Excerpt: When Bad Cops Happen to Good People by Array

Inmate Neglect

"Such indecent and disgusting dungeons as these cells, would bring disgrace upon the most despotic empire in the world!"

  • Charles Dickens, upon visiting New York City’s “Tombs”

New York City has a tradition of calling its lower Manhattan detention centers “The Tombs.” This started in 1838 with the New York City Halls of Justice and House of Detention. That building was an example of Egyptian Revival architecture, meant to resemble monuments to the Pharaohs. Three more structures had the nickname hung on them, not so much for their design as for the despair of the inmates barred within their walls. These days, the title could also go to Rikers Island, but it would no longer be metaphorical.

The July 15 death of Michael Lopez, 34, in his cell at Rikers was the eighth in-custody death at the facility this year, bringing to 11 the total of in-custody deaths for the NYC Department of Corrections. The DOC is on pace to eclipse last year’s total of 16 in-custody deaths, which was the most since 2016 and more than 2019 and 2020 combined. These numbers are staggering. Yes, the State of New York eliminated the death penalty in 2004. But NYC’s Corrections Department is currently executing more inmates than Texas.

The Death Penalty for “Crimes of Poverty”

According to The New York Post1, Michael Lopez faced charges of felony burglary, misdemeanor petit larceny, and assault in six open cases in Manhattan. Lopez had allegedly raided Duane Reade and Target locations in Manhattan for everyday items that included “clothing, a water bottle, dental hygiene products, mouthwash products, paper towels, toilet paper, dish detergent, and Tide Pods.”

The assault charge stemmed from Lopez allegedly punching a nurse’s arm at New York-Presbyterian Hospital. His Legal Aid attorney referred to the theft charges as “crimes of poverty,” an assessment confirmed by the fact that Lopez could not post a $5,000 bond, and therefore had been at Rikers for about two months. The inability to post bond ultimately cost Lopez his life, as he appears to have been the victim of deadly drug-trafficking within the jail itself.

Lopez was found unresponsive in his cell at the Anna M. Kross Center of Rikers at about 9:30 a.m. and was pronounced dead about 45 minutes later. Meanwhile, a second detainee in the same facility was found unconscious and was transported to Bellevue Hospital. Both are believed to have overdosed on fentanyl. If confirmed, Lopez’s death would be the fifth overdose by an inmate in DOC custody this year. Only five days prior, Elijah Muhammad2, 31, who had been receiving treatment for an unspecified mental illness3, had been found dead in his cell at the George R. Vierno Center of Rikers, also from a suspected fentanyl overdose. A rookie correction officer was fired, and others were disciplined after that incident.

A wrongful death lawsuit filed by Muhammad’s family blames “negligent supervision and security at the jail” for the death. The complaint alleges that days before his death, Rikers authorities had held Muhammad in solitary confinement for 32 hours, vastly exceeding the DOC guideline of six hours. You don’t have to be a psychiatrist to know that is no way to treat mental illness.

When finally released from solitary, the complaint alleges, Muhammad appeared disoriented, was barely able to walk, and clearly needed medical attention. But, according to the complaint, Muhammad “was Ieft to die in his cell and remained deceased in his cell for such a length of time that his body began to show signs of rigor mortis." Rigor mortis takes at least a couple of hours to set in, so it’s safe to say Muhammad was dead for that long before anyone checked on him. Again, this was a mental health patient who was obviously in physical distress when he returned to his cell, but no one checked on him for several hours?

Putting aside the neglect of a mental health patient for a moment, there’s another urgent question that must be answered: how do incarcerated men gain access to deadly narcotics? Inmates are subjected to thorough, invasive searches at intake, and authorities can search cells for contraband whenever necessary. It is impossible to imagine any ingenious drug-smuggling scheme that could succeed without guards being complicit. To that point, we recall the Georgia prison scandal of 2015-20164. The U.S. Department of Justice indicted more than 45 Georgia Department of Corrections officers and contract correctional officers in seven separate federal indictments. Guards had allegedly smuggled drugs and other contraband into prisons and had accepted bribes to facilitate drug deals.

