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A Review of the Jail Violence Tracking and Reporting Procedures of the Los Angeles County Sheriff's Department, 2017

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Office of Inspector General
County of Los Angeles

Max
Max Huntsman
Huntsman
Inspector General
Inspector
General

A Review of the Jail Violence Tracking
and Reporting Procedures of the
Los Angeles County Sheriff’s Department
July 2017

Contents
Introduction ................................................................................................................................ 1
Comparisons of Jail Violence Data Provided by the Department............................................... 2
Tracking Use-of-Force Data ........................................................................................................ 4
Facility Trackers: ..................................................................................................................... 5
e-LOTS: .................................................................................................................................... 6
FAST:........................................................................................................................................ 6
Force Alerts: ............................................................................................................................ 7
Use-of-Force Data Compilation and Reporting .......................................................................... 7
Use-of-Force Data Reported in Monthly Books:..................................................................... 7
Use-of-Force Data Reported in Sheriff’s Critical Incident Forum (SCIF) Presentations: ......... 8
Use-of-Force Data Reported in OIG Quarterly Reports: ......................................................... 8
Tracking Inmate Assault Data ..................................................................................................... 9
Los Angeles Times Data Compared to Data Provided to the Office of Inspector General ... 14
Discrepancies between the 2007 through 2013 Totals ........................................................ 14
Discrepancies Between the 2016 Totals ............................................................................... 14
CONCLUSION ................................................................................................................................. 15
RECOMMENDATIONS ................................................................................................................... 15

Office of Inspector Generalf

Introduction
Pursuant to section 6.44.190 of the Los Angeles County Code, the Office of
Inspector General (OIG) provides “comprehensive oversight, monitoring of, and
reporting about the Sheriff's Department and its jail facilities.” The OIG monitors
violence in the Los Angeles County jail system and regularly requests data from the
Los Angeles County Sheriff’s Department (Department) for tracking and trend
analysis. The OIG then publishes portions of this data in its quarterly report –
“Reform and Oversight Efforts: Los Angeles County Sheriff's Department”
(Quarterly Report).
Over three quarters between June 2016 and March 2017, the OIG requested data
on three types of jail violence for incorporation into its Quarterly Reports: (1) useof-force on inmates by staff, (2) inmate-on-inmate assaults, and (3) inmate
assaults on staff. The Department provided the requested data and reported that
the data was vetted and approved for publication. The Department also validated
the draft OIG reports prior to publication. As such, the jail violence data was
subsequently published in OIG Quarterly Reports dated October 2016, December
2016 and April 2017. In February of 2017, the Department released jail violence
data to the Los Angeles Times (Times) which purported to show some of the same
information as was published in the OIG Quarterly Reports; however, portions of
the Times data was inconsistent with data published in the OIG’s reports. In April
2017, the Department notified the OIG that the data provided to both the OIG and
the Times was inaccurate. The Department was not sure, however, why the data
was inaccurate nor could it provide new data that it could confidently report as
accurate.
As a result of these and other data inconsistencies both detected by the OIG and
reported to the OIG by the Department, the OIG conducted a review of the
Department’s methods for tracking, compiling and reporting jail violence data. The
OIG also reviewed the Custody Services Division’s (Custody) primary mechanisms
for reporting jail violence data internally, including the data included in the “Monthly
Books” and the data presented semi-annually at the Sheriff’s Critical Incident
Forum (SCIF).
The Department tracks statistics related to jail violence in a number of databases
and unit-level trackers. Custody Support Services (CSS), Custody’s data unit, then
aggregates the data and prepares the Monthly Books and SCIF presentations.1 The
1

See LASD, Custody Division Manual, § 4-10/000.05; and CCJV, Report of the Citizen’s Commission on Jail Violence,
September 2012, pp. 80-81. http://ccjv.lacounty.gov.

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Office of Inspector Generalf
SCIF, in particular, is an important assessment tool used by department executives
to identify and remedy systemic deficiencies related to force, violence and other jail
operations. As such, the accuracy and consistency of the data presented is integral
to the overall effectiveness of the SCIF process, prisoner welfare, and Departmental
strategic planning.
The Department’s failure to accurately track and report jail violence data was
documented nearly five years ago in the Report of the Citizen’s Commission on Jail
Violence which deemed the Department’s statistics on use-of-force “not reliable.” 2
As discussed in detail below, OIG personnel found that the same deficiencies exist
today. First, Custody has a decentralized system that includes multiple databases
and processes which track jail violence data. Second, there is little standardization
in data tracking processes and procedures and databases are not systematically
cross-updated. Third, there is no system-wide process for data reconciliation to
ensure that additions, deletions or amendments to jail violence data entries are
reflected in the yearly totals, which results in reporting of some totals that are
“stale” and do not reflect the most current information. Finally, there is a lack of
clear accountability for the accuracy of Custody’s jail violence data.
The OIG’s review consisted of four phases. First, the published yearly totals for the
three data-points discussed above were compared and inconsistencies were
identified. Second, a preliminary survey of the processes and procedures used for
tracking jail violence was conducted to identify potential causes of inconsistencies
and inaccuracies in the yearly totals. Third, a general examination of the processes
of preparing the yearly totals for publication was conducted to identify issues that
might contribute to inconsistencies or inaccuracies. Lastly, the OIG made
recommendations aimed at improving the quality and increasing the accuracy of the
Department’s jail violence data.

