As a 65-year-old jailed man suffered a seizure and fell unconscious at Rikers Island, two nurses arrived at his side without a gurney — and they forgot to remove covers from a defibrillator while trying to revive him, a new oversight report says.
The nurses’ lapse prevented the defibrillator from providing data about the medical condition of the detainee, Marvin Pines, who was awaiting sentencing on a Manhattan drug charge, said the Board of Correction report issued Thursday.
Defibrillators provide electric shocks meant to restart a patient’s heart. After a correction officer noticed the nurses’ mistake, the covers were removed — but the defibrillator flashed a message that no electric shock was needed for Pines.
Nonetheless, said the report, the nurses’ error “was illustrative of inexperience or a poor response to the emergency.”
Pines, who suffered the seizure Feb. 4 at Rikers’ North Infirmary Command, was the first of nine people in the city jails to die in 2023. The two nurses, who worked for Correction Health Services, were suspended for “improper use of medical devices and equipment” and later resigned, the report said.
“Emergency response staff should ensure … that they bring all necessary equipment to housing areas when responding to emergencies,” the board advised CHS, which provides health care at Rikers and is a division of the city’s Health + Hospitals Corp. In a written response, CHS agreed with the report’s finding.
The Board of Correction report also details the circumstances of three other jail deaths in 2023, citing familiar themes of missed rounds by correction officers, failure to enter information in log books, and delays in death notifications.
The board’s review comes as lawyers for detainees, the Legal Aid Society and the U.S Attorney’s office in Manhattan prepare motions which will argue control of the jails should be wrested from the city and placed in the hands of a court-appointed receiver.
The themes of poor record-keeping and missed rounds were prominent in the case of Joshua Valles, who was hospitalized May 19 from the now-closed Anna M. Kross Center and died May 27.
Days later, correction officials said Valles had died of a heart attack — but a preliminary autopsy revealed he had a skull fracture. The city Medical Examiner has yet to reveal the cause of death.
The Board of Correction review indicates officers didn’t tour every 30 minutes as required and didn’t check his cell regularly. “Tour of area, all appears secure,” a captain then wrote in a log book.
The report says Valles was in a fight on April 19, but didn’t show signs of injury and complained of a headache on May 7.
On May 19, he was locked in his cell and reportedly banged on the door with his hand and possibly his head, the report said. But log entries don’t refer to a reason for the lock-in.
From 11:08 a.m. to 1:31 p.m, staff either didn’t check on him or merely glanced into his cell. Medical staff was then called and he was taken to the Hart’s Island Clinic.
“When conducting tours, correction officers did not consistently check the cell Mr. Valles occupied,” the report said.
There, he said he had a severe headache and felt weak and lethargic. He was taken to the hospital and became unresponsive with extensive loss of oxygen to his brain. He was listed as brain dead on May 21 and was taken off life support on May 27.
