New York State Commission of Correction Final Report in the Matter of the Death of Bradley Ballard, 2014
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NEW YORK STATE COMMISSION OF CORRECTION In the Matter of the Death of Bradley Ballard, an inmate of the Anna M. Kross Center TO: Commissioner Joseph Ponte NYC Department of Correction 75-20 Astoria Blvd, Ste. 100 East Elmhurst, NY 11370 FINAL REPORT OF THE NEW YORK STATE COMMISSION OF CORRECTION FINAL REPORT OF BRADLEY BALLARD PAGE 2 GREETINGS: WHEREAS, the Medical Review Board has reported to the NYS Commission of Correction pursuant to Correction Law, section 47 (1) (d) , regarding the death of Bradley Ballard who died on September 11, 2013, while an inmate in the custody of the NYC Department of Correction at the Anna M. Kross Center, the Commission has determined that the following final report be issued. SUMMATION FINDINGS: . 1. 2. . Bradley Ballard was a 39-year-old African-American male who died on 9/11/13, at 1:31 a.m . . while in the custody of the New York City Department of Correction (NYC DOC) at the Anna M. Kross Center (AMKC). Ballard was discovered in the evening on 9/10/13, to be lying in his cell naked, unresponsive, covered with urine and feces, and in critical condition. Ballard was a known mental health patient with a diagnosis of schizophrenia and suffered from diabetes mellitus which required periodic insulin coverage. Ballard went into cardiac arrest shortly after being removed from his cell and was pronounced dead at Elmhurst Hospital. Ballard died from diabetic ketoacidosis (OKA) (serum glucose 1,200mg%)due to withholding of his diabetes medications complicated by sepsis due to severe tissue necrosis of his genitals as a result of a self-mutilation. Between 8/7/13, and 9/5/13, Ballard should have been encountered for finger sticks 58 times but was actually seen on only ten (10) occasions. The medical and mental health care provided to Ballard by NYC DOC's contracted medical provider, Corizon Inc. during Ballard's course of incarceration, was so incompetent and inadequate as to shock the conscience as was his care, custody and safekeeping by NYC DOC uniformed staff, lapses that violated NYS Correction Law and were directly implicated in his death . Had Ba l lard received adequate and appropriate medical and mental heal th care and supervision and intervention when he became critically ill , his death would have been prevented. The events that lead to Ballard's death were directly caused by the compounded fai lures of NYC DOC and its contracted medical provider, Corizon Inc., to maintain care, custody, and safekeeping of this inmate in accordance with New York State Correction Law, NYS Minimum Standards a nd Regulations for Management of County Jails and Penitentiaries, and Ballard's civil rights . Bradley Ballard was keeplocked in his cell :f;or six days prior to his death and was denied access to his life-supporting prescribed medications, denied access to medical and psychiatric care, denied access to essential mandated services such as showers and exercise periods, and denied running water for his cell . Ballard ' s deteriorating heal th and . mental status was observed over the course of this six day period by many NYC DOC officers , supervisors, and administrators, together with clinicians employed by Corizon Inc., who showed deliberate indifference to Ballard's serious medical needs by collectively FINAL REPORT OF BRADLEY BALLARD PAGE 3 failing to provide the very basics of medical care and failing to take appropriate action in a timely manner to a medical emergency which resulted in Ballard's death. The assertion by the NYC Department of Heal th and Mental Hygiene in its response to the Medical Review Board's Preliminary Report to the effect that Ballard likely died from lactic acidosis secondary to genital stricture is wrong. Lactic acidosis is commonly associated with OKA, and in this case, the deceased ' s blood sugar level was so extreme as to have unquestionably resulted from OKA, Ballard's genital stricture having been isolated from his circulation and as such not contributory to his lactic acidosis . The Medical Review Board concurs the New York City Medical Examiner's ruling that Bradley Ballard's manner of death is a homicide. FINDINGS RE : BRADLEY BALLARD'S COURSE OF INCARCERATION : 1. Bradley Ballard was born in Houston, TX. His father is deceased and his mother reportedly still resides in Houston. Ballard was the youngest of three boys . Ballard reported having an abusive childhood from his . biological father and stepfather. Ballard had no spouse and no children . BalJard had a GED from 1990 but no steady work history. Ballard reported alcohol and cocaine use, the most recent use in March, 2013. 2. Ballard' s criminal history began in 1992 at age 18 while living in Texas with an arrest for larceny. In 1994, he received a felony conviction for arson and was sentenced to 6 years in prison. Ballard also had prior arrests for possession of a controlled substance , evading arrest, and indecent exposure. Ballard's criminal history in New York State began on 12/10/04 when he was arrested fpr · Assault nd 2 after he grabbed a female in an office building and attempted to sexually assault her. Ballard then assaulted another male employee who attempted to come to the woman ' s aid. While in the custody of -NYC DOC, on 12/11/04, Ballard was charged with another count of nd Assault 2 after hitting a correction officer. Ballard was sentenced to seven years in NYS DOCCS. Ballard was released to parole on . 12/5/10 with a maximum expiration date of 12/15/13. Ballard violated his parole by moving back to Texas without permission and had an absconder warrant lodged against him. Ballard was arrested in Texas and extradited to New York and directly admitted to NYC DOC on 6/13/13. 3. Ballard had a medical history significant for diabetes mel l itus type II. He was prescribed Metformin HCL 500 mg bid and sliding sca l e insulin coverage daily . 4. Ballard's mental health history began at age 13 when he was referred to a psychiatrist by his school due to behavioral problems. Ballard was begun on psychotropic medication . Ballard had multiple different diagnoses over the years including bipo~ar disorder , schizoaffective disorder, and schizophrenia. Ballard reported prior suicide attempts FINAL REPORT OF BRADLEY BALLARD PAGE 4 in 1999 by cutting his wrists and by attempting to overdose on antipsychotics. Ballard had multiple inpatient hospitalizations both civil and forensic. His first hospitalization occurred while he was incarcerated in Texas at 22 years old . He was hospitalized for approximately two years. Ballard had prior hospitalizations at Bellevue Hospital 19 North, Kirby Forensic Psychiatric Center and at Kingsborough Psychiatric Center. He was most recently discharged from Kingsborough PC in January 2013. During his course of treatment, he has been prescribed various psychotropic medications including Mellaril, Thorazine, Valproic Acid, and Risperidone with only sporadic compliance when in the community . Ballard was seriously and persistently mentally ill when incarcerated in NYC DOC in June, 2013. · 5. Bradley Ballard was extradited from Harris County, Texas by NYS DOCCS - Division of Parole and directly admitted to Otis Bantum Correctional Center on 6/13/13. Ballard was housed in 3-West as a new admission/general population. 6. Ballard was seen for an intake medical assessment on 6/14/13 by Corizon, Inc . , Dr. J.J. Ballard gave his history of diabetes. He was ordered lab work (chem 20 , hemoglobin AlC, CBC) with follow up labs to be done on 9/20/13. Ballard was prescribed Metformin HCL 500 mg bid, Aspirin 81 mg qd, insulin - regular human sliding scale . Ballard was referred to be seen by mental health staff. 7. Ballard was seen for an initial mental health intake exam on 6/17/13 by Corizon, Inc. Ballard refused services stating "I don't believe in mental health and I don't want it". Ballard signed a refusal form. Ballard was provided information on how to obtain services if needed . 8. On 6/18/13, Ballard was transferred to George R. Vierno Center (GRVC). Ballard's medical chart was reviewed and current medication orders and insulin orders were continued. 9. On 6/19/13, Ballard was seen by mental health staff at GRVC for an intake assessment . Ballard stated he had no mental health issues and wanted to sign a refusal but did speak with the clinician. Ballard's prior history of suicide attempts was reviewed. Ballard reported that he had made attempts while he was under the influence of substances (cocaine, alcohol). Ballard stated that he did not have any suicide attempts in the last 13 years and had no current suicidal ideation . Ballard stated that he had better ways of dealing with his stress and would not try to kill himself again. 10. Ballard was scheduled to be seen twice daily for his finger sticks and blood glucose readings. He was only partially compliant with his insulin orders. Ballard is documented as "Refusing" his finger stick on 6/19, 6/20, 6/22, 6/23 , 6/25, 6/27 a.m . , 6/30 a.m., 6/30/13 p.m . Ballard is documented as "Not produced by DOC" on 6/18, 6/27 p .m., 7/1 a.m . , and 7/1/13 p.m . No member of the clinical or security FINAL REPORT OF BRADLEY BALLARD PAGE 5 sta ff encountered Ballard with this history of refusals and failures to produ c e him at clinic to determining the reasons therefor or to counsel him accordingly . This represents substandard medical and mental health treatment. 