Symptoms of Neglect in U.S. Jails and Prisons

The Rikers Island death toll vividly illustrates the consequences of abuse and neglect in prison facilities. We discussed the many forms of abuse in Chapter 7. Neglect is an equally important and related issue. Neglect is the fairly to provide the basic necessities of a humane existence.

Institutional neglect includes:

  • Callous disregard for physical and mental health emergencies
  • Facilities in disrepair, such as broken toilets, showers, light fixtures, and boarded-up windows
  • Failure to perform adequate health screenings
  • Failure to present detainees for court appointments
  • Failure to provide timely and effective treatment for physical and mental health issues
  • Inadequate air conditioning, circulation, or filtration
  • Inadequate lighting
  • Insufficient exercise
  • Insufficient nutrition
  • Poor hygiene

Across America, incarcerated human beings are warehoused in facilities that are unfit for livestock. If chickens were being raised under the same conditions that some inmates are housed in, the Food and Drug Administration would shut the facility down. Yet, there seems to be little hope that the conditions in which inmates are kept will improve. In this chapter, we present a few of the horror stories of prison neglect, hoping to raise awareness and stir hearts to compassion and action.

Callous Disregard for Inmates’ Mental and Physical Health

Perhaps no story better illustrates the consequences of poor mental health screening, as well as the callous disregard some guards exhibit for mentally ill inmates, than that of Nicholas Feliciano. On November 27, 2019, Feliciano, then 18 years old, attempted to hang himself in a Rikers Island jail cell. According to a report in The New York Times5, “more than a half dozen New York City Department of Correction officers stood by… not intervening even when he flailed his arms and then went still.” When finally cutting him down, officers “let his limp body drop to the floor.” The incident left Feliciano in a coma on life support for weeks. He suffered severe brain damage, necessitating round-the-clock care at Bellevue Hospital.

Feliciano’s mental illness and suicidal tendencies were well documented. He’d spent time in city juvenile centers and mental health facilities. He’d previously been held on Rikers Island, “where he had spent weeks on suicide watch and told staffers about his history of depression and psychiatric hospitalization.” Yet, when a parole violation landed Feliciano back at Rikers, medical staff failed to flag him as a suicide risk. He was placed in the general population, where gang violence was common.

Not surprisingly, Feliciano got into a fight and needed medical attention. He was placed in a cell where he waited hours for treatment. That was when Feliciano used a sweater to try to hang himself from a ceiling fixture. (It was the same fixture from which another detainee had attempted to hang himself six days prior, which was supposed to have been removed as a hazard.) As The Times story explains, “For seven minutes and 51 seconds, seven correction officers, a captain, and two paramedics walked by or peeked into Mr. Feliciano’s cell or watched him from a guard station. But none of them intervened, surveillance video showed.”

Certain guards were put on modified duty, where they would have no contact with detainees, but would still collect a paycheck. One of these was the ranking officer on the scene, Captain Terry Henry. Henry, according to The Times, “had been disciplined in a similar case in 2015, when, as a correction officer, he failed to provide medical aid to a man who complained of chest pain as he gasped for air and convulsed on the floor …. The man died, and the city settled the lawsuit for $1.59 million.” The incident did not impede Henry’s promotion to captain. And despite two subsequent complaints of “failure to supervise,” he was the supervising officer on the day of Feliciano’s attempted suicide.

Now, almost three years later, Henry and three other guards have been charged with reckless endangerment and official misconduct. Why did it take so long? And why are only four guards facing consequences, when surveillance video documented inaction by nine staff members?

But it’s not only mental health crises that Rikers officials and staff ignore. On July 28, 2022, the family of Mary Yehudah, a female Rikers Island inmate who died in custody, filed a $50 million notice of claim against the city alleging wrongful death. The family charges that when Yehudah, 31, arrived at Rikers on Feb. 2, she was not screened for diabetes, despite regulations mandating screening for chronic health conditions. Yehudah’s physical complaints over the next three months— heart palpitations, shortness of breath, high blood pressure, and dental issues—should have suggested diabetes to any reasonably competent healthcare provider.

On May 18, Yehuda died in custody. According to The New York Post6, neglect of Yehuda extended to the guards who failed to make their rounds. The family also alleges that when Yehuda was having the health crisis that resulted in death, “correction officers assigned to Yehudah’s housing area were not on their assigned posts, or completing their mandatory half-hourly tours of the facility.” By the time she was found unresponsive, it was too late.

