On Nov. 15, 2017, Juan Francisco Flores Hidalgo lay dying in the prison ward of Bellevue Hospital. His left leg had been amputated above the knee, the right half of his tongue was black with necropsy and an external pacemaker dangled from the right side of his chest, extending into the right subclavian vein and right atrium of his 63-year-old heart. A fentanyl delivery patch was attached to his upper right arm, his chest and upper abdomen were pockmarked by incisions and a tracheostomy tube protruded from the front of his neck, extending into his upper airway.
According to his attorney, Flores Hidalgo was originally held on $500,000 bail on Rikers Island in April 2017 to await trial on a drug possession charge that was eventually dismissed. In May, he began complaining of chest pains and was taken to Bellevue for treatment and then returned to Rikers. In August, he was returned to Bellevue to undergo surgery to remove a fistula on the outside of his heart. Following the procedure, he was returned to his cell on Rikers on Aug. 29. In the two weeks post-surgery, according to a later ambulance report, his tiny 5’5” frame ballooned up to roughly 190 pounds, possibly due to fluid retention and sepsis from internal injuries he sustained during the surgery. He continued to complain of chest pains but was ignored.
On Sept. 5, while on a DOC bus en route to a court appearance, he passed out from his pain. But he still was not taken to the hospital; instead, he was returned to his cell at the Anna M. Kross Center. Ten days later, he was rushed to Bellevue, where doctors discovered that his aorta and esophagus had been nicked during his prior surgery, causing massive systemic health failures. He languished in Bellevue in DOC custody until the department issued him a medical release dismissing his charges on Nov. 14.
By then, though, it was too late to save him. Juan’s family instructed his doctors to no longer emphasize therapeutic treatments and to have the medical staff focus on relieving his pain. They sent for his mother, Esmeralda de la Cruz, to come from San Francisco de Macoris in the Dominican Republic to stand vigil at his bedside with his family, but he died on Nov. 16 at 8:22 p.m, before she completed her trip.
After Flores Hidalgo’s death, his family filed a wrongful death lawsuit against the city, Department of Correction and Correctional Health Services, alleging that the fistula had been caused by medical neglect while he was in the care of the jail health services.
Although Local Law 137 requires the New York City Law Department to report all active litigation against the DOC in a biannual disclosure, the Flores family’s lawsuit has not been included in the New York City Law Department’s biannual reports nor in any to the agencies meant to have oversight over investigations into deaths in DOC custody. The Law Department did not respond to repeated requests for comment.
The DOC is legally required to report all deaths of people in custody to the state Commission of Correction and the state attorney general. The department also reports deaths to the New York City Board of Correction, its independent oversight agency. Yet, Flores Hidalgo’s death did not appear on any records of detainee deaths that those agencies released to City & State. The Nunez federal monitor, which is charged with overseeing conditions at Rikers, also has not included his death in the appendices attached to two of its recent reports, in October 2022 and April 2023.
In all, City & State found evidence that at least 113 people died while in DOC facilities or shortly after being granted medical or compassionate release between 2014 and 2022. Since at least seven people have died at Rikers or in a hospital after release so far this year, that means at least 120 people have died on DOC’s watch since 2014. That number includes people who died in DOC holding pens in borough courthouses, which the state Commission of Correction classifies as deaths in NYPD custody when they occur prior to someone being arraigned – even though they occur in DOC facilities. Only 68 of those 120 deaths were reported by the DOC to the public or the press. It is likely that even more people have perished in Rikers; while City & State documented the names of 120 people who have died, the NYC Open Data research portal also mentions a number of “unknown suicides” that occurred at the jails complex.
In the course of its investigation, City & State discovered that the records of deaths maintained by the city Department of Correction and Board of Correction, the state Commission of Correction, the federal Bureau of Justice Statistics and the federal monitor are full of discrepancies. An internal DOC database of deaths of people in custody, released in response to a FOIL request, shows a total of 91 deaths in DOC facilities between 2014 and 2022. Only 55 of those deaths were included in the Board of Correction’s death reports during its meetings in the same time frame. A list from the state Commission of Correction shows 107 deaths or after release to medical facilities during those same years; six people’s deaths were not recorded. The federal monitor’s appendices include the names of 97 people who died between 2014 and 2022, missing 16 names. Some of the people whose deaths were documented by the federal monitor – including Manuel Quiles, Kenneth Lear, Richard Johnson, Kareem Bryant and Mohamed Bachtobji – seem to have had their bodies unceremoniously buried in mass graves on Hart’s Island.
When asked about the missing deaths, state Commission of Correction spokesperson Kirstan Conley said, “The SCOC conducted a diligent search and provided all records on file about deaths of individuals in custody reported by the DOC.” The federal monitor told City & State that “the Monitoring Team is not permitted to provide records to the public or the press outside of the information in our reports.” The Board of Correction said: “The FOIL response you received were DOC records and they were produced as we received them from DOC (as we mentioned, we can’t guarantee their completeness or accuracy).” The city Department of Correction did not respond to multiple requests for comment.
Accounting for compassion
Some deaths may have gone undocumented because they occurred after “compassionate” or “medical” release, and the person was no longer technically in DOC custody. The DOC defines “compassionate” release as the release of a person previously sentenced and “medical release” as the release of someone pre-sentenced and detained for medical purposes.
The DOC has been accused in the past of granting compassionate release to individuals who are about to die in order to avoid counting them as deaths in custody. Last year, The New York Times reported that DOC Commissioner Louis Molina sent an email advising that a person in custody be released to get them “off the Department’s count.”
