Letter to Governor

  • e Diamond, Ph.D. 350 Lenox Road, Apt. 6P Brooklyn, New York. 11226
    November 30, 1988
    Governor Mario Cuomo Executive Chamber State Capitol
    Albany, New York 12224
    Dear Governor Cuomo:
    I believe that there are continuing instances of physical and sexual abuse on my unit (Childr en· and Youth, Kingsboro Psychiatric Center) which are either unreported, improperly investigated or covered up. I have been through various channels of supervisors and administrators as well as appealing to several state agencies (including the Commission of Quality Care, Regional Office, and the Bureau of Employee Relations) throughout the past five years and have yet to receive a proper response to my concerns. I currently fear for the safety and welfare of the patients I work with and feel the matter deserves your attention.
    Three out of my current caseload of four patients have been involved in alleged incidences of abuse. In each occurrence I have been unable to get any information nor find anyone within the state system who was willing to discuss these incidents with me. According to the administration at Kingsboro there is a policy of “containment” involVing allegations of abuse against patients and that the entire matter is not to be discussed outside the official investigation . According to this policy I am not to talk to my patients, their families or my supervisors concerning these incidents.
    One of the more recent occurrences involves a primary patient of mine who allegedly sexually molested another patient on the ward. This incident was not reported at the time. I expressed my concerns to my administrative supervisor (Dr. Jack Cohen) who stated that I had organic brain damage and that he was not interested in hearing my allegations.
    On October 16, 1986 one of .my assigned patients confided in me that she had been sexually abused by her teacher. Soon thereafter three other patients from the same classroom reported similar incidents to me.
    My patient had been desperately trying to come to turns with the alleged incident and had been seeking me out on a quite frequent basis for this purpose. However, soon afterwards, I was told by my superiors on the unit that my patient was not talking to me about the alleged incident and that I was not to discuss it with her {the patient), or anyone else. I was told that the patient was unable to trust males and that the investigation into the matter would be conducted entirely by females. I explained that the patient
    “‘·
    was indeed talking to me about the incident, that it was crucial that she continue to do so. I was once again told, this time quite emphatically, not to discuss the 1nc1d.ent With anyone.
    I feel that attempts to treat my assigned patient were seriously being interfered with, resulting in harm to her. I vehemently expressing my concerns to Or. Louis Jacobson, Chief Psychologist at Kingsboro, who responded by warning me not to make waves and advising me that if·I wanted to continue working at lCingsboro I would. have to learn how to listen to my supervisors.
    On January 27 the patient in question went AWOL and on February 2 I again expressed my concerns to my supervisor. My patient has proven to be quite self-destructive and highly vulnerable during past AWOLs and I feared for her safety. Dr. Jacol>son responded that he was tired of hearing of my concerns and wanted me to continue focusing on my psychological test reports. The next day my patient was discharged to an unknown relative with an unknown address and telephone number. I was ordered to falsify documents stating the she was being discharged to a group home.
    She later had to be saved by the police as she was being physically abused
    by a family member. Soon afterwards she was returned to Kingsboro.
    At this time the teacher in question was barred from appearing on the grounds of Kin gs bor o. However, I have seen this individual back on the campus several times since. Each time my patient heard that he was on campus she became highly upset since · he had threatened to harm her. On one of these occasions the patient went AWOL again, and, thankfully was ordered not to return Kingsboro Psychiatric Center by Brooklyn Pamily Court. Unfortunately, I fear that the teacher in question was simply allowed to seek employment elsewhere, and I have heard it mentioned that he is teaching adolescents aga in .
    Or.. Jacobson has continuously refused to talk to me about these as well as other related matters including the falsification and alteration of documents and reports related to my cases.
    During the past year I have received no appropriate supervision or evaluation of my w or k. However, my clinical privileges continue to be reduced and I was reported to the Office of Professional Discipline in order to have my license revoked . Dr. Jacobson and my present supervisor, Dr .
    Stephen Hershey have refused to talk to me about this.
    I have sought help from theNew Yorck State Psychological Society, but they will act only after I had received a resolution from within Kingsboro (an unlikely event) – they explained that they had little ability to investigate.
    I contacted the State Office of Professional Discipline and they referred my concerns to Ms . Mildred Breyer, then at Regional Office. Approximately a year and a half ago Ms. Breyer wrote saying that she will investigate and get back to me. I have yet to receive a response from her despite the fact that Ms. Breyer is now the director of my unit

  • over a year ago 1 wrote to Dr. Curry (then in charge of my unit, now Commissioner of Children and Youth) as per a grievance settlement between myself and the IC.ingsboro a d m in is t r a ti on. Dr. Curry was to investigate my concerns; I have not received a response.
  • I have been told by my present supervisor that it is my ethical responsibility­ to resign from my jo_b if I am unable to resolve my concerns within the system. I disagree — I feel ethically bound to pursue incidences of abuse of patients until 1 receive an appropriate response. I hope that you can help me in this matter.
    Sincerely you.rs,
    Kenneth Lee Diamond, Ph.D.

Statement to Commission of Quality of Care January 25, 1989

I have been employed at Kingsboro Psychiatric Center over six years.

I am very concerned about unreported or coverup of allegations of suspected abuse, both sexual and physical.

