United States v. City of New York; and New York City Department of Correction, Southern District of New York (Dec. 18, 2014) — Complaint

EXHIBIT A 



[Type text] 
 

  
 
 
 
 
              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 
 

RE:  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 
harm.   

                                                 
1 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.   

 
 
 

86 Chambers Street 
              New York, New York 10007 

U.S. Department of Justice 
 
United States Attorney 
Southern District of New York 



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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 
Society.   
  

                                                 
2  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.   
3  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. 
4 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 
Rikers.5   
 
  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.   
 
 
 
 
 
 

                                                 
5  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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I. SUMMARY OF FINDINGS 

 
  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 
injuries; 

 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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II. BACKGROUND 
 

A. 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.   

B. 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 18-
year olds to separate RNDC housing units so they are no longer co-mingled with the 16- and 17-
year 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.    

                                                 
6 See Department of Correction website, http://www.nyc.gov/html/doc/html/about/about_doc.shtml. 
7 Additional facilities are located in Brooklyn, Manhattan, Queens, and a floating jail barge in the Bronx.  See 
http://www.nyc.gov/html/doc/html/about/facilities-overview.shtml.   

8 North Carolina is the other state.   



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C. 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.   
   
III. LEGAL STANDARDS  

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 http://www.nyc.gov/html/doc/downloads/pdf/ANNUAL_REPORT_FY2013_ADOLESCENT.pdf.  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. 



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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. 
 
IV. INADEQUATE PROTECTION OF ADOLESCENT INMATES FROM HARM 

DUE TO EXCESSIVE AND UNNECESSARY USE OF FORCE BY STAFF AND 
HIGH LEVELS OF INMATE VIOLENCE  

 
A. 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 
data.    

 
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). 

 
1. 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 

                                                 
10 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.      
 

2. 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-on-
inmate 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. 

 

                                                 
11 From April 2012 through April 2013, adolescent fights resulted in 430 visible inmate injuries, according to 
DOHMH data.   
 
12 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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3. 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  

 
B.  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 
47.   

   
                                                 
13 RNDC inmates suffered 22 jaw fractures during the first 5 ½ months of 2012 alone.   
14 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 
issues. 



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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 well-
accepted contemporary correctional practices, as well as the Department’s own use of force 
policies.15   

 
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 
conduct.  

 
1. 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 

                                                 
15 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 
escalation.”   



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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 24-
hour 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 
conduct:    
 

 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.  
 

                                                 
16 24-hour reports include summaries of unusual incidents that occurred during a given day, including use of force 
incidents.   
17  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 
illustrative: 

 
 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
 
 
 

2. 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 
                                                 
18 DOC’s Use of Force Directive prohibits using force “[t]o punish, discipline, assault or retaliate against an 
inmate.”   
19 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:   
 

                                                 
20 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 
thereafter. 

 
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.   

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

Instructions  
 
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 
incident.   

 
 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 
Appendix.)   

 
 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 
Appendix.)   

 
 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 
face.   

 
 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 
areas.     
 

4. 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 
Turtles.”  

 
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   

 
5. 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.   

                                                 
21 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.   
 

6. 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.   
 
V. SYSTEMIC DEFICIENCIES LEADING TO EXCESSIVE AND UNNECESSARY 

STAFF USE OF FORCE AND HIGH LEVELS OF INMATE VIOLENCE 
 

  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
 
 
 

A.    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.   
 

1. 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 

                                                 
22 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 
                                                 
23   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.   
 

2. 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:  
 

1) 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    

                                                 
24 Oleoresin Capsicum (“OC”) spray, commonly known as pepper spray, is a chemical agent that irritates the eyes 
and respiratory system of a target.  
25  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
 
 
 

2) 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.   

 
3) 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.    

 
4) 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.   

 
5) 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 
identified: 
 

 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.)   
 

3. 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.   
 

B.     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.        

 
1. 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 
inadequate. 
   
   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.     
 

2. 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 
investigations.   
 
   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.   

 

                                                 
26 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
 
 
 

3. 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 
  

a. 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 

                                                 
27 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 
Appendix.)    
 

 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 
investigators.   

 
 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.   

 
b. 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. 
 

c. 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 
                                                 
28 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.   
29 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. 
 
  C.  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 
following: 
 

 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 non-
adolescent housing, the Department’s practice is too often to “counsel” such officers in an 
interview.30    
 
  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.   
 

D. 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 re-
classified 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), 
https://www.ncjrs.gov/pdffiles1/bja/182503.pdf.   For instance, the maturity levels of 16- and 17-
                                                 
30 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.     
31 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 
violence.    

