{"id":59498,"date":"2025-12-03T11:14:10","date_gmt":"2025-12-03T11:14:10","guid":{"rendered":"https:\/\/www.newsbeep.com\/us-ny\/59498\/"},"modified":"2025-12-03T11:14:10","modified_gmt":"2025-12-03T11:14:10","slug":"in-new-york-prisons-lack-of-medical-care-led-to-preventable-deaths","status":"publish","type":"post","link":"https:\/\/www.newsbeep.com\/us-ny\/59498\/","title":{"rendered":"In New York Prisons, Lack of Medical Care Led to Preventable Deaths"},"content":{"rendered":"

Photos and video by Angus Mordant for The Marshall Project
Photo illustration of David Riley by Celina Fang<\/a>; source image from David Riley<\/p>\n

Ashley Dolcy heard panic in her husband\u2019s voice. On most evenings, they would talk after she returned home from her job as an assistant principal at a school in the Bronx. Jason \u201cPoppy\u201d Phillips would call on a prison-issued tablet from his cell at Greene Correctional Facility near Albany, New York. On Dec. 14, 2023, he told her that, since lunch, he\u2019d increasingly had trouble breathing and swallowing. Alarmed that Phillips was struggling to breathe while locked in his cell, Dolcy called the main number at the prison to seek help. No one picked up.<\/p>\n

She then created a three-person call with her husband and his cousin, Valicia Philibert, a nursing professor. Philibert asked about his symptoms and then called the prison. Again, no answer. She called back, this time punching in 9-1-1 at the voicemail prompt. An officer picked up.<\/p>\n

Identifying herself as a nurse, Philibert said her cousin was in medical distress and needed immediate help. \u201cI remember saying to the officer, \u2018Although he\u2019s in prison, he shouldn\u2019t be treated like an animal.\u2019\u201d<\/p>\n

The officer immediately passed the information to the watch commander. That an officer answered his cousin\u2019s call and passed the message up the chain of command was a stroke of luck for Phillips. Ten minutes later, two nurses came to his cell door. Help, it seemed, had arrived.<\/p>\n

\"A<\/p>\n

\nGreene Correctional Facility, where Jason \u201cPoppy\u201d Phillips was incarcerated, is located south of Albany, NY.
\nAngus Mordant for The Marshall Project\n<\/p>\n

In the past decade, more than 30 people who were experiencing a health crisis in New York prisons died of preventable or treatable conditions, an investigation by The Marshall Project has found. A few men died from treatable infections. Several others succumbed to obstructed bowels. A prisoner with asthma died after he was denied access to an inhaler just feet away.<\/p>\n

If anyone could defy this trend, it was Phillips. He grew up in a big family in the Bronx, with 11 siblings. Family members described him as selfless, fun-loving and upbeat. He had at least six years left to serve on armed robbery charges from the Bronx and Westchester County. He\u2019d remained close to his family, and that closeness would prove fortunate when his breathing became labored.<\/p>\n

Phillips, it would turn out, had an infected epiglottis, the flap of cartilage in a person\u2019s throat that directs air to the lungs and food and liquid to the stomach. The infection is rare \u2014 about 3 out of every 100,000 adults contract it annually \u2014 and treatable: 99% of patients recover. But the infection is a medical emergency that, left untreated, can swell the epiglottis and choke a person to death.<\/p>\n

After Phillips\u2019 cousin called the prison for help, Nurses Megan Holbrook and Anthony Livoti arrived outside his cell with a sergeant and a guard at 6:25 p.m. \u201cOpen your mouth and say ahh,\u201d Livoti said, according to surveillance video from the prison reviewed by The Marshall Project. He shined a penlight through the plexiglass window in the steel door. Holbrook told Phillips to drink water. Phillips spoke urgently, but his words are unintelligible on video.<\/p>\n

Holbrook cut him off: \u201cA simple \u2018no\u2019 would have been sufficient.\u201d She looked at her colleagues and said, \u201cHe\u2019s nasty.\u201d As she turned to leave, she added, \u201cHave a good night.\u201d The cell door stayed locked. The nurses didn\u2019t listen to his lungs or breathing. The penlight exam took four seconds; the entire visit lasted less than a minute.<\/p>\n

