NEW YORK (AP) – These are the deaths in New York City's Rikers Island jail that don't make headlines — prisoners with diseases, disorders and addictions who succumb to heart attacks, infections and other causes officially filed away as "medical."
But hundreds of documents obtained by The Associated Press through public records requests raise serious questions about the quality and timeliness of the medical care many of these inmates received, with the treatment, or lack of it, cited as a factor in at least 15 deaths over the past five years.
— Rolando Perez, 36, died at Rikers in January, two days after he was put in "The Bing" — solitary confinement — for fighting.
Inmates told investigators they heard Perez screaming for his medication — pills he relied on since age 16 to control a severe seizure disorder.
The medical examiner said he died of a seizure disorder and heart problems and ruled his death natural.
He had been put in solitary without the required clearance from the mental health and medical staff.
— David Caban, a 38-year-old who had been diagnosed with schizophrenia, died four days after arriving at Rikers from a psychiatric hospital. He received care later deemed so substandard that a psychiatrist was fired.
The medical examiner found that Caban died of a sudden heart problem, aggravated by his mental illness, and ruled it natural.
But state investigators found that Caban received a drug injection to calm him down without being monitored or sent for emergency hospitalization. Then he was sent back to a dorm where he ran amok, charging at a guard. He was then handcuffed and left alone on a holding cell floor, rocking and grunting.
One guard checked on an unresponsive Caban and nudged him with her foot but didn't call doctors because, she said, he was still breathing. He was found dead 10 minutes later.
Such accounts have prompted city officials to re-examine the quality of medical and mental health care in the city's 11,000-inmate jail system and whether the outside company that holds a three-year, $126.6 million contract to provide treatment, Corizon Health Inc., should essentially be fired.
Experts say the problems documented by the AP are particularly troubling because New York City is better equipped to deal with inmate health needs than perhaps anywhere else, with 1,180 health workers employed by Corizon and the city, a mandatory doctor's visit within the first 24 hours of custody, 30 on-island clinics that handled more than 112,000 sick-call visits last year, and access to some of the nation's finest hospitals, which saw more than 3,700 inmate referrals last year.
In New York and in most other lockups across the nation, experts say there are many obstacles to delivering quality care, most significantly the flood of mostly poor inmates who come through the door with various maladies and addictions that have gone untreated for years.
Other factors: Policies entitling inmates to only "minimum standards" of care, often less than what is provided in the outside world; pressure to keep costs down; and guards who can be cynical and dismissive of inmate complaints.
"Everywhere you look at the system, it's structured to prevent prisoners from getting the health care they need," said Brad Brockmann, who heads the Center for Prisoner Health and Human Rights at Brown University.
Rikers, the huge jail complex on an island in the East River, has come under increased scrutiny this year after the AP detailed the deaths of two mentally ill inmates — one who was left unattended in a 101-degree cell and another who sexually mutilated himself while locked up alone for seven days.
Since then, reporters, lawmakers and federal prosecutors have investigated the city's jails, particularly the system's problems in dealing with violence and growing numbers of mentally ill, who now make up 40 percent of the inmate population.
Mayor Bill de Blasio's administration has quietly begun discussions about alternatives to Brentwood, Tennessee-based Corizon, the nation's biggest provider of health care behind bars, according to two city officials.
Those plans could include replacing Corizon entirely with city-run health care services, or hiring a teaching hospital to run the system and provide a steady stream of young, committed doctors, according to the officials, who spoke on condition of anonymity because they weren't permitted to discuss the plans.
In a statement, de Blasio spokeswoman Marti Adams said only that the administration has begun a "comprehensive review" of Corizon.
Experts say the teaching or nonprofit hospital model, used previously in New York City and currently in states such as Texas and Connecticut, can bring higher standards of inmate care than for-profit health providers.
"In New York City, these are large organizations which have greater public support and the ability to recruit qualified and enthusiastic staff," said Dr. Bobby Cohen, a member of the watchdog agency charged with overseeing city jails. He helped run jail health in the 1980s when it was overseen by Montefiore Medical Center, a hospital in the Bronx.
But experts say running jail health services around the clock is extremely complicated and costly, and not all teaching and nonprofit hospitals are accustomed to the tough and sometimes dangerous world of corrections.
A contract evaluation obtained by the AP shows city officials downgraded Corizon's performance from "good" in 2012 to "fair" in 2013, citing inconsistent leadership and care in several mental observation units.
Corizon spokeswoman Susan Morgenstern wouldn't discuss individual cases or the potential loss of the city contract but said in a statement that the company tries to provide quality treatment in a difficult environment, and "we regrettably sometimes face adverse outcomes despite our best efforts."
The city's health department said in a statement that the Corizon contract provides no financial incentive to skimp on care — the city pays for medications, lab testing and hospitalizations.
A spokesman for Correction Commissioner Joseph Ponte said Ponte has already made improvements to how guards and health workers deal with each other "to ensure inmates have access to care that is both timely and effective."
Of the 98 inmates to die in New York City jails over the past five years, at least a dozen had cancer and many more were suffering from health problems related to longtime drug or alcohol use. Fifteen had AIDS, HIV or hepatitis C.
The AP was able to obtain city and state investigative records on 44 of the 98 deaths. A review of those documents found 15 cases of neither homicide nor suicide in which the quality or timeliness of the health care was an issue.
That played out tragically in the May 2013 death of Mark Johnson.
Johnson, 32, died of a painful bacterial infection in his stomach and small bowel while jailed in a Rikers mental observation unit. For days, he demanded medical care from jail guards as he continued to suffer from bloody stools.
It wasn't until inmates in the housing area staged a protest — refusing to go for a meal until Johnson was attended to — that doctors came. Johnson underwent emergency surgery but died soon after, his stomach full of pus.
In its preliminary investigation, the department found no negligence on its own part and said Johnson had a pre-existing condition that caused his death.
"With antibiotics he could be alive today," said his mother, June Broer, who is suing the city. "It is heartbreaking. He should have gone to the hospital."