A year after a 49-year-old woman died in the psychiatric waiting room at Kings County Hospital, the Department of Investigations has issued a report that says, "Discrepancies were uncovered that called into question the accuracy of the medical records created by certain Kings County Hospital doctors." In other words, hospital staffers—doctors and nurses—falsified records and lied to investigators about the care that Esmin Green received.

Included in the DOI's report, a floorplan of the area where Esmin Green collapsed

The report (here's the PDF) found that while Green was involuntarily admitted to the hospital, on June 18, 2008, she was not given a medical examination over a four shifts over 24 hours; the NY Times reports, "Although a physician ordered blood work and an electrocardiogram for her, neither was done. The investigation found that a senior nurse made three false entries in Ms. Green’s medical records indicating that 45 minutes before she was discovered on the floor — in full view of other patients — she was in normal physical condition...A nursing aide made an entry in the record indicating that he observed her sleeping when she was actually lying facedown and dying, and the aide was on a break, the report said."

One of the horrifying details about Green's death is that, while in the waiting area, she collapsed onto the floor and no one came to her aid. She fell onto the floor, while convulsing, at 6:03 a.m. on June 19; she had been essentially in front of the security station window and was 20 feet from the registration desk. Though "at least two security guards and one doctor looked into the Main Waiting Room" and saw Green, they did nothing. Instead, the people who seemed to get up and talk to hospital staff were other patients or patients' family members in the waiting room. And when a nurse did arrive at 6:35 a.m., she nudged Green's body with her foot and didn't start CPR; that nurse alerted another nurse who also did not perform CPR. It was at 6:40 a.m. when a doctor started to try to resuscitate Green.

The report was forwarded to the Brooklyn DA's office. Green's family settled with the city for $2 million; the family's lawyer Sanford Rubenstein told the TImes the family hoped there would be a criminal investigation, noting that Green's daughter said, "All those who committed criminal acts regarding the death of my mother and the intent to cover it up should go to jail."