For years Building 10, which is abandoned above the second floor has been used by patients for meet up for sex. Last Tuesday January 17, 1984 GW, my patient, reported to me that he had just had sex with MW, an ex-patient  that he reported was on grounds. I went to Wilson and Perrotte to report this but they weren’t there. I wrote a report and left it for Pwrrotte later that day. Wilson got upset with me for writing the incident. She said since I hadn’t actually seen it the report shouldn’t have been filled out. I am not aware of any further reporting or phyiscal testing of these people.

GW also reported sexual encounters with KV and L?

Security Officer L? did discuss this with GW on Friday. I heard Security Officer L? I heard the officer state that Building 10 was used by crack addicts and other staff  for their own purposes.

It was reported at a community meeting on February 1988 that GW had locked himself (barricaded) in a bedroom with peer Otis Williams. The kids reported that Otis’ rectum was bleeding. There was a report about this in the progress notes but there was no incident report made.

I complained to my supervisor Dr. C. He said I misinterpreted the events. He said I had organic brain damage because of my perseverating interest in the abuse of patients.

Dr. Jacobsen, the chief psychologist, had told me a year earlier that I should see a psychotherapist because I was overidentifying with the patients by frequently reporting suspected abuse. I did go to the facility employee counselor . She felt I needed help in reporting incidents and referred me to Quality Care person.

On October of 1986 I reported an allegation involving JL , KV and teacher JF. For weeks later staff encouraged her to go to class with JF and she remained upset and went AWOL.  One year later JF left Kingsboro after being seen by Personnel and was later reported to have gotten a job teaching in a  NYC public school. Since then JF was seen by me and others several times near the Children and Youth building.

During another AWOL JL was discharged. I was told to fill out a discharge summary and service plan several weeks? (end of page 2 unclear)

During this time there were ways to contact JL. She said she didn’t want to return — she was afraid for her safety.

EB is a patient with a history of sexually and physically acting out. He and three other patients formed a “posse” to abuse other children. This posse continued for 3-4 months. The staff was afraid and couldn’t control them. The other boys were  EJ, RL and CL.

At a community meeting and by being told by CW’s therapist MV it was reported that CW was sodomized or violated by the handle of a brush or comb. There was no incident report or investigation that I am awas aware of this. I think it took place last summer. Team leader KP was aware of this.

I witnessed multiple patient to patient assaults involving E and others

I had filed an incident report on December 15, 1988. I found GW on the floor of the quiet room. The quiet room is on the bedroom wing. The wing door was locked. RC is a patient who gets placed in the Quiet Room and is unattended for hours on end. The kids report this to me and at community meetings. I filled out an incident report stating this.

ad sexual A long time ago it was reported that patient CH, long time discharged,  had sexual contact with G, an MHTA. At the time I report this to CB, then Team Leader, who told me it was being taken care of. There were frequent reports of G being physically abusive to kids as well as hitting them. Around 3-4 months ago the kids complained at a community meeting in the presence of MB. Statements were taken. The kids reported that G had meetings with them to pressure them to retract their statements. They did. TN said G threatened him with physical violence.

RR had been verbally abused by staff on numerous ocassions.  I had heard PF and others curse her calling her a “bitch” and “you’re disgusting”. PF told me at the time that she did slap RR when she lost her temper.

CR who is presently a social worker assistant told me that ND was reported to be having sex with staff DJ

It was also report that SC had sexual relationships with RE a MHTA during her inpatient status and after discharge.

(End of page 4 unclear)

I wrote a letter to GLarsen? executive head of Kingsboro expressing concern of physical and sexual abuse of patients.

TS now an ex-patient told me on 2/17/88 and 2/19/88 that a KPC employee in Building 10 was involved in selling crack.  As TS also sold crack he also report it to either P or HC. He told me they took him to Building 10 to find the worker but didn’t think they were serious.

It was widely reported and accepted by patients and staff that ex-patient CC returned to the ward several times after discharge and at least one ocassion displayed a gun, beeper and bragged to be a drug dealer.

Around 5 years ago CH and ?, both inpatients. She got pregnant while an in-patient.

This past January 23 a progress note on JO stated he had masturbated two female patients AC and BE

In December 1985 I requested an investigation into the suicide attempt of DT.  (end of page 5 unclear)

HC wrote on  a report that I was DT’s therapist. I was not DT’s therapist but a NYU social worker student was. I believe a cover-up was attempted.

About four weeks ago TM accused staff IG of fighting with him. He said play fighting turned serious and IG hit him during the fight. He directly went AWOL and was afraid of a coverup and getting an IM.

(TM would volunteer for  the Angel Guarduans during his passes)

I am especially concerned that Kingsboro’s containment policy on investigations doesn’t allow clinicaians to get involved in abuse treatment is their patients or their families.

Response of CQC

NEW YORk STATE
OFF1CE Of MENTAL HEALTH
KINGSBO!tO PSYCHIATRIC CENTER

PM ICI A AIIOACH, M, .H.

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Richard C. Suri.. , Ph .O., Commlnioner

February 16, 1990

Clarence J. sundram Chairman

Com:ni11ion on Quality ot Car• tor the M•ntally Diaacl•d

99 Waahington Avenue, Suite 1002 Albany, New York l22l0

Dear Mr. Sundram:

We are in receipt of yQur letter ot Dee•mb•r 21, 1989 in which you detailed the Commission’• concernJ and general obaervationa regarding the Children and Youth Unit durinq the recent inveatiqations of allegation• of abuse and neglect.