 
E. 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
 
 
 

F.   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. 
 

1. 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        

 

                                                 
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
 
 
 

2. 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. 

 
3. 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.   

 
4.    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, 

                                                 
33 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 

                                                 
34 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.  (http://www.huffingtonpost.com/2013/08/22/rikers-island-prison-fight-video_n_3799160.html).  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.         
35 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.       

 
G.   Inadequate Staff Training 

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

1. 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 long-
standing 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.  

2.       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 
adult???????????”   

     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 
                                                 
36 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.  
  

H.  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.   

 

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

38 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, http://bronxda.nyc.gov/information/2009/case3.htm. 

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

 



 Page 46
 
 
 
VI.  EXCESSIVE AND INAPPROPRIATE USE OF PROLONGED PUNITIVE 

SEGREGATION 

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.”  
(www.aacap.org/AACAP/Policy_Statements/2012/Solitary_Confinement_of_Juvenile_Offender
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), 
www.justice.gov/defendingchildhood/cev-rpt-full.pdf.  In addition, under the juvenile detention 
facility standards issued by the Juvenile Detention Alternatives Initiative of The Annie E. Casey 

                                                 
40 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), http://www.aecf.org/m/resourcedoc/aecf-
juveniledetentionfacilityassessment-2014.pdf/.   

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. 

 
A. 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 
                                                 
41 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. 

42 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 
goals.    
43 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 
future.   



 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 

B. 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 
segregation.   

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.)  

 

                                                 
44 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.   
45 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 

                                                 
46 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   

 
VII. REMEDIAL MEASURES 

 
  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: 
 

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



 Page 52
 
 
 

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

 
1. 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.   

 
2. 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. 

 
B.  Increase Number of Cameras in Adolescent Areas of Jails   

 
1. Install additional video surveillance cameras in all adolescent areas, 

including but not limited to housing areas, school/classroom areas, intake, 
search locations, and clinics.  

 
2. 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
 
 
 

C.  Strengthen the Department’s Use of Force Directive 
  

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

 
a. 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.  

 
b. 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.   

 
c. Explicitly prohibit, or further highlight and emphasize the 

prohibition on, the following:  
 

i. The use of unnecessarily painful escort or restraint 
techniques. 

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

threats. 
 

iii. 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 
threat. 

 
iv. 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. 

 
v. 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 
allow.  

 



 Page 54
 
 
 

vi. Harassing or verbally provoking inmates. 
 

vii. 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 
investigation. 

 
viii. Pressuring or coercing inmates, Departmental staff, medical 

staff, or teachers not to report a use of force incident. 
 

d. 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.  

 
e. 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.   

 
f. 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. 

 
2. 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.    

 
 D.       Use of Force Reporting 

 
1. 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 
requirement.   

 
2. 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.    

 
3. 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.    

 
4. 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.  

 
5. Clarify the definitions of the categories of institutional violence data 

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

 
6. 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.   

 
7. 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.   

 
8. 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.   

 
9. 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. 

 
10. 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.   

 
11. 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.    

 
12. Develop and implement a reliable procedure for identifying and timely 

addressing emergency grievances involving inmate safety issues.  
 

13. 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.      

 
E. Use of Force Investigations  

 
1. 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.     

 
2. 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.     

 
3. 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.  

 
4. 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
 
 
 

5. 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.   

 
6. 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.   

 
7. Ensure that investigation of the most serious use of force incidents are 

prioritized to ensure that they are investigated in an expedited manner. 
 

8. 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. 

 
9. 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.    

 
10. Develop and implement a standardized system for the organization and 

contents of investigation files to facilitate review and oversight. 
 

11. Ensure that facility-level investigations are appropriate, thorough, and 
timely.  In addition to the currently required reviews of certain facility-
level 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. 

 
12. 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
 
 
 

 
F. Safety and Supervision   
  

1. Ensure that inmates are adequately supervised at all times. 
 

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

 
3. 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.     
 

4. 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.   

 
5. 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.       

 
6. Transfer any inmates deemed to be particularly vulnerable or otherwise at 

risk to an alternative housing unit. 
 

7. 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.   

 
8. Offer adolescents enhanced programming and activities, especially in the 

evenings and on weekends, to engage them and reduce idleness.    
 

9. 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
 
 
 

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

 
11. Develop and implement measures to reduce staff turnover at adolescent 

housing facilities.   
 

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

 
13. 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.        

 
14. 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.  

 
15. 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. 

 
G. Training 

 
1. 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 role-
playing, 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.   

 
2. 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
 
 
 

3. 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. 