Comparisons of Jail Violence Data Provided by the Department
The OIG compared the 2016 inmate-on-inmate assault data released to the Times,
reported in the Monthly Books, presented at SCIF, and reported to the OIG. The
following table illustrates inconsistencies between totals for this data over the same
time periods.

2

Report of the Citizen’s Commission on Jail Violence, September 2012, pp. 43-45. http://ccjv.lacounty.gov.

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Office of Inspector Generalf

Inmate-on-Inmate Assault Data Provided by the Department
Year

Total

Report

2016

3354

Provided to LA Times, February 2017

2016

3371

Monthly Book, February 2017

2016

3500

SCIF, April 2017

2016

3716

OIG Quarterly Report, April 2017

The published totals for 2016 inmate-on-inmate assaults reflected substantial
variances depending on their source. The Department reported 3,716 incidents of
inmate-on-inmate violence to the OIG and 3,354 assaults to the Times for the same
period, a difference of 362, a variation of 9.7%. The Monthly Book and SCIF
presentations also reflect different totals, 3,371 and 3,500 assaults respectively.

Inmate-on-Staff Assault Data Provided by the Department
Year

Total

Report

2015

382

Monthly Book, February 2017

2015

414

SCIF, October 2016

2015

422

SCIF, April 2017

2015

464

OIG Quarterly Report, April 2017

Next, the OIG compared the 2015 inmate-on-staff assault data reported in the
Monthly Books, presented at SCIF in October 2016 and April 2017, and reported to
the OIG. The table above illustrates the variances between totals reported for the
same reporting period. The published totals for 2015 inmate-on-staff assaults also
reflected substantial variances depending on the data source. The Department
reported 464 inmate-on-staff assaults to the OIG, but reported a total of 382
assaults in the February 2017 Monthly Book for the same period, reflecting a
difference of 82, a variation of 17.7%. The SCIF presentations for October 2016
and April 2017 also reflect different 2015 inmate-on-staff assault totals of 414 and
422 incidents respectively.

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Office of Inspector Generalf

Use-of-Force Data Provided by the Department
Year

Total Force Reported

Report

2016

1833

OIG Quarterly Report, April 2017

2016

1833

Monthly Book, February 2017

2016

3

1849

SCIF, April 2017

Lastly, the OIG compared the 2016 use-of-force data reported in the OIG’s
Quarterly Report, published in the Monthly Books, and presented at SCIF in April
2017. The published 2016 totals for uses-of-force reflected a much smaller
variance between totals. Initially, it appeared that the small variances indicated
greater accuracy in the use-of-force totals; however, the processes used to
aggregate and publish these numbers suggests that the opposite is true.
The current process used by Custody to compile use-of-force totals virtually
guarantees that the totals will change from month-to-month as late or outstanding
reports and revisions are received and input. As a result, yearly totals that do not
exhibit significant variances may indicate that those totals have not been updated
and are therefore outdated. As such, the OIG focused its initial review on the
processes and procedures used to compile the data-set which reflected the greatest
potential inaccuracy -- use-of-force data.

Tracking Use-of-Force Data
When the Department is notified of a use-of-force incident, information about the
incident is documented in a number of data collection systems.4 These data
collection systems document, with some necessary overlap, different types of forcerelated data and are used for different purposes. The data collection systems are
not linked or reconciled with each other which results in data inconsistencies
between them.
The flow chart below depicts the data collection systems and the processes utilized
in documenting and reporting Custody use-of-force data. The red text indicates
issues identified by the OIG with each data collection system that have the potential
to create errors affecting the accuracy in the totals extracted from these systems.

3

The SCIF slide total as presented was 1,852; however, the slide included 3 cases from non-custody units which we
excluded in order to isolate cases pertaining only to custody facilities.
4
This discussion of the force review process is limited to only those aspects pertinent to data collection and
publication.

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Facility Trackers:
Facility Trackers are spreadsheets used by individual custody facilities to track useof-force incidents. Facility Trackers are generally more detailed than the other
systems listed above and give unit commanders immediate access to data
regarding their facilities. However, the criteria for the data-points recorded in these
trackers varies from facility to facility making it difficult to aggregate and analyze
information from multiple facilities. Moreover, information is entered into Facility
Trackers by employees with a wide variety of skill sets and job experiences,
increasing the risk that data entry errors, accidental deletions of data, and errors
during the transfer of data from one data collection system to another may occur.

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Office of Inspector Generalf
Lastly, the CSS unit is not always notified of updates made to facility Force Trackers
and the facilities and CSS do not regularly reconcile previously reported use-offorce data with updated information. As such, the totals from Force Trackers
reported to CSS quickly become outdated.

e-LOTS:
“e-LOTS” is an acronym for “electronic-Line Operations Tracking System.” e-LOTS
is a Custody Division database used to track force-related information. The
information contained in this database includes, but is not limited to the following:
use-of-force incidents; inmate extractions; allegations of force by staff on inmates;
prevented uses-of-force by staff; major inmate disturbances; the category of force
used in an incident; and tracking force investigations.5
The CSS unit reported that in the e-LOTS (and FAST, discussed below) database,
duplicate entries can occur when staff enters information under an incorrect report
number. If the record cannot be found using the correct report number, a new
entry is made which results in multiple entries for the same incident. Additionally,
the databases do not validate data entry fields; therefore, incomplete and incorrect
entries can be saved.

