Comptroller Stringer’s Investigation Reveals Failures in the City’s Preparation and Response to COVID-19, and Outlines Recommendations to Plan and Prepare for Future Public Health Emergencies

(New York, NY) — Today, New York City Comptroller Scott M. Stringer released the interim report of an ongoing investigation into the City’s planning and preparation for and response to the COVID-19 pandemic that describes ways in which the City’s initial response to COVID-19 was hampered by a lack of planning, coordination, and preparedness across City government, and outlines recommendations to help the City to improve its ongoing response to the COVID-19 pandemic and to better prepare for future public health emergencies. The Comptroller’s investigation — which is ongoing due to the City’s refusal to submit necessary documents and witnesses for examination — found the City, prior to COVID-19, never completed a citywide operational plan for responding to a pandemic and delayed developing a citywide operational plan for a moderate to severe COVID-19 outbreak. The investigation also identified gaps in the City’s emergency resource management, finding the City lacked critical information about key resources, including the number of available hospital beds in City hospitals and the amount of usable personal protective equipment (PPE) in City stockpiles. The investigation further found that New York City Emergency Management (NYCEM) encountered difficulties performing aspects of its City Charter-mandated planning and coordination duties during the run-up and initial response to COVID-19, raising questions about its capabilities, capacity, and resources.

“The COVID-19 pandemic threw our city into crisis, upending lives and livelihoods and exacerbating longstanding inequities in our most vulnerable communities. We lost 35,000 of our neighbors and loved ones, 900,000 jobs, and thousands of businesses,” said Comptroller Stringer. “We will never forget who and what we lost, and we cannot erase the mistakes of the past. But we can make sure we are better prepared for future emergencies and the next pandemic. Our investigation shows weaknesses in planning and preparation and failures to promptly make decisions when time was of the essence and every minute counted. As the pandemic continues to rage across the country and around the world, we must take stock of what we’ve learned. That means making sure we have a complete citywide operational plan in place for the next emergency, ensuring we have sufficient supplies and equipment, and guaranteeing our City agencies are coordinated and unified. The next emergency isn’t a matter of ‘if’ — but ‘when’. We must be confident that when the next crisis strikes, we will know exactly what to do and have the tools in our arsenal to beat back whatever comes our way.”

Comptroller Stringer’s investigation found the following:

• The City never completed a citywide operational plan for responding to a pandemic prior to COVID-19.
  • City records show that officials searched for a plan for a citywide pandemic response when COVID-19 emerged in January 2020 but found outdated and unfinished guidance of limited value.
  • The pandemic plan in effect for the City at the beginning of COVID-19 was a 2013 Draft Pandemic Influenza Operational Plan prepared by the Department of Health and Mental Hygiene (DOHMH). In January 2020, when the threat of COVID-19 became known to the City, the 2013 plan was still incomplete, had not been updated for seven years, and was not of use to City officials responding to COVID-19. The 2013 Plan recognized the need for further operational planning and identified areas that needed to be developed, including the need to:
    • plan for the supply chain and distribution of antivirals;
    • draft “pandemic-related materials” for the general public and healthcare professionals;
    • prepare “‘just-in-time’ infection control training;”
    • identify “[t]riggers” for school closures; and
    • resolve a wide variety of “major policy issues.”
  • 13 plans were identified as available to the City as of January 1, 2020 that appear related to some aspect of a pandemic response, all of which were either incomplete, out of date, or lacked operational guidance to direct the City’s pandemic response.

• Citywide operational planning for a moderate to severe COVID-19 outbreak was delayed.
  • The City’s efforts to create a citywide operational plan to respond to the potential worst-case scenario — a moderate to severe COVID-19 outbreak in the City — did not begin in earnest until mid-to-late February 2020. In February, City agencies were discussing whether to begin planning for the worst-case scenario.
  • E-mail documentation indicates that substantive inter-agency efforts to develop citywide plans for the COVID-19 response did not begin until early March 2020.
  • Key planning activities to address the need for additional hospital capacity, sheltering vulnerable populations, and preparing for a potential citywide shutdown continued weeks into the crisis, by which time the City had thousands of confirmed COVID-19 cases.

• The City encountered weaknesses in its emergency resource management which became apparent as it prepared for COVID-19.
  • The City did not adequately collect data regarding available emergency resources prior to the onset of the pandemic. As a result, when the first case of COVID-19 was diagnosed in the City, authorities did not have current, reliable information about those resources, including the number of available hospital beds in the City at any given time, the total amount of usable PPE that City agencies possessed in the City’s stock, or even the City agencies that used PPE as part of their regular operations.
  • City agencies had to be individually surveyed for the City to determine how many N95 masks it owned — and to discover that its entire supply of the N95 masks that provide the highest level of protection, surgical-grade N95 masks, had expired years earlier.