 
4. 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.    

 
5. 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 
Island.   

 
6. Develop and implement an effective and comprehensive competency-

based 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 
discrepancy.   

 
7. Ensure that staff are adequately trained on how to interact and manage 

adolescents with mental illnesses and/or suicidal tendencies.    
 



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H. Accountability 
 

1. 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.  

 
2. 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.  

 
3. 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.   

 
4. Develop and implement a formalized progressive disciplinary process for 

violations of use of force policies and procedures. 
 

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

 
a. 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.  

  
b. 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.   

 



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6. 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. 

 
7. 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.   

 
8. 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. 

 
9. Develop a strategic plan to create and maintain a culture of accountability 

at all levels of the Department. 
 

I. Inmate Discipline 
 

1. 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.   
 

2. 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.   

 
3. 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.   
 

4. 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 
DOC and DOHMH. 

 
5. 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.  

 



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

 
7. 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.   

 
J. Management and Leadership 

 
1. 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.   

 
2. Enhance management continuity at adolescent housing facilities, and limit, 

to the extent possible, the rate of turnover among Wardens and Deputy 
Wardens.   

 
3. 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. 

  
4. Require DOC’s top operational administrators to conduct periodic 

unannounced tours (including evening and weekend tours) of adolescent 
housing areas.   

  



BSpencer
Typewritten Text

BSpencer
Typewritten Text
Page 64



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APPENDIX 
 

REPRESENTATIVE USE OF FORCE INCIDENTS 
 

   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.       
 
2012 INCIDENTS 
 
*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, 
                                                 
48 An asterisk indicates that our consultant interviewed the inmate involved in the incident during our on-site tours.  



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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 
ground.   
 
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 



 Page 70
 
 
 
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 self-
defense 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 
investigators.   
 
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, 



 Page 72
 
 
 
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, 



 Page 73
 
 
 
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.  



 Page 74
 
 
 
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.  

 
2013 INCIDENTS 
 
*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 



 Page 75
 
 
 
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 
incident.   
 
*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 



 Page 76
 
 
 
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 
allowed.”   
 
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 



 Page 77
 
 
 
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 



 Page 78
 
 
 
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.   



 Page 79
 
 
 
 
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.

EXHIBIT A 



[Type text] 
 

  
 
 
 
 
              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 
 

RE:  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 
harm.   

                                                 
1 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.   

 
 
 

86 Chambers Street 
              New York, New York 10007 

U.S. Department of Justice 
 
United States Attorney 
Southern District of New York 



 Page 2
 
 
 
    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 
Society.   
  

                                                 
2  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.   
3  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. 
4 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.   



 Page 3
 
 
 
  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 
Rikers.5   
 
  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.   
 
 
 
 
 
 

                                                 
5  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). 



 Page 4
 
 
 
I. SUMMARY OF FINDINGS 

 
  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 
injuries; 

 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.   

 
 
 
    



 Page 5
 
 
 
II. BACKGROUND 
 

A. 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.   

B. 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 18-
year olds to separate RNDC housing units so they are no longer co-mingled with the 16- and 17-
year 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.    

                                                 
6 See Department of Correction website, http://www.nyc.gov/html/doc/html/about/about_doc.shtml. 
7 Additional facilities are located in Brooklyn, Manhattan, Queens, and a floating jail barge in the Bronx.  See 
http://www.nyc.gov/html/doc/html/about/facilities-overview.shtml.   

8 North Carolina is the other state.   



 Page 6
 
 
 

C. 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.   
   
III. LEGAL STANDARDS  

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 http://www.nyc.gov/html/doc/downloads/pdf/ANNUAL_REPORT_FY2013_ADOLESCENT.pdf.  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. 
 
IV. INADEQUATE PROTECTION OF ADOLESCENT INMATES FROM HARM 

DUE TO EXCESSIVE AND UNNECESSARY USE OF FORCE BY STAFF AND 
HIGH LEVELS OF INMATE VIOLENCE  

 
A. 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 
data.    

 
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 



 Page 8
 
 
 
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). 

 
1. 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 

                                                 
10 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. 



 Page 9
 
 
 
not accurately report incidents, and warn inmates to “hold it down” or otherwise pressure them 
not to report use of force incidents.      
 

2. 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-on-
inmate 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. 

 

                                                 
11 From April 2012 through April 2013, adolescent fights resulted in 430 visible inmate injuries, according to 
DOHMH data.   
 
12 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.   
 



 Page 10
 
 
 

3. 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  

 
B.  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 
47.   

   
                                                 
13 RNDC inmates suffered 22 jaw fractures during the first 5 ½ months of 2012 alone.   
14 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 
issues. 



