[Peace-discuss] Prison Suicides in NY

[David Green]

>From NY Times:
--------------------------------------------------------------------------------

February 28, 2005
In City's Jails, Missed Signals Open Way to Season of
Suicides
By PAUL von ZIELBAUER 
 
he warnings were right there in her medical file: a
childhood of sexual abuse, a diagnosis of manic
depression, a suicide attempt at age 13 - all noted
when Carina Montes arrived at Rikers Island in
September 2002.

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.