Sadly, the circumstances of Mary Yehudah’s death were all too familiar. A New York State medical review board had looked at prisoner deaths over a five-year period. In 2018, the board concluded that at least 50 state prisoners had died due to insufficient medical care. According to a report on Prison Legal News7, these deaths were entirely preventable with “simple medical or mental health treatment.”

PLN tells the story of Todd Heatley, an inmate at the Wende Correctional Facility in 2014. When his mother, Maureen, visited him, Heatley “was so distraught that he didn’t recognize her.” Mrs. Heatley urged staff to get her son medical help. A correction sergeant promised to take care of her son, but decided Heatley could wait to see medical staff sometime over the next couple of weeks. Three days later, Heatley had hanged himself from a bed sheet in his cell. The medical review board found that Heatley would likely be alive if he’d been given appropriate mental health care. The sergeant had “failed to recognize the symptom of confusion as a sign of mental illness” and provide for his safety until he could meet with medical staff.

In 2015, a prisoner at the Great Meadow Correction Facility took his own life, overwhelmed by a cruel and misguided decision to discipline him for his medical issues. Alfredo Lopez, 54, had been placed in solitary confinement when his inability to provide a urine sample for drug screening was deemed to be a failed test. This decision was made despite two important facts: first, all of his previous drug tests had been negative, and second, Lopez suffered from diabetes and nerve damage that made it difficult for him to urinate on demand. The DOC accommodates inmates diagnosed with “shy bladder,” but never put Lopez on that list. Instead, they threw him in the hole. And while he was in solitary, they discontinued his pain medication. That hardly qualifies as a plan of care.

In his suicide note, Lopez wrote, “I can’t take the abuse anymore,” He stated he hadn’t slept in 18 days and referred to “the mental anguish” he felt over the injustice.

Jack Beck with the Correctional Association of New York, a prisoner advocacy group, told PLN, “people inside are dying due to inadequate medical and mental healthcare.” Beck blames diminishing resources. DOC is allocating less money for medical expenditures, reducing payments to private mental healthcare providers by 28 percent in the five years from 2013 to 2018. At the same time, medical staffing in DOC was down more than 17 percent.

Prison healthcare jobs also pay far less than private-sector positions, making it difficult to recruit and maintain a competent medical staff. It’s no wonder the medical review board found “multiple cases where prison medical staff neglected basic checkups and mental health screenings, and failed to treat more serious medical problems until they had worsened to the point where death was inevitable.”

That was the situation in 2018, and we are unaware of any change in these circumstances. There was some movement, however, as the result of a lawsuit. Under a settlement, prison officials must now determine if prisoners suffer from serious mental illness. If so, those prisoners must go to a Residential Mental Health Treatment Unit. They can leave their cells for up to four hours daily for therapy.

NYC Department of Corrections Fails to Produce Inmates for Medical Appointments

Inmate access to medical care has been so bad for so long in New York City that the Department of Corrections is under an emergency court order to improve performance. Unfortunately, that December 6, 2021, order seems to have made no difference. On January 26, 2022, NYC DOC admitted in an affidavit filed in the Bronx County Supreme Court that the department had failed to provide inmates with timely medical care in violation of the court order. Internal records revealed a staggering 7,070 incidents in December alone in which inmates were denied access to health services. The New York Post8 reported that 1,061 of those denials occurred because the staff was unavailable to escort them. The December total of missed appointments was higher than in October and November, indicating that DOC's performance worsened after the court ordered improvements.

DOC Bureau Chief of Facility Operations Ada Pressley admitted in the affidavit that “this rate of production does not constitute substantial compliance with the pertinent directives to provide timely access to the clinics.” Put simply, DOC did not do what the court said they had to do. DOC claimed that 5,268 of the missed appointments happened because inmates refused to make the visit. But the Legal Aid Society challenged that assertion, noting that in 3,900 reported inmate refusals, DOC could not provide an explanation for why the inmate refused. Legal Aid claims that its “review of medical records, statements from incarcerated people, and even a review of DOC’s own data” casts doubt on DOC’s claim.