FAST:
“FAST” is an acronym for “Facility Automated Statistical Tracking.” FAST is a
Custody Division database which is also used to track incidents involving the useof-force by jail staff, but collects different data points than e-LOTS. The information
contained in FAST includes, but is not limited to the following: date/time/work shift
of the incident, location of the use-of-force, specific type of force used (OC Spray,
Taser, etc.), inmate’s mental history, weapons used, body part injured, and
identifying information related to the staff members and inmates involved in the
incident.
Although FAST is still being used at facilities to record force-related data,
department employees reported that the FAST system is unreliable and should not
be used. Specifically, database queries in FAST are downloaded to a Corel Paradox
table which must then be converted into Microsoft Excel spreadsheets. Paradox is a
relational database software package that is no longer supported by the company
that published the software. Department staff reported that the conversion process
between Paradox and Excel produces inaccurate results and that data corruption
may also occur when multiple people are using FAST at the same time.

5

See MPP 4-01/025.05 Electronic Line Operations.

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Office of Inspector Generalf

Force Alerts:
A Force Alert is used to quickly notify department management of a use-of-force
incident. The Force Alert contains a synopsis of the incident along with other
information relating to the incident. After a use-of-force is reported, facility staff
emails the Force Alert to all concerned departmental personnel and units, including
CSS. Each facility uses its own Force Alert form and the format and contents of the
alert forms vary between facilities.6

Use-of-Force Data Compilation and Reporting
As each reportable use-of-force is tracked by e-LOTS, FAST, Force Alerts, and
Facility Trackers, the use-of-force totals from these data collection systems should
be identical. Therefore, the published yearly totals for uses-of-force which are
compiled from these data collection systems should likewise be identical. However,
the OIG noted variances between the use-of-force totals published in the Monthly
Books, SCIF presentations, and OIG Quarterly Reports. As such, OIG personnel
reviewed the Custody Division’s processes of compiling and reporting yearly force
totals for each of these publications and discovered problematic issues unique to
each publication.

Use-of-Force Data Reported in Monthly Books:
The Department has suspended the publication of the Monthly Books pending an
internal review of its data tracking and reporting processes.
The process of tracking use-of-force data in the Monthly Books began with a Force
Alert. When the Department learned of a reportable use-of-force, the involved
facility sent a Force Alert via e-mail to the CSS unit. The CSS unit entered
preliminary data from the Force Alert into a tracking spreadsheet and produced a
daily use-of-force report reflecting all uses-of-force from the previous day. At the
end of each month, the daily use-of-force totals were aggregated and published in
the Monthly Books. At year end, the December Monthly Book contained the yearly
use-of-force totals. OIG personnel reviewed the methodology used in producing
the use-of-force totals and determined that the totals published in the Monthly
Books were rarely updated.
The actual use-of-force totals often changed for one or more the following reasons:
allegations of force which are later substantiated and documented as a use-of-force
(increasing the total); force incidents being deleted because they were reported in
error or there was a duplicate report number (decreasing the total); and late
6

Although Force Alerts work well in notifying management when incidents happen, their inconsistent formats and
inconsistent data points make their use as a statistical tool problematic.

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Office of Inspector Generalf
reporting or discovery of a use-of-force (increasing the total). However, the CSS
unit rarely updated previously published use-of-force totals with this subsequent
information. As such, the use-of-force totals reported in the Monthly Books became
“static” and inaccurate.7 In recognition of this and other issues, the Department
suspended the publication of the Monthly Books pending its internal review.

Use-of-Force Data Reported in Sheriff’s Critical Incident Forum (SCIF) Presentations:
The Sheriff’s Critical Incident Forum (SCIF) is a semi-annual meeting of department
executives and facility/unit commanders held to review statistical data and issues
pertaining to the function of the L.A. County jail system. Custody Support Services
(CSS) collects data from all Custody Services Division facilities for presentation at
the SCIF.8 None of the information contained in the Monthly Books is used in SCIF
presentations. Instead, SCIF presentations are based on use-of-force data from eLOTS, FAST and the Facility Trackers.
At the outset, department staff reported to OIG personnel that the e-LOTS and
FAST databases frequently produced different use-of-force totals and were thus
unreliable sources of information for statistical analysis. This uncertainty regarding
the e-LOTS and FAST totals has caused CSS to rely more heavily on the totals
obtained from the individual Facility Trackers for incorporation into SCIF
presentations. As such, the individual Facility Trackers have become the default
source for the use-of-force totals presented during SCIF .
This reliance on the individual Facility Trackers has created additional accuracy
problems as the Facility Trackers are not standardized, do not track the same data
points, and do not employ a consistent tracking methodology. It is also uncertain,
given the different levels of training and expertise possessed by the employees
charged with maintaining the Force Trackers at each facility, that facility Force
Tracker data is free from calculation or input error.

Use-of-Force Data Reported in OIG Quarterly Reports:
The processes used by the Department to report and then validate use-of-force
totals to the OIG also appear to be problematic. During this review, OIG personnel
requested information regarding the Department-validated use-of-force totals
published in the OIG’s Quarterly Report in April 2017 (a total of 1,833 force

7

Department personnel indicated that the Monthly Book was initially meant to provide departmental command
staff a “snap shot” of the most immediate information available at the time. It was never meant to be a definitive
statistical resource. Nevertheless, the Department released use-of-force totals from the Monthly Books for
publication without qualification or caveat.
8
See, LASD, Custody Division Manual, 4-10/000.05 Sheriff’s Critical Issues Forum (Emphasis added).

