A new report from the Board of Correction states that “a pervasive issue of insufficient supervision by correctional staff” was a factor in most tragedies behind bars
By: Reuven Blau
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.”
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.
