IHS’s Ability to Collect and Preserve Medical Forensic Evidence Varies by Hospital

IHS has limited information on the ability of IHS and tribally operated  hospitals to collect and preserve medical forensic evidence in cases of  sexual assault and domestic violence, as needed for criminal  prosecution—that is, on the hospitals’ ability to offer medical forensic  services. We also found that the services available at a  hospital generally developed without direction from IHS headquarters and  have fluctuated over time. In addition, the utility of such evidence in any  subsequent criminal prosecution depends on hospital staff’s properly  securing and storing physical evidence, which may in turn depend largely  on coordinating with law enforcement agencies. Of the 34 hospitals categorized as remote, 22 hospitals reported  that they are able to perform medical forensic exams for adults, children,  or both; 12 of the 34 hospitals reported referring victims to other facilities. Local medical  providers chose to provide such exams in response to an unmet need for  such services in their area, not because IHS headquarters directed them  to do so. IHS and Tribal Hospitals Face Several Challenges in Standardizing and Sustaining the Provision of Medical Forensic Services

Since enactment of the Indian Health Care Improvement Reauthorization  and Extension Act of 2009 (on March 23, 2010) and the Tribal Law and  Order Act of 2010 (on July 29, 2010), IHS has made significant progress  in developing policies and procedures regarding medical forensic services  for victims of sexual abuse, as the acts required. The new policy, issued in March 2011, is an important and sound first  step in what is planned to be a continuing effort to provide a standardized  level of medical forensic services. These challenges include systemic  issues—such as overcoming long travel distances and developing staffing  models that overcome problems with staff burnout, high turnover, and  compensation—so that standardized medical forensic services can be  provided over the long term. In general, our work confirmed that IHS is aware of the challenges that it  faces and either has initiatives under way to address them or is trying to  formulate such initiatives. Establishing Plans to Help Ensure That Hospitals Consistently Implement and Follow the March 2011 Sexual Assault Policy

Now that its initial sexual assault policy is in place, IHS faces the  challenge of ensuring that its hospitals consistently implement the policy  and follow its guidelines. Developing Policies on Domestic Violence and Child Sexual Abuse

IHS’s March 2011 sexual assault policy instructs IHS hospitals to provide  a standardized response to adult and adolescent victims of sexual  assault. Factors besides Medical Forensic Evidence also Contribute to Decisions to Prosecute Cases of Sexual Assault and Domestic Violence

Decisions to prosecute sexual assault or domestic violence cases are  based on the totality of evidence collected, one piece of which is medical  forensic evidence collected by IHS and tribally operated hospitals. Prosecutors and law enforcement officials said they  consider several factors—including medical forensic evidence collected  by hospitals. In some cases, medical forensic evidence  may be a crucial factor; in others, however, it may not be relevant or  available. Some victims in small reservations or isolated villages may refuse to  cooperate or may retract their initial statement, for example, because of  pressure exerted on them by family or community members who may  depend on the alleged perpetrator for necessities such as food or fuel. As  a result, the victim may be unavailable to testify. Additionally, according to  several prosecutors with whom we spoke, the availability to testify of  medical providers who performed the associated medical forensic exams  at IHS or tribally operated hospitals is an important factor because such  testimony can help demonstrate that an assault occurred or help  otherwise support a victim’s account of an assault. Recommendations for Executive Action

To improve or expand medical forensic exams and related activities for  the 28 IHS operated hospitals, we recommend that the Secretary of  Health and Human Services direct the Director of the Indian Health  Service to take the following five actions:    Develop an implementation plan for the March 2011 IHS sexual  assault policy (Indian Health Manual, chapter 3.29)—and monitor its  progress—to clarify how the agency will support its hospitals and staff  in fulfilling the policy, in particular, that the hospitals or staff:    obtain training and certification in providing forensic medical    obtain equipment like cameras needed to collect evidence;    provide medical forensic exams on site or at a referral facility  within 2 hours of a patient’s arrival; and  collaborate with law enforcement agencies, prosecution, and other  stakeholders identified in the policy with the objective of creating  sexual assault response teams and obtaining regular feedback  from such stakeholders on evidence collection and preservation. Appendix I: Objectives, Scope, and Methodology

