|February 28, 2005 | New York Times
DAY 1: Dying Behind Bars
DAY 2: Lost Files, Lost Lives
DAY 3: Mistreating Tiffany
But none of them, state investigators said, were ever seen by the mental health specialist caring for her. He could never track down the file, which by December included another troubling fact: Ms. Montes had been placed on suicide watch by a jail social worker. Not that the suicide watch was terribly reliable; it depended in part on inmates paid 39 cents an hour to check on their suicidal peers.
In her five months at Rikers, investigators later discovered, Ms. Montes never saw a psychiatrist.
It did not, however, take a psychiatrist to pick up on the alarms she sounded near the end, when another inmate saw her tearing bedsheets and threatening to kill herself. But the guard who was called had no idea she was on suicide watch, did not notice the sheets and never reported the incident. Six hours later Ms. Montes was dead, hanging from a sheet tied to a ventilation grate.
She was 29. Her offense: shoplifting 30 lipsticks.
The death of Carina Montes was one in a spate of suicides in New York City jails in 2003 - six in just six months, more than in any similar stretch since 1985. None of these people had been convicted of the charges that put them in jail. But in Ms. Montes's death and four of the five others, government investigators reached a stinging judgment about one or both of the authorities responsible for their safety: Prison Health Services, the nation's largest for-profit provider of inmate medical care, and the city correction system.
In their reports, investigators faulted a system in which patients' charts were missing, alerts about despondent inmates were lost or unheeded, and neither medical personnel nor correction officers were properly trained in preventing suicide, the leading cause of deaths in American jails.
Prison Health came to Rikers in 2001 after signing a three-year, $254 million contract and promising to deliver the health care that, compared with jails around the country, had helped make New York something of a model. And it spoke confidently about tackling the jails' biggest problem: how to handle their vast and volatile population of the mentally ill.
The rash of suicides, and nine more during Prison Health's tenure, is one measure of the company's uneven and at times troubling record in meeting that challenge. But there are others.
Ten psychiatrists with foreign medical degrees were allowed to practice without state certification for more than a year after they were supposed to have been fired for failing to pass the necessary test. When it finally dismissed them on the city's orders in 2003, Prison Health was left with about one-third of its full-time psychiatrist positions empty, according to city health department figures.
The company has employed five doctors with criminal convictions, including one who had been jailed for selling human blood for phony tests to be billed to Medicaid. In all, at least 14 doctors who have worked for Prison Health have state or federal disciplinary records, among them a psychiatrist forbidden to practice in New Jersey after state officials blamed him for a patient's fatal drug overdose.
The city's Board of Correction, an oversight agency that sets minimum standards for jails, has complained that the company shuffles doctors from jail to jail - regardless of where they are needed - to avoid city fines and create the illusion that each building is properly staffed.
Many of the 30 current or former Prison Health employees interviewed for this article described an effort that, whatever its good intentions, frequently fails to adequately treat the mental illnesses that inmates take into jail and that follow them back out.
Dr. Douglas Cooper, a psychiatrist who helped supervise mental health treatment at the nine Rikers jails until, he says, he quit in frustration in 2003, summed up the care as triage, buffeted by a sense of nonstop crisis. "The staff does the best they can," he said, "and what's left they sweep under the rug."
Prison Health Services, a Nashville-area corporation that bills itself as the gold standard of jail health care, says it has done a solid job at Rikers and a 10th jail, in Lower Manhattan, caring for more than 100,000 inmates a year as part of its largest contract among scores across the nation.
The company says it has worked hard to find qualified mental health specialists, held increases in medical expenses below the national average, and saved the city hundreds of thousands of dollars.
There is little dispute that New York City has long insisted on more generous jail care than most other places; the suicide rate, even under Prison Health, is about half the national average for jails.
Then again, the rate was lower before Prison Health arrived. And in the four years since, the rate of suicides at Rikers has been higher than in the Los Angeles jail system, the largest and one of the most violent in the nation.
Suicides - "hang-ups" in the cold vernacular of the cellblock - have always been a jailhouse reality. Because inmates can be resourceful when they set out to kill themselves, few people believe that hang-ups can be prevented entirely.
Yet they can be a critical barometer of how well medical and correction workers are performing an essential task: protecting the vulnerable people in their care. In 2003, something broke in the city's jail system, and inmates slipped through a bewildering series of cracks.
