Mental illness and missed medical appointments: Board of Correction issues report on Rikers deaths during second half of last year

The Board of Correction issued a report on Friday detailing the final four Rikers Island detainee deaths of 2023. Eagle file photo by Jacob Kaye

By Jacob Kaye

Nearly all of the four men who died on Rikers Island in the second half of last year entered the troubled jail complex with mental health and addiction issues, and failed to receive regular medical care or adequate supervision from the Department of Correction, a new report from the Board of Correction found.

The deaths of William Johnstone, Curtis Davis, Donny Ubiera and Manish Kunwar were riddled with lapses in security by Department of Correction officers and missed medical appointments, despite the complicated mental and physical health conditions nearly all four men had when entering Rikers.

The events leading up to their deaths were detailed in a report issued Friday by the Board of Correction, the independent oversight board that monitors and sets minimum standards for the city’s jails. The board, which has been slower to release reports on detainee deaths in recent years, released a report on their investigations into the first four deaths of 2023 in November.

Much like the deaths in Friday’s report, the detainees who died during the first half of last year were often left unsupervised for hours before dying and were not taken to scheduled medical appointments by DOC officers.

Three of the deaths detailed in Friday’s report together led to the suspension of eight DOC staffers, including five officers, an assistant deputy warden and two captains, including one who was later demoted and put on modified duty, barring them from working directly with incarcerated people. In all, the suspensions added up to over 140 days of missed work.

Only Ubiera’s death didn’t result in officer suspensions, according to the BOC.

Despite the suspensions, the BOC in its report said that it “does not highlight the above trends to assert that DOC or [Correctional Health Services] staff’s actions, or lack thereof, contributed to an individual’s death; but to note areas for improvement and make recommendations with the aim of preventing future operational failures.”

In a statement to the Eagle, a DOC spokesperson said, “the Department will review the Board’s recommendations.”

In all, nine people in 2023 died in DOC custody, a significant drop from the 19 people who died in DOC custody the year before.

Including the two detainees who have died so far this year, 31 people have died in DOC custody since Mayor Eric Adams first took office.

50 missed medical appointments

No other detainee in Friday’s report missed more medical appointments than Johnstone, who was the sixth person to die in DOC custody last year and the first to die of the men listed in the BOC’s report. He is also the only detainee in the report whose cause of death has yet to be identified.

Johnstone, who was 47 years old when he died, first entered Rikers on March 28, 2023, and was being held on $40,000 bail.

Johnstone told DOC staff that he was diagnosed with congestive heart failure, diabetes, and high blood pressure, and that he received treatment for tuberculosis prior to his incarceration.

He also told health staff at the jail that he had been previously diagnosed with schizophrenia with hallucinations, bipolar disorder, post-traumatic stress disorder and depression. Additionally, he admitted to having current thoughts of self-harm or suicide.”

Johnstone also told DOC officials that he used crack and cocaine, marijuana and smoked a pack of cigarettes a day.

Shortly after arriving at Rikers, Johnstone was placed into a dormitory-style mental observation housing, according to the BOC. A week later he was moved into a cell-style observation unit.

Not long after, Johnstone said that he wanted to die or to “overdose on drugs again” while speaking to a mental health clinician, the BOC’s investigation found.

According to the investigation, Johnstone refused to attend five mental health visits and a psychiatric medication reevaluation appointment.

But it wasn’t just his refusals that led to missed appointments.

Johnstone was scheduled for a routine, EKG appointment early on during his incarceration but DOC officers failed to take him from his cell to the medical facility.

The appointment was rescheduled and canceled another 50 times.

When Johnstone was finally brought to take the test by the DOC, he refused to have the test done, according to the BOC.

The DOC was found in 2022 to have been in contempt of court for its failure to produce detainees to medical appointments. Despite allegedly making improvements, attorneys, detainees and lawmakers have contended that the DOC has largely continued its failure to get detainees to doctors.

In 2023, detainees were produced for scheduled medical appointments 20 percent of the time, according to DOC data.

Three weeks after Johnstone was first admitted to the mental observation unit – where he was believed to be using drugs throughout his stay – he was moved to a general population unit.

CHS staff said prior to his move that Johnstone denied suicidal ideation and that he did not require suicide watch.

After his move to general population, Johnstone went from having near constant supervision to very little.

After reviewing surveillance footage, BOC staff found that the “B” post correction officer, or the officer charged with touring the floor of a housing unit every 30 minutes, on the day of Johnstone’s death was allowing people in custody to freely enter and exit cells, which is against DOC policy.

During a two-hour period in the middle of the day on July 15, the officer only took two tours of the housing unit.

After completing a walkthrough at 12:03 p.m., the officer left and didn't return until 1:46 p.m.

Despite missing three walkthroughs, the logbook post created by the B post officer that day did not reflect their absence, the board found.

“It notes that the B post officer performed tours of the area at 12:30 pm and 1:00 pm when video evidence does not support this documentation, before signing off the post at 1:30 pm for personal reasons,” the report reads.

At 1:47 p.m., a B post officer began a tour of the housing area and found that Johnstone’s cell window had been covered by magazine clippings. Looking through the open food slot, the officer saw that Johnstone was unconscious, according to the BOC.

The officer eventually entered the cell but did not turn on their body-worn camera.

After attempting to revive Johnstone with various methods, including several doses of Narcan, chest compressions and an epipen, the detainee was taken off Rikers Island by paramedics and taken to Mount Sinai Queens Hospital. He was pronounced dead at 3:50 p.m.

Similar circumstances

Johnstone’s death, and the events leading up to it, weren’t too dissimilar than the deaths of Ubiera, Davis and Kunwar.

In three of the four deaths explored in the report, B post officers either didn’t tour every half hour prior to the death or didn’t do a complete tour, failing to look into cells, as required by DOC policy.

In all four deaths, BOC staff found that officers had kept incomplete logbook records, according to the report. In several cases, officers lied about completing tours of housing areas when they actually hadn't.

In two of the deaths, detainees were being held in cells with unlocked doors and all four cases, cell windows had been allowed to be covered.

Also, according to the report, “all of the individuals whose deaths are covered in this report had self-reported mental health histories prior to incarceration, and some described drug use and treatment in the community.”

At least half of the over 6,000 Rikers Island detainees are believed to have a mental illness diagnosis.

According to the BOC, each of the four men told DOC staff when entering Rikers that they either had suicidal ideation, had attempted to kill themselves in the past or had a serious mental illness.