Consistent with the Commi11i0n1 ob1arvation1, we believe that signiticant 1tep9 hav• been taken to integrat• the Children’• Unit into th e organi:z:ational atructurc o! the hoapital, and to mako nec111ary change• in the admini1trative and clinical organizational structure• within the unit.

With the appoint ent of Alvin Smith, Ph.D. •• Unit Chiet we have baen &Dle to be;in the long term proc••• of addresain; the or;anizational and policy i11u11 which impacted 10 severely on the functioning ot the unit prior to rebruary, 1989.

We have developed Plan of Corr• tiva Action (appended) which addre•••• the recommendations a• outlined in your letter.

We would also, however, like to use this opportunity to raise an i11ue for con•idn-ation by the Commi1si0n. Whil• we cannot dispute the n•ed tor ataft training in specific ar••• as identitied by the inve1ti;ation, ••·well as·through internal m1a1ures, it has b••n our experience that a sustained incremental approach to traininq which allow• for the development of skills and competence through practice and 1up1rviaion ia equal in importance to the training initiatives. Thia is particularly important if the objectiv• i• to permanently change staff behavior and clinical practice.

681 Clarkton Avenue. irooklvn, New Yortc 11203 • (719) 7’36-1700

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  • February 16, 1990

    This represents • long term syste ic corrective action strataqy which on the Children’s Ur.it be;an with orqanizational ( i. e, • truct\.lral change and i• now in the policy revision /development/implementation phaae. The identified deticiencies ot •taft are beinq addressed, and will continue to ce addressed. however, permanent, la1tinq chana• will take tim and require paeinq in the introduction ot new coneel)ts, a• well as, opportunitie1 to reevaluate educational strategiea once statt have been observed in eircumstanee1 where l• rned skills have ceen utilized.

    Al an example, we have over the paat tew month• focused on the development of a1ic skills (e.g. Behavior Management, etc.) and the development ot new clinical team•– with ;reater profe1aionsl stat! involvement. We anticipate that educational effort• in ar••• like working with the sexually abused adolescent will only become permanent part• of the clinical care once the basis ayatemic •r••• ot concern are routinely addra111d While we believe that aic;nificant proqre11 ha1 been made in this regard, it will take time to achieve an improved uniform level of performance.

    We will be monitoring pro;resa in the area• outlined in the Plan of Correction at re;ular intervals and trust it is reapon•ive to your concerns.

 

CURENCEJ SUNORAM

CHAIRMAN

STATE OF NEW YORK

COMMISSION ON 0UAUTY OF CARE

Fo” THE MENTALLY OISABLEC

99 WASHINGTON Avu •uc Su1T1; 1002

ALa AN,Y New YORK 122!0

(5l 8)4 7 3 – 40 90

(T OOl 473-7871

December 21, 1989

JAMES A. CASHEN

!RENE L. PL.A TT

COl,IMISSIONEAS

Ms. Patricia Roach Executive Director

Kingsboro Psychiatric Center

681 Clarkson Avenue

Brooklyn, NY 11203

Dear Ms. Roach:

As you are aware, as a result of a letter sent to the Governor alleging multiple incidents of abuse and neglect involving children at Kingsboro Psychiatric Center, as well as a failure to properly report and investigate these activities, the commission has been conducting an investigation into these and other activities since the end of January, 1989. The initial information provided to the Commission led to eleven cases of alleged child abuse or neglect being reported to, and accepted by, the State Central Register for Child Abuse and Maltreatment. In responding to these eleven reports, Kingsboro Psychiatric center and the Office of Mental Health Regional Office for New York City commenced an investigation in the course of which over thirty additional previously unreported incidents of suspected abuse or neglect were called in to, and accepted by, the Register.

The purpose of this- l etter is to share with you our overall observations about the operations of Kingsboro Psychiatric Center’s Children and Youth Units during the period covered by the investigation, as· well as to offer several recormnendations. Each individual case is the subject of a separate letter.

At the outset, I would like to express the Cormnission’s appreciation for the cooperation and assistance we have received from the staff of Kingsboro Psychiatric center and the OMH Regional Office for New York City during the course of this investigation. In particular, we would like to recognize the efforts of Mark Bienstock, Margaret Hotz, Carla Bromberg and the

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Ms. Patricia Roach -2- December 21, 1989

special investigators. In addition, we want to note that both you and your Assistant Director, Mr. Weeks, offered the Commission full- supportand assistance during the course of this investigation. The Commission acknowledges and compliments the prompt investigative efforts undertaken by Kingsboro Psychiatric Center and the OMH Regional Office in this matter, as well as the quick actions that were taken early in the investigative process to reassign clinical and supervisory staff and to effect changes in the management structure of the Children and Youth Units to ensure the protection of children in custody.