The first, Jose Cruz, a 48-year-old with H.I.V. and hepatitis, hanged himself with a torn bedsheet in January. Even though he had been put on suicide watch, correction officers placed him at the end of a cellblock where they could not see him from their post, said the State Commission of Correction, a panel appointed by the governor to investigate every death in jail. The medical staff, the commission noted, had inadequate training in preventing suicides.
Thirteen days later, Joseph Hughes, a severely disturbed 24-year-old charged with murder, was found hanged four hours after a jail psychiatrist wrote that he was no danger to himself. The commission criticized the Prison Health staff, saying that Mr. Hughes's history of hallucinations and suicidal gestures required closer observation.
Ten days after that, guards cut down Ms. Montes - whose increasing desperation had gone unnoticed because her medical file was missing, a failing the state commission had already criticized in three other deaths during Prison Health's time at Rikers.
After two more suicides, an inmate found James Davis, 43, in his cell in June with a bootlace tied around his neck. A doctor, two nurses and two guards spent 15 minutes vainly administering C.P.R., unaware that oxygen tanks and cardiac medication were nearby, the commission said.
No one thought to unknot the bootlace.
Sixteen days later in a jail-clinic waiting room, a 19-year-old who had just returned from a psychiatric evaluation unit managed to hang himself from a metal stud in the ceiling, according to the city's Board of Correction. Another inmate rescued him while he was still semiconscious.
The city's health department, which now oversees Prison Health's work at Rikers, did not contest many of the commission's findings, though it defended the work of the psychiatrist who evaluated Mr. Hughes as "not inappropriate." Company executives did not respond to the commission's reports, saying that they had never read them because city officials did not give them copies.Promising Vigilance
The catalog of missteps and missed signals could not have come as a complete shock to city officials. Prison Health, after all, had attracted criticism around the country for faulty care. And by the time of the suicides, the state commission was busy investigating - and blaming - Prison Health for inmate deaths in county jails upstate.
The city, though, has insisted that it has the tools to strictly monitor the company's performance. The state commission, too, concedes that city health officials are more vigilant than any county sheriff.
In fact, soon after the city hired Prison Health in 2001 to salvage jail medical services after three tumultuous years under the direction of St. Barnabas Hospital, New York City officials battled the company over its failure to meet many of the city's most basic clinical standards, and threatened to cancel the contract. Now, after a series of changes the city ordered - including suicide prevention and oversight measures prompted by the 2003 deaths - the health department says care has improved. On Jan. 1, it granted the company a $300 million contract for another three years.
"They were the most qualified bidder and they were the most cost effective," said Dr. Thomas R. Frieden, the health commissioner, who described Prison Health as willing to make improvements when asked. "I don't think they're angels."
Others are more skeptical. The city comptroller's office, prompted by Prison Health's record and questions raised by The New York Times, asked the health department to delay signing the new contract until the department addressed concerns, including the Board of Correction's complaints of staff shortages at Rikers. Dr. Frieden replied that he saw no reason to wait.
But the new contract, according to two state officials, appears to violate a state law intended to keep business interests from influencing medical care. For example, it fails to ensure that doctors are the ultimate overseers of all medical treatment, policy and records. And the contract makes the doctors who are actually doing the work at Rikers subcontractors to Prison Health, the reverse of what the law requires.
The health department and the company say the contract is legal.
For those who work in the jails, though, the larger issue is the quality of the care. Figures provided by the city and St. Barnabas show that the clinical staff at Rikers has shrunk by 20 percent since the hospital was in charge, despite only a modest decline in the jail population. And several doctors and other employees said that mental health care is worse than before.
Forever unable to find enough psychiatrists, the company plugs the gap by hiring part-timers, as well as psychiatrists from temporary agencies, some of whom may never have treated inmates. More than one-third of the mental health staff is part time.
Doctors rely on medical charts that have often been out of date or simply unavailable because of a shortage of clerks, according to the Board of Correction. Psychiatric evaluations and medications have been delayed for days or weeks, while inmates sometimes turn violent or suicidal, say the board and Prison Health employees.
