A disregard of social distancing protocols. A failure to distribute masks, forcing detainees to use sheets and pillowcases to protect themselves. And a denial of basic medical treatment — including a CPAP machine taken away. 

Those are some of the findings of the city’s jail watchdog in its probe into the deaths of three detainees in local lockups during the peak of the pandemic last spring. 

“Nobody in New York State should be sentenced to death,” said Alice Fontier, managing director of Neighborhood Defender Service of Harlem.

Jail officials and government leaders made multiple mistakes that contributed to the deaths of the three men, the 27-page draft report by the city Board of Correction found. 

In some cases, the inmates’ lawyers were not notified about how dire the situation was becoming behind bars, the review concluded. Lawyers also had difficulty obtaining medical records that could have been used to help make their clients’ cases for early releases, according to the report. 

“All three were housed in crowded jail dormitories at the height of the initial outbreak,” the review reads. “While each of these men were the subject of early release applications, those applications were either opposed by the state or made too late.” 

The Board of Correction report was obtained by the Neighborhood Defender Services via a Freedom of Information Law request and shared with THE CITY. 

The board, which makes the rules for the city’s lockups, reviewed the deaths of Michael Tyson, 53; Walter Ance, 63; and a 30-year-old man. 

The names of all the men are redacted, aside for the first letter of their first and last names, in the report. But THE CITY was able to identify two of them via sources and documented details. 

A spokesperson for the city’s Correctional Health Services declined to comment on the report, citing its draft status.

Peter Thorne, a Correction Department spokesperson, said: “From comprehensive testing, to social distancing in our facilities, we have taken every possible measure to keep all those who work and live in our jails safe throughout the pandemic. These measures have proved effective: transmission within our jails is, and has remained, lower than the citywide average.”

The board’s findings come as the Cuomo administration refuses to grant the city permission to vaccinate people behind bars unless they have health risks that make them vulnerable to COVID-19. 

“New York City has explicitly asked the State government for permission to vaccine the incarcerated,” tweeted mayoral spokesperson Bill Neidhardt. “Cuomo’s health department denied our request.” 

Missed a Parole Meeting

Tyson became the first city jail inmate to die from COVID-19 complications when he passed away on March 26. He had been behind bars since Feb. 28 as he awaited a hearing on a parole violation, jail records show. He got locked up for allegedly failing to show up at a meeting with his parole officer on May 8, 2019. 

Tyson and Ance were held on the Vernon C. Bain Center jail barge moored off The Bronx, a facility known colloquially as “The Boat.” They were kept in 50-bed dormitory housing areas “that were always between 78% and 100% capacity” in March and into April, the report said. 

Tyson was medically vulnerable and was being held on a nonviolent offense, making him a good candidate for early release, his supporters said. 

“[He] had a history of heart surgery, diabetes and high blood pressure,” the board report said. 

After he was first arrested, approximately 18 hours passed before he was brought from intake areas to Bain Center, records show. Detainees have long complained about how long it takes before they are given a bed and the ability to shower. The unit was at 81% capacity, with 41 of 50 beds taken, the report said. 

Tyson, who complained of a cough, was briefly taken to Lincoln Hospital for undetermined reasons. He returned shortly after to the same housing unit, which was by then 90% full and rose to full capacity eight days later, according to the board review. 

Died Before Decision

All told, jail officers brought Tyson to the medical clinic at least 11 times and to the hospital twice for a total of four nights, the review showed. 

On March 23, he tested positive for COVID-19 and was sent to the Rikers Island unit where all detainees with the virus were being kept, the Eric M. Taylor Center, records show. That was the same day his parole violation hearing was initially scheduled, though it had been delayed due to the pandemic. 

Three days later, as Tyson’s condition worsened, he was sent to Bellevue Hospital. A week later the Legal Aid Society, which was representing him, “petitioned the Bronx Supreme Court for the immediate release of 100 individuals, including Mr. (Tyson),” the report said. 

Medical workers greet Mayor Bill de Blasio outside Bellevue Hospital, April 10 2020. Credit: Ed Reed/Mayoral Photography Office

His defense lawyer argued that he was high risk due to his age and medical condition. The court filing also noted Tyson was not in jail on a violent offense. He died two days later, before a legal decision was rendered. 

