A litany of Department of Correction failures contributed to the deaths of seven inmates in New York City’s troubled jail system during the second half of 2022, according to a report released Wednesday from a city oversight board.

The New York City Board of Correction said in the 35-page document that egregious inaction from correction officers who didn’t properly supervise inmates or failed to provide first aid contributed to the department’s 19 in-custody deaths last year.

The report focused on the circumstances of seven deceased inmates: Michael Nieves, Kevin Bryan, Gregory Acevedo, Elmore Robert Pondexter, Erick Tavira, Gilberto Garcia and Edgardo Mejias.

Three of them died by suicide. The other deaths were listed as a fentanyl overdose, an anoxic brain injury, and drowning. One death was listed as inconclusive.

In several of these cases, officers’ failures to follow policies were partly responsible for the inmates’ deaths, the report alleged.

In Nieves’ case, two correction officers and a captain were working in the unit on August 25 when the inmate cut his own throat with a shaving razor that was provided to him by guards.

Nieves had a history of paranoia, impulsiveness and suicidal behavior. He hid the razor and told guards he lost it when they asked for it back.

Correction officers couldn’t find the blade on him or in his cell — until Nieves sliced his own throat with it about an hour later.

An officer found him bleeding, but didn’t try to staunch the blood or give him any kind of first aid, the report said. Instead, he and the other guards waited for the medical staff to arrive nine minutes later.

By then it was too late — he died from the wounds five days later. Two officers and a captain were later suspended over their conduct.

The report cited other errors as well, such as the DOC’s failure to keep hard drugs out of the hands of inmates like Gilberto Garcia, the 26-year-old man who died of a fentanyl overdose in Rikers Island on October 31.

In another incident, the “B” post officer assigned to Erick Tavira’s mental observation unit in the George R. Vierno Center on Rikers Island frequently left his post instead of touring every 15 minutes as required.

Tavira hanged himself with a bedsheet on October 22.

“‘B’ post officers work inside the housing area, interact directly with people in custody, and are
the first line of response in case of emergencies,” the report said. “It is vital that the post is staffed at all times and that officers are vigilant.”

The Legal Aid Society, the city’s largest legal aid nonprofit, pushed for a federal takeover of the violence-plagued jail system last year.

But a Manhattan federal judge denied the request, saying that while she was deeply concerned about safety issues at Rikers, a takeover might divert resources from inmates.

The DOC did not respond to a request for comment.

The report called for a slew of changes and a “comprehensive, holistic” review of in-custody deaths.

The DOC, the board and the city’s Correctional Health Services should hold “timely death review
conferences to discuss the circumstances around each death, what operational or clinical problems can be identified, and how both agencies can work collaboratively to prevent further incidents,” the report said.

It also said the DOC should “ensure that correction officers and captains conduct regular tours and directly supervise people in custody, in accordance with DOC’s own policies,” among other things.

The CHS said in a response that it took issue with some of the report’s findings — the board left out facts and mischaracterized others, it said.

And it claimed that the board itself has the authority to call the post-mortem meetings the report said it wanted.

“It remains entirely up to the BOC to convene the Board’s death reviews as timely as it wishes, separately from any independent review each agency may conduct,” the statement said.

Additional reporting by Craig McCarthy