 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 well-
accepted contemporary correctional practices, as well as the Department’s own use of force 
policies.15   

 
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 
conduct.  

 
1. 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 

                                                 
15 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 
escalation.”   



 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 24-
hour 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 
conduct:    
 

 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.  
 

                                                 
16 24-hour reports include summaries of unusual incidents that occurred during a given day, including use of force 
incidents.   
17  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 
illustrative: 

 
 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
 
 
 

2. 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 
                                                 
18 DOC’s Use of Force Directive prohibits using force “[t]o punish, discipline, assault or retaliate against an 
inmate.”   
19 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:   
 

                                                 
20 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 
thereafter. 

 
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.   

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

Instructions  
 
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 
incident.   

 
 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 
Appendix.)   

 
 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 
Appendix.)   

 
 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 
face.   

 
 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 
areas.     
 

4. 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 
Turtles.”  

 
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   

 
5. 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.   

                                                 
21 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.   
 

6. 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.   
 
V. SYSTEMIC DEFICIENCIES LEADING TO EXCESSIVE AND UNNECESSARY 

STAFF USE OF FORCE AND HIGH LEVELS OF INMATE VIOLENCE 
 

  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
 
 
 

A.    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.   
 

1. 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 

                                                 
22 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 
                                                 
23   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.   
 

2. 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:  
 

1) 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    

                                                 
24 Oleoresin Capsicum (“OC”) spray, commonly known as pepper spray, is a chemical agent that irritates the eyes 
and respiratory system of a target.  
25  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
 
 
 

2) 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.   

 
3) 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.    

 
4) 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.   

 
5) 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 
identified: 
 

 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.)   
 

3. 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.   
 

B.     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.        

 
1. 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 
inadequate. 
   
   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.     
 

2. 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 
investigations.   
 
   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.   

 

                                                 
26 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
 
 
 

3. 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 
  

a. 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 

                                                 
27 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 
Appendix.)    
 

 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 
investigators.   

 
 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.   

 
b. 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. 
 

c. 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 
                                                 
28 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.   
29 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. 
 
  C.  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 
following: 
 

 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 non-
adolescent housing, the Department’s practice is too often to “counsel” such officers in an 
interview.30    
 
  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.   
 

D. 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 re-
classified 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), 
https://www.ncjrs.gov/pdffiles1/bja/182503.pdf.   For instance, the maturity levels of 16- and 17-
                                                 
30 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.     
31 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 
violence.    

 
E. 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
 
 
 

F.   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. 
 

1. 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        

 

                                                 
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
 
 
 

2. 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. 

 
3. 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.   

 
4.    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, 

                                                 
33 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 

                                                 
34 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.  (http://www.huffingtonpost.com/2013/08/22/rikers-island-prison-fight-video_n_3799160.html).  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.         
35 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.       

 
G.   Inadequate Staff Training 

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

1. 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 long-
standing 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.  

2.       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 
adult???????????”   

     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 
                                                 
36 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.  
  

H.  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.   

 

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

38 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, http://bronxda.nyc.gov/information/2009/case3.htm. 

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

 



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VI.  EXCESSIVE AND INAPPROPRIATE USE OF PROLONGED PUNITIVE 

SEGREGATION 

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.”  
(www.aacap.org/AACAP/Policy_Statements/2012/Solitary_Confinement_of_Juvenile_Offender
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), 
www.justice.gov/defendingchildhood/cev-rpt-full.pdf.  In addition, under the juvenile detention 
facility standards issued by the Juvenile Detention Alternatives Initiative of The Annie E. Casey 

                                                 
40 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), http://www.aecf.org/m/resourcedoc/aecf-
juveniledetentionfacilityassessment-2014.pdf/.   

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. 

 
A. 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 
                                                 
41 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. 

42 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 
goals.    
43 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 
future.   



 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 

B. 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 
segregation.   

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.)  

 

                                                 
44 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.   
45 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 

                                                 
46 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   

 
VII. REMEDIAL MEASURES 

 
  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: 
 

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



 Page 52
 
 
 

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

 
1. 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.   

 
2. 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. 

 
B.  Increase Number of Cameras in Adolescent Areas of Jails   

 
1. Install additional video surveillance cameras in all adolescent areas, 

including but not limited to housing areas, school/classroom areas, intake, 
search locations, and clinics.  

 
2. 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
 
 
 

C.  Strengthen the Department’s Use of Force Directive 
  

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

 
a. 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.  

 
b. 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.   

 
c. Explicitly prohibit, or further highlight and emphasize the 

prohibition on, the following:  
 

i. The use of unnecessarily painful escort or restraint 
techniques. 