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Office of Inspector Generalf
incidents) and the totals from the “Force by Facility” report presented in the April
18, 2017 SCIF (a total of 1,849 force incidents).
After reviewing the Department’s response, OIG personnel asked if work papers
were kept memorializing the processes used to calculate the Quarterly Report totals
and the totals presented at the SCIF. OIG personnel stated that work papers would
include any printouts from data collection systems used to arrive at the published
totals and any supporting documents related to the process of calculating those
totals. Work papers would also include the documentation necessary for a reviewer
to reconstruct the totals that were published in the Quarterly Report and SCIF
presentations. Department staff reported that they do not keep work papers for
use-of-force totals and have never been instructed to keep such documentation.

Tracking Inmate Assault Data
OIG personnel reviewed the methods used to track “Inmate-on-Inmate” and
“Inmate-on-Staff” violence (collectively “Inmate Assaults”). The Department
begins tracking an Inmate Assault as soon as it is reported and a Uniform Report
Number (URN)9 is generated. Each URN is a unique number that is used to identify
the incident and is entered on all crime reports and supplemental reports and forms
concerning that incident. All information relating to the initial incident is filed under
the URN. Involved personnel forward their completed Crime Report (SH-R-49) and
related Custody Services Division Crime Analysis Supplemental Form (SH-R-49C)10
documenting the incident to Operations staff for processing.
Each morning, operations staff generates a “URN Log” from the Los Angeles
Regional Crime Information System (LARCIS)11 database which lists all report
numbers generated for incidents from the previous day. Operations staff then
9

See MPP 4-02/010.00 Uniform Report Number. A “Uniform Report Number” (URN) is a 15-digit number used to
classify and compile statistical information.
10
Manual of Policy and Procedures 4-01/020.40, Supplemental Reports, requires that line personnel complete the
Custody Services Division’s Crime Analysis Supplemental form (SH-R-49C). OIG personnel noted that certain
custody facilities were not aware of or utilizing form SH-R-49C.
11
LARCIS shows a summary of all pertinent information contained within a report including but not limited to the
following: crimes committed; involved people (suspect, victim, witness, informant, etc.); vehicles involved in an
incident; property mentioned in reports (e.g. stolen, recovered, or damaged property); crime analysis and modus
operandi information; and case management/assignment information.
Immediately following an Inmate Assault, facility line staff obtain a Uniform Report Number (URN) from LARCIS
and completes a crime report (SH-R-49) and related supplemental form (SH-R-49C). By the end of their shift or the
following shift if deferred, the deputy forwards the Crime Report to Operations for processing. The unit initiating a
first report where an URN is issued is responsible for making the necessary data entries into the LARCIS database.
Additional information from subsequent supplemental reports must also be entered in LARCIS. This information is
typically entered and updated at the unit level by supervising sergeants and administrative staff. (See MPP 401/140.00-140).

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Office of Inspector Generalf
review the URN Log to ensure that they have received completed crime reports for
every report number listed. Missing or late reports are noted by staff. Operations
staff then process the crime reports and forward them to the Custody Division’s Jail
Investigations Unit (JIU) for investigation.12
Once the JIU receives a crime report, a staff member will review the report and
enter the details of the assault into an incident tracking spreadsheet (JIU Tracker).
The JIU Tracker is the data collection system used to produce Inmate Assault data
for the Custody Division. The Inmate Assault totals presented to Department
command staff at the Sheriff’s Critical Issues Forum (SCIF) are compiled by JIU.
JIU also compiles the Inmate Assault totals for the Monthly Books as wells as any
other data requests related to Inmate Assaults.
When compiling Inmate Assault totals, the JIU only counts Inmate Assaults which
have been entered into the JIU Tracker. If the JIU does not receive a completed
crime report, then that incident will not be entered into the JIU Tracker and will not
be included in the total number of Inmate Assaults reported for that time period.
As such, missing and/or delayed reports result in an underreporting of Inmate
Assault data in both the Monthly Books and SCIF presentations.13 The flow chart
below depicts the processes utilized in documenting and reporting Inmate Assault
data. The red text indicates issues identified by the OIG with each data collection
system that may impact the accuracy in the totals extracted from these systems.

12

JIU begins the Department’s criminal investigation process that is not the subject of this review; therefore,
discussion of this investigation process is limited to only those aspects pertinent to data collection and publication.
13
Custody Support Services (CSS) reported that the Inmate Assault data used for the Monthly Books and SCIF
presentations is prepared and provided solely by JIU. CSS does not verify or modify the Inmate Assault data
provided by the JIU.OIG compared 6 months of JIU data from 2016 and traced them to the monthly reports issued
by CSS and concluded that CSS reported the JIU numbers without modification.

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The OIG has identified three significant issues affecting the accuracy of Inmate
Assault data reported in the Monthly Books and SCIF presentations: (1) custody
facilities are not submitting their crime reports in a timely manner; (2) multiple
assaults in one incident are not always tracked; (3) and previously published
Inmate Assault totals are not updated.

Facilities are not Sending Crime reports to the Jail Investigative Unit in a Timely
Manner
Generally, the Department mandates that all written reports should be completed
at the end of the handling employee’s shift unless the report is deferred. Deferred
reports should be completed within 24 hours unless otherwise approved by a watch
commander.14 However, custody facilities do not always submit crime reports to
14

LASD, Custody Division Manual, 4-01/000.00, et seq.