11. Ballard was involved with a use of force by DOC officers in the evening on 6/30/13 . Ballard had begun to display radical changes in his behavior and became assaultive . At 7:00 a.m., on 7/1/13, Ballard was seen in the medical clini·c for an injury assessment. Ballard denied any physical pain or discomfort but also refused to be physically examined.by medical staff. Ballard stated he was upset with the way he was being treated by DOC and that if he continued to stay at GRVC he may hurt someone or himself. Ballard now reported that he had multiple prior mental health hospitalizations and that he was not on psychotropic medications because he was refusing them. Corizon, Inc. Dr . N.U . referred Ballard to AMKC C-71 mental health unit for evaluation. 12. Ballard was seen at C-71 by R-PAC 0 . 0. Ballard was found. to be acutely paranoid and delusional . He was uncooperative with the assessment and refused stat medications. Ballard was referred to and admitted to Bellevue Hospital psychiatric unit on 19 North . 13 . Bal lard was highly agitated and paranoid upon arrival to Bellevue 19 North. Ballard was assaultive with DOC staff and reported he was "on a w~rpath with corruption at Riker's Island" . At his assessment, Ballard presented as grandiose, paranoid, and had persecutory delusions. Ballard stated he was "the Second Christ" and had known this since he was 17 years old. He claimed he was in the National Guard and was the highest officer tit led "Supply Commander Omega Supreme". Ballard was diagnosed with paranoid type schizophrenia and begun on medications. Ballard initially refused medications and became highly agitated with treatment team members, necessitating a crisis intervention and IM medication. An order for treatment over objection was filed by the attending psychiatrist and Ballard was started on Risperdal and titrated up to 2 mg tid . Ballard continued on the medication while the treatment over objection case proceeded . Ballard's aggression and paranoia improved; however , he s t ill had delusions of grandeur. The court refused to grant the treatment over objection order . 14 . Ballard was hospitalized until August 7, 2013 . Ballard was a participant in most of the therapy groups but stated he would not eat or drink if returned to Riker ' s Island because he did not want to be there. Eventually Ballard said he would be alright returning to Riker's as he did not like some of the other patients on the unit . Ballard was discharged back to GRVC on Risperdal 3 mg bid. 15 . Upon his return to GRVC, Ballard was seen for a psychiatric evaluation NP A.A. Ballard' s discharge summary from Bel l evue was reviewed. Ballard still continued to endorse grandiose delusions saying he had "a million children". Ballard was diagnosed with FINAL REPORT OF BRADLEY BALLARD PAGE 6 paranoid schizophrenia and continued on his medications. 16. Ballard was seen by medical on 8/7/13, for a re - assessment after being returned from the hospital . Ballard' s medications, insulin, Metformin, bi-daily finger sticks, and blood glucose checks were started again . Ballard was also ordered to have a fasting glucose test on 8/12/13 . From 8/7/13 to 9/5/13, Ballard, per the 8/7/13 order, should have had 58 occasions of blood glucose readings with sliding scale insulin administered . According to documentation provided by Corizon Inc., Ballard is documented as being seen only 10 times . On 11 dates there was no entry in Ballard ' s record at all regarding any blood glucose check. Thirteen times there was no AM entry in the record . Three times there was no PM entry in the record . Bal l ard is documented as " Not Produced by DOC" five times. Ballard is documented as " Refusing " three times. Ballard is documented as " no show " two times. There was no explanation for the times Ballard was not produced with exception of 9/3/13 , a . m. due to "acti ve alar ms in the building . " There are no signed refusal forms on fi l e for the occasions Ballard reported to refuse. No attempt was made to encounter Ballard with regard to the reason for these failures to produce, and there was no inquiry in regard to the failure to produce him by senior Corizon, Inc. or DOC personnel. This represents substandard medical and mental health trea t ment. 17. Ballard was seen in the GRVC mental health clinic by RN D.H . for medication delivery on 8/8/13 . Ballard was refusing medicati on stating "I am not taking medication , I don ' t need any medication . I went to the hospital for something else and they started me on Risperdal . I took it in the hospital but I am not taking it anymore . " RN D.H . consulted with Dr . C. who recommended that Ballard be referred for an evaluation. 18. Ballard was transferred to Anna M . Kross Center's (AMKC) mental health unit for an assessment on 8/8/13. Ballard was seen b y Dr. F . R . Ballard stated "I came back from Bellevui yesterday; I said I was going to take medications , but I changed my mind. I don ' t want to take any antipsychotic medications; they are giving me Risperdal and it does not help my sleep. The only medi cations I would take are medications to he l p me sleep." Dr . F.R. also reported to the Commission during the investigation that Ballard had claimed he had "fooled the staff" at Bellevue Hospital by saying he was taking the Risperdal when he in fact not. Ballard denied any su"icidal or homicidal ideations. He denied having any auditory or visual hallucinations but still had grandiose delusions. Ballard was refusing all antipsychotics but did agree to be started on Seroquel 100 mg hs as he had taken it in the community and believed it would help him sleep. He was approved to be placed in mental observation housing. 19 . On 8/9/13, Ballard's chart was reviewed by Dr . D . R . who stated that Seroquel was not approved for Ballard as no request was submitted. FINAL REPORT OF BRADLEY BALLARD PAGE 7 Seroquel is a non- formulary medication at NYC DOC. Corizon, Inc. Dr . D.R. ordered Ballard to be continued on Risperdal 3 mg bid for 7 days . 20. On 8/12/13, Ballard' ~ insulin was reordered for directly observed therapy by CRIC (Chronic Renal Insufficiency Coverage) standard coverage for 14 days . The fasting glucose test that was ordered on 8/7/13 was not completed as there were no lab results listed on the copy of Ballard's lab requisition form . 21. On 8/12/13, Ballard was re-housed in AMKC' s Mod 11 A side-mental health observation dormitory . 22. On 8/14/13, Ballard was seen by LCSW L.U. for a psycho-social evaluation and comprehensive treatment plan . Ballard reported his mental health history and that he had been coming to Riker's Island since 2004 . He denied any symptoms and was compliant with his medication but still showed some grandiose ideation by claiming to have over a million adopted children, that he was serving in the National Guard, and had received an honorary doctorate from NYU. Ballard's identified treatment goals were to manage his psychotic symptoms by complying with medications and psychotherapy . Ballard's treatment plan included mental observation housing, weekly visits with a mental health clinician, weekly group therapy sessions, and bi-weekly visits with psychiatry. Ballard's treatment plan was signed off by Dr . D.R. on 8/20/13 . 23 . Ballard was scheduled to be seen in medical for a diabetes care clinic on 8/14/13. Ballard was not seen and was rescheduled. There was no accompanying information in the chart as to why Ballard was not seen . 24 . Ballard was seen on 8/15/13 by NP R.A. for a psychiatric medication follow-up. Ballard stated he was doing better and that the medications were working. He denied side effects, hallucinations, or suicidal ideations. NP R.A. continued Ballard's diagnosis as paranoid type schizophrenia. NP R.A. ordered Ballard to start Seroquel 100 mg hs, a sub-therapeutic level for psychosis , for 14 days (stop date of 8/29/13). There was no notation in the record as to why Ballard's medication, Risperdal 3 mg bid, which he reported to be effective, was switched to a sub-therapeutic level of Seroquel which had been previously disapproved by Dr. D. R. on 8/9/13 . Additionally, there were no corresponding orders for re-evaluation or titration after the initial 14 days of therapy . NP R.A. stated to Commission staff during the investigation that he had ordered Ballard's medication based on Dr. F . R.' s note from 8/8/13 and did not notice Dr . D.R .'s note from 8/9/13 denying it. NP R.A. also stated he did not notice that the current medication order for Ballard was Risperdal 3 mg bid. The lack of a documented clinical rationale for changing a psychotropic medication for patient with reported efficacy of the current medication regimen supported by a FINAL REPORT OF BRADLEY BALLARD PAGE 8 physician's order and the failure to thoroughly read a patient's medical chart and history constitutes incompetent psychiatric care. 25 . Ballard was scheduled to be seen in medical for his diabetes clinic on 8/20/13 . It was documented that Ballard refused to come to the clinic . A signed refusal form was not in Ballard' s medical file for that date, nor was he encountered or counseled accordingly . 