Of course, the demands on Prison Health and the correction system are tremendous. The mentally ill have flooded New York's jails ever since the city cracked down a decade ago on lesser crimes like vagrancy. As many as one in four of the 14,000 prisoners in city jails on an average day have psychological ills, which need close supervision and expensive medicines. Often they fake symptoms or attempt suicide as a way of getting special treatment. In those ways, a mentally ill inmate jailed on a minor charge usually requires closer attention than a career criminal.
"If you asked every jail administrator in the country what kind of criminal they want in their jails, everyone would say murderers," said Michael P. Jacobson, who was city correction commissioner from 1995 to 1997. " 'Give me a nice murderer.' "
Just what society owes these troubled inmates is open to debate. But the guilt or innocence of most of them have not been settled. Many are in jail on minor charges or because they are unable to make bail. And though most leave within a week, many remain for months, and jail is the only place where they are likely to get any treatment or medication. The city, in fact, is required to create treatment plans for the most seriously disturbed upon their release.
Since The Times began last year to request information on the suicides, examining jail records and details of the Prison Health contract, city and company officials have made changes to prevent more deaths. The rate of suicides has slowed; in the 20 months since the spate of six suicides, there have been four.
Still, there are lapses. One of those four, David Pennington, 27, killed himself in July. Over three days in which he became increasingly irrational, correction officers went to the mental health staff for help three times, and a doctor even sent him to a psychiatrist, yet Mr. Pennington was never examined, state records say.
In a letter, a health department official disputed that finding and defended the care Mr. Pennington received. The official said the inmate was seen by a psychiatrist the day he died and was not clearly suicidal. The psychiatrist was fired three months later, Prison Health said, for reasons unrelated to the death.
In the end, though, Prison Health is just the latest partner of a bureaucracy with its own blemished history: the correction system, which was unable to deal decisively with suicides for decades, as recommendations from state and local authorities were ignored, and fitful attempts at change failed.
A Moment of Opportunity
The company's arrival at Rikers in January 2001 was a milestone for New York. The contract, negotiated with the administration of Mayor Rudolph W. Giuliani, was a linchpin in the city's effort to privatize government programs, and made New York's jail system the largest in the nation to entrust its health care to a commercial enterprise.
The deal was driven in great part by a determination to save money, and dovetailed with efforts to get the city out of the business of everything from job training to welfare enforcement. For years the city had used public hospitals to provide care in its jails, only to face skyrocketing costs and plenty of embarrassments. Prison Health, with its already shaky reputation, marked a calculated gamble.
The contract, though, was an even bigger deal for Prison Health. It raised the company's $382 million yearly revenue by 21 percent, and pushed Prison Health to the forefront of a booming correctional health care industry. It also made the company responsible for treating more mentally ill people than anyone else in the nation except the Los Angeles County Jail.
Yet Prison Health had not told its new employer the whole nature of its operations, records and officials in the city comptroller's office suggest. In 1999, the company bought EMSA Correctional Care, which had been working for the city's Department of Juvenile Justice for three years. Prison Health, according to documents and interviews with city officials, subsequently became responsible for providing care to the 5,000 youngsters in the juvenile system every year.
That care, during 2000, would come under fire by a half-dozen Family Court judges in the city, who found that children were often receiving inadequate treatment.
But when negotiating the Rikers contract later that year, Prison Health filed papers with the city saying the company had "no N.Y.C. presence." The comptroller's office, which was not obligated to review the Rikers contract at the time, now says that Prison Health's filings were incomplete and misleading.
The company rejects that claim, and says the papers were accurate and honest, and had properly listed EMSA as an affiliate doing the work at juvenile justice. City health officials say they have no problems with Prison Health's representations.
Prison Health not only won the Rikers contract, but also benefited from an added bonus: an easy act to follow. St. Barnabas Hospital in the Bronx had just been fired after a striking number of jail deaths - 34 in its final year, including 2 suicides - prompted a criminal investigation. Though no charges resulted, the Board of Correction, an eight-member watchdog panel, complained about the cost-cutting it saw as a root cause.
But under Prison Health, the rates of inmate deaths and suicides have risen slightly. In a foreshadowing of the spurt of suicides to come, six inmates killed themselves from May 2001 to January 2002.
In a string of memos to city health officials, the Board of Correction told of missing medical records, delayed psychiatric medications and minimal, inexperienced staffs. Correction officers, it said, sometimes had to pitch in, referring inmates for mental evaluations.