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Office of Inspector Generalf
the JIU within that period. The OIG noted that certain custody facilities were not
aware of or utilizing form SH-R-49C.
As depicted in the table below, the OIG reviewed six months of Inmate Assault
reports (July through December 2016) and determined there were a total of 103
assault incidents noted in the LARCIS database in which late reports were
submitted to the JIU.
Reports
Incident Month
Outstanding as of
July
9/4/2016
August
10/5/2016
September
11/4/2016
October
12/6/2016
November
1/5/2017
December
2/8/2017
TOTAL LATE REPORTS

CRDF IRC MCJ NCCF
0
0
3
5
1
1
2
4
2
0
4
3
1
0
19
5
1
0
12
4
1
0
5
3
6
1
45
24

North
7
5
0
1
0
0
13

South
1
1
0
1
0
0
3

TTCF
1
0
3
2
5
0
11

Totals
17
14
12
29
22
9
103

According to the JIU, when reports are not submitted to JIU in a timely manner,
this results in the incidents not being input into the JIU Tracker. As a result of
outstanding reports, the JIU tracker likely underreports Inmate Assault totals for
both the Monthly Books and the SCIF presentations.

Multiple Inmate Assaults in One Incident.
Another identified accuracy issue is the potential underreporting of Inmate Assault
data in the JIU Tracker when there are multiple inmate assaults in one incident. An
assault is an attempt to commit a battery against a single victim. Multiple assaults
against both inmates and staff can occur within a single incident of jail violence.
According to the JIU staff, Inmate Assault totals do not necessarily include all the
assaults in an incident of jail violence in which there were multiple assaults reported
under the same report number. For example, if a single incident involves three
“Inmate-on-Inmate” assaults and two “Inmate-on-Staff” assaults, the numbers
reflected in the JIU tracker will be one “Inmate-on-Inmate” assault and one
“Inmate-on-Staff” assault. The JIU Tracker documents the types of jail violence
that occur in each incident. It does not track the number of incidents of jail
violence or individual assaults.
The OIG recognizes that the JIU Tracker was not designed to track the number of
incidents of jail violence or individual inmate assaults. However, it is important to
recognize that one “incident” of jail violence can involve numerous individual
inmate assaults, both on other inmates and on staff, and that these two concepts
should not be conflated.

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Previously Published Inmate Assault Totals were not Updated
Once the JIU Tracker totals had been reported in the Monthly Books, they were
generally not updated to reflect additional data later input from missing or
outstanding reports. For example, OIG personnel discovered that “Inmate-onStaff” assaults for 2015 as reported in the February 2017 Monthly Book still
displayed the same total that was first published at the end of 2015 (382). OIG
personnel then verified that a subsequent SCIF presentation reflected an updated
total of 414 for 2015 “Inmate-on-Staff” assaults, a 7.7% increase. The lack of
subsequent updates to the published totals in the Monthly Books results in the
permanent underreporting of Inmate Assault data.

Inmate Assault Totals Should Vary Depending on the Date They are Generated.
Inmate Assault totals in the Monthly Books present another example of how
consistency in reported totals in all reports may actually indicate that the reported
data is stale or less accurate. Depending upon when the report is created,
inconsistent totals that change over time may indicate greater accuracy as totals
are updated. Indeed, Inmate Assault totals should change over time as the JIU
Tracker is updated. As such, totals that are generated at a later date for the same
year will usually yield different results. The table below reflects three different
reported totals for 2015 “Inmate-on-Staff” assaults. The variation is as much as 40
between two reports that were generated approximately 14 months apart.

Inmate-on-Staff Assaults for 2015
YEAR

REPORT

2015
2015
2015

February 2016 Monthly Book
SCIF
SCIF

Inmate-on-Staff Assaults

Date Issued

382
414
422

2/16/2016
10/27/2016
4/18/2017

The table below reflects variances in 2016 “Inmate-on-Inmate” assaults. The
variance is as much as 396 between the February 2017 and April 2017 reports.
Though such high variation is troubling, it suggests that the “Inmate-on-Inmate”
assault totals are being updated with new data.

Inmate-on-Inmate Assaults for 2016 as Reported in 2017
YEAR

REPORT

2016
2016
2016

February 2017 Monthly Book
Provided to LA TIMES
SCIF

Inmate-on-Inmate Totals

Date Issued

3104
3354
3500

2/1/2017
2/14/2017
4/18/2017

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Los Angeles Times Data Compared to Data Provided to the Office of Inspector
General
When the Los Angeles Times inquired about the total number of “Inmate-onInmate” assaults, the Department provided totals that differed from the totals
previously published by the OIG. OIG personnel compared the two sets of totals
and found significant differences in the totals for each year from 2007 through 2013
and for 2016.
2007

2008

2009

2010

2011

2012

2013

2014

2015

2016

Totals

Provided
to LA
Times

2,496

2,393

2,235

2,124

1,880

2,621

3,076

2,849

3,104

3,354

26,132

Provided
to OIG

1,804

1,494

1,370

1,395

1,302

1,682

2,746

2,849

3,104

3,716

21,462

Difference

692

899

865

729

578

939

330

-

-

(362)

4,670

Percent
Difference

27.7%

37.6%

38.7%

34.3%

30.7%

35.8%

10.7%

0.0%

0.0%

10.8%

17.9%

Discrepancies between the 2007 through 2013 Totals
The Department’s explanation for the different 2007 through 2013 totals is that the
totals were generated by the FAST database. At the time, the Department did not
realize that the FAST database limited the number of assaults that could be
transferred from its Paradox software into the Excel spreadsheet that was used to
tabulate the results. Consequently, the Department acknowledged, the numbers
provided to the OIG for 2007 through 2013 underreported the totals due to this
software issue. This problem was identified by department staff and a “work
around” was used to produce the totals for the Los Angeles Times, which may be
more accurate – or at least not definitively incorrect. The OIG was not provided
work papers and therefore this error cannot be replicated.