26. On 8/21/ 13, Ballard was seen for a mental health follow up by LMSW L.V. Ballard reported that he was alright and had been compliant with his medications. Ballard _ had been observed in the dayroom watching TV with his peers when called to see the clinician . Ballard reported having to be at court (parole hearing) on 8/22/13 and was hoping to be placed in a program . Ballard stated he felt angry because he was unlawfully arrested and being kept against his will . Ballard stated he was tired of talking to doctors who "ask 1 , 000 questions that are all the same" . Ballard stated "talking does nothing, I want action" and then added the action he wants is "I want sex, I want money, I want alcohol , I want drugs". LMSW L.V . found Ballard to have a labile irritable mood. He was not endorsing any hallucinations. Although no acute psychiatric distress was noted at that time, LMSW L.V. reported to Commission staff that Ballard still had symptoms of paranoia and grandiose thoughts. LMSW L.V. stated to Commission staff that she referred Ballard to be seen by the psychiatrist; however , no referral was documented in the chart . Ballard was to continue on mental observation housing and follow-up in one week . 27. On 8/22/13, Ballard was scheduled for a d i abetes clinic call out . According to the record, Ballard was not seen by the provider and was rescheduled . There is no information as to why Ballard was not seen nor was he encountered or counseled accordingly. 28. On 8/26/13, Ballard was seen in the medical clinic by Dr. L.A. for complaints of dry skin and asking for dry skin lotion. Ballard had an unremarkable examination and was prescribed Derma Vantage lotion bid for 14 days. However, it is noted in the chart under current medications that Ballard's regular sliding scale insulin order had a stop date of 8/26/13. Ballard had not been seen in the diabetes management clinic on 8/14, 8/20, and 8/22/13 . No information was contained in the chart to the effect of the physician reviewing or renewing Ballard's insulin order or inquiring as to why Ballard had not been seen on the previous dates. The lack of follow up for a known chronic condition such as diabetes, after Ballard had three missed appointments and was present in the clinic for a benign complaint (dry skin) , constitutes uncoordinated and incompetent medical care . 29 . On 8/28/13, Ballard was involved in a f i ght whereby Ballard was reported to have thrown hot water on two other inmates. Ballard was FINAL RE PORT OF BRADLEY BALLARD PAGE 9 seen in the medical clinic by RPA J.R. f o r an exam fol l owing t he fight who reported no injuries and had an unremarkable exam . 30. Later , on 8/28/13 , Ballard was seen by LMSW L .V. for a treatment plan review and clinical follow up. Ballard . was seen cell side due to being keepldcked for the earlier fight incident. Ballard stated he was alright but did not want to discuss the fight incident. Ballard became agitated, demanding to be let out of his cell and stated his wife works in the building and LMSW L.V. should tell her he wants to go home. LMSW L . V . found Ballard to present with a labile, ·angry, and irritable mood. Although Ballard was not endorsing any auditory or visual hallucinations, U1$W L . V. did find Ballard to be in some psychiatric distress. LMSW L.V. stated to Commission s taff that she referred Ballard to be seen by the psychiatrist; however, no referral was documented in the chart. Ballard was maintained in mental observation housing. There was no explanation of this lapse. 31. A blank progress note, unsi gned , for diabetes follow up was found in Ballard's chart dated 8/29/13. There is no information as to who Ballard was to be seen by or why he wasn ' t produced. · 32. On 8/29/13, Ballard was seen by R-PAC F.S. on a referral. Corizon, Inc. Mental Health had received a letter from the Legal Aid Society expressing concerns over Ballard's mental health. The author of the letter stated that when Ballard was at his court appearance he was showing signs and symptoms of paranoid and persecutory delusions and may need to be re-hospitalized . It was reported that Ballard was delusional, stating that the National Guard owed him large amounts of money, and paranoid stating homosexuals were trying to get close to him, gang members were after him, and that his paperwork was being tampered with. The judge in Ballard's case was apparently open to an alternative to incarceration such as a supportive housing program but Ballard did not appear to be sufficiently psychiatrically stable to be accepted. R-PAC F . S . found Ballard in the day room playing chess with another inmate. Ball ard stated he did not need to speak to mental health and that everything was ok. Ballard appeared to be adequately managing his activities of daily living but was easi ly irritated a nd had some paranoid behaviors . RPAC F . S . reported to Commission staff that Ballard was not readily engaging in conversation and a comprehensive evaluation was unable to be completed. R-PAC F. S. denied receiving any other referral information on Ballard other than the note from Legal Aid . R-PAC F . S. made a referral to have Ballard seen at the Hart's Island clinic in the morning on 8/30/13. There is no documentation of Ballard being seen in Hart ' s Island Clinic on 8/30/13. 33 . Ballard was next seen on 8/31/13 by 0.0., R-PAC for a psychiatric medication follow up . Bal l ard reporte d he did not know why he was still in Rikers Island and that he wanted to go home . He state d that the last time he was in court it was agreed that he would be going to a program and should be gone . Ballard was requesting medication FINAL REPORT OF BRADLEY BALLARD PAGE 10 that could help him sleep. R-PAC 0 . 0 . found Ballard presented mildly anxious and irritable. Ballard denied any audio or visual hallucinations. He was preoccupied with thoughts of going home. Ballard's diagnosis remained paranoid schizophrenia and he was continued on Seroquel 100 mg hs . 34. On 8/31/13, Ballard was involved in fight with an inmate in his housing area. Ballard and his assailant refused to stop fighting when ordered by correction officers and chemical agents (OC) was used. Ballard was taken to the medical c1inic for an exam and was seen by RPA S.N. Ballard reported no injuries and had an unremarkable exam . He was returned to his housing area . 35. On 9/1/13, Ballard was seen by Dr. A.K. in the AMKC clinic due to self-inflicted injuries . Ba ll ard had caused abrasions to his forehead and arms and was reportedly hitting his head on his cell wall. Ballard stated he was going to hurt himself until seen by mental health. Ballard was referred to mental health and was seen by Dr. A.G. on 9/2/13 . Ballard reported he was f i ne and denied causing any self-inflicted inj uries. He denied any suicidal or homicidal ideation or perceptua l disturbances but did appear to have some paranoid ideation . Ballard was suspicious that he was actually getting Seroquel and stated he was refu sing it. Dr . A.G. explained to Ballard that he may be receiving a generic of Seroquel to which Ballard was receptive and stated he would take the medication. Ballard was continued on Seroquel 100 mg hs . 36. It is noted by the Medical Review Board that Ballard's irritability, agitation, and aggression all significantly increased after being discontinued from Risperdal 3 mg bid on 8/15/13 and then.started on Seroquel 100 mg hs, both contrary to physician orders. No comprehensive clin.ical review or assessment of Ballard's medication efficacy was documented by any psychiatric provider in relation to his changes in behavior in the face of subtherapeutic and otherwise ineffective therapy not authorized by a physician. This represents inadequate psychiatric care by Corizon , Inc. 37. On 9/3/13 , Ballard was transferred to AMKC's Quad Lower 4, a mental health observation h o u sing area, and placed in an individual cell . 38 . On 9/4/13, Ba l lard was scheduled to be seen by L.V ., LMSW for a regularly scheduled appointmen t. Ballard was not seen due to being transferred to another housing unit. Ballard was to be re-scheduled to be seen by the clinician assigned to Quad Lower 4 . However, Ballard was not rescheduled and had no further clinical encounters with mental health clinicians or psychiatry through to the terminal event despite specific orders in his treatment plan for weekly clinician visits and biweekly psychiatry visits. 39 . An entry was made in Ballard' s medical chart on 9/4/13 by Dr. Y.P., reordering Metformin HCl 500 mg bid. There wa s no entry or any FINAL REPORT OF BRADLEY BALLARD PAGE 11 reference to an insulin coverage order for Ballard. There is no evidence that a review of Ballard's medical chart was completed prior to renewing his medications . This represents inadequate medical care . NYC DOH-MH ' s assert ion that sliding-scale insulin was not appropriate for this patient begs the question that Mr . Ballard died from being deprived of needed insulin for 11 days, a severe lapse for which there is no explanation and for which no defense is offered. 40. On 9/5/13, a progress note for Ballard was generated by Dr. N . G . for a diabetic clinic appointment. The only information on the progress note was that Ballard was "rescheduled." There was no information indicating why Ballard was not produced for the clinic nor was there any inquiry or follow up by Corizon, Inc. or DOC senior staff. This was the fourth missed appointment within 30 days without any clinical intervention or follow up . The last documented admini stration of insulin for Ballard occurs on 8/30/13 at 4 :50 a.m. It is noted that, on Ballard's chart, under "current medications" no order for insulin is listed. Metformin HCL 500 mg bid is listed with a stop date of 9/6/13. It is apparent that as of 8/30/13 , Ballard's insulin was dropped without any clinical exam or follow-up performed . The lack of coordinated care for and the mismanagement of Ballard's diabetes represents grossly negligent medical care b y Corizon, Inc ., endangered Ballard's life and subsequently caused his death. 