David Riley, his cellmate, said that after the nurses left, Phillips increasingly struggled to breathe and swallow as the hours passed.<\/p>\n

At 9:16 p.m., a guard collecting tablets spoke to the men through the cell door and made a radio call. Two minutes later, officers arrived and escorted Phillips to a holding cell, where nurses Holbrook and Livoti saw him again. Holbrook noted in medical records that Phillips\u2019 vitals were normal and that his lungs sounded clear, with no labored breathing or swelling.<\/p>\n

\u201cIt\u2019s got nothing to do with my vitals,\u201d Phillips told his bunkmate after he was returned to his cell. \u201cMy airway is constricted.\u201d<\/p>\n

Riley said Phillips paced the cell, craning his neck up, trying to breathe. He wrote down a phone number and asked Riley to call his wife and two daughters to tell them that he loved them. Those would be his last words.<\/p>\n

\"David<\/p>\n

\nDavid Riley recounting what happened to his cellmate, Jason \u201cPoppy\u201d Phillips<\/p>\n

The audio player has not loaded successfully.<\/p>\n

Panic-eyed, Phillips stopped talking, and began bouncing up and down on his toes, hanging on to Riley\u2019s shirt and arm.<\/p>\n

At 10:35 p.m., Riley began kicking the cell door and screaming for medical assistance, that his cellmate couldn\u2019t breathe. During the next 30 minutes, he yelled for help 40 times. Prison policy<\/a> states that having difficulty breathing is a healthcare emergency requiring an immediate response.<\/p>\n

At 11:06 p.m., two correctional officers stopped at the cell. One went to fetch medical help, while Officer Osarodion Igbe stayed at the door. He repeatedly told Phillips to sit down and relax, that help was coming. Twice, he radioed to a supervisor for medical help: \u201cThis man is a critical patient.\u201d \u201cGet the boss, please.\u201d<\/p>\n

Riley kept protesting: \u201cHe\u2019s not breathing bro, what the hell am I supposed to do?…There\u2019s no mercy!\u201d<\/p>\n

Phillips collapsed on the cell floor as the officer watched through the window. Riley later told Igbe that he was foaming at the mouth.<\/p>\n

At 11:30 p.m., Nurses Holbrook and Livoti returned with Sergeant Michael Sarrubbo. Phillips was lying face down on the concrete floor.<\/p>\n

\u201cHe\u2019s not breathing,\u201d Riley shouted.<\/p>\n

\u201cWe have to check him,\u201d Livoti said. \u201cHe\u2019s on the floor.\u201d<\/p>\n

Holbrook continued to assert that Phillips wasn\u2019t in a medical emergency. \u201cHe\u2019s on the ground for bed,\u201d she said, according to the video. \u201cHe\u2019s fine.\u201d<\/p>\n

\u201cI\u2019m telling you,\u201d the nurse continued. \u201cI\u2019m telling you, you need to stop.\u201d<\/p>\n

Riley lost it: \u201cShut the fuck up, bitch!\u201d<\/p>\n

The sergeant ordered the area cleared. The nurses left without opening the cell. Sarrubbo walked up and down the hallway, taunting the incarcerated men: Who wanted to talk with the nurse now?<\/p>\n

\u201cFucking pussies,\u201d Sarrubbo announced, according to the video, as he left Phillips lying face down on the cell floor, unexamined and unconscious.<\/p>\n

Just after midnight, another officer entered the cell block through the main sliding door in front of the control room. The hall reverberated with shouts and banging doors.<\/p>\n

\nIn late 2023, Jason \u201cPoppy\u201d Phillips had an infected epiglottis, a medical emergency that, left untreated, can choke a person to death. Experts said that had Phillips received emergency care earlier in the evening, he likely would have survived.
\nSurveillance footage from New York State Department of Corrections and Community Supervision; intro video footage by Angus Mordant for The Marshall Project; Video edited by Celina Fang\/The Marshall Project, Voiceover by Ashley Dye\/The Marshall Project\n<\/p>\n