Discrepancies Between the 2016 Totals
The JIU staff reported that the 2016 total reported to the OIG was incorrect and
was issued in error. The JIU staff explained and provided work papers which
showed that the numbers provided to the OIG reflected assaults that occurred in
non-jail units such as Transportation and Court Services while inmates were enroute to or present in courts for their case appearances. As such, the JIU reported

Page 14

Office of Inspector Generalf
the number provided to the OIG over-stated the number of “Inmate-on-Inmate”
assaults.
OIG personnel reviewed the work papers and verified the Department’s explanation
accounted for the differences in the 2016 totals. However, to exclude inmate-oninmate assaults because those assaults do not occur within the jails is
misrepresentative of the true number of in-custody inmate-on-inmate assaults.

CONCLUSION
There is no single unit in the Department that is responsible for reconciling,
verifying and validating the accuracy of jail violence statistics. The Department has
acknowledged that this absence of centralized accountability allowed for inaccurate
data to be generated and, if continued, would impede the Department’s ability to
correct the problem.
The Department maintains that it has not intentionally misled stakeholders in
releasing inaccurate data, and the OIG review did not reveal information to suggest
otherwise. However, on May 24, 2017, after the inaccuracies were discovered,
department executives and the Custody Compliance and Sustainability Bureau
again presented jail violence data at a Public Safety Cluster Agenda Review Meeting
(CAR). This data was generated in the same manner, using the same databases
and may reasonably be expected to contain similar errors.
The Department’s system of tracking jail violence is comprised of a confusing
collection of databases and processes. Each database is stand alone and there is
no uniform procedure for reconciliation to ensure that subsequent additions,
deletions or amendments are input to each database and are tracked consistently.
Because these data are used by the Department to identify systemic deficiencies
that impact safety and jail operations, report information to the OIG and other
stakeholders, and for strategic planning purposes, it must be accurate if they are
expected to be useful.

RECOMMENDATIONS
1.

A single unit should be responsible for compiling, reconciling, verifying, and
validating the accuracy of all jail violence data. Any future statistical
methods and data reconciliation should adhere to generally accepted record
keeping standards. The responsible unit should keep organized work papers
for later evaluation and replication of its work, and data generated by this
unit should be periodically audited and/or overseen by the AAB.

2.

The Department should not release any data unless it is sure of its accuracy
within a certain and identified margin of error. Any margins of error,

Page 15

Office of Inspector Generalf
qualifying variables, or potential discrepancies must be clearly identified and
reported with the data.
3.

The Custody Services Division should ensure that any future Monthly Books
or reports that contain data include the most current data available. Monthly
Books or other reports which include data previously reported should be
updated with the most current data.

4.

The Department should identify which data collection system it will utilize for
tracking and reporting each data set, and the single and centralized unit
discussed in recommendation 1 above should be responsible for immediately
reconciling and updating each dataset across all data collection systems.

5.

The Department should create a standardized Facility Tracker template for
use by all custody facilities to ensure consistency. This template could be
modified to include the particular data requirements of each unit, but a
baseline set of tracked data elements should be standardized across all
facilities for ease and accuracy of compilation and analysis.

6.

The Department should create a standardized Force Alert form for use by all
custody facilities to ensure consistency. Although Force Alerts work well in
notifying management when incidents happen, their inconsistent formats and
inconsistent data points make their use as a statistical tool problematic.
Standardized Force Alert forms should reduce error in the reporting and
tracking of use-of-force incidents and create a more useful data set for future
analysis.

7.

Clear data collection and entry guidelines should be established and manuals
and training provided to ensure that data is entered into all databases in a
consistent manner at all custody facilities.

8.

Custody facilities should conduct monthly reconciliations between incident
alerts, databases (e-LOTS and FAST) and trackers to ensure consistency of
the total number of force incidents. These reconciliations should then be
verified for accuracy by the single and centralized unit discussed in
recommendation 1 above.

9.

All positions tasked with compiling statistical data should be staffed with
qualified civilian personnel with an appropriate level of education, training
and expertise in data collection/reporting and database management. All
personnel should be trained in a single and consistent data entry method by
qualified personnel.

10.

The Department should re-evaluate the methodology used for compiling
Inmate Assault data and develop a more accurate reporting mechanism for
incidents which include multiple assaults against inmates and/or staff within
a single incident of jail violence.

Page 16

Office of Inspector Generalf
11.

The Department should implement an Inmate Assault Alert system similar to
the one used for Force Alerts to quickly inform the Jail Investigations Unit of
inmate-on-inmate or inmate-on-staff incidents. Inmate Assault Alert details
could then be reconciled with LARCIS to ensure that every assault is tracked.

12.

Manual of Policy and Procedures 4-01/020.40, Supplemental Reports,
requires that line personnel complete the Custody Services Division’s Crime
Analysis Supplemental form (SH-R-49C). Custody should ensure the
appropriate data is memorialized and the correct forms are utilized by line
staff. In addition, the Department should enforce the time deadline for the
submission of crime reports and related crime analysis supplemental forms to
the Jail Investigations Unit.

13.

The Department should consider discontinuing its use of the FAST database
altogether.

The OIG will continue to monitor this issue and any corrective action taken.

