NEW YORK — An exhaustive report on 10 of the 16 deaths in 2021 in city jails details a range of staffing problems, systemic failures and mismanagement by jail staff that contributed to the fatalities.
The Board of Correction report focused on the six suicides and four overdoses last year and was based on interviews with detainees and staff, video surveillance and DOC and medical records.
Among the findings:
— Eight of the 10 deaths involved correction officers not doing rounds and poor supervision. Tomas Carlo Camacho was not checked on for two hours on March 2, 2021 in a clinic though officers were supposed to look in on him every 30 minutes. Camacho asphyxiated himself by sticking his head in a food slot.
— At least four deaths involved officers’ failure to make sure detainees were alive and breathing. Thomas Braunson, who died April 19 of an overdose of fentanyl, heroin and PCP, was using drugs that would have been in full view of staff had they properly patrolled their posts.
Brandon Rodriguez, similarly, was put in a punitive caged shower stall on Aug. 10, the report said. The area he was in was unstaffed for 33 minutes, the period he hung himself. For some time before that, he had been yelling he wanted to kill himself.
“Under the circumstances Rikers was in at the time of his detention, it’s unconscionable to not screen for suicide, not to mention DOC had records of Brandon’s bipolar diagnosis from a prior detention,” said William Wagstaff, a lawyer for Rodriguez’s family.
Segundo Guallpa died Aug. 30 in the West Facility after staff failed to check on him for five hours, from 6:30 p.m. to 1:11 a.m., the report said. He had already hung himself — and his “pulseless, stiff and cold” corpse suggested he was dead a long time before he was found.
— In three cases, staff didn’t intervene when detainees went into medical distress in front of them, the report said.
In one such case, Javier Velasco hung himself March 19 after being removed from suicide watch. When he was found unconscious, an officer did not immediately render aid for four minutes and medical staff and EMS were not called for nine minutes, the report said.
Officers at the scene offered conflicting accounts of who was responsible for reporting medical emergencies.
— Easy access to illegal drugs factors in the number of deaths at Rikers.
Jose Mejia died on June 10, 2021 when he overdosed on methadone, the report said. Mejia ingested the drug, then staggered into a jail dayroom. According to the report, video shows that for the next 40 minutes he struggled to stay upright. A floor officer spoke to him but didn’t raise an alarm, the report said.
Detainees helped Mejia to his cell. For the next three hours, detainees and officers looked in on him. Around 3 p.m., a detainee checked on him and reported he was cold to the touch. An officer finally called for medical aid at 3:45 p.m. He was declared dead at 4:39 p.m.
William Brown was in a dorm smoking apparent drugs with other detainees Dec. 14, 2021 in the Anna M. Kross Center as the unit went unstaffed for four hours, the report said. He started passing out, others started vomiting. Staff didn’t immediately start CPR. Brown died of an overdose of synthetic marijuana.
Many officers are not trained to use Narcan, a widely used anti-overdose drug, the report noted.
Correction Commissioner Louis Molina’s aides said the contraband drugs are largely coming in through the mail.
— Officers fail to provide immediate medical care or call medical staff and EMS when they are needed in emergencies, the report said.
In the June 30 death of Robert Jackson of a heart attack, detainees first noticed him in medical distress, pulled him from his cell and alerted staff. There had been no officer on post. A medical emergency was called at 8 p.m. and again at 8:30, but medical staff did not arrive until 9:24 p.m. — nearly 90 minutes later, the report said.
— Missed medical appointments also contributed to deaths — and the report cast doubt on the accuracy of Correction Department records in cases of detainees who are not taken for treatment.
Detainees told investigators that Esias Johnson had been begging staff to take him to a clinic for two days before he died. But Correction Department records claim Johnson refused to go to a medical appointment the day before he died.
Before he died, Tomas Carlo Camacho missed 26 medical appointments, including 17 because DOC didn’t produce him, the report said.
“The report highlighted some of these things that are preventable,” said Board of Correction member Julio Medina at a meeting Tuesday.
“I think it’s the most disheartening thing that we’re talking about,” Medina said. “We want to figure out how we stop this. You can’t go on the island and die. We all know there’s no excuse for that.”
The report came two days before the 14th detainee this year — Kevin Bryan, 35 — died in city custody on Wednesday. Bryan hung himself in a staff bathroom in the Eric M. Taylor Center.
The Board of Correction made 22 recommendations that center on better training, faster emergency response, and better coordination between jail managers and Correctional Health Services, a unit of NYC Health + Hospitals that provides health services at Rikers.
The report also called for body scanning of all staff to keep out contraband, and electronic record keeping.
In the wake of the report on the inmate deaths, city Comptroller Brad Lander seemed to be edging toward backing a federal takeover of city jails, which will be the focus of a federal court hearing in November.
“The comptroller is deeply disturbed by the report and seriously weighing receivership,” Lander spokeswoman Chloe Chik said.
Molina’s staff insisted at the Board of Correction meeting that they were making “significant progress” in areas of security, reducing violence, increasing staffing and hiring of new officials — all tasks promised by an action plan the city filed in the court case that could lead to a federal takeover.