\u201cIt\u2019s crazy over here,\u201d he said.<\/p>\n

Officer Igbe nodded. \u201cOne inmate, it actually looks like he\u2019s going to die.\u201d He explained that the prisoners were kicking their doors and shouting he\u2019s dead. He told his colleague that the sergeant and medical staff didn\u2019t believe it. \u201cThe nurses went there, but said they were playing games.\u201d<\/p>\n

At 12:17 a.m.\u2014 about six hours after his cousin\u2019s call for help \u2014 guards entered the cell and cuffed Phillips. He had no pulse. They placed him on a gurney and moved him to a holding pen, where guards unsuccessfully attempted CPR. A defibrillator recommended no shock. EMS workers arrived and tried to intubate him but couldn\u2019t get the tube down his blocked throat. They declared Phillips dead at 1 a.m.<\/p>\n

The Marshall Project made numerous attempts to reach Holbrook, Livoti, and Sarrubbo, including phone calls, email and certified letters. They didn\u2019t respond. Igbe declined to comment. The prison department declined to discuss Phillips\u2019 death or any other individual case.<\/p>\n

Several doctors and prison medical experts \u2014 after reviewing details of the case \u2014 told The Marshall Project that had Phillips been taken to an emergency room earlier in the evening, he likely would have survived.<\/p>\n

Five years earlier, epiglottitis killed a man<\/a> at Fishkill prison, about an hour north of New York City. Another man<\/a> died in a Western New York prison after an asthma attack as his cellmates unsuccessfully tried to wake a sleeping nurse to bring lifesaving medicine. At Great Meadow prison north of Albany, a man died after not receiving treatment for water intoxication<\/a>, which occurs when someone ingests more water than the body can handle, leading to organ failure.<\/p>\n

Unlike most states, New York has an independent agency, the State Commission of Correction, with broad powers to investigate the inner workings of prisons and jails. The commission investigates all deaths; it publishes reports on natural deaths if there is suspicion of wrongdoing, negligence or misconduct in the medical care.<\/p>\n

To find out how often people in New York prisons die of preventable or treatable ailments, The Marshall Project examined 76 commission reports about deaths in the state\u2019s prisons published from 2016 to 2024. This analysis did not include deaths from suicide, homicide, overdose or accident.<\/p>\n

One quarter of the reports describe deaths that were \u201cpreventable,\u201d could have been prevented or should have been prevented.<\/p>\n

\nJaziyah Philibert holds a photo of her father, Jason \u201cPoppy\u201d Phillips, who died of untreated epiglottitis at Greene Correctional Facility.
\nAngus Mordant for The Marshall Project\n<\/p>\n

Another quarter of the Commission of Correction\u2019s death reports don\u2019t explicitly state that a death was \u201cpreventable\u201d but describe multiple violations of standards of care. Some reports describe \u201cgross negligence,\u201d \u201cgross error,\u201d and \u201cgrossly inadequate care\u201d that led to fatalities.<\/p>\n

These deaths are emblematic of an inadequate health care system, said Lauren Brinkley-Rubinstein, a professor of population health science at Duke University who specializes in health care for incarcerated people.<\/p>\n

\u201cPreventable deaths represent the most extreme, negative health outcome you can imagine,\u201d she said. \u201cIf we can connect the dots between deaths and lack of access to quality care, we can certainly assume that there are serious issues with quality of care affecting the larger population of incarcerated people in New York state prisons.\u201d<\/p>\n

In one case, a nurse stopped caring for a man<\/a> in life-threatening respiratory distress. She failed to treat him, refer him to a doctor or send him to an ER. In another case, nurses didn\u2019t assess the airway and breathing of a man<\/a> choking to death on a plastic ball. In other instances, nurses failed to act on alarmingly low oxygen saturation rates<\/a> or dangerously high blood sugar levels<\/a>.<\/p>\n

Experts credit the reports for singling out preventable deaths and negligent care but caution that the published documents are of limited use for holding prison officials accountable. It takes the commission an average of two and a half years to publish a report following a prisoner\u2019s death, The Marshall Project found. That\u2019s longer than the statute of limitations for suing the prison department in state court following an incarcerated person\u2019s death. The commission\u2019s investigation into Phillips\u2019 death is ongoing.<\/p>\n

