Six people died by suicide, and at least four died from drug overdoses. One man choked to death on an orange, and another died after making a brazen escape attempt into the East River. The lone woman to die, who was 31, suffered from complications from treatable diabetes.

In all, 19 incarcerated people died at Rikers Island jails, or at local hospitals, in 2022. It was the deadliest year for people in city custody in a quarter century.

The death rate at city jails is reflective of increases in deaths at jails across the country. And just as overdoses from fentanyl have become more common in the city at large, correction officials say these are more common in city jails, too.

But as detailed below, in most of the deaths in custody in 2022, investigations from the Board of Correction oversight agency documented negligence by officers, including failures to aid detainees in distress and follow rules about patrolling housing units.

In the hours last February before Tarz Youngblood became the first person to die at Rikers this year, officers failed to make mandated rounds and address the fact that he had blocked the window to his cell, according to surveillance video reviewed by the board. That meant that no one tried to save him during the critical time when his death from a fentanyl and heroin overdose could potentially have been reversed through naloxone, a drug that can reverse the effects of overdose.

George Pagan died the following month from sepsis after an acute illness in which he lost control of his bodily functions. But the board found that Pagan was neither brought to nine scheduled medical appointments nor given the medication he was prescribed. Officers also failed to patrol his dormitory in the hours before his death.

A day later, when Herman Diaz choked on an orange, other incarcerated people tried the Heimlich maneuver because the only officer on duty did not leave his post and render aid. They carried Diaz to the clinic, where he died.

Some officers were fired or suspended in the aftermath of deaths in 2022, though the specific reasons were not laid out by the Department of Correction.

Headed into the new year, institutional challenges remain. As suicides have become more common at Rikers, Gothamist reported in October that fewer than one in five officers had completed a mandated course on preventing suicide. Missed medical appointments — 12,354 from February to October largely due to a lack of escorts to bring people to clinics, according to the Legal Aid Society — are the subject of a court hearing in late January.

Meanwhile, the population at Rikers is increasing, with longer stays and more daily admissions, and is projected to go up by more than 1,000 people within two years.

Tarz Youngblood

Age: 38
Date of death: Feb. 27
Location of death: Rikers Island
Cause: Overdose from fentanyl and heroin.

Youngblood was found unconscious in another man's cell. In this unit, officers did not make the mandated rounds in the hours before his death, according to surveillance video reviewed by the Board of Correction, and did not address the fact that the window to the cell was obscured.

George Pagan

Age: 48
Date of death: March 17
Location of death: Rikers Island
Cause: Sepsis.

Pagan “regularly urinated, defecated, and vomited on himself,” but he was neither brought to nine scheduled medical appointments nor given the medication he was prescribed, according to the Board of Correction. The officers assigned to his dormitory were not patrolling his floor, as required, in the hours before he fell ill.

Herman Diaz

Herman Diaz

Age: 52
Date of death: March 18
Location of death: Rikers Island
Cause: Accidental choking.

Diaz collapsed and choked while eating an orange, according to the Board of Correction, and his unit was not staffed with the mandated two officers. Other incarcerated people used the Heimlich maneuver because they were unable to get the one officer on duty to render first aid. They then carried Diaz to the clinic, where he was pronounced dead.

Dashawn Carter

Age: 25
Date of death: May 7
Location of death: Rikers Island
Cause: Suicide.

Carter died just two days after arriving at Rikers. He had been placed on suicide watch during a previous stay, according to the board of correction, but at the time of his death was housed in general population. Two officers and two captains were suspended following his death.

Mary Yehudah

Mary Yehudah

Age: 31
Date of death: May 18
Location of death: Elmhurst Hospital
Cause: Severe diabetic ketoacidosis

Yehudah's family alleged in a lawsuit against the city that she suffered cardiac arrest as a result of an untreated and preventable complications from diabetes. She was found unresponsive in her cell and later died at the hospital. A board of correction investigation found that she had left her cell just once in the five days prior to her hospitalization and her housing unit was not regularly patrolled by correction officers as required.

Emanuel Sullivan

Age: 20
Date of death: May 28
Location of death: Rikers Island
Cause: Unknown; medical examiner report is pending.

