We are shocked and distressed by this situation. It is clear that some of our employees failed to act based on our compassionate standards of care. Immediately after the incident was discovered on June 20, and following a preliminary investigation by HHC staff, HHC President Alan D. Aviles directed the suspension and termination of those involved. The case and video surveillance tapes were immediately turned over to a number of health oversight agencies, medical misconduct boards and law enforcement.

For the past year, we have been making improvements to the psychiatric program at Kings County, including adding more staff, improving crisis management training to care for patients in distress and expanded space to address the overcrowding. As a result of this tragic incident, we will put into place additional and significant reforms to help ensure the care and safety of psychiatric patients under our care is not compromised.

Recent and future reforms to the Kings County Psychiatric Emergency Program include:

• Additional staffing.
• Expanded crisis prevention training for staff, including managing of agitated patients.
• Expanded space to address overcrowding.
• Shorten patient wait time for treatment, release or placement to inpatient bed.
• The appointment of a new interim administrator who will report directly to Mr. Aviles.
• Patients in the psychiatric emergency unit will be checked every 15 minutes.
• A clinical staff person will be assigned this responsibility for each shift.
• Timely documentation of patient care and assessment.