41. On 9/6/13, LPN A.D . documented in Ballard' s medical chart under in the "Consul tat ion Request and Hospital Transfer Form" that he performed a finger stick and blood glucose check on Ballard at 5:46 p.m. which read 95. The Medical Review Board found evidence that LPN A.D. created a false entry in Ballard's medical chart. Recorded video camera footage for the 24 hour period covering 9/6/13 (as cited in Finding# 18 in Part II of this report) revealed no medical staff were present at Ballard' s cell, and Ballard was not removed from the cell at any time. NYC Department of Health and Mental Hygiene in its response to the Medical Review Board's Preliminary Report offered that LPN A.D. had taken a written data from another patient, and in error, entered it in Ballard's chart. 42 . On 9/10/13, at 10: 33 a . m., approximately 13 hours prior to the terminal event, Dr. N.G. documented a "Transfer Chart Review . " Notations were made that Ballard had pending or missed labs (not identified), that all necessary labs had been ordered (not identified), that a Quantifer.o n test indeterminate was ordered fo r 9/12/13, and that a special dietary consult was requested. Under current medications, "None" was listed. Under past medical history "Serious Persistent Mental Illness (SPMI) is listed as "No" despite Ballard's extensive mental health history and designation as SPMI in the chart . A referral was made to dietary for consult of a special diet due to Ballard's diabetes. The information documented was completely inconsistent with Ballard's known and established FINAL REPORT OF BRADLEY BALLARD PAGE 12 history and is apparent that a proper and thorough chart review was not completed by Dr. N.G. 43 . There were no further documented encounters for Ballard with medical or mental health staff from 9/3/13 through the terminal event, eight (8) days later . RECOMMENDATIONS OF THE MEDICAL REVIEW BOARD RE: BRADLEY BALLARD'S COURSE OF INCARCERATION : TO THE DEPUTY COMMISSIONER, DIVISION OF HEALTH CARE IMPROVEMENT, NYC DEPARTMENT OF HEALTH AND MENTAL HYGIENE: ACCESS AND 1. That the Division shall conduct a quality assurance review of the psychiatric care provided by NP R.A. to Ballard on 8/15/13. The focus of the review should include why a sub-therapeutic dosage of an antipsychotic medication (Seroquel) was ordered without documented supporting clinical indication, counter therapeutic to the reported efficacy of the current medication (Risperdal) and contrary to a prior order of a reviewing psychiatrist . 2. That the Division shall conduct an inquiry with the AMKC clinic director as to why Ballard did not receive the fasting glucose laboratory study as ordered for 8/12/13. A comprehensive review shall also be undertaken 1::'0 examine the laboratory requisition procedure to determine the frequency and circumstances of dropped laboratory orders by Corizon , Inc. 3. The Division shall conduct an inquiry with the AMKC clinic director as to how an o r der for CRIC standard sliding scale i n sulin for Ballard was dropped on 8/30/13, and was not renewed withou t clinical evaluation or follow up. 4. The Division shall conduct an inquiry with the AMKC clinic director as to why Ballard was not produced for five separate ca llouts for specialty clinics for purpose of managing his diabetes and why follow up explan ation by senior Corizon , Inc. and DOC staff did not occur . Further inquiry shall .include how providers failed to recognize Ballard was in need of being seen in a specialty clinic when Ballard was readily available at the medical clinic on 8/26/13 for a non -a cute complaint. 5. The Division shall conduct an inqu i ry into the psychiatric care provided to Ballard by Dr. A.G . to include the failure to review Ballard's course of changing behavior, his having been referred for causing self-injury, and the failure to correlate this to his change in medication two weeks prior. 6. The Division shall conduct a quality assurance review with Dr . Y.P. who failed to .thoroughly review Ballard' s medical chart prior to FINAL REPORT OF BRADLEY BALLARD PAGE 13 renewing a medication on 9/4/13 whereby missing the Ballard was without a current order for insulin. fact that 7. The Division shall conduct a quality assurance review with Dr. N.G. who conducted a transfer chart review of Ballard on 9/10/13 and failed to properly note his mental health history and current medications. A representative sample of patient chart reviews by Dr. N.G. shall be conducted to illuminate his practice pattern in this regard. 8. The Deputy Commissioner shall complete all recommended .inquiries and quality assurance reviews and provide_a comprehensive report to the Medical Review Board with findings and corrective acti ons taken on or before November 21, 2014. 9. The Deputy Commissioner sha l l conduct an investigation into the conduct of LPN A.O. who entered incorrect medical data for Ballard on 9/6/13. Administrative action should be taken at the completion of the investigation if found to be in violation of policy and procedures. FINDINGS RE : TERMINAL EVENT: 44. On 9/3/13, Ballard was transferred to AMKC's Quad Lower 4, a mental health observation unit, and placed into cell # 23 . On 9/3/14, Ballard was let out of his cell for programming and social interaction on the housing unit. 45. Video Footage of Quad Lower 4 on 9/4/13, revealed the following: • • • • • • • • At 12:15 p.m., Ballard is in the day room for Quad Lower 4 socializing with other inmates. At 1 : 35 p .m., Ballard is observed dancing in the day room. Ballard stops and stands still holding his hands upward as if he were praying. At 1 : 50 p .m ., Ballard is observed again dancing in th_e day room. At 1 : 54 p.m., Ballard is observed removing his shirt . At 1:56 p.m., Ballard is observed twisting his shirt into a phallic symbol and making a lewd gesture . The gesture was reported to have been done toward a female correction officer. At 1:57 p . m. , Ballard puts his shirt back on . At 2:24 p.m., Ballard is observed holding his hands upward again as if in prayer. At 2 : 50 p .m. , officers confront Ballard in the day room . FINAL REPORT Of BRADLEY BALLARD PAGE 14 • · At 2:53 p . m., Ballard is secured in handcuffs by two officers and a captain and escorted back to his cell. • At 2:55 p.m., Ballard is secured in his cell . _46 . There is no notation in the housing area logbook about Ballard being keeplocked in his cell pending disciplinary action or any entry about any disciplinary infraction . This in violation of 9 NYCRR § 7003 . 3 (J) (6) (i - iv) that requires "any significant events and activities occurring during supervision" be properly documented in the logbook. 47. There is no written misbehavior report .documenting for what infraction Ballard was being administratively segregated and no documentation authorizing Ballard's administrative segregation pending a disciplinary hearing. These are in violation of 9 NYCRR § 7006. 4 (a) (b) (1-5) Misbehavior reports which states : (a) When a staff member has a reasonable belief that an inmate has committed an offense that constitutes a violation of the facility's rules of inmate conduct, and such viol ation is not i nformally resolved, such staff member shall prepare a written misbehavior report. (b) Each misbehavior report shall include: (1) (2) (3) the name(s) of the inmate(s) charged with misconduct; the date, time and place of occurrence; a description of the incident or behavi or involved and the rule(s) allegedly violated; (4) the date and time the report is written; (5) the reporting staff member's printed name and signature. and §7006. 7 (a) (b) (c) Administrative disciplinary hearing which states : segregation pending the a (a) An inmate who t hreatens the safety, security, and good order of the facility may be immediately confined in a cell or room pending a disciplinary hearing and may be retained in administrative segregation until the complet i on of the disciplinary process. (b) Within 24 hours of such confinement, the inmate shall be provided with a written statement setting forth the reason(s) for such confinement. Upon receipt of the written statement, the inmate s hall be provided with an opportunity to respond to such statement orally or in writing to the chief administrative officer . FINAL REPORT OF BRADLEY BALLARD PAGE 15 (c) The chief administrative officer shal l revi ew the administrative confinement within 24 hours of such confinement in order to determine if continued confi nement is warranted . 