A lack of routine inspections by correction officers, delay in critical first aid, and not screening for self-harm are just a few of the findings detailed in a report released Monday by the city’s jail oversight board investigating deaths at Rikers Island.

The 35-page report from the city’s Board of Correction examining deaths of incarcerated people in 2021 comes as the rate of deaths at the Rikers Island jail complex so far this year outpaces last year’s, where six people died by suicide and another four died from drug overdoses. Overall, there were 16 deaths in city custody last year, and 13 so far this year.

The deaths at the beleaguered jail complex have reinforced calls from advocates for incarcerated people for a federal takeover of the facility.

Here are four takeaways from the board’s report:

No inspections every 30 minutes

Video surveillance footage showed that in the hours before eight of the 10 suicides and fatal drug overdoses last year, correction officers failed to walk around the housing areas and look inside each cell to make sure people in custody were “breathing and alive.” In some cases, officers stated in their logbooks that they had made the appropriate checks, but video surveillance contradicted those claims.

Department of Correction policy requires officers to do rounds every 30 minutes. But after seven hours waiting in a pen for an officer to escort him back to his housing area following a medical evaluation, Tomas Carlo Camacho — who had previously been placed on suicide watch — was not checked on for almost two hours. During that time, he stuck his head through a slot in the door of the pen in an apparent effort to asphyxiate himself. He was unresponsive and died three days later at a hospital.

Javier Velasco was also in a housing area where officers did not tour at half-hour intervals and did not look inside cells to make sure people were alive and breathing. He was pronounced dead about an hour after he was finally found hanging in his cell.

For more than four hours leading up to the time that William Brown smoked something that made him sick, there were no correction officers in his housing area despite the fact that an officer documented in a logbook that he was touring the unit every 30 minutes. The cause of death was synthetic cannabinoid intoxication.

Delay in rendering First Aid

Uniformed staff members are required to administer CPR or first aid to unresponsive detainees until medical personnel arrive on the scene. Yet after Camacho appeared to asphyxiate himself in the slot of a door, “correction officers did not render immediate first aid,” the report said. Instead, they waited for medical personnel to arrive.

Segundo Guallpa was found with a noose tied around his neck 11 days after being admitted into custody. Video surveillance footage “revealed that two officers and a captain entered Mr. Guallpa’s cell and appeared to be talking and looking at Guallpa’s body, rather than rendering aid.”

Officers also failed to aid those suffering from drug overdoses. Thomas Braunson died from a combination of drugs that he ingested while in custody, including heroin and fentanyl, but officers didn’t try to save his life after he was found unresponsive. Braunson laid there for 10 minutes before medical personnel arrived.

Mental health treatment failures

After first getting locked up, Wilson Diaz-Guzman told medical personnel that he had “thoughts of hurting or killing himself.”

He was then referred for a mental health assessment, but that assessment wasn’t signed by a clinician until after he died. Diaz-Guzman was assigned to a general population housing unit, and died by suicide.

A suicide prevention screening was also apparently not prepared for Brandon Rodriguez, who was locked in a shower pen after attempting to kick an officer. While in the shower pen, he yelled that he wanted to kill himself, which he did, shortly thereafter.

Missed medical appointments

Medical care can provide a critical intervention for those suffering from suicidal ideation or drug addictions. But incarcerated people miss thousands of medical appointments each month, often because officers fail to pick them up from their housing areas to escort them.

Earlier this year, a judge ordered the Department of Correction to pay $100 for each of the thousands of medical appointments that incarcerated people at Rikers Island missed because they weren’t brought to the infirmary.

Those who died at Rikers last year missed many medical appointments, the report found. The department failed to bring Camacho to 17 medical appointments before his death. Brown was not brought to seven appointments.

In response to the report, a spokesman for the Department of Correction said the following in a statement:

“Each and every one of these deaths, all of which occurred under the previous administration, were individual tragedies that took place during an unprecedented time when fallout from a global pandemic has been taxing every correctional system in the nation. We are committed to improving care and safety in our facilities wherever possible and we are in active discussions with the Board of Correction regarding several of their recommendations.”

This story has been updated to clarify Wilson Diaz-Guzman's treatment at Rikers. He was referred for a mental health assessment that wasn't signed until after his death, but that delay was not related to his placement in general population nor did it affect the care he received, according to Correctional Health Services, which provides medical care at Rikers.