The New York State Commission on Correction released a new report this week, detailing the findings from its investigation into the horrific and preventable death of mentally ill black inmate, Bradley Ballard.
Ballard was left in his cell for six days straight in September, 2013. Guards shut the water off to his cell for over four days, and not once during that time was he treated for his schizophrenia and diabetes. On the rare occasion that he was seen by a medical worker, their talks did not last for more than a minute at a time. He was eventually found naked on the floor, covered in feces and urine with a rubber band wound tightly around his cut and infected genitals. Ballard would go into cardiac arrest just a few minutes after being removed from his cell and die from “diabetic ketoacidosis due to withholding of his diabetes medications complicated by sepsis due to severe tissue necrosis of his genitals as a result of self-mutliation.” The commission agreed with earlier assessments that Ballard’s death was, in fact, a homicide.
We’ve known a few of the major details of this case since his family filed a lawsuit on his behalf a few months back. But this report contains more explicit details of Ballard’s mistreatment that should reinforce the intense unease the incarcerated’ and their advocates feel over the continued role and impunity of Rikers’ for-profit inmate healthcare provider, Corizon Health Services, which will soon oversee inmate care in Rikers’ soon-to-be-constructed $14.8 million super-solitary unit known as the ESHU.
Between generous redactions, we are afforded a glimpse at the disturbing reality inmates face under the care of Corizon staff and Rikers’ corrections officers. You should read the actual report because you can’t beat primary sources, but I’ll admit it is a bit cumbersome given the heavy blocks of redacted text and it’s call-and-response format. I created this annotated version of the report to organize the components a bit more logically, which I hope is helpful to some readers.
The commission does not mince words or shy away from assigning blame. It calls out Corizon repeatedly and unequivocally for “substandard medical and mental health treatment.” They write that Corizon’s work was “so incompetent and inadequate as to shock the conscience,” and that Ballard would have survived had he received the appropriate care. Corizon staff are said to have shown “deliberate indifference to Ballard’s serious medical needs by collectively failing to provide the very basics of medical care and failing to take appropriate action in a timely manner to a medical emergency.”
Ultimately, the commission writes, “The lack of coordinated care for and mismanagement of Ballard’s [redacted] represents grossly negligent medical care by Corizon, Inc., endangered Ballard’s life and subsequently caused his death.”
The commission also lays out a host of recommendations that I will analyze in a later post. Overall, they’re OK, but many lack the teeth and tenacity required for real progress, and many more are simply calls for further investigation. The commission does, however, offer the closest thing we have to an official push for ending Corizon’s contract; they write, “The deputy commissioner should consider and determine whether Corizon Inc., a business holding itself out as a medical care provider, is fit to continue as New York City service contractor in light of delivery of flagrantly inadequate, substandard and dangerous medical and mental healthcare to Bradley Ballard.”
What the report offers are not actual policy changes, just recommendations. So while we wait to see what New York plans to actually DO about Corizon, I think it would be useful to take a look at what their care actually looks like in order to underscore how completely ridiculous it is that they should be allowed to continue working on Rikers Island.
Below, I’m going to narrate Bradley’s story as told in the report. Many of these details are gleaned from video recordings due to incomplete and falsified log books by corrections officers and medical staff.
As you read, remember that these are the medical “professionals” that NYC Corrections officials just voted to put in charge of inmate health and screening at its new super-secure solitary unit. Ask yourself: How can Corizon be trusted to decide who is mentally and physically fit for the torture of solitary when it ignores medical charts, enters incorrect data and prescribes the wrong medication to save money? How is Corizon expected to care for ESHU inmates when it routinely skipped solitary cells during inspection rounds, failed to provide Ballard with medication for days on end, and missed multiple call-outs for the clinic?
How can Corizon be trusted to care for anyone, anywhere, much less in a jail with over 40% of inmates diagnosed with mental illness and a documented institutional history of violence, abuse and neglect?
Note: Links in the following section go to the sections of the annotated report where this information is mentioned.
Who was Bradley Ballard?
Bradley Ballard was a black man born and raised in Houston, Texas. He was the youngest of three boys, and his father died early on in his life. Between redactions, the report mentions he had an abusive childhood and only received a high school education.