Page 17

(71
-

iCE CFJ-HE Sfl[EREFE

1054

COUNTY OF LOS ANGELES
C4LIroR4L

JD’i

MCDONXELL, ShERIFF

August 22, 2017

Max Huntsman, Inspector General
Los Angeles County Office of Inspector General
312 South Hill Street, 3rd Floor
Los Angeles, California 90013
Dear Mr. Huntsman:

RESPONSE TO THE LOS ANGELES CO!Th[TY OFFICE OF INSPECTOR
GENRLAL REPORT ON A REVIEW OF THE JAIL VIOLENCE,
TELA.CKING, ATD REPORTING PROCEDURES OF THE
LOS ANGELES COTXNTY SHERIFF’S DEPARTIvtENT
Attached is the Los Angeles County Sheriff’s Department’s (Department)
response to the Los Angeles County Office of Inspector General’s (OIG) final
report entitled, “A Review of the Jail Violence Tracking and Reporting
Procedures of the Los Angeles County Sheriff’s Department.”
As I believe you are aware, this past spring, prior to the release of the aboveentitled report, I directed our internal Audit and Accountabifity Bureau
(AAB) to conduct a Department-wide examination of our Information and
Technology (IT) Systems. The examination was conducted in accordance
with Generally Accepted Government Auditing Standards. The results of the
examination were presented to me on July 11, 201%, and identified
deficiencies in internal controls governing the collection, storage, and
dissemination of data. In addition, AAE identified the use of antiquated and
obsolete IT systems which need to be reconciled with other IT systems to
obtain accurate information.
The examination also identified root causes related to data inconsistencies as
a Department-wide issue rather than a singular issue isolated to Custody
Operations. AAE recommended that deficiencies with the IT systems be
addressed and solved as a Department-wide effort. Consequently, the
Technology and Support Division, as the governing body for the Department’s
211 WEST TENPLE

Siiii, Los ANGELES,

CMIFo1uA 90012

Aadin o/ Peice
—

nce 1850

—‘

Mr. Huntsman

-2-

August 22, 2017

IT systems, will be included as part of any corrective action, as well as
Custody Operations.
We thank you and your staff for your efforts in reviewing the Jail Violence
and Reporting Procedures in Custody Operations and your specific
recommendations are addressed in the attached document. As you may note,
the reforms identified by our internal examination are generally in line with
recommendations in your report. We are confident that the implementation
of such reforms will bring progress toward our goal of a comprehensive data
solution. In the meantime, as we carry on our day-to-day work amongst the
challenges of legacy systems, we respectfu]ly disagree with any assertion that
there exists a lack of control, a manipulation of data, or any intent to mislead
or provide false fliformation to the public. The examination we conducted, as
well as all of the underlying documentation, recommendations, and
processes, is available for your review should you wish to see it.
The Audit and Accountability Bureau has the responsibifity to monitor and
document the Department’s response related to this review.
Should you have any questions regarding the Department’s response, please
contact Captain Steven E. Gross at (323) 307-8302.
Sincerel

I
JI McDONNELL
SHERIFF

RESPONSE TO THE LOS ANGELES COUNTY OFFICE OF INSPECTOR GENERAL
REPORT
COUNTY OF LOS ANGELES

—

SHERtFF

SUBJECT: A REVIEW OF THE JAIL VIOLENCE TRACKING AND REPORTING
PROCEDURES OF THE LOS ANGELES COUNTY SHERIFF’S DEPARTMENT
Response of Recommendations by the OIG
1. A single unit should be responsible for compiling, reconciling, verifying, and validating
the accuracy of all jail violence data. Any future statistical methods and data
reconciliation should adhere to generally accepted record keeping standards. The
responsible unit should keep organized work papers for later evaluation and replication
of its work, and data generated by this unit should be periodically audited and/or
overseen by the AAB.

Response: Concur.
A standardized methodology for data collection and verification reduces the likelihood of
inconsistent data. A centralized unit adhering to a standardized data governance
process increases accuracy and ensures accountability. The AAB is an independent
audit organization and has authority to audit, but no authority to oversee another unit as
indicated in the recommendation.
The OIG’s report references the Generally Accepted Recordkeeping Principles (the
Principles) established the Association of Records Managers and Administrators
(ARMA). The Principles create a high-level framework of good practice which would
include the maintenance of all work papers related to these processes for accountability
and validation purposes. The Department will identify the appropriate positions as
stated in recommendation 9, and identify if a funding request is warranted. However, in
the meantime, training will be sought to educate the current Custody staff responsible
for these tasks.
2. The Department should not release any data unless it is sure of its accuracy within a
certain and identified margin of error. Any margins of error, qualifying variables, or
potential discrepancies must be clearly identified and reported with the data.
Response: Concur.
The data should be cited and sourced to indicate the origin of the data, as well as the
time period, the unit responsible for releasing the data, and any variables or disclaimers
known in advance. If data is preliminary, the release of that data should be contingent
on whether the need for the data outweighs the delay for its validation.