We’re suspicious as well. Given what we know about the understaffing of healthcare workers at DOC facilities, the more likely reason for the missed visits is that medical staff canceled on the prisoners.

The court filings that reveal the extent of the problem are in response to a class action by The Legal Aid Society, Brooklyn Defender Services and Milbank LLP. That lawsuit accuses the DOC of failing to provide inmates with adequate medical care. Plaintiffs are now asking the judge to hold the DOC in contempt for violating the court’s order. In a joint statement, the firms wrote, “Every day, we hear from people that their calls for help go unanswered. The City has now admitted that DOC is flagrantly violating a court order requiring the agency to address this problem. This is outrageous and illegal.”

For its part, the City issued a statement that ensuring detainees have timely access to medical care “is and always has been a priority for the department.”

Squalid Conditions Presenting a Humanitarian Crisis

In the fall of 2021, some New York State and City officials toured the Rikers Island complex. According to a report in The Guardian9, many are “left traumatized.” One such was the former public defender Tiffany Cabán. “People were relieving themselves into bags. They were sleeping on floors,” Cabán said. “These were the kinds of things you think about if they were happening in another country, you would believe without any hesitation that these were human rights violations. Nobody should ever be treated or kept in these conditions.”

The jail complex at Rikers Island is slated to close permanently in 2026, after a New York City Council vote. But the ongoing humanitarian crisis at Rikers has raised questions about whether the complex can even survive that long. Put simply, the facility is falling apart. There are about 500 inoperable cell doors, and a severe shortage of functional toilets. These problems are exacerbated by overcrowding and an acute staff shortage plagued by absenteeism.

A spokesperson for the guard’s union, the Correction Officers’ Benevolent Association, blamed the crisis at Rikers on Mayor Bill De Blasio and his refusal to hire more staff. COBA also cites the Covid-19 pandemic as a reason for understaffing. “We had 1,800 correctional officers [in 2021] that got Covid – officers out with long-term Covid,” a COBA spokesperson told The Guardian. “We have officers physically and mentally exhausted from working these 25-hour or more shifts. They’re going to work on Monday, not knowing they’re going home on a Wednesday.”

The City has attempted unsuccessfully to hire more guards. DOC announced plans on September 7, 2021, to hire 600 new correctional officers, but only 64 new recruits attended the last training session.

Critics counter that the staff is adequate, but is poorly managed. After attending a public hearing on the matter, Assemblywoman Emily Gallagher, representing north Brooklyn, wrote in a tweet, "The [independent] federal monitor says DOCs have more than enough staff, and the problem is poor management. I believe that."

But if staffing is adequate, why are inmates literally dying from neglect? Take the case of Isa Abdul Karim, the 11th inmate to die at Rikers in 2021. Karim, 41, who relied on a wheelchair, was already suing Rikers for being “beaten and punitively denied medical care during a previous stay,” according to a story on The Intercept.com10. Karim’s attorney claims he was reincarcerated for a technical parole violation. The Intercept reports that Karim “spent 10 days on an intake unit at Otis Bantum Correctional Center, held in crowded pens with as many as a dozen people in each cage, spending the entire period in his wheelchair because of the lack of bunks.”

Speaking anonymously for fear of reprisal, a medical staffer described the holding area as "a crowded place with a lot of violence and assaults and self-harm. Officers are spraying pepper spray all the time. Nobody’s wearing a mask, and they’re all in an enclosed, dank hallway. No one’s receiving medical care in there.”

It should surprise no one that Karim contracted Covid while in “the pens.” He was removed to a quarantine facility, where he received treatment and appeared to recover. He was discharged from the infirmary and assigned to a housing unit. There, “Karim suddenly experienced acute shortness of breath, became unconscious, and collapsed. He received CPR, but to no avail, and he was pronounced dead even before an ambulance arrived.” His death was listed as “natural causes,” but his attorney said the cause of death was “abject neglect.”

The anonymous medical staffer had this theory. He told The Intercept, “We stress their bodies in significant ways because of environmental conditions, lack of sleep, lack of consistent access to food and medicine, because they’re not afforded access to the yard. That’s Karim’s story. That’s also Brandon Rodriguez’s story. That’s also Esias Johnson’s story.”