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

threats. 
 

iii. 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 
threat. 

 
iv. 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. 

 
v. 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 
allow.  

 



 Page 54
 
 
 

vi. Harassing or verbally provoking inmates. 
 

vii. 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 
investigation. 

 
viii. Pressuring or coercing inmates, Departmental staff, medical 

staff, or teachers not to report a use of force incident. 
 

d. 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.  

 
e. 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.   

 
f. 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. 

 
2. 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.    

 
 D.       Use of Force Reporting 

 
1. 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 
requirement.   

 
2. 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.    

 
3. 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.    

 
4. 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.  

 
5. Clarify the definitions of the categories of institutional violence data 

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

 
6. 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.   

 
7. 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.   

 
8. 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.   

 
9. 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. 

 
10. 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.   

 
11. 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.    

 
12. Develop and implement a reliable procedure for identifying and timely 

addressing emergency grievances involving inmate safety issues.  
 

13. 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.      

 
E. Use of Force Investigations  

 
1. 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.     

 
2. 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.     

 
3. 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.  

 
4. 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
 
 
 

5. 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.   

 
6. 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.   

 
7. Ensure that investigation of the most serious use of force incidents are 

prioritized to ensure that they are investigated in an expedited manner. 
 

8. 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. 

 
9. 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.    

 
10. Develop and implement a standardized system for the organization and 

contents of investigation files to facilitate review and oversight. 
 

11. Ensure that facility-level investigations are appropriate, thorough, and 
timely.  In addition to the currently required reviews of certain facility-
level 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. 

 
12. 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
 
 
 

 
F. Safety and Supervision   
  

1. Ensure that inmates are adequately supervised at all times. 
 

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

 
3. 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.     
 

4. 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.   

 
5. 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.       

 
6. Transfer any inmates deemed to be particularly vulnerable or otherwise at 

risk to an alternative housing unit. 
 

7. 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.   

 
8. Offer adolescents enhanced programming and activities, especially in the 

evenings and on weekends, to engage them and reduce idleness.    
 

9. 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
 
 
 

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

 
11. Develop and implement measures to reduce staff turnover at adolescent 

housing facilities.   
 

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

 
13. 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.        

 
14. 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.  

 
15. 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. 

 
G. Training 

 
1. 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 role-
playing, 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.   

 
2. 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
 
 
 

3. 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. 

 
4. 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.    

 
5. 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 
Island.   

 
6. Develop and implement an effective and comprehensive competency-

based 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 
discrepancy.   

 
7. Ensure that staff are adequately trained on how to interact and manage 

adolescents with mental illnesses and/or suicidal tendencies.    
 



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H. Accountability 
 

1. 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.  

 
2. 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.  

 
3. 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.   

 
4. Develop and implement a formalized progressive disciplinary process for 

violations of use of force policies and procedures. 
 

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

 
a. 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.  

  
b. 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
 
 
 

6. 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. 

 
7. 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.   

 
8. 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. 

 
9. Develop a strategic plan to create and maintain a culture of accountability 

at all levels of the Department. 
 

I. Inmate Discipline 
 

1. 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.   
 

2. 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.   

 
3. 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.   
 

4. 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 
DOC and DOHMH. 

 
5. 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
 
 
 

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

 
7. 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.   

 
J. Management and Leadership 

 
1. 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.   

 
2. Enhance management continuity at adolescent housing facilities, and limit, 

to the extent possible, the rate of turnover among Wardens and Deputy 
Wardens.   

 
3. 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. 

  
4. Require DOC’s top operational administrators to conduct periodic 

unannounced tours (including evening and weekend tours) of adolescent 
housing areas.   

  



BSpencer
Typewritten Text

BSpencer
Typewritten Text
Page 64



 Page 65
 
 
 

APPENDIX 
 

REPRESENTATIVE USE OF FORCE INCIDENTS 
 

   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.       
 
2012 INCIDENTS 
 
*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, 
                                                 
48 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 
ground.   
 
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.   
 



 Page 68
 
 
 
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 



 Page 70
 
 
 
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 self-
defense 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 



 Page 71
 
 
 
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 
investigators.   
 
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, 



 Page 72
 
 
 
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, 



 Page 73
 
 
 
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.  



 Page 74
 
 
 
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.  

 
2013 INCIDENTS 
 
*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 



 Page 75
 
 
 
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 
incident.   
 
*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 



 Page 76
 
 
 
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 
allowed.”   
 
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 



 Page 77
 
 
 
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.