It was not supposed to be that way. Stung by the St. Barnabas experience, city health officials had set up elaborate ways of measuring Prison Health's performance, including a beefed-up quarterly report card with 35 standards. But during its first year, the company met those standards only 39 percent of the time. Its overseer at the time, the city's Health and Hospitals Corporation, threatened in July 2001 to scuttle the contract, and fined the company $568,000.
Company executives say that the transition from St. Barnabas was rocky, but that their performance has improved, and they have managed some significant achievements: speeding distribution of medicine, creating a program to monitor inmates with hypertension and installing a computer system for appointment scheduling.
Yet the company has not made good on several requirements in its contract. For example, it frequently sends inmates to hospitals without performing tests or providing information on their medical history and treatment, according to reports by the State Commission of Correction. And Prison Health never came up with the rigorous suicide-prevention plan it promised the city in 2000.
"I had no training as to what we do when a patient becomes depressed and becomes suicidal," said Michele Garden, a psychologist who was treating Mr. Cruz, the first to kill himself in 2003. She quit later that year.
The correction system had its own problems, having failed to tackle the issue of suicides despite a series of detailed studies that began in the late 1960's.
The city hired a suicide-prevention coordinator in 1980, but gave him only a paltry budget. John Rakis, who got the job, recalls having doubts about the assignment while interviewing his first patient in the only spot available in the Bronx House of Detention: the barbershop.
"He was hallucinating, and at some point got up and started screaming and threw over the barber chair," said Mr. Rakis, who now advises the state and city on jail health care. "I went upstairs and thought, 'I don't think this is going to work.' "
He was right. When he quit in 1984, the Correction Department eliminated the job. A rash of suicides followed in 1985 - 11 for the year, with 3 in one week.
In the early 1980's, the city created a Prison Death Review Board, including members from the mayor's office and the Health and Hospitals Corporation, to investigate and prevent deaths. But fearing that the board's inquiries could fuel lawsuits, Health and Hospitals representatives began refusing to discuss the deaths, said Board of Correction officials. The review board has not met since 1997.
When Prison Health arrived in 2001, the entire machinery for monitoring suicidal inmates remained lethally porous. The system depended, as it still does, on "suicide prevention aides," inmates paid pennies an hour to make checks every 10 minutes. In an investigation last year, the state commission found that one of these aides was responsible for watching troubled or newly admitted inmates in 34 separate cells.
Guards were supposed to help, too, looking in on suicidal inmates every 15 minutes. But that often became a half-hour, said the correction commissioner, Martin F. Horn.
"You could pick and choose which rules you wanted to follow," said Mr. Horn, who arrived in January 2003.
Inmates continued to kill themselves, and in its reports on the deaths, the state commission insisted repeatedly that those on suicide watch be observed at all times. In late 1999, it sent all jails and prisons a directive to make that the rule. City correction officials ignored it.
Not until four years later, after the spate of six suicides, did the city follow the directive. Two weeks after the sixth suicide, in July 2003, the health department replaced the Health and Hospitals Corporation as Prison Health's direct overseer, and took action to tighten suicide watches.
The Correction Department ordered a flurry of other changes to ensure closer monitoring, and hired Lindsay M. Hayes, a nationally known expert on jail suicides, to recommend improvements. But it gave The Times only an edited version of his report, stripped of his analysis and recommendations, and would not allow Mr. Hayes to discuss his findings publicly. The health department also refused to disclose its own investigations of the 2003 suicides.
Yet Mr. Horn, who became correction commissioner the month the six suicides began, said they were a jarring sign that something was dangerously wrong.
"I found it personally distressing," he said. "I was shellshocked."'
A Scramble for Help
On any given day, a psychiatrist walking the halls at Rikers could be a doctor from a temp agency who had never practiced there before. He could be a doctor who had never treated prisoners at all.
Or he could be someone like Dr. Edward M. Berkelhammer, whose work the New Jersey Board of Medical Examiners called "a danger to the public" in 1986. It suspended his medical license for two years, fined him and ordered him to see a psychiatrist himself after a patient died in his care.