Federal law requires reporting to the U.S. attorney general and the U.S. Bureau of Justice Statistics “if the incarcerated person, absent the medical condition, would have been in prison at the time of death, it counts as a reportable death.” The language of the law requiring state carceral facilities to report deaths to the SCOC reads: “Each facility shall report the death of any inmate committed thereto, whether or not such death actually occurs at the facility … in a form and manner prescribed by the commission’s medical review board as described in the commission’s Reportable Incident Guidelines for County Correctional Facilities.” However, this manual only requires reporting if “the deceased is an inmate” and does not address the deaths of people who have been granted medical, compassionate or work release.
Both the DOC and SCOC have claimed that the deaths of detainees who die after being granted medical or compassionate release do not need to be reported to oversight agencies. “Correctional facilities are not required to report when individuals are granted compassionate release,” said Conley, the SCOC spokesperson.
State Sen. Julia Salazar, who chairs the state Senate Crime and Correction Committee, told City & State in a statement that “any discrepancy between deaths actually occurring in NYC Department of Corrections’ custody and the number of deaths that the agency is reporting to the State Commission on Correction and to the public is unacceptable.”
“The NYC DOC remains indifferent to the conditions that enable dozens of deaths in their custody every year,” she added. “While we fight for policies that will reduce the number of people incarcerated and therefore the number of deaths in custody, the least that our City agencies can do is accurately report each of these deaths to the appropriate bodies in the name of transparency and accountability.”
“Practice, not a policy”
In May, the federal monitor revealed in a widely reported court filing that two detainees had died following medical or compassionate release during a three-week span, and their deaths were not reported. In response, the DOC announced that it would no longer report deaths in custody to the public or the press, as it was merely a “practice, not a policy” or legal requirement. The announcement caused uproar and triggered a letter from City Council Speaker Adrienne Adams, who encouraged the court to consider interventions that would remedy the conditions at Rikers.
During a subsequent hearing in federal court, the Law Department argued to Judge Laura Swain that “the department has a different way of counting those (deaths) than the monitor because the monitor lumped together in deaths in custody persons who are no longer in custody, specifically, compassionate release individuals, persons who were released under the compassionate release policy because of severe medical conditions.”
During a July 18 Board of Correction meeting, Molina attempted to defend the change in reporting policy: “We wanted to be able to empower families to be able to divulge to the public, if they want, if their loved one has passed away.” His explanation was refuted by New York County Defender Services attorneys who testified at the same hearing that when their client, Joshua Valles died in May of this year, after Molina changed the policy, DOC did not notify his family – even though he was in the intensive care unit for days before his demise. In a report to the court on July 10, the monitor disclosed that the DOC approved 41 people for medical release between Jan. 1 and June 30.
The DOC cited the privacy rights of those who died on 9/11 that were codified in the lawsuit The New York Times brought against the New York City Fire Department for disclosure of the last utterances made during 911 calls by those trapped in the twin towers as its rationale for not disclosing names of people who have died in DOC facilities in a response to a FOIL appeal filed by City & State. This legal theory has yet to be tested in courts.
When the DOC fails to record the deaths of detainees who have been medically or compassionately released, it does more than just make Rikers look like less of a deathtrap. It can also prevent oversight agencies from investigating the circumstances of detainees’ deaths.
Sarena Townsend, DOC’s former deputy commissioner of the intelligence, investigation and trials division, told City & State that the records of people who are medically or compassionately released are not even shared with DOC’s own investigative division.
“The DOC should have a policy where it notifies the Investigation Division of every single compassionate release before the release itself,” she said. “This way, there would be an investigation into the circumstances of the need for a release and a record of who was released and why. Without such notification, the department is able to release individuals without there being any investigation into whether staff misconduct played a role in causing or hastening the death of a detainee.”
Correcting the record
Even after excluding deaths that occurred after medical or compassionate release, there remain unexplained absences in the lists of deaths still in DOC custody.
At around 3 a.m. on Nov. 20, 2018, Daniel Torres awoke in his cell at the Anna M. Kross Center with chest pains. According to a wrongful death lawsuit filed by his family, Torres cried out for help, but no one came. In a nearby cell, Jorge Torres (no relation) awoke to see Daniel in a panic and began yelling for the guard. Their cries were ignored for over 45 minutes. Finally, medics arrived and transported Daniel to the clinic at around 4:20 a.m.
While at the clinic, corrections officers somehow lost sight of Daniel and later found him on the floor of the clinic bathroom, unresponsive and covered in vomit. He was then transferred to East Elmhurst Hospital where he died in the prison ward. Torres was never granted a compassionate release, and there is no question that he was still in the custody of the DOC when he died. Yet, his death was not reported to the public, the press, the monitor, the BOC or the SCOC.
In December, the City Council began working on a bill that would require the DOC to report all deaths in custody, after work release or after the dates a person was medically or compassionately released. Council Member Tiffany Cabán, who plans to co-sign the legislation, said the bill was necessary: “DOC is a rogue agency (whose) leaders do everything in their power to undermine every oversight body assigned to them and avoid any semblance of accountability. The reason they want to escape oversight is the reason they are subjected to oversight in the first place: Rikers Island is a hellhole, a torture dungeon, a death chamber, a modern-day slave plantation, a site of relentless suffering and terror in every direction. Of course they want to hide what goes on there.”
When asked about Molina’s decision to cease disclosing deaths in DOC custody, New York City Mayor Eric Adams responded: “I support him to do the job I hired him to do, and whatever methods he needs to do it within the boundaries of not violating any laws or rights of people, I support.”
If Juan Francisco Flores Hidalgo, Daniel Torres, Mark Louzon, Manuel Quiles, Kenneth Lear, Mohamed Bachtobji, Richard Johnson, Kareem Bryant, Maria Marrero and others could speak from their graves, it’s doubtful they would agree with the mayor.
Kelly Grace Price is a reporter and founder of Close Rosie’s who was previously detained on Rikers Island.