48. Video Footage of Quad Lower 4 on 9/4/13, revealed the following: • • • 49. At 4 : 57 p.m., a meal tray is delivered to Ballard's cell . At 5 : 01 p.m., a beverage container is delivered to Ballard's cell. At 11:57 p . m. , garbage is observed being pushed out from underneath the cell door by Ballard . Video Footage of Quad Lower 4 on 9/5/13, revealed the following: • • • At 12:08 a.m., Ballard is flooding his cell as water is seen coming out from under his cell door . No notation is made in the logbook regarding this incident. At 1:03 a . m., a captain is observed at Ballard's cell. At 5 : 57 a.m. , t he breakfast meal is served but not delivered to Ballard . There is no notation in the logbook that Ballard refused the meal . This is in violation of NYS Correction Law Article 20 §500 - K Treatment of Inmates that applies Article 6 §137 (6) (a) and states : The inmate shall be supplied with a of wholesome and nutritious food, that such food need not be the same to inmates who are participating facili t y. • • • • • sufficient quantity provided; however, as the food supplied in programs of the At 12:50 p.m. , Ballard appears to be banging on his ce l l door. An officer stops at his cell and speaks to him. At 1:03 p.m., Ballard receives a lunch meal tray . At 4:48 p.m., a mental health clinician appears to stop at Ballard's cell and speak with him. The clinician is at Ballard's cell for less than one minute . At 6:59 p.m., a dinner meal tray is delivered to Ballard's cell. At 7:24 p.m., a mental health clinician is observed making rounds on the unit. The c l inician does not stop to speak to Ballard. 50. In the 24-hour period covering 9/5/13, Ballard did not r eceive any medications delivered to his cell despite current orders for Metformin and Seroquel . 51 . During the same 24 - hour period of 9/5/13, Ballard was not provided with access to a shower in vio lation 9 NYCRR § 7005.2 (a) Showers which states : FINAL REPORT OF BRADLEY BALLARD PAGE 16 Hot showers shall be made available to all prisoners daily . Consistent with facility health requirements, the chief administrative officer may .require prisoners to shower periodically. 52 . During the 24-hour period covering 9/5/13, Ballard was not afforded any access to exercise in violation of 9 NYCRR §7028.2 (b) ( 1 , 2) Exercise periods which states: All inmates who have completed the class if ication process pursuant to sections 7013 . 7 and 7013.8 of this Title, except as otherwi~e provided in subdivision (c) of this se~tion or section 7028.6 of this Part, shall be entitled to exercise periods which, at the discretion of the chief administrative officer, shall consist of: ( 1) at least 1-1/2 hours during each of five days per week; or ( 2) at least one hour seven days a week. No specific written determination was made to deny Ballard's exercise access based on any ·threat to the safety and security of the facility or of others in violation of 9 NYCRR 7028.6 (a) (b) which states : (a) The exercise periods of a prisoner may be denied, revoked, or limited when it is determined that such exercise period would cause a threat to the safety, security, or good order of the facility, or the safety, security, or health of the prisoner or other prisoners. (b) Any determination to deny, revoke, or limit a prisoner ' s exercise period pursuant to this section shall be made by the chief administrative officer in writing, and shall state the specific facts and reasons underlying such determination . A copy of this determination shall be given to the prisoner. 53. During the 24-hour period covering 9/5/13, Ballard was not seen by a mental health clinician. This is in direct violation of NYC Department of Health and Mental Hygiene Correctional Health Services Policy: MH 26 Mental Observation Unit which states: The Mental Health Unit Chief or their designee shall maintain a daily account of the inmates on the mental observation unit and shall track visits to each patient. Mental health staff shall conduct rounds on the MO Unit seven (7) days a week. The rounds conducted will be documented in the "Rounds Logbook" . 54 . Ballard was also not seen by any staff from medical during the 24 FINAL REPORT OF BRADLEY BALLARD PAGE 17 hours covering 9/5/13, which is in violation of NYS Correction Law Article 20 §500 - K Treatment of Inmates that applies Article 6 §137 (6) (c) which states : Where such confinement is for a period in excess of twentyfour hours, the superintendent shall arrange for the facility heal th services director, or a registered nurse or physician ' s associate approved. by the facility health services director to visit such inmate at the expiration of twenty-four hours and at least once in every twenty-four hour period thereafter, during the period of such confinement, to E:Xamine into the state of heal th of the inmate, and the superintendent shall give full consideration to any recommendation that may be made by the facility health services director for measures with respect to dietary needs or conditions of confinement of such inmate required to maintain the health of such inmate. 55 . Video Footage of Quad Lower 4 on 9/6/13, revealed the following : • • • • 56. At 2 : 49 a . m., an officer and a captain are at Ballard' s cell. At 3: 23 a. m., Ballard is at his cel l door and an officer responds. At 3:24 a.m., the officer leaves from in front of Ballard's cell. At 4:47 a . m., an officer is at Ballard's cell . It is noted at 5 : 30 a . m. that an officer stationed at a constant supervision post at cell #14 for inmate M.H., abandons his post until 6 : 22 a . m. This is in violation 9 NYCRR §7003. 2 (d) (1, 2) Security and Supervision which states: Constant supervision shall mean the uninterrupted personal visual observation of prisoners by facility staff responsible for the care and custody of such prisoners without the aid of any electrical or mechanical surveil1ance devices. Facility staff shall provide continuous and direct supervision by permanently occupying an established post in close proximity to the prisoners under supervision which shall provide staff with: ( 1) a continuous clear view of all prisoners under supervision ; and (2) the ability to immediately and directly intervene in response to situations or behavior observed whi c h threaten the health or safety or prisoners of the good order of the facility . 57. Video Footage of Quad Lower 4 on 9/6/13, revealed the fo l lowing: FINAL REPORT OF BRADLEY BALLARD • • PAGE 18 At 6:13 a.m ., the breakfast meal is delivered to Ballard's cell. At 7:34 a.m . , the constant supervision post at cell #14 is abandoned until 8: 4 6 am in violation of 9 NYCRR §7003 . 2 (d) ( 1, 2) . • • 58. At 9: 31 a. m., Ba l lard is observed to be f loading his cell again. At 9 : 33 a.m . , an officer is at Ballard's cell . At 10:24 a.rn . , Ballard is still flooding his cell. Maintenance staff is observed shutting off the water to Ballard ' s cell . There is no notation in the l ogbook as to Ballard's water being shut off in violation of 9 NYCRR § 7003.3 (J) (6) (i - iv) . Additionally, there is no documentation as to who authorized the water deprivation order, how long it was to be in effect, and who was to review it to see if it was still warranted . Although it may be necessary to shut off water to an occupied cell when an inmate is becoming disruptive and flooding the cell, affecting the iafety and order of the facility , it must be periodically turned back on for the purposes of flushing the toilet, access to drinking water, and otherwise providing proper sanitation. Ballard' s water remained turned off and unchecked for over four aod half days through the terminal event. This is in blatant violation of NYS Correctio_n Law Article 20 § 500 K Treatment of Inmates that applies Article 6 §137 (6) (b) which states: Adequate sanitary and other conditions required for the health of the inmate shall be maintained. 59. Video Footage of Quad Lower 4 on 9/6/13, revealed the following : • • • • • 60 . At 1:14 p.m. , the lunch meal was delivered to Ballard's cell. At 1:25 p . m., an officer opens Ballard's cell door. Ballard tosses out food trays and a cup. At 5:48 p.m. , the dinner meal tray was delivered to Ballard's cell. At 7:00 p.m., a mental health clinician conducts rounds on the unit . The clinician looks in Ballard's cell but does not engage in any conversation with him. At 7 : 22 p .m ., rounds were conducted by an Assistant Deputy Warden (ADW; name illegible in logbook) . The ADW makes motions that indicate that the area near Ballard' s cell was malodorous . There were no orders documented in the logbook to address the situation. The ADW failed to make a command decision and take proper action of an obvious heal th and safety situation with Ballard's cell which had water shut off to it for over 24 hours . During the 24-hour period covering 9/6/13 : FINAL REPORT OF BRADLEY BALLARD a. PAGE 19 Ballard did not have any medications delivered to his cell nor was he seen by any staff from medical wh ich is in violation of NYS Correction Law Article 20 § 500 K Treatment of Inmates that applies Ar_t icle 6 § 137 (6) (c) . b. Ballard was not provided with access to a shower in violation 9 NYCRR § 7005.2 (a) . c. Ballard was not afforded any access to exercise in violation of 9 NYCRR § 7028. 2 (b) (1,2). Also, no specific written determination was made_ to deny Ballard's exercise access based on any threat to the safety and security of the facility or others in violation of 9 NYCRR 7028 . 6 (a) (b). d. Ballard was not actually seen by a mental health clinician during mental heal th rounds. This is i n direct violation of NYC Department of Health and Mental Hygiene Correctional Health Services Policy: MH 26. 