Dr. Berkelhammer was putting a 26-year-old woman through drug detoxification when his mistake in administering drugs resulted in her overdose, the board ruled. He was working with an expired license, and he continued to compound his troubles. In 1989, New York suspended him for two months for lying about his record in applications for a license. And in 1990, New Jersey revoked his license for failing to obey its orders.
In an interview, Dr. Berkelhammer said that the girl's death was a single incident long ago, and that he was "very well thought of" at Kings County Hospital in Brooklyn, where he worked for several years afterward, treating psychotic inmates. "Of all the people at Rikers, I'm the last person anyone has to worry about," he said.
Indeed, there are doctors at Rikers with checkered pasts, including criminal convictions.
Dr. Ammaji Manyam, for instance, was sentenced to a year in jail in 1990 on charges of conspiracy and attempted grand larceny, for selling blood in a scheme to charge the state for bogus tests. Her medical license was revoked in New York, New Jersey and California, but restored in New York in 1997, after she said she wanted to work in a jail clinic because she knew from experience how poor the medical services were. Dr. Manyam did not return calls seeking comment for this article.
Others have had their medical credentials called into question. New York officials revoked the license of a Prison Health psychiatrist, Joseph S. Kleinplatz, in 2003 after Illinois officials concluded that his diploma from a Mexican medical school had been forged. The company then fired him. His lawyer, Karen S. Burstein, said he was a good doctor with a real diploma; a state appellate court has ordered that his case be reconsidered.
The health department is now reviewing Prison Health's system for checking doctors' credentials.
Becky Pinney, the vice president in charge of Prison Health operations in New York City, said the company had done its best to weed out doctors with disciplinary records. Most of them, she said, had first been hired by St. Barnabas Hospital - though Prison Health rehired them, as it did most of the hospital's staff at Rikers. She said the company was thorough in investigating job candidates, running names through state and federal databanks, and rechecking credentials every two years.
Finding qualified doctors, particularly psychiatrists, is a fundamental challenge for any jail medical operation. While Prison Health says it pays competitive salaries, doctors who have left for other jobs said they made much more working fewer hours.
"You have so many people vying for psychiatrists in a city this size, it makes it even more difficult," Ms. Pinney said. The company has responded aggressively, she said, recruiting at Columbia University's medical school and mailing solicitations to every psychiatrist in the city and North Jersey.
The company, then, often takes what it can get - witness the 10 unlicensed psychiatrists who Prison Health was supposed to fire by the end of 2001 because they had failed to pass state medical tests. The city allowed the company to keep them on for another 16 months, but when the doctors failed even then to obtain certification, it had them dismissed.
Prison Health soon rehired three of the psychiatrists, at reduced salaries, as social workers and mental health specialists.
"There's a reason these people have failed to demonstrate to the board that they are qualified," said Dr. Robert L. Cohen, who was medical director at Rikers from 1982 to 1986, when Montefiore Medical Center ran health care.
But if hiring doctors is hard, keeping them is tougher, say many who have worked at Rikers. "They cannot get psychiatrists to stay there," said Roberta Posner, a psychologist who headed a mental health unit when she was fired in 2001 after 12 years at Rikers. The company would not say why it dismissed her; Ms. Posner said it was for complaining. "The staff is so stressed and so spread out that they can barely manage," she said.
There are only 10 full-time psychiatrists working with inmates at Rikers, the company said. It employs 30 part-timers, and 8 others from two temporary agencies, including one in Atlanta called Psychiatrists Only.
Some current and former workers at Rikers said the reliance on such help disrupts treatment. A deputy health commissioner, James L. Capoziello, conceded, "It's not the optimal way of doing things."
When doctors cannot be found, the company has filled in with less skilled workers, say city officials and Prison Health employees. Since 2002, the city has allowed more than one-third of the psychiatrist positions to be filled by nurse practitioners or physician assistants, who are licensed to diagnose medical problems and prescribe medications. The health department says that the company is now using only seven of those workers to substitute for psychiatrists, and that it plans to end the practice.
Cathy Potler, deputy director of the Board of Correction, said that some of those nurses and physician assistants had little or no background in psychiatry.
"The result," she told city officials in a May 2003 letter, "is that the least experienced mental health staff are assigned to the facility with patients who are in need of the highest level of care."