Our objectives were to determine (1) the ability of Indian Health Service  (IHS) and tribally operated hospitals to collect and preserve medical  forensic evidence for use in criminal prosecution in sexual assault and  domestic violence cases; (2) what challenges, if any, these hospitals face  in collecting and preserving such evidence, particularly in remote Indian  reservations and Alaska Native villages; and (3) what factors besides  medical forensic evidence collected by these hospitals contribute to a  decision to prosecute such cases.
Why GAO Did This Study

The Justice Department has reported that Indians are at least twice as likely to be raped or sexually assaulted as all other races in the United States. Indians living in remote areas may be days away from health care facilities providing medical forensic exams, which collect evidence related to an assault for use in criminal prosecution. The principal health care provider for Indians, which operates or funds tribes to operate 45 hospitals, is the Department of Health and Human Services' Indian Health Service (IHS). In response to a Tribal Law and Order Act of 2010 mandate, GAO examined (1) the ability of IHS and tribally operated hospitals to collect and preserve medical forensic evidence involving cases of sexual assault and domestic violence, as needed for criminal prosecution; (2) what challenges, if any, these hospitals face in collecting and preserving such evidence; and (3) what factors besides medical forensic evidence contribute to a decision to prosecute such cases. GAO surveyed all 45 IHS and tribally operated hospitals and interviewed IHS and law enforcement officials and prosecutors..

What GAO Found

GAO's survey of IHS and tribally operated hospitals showed that the ability of these hospitals to collect and preserve medical forensic evidence in cases of sexual assault and domestic violence--that is, to offer medical forensic services--varies from hospital to hospital. Of the 45 hospitals, 26 reported that they are typically able to perform medical forensic exams on site for victims of sexual assault on site, while 19 reported that they choose to refer sexual assault victims to other facilities. The hospitals that provided services began to do so generally in response to an unmet need, not because of direction from IHS headquarters, according to hospital officials. Partly as a result, levels of available services have fluctuated over time. GAO found that the utility of medical forensic evidence in any subsequent criminal prosecution depends on hospital staff's properly preserving an evidentiary chain of custody, which depends largely on coordinating with law enforcement agencies. IHS has made significant progress since 2010 in developing required policies and procedures on medical forensic services for victims of sexual assault; nevertheless, challenges in standardizing and sustaining the provision of such services remain. In March 2011, IHS took a sound first step in what is planned to be an ongoing effort to standardize medical forensic services by issuing its first agencywide policy on how hospitals should respond to adult and adolescent victims of sexual assault. Remaining challenges include systemic issues such as overcoming long travel distances between Indian reservations or Alaska Native villages and IHS or tribal hospitals and developing staffing models that overcome problems with staff burnout, high turnover, and compensation, so that standardized medical forensic services can be provided over the long term. In addition, other challenges include establishing plans to help ensure that IHS hospitals consistently implement and follow the March 2011 policy, such as with training guidelines, and developing policies on how IHS hospitals should respond to domestic violence incidents and sexual abuse involving children who have not yet reached adolescence--neither of which is included in the March 2011 policy. GAO found that IHS is aware of these challenges and has initiatives under way or under consideration to address them. Decisions to prosecute sexual assault or domestic violence cases are based on the totality of evidence, one piece of which is medical forensic evidence collected by hospitals. In some cases, medical forensic evidence may be a crucial factor; in other cases, however, it may not be relevant or available. Law enforcement officers and prosecutors said that they also consider several other factors when deciding to refer or accept a case for prosecution. For example, some victims in small reservations or isolated villages may refuse to cooperate or may retract their initial statements because of pressure from community members who may depend on the alleged perpetrator for necessities. As a result, the victim may be unavailable to testify. Several prosecutors also told us that the availability to testify of the providers who perform medical forensic exams is an important factor, because such testimony can help demonstrate that an assault occurred or otherwise support a victim's account. IHS's March 2011 policy, however, does not clearly and comprehensively articulate the agency's processes for responding to subpoenas or requests for employee testimony.

What GAO Recommends

GAO is making five recommendations aimed at improving IHS's response to sexual assault and domestic violence, including to develop an implementation and monitoring plan for its new sexual assault policy and to modify sections of the policy regarding required training and subpoenas or requests to testify. The Department of Health and Human Services and the state of Alaska generally agreed with GAO's findings and recommendations.