Johnson, just 24, had died in Rikers earlier that month of an apparent drug overdose. Rodriguez, 25, was one of two inmates to die of apparent suicides the previous August.

There is also a bitter irony to Karim’s death. His circumstances fell under the newly signed Less Is More Act. The law was a response to the crisis at Rikers, and would keep parolees with non-criminal, technical parole violations from going back to jail. Less Is More became law on September 17, 2021, but did not go into effect until March 2022. Nevertheless, 191 detainees were immediately released on September 17. Karim was not one of them. He died on September 19. Also, after Karim’s death, Mayor Bill DeBlasio issued a new policy that inmates should not be held in the intake pens for more than 24 hours.

If Tiffany Cabán had her way, Karim would never have returned to Rikers. “When you look at the people who are on Rikers, these are people who should just be released into their communities with support,” Cabán said after her tour of the facility. “We know they are overwhelmingly there because they cannot afford their bail.”

Rikers Island, of course, is not the only decrepit facility holding inmates in squalid conditions. In Indiana11, 26 inmates are now suing Miami Correctional Facility for cruel and unusual punishment, citing living conditions in a restrictive housing unit. Inmates complained of being shocked by live wires and sleeping in cells flooded with sewage, urine, and feces. Additional complaints include having to live in total darkness, because the prison did not repair broken light fixtures and replaced broken windows with sheet metal that blocked out the sun but did not keep out the chill air. Inmates complained the cells were too cold to sleep in. There is no other word for such squalid conditions than torture.

One of the plaintiffs, inmate Jeremy Winners, “has a history of severe mental health issues,” such that the prison’s mental health staff advised against placing him in the dark. Nevertheless, Winners spent approximately three months in the restrictive housing unit in near-total darkness. Winners now claims that “being in constant darkness caused him severe emotional and psychiatric problems.” He became so distraught “that he swallowed razor blades.” The lawsuit accurately asserts that “Placing a person in prolonged, isolated darkness for an extended period is a form of torture. It is particularly problematic if the person has preexisting mental health issues.”

Kenneth Falk, legal director of the American Civil Liberties Union of Indiana, which is representing the inmates, said stories from the prison’s restrictive housing unit “shock the conscience and violate the Constitution.” In a press release, Falk stated, “The Eighth Amendment requires that incarcerated people must receive the minimal civilized measures of life’s necessities.” Clearly, that was not happening at Miami Correctional Facility.

More Despair Leading to Self-Harm

The case of Esias Johnson, mentioned above, is particularly galling. The troubled 24-year-old Massachusetts man, jailed for a misdemeanor, was held in Rikers Island for a month, because his jailers would not present him in court to pay the bail a judge has set at one dollar. He died in his cell on September 9, 2021, of an apparent drug overdose. According to The New York Daily News12, Johnson had told his family “he saw no way out of Rikers.”

Tracy Johnson's mother told The News, "He had been talking about the court dates. He was saying, ‘I’m giving people the info, and they aren’t doing what they are supposed to do. Nobody is helping me. I feel I’m going to be stuck here.’ He gave them the information, and they didn’t listen to him.”

Johnson’s parents claim DOC officials failed to bring their son to three court appearances. They tried to pay the bail online, but were unable. Johnson had commissary money and could have paid the bail, but to do that, he had to be seen by a judge. But how could he if Rikers officials wouldn’t take him to court?

Johnson had been arrested on August 6 in Forest Hills, Queens, on a misdemeanor assault charge. During processing, police discovered a warrant issued on June 21 by the Hunterdon County Prosecutor’s Office in New Jersey. Queens Criminal Court Judge Denise Johnson ordered Johnson remanded on $1 bail and set an August 20 court date. Records indicate that the court date was rescheduled, but DOC offered no explanation. Johnson died before he ever got to court.