61 . Video Footage of Quad Lower 4 on 9/7/13 , revealed the following: • • • • • 62. At 5 : 54 a.m., it appears that Ballard refuses his breakfast meal tray. No tray is delivered. At 8:17 a . m., an officer is seen utilizing a deodorizer spray in front of cell #23. Nothing more is noted or documented to address the problem . At 12 : 22 p.m ., Ballard's lunch meal tray is delivered . At 12:59 p.m ., a mental health clinician stops by Ballard's cell and speaks with him briefly. The clinician leaves the area within the minute. At 5:00 p.m., Ballard's dinner meal tray is delivered. During the 24-hour period covering 9/7/13: a. Ballard did not have any medications delivered to his cell nor was he seen by any staff from medical which is in violation of NYS Correction Law Article 20 §500 - K Treatment of Inmates that applies Article 6 §137 (6) (c) . b. Ballard was not provided with violation 9 NYCRR §7005.2 (a). access to a shower in c. Ballard was not afforded any access to exercise in violation of 9 NYCRR § 7028. 2 (b) (1, 2) Also, no specific written determination was made to deny Ballard's exercise access based on any threat to the safety and security of the facility or others in violation of 9 NYCRR 7028.6 (a) (b) . Although Ballard was seen by a mental health clinician , the round FINAL REPORT OF BRADLEY BALLARD PAGE 20 conducted was observed to be a ''drive-by" assessment that took less than one minute . This is insufficient to properly assess the daily status of a pat i ent with serious persistent mental illness. The water to Ballard' s cell remained shut off continuously in violation of NYS Correction Law Article 20 § 500 - K Treatment of Inmates that applies Article 6 § 137 (6) (b) which states: Adequate sanitary and other conditions required for the health of the inmate shall be maintained. 63 . Vi~eo Footage of Quad Lower 4 on 9/8/13, re~ealed the following : • • • • • • • • • 64 . At 12:22 a.m ., an officer is seen speaking to Ballard at his cell. At 5 : 28 a . m. , a breakfast meal tray is delivered to Ballard' s cell . At 6:44 a.m . , an officer is observed at Ballard ' s cell speaking to him . At 7 : 53 a .m. , an officer is observed at Ballard's cell speaking to him . At 8 : 31 a.m ., an officer delivers a drink carton to Ballard's cell. At 9 : 58 a . m., a c a ptain is observed at Ballard' s cell speaking to him . At 1: 00 p.m., the l unch meal is del ivered to Ba l lard ' s cell . At 5 : 04 p . m. , the dinner meal is delivered to Ballard ' s cell . At 7:23 p . m. , a mental health clinician was at Ballard' s cell . The clin ician l eaves the area_ by 7:24 p.m. During the 24-hour period covering 9/8/13 : a. Ballard did not have any medi cat i ons delivered to his cell nor was he seen by any staff from medical which is in violation of NYS Correction Law Article 20 §500 - K Treatment of that applies Article 6 § 137 (6) (c) . b. Ballard was not provided with vio l ation of 9 NYCRR § 7005 . 2 (a) . c. Ballard wa s not afforded any access to exercise in viol ati on of 9 NYCRR § 7028 . 2 (b) (1, 2) . Also no specific written determination was made to deny Ballard ' s exerc i se access based on any threat to the safety and security of the facility or others in violation of 9 NYCRR 7028.6 (a) (b) . d. Al though Ballard was seen by a access mental to a Inmates heal th shower in clinician, FINAL REPORT OF BRADLEY BALLARD PAGE 21 the round conducted was observed to be a "drive-by" assessment that took less than one minute . This is insufficient to properly assess the daily status of a patient with persistent mental illness . e. The water to Ballard ' s cell remained shut off continuously in violation of NYS Correction Law Article 20 §500 - K Treatment of Inmates that applies Article 6 § 1 3 7 (6) (b) which states : Adequate sanitary and other conditions required for the health of the inmate shall be maintained. 65 . Video Footage o f Qu ad Lower 4 on 9/9/13, revealed the following : • • • • • At 2 :1 5 a . m., an officer is observed at Ballard ' s cell with a flas h light looking in. The officer is there until 2:17 a . m. The offi cer d oes not enter the cell . There is no notation in the logbook as to what the off i cer was observing. At 5 : 37 a.m., an off icer delivers a small container (unknown) to Ballard . No actual breakfast meal tray was delivered to Ballard ' s cel l. At 6 : 00 am an officer is at Ballard's cell with an inmate porter. An item (unknown) is tossed into Bal l ard's cel l. At 8 : 12 a .m., an officer is observed at Ballard's cell speak i ng to h i m. At 8 : 19 a.m., food items were delivered to Ballard by Officer C. • • At 10: 33 a . m. , a Captain and an ADW are at Ballard's cell . Ballard' s cell door is opened and they are speaking to Ballard . Ballard' s cell door is re-secured at 10 : 34 a . m. There is no notation in the logbook about the visit with Ballard. No action was taken on Ballard's continued deprivation of running water in his cell by the Captain or ADW in violation of NYS Correction Law Article 20 §500 - K Treatment of Inmates that applies Article 6 § 137 (6) (b). At 1 2 : 40 p . m. , a lunch meal tray is delivered to Ballard's ce l l. 66 . While viewing the activity around 12:40 p.m . of meal trays being delivered , the neighboring inmate to Ballard in cell 24 is observed to run out of the cell when it is opened to deliver his food . It was noted from viewing the prior 72 hours of video footage that this inmate had also not been provided access out of his cell for exercise, programs , or a shower. It is indicative from the video footage that the violations noted of 9 NYCRR §7028 . 2 (b) (1 , 2 ) Ex ercise , and 9 NYCRR § 7005. 2 (a) Showe rs were not specific to Ballard but are pervasive violations in the management of the housing area. 67. Video Footage of Quad Lower 4 on 9/9/13, revealed t he following: FINAL REPORT OF BRADLEY BALLARD • • • • • • • 68 . At 5: 06 p .m., a mental heal th clinician is observed doing rounds in the unit but Ballard is not seen. At 5:18 p.m., a dinner meal tray is slid underneath Ballard's door to him . At 6:18 p.m., an officer and an inmate are at Ballard's cell delivering what appears to be paperwork. At 7:45 p.m., the ADW M. and Captain J . are seen touring the unit. At 9:04 p . m., it is observed that medications are delivered to cell 24 next door to Ballard. No medications were delivered to Ballard .· At 10 : 36 p.m., an officer is observed at Ballard's cell speaking to him . At 11: 56 p . m. , an officer is observed at Ballard's cell speaking to him. During the 24-hour period covering 9/9/13: a. Ballard did not have any medications delivered to his cell nor was he seen by any staff f.r om medical which is in violation of NYS Correction Law Article 20 § 500 that appl ies Article 6 § 137 (6) (c) . K Treatment of Inmates b. Ballard was not provided with access to a shower in violation of 9 NYCRR § 7005 . 2 (a) . c. Ballard was not afforded a ny access to exercise i n violation of 9 NYCRR § 7028 . 2 (b) (1,2). Also, no specific written determination was made to deny Ballard' s exercise access based on a n y threat to the safety and security of the facility or others in violation of 9 NYCRR 7028 . 6 (a) (b). d. Ballard was not actually seen by a mental heal th clinician during mental health ro unds. This is in direct violation of NYC Department of Health and Mental Health Services Policy: MH 26 . e. 69. PAGE 22 Hygiene Correctional The water to Ballard's cell remained shut off continuously in violation of NYS Correction Law Article 20 § 500 - K Treatment of Inmates that applies Article 6 §137 (6) (b) which states: Adequate san i t ary and other conditions required for the health of the inmate .shall be maintained . Video Footage of Quad Lower 4 on 9/10/13, revealed the following : a. Review of the video · footage beginning on 9/10/13, revealed that the constant supervision post at cell #14 for inmate M. H. is abandoned multiple times. From 1 : 29 a.m . , to 1:37 a.m., (8 minutes) , from 1:37 a.m . to 2 : 13 a . m. (36 minutes), and from FINAL REPORT OF BRADLEY BALLARD PAGE 23 2:14 a . m. to 2 : 58 a.m . (44 minutes) . These are all viol ations of 9 NYCRR § 7003.2 (d) (1,2) Security and Supervision . b. Between 2 : 15 a.m . and 3:15 a.m . , no general supervisory tour of the housing area was conducted by the assigned officer. Officer C . was assigned as the "C" post officer for the 11 : 00 p.m. to the 7:31 a . m. tour. Officer C . made false entries into the housing logbook by signing as having conducted tours at 2 : 30 a . m. and 3:00 a.m. This is also in violation of 9 NYCRR § 7003 . 2 (a) (1 , 2) (b) which states: (a) Supervisory visit shall mean: ( 1) a personal visual observation of each i ndividual prisoner by facility staff responsible for the care and cus t ody of such prisoners to monitor their presence and proper conduct ; and ( 2) a personal visu al inspection of each occup i ed individual prisoner housing unit and the area i mmediately surrounding such housing uni t b y facil i ty staff responsible for the care and custody of pri soners to ensure the safety, security and good order o f t h e facility . (b) General supervis ion shall mean the avai l abi l i ty to p risoners of facility staff responsible for the care and custody of such prisoners which shall incl ude s upervisory visits conducted at 30-minute int erval s . 70 . At 2: 30 a . m. , Cap tain J. signed the logbook for the " C" post indicating a tour of the area was completed; however , the video revealed that no officers walked through the unit for at least an hour. Captain J . made a false entry in the "C" post logbook . 