The public versions of the death reports are also heavily redacted, with black boxes often covering more than half of the text, sometimes almost all of it.<\/p>\n

The redactions go far beyond what is necessary to protect medical privacy or sensitive content like mental illness or HIV status, said Bob Keach, an Albany lawyer who has filed numerous cases against the prison system and county jails. \u201cThose redactions are nothing more than a shallow effort to hide the truth and underlying facts of a detainee\u2019s death from their families and the public,\u201d he said. \u201cIt\u2019s hard for me to say that, but looking at the full reports versus the unredacted reports, that\u2019s the only conclusion I can draw.\u201d<\/p>\n

<\/p>\n

\n

Michael Carey died after he couldn\u2019t access an emergency inhaler during an asthma attack at Groveland prison. The public version of the report on Carey\u2019s death is heavily redacted.
\nState Commission of Correction\n<\/p>\n

\n

Michael Carey died after he couldn\u2019t access an emergency inhaler during an asthma attack at Groveland prison. The public version of the report on Carey\u2019s death is heavily redacted.
\nState Commission of Correction\n<\/p>\n

\n

Michael Carey died after he couldn\u2019t access an emergency inhaler during an asthma attack at Groveland prison. The public version of the report on Carey\u2019s death is heavily redacted.
\nState Commission of Correction\n<\/p>\n

\n

Michael Carey died after he couldn\u2019t access an emergency inhaler during an asthma attack at Groveland prison. The public version of the report on Carey\u2019s death is heavily redacted.
\nState Commission of Correction\n<\/p>\n

\n

Michael Carey died after he couldn\u2019t access an emergency inhaler during an asthma attack at Groveland prison. The public version of the report on Carey\u2019s death is heavily redacted.
\nState Commission of Correction\n<\/p>\n

\n

Michael Carey died after he couldn\u2019t access an emergency inhaler during an asthma attack at Groveland prison. The public version of the report on Carey\u2019s death is heavily redacted.
\nState Commission of Correction\n<\/p>\n

\n

Michael Carey died after he couldn\u2019t access an emergency inhaler during an asthma attack at Groveland prison. The public version of the report on Carey\u2019s death is heavily redacted.
\nState Commission of Correction\n<\/p>\n

\n

Michael Carey died after he couldn\u2019t access an emergency inhaler during an asthma attack at Groveland prison. The public version of the report on Carey\u2019s death is heavily redacted.
\nState Commission of Correction\n<\/p>\n

\n

Michael Carey died after he couldn\u2019t access an emergency inhaler during an asthma attack at Groveland prison. The public version of the report on Carey\u2019s death is heavily redacted.
\nState Commission of Correction\n<\/p>\n

<\/p>\n

Keach detailed how difficult it is for families to learn what happened. They are not notified of the investigation or report. Some redacted reports are on the commission website. If not, the family must file a public records request. To obtain a full, unredacted report, next of kin must file a lawsuit.<\/p>\n

\u201cIt appears that the Commission of Correction is more concerned about protecting the rights of prison employees than they are with addressing the death of a detainee and informing the family of that detainee about what happened,\u201d he said.<\/p>\n

Corrections Commission spokesperson Kirstan Conley said the commission redacts reports to protect privacy. The next of kin status is not always apparent and does not provide an absolute right to the dead person\u2019s legally protected information, she added. \u201cA court is generally the appropriate venue to make legal determinations on whether to release unredacted reports containing confidential records,\u201d she said.<\/p>\n

New York prisons spokesperson Thomas Mailey said the department reviews all deaths of incarcerated people and undertakes corrective actions recommended by the commission. \u201cThese corrective actions may involve changes in equipment or procedures and education or retraining for staff who were involved with the care of the patient,\u201d Mailey said.<\/p>\n

The New York Legislature gave the commission an additional $1.5 million in this year\u2019s budget to inspect state prisons.<\/p>\n