The Commission’s major findings are as follows:

  1. From its inception, the Children and Youth Service has been clinically, physically and administratively separated from Kingsboro Psychiatric Center and has not had consistent working relationships with other departments of the facility (e.g., Quality Assurance, Education and Training, etc.), that may have been able to assist it in carrying out its mission. The problems caused by this isolation were compounded by the high level of staff turn-over in senior management, as well as multiple changes in the administrative structure and operations of the Children and Youth service. Planning the creation of a new Brooklyn.Children’s Psychiatric center also resulted in the transfer of key management and administrative staff, leaving critical vacancies for extended periods of time. In addition, the’Acting Executive Director (Ms. Breyer) split her time between administering the inpatient units and developing and planning community resources for the new children’s psychiatric center. There were extended vacancie in the treatment team leadership positions. At the same time, Kingsboro Psychiatric center itself was undergoing leadership changes and experiencing vacancies in key positions, while the facility was beset with significant problems of overcrowding and quality care.

    The overall effect of these factors was that there was a lack of effective leadership and direction of the Children and Youth program, an absence of staff training, direction and supervision in proper procedures for the care and treatment of children in their custody, and major breakdowns in the systems of

    docwnenting, reportin_g and investigating untoward incidents•

    .

  2. This investigation was hampered by the absence of required documentation, prompt reporting and investigation of incidents, as well as by the disorganized maintenance of facility records which resulted in the unavailability or inaccessibility of records. These deficiencies had a critical impact because of the difficulty children had in identifying the dates and times of incidents that had occurred long before they were reported to the State Central Register. It was often impossible to establish with sufficient confidence many of the incidents, about

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    Ms. Patricia Roach -3- December 21, 1989

    which we received credible testimony, had occurred. Without such information, it was not possible to identify staff responsibility for supervision of the children involved in reported incidents.

    The commission has therefore recommended to the Department of Social Services that these cases be “unfounded.” In other cases involving the inappropriate use of seclusion or improper restraints, we found an absence of clear facility policy or training to guide staff conduct, essentially leaving staff to manage children’s behaviors as best they could. Here again, although there was credible evidence that these incidents had occurred, the Commission determined it inappropriate to recommend “indicatin11gsuch cases. Finally, in a number of cases, the commission determined that the children’s allegations were not truthful.

  3. Notwithstanding the recommendation to 11 unfound”the majority of these cases, this investigation provided strong evidence, from the credible accounts of both children and staff, of a persistent pattern of inadequate supervision of children over long periods of time. The absence of supervision permitted children to be threatened and assaulted by their peers and, in some instances, to be coerced into surrendering money, clothes and other possessions with the threat of bodily harm. Several children within the program admitted to multiple incidents of sexual activity, including intercourse. Most of these ep sodes apparently occurred during the educational program when children would cut class and go to the abandoned portion of Building 10, · above the second floor. Although staff had been aware for some time of children gaining access to this area, no effective action was taken to prevent this until this investigation commenced. The weaknesses in supervision of patients permitted a numcer of children to leave without consent or to escape, as well as permitted incidents of alcohol and drug abuse by several children, some of whom had previously been identified as alcohol or drug abusers.
  4. Finally, we noted a long-standing absence {prior to the commencement of the current investigation) of appropriate investigation, follow-up and corrective action when incidents occurred or when supervisors and administrators became aware of improper staff activities. For example, staff were left to deal with the acting-out behavior of children through physical restraints and the misuse of a Quiet Room for seclusion.

Children were locked in the Quiet Room despite a policy forbidding seclusion, despite a lack of a physician’s order, and without monitoring by staff. These practices were made known to facility administrators but corrective actions were not taken.

In several of the incidents involving sexual activity of children or alcohol or drug abuse, there was inadequate follow-up to ensure prompt medical attention, testing of children, or measures to preven·t recurrence of such incidents. Needless to say, all’of

 

Patricia Roach -4- December 21, 1989

these factors evince significant weaknesses in developing and implementing adequate treatment plans for the children in custody.

********************

The Commission notes that, during the course of this investigation, a number of steps have been taken to correct the problems identified in the Commission’s investigation, as well as in those of Kingsboro Psychiatric Center and the OMH Regional Office, including:

  • incorporation of the Children and Youth Unit into the management structure of Kingsboro Psychiatric Center;
  • the appointment of a Chief Medical Officer for the Children and Youth Service;
  • assignment of a Director of Education to oversee the Inpatient Adolescent School;
  • improvement of environmental conditions in the Children and Youth Unit;
  • movement of the dining facilities and the school program out of Building 10 and into Building 6;
  • the development of clinical teams;
  • the filling of key .leadershippositions;
  • the revision of the level system; and
  • the scheduling of inservice training for staff.

In addition to the measures already taken, the Commission recommends that Kin9a.bo o Psychiatric Center:

  1. review the· adequacy of direct care, clinical and supervisory staff on the day, evening and weekend shifts, a• well as the adequacy of structured programs and patient supervision after normal business hours and on weekends. Please advise us of what changes, if any, you deem necessary;
  2. develop comprehensive policies regarding the drug and alcohol screening of children, particularly in instances where children are suspected of, or admit to, the use of drugs and/or alcohol. There is a need to
    • recognize the danger of children using drugs or alcoholimageimagePatricia Roach -5- December 21, 1989while receiving psychotropic medications from the facil ty;.
  3. given the chaotic state in which facility records were maintained, develop procedures and guidelines concerning the creation and maintenance of a comprehensive system of records, including those specifically required to be maintained by law or existing OMH policies and regulations;
  4. review existing procedures for the identification, reporting and investigation of incidents of abuse and maltreatment of children, and ensure that staff are fully familiar with the requirements of law and OMH policies;
  5. develop procedures to ensure the implementation of recommendations emanating from investigations, unless the facility has clearly communicated its disagreement with the recommendations. In the course of this investigation, several incidents were uncovered that could have been prevented had the facility aggressively implemented previous recommendations made by the Commission;
  6. consider instituting a practice of periodically interviewing staff and children with regard to program, supervision, and care and treatment. These interviews should also address staff and children’s perceptions of their safety. In addition, the facility should consider a routine exit interview to be done with each child at the point of discharge;
  7. given the substantial confusion that staff appear to have about how to respond to incidents involving sexual activity among children, develop a policy and guidelines ta assist the staff to appropriately respond ta such incidents. We would reiterate the recamaendations previously made to the Office of Mental Health as result of the investigation into Western

