four hours. The NCU’s complete
analysis relating to their work tracking medical treatment times can be found at:
https://www1.nyc.gov/assets/doc/downloads/pdf/6th_Monitor_%20Report-10-17-18%20.pdf#page=59.

Recommendations
1. DOC and CHS should immediately begin jointly publishing monthly data on the number,
type, cause, and location of injuries to people in custody (serious and non-serious), as these
indicators are critical to prevention efforts.
2. Within the next three months, DOC should come into compliance with their existing policy
for reporting serious injuries. DOC should report all serious injuries to people in custody
determined to be serious by correctional health staff.
3. Within the next nine months, DOC and CHS should establish new protocols and take steps
to increase accountability including: assessment of which supervisory reviews are needed
and whether changes to the Injury to Inmate Report form are needed; development of an
electronic injury-tracking system; and training to ensure that injury reports are complete
and include accurate, final diagnoses and dispositions.
4. DOC and CHS should immediately begin providing the Board with monthly access to all
DOC Injury Reports that CHS designates as associated with a serious injury. This will
support DOC’s and CHS’s efforts to improve their process and increase accountability.
5. Within the next three months, DOC should review the conditions leading to the high
number and rate of serious injuries at AMKC and implement a plan to reduce injuries there.
DOC should use video review to inform this injury analysis, so that the locations and causes
of serious injuries are better documented.
6. DOC should contract with an independent auditor to assess reporting of serious injuries to
staff. The audit’s goals would include understanding who is getting injured (civilian v.
uniform, DOC v. DOE v. CHS v. contractors v. volunteers, etc.); how (assault v.
construction-related v. slip and fall, etc.); when and where injuries are occurring; and what
types of injuries are sustained. Ultimately, these audits must inform injury prevention
planning and public reporting.37
7. BOC should conduct an annual audit of Injury to Inmate Reports.

Currently, DOC will not share any medical information or injury diagnoses related to staff injuries with the Board.

Appendix A: CHS Serious Injury Inclusion Criteria

Appendix B: DOC Serious Injury Categories & Policy Definitions

Appendix C: DOC Injury to Inmate Report (Form #167R‐A)

Page 1 of 2

Page 2 of 2

Appendix D: Injury Report Audit Template