71 . At 3 : 29 a . m., the constant supervision officer left his pos t a nd walked down to cell #23 to check on Ballard. The officer remained t h ere until 3 : 32 a . m. 72 . Video Footage of Quad Lower 4 on 9/10/13 , revealed the following : • • • • • At 3:30 a . m., the ADW toured the area and signed t h e log book . From 3:35 a.m. to 4:11 a . m. , the officer conducting the constant supervision at cell #14 abandoned h is post . At 3 : 45 a.m . and 4:00 a . m. , Officer C . made two more false entries in the logbook for conducting rounds of the C post. No rounds were observed being conducted on the video . At 4:55 a . m. , a second security inspection is documented as being done by Officer C . This is also a falsified logbook entry as no security inspection is observed having been conducted on the housing area video . At 5:25 a.m., the breakfast meal begins being de l ivered and Captain J. conducted a tour of the area. FINAL REPORT OF BRADLEY BALLARD PAGE 24 73. At 5:29 a.m., Ballard's cell is opened to deliver a breakfast meal tray. The inmate delivering the tray pulls his shirt up over his nose and mouth indicating that the conditions in Ballard's cell were grossly unsanitary and malodorous. The meal tray was not taken by Ballard . There was no notation in the logbook about the unsanitary conditions in Ballard' s cell. Both officers and a supervisor (Captain J .) were in the immediate area to observe this but took no action . This is a violation of NYS Correction Law Article 20 § 500 K Treatment of Inmates that applies Article 6 § 137 (6) (b). 74 . Video Footage of Qu~d Lower 4 on 9/10/13, revealed the follo~ing: • • • • • • • • • • • • • 75. From 5 : 14 a.rn . to 5:55 a . rn., the officer conducting the constant supervision at cell #14 abandoned his post . From 6 : 10 a . m. to 7:00 a . m. , the officer conducting the constant supervision at cell #14 abandoned his post . At 9 : 22 a.rn . , Officer C. delivers what appears to be a towel to Bal l ard's cell. At 9:49 a . m. , a mental health clinician is seen on the unit but Bal l ard is not seen . It is observed that officers walking by Ballard' s cell keep reacting to the ma l odorous condition corning from it; however , no action is taken . At 12 : 4 6 p .m ., an officer and a civilian are observed at Bal lard ' s cell . At 12:57 a . m., a lunch meal tray is delivered to Ballard' s cell . At 3 : 00 p.m., Officer M.S. assumed supervision of the C post for the 3 : 00 p . m., to 11 : 00 p . rn. tour . At 4 : 18 p . m. , an inmate standing near Ballard's cell is observed to be covering his mouth and nose with his shirt . At 5 : 28 p . m. , a mental health clinician conducts rounds in the unit but does not see Ballard . At 5:35 p . m. , an office r opened Ballard's cell and delivered a dinner meal tray. At 5 : 45 p.m., a mental health clinician was observed doing rounds on the unit. Psychiatrist Dr. N. is documented as leaving the housing area at 6:45 p . m. Ballard was not seen by the clinician. Ballard had not had a therapeutic clinical encounter with mental health or psychiatry since 9/2/13. At 8:21 p.m., an officer is at Ballard's cell checking on him . An inmate standing nearby can be seen covering his nose. At 8:25 p.rn . , an officer and ADW B . are observed at Ballard's cell. The ADW kicks at Ballard's cell and is covering his nose . There was no notation of the obvious unsanitary conditions of Ballard and his cell in the ADW 8 : 30 p.m . logbook entry. There were no orders or FINAL REPORT OF BRADLEY BALLARD PAGE 25 actions taken to address the situation by the ADW . This is flagrant violation of NYS Correction Law Article 20 § 500 Treatment of Inmates that applies Article 6 § 137 (6) (b}. in K 76 . At 8 : 35 p . m., an officer is seen kicking at Ballard's cell door . 77. At 9:47 p.m., while being let out of his cell for medications, the inmate in cell #24 runs out of the cell and begins to immediately assault another inmate who was standing in the hallway. Officer M.S. separates the two inmates and secures them in their individual cells . 78. Officer M.S . documented in a report that he observed Ballard laying naked in his cell and having difficulty breathing at 9:30 p.m . and made notification to the A -post officer to contact the clinic . The clinic, however, documents that they were not notified until 10:52 p.m. 79. and LPN A.D. responded from the clinic to Quad 4 Lower along with Officer D.C. and two inn:iate clinic workers. They arrived at Ballard's ce ll at 10:56 p.m. At 10 : 57 p .m., Ballard's cell is opened. Neither the medical staff nor the correction officers enter into Ballard's cell. Dr. A.H . documents that Ballard was found lying naked on his right side on the cell floor, covered in filth and feces. The cell was documented as unkempt with food on the floor. Dr. A.H. documented that Ballard appeared severely obtunded, and there was a pungent odor of perspiration and feces. Officer D.C. documented he asked Ballard if he could get up on his own. Ballard attempted to get up but then lay back down and said "I need help ." 80. At 11: 01 p .m., two inmate workers entered the cell and wrapped Ballard in a blanket . Ballard is then carried out and placed on a gurney. At 11 :02 p.m., Dr. A.H. is observed doing a brief assessment, and then Ballard is escorted on the gurney out to the clinic. Inmates s hould never be employed to assist in medical emergencies. It is incumbent upon responding clinicians to encounter and handle the patient. 81. Ballard arrived at the Hart's Island medical clinic in AMKC at approximately 11:07 p .m. _ Ballard' s vitals were BP 90/50, pulse 117, and respiratory rate 8. Dr. A.H. administered oxygen and had an IV established with normal saline. A blood glucose reading was taken and registered as "High 11 • EMS was notified to transport Ballard to the hospital. 82. At approximately 11:29 p.m., Ballard had a cardiac arrest. CPR and resuscitation measures were begun. Dr. A . H. • • At 11:35 p . m., Ballard was given 40 units of vasopress i n . At 11 : 40 p.m., Dr. F.F. from UrgiCare and FDNY EMS arrived to assist. FINAL REPORT OF BRADLEY BALLARD • • • • • 83 . PAGE 26 At 11:44 p.m., Dr . F . F . intubated Ballard. CPR continued . At 11:44 p . m. , epinephrine 1:10,000 was administered . CPR was continued . At 11:54 p . m. , epinephrine 1:10,000 was administered. CPR was continued . At 12:04 a . m. , 1 amp of sodium bicarb was administered . CPR was continued. At 12:05 a . m., Ballard developed a ventricular tachycardia and was shocked into a normal sinus rhythm with a pulse rate of 80 and BP of 110/68 . Ballard was transported to Elmhurst Hospital . Ballard arrived at Elmhurst Hospital at 12 : 46 a.m. Ballard went back into cardiac arrest and CPR was being done by EMS. Dr . L . I . asswned care for Ballard . Ballard regained vitals at 12:49 a . m., with a pulse of 118, and BP of 145/102. STAT labs were ordered for Bal lard which revealed : Basic Metabolic Panel Panic levels for : Sodium: 162 Potassium : 6 . 5 BUN: 125 Glucose: 1222 CO2 : 14 Abnormal leve l s for: Chloride: 113 Creat i nine: 7.5 Blood Gas with Na, K, Ca, Lactate-venous Panic levels for : tCO2: 12 . 9 Cl-: 124 Abnormal Levels for : pH: 6. 845 pCO2 : 66 . 4 pO2: 67 . 9 HCO3 : 10 . 9 Act BE: -24 . 4 Na+: 159 K+: 6.2 Lactic: 13 . 8 CK : 383 84. Ballard maintained vitals until 1:14 a.m . when he suffered another cardiac arrest. Resuscitation efforts were begun again but with no response . Ballard was pronounced dead by Dr . L . I. at 1:31 a.m. 8 5. Ballard's untreated diabetes l ed to the development of severe hyperglycemia and ketoacidosis . Additionally, Ballard had become FINAL REPORT OF BRADLEY BALLARD PAGE 27 septic due to severe tissue necrosis of his scrotum area. The circulation to Ballard's scrotum had become restricted days earlier after he tied a ligature around the area approximately five times. At autopsy, the medical examiner had found that Ballard's scrotum was gangrenous and his testes necrotic. The cloth u?ed to form the ligature assumed the color of Ballard's skin, making-it difficult to be seen upon examination. 86. During the day on 9/11/13, video footage revealed inmates and staff entering into Ballard's cell to conduct cleaning . A mattress that appeared to be covered in feces was removed from the cell. The water was observed being turned back on in Ballard's cell at approximately 4:50 p.m. RECOMMENDATIONS RE: TERMINAL EVENT: TO THE ASSISTANT ATTORNEY GENERAL FOR CIVIL RIGHTS, U.S. DEPARTMENT OF JUSTICE: That the Assistant Attorney General for Civil Rights take official notice of the findings of the Medical Review Board in the case cited herein and initiate both individual criminal civil rights investigations and a CRIPA investigation into the New York City Department of Correction's Anna M. Kross Center and their contracted medical provider, Corizon Inc . TO THE COMMISSIONER OF NYC DEPARTMENT OF CORRECTION: 1. The Commissioner should remove Warden R.A. assigned to AMKC during Ballard's terminal event from all command duties due to failing to maintain a correctional facility in a safe, stable, and humane manner and in violation of NYS Correctional Law and NYS Minimum Standards and Regulations . for Management of County Jails and Penitentiaries. 2. The Commissioner shall conduct an investigation into the conduct of the Assistant Deputy Warden who conducted rounds of Ballard' s housing area on 9/6/13, at 7:22 p.m. who failed to take administrative action regarding Ballard's water being turned off . At the completion of the investigation, administrative action shall be taken for any identified misconduct. 