NEW YORK (PIX11) — “Longstanding” issues contributed to the deaths of three Rikers Island inmates — including one who didn’t receive medical aid after choking on an orange, the New York City Board of Correction found in a report released Monday.

Tarz Youngblood, George Pagan and Herman Diaz all died within the first three months of 2022. Sixteen inmates died in Department of Correction custody in 2021, according to the report; the Board of Correction is also in the process of investigating those deaths.

Inmate Dashawn Carter, 25, died May 8. His death is not part of the report.

“These investigations do not focus on criminal wrongdoing or individual fault but rather on identifying areas of improvement and lessons to be learned to prevent further tragedies,” the Board of Correction wrote. “Many of the issues described in this report are longstanding, present in our city’s jails for years and, in some cases, decades.”

The board added it wants to “work in partnership” with Department of Correction Commissioner Louis Molina to find a solution for “persistent problems.” The final report was put together from interviews with inmates and decedents’ legal teams, reviews of surveillance footage, relevant Department of Correction materials, medical records and press coverage.

The board found seven “key findings” in their investigation, including: unstaffed posts, lack of floor officers, insufficient rounds, lack of emergency medical response and missed medical appointments. The deaths of Youngblood, Pagan and Diaz were mentioned specifically in these findings.

Youngblood, 38, was the first reported death of 2022. He died on Feb. 27 at about 11:44 a.m., according to the report. About an hour before, Youngblood was carried out of a cell — which was assigned to another inmate — and downstairs by his fellow inmates.

According to the Board of Correction report, officers were not observed making rounds near where Youngblood was found, even though there was a floor officer on staff. Review of video footage showed that jail staff did not conduct rounds every 30 minutes or check the cell Youngblood was in for at least three hours before his death. The cell’s window was obstructed by a covering leading up to Youngblood’s death.

Additionally, the post officer assigned to Youngblood’s unit was not permitted to work directly with inmates. Because of this, Youngblood didn’t receive medical attention until eight minutes after he was initially carried out of the cell by other inmates.

Pagan, 48, and Diaz, 58, died within a day of each other — March 17 and 18, respectively. Pagan died nine days after he arrived at Rikers’ Eric M. Taylor Center. According to the Board of Correction report, other inmates noticed his “visibly poor medical state.”

“He was weak, barely ate and spent his days laying on his bed or the floor,” the report found. “People in custody brought him food and drink.”

There was no officer in Pagan’s dormitory until 2:30 p.m., according to the report. The officer meant to be touring the dorm’s floor instead stood in a control room with another officer on duty.

Eventually, inmates reported Pagan’s condition to one of the officers, who called in a medical emergency. However, according to the report, there is a discrepancy between when the officer said they called medical services and when Correction Health Services received the call. The officer said they called in the emergency at 5:35 p.m., while CHS said the call was not placed until 6:12 p.m. Medical staff arrived at 6:22 p.m.

“CHS stated that they cannot speak to the discrepancy and stand by their records,” the Board of Correction wrote. “If DOC’s account is accurate, it took over 30 minutes for a medical team to leave the clinic and make their way to the unit. If CHS’s account is accurate, the response time was around 10 minutes.”

According to his legal team, Pagan — who had a history of drug and alcohol addiction, as well as a “concerning” medical history — was in “very, very bad shape” prior to his incarceration on March 9. Pagan’s legal team added he had life-threatening conditions that required regular monitoring and treatment.

In the nine days he was detained, Pagan reportedly missed nine separate medical appointments for Clinical Institute Withdrawal Assessment or medication administration.

“Pagan did not receive his methadone medication on three occasions nor critical alcohol withdrawal medication on four occasions, including for almost 48 hours before he was transported to the clinic for emergency care on March 16,” the Board of Correction found. “At that point, he was hallucinating and unable to walk.”

Diaz, the last death cited in the report, died March 18. On the day of his death, there was no floor officer, and the officer on duty was not permitted to interact directly with inmates, according to the Board of Correction.

According to witnesses, Diaz choked and collapsed while eating an orange about 10:16 a.m. March 18. Other inmates used the Heimlich maneuver on Diaz, turned him on his side and checked his mouth and throat afterward. At one point, Diaz’ lips were turning blue, witnesses added.

When other inmates alerted the officer on duty, the officer did not exit their station or administer aid to Diaz, the report found. Instead, they called in to the clinic.

According to the Board of Correction, an officer’s expected role in rendering first aid is “unclear.”

Just as in Pagan’s case, there is a discrepancy in reporting — or whether or not an emergency was called in at all. Department of Correction officials said the officer made two calls — only one is on the record, placed at 10:20 a.m. However, Correction Health Services said they did not receive any calls reporting an emergency.

“In the absence of a medical response, at approximately 10:20 a.m. the ‘A’ officer opened the unit’s entrance gate to allow people in custody to carry Mr. Diaz to the clinic. Along the way to the clinic, officers opened doors and gates to allow them passage to the clinic. None of the officers rendered first aid to Diaz,” the report found. “Diaz was pronounced dead at 10:58 am.”

The Board of Correction found there were “common” elements in all three 2022 deaths. The board made recommendations to both the Department of Correction and Correction Health Services, specifying that the two agencies need to develop and implement an action plan together.

In a letter filed in federal court, United States Attorney Damian Williams made the case for Rikers to be relinquished to federal control. He cited “unsafe and dangerous conditions.”

“We remain alarmed by the extraordinary level of violence and disorder at the jails and the ongoing imminent risk of harm that inmates and correction officers face every day,” Williams said.

Williams added that, without “dramatic systemic reforms,” federal officials could seek an outside appointment to run the jail.

Correction Officers Benevolent Association President Benny Boscio slammed the suggestion of a federal takeover. He feels correction officers should be the ones handling problems at Rikers. He also said he believes Mayor Eric Adams and Molina should be given time to make the necessary changes. 

A judge gave the city until May 17 to come up with a plan to fix the jail’s issues. The plan would be discussed May 24, and could prevent a federal takeover from taking place.