His lawyers only became aware of his plight after he was sent to the hospital, the report said.  

On March 27, Gov. Andrew Cuomo issued a directive aimed at reducing the jail and prison population. But the state never detailed the eligibility criteria for people being held on low-level parole violation warrants like Tyson. 

‘He Was Really Scared’

Ance’s public defender, Alejandra Lopez, desperately tried to get him released during the early onset of the pandemic, records show. 

Bureaucratic red tape hampered that effort, according to the board review, which noted NYC Health + Hospitals required signed HIPAA authorization for attorneys to see their clients’ medical records. 

The chaotic early days of the pandemic, including no on-site paralegals, made it hard for lawyers to get that proper approval, the report said. 

Walter Ance. Credit: Courtesy of the Ance Family

Ance, who had asthma and other medical issues, had been in jail for close to 13 months after being charged with stabbing his estranged wife in the chest, according to court records. He had been scheduled to go to trial in the summer of 2020. 

During a jailhouse phone call, he told his son people in his packed housing unit were coughing and that he was doing his best to keep away from them. But he had no mask or gloves and was instead using his sheets and pillowcase to protect his face, according to the recorded call cited in the report. 

“He said it was impossible to social distance there,” his niece, Lourdes Ance, 43, told THE CITY in April. “He was really scared.”

Walter Ance was moved to Bellevue Hospital on March 27 and put on a ventilator at some point afterward, medical records show. His family was not told when he was sent to the hospital as required by department regulations, the report said. 

He died 15 days later on April 11. 

CPAP Taken Away

The report also highlighted the death of an unnamed 30-year-old man who had a history of asthma, gout and sleep apnea that required a CPAP machine. 

The man from Forest Hills, Queens, who was locked up on parole violation tied to a child pornography case, had also been diagnosed with depression and displayed “symptoms consistent with diagnoses of Asperger’s/Autism Spectrum,” according to the BOC review. 

He was initially put in a protective custody unit due to the nature of his crime and then moved to a medical unit where he could use a CPAP machine. 

When he contracted the virus, he was brought to another housing area where his CPAP machine, and others in that location, were all taken away “out of fear that they might spread COVID-19,” the report said. 

He complained to his mother on March 29 about the lack of access to Tylenol and about long wait lines for the medical clinic, according to the report, which cited recorded phone calls. 

A day later, he told his mother “that he needed a nebulizer and that medical staff were refusing to provide him with one because they feared it would spread germs through the housing area,” the report said. 

“He also reported that he was coughing so badly the night before that he had vomited three times and that his fever had reached 102 F and he was experiencing weakness and major pains and aches in his legs and feet,” according to the review, which noted his COVID-19 test was positive on March 28 but he wasn’t told about the result until “at least March 30.” 

Jail staff transported him to Bellevue Hospital after he began to struggle to breathe on March 31, records show. His condition there deteriorated and his lawyer filed an emergency email motion with the Queens Criminal Court requesting a compassionate release on April 7. 

But he was already on a respirator and doctors were unable to move him. He died a few weeks later on April 23. 

From March 14 to March 26, the report said, the man was in a medical dorm that averaged 65% capacity.

“This meant that although the department had committed to trying to provide alternate bed spacing in dorms to stem the outbreak, alternate bed spacing was not possible in [his] medical dorm,” the report noted.

‘Making Repeatable Mistakes’

A section of the report containing recommendations was heavily redacted.

Still, the board report urged government officials to release more inmates, saying, “maintaining a reduced jail population is critical.” That should include detainees who are “medically vulnerable and those who can safely remain in the community pending trial,” the report concluded. 

From the Board of Correction’s report on three early COVID-19 deaths of city inmates. Credit: Obtained by THE CITY, via Neighborhood Defender Service

Philip Desgranges, a Legal Aid attorney who represented Tyson, echoed the findings. “State and city officials need to do more to reduce the jail population, and maintain a smaller population to prevent other preventable tragedies, like Mr. Tyson,” he said. 

He noted government officials have made some moves in the right direction but that the city jail population of 5,461 as of Feb. 20 is now close to the 5,625 population number from the January before the pandemic. 

“Unfortunately, those steps were a little too late for Mr. Tyson,” he said. “But what we are seeing now is exposing more people to the risk of dying from COVID. We are making repeatable mistakes.”