    evYork Children’s Psychiatric Center;

  8. conduct a comprehensive review of staff training needs and develop a training plan to meet these needs, with sufficient specificity to ensure that all staff receive appropriate training on a scheduled basis. Among the areas where training appears to be needed are: Incident Reporting; Management of Aggressive and Acting Out Children; Appropriate Uses of Restraint and Seclusion; Responding to Drug and Alcohol Abuse by

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‘ .· CLAR ENCE J . SUNORAM

Cl-4AIAMAN

STATE OF NEW YORK COMMISSION ON QUALITY OF CARE

FOR THE MENTALLY OISABI..E0

99 WASHINGTON AVENUE. Su1T1; 1002

ALBANY. Na:w YOltl( 12210·2895 (518) 473-4090

(TOO) 1-800-624-4143

May 15r 1997.

aizaheth i. Staclt

iillia11t P. Benjamin

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XDRZWX•@il),ri!Y

COMMl$SIONEMS ·

Ms. Elizabeth R. Schuster As ociate Counsel

Public Employees Federation, AFL-CIO

1168-70 Troy-Schenectady Road

P.O. Box 12414

Albany, NY 12212-2414

Dear Ms. Schuster:

Your letter of April 28, 1992 to Ray Barron ·was referred to· me as the Commission’s records access officer under the State’s “freedom of infer.nation” law (Public Officers Law, Article 6).

You are correct that information provided by psychologist Dr. Kenneth L. Diamond was used in an investigation of multiple alleged incidents of abuse and neglect of children and other related matters at Kingsboro Psychiatric Center. When the Commission began its investigation of the incidents reported by Dr. Diamond, other additional incidents were discovered and the enclosed letter of findings was sent to the facility director. As you know, specific child abuse/neglect case findings are precluded from disclosure under the above law and other statutory provisions. A copy of the facility’s response is also enclosed.

trust this responds to your request.

Sincerely yours,

7.J

Gary W. Masline, JD MSW Executive Assistant

to the Chairman

GWM:gc Enclosures

cc: Clarence Sundrarn Elizabeth Chura

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Grievances Presented to Staff Meeting April 16, 1995

 

Letter to Patricia Lambert August 14, 1994:

“I am still awaiting replies to the letter I have sent you. I believe that conditions under which I am presently working are intolerable. Attempts to resolve these issues with administrators such as Dr. Reese and Mr. Jorawar have resulted in further cover-up and harassment. My physical safety has been threatened as well as my career. As a result, I am having extreme difficulties dischargong my responsibilites as a state psychologist and once again request your immediate intervention.”

As I have repeately expressed, I have been forbidden from reporting my concerns for patients’ welfare and its coverup on State time.

Despite documentation that there is

 

Kenneth Lee Diamond, Ph.D. Kingsboro Psychiatric Center Brooklyn, New York
GRIEVANCES Current Draft: April 16, 1995
INTRODUCTION TO CURRENT GRIEVANCES
I have written the following notes in order to make asspecific and concise aspossible my grievances against Kingsboro Psychiatric Center.
The precipitating incident for the present grievances was the failure of Ms. Lambert, former Executive Director of Kingsboro, to respond to my letter to her dated August 14,
1994. This letter states, in part:
“I amstillawaitingrepliestothelettersIhavesentyou. Ibelievethatconditionsunder which I am presently working are intolerable. Attempts to resolve these issues with administrators such asDr. Reese and Mr. Jorawar have resulted in fiirther cover-up and harassment. My physical safety has been threatened aswell asmy career. As a result, I am having extreme difficulty discharging my responsibilities asa state psychologist and once again request your immediate intervention.
“1 have enclosed my most recent correspondence with Kingsboro administration which details some of the concerns.”
AcopyoftheaccompanyingdocumentIsentMs.Lambertwas affixedtothepresent grievance. This document was sent to her after various unsuccessfully attempts to have it addressed by Mr. Jorawar.
\
These present notes are not as comprehensive, specific, readable (indeed, at times they appear rambling in my attempt to straighten out confusing bureaucratic circles) or accurate as I would have liked. The issues are complex and long standing. There seems to have been a reoccurring pattern of having to go through the “chain of command” up to theendandthen sentinacirclebacktothebeginning.AsaresultIhavewellovera hundred pages of notes to present, of which, by necessity, this current document is an