The Legislature also voted in June to overhaul the commission. The legislation would expand the three-person commission leadership \u2014 all currently appointed by the governor \u2014 by adding six new members, including a formerly incarcerated person, behavioral health professionals and a lawyer experienced in representing poor people or prisoners. Legislators and the Correctional Association of New York would appoint the additional commissioners. The bill is still awaiting the governor\u2019s signature. When a reporter asked Gov. Kathy Hochul in October why she\u2019d yet to act on the omnibus bill that includes the commission reforms, she said she was taking the time needed to read \u201cevery word of the bills that have been passed, over 850 this year.\u201d<\/p>\n

Seventeen hours before his excruciating death in 2016, Joseph Schlum was admitted to the infirmary at Five Points Correctional Facility in western New York. An autopsy later revealed that part of his small intestine had died and blocked his bowels. His large intestine had swelled so much that it pushed his diaphragm up to his nipples.<\/p>\n

In the infirmary, according to a later Commission of Correction report, a nurse practitioner missed clear signs of the obstructed bowel and \u201ccarelessly prescribed laxatives,\u201d which exacerbated the crisis.<\/p>\n

Nurses did note that Schlum was throwing up blood and that his pain was increasing, but a doctor failed to notice these signs, which called for an immediate hospital admission.<\/p>\n

Nurses later observed but failed to call the doctor about severe changes in Schlum\u2019s condition: He stopped passing stool or gas, while his bowels did not make the low gurgling sounds of a healthy digestive system, all signs of a progressing obstruction.<\/p>\n

Schlum<\/a> was found dead on the floor of his infirmary cell. According to the autopsy, Schlum died of terminal aspiration: choking on the inhaled contents of his gastric system.<\/p>\n

\"Rahsheek<\/p>\n

\nRahsheek Hill protested at Greene Correctional Facility on the one-year anniversary of his brother\u2019s death.
\nAngus Mordant for The Marshall Project\n<\/p>\n

Dr. Robert Greifinger is a former chief medical officer for New York state prisons who has worked on more than 80 lawsuits around the country as an expert witness or as a court-appointed monitor of correctional health facilities.<\/p>\n

Greifinger has observed a common problem in how prison nurses, doctors and guards approached cases that ended in death or serious disability. The common thread was \u201dcynicism, in the form of inordinate distrust of prisoner patients,\u201d he wrote in the Correctional Law Reporter.<\/a><\/p>\n

\u201cI am talking about stereotyping attitudes (e.g., \u2018They all lie\u2019), minimizing symptoms (e.g., \u2018She is just drug-seeking\u2019), assigning motives with no basis (e.g., \u2018He just wants to get out of the jail\u2019), and generally negative approaches to patients solely because they are prisoners (e.g., \u2018What does he want, a Cadillac? My mother can’t get a doctor’s appointment for weeks, and she isn\u2019t an offender\u2019).\u201d<\/p>\n

Cynicism among prison staff leads to inaction, Greifinger wrote, and then incarcerated people suffer and die.<\/p>\n

Michael Carey had a long history of asthma when he was admitted to the inpatient infirmary at Groveland Correctional Facility for an infected toe in April 2015. He was scheduled for release the next month. He had his inhaler for Advair, a steroid taken daily to suppress asthma but not used in emergencies or acute asthma attacks. On the day he was admitted, he suffered a severe asthma flare-up; nurses treated him with Albuterol, which is used in emergencies. Two days later, he felt shortness of breath in the evening and requested an Albuterol inhaler.<\/p>\n

At 12:30 a.m., he began wheezing and told his cellmates he needed Albuterol. The two men testified that they buzzed the call button. Through the large plexiglass window, they saw Nurse Lisa Salvador asleep in her office with her head on a desk. They pounded on the window, but she didn\u2019t budge.<\/p>\n

Carey had another attack at 2:30 a.m. Again, his cellmates rang the call button and pounded on the window, and again the nurse did not move.<\/p>\n

When the guards opened the cell doors at 6 a.m., Carey had been dead for more than two hours.<\/p>\n

In its report, the commission concluded that Carey\u2019s death may have been prevented with proper care. The infirmary, just feet away from the bed where he died, stocked Albuterol.<\/p>\n

Carey\u2019s family filed a lawsuit against the prison department, and the case was settled earlier this year. The prison department investigated Salvador but did not discipline her. She later resigned while facing disciplinary charges for refusing to treat a patient and throwing a walking cane and hitting a prison guard. Salvador did not respond to emails or certified and hand-delivered letters seeking comment.<\/p>\n