Persistent Problems and Possible Solutions

The problems to be overcome in the prison system are many and profound. Those that fall into the category of negligence include:

  • Overcrowding — When populations exceed capacity, inmates cannot be properly supervised or be guaranteed the basic necessities of humane treatment.
  • Poor facilities — It’s impossible to exaggerate the deplorable conditions in many American jails and prisons. Infrastructure must be rehabilitated, modernized, and maintained.
  • Staffing shortages — Overworked and overstressed guards are more likely to overlook inmates in crisis.
  • Guard misconduct — Prison staff must understand that they’re not just guarding the cells, their’ guarding the prisoners. They have a duty to ensure the safety and welfare of the incarcerated people in their charge. Guards of poor character ignore prisoner complaints and engage in corrupt practices. They must be weeded out and replaced with conscientious officers.
  • Mental health issues among the incarcerated — Treatment of mental health issues can prevent mental health crises that disrupt regular order and threaten discipline and safety. They can also help ensure that inmates will not re-offend once they are free, which can gradually reduce the prison population to ease overcrowding.
  • Drug issues — Inmates who enter with addiction issues should have treatment. Security must be improved to prevent inmates from accessing drugs while in custody.
  • Physical health issues of prisoners — Individuals in the criminal justice system often have underlying health issues, many drug-use-related. This includes conditions such as Hepatitis C, which require ongoing treatment. Prisoners must be screened for health issues at intake and receive prompt care when indicated. Some inmates have disabilities. Facilities must provide accommodations. Incarceration is also not good for the human immune system, which thrives on fresh air, sunshine, and exercise. Programs must be implemented to address health issues across the board, and get inmates necessary treatment in a timely manner.

All of these issues come down to an allocation of unfortunately scarce resources. Equally unfortunate is the unwillingness to prioritize prison reform, because other needs seem more urgent, and other recipients of funds seem more sympathetic. Competing interest groups can also argue that crises exist in public education, public housing, public health, and a wide swath of the nation’s infrastructure. This tension has led to a deadlock, and allowed extremist voices to gain volume. One side argues that prison is supposed to be punishment, and so horrible conditions provide a deterrent to crime. The other side argues that all prisons should be closed, and everyone released, as if all incarcerations are political and there aren’t genuinely dangerous persons inside who need to be segregated from society for the public good. A rational society would realize that penal institutions are necessary, but inhumanity towards prisoners is not.

Until our society becomes more reasonable, the hope for improved conditions lies with the courts. As noted in this chapter, many nonprofit organizations and pro bono law firms have taken up the fight and won significant victories on behalf of inmates. Court orders compelling improvements in prison conditions may be the only way to break the legislative deadlock and force the allocation of resources our jails and prisons require.

End of Excerpt


  1. Rikers Island detainee dies of overdose, death toll hits 11. (2022). Retrieved 9 August 2022, from Nypost.com.
  2. Family of NYC Rikers Island inmate found dead plans to file $25 million lawsuit against city, attorney says. (2022). Retrieved 9 August 2022, from News.yahoo.com.
  3. In a Rikers Jail Cell, a Man Lay Dead for Hours Before He Was Discovered. (2022). Retrieved 9 August 2022, from Nytimes.com.
  4. Further Corruption Involving Georgia Department of Corrections Guards Exposed. (2016). Retrieved 9 August 2022, from Justice.gov.
  5. Rikers Island detainee dies of overdose, death toll hits 11. (2022). Retrieved 9 August 2022, from Nypost.com.
  6. Family of Rikers inmate files $50 million wrongful death notice of claim against city. (2022). Retrieved 9 August 2022, from Nypost.com.
  7. Report Shows 50 New York Prisoners Died from Inadequate Medical Care in Last Five Years (2019). Retrieved 9 August 2022, from Prison Legal News.
  8. NYC DOC officials admit inmates aren't getting medical care: court records. (2022). Retrieved 9 August 2022, from Nypost.com.
  9. ‘Abject neglect’: critics report chaotic and deadly conditions on Rikers Island. (2021). Retrieved 9 August 2022, from The Guardian.
  10. Death on Rikers: Isa Abdul Karim Sued Over Previous Jail Mistreatment, Then Landed Back There and Caught Covid-19. Pinto, N., & Pinto, N. (2021). Retrieved 9 August 2022, from The Intercept.
  11. More inmates sue Miami Correctional for torture inside isolation units. (2022). Retrieved 9 August 2022, from KokomoTribune.com.
  12. Rikers prisoner dies after NYC jailers wouldn’t take him to court, refused $1 bail payment — ‘They didn’t listen,’ says anguished mom. (2021). Retrieved 9 August 2022, from NYDailyNews.com.

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