abridgment. AsIhaverepeatedlyexpressed,Ihavebeenforbiddenfromreportingmy concerns for patients welfare and its cover-up on State time.
I will try to limit myselfto conditions since I reported child abuse to Employee Relations (local) on February 9, 1989. (However, when necessary to make a point or provide a clearer explanation, I shall mention earlier instances.) This limitation is in some cases arbitrary and I do wish to present a more complete accounting when time and conditions permit. In addition, many of the more pressing concerns which involve legal or criminal matters havealreadybeenreferredtotheproperauthorities. Alsoexcludedarerecent incidences which are being addressed in confidence by other agencies and forums.
Please note that Mr. Ned Mack, the person who I assume will make a decision or at least a review of this current step in the grievance process has already proclaimed that my past attempts to have these same issues addressed are “insulting.” I amnot sure what he 1 particularlyfindsinsulting.I amconcernedabouthowobjectiveMr.Mackcanbeinthese : matters.
The advise and directives I have gotten during this present grievance process is the same advise and directives I have gotten over and over again , sending meto the same offices which have repeatedly harassed meand covered-up my problems in the past. The remedy that I seek is a proper forum during State time to address my concerns in regards improper patient care without fear of retaliation or cover-up.
PRESENT CONDITIONS
Despite documentation that there is afull schedule of activities and groups for the
patients, very little of this is actually taking place and, in fact, during most of the day patientsarerestrictedtooneroomwithnothingtodo. (Theissueofpatientsnot
receiving treatment documented in their charts became of special interest to me when I
was assigned asProgram Coordinator in the summer of 1994.) Most recently, it was
reported to meby other stafl‘that earlier in this month, during aHCFA survey, patient
group attendance sheets were falsified in order to respond to requests for documentation from surveyors. I presented related charges to Albany and others in connection with the/” previous HCFA survey several months ago.
I haverepeatedlynotifiedtheunionofmyconcerns.Forinstance: January 2, 1995 letter to PEF President James Sheedy:

“Conditions remain horrendous, the welfare of the patients are in jeopardy, and union members are being pressured to falsify documents in order to cover up these conditions ”
Letter to union September 21, 1994:
“I continue to fear for the patients’ welfare, they are not receiving proper treatment nor care. Severalotherunionmembershaveapproachedmewithsimilarconcernsbutare afraid to speak out. Attempts to address these issues with administration only result in cover-up and retaliation.”
In a meeting with the union on December 7, 1994 I strenuous deplored these and related conditions Despite the union’s assertion that they have made vigorous attempts to resolve these issues with management, I have seen very little results except for continuing ‘ retaliation and cover‐up.
I informedothersatKingsboroofmyconcernsaswellForinstance,approximatelytwo months ago, I wrote the following to Dr. Reese, Director of the Psychology Department:
“Most importantly, I have told you repeatedly that I amhaving extreme difficulty fimctioningatKingsboroPsychiatricCenter. Ifeelthatpatientsarenotreceivingproper treatment and that both my personal safety and career has been threatened as a result of attemptsto addressthisconcern. Youhavetoldmethattherewasnothingyoucando about this. As a result, I have sought alternate channels for help and await advice on how to proceed.”
Most recently, on March 16, 1995 I sent a letter (as ordered by Ms. Osman, who is conducting this present grievance process) to Mr. Robert Morrison of Kingsboro’s QualityAssuranceDepartment,mentioningseveralinstancesofimproperpatienttreatment ( and neglect.
HISTORY OF RECENT CONCERNS
OnFebruary9,1989ameetingwasheldbythe OfficeofEmployeeRelations(local)in ordertoquestionmeaboutconditionsatChildrenandYouth. IexplainedthatIhadbeen retaliated against in the past for expressing myconcerns and asked for union / representation.Ms.BacofEmployeeRelations(local)refused,statingthatIwould not
be allowed union representation since she was conducting an interview n o t an interrogation. After protesting but seeing no other alternative, I told Ms. Bac and Ms. Panza ( o f Labor Relations (7)) of my concerns in regards child abuse/neglect at Children and Youth. I also reminded them of my numerous unsuccessful attempts to have these issues addressed through memos, documents, letters, telegrams sent to members of Kingsboro administration aswell asto the Bureau of Employees in Albany and of their consistent failure to respond.
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lllllllllllll!linionwas preparedto fight it.
A couple of months afterwards, a meeting was held with Mr. Bill Smith, MrRoy Owens (my union representatives) and myself in which it was explained to me that management had not been responsive to their informal efforts to resolve myconcerns and that they were going to file formal grievances.
I was given very little official and no in-title work in my new assignment at Program Evaluation; was prohibited from communicating with my previous unit; and was not allowed to work with patients. I spent time teaching myselfcomputer programming and readingpsychologyjournals. WhenIreportedfindingfalsifieddocumentsrelatedtothe Children and Youth investigation on one of the computers where I then worked, I was swiftly reassigned to another building asa library clerk and messenger, work previously done by a patient.
In the summer of 1989, as a result of my statements to the State Commission of Quality of Care, an investigation at Kingsboro was finally conducted. In this investigation Mr Robert Kretzel of Employee Relations (Albany) recorded weeks of meetings with me concerning specific incidences of child abuse/neglect. Mr. Kretzel explained that the investigation was “event-driven” and that only statements directly related to a list of specificincidenceswouldbeconsideredrelevant. Iexpressedmyfearthatthiswould preclude incidences of retaliation and cover-up by Kingsboro, Employee Relations (local
i
i andAlbany)andotheragencies,butMr.Kretzeldeclaredthat therewouldbeaseparate
investigation into these other matters. I have since gotten little response to myinquires about this separate investigation or my requests that I beallowed to submit relevant details andsupportiveinformation. Inlinewiththis,relevantnotesanddocumentswere confiscated from me by management.
Meanwhile, while working at the library I received a letter reducing my clinical privileges in all areas and requiring that I be supervised in my work with patients. This made little sense since I was not being allowed to do any work with patients, and I was also forbidden by management from contacting my supervisor.
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Finally in November 1989 I requested the intervention of my lawyer Almost immediately afierwards I was reassigned and a few weeks after that finally received a response to my grievance from Mr. Ned Mack stating that mygrievance was moot since I had already been reassigned (l?)
Employee Relations (both local and Albany) should have acted before I had to involve my lawyer. By their inaction they were sanctioning the out-of-title work I was assigned to for close to a year.
I was next reassigned out-of‐title work asaremediation instructor. I was informed of no significant problems with my work, received agood evaluation, yet on DATE I received a letter form the Ofiice of Professional Disciple notifying me of an investigation into charges of professional misconduct in connection with my work at Kingsboro. No
substance was found to the charges However, numerous irregularities were discovered in mysubpoenaedpersonnelfileincludingthemissingpositiveevaluationof DATE.I complained to Bill Smith concerning this and management responded with a memo stating that the evaluation was taken out several months after it was already found missing since it
had been overdue(!?)
When M r , Smith filed grievances [DATE} with Employee Relations in Albany, I sent a separate return-receipt certified letter informing them of such and requesting that they notify me if there were any problems. They never did. Employee Relations did respond to another letter I sent months later stating that they never received the grievance. M r . Smith had mailed this grievance on DATE, gave mea copy and stated that he received a
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verbal response from the Bureau in Albany simply stating that the grievance was found not worthy.
I first discussed many of the issues affixed to the current grievance with M r . Jorawar on June 21, 1991. These included my return to Children and Youth, clearing my name of false charges and difficulties getting continuing conditions related to the lack of proper patient treatment addressed. At the time, the latter included patients bringing back drugs
and alcohol to the wards; false documentation of treatment not actually received; and falsificationofrecords.(Manyofthespecificchargesreferredtowere laterdetailedina taperecorded meetingwiththeEmployeeRelations(local)onDecember21991; see below.) At that time Mr. Jorawar said he would bring the concerns up with Ms. Lambert,
and get back to me. The only response I received after a couple of months’ wait was written counseling for not adequately performing work asasocial work assistant. Mr. Jorawarremainednon-responsivetomynumerousattemptstoreachhim. AsaresultI contacted Ms. Adele Davis from Civil Service Commission in Albany DATE. She wrote
backstatingthatmanagementwasgoingtocontactmeinregardsmycomplaints. When Kingsboro failed to do so and even maintained that they were not even aware of my complaints, I again contacted Ms. Davis in a letter dated August 18, l 9 9 l . She had to have Mr. Jorawar ordered to meet with me, I was soon thereafter transferred to another