'Juggling Hand Grenades'
As soon as Dr. Douglas Cooper arrived at work in the summer of 2003, the phone would ring and, he said, his heart would sink. He was facing another day of too few employees, too many psychotic inmates and a corporate boss that he says was more interested in paperwork than patients.
As the assistant supervising psychiatrist for all nine Rikers jails, he would have to figure out how to handle more than 300 patients at the island's largest mental health unit, in the largest jail at Rikers, where he worked. On the line was Prison Health's Rikers office, ordering him to send one or two of his four or five psychiatrists - each of whom might already have 30 patients to see - to jails that could not meet their city-mandated staffing quotas that day.
Rikers had a lyrical name for the practice: floating. But Dr. Cooper likened it to a bumpy ride on a unicycle with three punctures and only one patch. "They move the patch around to whichever hole is leaking air the fastest," he said.
Mental health care, he said, was merely damage control, and the inmates treated first were the many who knew they could get attention by threatening violence to themselves or others. Meanwhile, the staff tried to keep tabs on the patients who were quieter but often in more peril.
"You were juggling hand grenades, and one of them was going to go off, hopefully not in your hands," said Dr. Cooper, 52, who quit that August after nine years at Rikers.
His experience goes to the heart of what many employees say is the reality of daily medicine at Rikers. In interviews, more than two dozen current and former Prison Health doctors, physician assistants, psychologists and social workers said they were spread so thin that most mental health care was minimal. Most spoke on the condition that their names not be printed, saying they feared losing their jobs.
The numbers do not lie, they say. In 2000, the last year under St. Barnabas, the jails had about 830 full-time clinical employees, according to the hospital. Today, Prison Health has a clinical staff of about 670, the health department said.
That figure, set by the city, is inadequate, Dr. Cooper said - "designed to ration health care to cut costs as close to the bone as possible, and to provide a semblance of health care when one doesn't really exist." Prison Health, or P.H.S. as it is commonly known, goes along, more concerned with pleasing the city than with serving patients, he said.
The company's approach, he said, is essentially this: "Put your best face forward, hide as many problems as you can and hang on to the contract for as long as you can."
As a case in point, he and others cited the way the company regards different kinds of paperwork. Medical records, on one hand, are often outdated or unavailable, they said. Senior clinicians said they commonly had to sign off on treatment without seeing a medical history, a practice they said could jeopardize their licenses, and inmates' health.
But at the same time, employees said, Prison Health uses doctors and other highly trained specialists to produce and double-check another set of papers: the blizzard of documents that city bureaucrats use to gauge the company's performance. The paper chase actually appears to have grown out of an effort by the city to prevent a reprise of the St. Barnabas years. In its first contract with Prison Health, the city listed the numbers of doctors, nurses, clerks and other staff required at each jail. Failure to document compliance with that list, known as the staffing matrix, for a single day, or even a shift, could result in a $5,000 fine.
But Prison Health has turned the matrix into a meaningless yardstick, several doctors and physician assistants said. Some mental health clinicians said that a number of their most experienced colleagues - the clinical supervisors helping run the medical programs in each jail - work full time reviewing reports for the city, making sure boxes are marked and evaluations signed. Even those working with inmates said they were overwhelmed.
"It became impossible to have a therapeutic conversation with a patient - it was just checking off boxes," said Dr. Daniel Selling, a clinical psychologist who quit in March after about eight months at Rikers. "The P.H.S. administration could care less what I do with a patient."
In the practice known as floating, the company has often sent a doctor or nurse with a backlog of patients at one jail to another where there are fewer inmates to treat, simply to avoid fines, the Board of Correction said. The city has repeatedly fined Prison Health for incomplete filings, but never for treatment that resulted in injury or death.
"The constant shuffling of mental health providers from one facility to the next keeps them from being able to see his/her patient caseload," Ms. Potler, the board's deputy director, complained to city officials in her May 2003 memo. The company says it has greatly reduced that problem.
Floating, in turn, led to fudging, said several current and former employees. To sidestep a fine, they said, Prison Health has had employees sign in at one jail but then work at another. When there have been too few doctors to float, medical administrators have signed in - but without seeing any patients, said three senior clinicians. One added, "The practice is clearly fraudulent."