The commission redacted<\/a> well over half of its report on Carey\u2019s death. The Marshall Project found an unredacted report<\/a> in a federal court file, which showed that Carey\u2019s request for emergency Albuterol went unfilled. \u201cThe only inhaler found in Carey\u2019s room was the long acting medication Advair.\u201d That sentence was redacted in the report on the commission\u2019s website.<\/p>\n

When Nurse Holbrook came into work at Greene prison the afternoon following Phillips\u2019 death, she added another note to his medical records. She wrote that when she came to Phillips\u2019 cell door at 11:30 p.m. the night before, she saw him \u201cbreathing and moving lower extremities while laying on mattress.\u201d<\/p>\n

But others didn\u2019t observe Phillips moving at that time. Officer Reuben Desir was present during Holbrook\u2019s 11:30 p.m. visit. Security video later captured Desir talking with a colleague in the control room. In the video, Desir tells the other officer, \u201cThe last time I saw [Phillips], I did not see him move, and that was 11:30. I\u2019ll deal with whatever consequences.\u201d Desir didn\u2019t respond to requests for comment.<\/p>\n

A state autopsy later determined that Phillips\u2019 lungs were severely swollen, congested and filled with frothy white fluid.<\/p>\n

In the nearly two years since Phillips\u2019 death, no prison employees have been disciplined. Holbrook, a contract nurse, no longer works for the department.<\/p>\n

\nCheray Grant comforts her daughter, Jaziyah Philibert, during a candlelight vigil.
\nAngus Mordant for The Marshall Project\n<\/p>\n

Phillips was 38 when he died, leaving behind his wife and two teenage daughters. Dolcy, his wife, has retained a lawyer and plans to file a lawsuit against the corrections department in December.<\/p>\n

Dolcy recently watched the security videos from the night of her husband\u2019s death. She watched the nurses on the video interacting with Phillips through the small plexiglass window twice that evening and was struck by the lack of professionalism. They had no sense of urgency or empathy for someone in distress, she said.<\/p>\n

As an educator, Dolcy has to follow rules of professional conduct or risk losing her license. She can\u2019t understand why prison employees could fail in their duties and receive little accountability. Most of all, she thinks about the sense of helplessness her husband must have felt struggling to breathe that night.<\/p>\n

\u201cI can\u2019t even fathom what that must have felt like to be stuck in a small cell where you can’t call for help,\u201d she said. \u201cThe people that can help are just looking at you.\u201d<\/p>\n","protected":false},"excerpt":{"rendered":"Photos and video by Angus Mordant for The Marshall ProjectPhoto illustration of David Riley by Celina Fang; source…\n","protected":false},"author":2,"featured_media":59499,"comment_status":"","ping_status":"","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[6],"tags":[9,31967,11,10,31966,31968,4719],"class_list":["post-59498","post","type-post","status-publish","format-standard","has-post-thumbnail","category-new-york","tag-new-york","tag-new-york-department-of-corrections","tag-new-york-headlines","tag-new-york-news","tag-prison-and-jail-conditions","tag-prison-health","tag-prisons"],"_links":{"self":[{"href":"https:\/\/www.newsbeep.com\/us-ny\/wp-json\/wp\/v2\/posts\/59498","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.newsbeep.com\/us-ny\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.newsbeep.com\/us-ny\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.newsbeep.com\/us-ny\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/www.newsbeep.com\/us-ny\/wp-json\/wp\/v2\/comments?post=59498"}],"version-history":[{"count":0,"href":"https:\/\/www.newsbeep.com\/us-ny\/wp-json\/wp\/v2\/posts\/59498\/revisions"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/www.newsbeep.com\/us-ny\/wp-json\/wp\/v2\/media\/59499"}],"wp:attachment":[{"href":"https:\/\/www.newsbeep.com\/us-ny\/wp-json\/wp\/v2\/media?parent=59498"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.newsbeep.com\/us-ny\/wp-json\/wp\/v2\/categories?post=59498"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.newsbeep.com\/us-ny\/wp-json\/wp\/v2\/tags?post=59498"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}