He struggled with cocaine and alcohol abuse, was a diagnosed paranoid schizophrenic and had diabetes. His crime and exact path to Rikers are redacted from the report, but we know he was 39 years old upon entering the jail in June, 2013. His mother remained many thousands of miles away in Houston, which means Ballard was alone, without friends or family in NYC to check on or stand up for him.
Arriving at Rikers Island & Changes to medication
As soon as Ballard arrived at Rikers, the report indicated that Corizon medical staff and correction officers failed in their duties to him on multiple occasions, missing 5 separate “call-outs” to bring Ballard to specialized clinical sessions.
Through redactions, we can see the commission upbraid Corizon for what it apparently did next: change his delicate psychotropic medication regimen without explanation or medical rationale. The report states “The lack of a documented clinical rationale for a patient with reported efficacy of the current medication regimen supported by a physician’s order and the failure to thoroughly read a patient’s medical chart and history constitutes incompetent psychiatric care.”
[NOTE: Corizon has been known to swap out inmate prescriptions and delay treatments as part of its “cost savings” strategy. This dangerous practice has been employed by Corizon at other facilities with similarly gruesome results.]
Soon after his prescriptions were changed, Ballard was involved in a “use of force” incident with correction officers. A few days later, he got in a fight with another inmate. His behavior deteriorated rapidly, but Corizon staff seemed oblivious to how their changes to his medication might be involved.
On September 3rd, three months after his arrival and three months into his increasingly erratic behavior influenced by the changes in his medication, Ballard was transferred to the Anna M Kross Center (AMKC). He was given an individual cell.
Sept. 4th: “Lewd gesture” at AMKC leads to solitary
Ballard was seen on camera in the day room at AMKC with other inmates. It had been two days since his last mental health consultation. According to camera footage, Ballard was dancing around the day room, occasionally pausing to place his hands upward “as if he was praying.”
Eventually, Ballard took his shirt off, twisted it into a phallic shape and began making a lewd gesture at a female guard. Moments later, corrections officers moved in and handcuffed him, placing him in administrative segregation. Ballard was “keeplocked” in his cell, which means that he was confined in his cube instead of moved to an actual solitary unit, like the SHU.
There was no mention of this incident in the log book and no specific violation was cited for isolating Ballard.
Sept. 5th: Ballard floods his cell
Just after midnight, in the early morning hours, video showed water pouring out of Ballard’s cell. Nothing was noted in log book. A captain visited his cell around 1AM but no action was taken.
Breakfast came around 6AM but Ballard was skipped and not fed. There wasn’t any note as to why in the log book. At around 12:50PM, Ballard started banging on his cell door, and 10 minutes later, food finally arrived. It was his first meal since 4PM the day before.
45 minutes later, a medical staffer visited his cell, but stayed for less than one minute. After dinner, the medical staffer on rounds that night skipped his cell.
Ballard was denied a shower, exercise, programming, medication or mental healthcare, and he missed a meal — all of which he was entitled to and all of which constitute civil rights violations by correction and medical staffers.
Sept. 6th: Water is turned off to Ballard’s cell
Over the course of two hours during the early morning of Sept. 6th, there was a flurry of activity outside Ballard’s cell. Several corrections officers made brief visits, but no action was taken, and no notes were made in the log book as to what they said or saw.
A few hours after breakfast was served, Ballard flooded his cell again. This time, however, maintenance workers came and turned the water off. There was no note in the log about the incident. Ballard’s water would be turned off for the next four and a half days straight — for the rest of his life.
Ballard received his lunch and, when an officer later opened his cell door, Ballard threw the tray and a cup out.
During the night round after dinner, a medical staffer looked into Ballard’s cell but didn’t speak to him. Later that night, an Assistant Deputy Warden (ADW) doing rounds was seen on video making a gesture that indicated bad smells were coming from Ballard’s cell.
Ballard was once again denied a shower, exercise, programming, medication and mental healthcare. He had no water to drink, clean or flush his toilet. He had not left his cell since he was placed inside of it. He had not had a consultation with a mental health professional for 4 days.
Sept. 7th: Isolation worsens, as do smells
The next day, Ballard refused breakfast. A few hours later, an officer was seen spraying deoderant outside of his cell. No notes were made in the log.
Lunch came, and a half hour later, Ballard spoke with a mental health staffer for less than one minute.
