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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

 

 

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