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unit where patients were much better treated and I no longer was in a position to have to report frequent patient mistreatment.
In December21, I992Mr.Jorawar calledameetingtoinformmethat I’dbefiredif I lr didn’t sign what I considered fraudulent psychological reports. I finally agreed to sign
these reports under duress since I saw little alternative and because Mr. Jorawar agreed to resolve my concerns. He said hewould schedule another meeting approximately a
couple of weeks later to discuss the implementation of a plan to resolve my concerns. Another meeting was never scheduled. Since that time I had been unable to meet with management until shortly after The Inspector General’5 Office intervened one year later.
The plan originally proposed in December 2l, l992 never was enacted. For instance, this plan included sending a letter to Dr. Reese requesting apromotion. I have been an entry-level psychologist for over a decade and have never received a promotion. Dr. Reese refused to provide a written response to this letter but has repeatedly informed me verbally
thatKingsborowasnolongerpromotingfromwithinitsownagency. Thiswaslast repeated in a January 1995 Psychology Meeting, (Among other correspondence related to this see Memo/letter? to union dated October 3, 1993 reporting a “situation {that}
appears to be against Civil Service procedures…,”.)
I contactedtheInspectorGeneral’5Officeinregardmyconcerns;theyhadme interviewed and then stated that they would follow through to see that those issues they could change would beinstituted byKingsboro (removal of geographic restrictions and an
evaluationindicatinganyproblemswithmywork). Duetotheirinterventionameeting was finally scheduled with Mr. Jorawar in December 1993, ayear afler the original meeting. The investigator for the Inspector General’s Office told methat they could not
resolve many of the remaining issues since they were within the providence of my union and management to work out. Since that time the union has been unable to resolve any of the remaining issues with management,
As a result, I wrote to the President of PEF DATE, and Mr. John Dillon was assigned to investigate my concerns. He has up to this date been unable to resolve any of the remaining concerns,
Afier complaining to the union of afalsified transcript of ameeting with Mr. Jorawar (at which I was improperly refused union representation), I decided to write asexplicitly asI could a point by point response to the false statements attributed to me. An early draft of
this document was sent to Mr. John Dillon on May 9, I994.
I was finally given a follow‐up meeting on July 6, 19940) to present my responses but due to time limitations I was able to only read the first two pages of a seventeen-paged document. Management agreed to schedule another meeting to permit me to continue
and later sent mea written “Discussion” of the July 6, 1994 meeting which again misrepresented my position and ignored the portion of the statement that I did read. I was never informed beforehand of the next meeting ( contacted at my home by M r . Dillon the
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day of meeting), Since it became apparent that I would not get anadequate response I combinedmywrittenresponseto theDecember 1993meetingtogetherwithawritten response to the then most recent meeting into a document dated August 14, 1994. I sent a letter to Ms Lambert together with the document complaining of conditions When it became apparent that I would get no response from her (as in numerous times past) I filed
this current grievance,
After this time harassment against me intensified and I started receiving death threats. At the advise of the union and others I brought these incidences to New York Police Department,NYNEX, legalauthoritiesandothers,
Therehavebeennumerousirregularitiesinthecurrentgrievancesmeeting. Forinstance,I neverreceivednotificationofthefirst meetingsetupbyEmployeeRelations(Albany)to hearmygn’vancesNoonebutmyselfshowedupforthe grievancemeetingofMarch3, 1995. More significantly, in agrievance meeting of March 16, 1995, Ms. Osman, ignored my claims of retaliation and cover-up by Kingsboro, and ordered meto report my concerns in regard to patient treatment to Kingsboro’s Quality Assurance Department
(Dr. Reese, who attended this meeting, explained to methat Ms. Osman had no authority to make such an order.) I have enclosed a copy of the resulting letter which I sent on March 17, 1995. This letter mentions several instances of improper patient treatment within a half-hour period, including finding patients unattended, one semi-nude, another sitting in a pool of urine aswell as pressure from administration to falsify patients‘ charts. As in most of my past attempts to get similar matters addressed within Kingsboro, I have
received no response, and conditions essentially remain unchanged.

