This article was originally published on Sep 12 3:46pm EDT by THE CITY

The entrance to Rikers Island on Hazen Street in Queens, Jan. 21, 2019. | Ben Fractenberg/THE CITY

After jail officers found Tomas Carlo Camacho unconscious with his head stuck in a cell-door handcuff slot inside a Rikers Island medical unit on March 3, 2021, investigators initially believed his death 13 days later was the result of a bizarre accident. 

But a report by the city’s Board of Correction published Monday revealed Camacho’s death had been a suicide that likely could have been prevented if jail staff had properly watched him.

The 48-year-old’s demise after a history of self-harm was not an anomaly, the report found after a review of medical records and interviews of jail staff about four drug-related deaths and six suicides in city jails in 2021.

“The pervasive issue of insufficient rounding [making rounds] and supervision by correctional staff was present in at least eight of the 10 deaths reviewed in this investigation,” the 35-page report said. 

The review comes as 13 detainees have died so far in city jails this year, following 16 fatalities last year, the highest total in decades. The report also comes as Correction Commissioner Louis A. Molina has embarked on a reform plan to avoid a potential federal takeover of the jails system. 

Also Monday, U.S. Attorney Damian Williams, of New York’s Southern District, and members of his executive team toured Rikers

Known Problems

In Camacho’s case, correction officers failed to look in on him for about two hours before finding him with his head stuck through the cuffing port, according to the board review.  

Correction Department policy requires officers to check on detainees every 30 minutes to make sure they are breathing. 

When Rikers medical staff first screened Camacho in August 2020, he told them he had several mental health conditions, a psychiatric hospitalization history and past suicide attempts, according to the report. 

Jail doctors prescribed Camacho medication to manage his mental illness but, according to internal health records, he refused “most doses after November 2020.”

Tomas Carlo Camacho, left, died after being found unconscious inside a Rikers Island medical unit on March 3, 2022. His son, Kevin Carlo, right, has demanded answers. | Courtesy of Camacho Family

Over seven months beginning in August 2020, Camacho missed at least 26 medical appointments, according to the Board report. Seventeen of the appointments were canceled because jail officers did not bring him to the clinics, seven because he allegedly refused to attend and two because medical staff canceled. 

Camacho was placed on suicide watch from Oct. 9 until Oct. 13, 2020, after he swallowed a pen “because he was depressed,” the report said. 

He was also admitted to the Bellevue Hospital Prison Ward from Dec. 28, 2020, to Feb. 4, 2021, records show. The hospital discharge report concluded that a “chronic risk of harm to self and others remain[ed] elevated due to chronic mental illness, noncompliance, and legal history.”

The report added, “However, his risk of harm to self and others, acutely, remain[ed] low due to resolution of acute psychiatric symptoms, good response to treatment, and no suicidality.”

On March 2, 2021, he was put in the “Hart’s Island Clinic 12” housing pen on Rikers Island, records show. 

“The clinic was staffed with five officers, who were required to tour every 30 minutes but did not do so,” the Board report said. 

On March 3, no one checked on Camacho from 5:28 p.m. and 7:12 p.m., the death review found. 

At approximately 6:53 p.m. that night, he stuck his head through the cell door’s so-called “cuffing port/food slot” and dropped to his knees and stretched his legs. 

The correction officer assigned to the area told investigators that he wasn’t there because he was moving another detainee per orders from a supervisor. 

Correction officers found Camacho with his head through the slot — unresponsive but with a pulse — at 7:12 p.m., the Board review said. They did not render immediate first aid as required under Department of Correction policy, the report said. 

He was brought to Elmhurst Hospital and granted a compassionate release the next day, March 4. He died in the hospital on March 16. 

Camacho had been in jail facing assault charges for allegedly repeatedly striking a medical staffer at Lincoln Hospital, causing permanent eye damage, according to the Bronx District Attorney’s office. 

If Camacho survived the suicide attempt, he would have likely been re-arrested and brought back to jail, the Board report noted. 

Monitoring and Modernizing

As for the other deaths, the Board review also faulted multiple systemic issues plaguing the department. 

They were: lack of staff, free-flowing drugs, bogus handwritten recordkeeping in antiquated log books, lack of emergency first aid by officers, missed medical visits and problems with the city’s suicide watch prevention policy. 

The report made a series of recommendations, including converting record-keeping to a digital system. A similar suggestion was made by the city’s Department of Investigation in March 2019 following a report into allegations of senior officers downgrading violent incidents. 

Books in which jail officers manually detail basic information about incidents and detainee checkups during each tour remain the de facto record system behind bars, THE CITY reported in May

The Board also recommended that jail officers do a better job of tamping down the flow of drugs into facilities. 

Manhattan U.S. Attorney Damian Williams toured Rikers Island on Monday, Sept. 12, 2022. | Courtesy of the Southern District

“The prevalence of drugs, often laced with fentanyl, combined with deficient supervision and reduced staffing, threatens the lives of those in custody on a daily basis,” the report said. 

The board cited a story published by THE CITY in February, which found that even when visitors were banned during the pandemic more drugs showed up inside city jails. 

Between April 2020 and May 2021, the Correction Department seized banned drugs found inside city jails more than 2,600 times.

The Board also recommended jail medical staff hold “timely” death review conferences to go over what happened and look for ways to prevent fatalities. 

Officials at Correctional Health Services, the division of the city public hospital system that provides medical care for people behind bars, maintain that they already conduct those reviews. Health officials also countered that the Board of Correction had the authority to make those assessments. 

The board additionally suggested jail officials install a dedicated phone line for medical emergencies “that does not rely on information being relayed through multiple staff to reach the medical response team.” 

The report asked medical staff to track the number of fatal drug overdoses in jail, and the number of times the drug Narcan is used to revive people. 

NY1 reported last month that jail medical staff and some other trained personnel administered Narcan at least 431 times for suspected overdoses between January 2021 and June 2022.

Longtime observers of the city’s jail system noted the report isn’t the first to point out these problems.

“How many times can we be told over and over again that management has collapsed? That there aren’t procedures in place?” asked Elizabeth Glazer, director of the Mayor’s Office of Criminal Justice from 2014 until 2020, who has advocated for a federal receiver to take over the troubled jail system.

“That communication is bad? And it leads to violence and death.”

THE CITY is an independent, nonprofit news outlet dedicated to hard-hitting reporting that serves the people of New York.

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