NYC Rikers Island oversight report cites missed medical visits as indirect factor in jail deaths

The failure of Rikers Island staff to get detainees to their medical appointments was an indirect factor in the deaths of nine people in the jails in 2022, the city Board of Correction said Wednesday.

A 31-page report from the oversight board disclosed that Dashawn Carter, who hung himself May 7, missed 92 medical appointments — including 76 because staff didn’t produce him during two Rikers incarcerations spanning 2019 to his death.

Elijah Muhammad, who died of a fentanyl overdose on July 10, missed 118 medical visits from September 2020 to his death including 100 because he wasn’t produced. In July notably, he missed his methadone six days in a row because he wasn’t produced and began showing withdrawal symptoms, the board says.

And Anibal Carrasquillo, who also died of a fentanyl overdose June 20, missed 207 appointments from 2019 through his death with 193 because no officers produced him, the report said.

In all, the report says the cases of all nine deceased detainees involved at least one missed visit. Carter, Muhammad and Carrasquillo all had been suicidal in the past, and suffered from psychiatric conditions and drug addiction, the report said.

“When individuals who require psychiatric treatment or therapy are not consistently brought to their mental health or medication appointments, they run the risk of decompensating,” the board found.

“When individuals who are diagnosed with substance abuse disorders … and who are undergoing withdrawal symptoms enter a facility where drugs are rampant and easily accessible, the risk of overdose sharply increases.”

The board also found discrepancies between Correctional Health Services, the jails’ in-house medical provider, and Correction Department records. The Correction Department claimed many fewer instances where staff failed to bring detainees to their visits, the report said.

The Correction Department did not have immediate comment Wednesday.

“CHS (Correctional Health Services) is not responsible for custody management and does not and cannot independently track the movement and placement of persons in DOC custody,” the medical agency said.

The Legal Aid Society filed a class action lawsuit in November over the missed medical appointments. In May, Bronx Judge Elizabeth Taylor found the city in contempt of her order to fix the problem and fined the city about $200,000. The city has appealed.

The board also found some of the same problems in the 2022 deaths that it highlighted in an October report on 10 suicides and fatal overdoses in 2021 — including a failure of staff to properly tour or patrol jail areas, and inaccurate logbook entries.

The board also found correction staff failed to flag signs of contraband and drug use and failed to give first aid in three deaths. In the case of one detainee death, there was no officer on the detainee’s floor, the report said.

Also, the board noted that there have been 12 suicides at Rikers since the start of 2021 to date in 2022 — but there were none reported in 2018, 2019 and 2020.

The Board of Correction report comes in advance of Thursday’s hearing in federal court before Manhattan Federal Judge Laura Taylor Swain in a class action lawsuit over violence in the jails. At the hearing, the question of whether Swain should wrest control of the jails from the city and appoint an outside receiver will be discussed.