Sullivan was found unresponsive in his cell in a housing area populated mostly by members of the Bloods gang. Surveillance video reviewed by the Board of Correction showed that officers on patrol on the day that Sullivan died did not check individual cells, as required.

Antonio Bradley

Antonio Bradley

Age: 28
Date of death: June 18
Location of death: Lincoln Hospital
Cause: Suicide.

Bradley died at a hospital three days after he was released by the Department of Correction on compassionate release, so he's not counted toward the city's official in-custody death total. Media outlets, however, include this death since it followed a suicide attempt in a Bronx court holding cell.

Anibal Carrasquillo

Age: 39
Date of death: June 20
Location of death: Rikers Island
Cause: Overdose from fentanyl.

Carrasquillo was in nine facilities on Rikers Island over the course of three years. Incarcerated people interviewed by the Board of Correction after his death said that he had complained of chest pains earlier that day, but was not taken to the medical clinic. An officer was suspended following his death.

Albert Drye

Age: 52
Date of death: June 21
Location of death: Rikers Island
Cause: Cardiogenic shock and endocarditis

Drye died at the Bellevue Prison Hospital Ward following an illness.

Elijah Muhammad

Age: 31
Date of death: July 10
Location of death: Rikers Island
Cause: Drug overdose.

For more than a day leading up to his death, Muhammad was held in solitary confinement in a caged shower known as a "de-escalation unit," according to a correction official. In the hours before his death, an officer noticed Muhammad was "incoherent and sluggish but failed to activate a medical emergency or alert the area captain," according to the Board of Correction. The correction officer was fired in the wake of Muhammad's death.

Michael Lopez

Age: 34
Date of death: July 15
Location of death: Rikers Island
Cause: Unknown; medical examiner report is pending.

Lopez was in a mental observation unit when he died, his attorneys at the Legal Aid Society said, but he was deprived of services he needed to survive.

Ricardo Cruciani

Age: 68
Date of death: Aug. 15
Location of death: Rikers Island
Cause: Suicide.

Cruciani was a doctor facing a life sentence after being convicted of sexually assaulting patients. The Board of Correction found that an officer did not render immediate aid after finding him with a sheet around his neck.

Michael Nieves

Michael Nieves

Age: 40
Date of death: Aug. 30
Location of death: Elmhurst Hospital
Cause: Suicide.

Nieves suffered from "severe mental illness," according to his attorneys at the Legal Aid Society. After Nieves died, two officers and a captain were suspended for their role in his death.

Kevin Bryan

Kevin Bryan

Age: 35
Date of death: Sept. 14
Location of death: Rikers Island
Cause: Suicide.

Bryan was incarcerated for less than a week, held on $5,003 bail on burglary charges.

Gregory Acevedo

Age: 48
Date of death: Sept. 20
Location of death: Mount Sinai Hospital
Cause: Unknown; medical examiner report is pending.

Acevedo climbed a recreation yard fence at the top of the Vernon C. Bain Center Jail — a barge that sits off Hunts Point in the Bronx and is commonly known as “the boat” — and leaped into the East River. He was rescued and died later in the day from his injuries.

Elmore Robert Pondexter

Elmore Robert Pondexter

Age: 59
Date of death: Sept. 23
Location of death: Bellevue Hospital
Cause: Unknown. Medical examiners report is pending.

Four days before his death, Pondexter collapsed in his housing area. He was hospitalized and granted compassionate release hours before he died, five days later.

Erick Tavira

Erick Tavira

Age: 28
Date of death: Oct. 22
Location of death: Rikers Island
Cause: Suicide.

Tavira was being held in a mental health observation unit when he died by suicide. He had been incarcerated for 15 months while awaiting trial. A preliminary death review from the Board of Correction found that officers failed to check on Tavira every 15 minutes in the hour before he died.

Gilberto Garcia

Age: 26
Date of death: Oct. 31
Location of death: Rikers Island
Cause: Overdose from fentanyl.

Three years to the day after his arrest, Garcia was found dead in his housing unit.

Edgardo Mejias

Age: 39
Date of death: Dec. 11
Location of death: Rikers Island
Cause: Unknown; medical examiner report is pending.

Mejias, held on bail while awaiting release to an alternative program that would have freed him, had been suffering from asthma in the weeks before his death, according to his attorney.