• The role and responsibilities of NYCEM were insufficiently clear.
  • New York City Emergency Management (NYCEM), the City agency responsible for coordinating its planning for and response to emergencies, struggled to perform its City Charter-mandated planning and coordination duties during the run-up and response to COVID-19.
  • Agency roles in emergency response are defined by the Citywide Incident Management System (CIMS), which specifies that DOHMH, the New York City Fire Department (FDNY), and the Police Department (NYPD) — not NYCEM — are the primary City agencies for citywide public health emergencies and should serve as the COVID-19 command element. CIMS identifies NYCEM’s role as a primary agency only for responses to natural disasters or weather emergencies unless otherwise specifically designated. However, in internal documents and in communications with other agencies, NYCEM repeatedly — and incorrectly — asserted that it was leading the City’s COVID-19 preparation and response efforts with DOHMH. DOHMH officials found themselves repeatedly correcting NYCEM to make it clear that DOHMH is the lead agency for COVID-19 response.
  • NYCEM did not consistently coordinate response efforts with DOHMH, NYPD, and FDNY — excluding these critical agencies from key decision making and communications. E-mails between agency officials indicate at minimum significant confusion among City agencies about responsibilities in the COVID-19 response.
  • NYCEM also struggled to support other agencies critical to the City’s COVID-19 response, including by failing to address a critical request from the Office of the Chief Medical Examiner for additional morgue space for a week, and requested that other agencies support NYCEM operations, despite NYCEM’s support role.

Comptroller Stringer outlined the following recommendations that the City should implement to improve preparation, planning, and response efforts for the next pandemic and other public health emergencies:

• Create, complete, and regularly update a citywide operational plan for future pandemics.
  • Although the City recognized that it needed a citywide operational pandemic plan, it did not have one at its disposal when COVID-19 struck. Such a citywide operational pandemic plan should be created setting forth at an appropriate level of detail clear operational duties and organizational structures.
  • The citywide operational pandemic plan must specifically identify what tasks will need to be done, who will be responsible for each task, how each task is to be completed, and what resources are required to complete each task, relying on appropriate authoritative guidance, such as from FEMA or other subject matter experts.
  • The citywide operational pandemic plan should be readily accessible to key decision makers and any others responsible for its implementation, and be regularly updated.
  • The City must ensure that procedures are established to frequently review and regularly update the City’s operational emergency plan.

• Promptly conduct a thorough review of the City’s emergency planning to develop and update citywide operational plans for potential threats other than pandemics.
  • The City should promptly conduct a thorough review of its emergency planning to ensure that it has complete, up-to-date, citywide operational plans for any threats other than pandemics that may require a citywide response.
  • Consistent with the drafting of updated pandemic plans, any plans created or updated pursuant to this review should include clear operational tasks and organizational structures based on appropriate authoritative guidance and be easily available to relevant stakeholders.
  • Procedures should be established to ensure that all plans are regularly reviewed and updated as necessary.

• Identify and maintain stockpiles of critical supplies, and implement controls to timely identify, procure, and replace stocks.
  • The City must identify and maintain stockpiles of critical supplies that are likely to be unavailable, either due to supply or demand, in the case of potential emergencies.
  • Systems and controls should be implemented to ensure that stockpiles remain available and usable in case of an emergency.
  • The determination of what critical supplies must be maintained and decisions concerning the management of those stockpiles should be made in consultation with the commissioners of each agency that would be called on to respond to an emergency.
  • Decisions to cease maintaining stockpiles of specific supplies or to reduce the level of supplies in City stockpiles should be made in consultation with the commissioners of each of the agencies identified at the time the stockpile is established as likely to draw on the stockpile in the event of an emergency.

• Improve the data collection, management, and dissemination of information needed by decision makers and emergency response agencies.
  • The City should improve its systems for collecting, managing, and disseminating critical data related to resources needed to respond to emergencies.
  • Processes to ensure that critical information is shared quickly and widely to all potential agency stakeholders should be developed.
  • Commissioners of each agency that would be called on to respond to an emergency should be consulted to determine what information constitutes critical data requiring collection and dissemination.

• Review NYCEM’s capability to fulfill its Charter-mandated planning, coordination, information sharing, and support roles, clarify NYCEM’s role in emergency responses, and provide the support needed for NYCEM to fulfill its roles.
  • The City should review NYCEM, including its structure, resources, and budget, to determine its abilities to plan for emergencies, to coordinate and support emergency response efforts, and to facilitate information sharing among City agencies.
  • Consistent with the City Charter and CIMS, the City should clarify NYCEM’s emergency response roles, in particular in relation to emergencies where NYCEM is not designated as a primary agency.
  • Based on that review and clarification, the City should ensure that NYCEM has sufficient resources and authority to fulfill its roles.

The Comptroller’s authority to conduct this investigation was recently affirmed by the First Department of the Appellate Division. In November 2020, Comptroller Stringer took court action to force the City to comply with a subpoena issued pursuant to his investigation into the City’s preparedness for and response to the COVID-19 pandemic. Following months of stalling and refusals to fully comply with the subpoena issued in June 2020, the Comptroller filed a petition on November 18, 2020, in New York County Supreme Court seeking a court order to compel the City to promptly and completely comply with the subpoena. The petition detailed how the City consistently stymied the production of documents, repeatedly missed production deadlines, several of which the City set for itself, and declared it would not be able to provide all requested documents until April 2021 at the earliest — nearly a year after the Comptroller launched the investigation. In its response to the Comptroller’s action, the City claimed that it would not be able to comply with the subpoena until November 2021.

The authority of the Comptroller’s Office to conduct the investigation and to issue its subpoenas in connection with its investigation was upheld by order of the Supreme Court on December 16, 2020. To read the decision click here. On August 12, 2021, the Appellate Division, First Department, unanimously affirmed the Supreme Court decision upholding the authority of the Comptroller’s Office to conduct the investigation and issue its subpoenas. To read the Appellate Court’s decision, click here.

To read Comptroller Stringer’s investigation of the City’s response to the COVID-19 pandemic, click here.

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