Ballard received dinner. That was the end of his day.
Once again: no shower, exercise, programming, medication or mental health care. He still didn’t have access to running water to drink or flush the toilet, and it’s was almost a week since his last mental health consultation.
He’d been off his schizophrenia and diabetes meds for several days at this point. In fact, the report notes that between 8/7/13 and 9/5/13, Ballard should have been encountered 58 times for finger sticks for diabetes, but he was only seen 10 times.
Sept. 8th: Day punctuated by meals only
Between midnight and 9 am, there were several brief moments where guards would appear outside Ballard’s door. At one point, an officer brought him a drink carton.
Lunch came, then dinner. He spoke to a mental health clinician for less than one minute. That was the end of his day.
No shower, no exercise, no programming, no medication and no mental health care. No water to drink or with which to flush his toilet. He had not left his cell since he was first put inside of it.
Sept. 9th: Rising alarm, but no action or notes taken
At 2am on his 5th day of isolation, an officer was seen on video peering into Ballard’s cell with a flash light, but no notation as to what he saw was made in the log book.
A small container was brought to him close to breakfast time, but no actual tray of food was brought. It’s unknown what was in the container. An officer and inmate porter later appeared at the cell door, and threw an unknown object inside. Some food was brought later. An officer and the ADW stopped by his cell briefly, but no notes were made concerning their visit.
Lunch came, and when a neighboring inmate’s cell door opened to receive his tray, the inmate sprinted out into the hallway. The report noted that that inmate apparently hadn’t been let out, given a shower, exercised, etc., for days on end, either. He was secured and returned to his cell.
The healthcare worker conducting rounds that night skipped his cell again. Dinner was slid beneath the door. An officer and inmate delivered what appeared to be paperwork to the cell.
Medication was given to the inmate next door, but not to Ballard. At 10:30 and midnight, officers briefly visited his cell door.
Another day went by without a shower, exercise, programming, medication or consultation. He was denied access to water continuously since it was turned off days before. He still couldn’t flush his toilet. He hadn’t left his cell since he was placed inside.
Sept. 10th: Officers are MIA throughout the day
All throughout the early morning of Ballard’s last day at Rikers (and on earth) officers were seen abandoning their posts and falsifying their entries in the log book on multiple occasions. The inmates were more or less unsupervised on this day.
When an inmate brought Ballard breakfast that morning, he could be seen covering his nose with his shirt against the stench emanating from the cell. An officer threw a towel into Ballard’s cell. A few hours later, an officer and unidentified civilian were seen outside his cell.
Lunch came. Dinner came. Officers had abandoned their constant observation posts throughout the day. Inmates were seen covering their faces around Ballard’s cell. Videotape shows something was clearly wrong and that people on his cell block couldn’t ignore it.
Ballard was skipped again for mental health consultation. It had been 8 days since his last one. Still no shower, exercise, programming, medication or mental health care. No running water for 4 days. He still hadn’t left cell.
Sept. 10th (Evening): Ballard, inches from death, removed from cell
That night, visiting officers and ADW began holding their noses and kicking Ballard’s cell door. Nobody went inside. No orders or actions were taken. No notations were made in the log book.
When his neighbor’s door was unlocked to receive medication, videotape showed the inmate spring out and attack another inmate in the hallway. They were separated and returned to their cells.
Only then — several days after he was first “keeplocked” — did officers take their first notes on Ballard’s isolation. An officer wrote that Ballard was naked on the floor of his cell and having difficulty breathing. He was covered in feces and urine, and had sepsis from a wound on his genitals from a rubber band wrapped tightly around them; he had been self-mutilating.
The corrections officer ordered medical staff to contact the clinic, but it wasn’t followed for over an hour.
Two inmates and a Corizon doctor eventually arrived at Ballard’s cell. Ballard said he couldn’t get up, but instead of tending to him immediately, the Corizon staffer instructed the inmates to carry him wrapped in a sheet. He wouldn’t touch Ballard’s filthy, mutilated and nearly-dead body.
What happened next is completely redacted from the report. But we know Ballard died from his injuries and lack of medical attention just a few moments after being extracted from his cell.
Hours later, video showed a feces-covered mattress being removed. The water was then turned back on.
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