1

3. The Custody Services Division (CSD) should ensure that any future Monthly Books or
reports that contain data include the most current data available. Monthly Books or
other reports which include data previously reported should be updated with the most
current data.
Response: Concur.
Adhering to a standardized data governance process increases accuracy and ensures
accountability. The Custody Services Division (CSD) have discontinued the Monthly
Books, but will ensure that any future reports that contain data include the most current
data available and that reports which include data previously reported are updated with
the most current data.
4. The Department should identify which data collection system it will utilize for tracking
and reporting each data set, and the single and centralized unit discussed in
Recommendation No. I should be responsible for immediately reconciling and updating
each dataset across all data collection systems.
Response: Concur.
A standardized methodology for data collection and verification reduces the likelihood of
inconsistent data.
5. The Department should create a standardized Facility Tracker template for use by all
custody facilities to ensure consistency. This template could be modified to include the
particular data requirement of each unit, but a baseline set of tracked data elements
should be standardized across all facilities for ease and accuracy of compilation and
analysis.
Response: Concur in part.
Facility Trackers should only be employed as a subset of a centralized database.
Relying on these independent trackers as the source of data undermines the
Department’s goal of consistency, transparency, and accountability. Independent
trackers do not employ the same security as Department databases which require a
login by specified personnel.
6. The Department should create a standardized Force Alert form for use by all custody
facilities to ensure consistency. Although Force Alerts work well in notifying
management when incidents happen, their inconsistent formats and inconsistent data
points make their use as a statistical tool problematic. Standardized Force Alert forms
should reduce error in the reporting and tracking of use-of-force incidents and create a
more useful dataset for future analysis.

2

Response: Concur in part.
Force Alerts are internal notifications to management that a force incident occurred, and
as such, should only be used for that purpose. Force Alerts should not be used for
statistical data tracking. Utilizing Force Alerts for data tracking further exacerbates the
issue of having multiple points of data entry, requiring a greater need for reconciling
data.
7. Clear data collection and entry guidelines should be established and manuals and
training provided to ensure that data is entered into all databases in a consistent
manner at all custody facilities.
Response: Concur.
This issue is prudent for the Department as a whole to increase accuracy and ensures
accountability.
8. Custody facilities should conduct monthly reconciliations between incident alerts,
databases (e-LOTS and FAST), and trackers to ensure consistency of the total number
of force incidents. These reconciliations should then be verified for accuracy by the
single and centralized unit discussed in Recommendation No. 1 above.
Response: Concur in part.
Incident alerts should not be used for statistical tracking. The Department plans to
sunset FAST as it is an antiquated IT system which has been shown to be historically
unreliable. The database e-LOTS was created for Custody with the intent of providing
management with the progress of a force investigation. The goal is to reconcile FAST
and e-LOTS into one system called CARTS, a project already underway.
9. All positions tasked with compiling statistical data should be staffed with qualified civilian
personnel with an appropriate level of education, training, and expertise in data
collection/reporting and database management. All personnel should be trained in a
single and consistent data entry method by qualified personnel.
Response: Concur.
In 2015, the Department created the Chief Data Officer position in order to make sure
that information is accessible, properly managed, secured and disseminated in a
consistent manner. Custody concurs that each custody facility should have a
professional staff position with the responsibility of maintaining and tracking data. The
position should be part of the Chief Data Office for data dissemination, which is then
responsible for any public data sharing responsibilities.

3

10.The Department should re-evaluate the methodology used for compiling Inmate Assault
data and develop a mote accurate reporting mechanism for incidents which include
multiple assaults against inmates and/or staff within a single incident of jail violence.
Response: Concur.
The current method of relying on the Jail Investigations Unit (JIU) to track assault
incidents is ineffective. The Custody Division is currently implementing protocols so that
jail violence is tracked by incident as well as by victims, as often there are more victims
involved in a single incident. LARCIS currently provides reports with these totals and
will be utilized as the sole source. Additionally, the Department will evaluate whether
force incidents should be tracked by individual incidents, or by victim as is currently the
standard used in Patrol Operations. That standard is defined by the Criminal Justice
Information Services (CJIS) Division Uniform Crime Reporting (UCR) Program.
II. The Department should implement an Inmate Assault Alert system similar to the one
used for Force Alerts to quickly inform the Jail Investigations Unit of inmate-on-inmate,
or inmate-on-staff incidents. Inmate Assault Alert details could then be reconciled with
LARCIS to ensure that every assault is tracked.
Response: Concur in part.
Alerting management and investigators of an assault incident is a necessity. This is not
unique to Custody Operations. Patrol Operations documents these incidents in the shift
Watch Commander Logs where any type of notifications can be delivered through the
Station/Bureau Administration Portal to concerned parties. Currently, the policies within
the Custody Division Manual requires watch commanders to initiate an “Incident Alert,”
for all significant issues including serious assaults, riots, significant injuries, and/or
assaults against staff. The County jails average about 300 to 400 assaults on a monthly
basis. Initiating an additional “Incident Alert” specifically for all assaults will result in an
additional tracking mechanism, which would require staff to manually track these
incidents. The results of another “tracker” could easily cause unreliable statistics. The
Department currently utilizes LARCIS and will discontinue the use of the Jail
Investigation Unit tracker as a tool to cross reference completed assault reports.
The Department concurs that utilizing a single source to track all crimes is more
efficient.
12. Manual of Policy and Procedures, Section 4-01/020.40; Supplemental Reports, requires
that line personnel complete the Custody Services Division’s Crime Analysis
Supplemental form (SH-R-49C). Custody should ensure the appropriate data is
memorialized and the correct forms are utilized by line staff In addition, the
Department should enforce the time deadline for the submission of crime reports and
related crime analysis supplemental forms to the Jail Investigations Unit.

4

Response: Concur.
The JIU acts as the detective bureau for Custody. Similar processes with the submission,
approval, and tracking of crime reports as used in Patrol Operations should be applied to
Custody for overall consistency throughout the Department.
13.The Department should consider discontinuing its use of the FAST database altogether.
Response: Concur.
As mentioned above, the Department plans to sunset FAST as it is an antiquated IT
system. Any future IT system changes should be done in collaboration with the
governance policies created and set forth by the Technology and Support Division.

5

 

 

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