A string of institutional failures contributed to the death of an Afro-Latinx transgender woman at a Rikers Island jail last June, according to a “scathing” official report released Tuesday recommending systemic changes in the jail’s housing policies and overhauling its mental health care for inmates.

Layleen Xtravaganza Cubilette-PolancoCourtesy of Melania Brown

The New York City Department of Correction’s refusal to house Layleen Xtravaganza Cubilette-Polanco in a general population area with women “resulted in increased pressure to place Ms. Polanco in the [Restrictive Housing Unit] — a Unit unsuitable to manage both her medical and mental health needs,” according to the report issued Tuesday by the Board of Correction, an independent overseer for New York City jails.

Cubilette-Polanco, 27, died in solitary confinement June 7 last year after an epileptic seizure, according to a medical examiner’s report. Earlier this month, Bronx District Attorney Darcel Clark announced that an investigation by her office and the New York City Department of Investigation concluded that staffers at the Rose M. Singer Center jail on Rikers Island were not criminally responsible for her death.

This week’s report from the Board of Correction, however, details a number of missteps that it says placed Cubilette-Polanco in peril, including transferring her from a mental health ward to solitary confinement, leaving her for long stretches of time alone and failing to alert guards checking on her that she had a history of seizures.

‘Radical changes in behavior’

Cubilette-Polanco was in solitary confinement over the objections of at least one psychiatrist due to her history of seizures. Several weeks before death, from May 15-24, she had been hospitalized at the Elmhurst Hospital Prison Ward for psychiatric care after “showing radical changes in behavior” including shouting, crying, rolling around on the floor, talking to herself, expressing a desire to take her own life, panicking and charging at a jail guard, according to the Board of Correction report.

The report reveals that when she returned to Rikers Island, the jail staff tried to get her sent to restrictive housing, or solitary confinement, as a punishment for charging at the guard. However, a psychiatrist “verbally stated that due to [her] medical history as it pertains to seizure disorder, that he would not be able to authorized [sic] a cell housing placement” in a restrictive housing unit, according to a senior jail official quoted by the board. Despite the doctor’s concerns, however, she had been placed in solitary confinement as a result of the assault, as previously reported by city officials.

Jackie Sherman, chair of the Board of Correction’s Prison Death Review Board, told NBC News that the Department of Correction still has work to do on how it houses transgender people. Cubilette-Polanco’s story is one such example as to why, Sherman said.

“There are facts laid out in the report that suggest that the idea of housing Ms. Polanco in a general population dorm for women was not seriously considered,” Sherman said. “She spent a long stretch of time in the new admissions area.”

The Department of Correction’s decision not to house the trans woman with cisgender women likely resulted in her inappropriate placement in solitary confinement, the report states.

Ultimately, the staff found a mental health provider May 29 to sign off on Cubilette-Polanco’s placement in solitary confinement. Once there, Correctional Health Services, the jail’s medical provider, did not notify guards of her seizure disorder, according to the Board of Correction report. In the immediate hours surrounding her death, officers left her alone for 57, 47 and 41 minutes. Those that did check hadn’t been trained in how to confirm signs of life, the report said.

‘Underlying systemic issues’

Jennifer Jones Austin, chair of the Board of Correction, said her death “identifies a number of underlying systemic issues that must be addressed” by the Department of Correction and the Correctional Health Services. In a statement, she urged New York City officials to “immediately implement” all 25 recommendations laid out in the board’s report.

The 25 recommendations include housing trans women in general population with cisgender women, mandating that medical needs are communicated to jail, and training guards doing rounds to confirm signs of life.

Jeanette Merrill, a spokesperson for the Correctional Health Services, said the agency is guided by best practices in patient care.

“We disagree with the conclusions the Board reached in the report, as well as their misguided recommendations regarding the clinical care that was provided,” she said in a statement. “Our doctors, nurses and other health care professionals consistently provide the highest quality health care to all of our patients.”

Department of Correction Commissioner Cynthia Brann, however, thanked the board and sent condolences to Cubilette-Polanco’s family.

“We have worked tirelessly to create a correctional system that is safer, more humane, and fairer, fundamentally reforming our housing structure to ensure that all people, regardless of their gender identification, have the access to the resources they need,” Brann said in a statement. “We are committed to working with our partners at Correctional Health Services (CHS) to keep all individuals in custody safe and we are carefully reviewing all of the Board’s recommendations.”

June 12, 202003:09

The Board of Correction report comes less than two weeks after Cubilette-Polanco’s family released security footage from outside her jail cell the day she died, which was obtained in a civil lawsuit. That video shows Rikers officers knocking on her door for approximately 90 minutes and laughing before opening her cell and getting her medical attention.

David Shanies, a lawyer for her family, said they will be watching to see if the board reform recommendations are adopted.

“The Board’s fittingly scathing report marks the first time government officials have acknowledged that Layleen’s death was the result of the City’s unsafe and discriminatory policies and public servants’ reckless decisions,” Shanies said.

Follow NBC Out on Twitter, Facebook & Instagram

CONTACT US

We're not around right now. But you can send us an email and we'll get back to you, asap.

Sending

Log in with your credentials

Forgot your details?