3. The Commissioner shall conduct an investigation into the conduct of the Assistant Deputy Warden and Captain present at Ballard' s cell on 9/9/13, at 10:33 a.m., who violated NYS Corre~tion Law by failing to take administrative action regarding Ballard' s water being turned off. At the completion of the investigation, administrative action shall be taken for any ident ified misconduct. 4. The Commissioner shall conduct an investigation into the conduct of the Assistant Deputy Warden who was prese nt at Ballard's cell on FINAL REPORT OF BRADLEY BALLARD PAGE 28 9/10/13, at 8:25 p . m., who failed to take any administrative action regarding Ballard ' s obvious unsanitary living conditions and deteriorating health . The Medical Review Board opines that the ADW should be removed from all supervisory capacity for failing t o properly maintain a correctional facility in a safe, stable, and humane manner i n accordance with NYS Correction Law and should be the subject of administrative action. 5. The Commissioner shall conduct an investigation and take administrative action regarding the misconduct of Captain J . who: • Made a fa l se entry in the Quad Lower 4 "C" post logbook on 9/10/13, at 2:30 a . m. , when video evidence showed no tour was completed. • Violated NYS Correction Law by failing to take appropriate action on 9/10/13 at 5 : 29 am when the captain was present to o b serve conditions in Ballard' s cell that were grossly unsanitary and inhumane. 6. The Commissioner shall conduct an investigation and take administrative action regarding the official misconduct of Officer C., assigned to supervision of Quad Lower 4 housing area on 9/10/13, from 11:00 p .m. to 7:31 a.m .~ who made false logbook entries for completing supervisory tours when video evidence shows no tour was completed . 7. The Commissioner shall conduct an investigation into · the actions of Officer M. S . on 9/10/13, who failed to notify the medical clinic in a timely manner when Ballard was observed to be in severe distress . At the completion of the investigation, administrative action shall be taken for any identified misconduct. 8. The Commissioner shall immediately revise and implement procedures for water deprivation orders in special housing situations . Revised procedures must include the following : • • .• • • All deprivation orders must be authorized by an Assistant Deputy Warden or higher ranking official . Each deprivation order must be reviewed on a daily basis by a Deputy Warden or an Assistance Deputy Warden who is assigned as a watch commander. The review shall be documented by the reviewing Warden . Deprivation orders may only be in effect for seven (7) days and must be re-authorized and approved by the Warden. Any deprivation order for "mental heal th" reasons must be approved by an appropriate clinical professional.· During an active water deprivation order, an inmate's in cell water must be turned on minimally for ten (10) minutes five (5) times a day as follows: approximately 30 minutes prior to FINAL REPORT OF BRADLEY BALLARD • 9. PAGE 29 the service of each meal; once during the night shift and .once during the evening shift. All times water is turned on and off must be appropriately documented in the housing area log book. The Commission er shall review policy and procedures and take administrative action to assure that staff are in compliance with 9 NYCRR § 7006 . 4 (a) (b) (1-5) Misbehavior reports and § 7006 . 7 (a) (b) (c) Administrative segregation pending a disciplinary hearing . 10 . The Commissioner shall review policy and procedures and take administrative action to assure that staff are in compliance with 9 NYCRR § 7003. 3 (J) (6) (i - iv) that requires "any sign ificant events and activities occurring during supervision" be properly documented in the logbook . 11 . The Commissioner shal l review policy and procedures and take administrative action to assure that staff are in comp l iance with 9 NYCRR § 7005 . 2 (a) Showers ; in t hat inmates who are administr atively segr e g ated a r e given access to showers in accordance with the standard requirements . 12 . The Commiss i o n e r shall revi ew policy and procedures and take administrativ e action to assure that staff are in compliance with 9 NYCRR §7028.2 (b) (1,2) in t hat all i nma t es are provided with dai l y · access to outdoor exercise periods a n d in compliance with 9 NYCRR 7028.6 (a) (b) i n that any determi nation to revoke or deny an inmate access to exercise must be made by the chief administrative officer with document ed justification why such order is in effect. 13. The Commissi oner s h all review policy and procedure s and take administrative action to assure that staff are in compl iance with 9 NYCRR § 7003.2 (d) (1,2) Security and Supervision in that constant supervision posts are con tinuously occupied until properly relieved as required by the stan dard. 14 . The Commi ss i on shall provide the Medical Review Board with a comprehensive report on all admi n istrative and correct i ve actions taken on or before November 21, 2014. TO THE DEPUTY COMMISSIONER, DI VISION OF HEALTH CARE IMPROVEMENT, NYC DEPARTMENT OF HEALTH AND MENTAL HYGIENE: 1. ACCESS AND The Deputy Commissioner should consider and determi ne wheth er Corizon, Inc., a business corporation holding itself out as a medical care provider , is fit to continue as a New York City service contractor in light of delivery of flagrant l y inadequate, substandard and dangerous medical and mental health care to Bradley Ballard . FINAL REPORT OF BRADLEY BALLARD 2. PAGE 30 The Deputy Commissioner shall review the conduct of all clinic staff assigned to conduct rounds in the mental health observation housing area between 9/4/13, and 9/10/13. The review shall focus on: a. Failure to make daily or adequate contact with mental health clinicians did not occur with Bradley Ballard. b. Failure of clinicians to observe, make notification, and otherwise take appropriate action of a patient who obviously was in extremis. At the completion of the review administrative, action shall be taken for any identified misconduct. 3. The Deputy Commissioner shall conduct a review with the AMKC mental health unit chiefs as to why Bal l ard was not scheduled clinical appointments as part of his approved treatment plan between 9/3/13, and 9/10/ 13 . At the completion of the review, administrative action shall be taken for any identified misconduct . 4. The Deputy Commissioner shall conduct an inquiry as to the failure to deliver medical and/or psychiatric medications to Ballard between 9/3/13, and 9/10/13 . The Deputy Commissioner shall make administrative changes necessary to assure that patients who are administratively segregated are provided prescribed medications . At the completion of the review, administrative action shal l be taken for any identified misconduct. 5. The Deputy Commissioner shall conduct a review of the professional conduct of Dr . A . H. and LPN A . D. who both failed to immediately attend to and remove Ballard. from his cell and inappropriately ordered inmates to perform said rescue measures in their place . The practice of utilizing inmate workers in the medical clinics or at medica l emergency scenes to perform work tasks beyond routine sanitation and cleaning or porter duties shall cease immediately. At the completion of the review administrative, action shall be taken for any identified misconduct . 6. The Deputy Commissioner shall conduct a review of the deli very medical services to inmates who are placed in punitive or administrative segregation to assure that inmates are seen by medical staff daily in compliance with NYS Correction Law Article 20 § 500 - K Treatment of Inmates that applies Article 6 § 137 (6) (c) . The Deputy Commissioner shall provide the Medical Review Board with a comprehensive report of the review findings and corrective actions taken. 7. The Deputy Commissioner shall conduct a thorough review of delivery of mental health services to patients in mental h ealth observation units in AMKC, and throughout the Department's institutions . The Deputy Commissioner shall implement administrative changes necessary to assure compliance with NYC Department of Heal th and Mental FINAL REPORT OF BRADLEY BALLARD PAGE 31 Hygiene Correctional Health Services Policy: MH 26 that requires clinicians to conduct daily rounds in the mental health observation units. The Deputy Commissioner shall provide a comprehensive report to the Medical Review Board wi th findings and corrective actions taken on or before November 21, 2014. WITNESS, HONORABLE PHYLLIS HARRISON-ROSS, M.D., Commissioner, NYS Commission of Correction, Alfred E. Smith Office Building, 80 South Swan Street , 12 th Floor, in the City of Albany, New York 12210 this 16~ day of December 16, 2014. PH-CO:ams 13-M-142 12/14 cc: Eric Berliner, D~puty Commissioner, Health Services Unit Heidi Grossman, General Counsel/Acting Chief of Staff Sonia Angell, M.D., Deputy Commissioner Division of Prevention and Primary Care Department of Health & Mental Hygiene George Axelrod, Deputy Execut ive Director, NYC Department of Health & _Mental Hygiene Homer Venters, Assistant Commissioner Stuart Delery, Assistant Attorney General For Civil Rights, US Department of Justice