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Notes for Grievance Meeting February 27, 1995 Kingsboro Psychiatric Center Brooklyn,NewYork
Draft: February 26, 1995
I was informed in the last meeting that I was not entitled to results of investigations conducted by the State in connection with patient conditions at Kingsboro. While I agree that there are reasons in certain cases to keep some of the findings confidential there are
circumstances where it is absolutely essential that staff be informed of the results directly related to patients they amtreating.
For instance, I amcurrently working with a patient who accuses staff members of abusinghim. Heisanextremelydifficultpatienttoworkwithashefrequentlyelicitsstaff rage and anger by spitting at them, exposing his genitals, making bigoted statements, etc. I have daily psychotherapeutic contacts with this patient, but believe that hecan not
receive proper treatment from me unless I know whether in fact staff is abusing him or not. Oneofissuesishisabilitytoaccuratelyreportandinterpreteventsintheoutside world, I can not do soeffectively without knowingthe “reality” asdetermined by the
investigation into his charges. Should I treat this patient asavictim or asanaggressor -‐ that makes a big difference! In effect, by not releasing this information to those who work with him, his treatment is being hindered and the welfare of the people who live and those that work with him are being potentially threatened
The need for concrete information was most clearly seen when I worked at Children and Youth. For example, aformer patient of mine complained to methat her teacher was sexuallyabusingher. (Ibelievethatthefollowingseriesofincidenceswerenotcovered by the Bureau’s August 1989 investigation.) I informed the Treatment Team Leader who
said that he would investigate. Other patients came to mewith similar reports I was told that I could not talk to my patients about these issues because there was an investigation underway. This despite the fact that the patient who had first alleged abuse desperately wanted to talk about the abuse during therapy sessions and even throughout the day.
She was showing extreme signs of stress and was in immediate need of my psychotherapeutic interventions asshe was apparently not speaking to anyone else about these incidences. I was forbidden from taking about this in family sessions when her motherdemandedtoknowwhyherdaughtersuddenlyseemedtobefallingapart. Thisis

a child allegedly raped by staff in a psychiatric hospital and forbidden to receive treatment for it! The staff member was allowed to continued to work on the ward and a treatment plan was developed to encourage the patient to stay in his classroom. After several weeks of no apparent indication of any investigation, I reported the incident to Commission of Quality of Care.
The staffagainst whom the allegations were made was finally ordered offground. However, he returned several times thereafier, apparently unnoticed by administration, but certainlynoticedbyotherstaffincludingmyself,andmostsignificantly, thepatients themselves, who reacted with severe signs of distress.
As far as reporting these matters, I was told at the time that it was sufficient to tell ChildrenandYouthadministrationwhowoulddoanynecessaryfollow-up. Iwas specifically told not to write incident reports, or anyway follow-up on my concerns since it was already being investigated. I was told to utilize incident forms only after I reported these and other incidences to Governor Cuomo and the Commission of Quality of Care.
For specifics about this and similar incidences please see documents turned over by me (as well asby others) to Mr. Kretzel during the August 1989 Bureau of Employee Relations (Albany) investigation into these matters
My main concern with regards to not getting any feedback from alleged investigations by Kingsboro is that proper investigations do not, in fact, take place For years I have been told that my allegations were being investigated, but conditions do not change. I was never interviewed with regard to what myspecific charges were, never given the opportunity to present supporting records and documents. This pattern of non-response to serious charges continues to this date.
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