A cascade of staffing and medical breakdowns contributed to the deaths of three Rikers Island detainees this year, a jails watchdog concluded in a report released Monday.

The deaths of Tarz Youngblood on Feb. 27, George Pagan on March 17 and Herman Diaz one day later on March 18 each exposed systemic problems at the beleaguered jail complex, including staff indifference, missed medical treatment and delayed emergency response.

“There are common elements in all three deaths, which result in the Department of Correction’s failure to provide minimally adequate coverage and supervision within housing areas in the city’s jails,” the Board of Correction concluded.

“DOC and [Correctional Health Services] do not seem to have an acceptably functioning system for providing emergency care to persons in life-threatening situations.”

In all three cases, it was inmates who rendered aid on the dying detainees, the report found.

FILE - This June 20, 2014 file photo shows the Rikers Island jail complex in New York, with the Manhattan skyline in the background. (Seth Wenig/AP)

Correction Commissioner Louis Molina and Mayor Adams have blamed prior administrations for the troubles in the city jails, but these deaths took place on their watch. A fourth inmate, Dashawn Carter, 25, died by hanging at the Anna M. Kross Center at Rikers on Saturday, sources and jail officials confirmed. In 2021, 16 detainees died in custody.

The Correction Department said in a statement “every death in custody is a tragedy.” But Correctional Health Services, which handles inmates’ medical care, insisted its emergency response system “functions acceptably and appropriately.”

Youngblood, 38, was in a unit where officers are supposed to conduct rounds every 30 minutes.The Board of Correction found that officers had not checked the cell where Youngblood was held for at least three hours before his death. Security footage captured inmates carrying Youngblood, who was unconscious, out of a cell at 10:30 a.m. to a table, where they attempted to revive him. Medical staff arrived eight minutes later. Youngblood was declared dead just over an hour later.

Pagan was housed in a dorm in the Eric M. Taylor Center despite his extremely poor health.

“He regularly urinated, defecated and vomited on himself. He was weak, barely ate, and spent his days laying on his bed or the floor,” the report said, citing witness statements and video.

Attorneys, past Rikers Island inmates and other supporters hold a rally in favor of closing Rikers Island outside the Criminal Court Building on Schermerhorn St. in Brooklyn on Monday, Sept. 27, 2021. (Theodore Parisienne/for New York Daily News)

As the Daily News reported last week, there was no correction officer patrolling the floor of Pagan’s dorm on the day he died until 2:30 p.m.

When that officer did arrive, he or she hung out in the secure control room, known as the “bubble,” instead of conducting rounds, the Correction Board found.

Pagan’s cause of death was unclear. But the report stated that he had recently relapsed and did not receive medicine for alcohol and opioid withdrawal on several occasions in the days prior to his death.

“At that point, he was hallucinating and unable to walk,” the report found.

Pagan missed nine scheduled medical appointments over a six-day period before his death.

At 5:32 p.m. inmates alerted jail staff that Pagan was in the midst of a “medical emergency,” according to the report.

It wasn’t clear when that was sent up the chain of command. Correction Department officials claimed that a medical emergency was called at 5:35 p.m.. But Correctional Health officials said they didn’t get the call until 6:12 p.m.

“Neither party has explained what led to this reporting discrepancy,” the Correction Board said.

At any rate, medical help reached Pagan 50 minutes after inmates notified staff. He died the next morning at Elmhurst Hospital Center.

A sign marks the location of the Rikers Correctional Center in the East River on March 9, 2021 in New York City. (Gary Hershorn/Getty Images)

Diaz, 52, was also in a dorm in Taylor Center when he choked to death on an orange with, once again, no floor officer present, The News previously reported.

No correction officer was patrolling the floor, and another officer refused to leave the security bubble, despite inmates’ pleas.

Herman Diaz, 52, a Rikers Island inmate died Friday, March 18, 2022, after he choked on an orange.

“There was no staff assigned to the housing area that could provide immediate first aid when Mr. Diaz began choking,” the report concludes.

Correction Department and Correctional Health once again contradicted each other on the medical response. Correction officials claim they did call for help, but the health service claims it received no such call, the report said.

The News has reported extensively on the consequences of the ongoing staffing crisis at Rikers, which has resulted in numerous posts going unmanned. Roughly a third of the jail’s 7,700 uniformed staff are out sick on a given day. Molina must submit a plan to fix Rikers for court approval by May 17.

Copyright © 2021, New York Daily News

Copyright © 2021, New York Daily News