An independent oversight board for the Rikers Island jail complex issued a damning report on Monday that found three inmates died this year after they fell ill and correction officers failed to render aid.

One man was sick for days, vomiting and defecating on himself, but correction officers didn’t bring him to nine scheduled medical appointments, the report said. Another wasn’t resuscitated by two correction officers assigned to his unit, one of whom wasn’t even medically cleared to interact with inmates. And a third died after choking on an orange; he was brought to the medical clinic by other incarcerated people because officers didn’t help.

And yet on Tuesday, when the oversight body, the New York City Board of Correction, held a public meeting with the Department of Correction that runs Rikers, board members barely pressed correction officials on their allegations. One board member recently appointed by Mayor Eric Adams, Joseph Ramos, even described recent deaths — including an apparent suicide — as “natural.”

The board’s findings come as advocates and defense attorneys for Rikers inmates are agitating for a federal receivership, in which a judge would order control of the jails be turned over to the federal government.

“Receivership now, or the next life is solely on your hands!” said Victoria Phillips, an activist with the Urban Justice Center, during the public comment portion of Tuesday’s meeting.

“Our clients live under constant threat of death or serious harm while living in New York City’s jails,” said Natalie Fiorenzo of New York County Defender Services, which represents many incarcerated people at Rikers. “Our clients desperately need Rikers to be put under a federal receivership.”

U.S. Attorney Damian Williams of the Southern District of New York last month raised the prospect of asking a federal judge to create such a receivership, and to that end Department of Correction officials have until next Tuesday to file a plan with the court detailing how they will make systemic improvements at the facility. City officials oppose a federal takeover.

Staffing, though, is a nagging concern due in part to a liberal sick leave policy, according to a federal oversight monitor that since 2015 has recommended changes at the facility. As of January, 30% of the correctional staff were out sick, which has led to thousands of medical appointments to be missed because there aren’t enough officers to bring detainees to the clinic. It has also led to a rate of violence seven to eight times that of other jail systems, the monitor said.

Asked Tuesday by one board member what changes will be put into place to handle medical emergencies given the staffing shortages, Department of Correction Commissioner Louis Molina did not cite specific plans. He said there are fewer unmanned posts than there were earlier this year, and he is reviewing the board’s recommendations about how to prevent deaths. “There is more information that, I think, will be revealed in terms of improving communications strategies to activate emergency alarms,” he said.

Molina said he inherited the problems at Rikers Island, and noted several statistics showing improvements in safety. Assaults on uniformed staff are down 27% so far this year compared to last year, he said, and slashings or stabbings decreased 35% in April compared to March.

Molina said that weapons searches have increased, and so far 2,300 weapons have been recovered this year. Some weapons are fashioned from shards of plexiglass, he said, so mesh is being installed on plexiglass barriers in the facility to prevent the barriers from being broken and turned into weapons.

The board’s report detailed the circumstances around three deaths in 2022:

  • Tarz Youngblood, 38, was assigned to a unit in which one of the two officers was not medically cleared to “work directly with incarcerated individuals.” Officers also did not make the mandated rounds, according to surveillance, and did not address the fact that the window to Youngblood’s cell was obscured. The report said: “DOC staff’s failure to regularly check on the status of every person every thirty minutes (particularly at night) is a chronic and life-threatening issue.”
  • George Pagan, 48, “regularly urinated, defecated, and vomited on himself,” but he was not brought to nine scheduled medical appointments nor given the medication he was prescribed. One of the mandated officers assigned to his dormitory was not there as he fell ill, and the other officer did not tour the housing area as required. There is a discrepancy about when officers called in the medical emergency that Pagan experienced immediately before his death, but he may have been waiting for medical care for as long as 47 minutes.
  • Herman Diaz, 52, collapsed and choked while eating an orange. One of the two officers assigned to his housing unit was not on duty at the time. The report said that other incarcerated people used the Heimlich maneuver because they were unable to get the officer on duty to render First Aid. The other inmates then carried Diaz to the clinic, where he was pronounced dead.

The fourth death occurred on Saturday, when Dashawn Carter, 25, died in an apparent suicide by hanging, officials said. The board’s report did not cover that incident.

“When an individual dies in a New York City jail it’s a failure of the whole system,” Molina said at Tuesday’s meeting.

There are 5,494 people incarcerated at Rikers, according to board statistics cited at the meeting. Almost all are pre-trial and therefore considered innocent of the crimes they’re charged with. Nearly half have had multiple contacts with Rikers’ mental health services, indicating mental illness. More than 300 people have been held at Rikers for more than three years, and more than 400 have been there for more than two years.

Benny Boscio, the head of the correction officers’ union, said more officers simply need to be hired. Mayor Eric Adams is seeking nearly 600 new officers in his proposed budget.

Boscio also defended officers who don’t render aid to a sick inmate if they’re alone in a unit: “If the incident is staged, then the detainees in the housing area can take that officer hostage, take the keys to leave the housing area.”

Ramos, the new Adams’ board appointee, blamed “negative publicity” for the problems at Rikers, and said correction officers should be given credit for saving lives after detainees attempt to die by suicide. Regarding the recent deaths, Ramos said: “I personally feel that they were natural deaths.”

Board member Bobby Cohen, who is a doctor, responded with a sigh: “These were not natural deaths.”

“They took place in housing areas which did not have any officers present,” Cohen said. “There were great failures in getting emergency care to people….Serious medications for potentially life-threatening situations were not provided to men who needed them because there were no officers to bring them the medication.”

He added, “Something is very, very seriously wrong.”

Adams himself visited Rikers last week, but didn’t meet with inmates nor tour the facilities, according to The Daily News.