Jail guards blocked medical staff from checking on Rikers detainee who died, report finds

New York City’s jail oversight board urged correction officers to regularly monitor housing areas at Rikers Island and not interfere with medical treatment for sick detainees in a new report on two recent deaths in custody.

Officials said the report is aimed at stopping “operational failures” that could contribute to detainee deaths.

The Board of Correction found that officers repeatedly refused to let medical staff check Charizma Jones’ vital signs while the 23-year-old was locked in an isolation cell in the infirmary at Rikers’ Rose M. Singer Center this past spring. She died at a hospital weeks later, according to the report, which was released on Monday.

Investigators also found that guards at the North Infirmary Command facility failed to conduct all their required rounds before Anthony Jordan, 63, had a medical emergency in August. He went into cardiac arrest shortly after and was pronounced dead at a hospital, the report stated.

Five people died in city Department of Correction custody or shortly after their release this year, according to the Board of Correction. Jail staff have faced heightened pressure to prevent deaths after 19 people died in 2022, marking the highest death rate in over a quarter-century. But even though the number of deaths has dropped since then, Judge Laura Taylor Swain, who oversees conditions on Rikers Island, said in a recent court ruling that she was inclined to order a federal takeover of the notorious jail complex, which has long been plagued with violence and allegations of rampant sexual abuse.

The oversight board in its report recommended that jail officials:

• Remind correctional staff not to interrupt, interfere or deny access to medical care for people in custody.
• Stop using paper logbooks and transition to a digital recordkeeping system.
• Set up a phone line for correctional and medical staff to communicate directly during medical emergencies.
• Retrain staff on basic responsibilities, like how often to tour the units they supervise and how to record their activity in logbooks.
• Ensure all deaths in custody are reported to the executive director of the Board of Correction within a half-hour.
• Assign more staff to monitor surveillance cameras and make sure broken cameras are repaired quickly.

The report advised Correctional Health Services, which provides medical care in city jails, to create a system for its staff to report any interference with care. The board also asked jail and health officials to find out why emergency medical staff initially responded to the wrong Rikers facility during Jordan’s medical emergency and ensure something similar does not happen in the future.

The Department of Correction said in a statement included in the report that it was currently “unable to provide a substantive response” to the findings because the New York attorney general’s office and the city Department of Investigation were still reviewing Jones’ death. Jail officials asked for a chance to respond to “any inaccuracies or omissions in this report” after those investigations are completed.

Correctional Health Services said in its own response included in the report that medical staff were expected to tell their supervisors if they encounter barriers to treating patients and that jail leaders may be notified if needed. The agency also said it was working with the correction department and FDNY to guarantee prompt transport for patients who need to go to the hospital.

In a statement, a spokesperson for the Department of Correction said the health and safety of every person in the department’s care is its ‘foremost concern’ but declined to comment on the specifics cases while investigations are ongoing. A spokesperson for Correctional Health Services declined to comment beyond the agency’s response in the report.

Sarena Townsend, a former deputy commissioner for the correction department who used to oversee staff discipline at Rikers, said that the issues raised in the report were “avoidable mishaps” and that jail officials “need to do better.”

“Multiple failures in both cases cited in the BOC report strike serious concern about our ability to keep people alive while in city custody,” she said in a text message.

Here are more details on Jones and Jordan, the two detainees who died in custody, according to the Board of Correction.

Charizma Jones

Jones had been incarcerated in the women’s jail on Rikers Island for about seven months when she started to feel sick and broke out in a rash, according to medical records cited in the report.

On April 28, the report stated, she called 311 and reported that her throat was swollen, and she had hives and welts all over her body. Medical providers examined her at the clinic, gave her Benadryl and asked correctional staff to place her in medical isolation.

After receiving medication for a few days, Jones asked to leave isolation and said, “I feel good … I’m ready to get out of here,” the report stated. She was discharged from the infirmary on May 3.

But the next day, she called 311 again and said she wanted to go to an “actual hospital” because her skin was turning orange and staff were refusing to give her antibiotics. “My throat is closing,” she told 311, according to the Board of Correction. “This is an emergency, and they said they have no doctors available.”

Other people in custody who were housed in Jones’ unit told investigators that they watched her lean against a vestibule for balance after making that call. Someone held her so that she wouldn’t fall on the floor and watched her eyes roll back in her head, the report stated.

Witnesses said a correction officer repeatedly called the clinic for help but was told no staff were available to respond, the oversight board said. Fellow detainees then put Jones on a chair, rubbed ice on her skin to cool her down and refused to comply with staff orders until Jones was taken to the clinic.

By then, Jones was complaining of nausea, vomiting, a fever and chills, according to the report. She was placed in an isolation cell in the infirmary with a broken surveillance camera, and correction officers blocked medical staff from entering the cell five times over the course of two days, citing “safety” and “security” reasons, the report said.

When officers opened the door on the morning of May 6, medical staff found Jones with a high fever and an inflamed or damaged liver, prompting them to call 911, per the Board of Correction. Jones spent weeks in several different hospitals, occasionally refusing doctors’ treatment, and eventually went into septic shock. She died from organ failure on July 14, the report said.

MK Kaishian, an attorney representing Jones’ family, said Jones had a history of mental illness and should not have been placed in medical isolation, which Kaishian said is essentially solitary confinement. She said Jones’ family still has questions about what her mental state was when she was in medical isolation and how that might have affected her trajectory.

“We know that she entered Department of Correction custody with a history of diagnosed mental illness, which means that right from the start she should have been exempted from all forms of solitary confinement under the law,” Kaishian said on Tuesday.

A City Council bill passed last year banned solitary confinement for extended periods of time and required Rikers staff to keep people with contagious diseases in the “least restrictive environment that is medically appropriate.”

Anthony Jordan

Jordan asked correction officers to take him to a clinic and also called a health hotline hours before a medical emergency on Aug. 19, but “his requests were ignored,” detainees in his housing unit told investigators.

The Board of Correction found officers assigned to his unit skipped several mandatory tours of the area that day. Around 3:30 p.m., Jordan collapsed and was taken to the clinic, the report stated. He returned to his unit less than an hour later.

Early the next morning, according to the report, Jordan struggled to breathe and fell out of bed. Other detainees helped him get back into bed and alerted a correction officer, who had not toured the area for about 40 minutes. The officer made a call and then stayed with Jordan while he waited for health care providers to come, the oversight board found.

Medical staff gave Jordan oxygen, monitored his heart and called for a hospital transport, the report stated. But emergency medical officers accidentally responded to the wrong jail, according to the Board of Correction, and it took almost an hour for Jordan to get in an ambulance.

Jordan went into cardiac arrest on the way to the hospital, and medical staff couldn’t revive him, the board said. He was pronounced dead soon after.

This story has been updated with additional information.