Health department officials said they were not aware of any deception by Prison Health. But they said the staffing matrix had been changed in the new contract to ensure that a core group of mental health workers at each jail cannot be floated. The fines have been eliminated, officials said, and the company will be graded more on treatment than on paperwork.
Company officials denied that any employees had been forced to sign in at jails falsely. Ms. Pinney said that she tried to avoid moving employees between jails, but that it was sometimes necessary to meet patients' needs. The complaints about short-staffing, she said, were untrue, if expected.
"We've set a very high standard of performance for our employees," she said. "Some people like that and some people don't like that."
Several doctors said that an overextended and discouraged medical staff would not pick up on suicidal behavior.
"People lose touch, because the pressure is on," one mental health supervisor said in exasperation. "And if patients are not the priority," he added, "the consequence is those six suicides."
Alone at the End
From the first days she spent at Rikers Island, charged with shoplifting 30 tubes of Revlon lipstick from a Rite-Aid in the Bronx, it was obvious that Carina Montes was carrying around something a lot weightier than stolen merchandise.
A 29-year-old former gang member with a gunshot scar on her stomach and a teardrop tattooed under her right eye, Ms. Montes was sexually abused as a child. She was 8 when she began seeing a psychiatrist for depression, medical records show. She tried to kill herself three times, at ages 13, 18 and 25, and arrived at Rikers severely depressed.
She told some of this in her intake exam, to a physician who diagnosed manic depression and prescribed antipsychotic medication, state investigators said. But little of the information would follow Ms. Montes, they said, as Prison Health passed her from one staff member to another, losing track of her records and even seeming for months to lose track of the young woman herself.
Over the five months she had left, she would never be seen by a doctor again, the State Commission of Correction found. At the end, she would have no one to help her but other inmates and a rookie jail guard.
Isolation was nothing new for Ms. Montes. Born in Puerto Rico, she dropped out after the ninth grade into a different sort of education, selling crack on the Grand Concourse, then paying for it in city jails and upstate prisons. Paroled from a drug sentence in March 2002, she had no family to turn to - just Ana Torres, a lover who took her in from a women's shelter.
That Sept. 13, the day after Ms. Montes landed at Rikers, the doctor recommended an immediate mental health examination. But nearly three months passed before Prison Health performed the exam, which took place only because a guard had noticed Ms. Montes acting strangely, records show.
The social worker who finally examined her on Dec. 7 was a "floater" who rarely worked in the women's jail. Learning of Ms. Montes's three attempts to kill herself, he placed her on suicide watch.
It took another 23 days before Ms. Montes was seen by a mental health specialist, Brett Bergman. But he did not know his patient was on suicide watch, he later told investigators, because he could not find her medical file. "Patient appears to be doing well and was stable," Mr. Bergman wrote. Although he saw her twice more in the next month, he still could not locate the file.
No other clinician had a chance to help her; on Dec. 2, after she fought with another inmate, the correction staff placed her in a protective-custody cellblock that had no regular mental health services.
On Feb. 6, her isolation proved deadly. Although she was on suicide watch, Ms. Montes had not been seen by any mental health worker for nine days, records show. No one noticed that Ms. Montes, a diabetic, had refused her insulin injections for two days.
But another inmate, Linda Vega, saw her weeping in her cell that morning, distraught over a quarrel with a new lover four cells away. "Everything I love don't love me," she lamented, according to Ms. Vega, and said she would hang herself. "I then noticed sheets torn apart between her legs," Ms. Vega told city investigators.
At 11 a.m., alerted by inmates, a newly hired guard, Kje Demas, stood outside Ms. Montes's open cell door and asked if she was all right. "I'm O.K., I'm just going through something," she said, the guard told investigators. Officer Demas said he had never been told she was on suicide watch. He did not see the bedsheets or any cause for alarm.
Shortly before 5 p.m., another guard heard inmates screaming and found Ms. Montes hanging from an air vent.
The Correction Department fired Officer Demas for failing to notify a superior. The health department said it "counseled" Mr. Bergman and his supervisor for not reviewing the medical charts they could not find, and imposed a rule that inmates on suicide watch be interviewed every two days.
There was no penalty for Prison Health.
Ms. Montes's body was shipped a few miles northeast of Rikers - to Hart Island, where the city buries its unclaimed dead.
Joseph Plambeck contributed reporting for this article.