“Nicholas Feliciano was hauled into a holding pen at Rikers Island on the night before Thanksgiving, after a brawl broke out among detainees at the jail. His lip had been gashed and his friend, Alfonso Martinez, had been stabbed.
As Mr. Martinez was being taken to an infirmary, he recalled his friend saying, “If they separate us, I’m going to kill myself.” It was no idle threat. Mr. Feliciano, 18, had tried to take his own life several times before, most recently at a juvenile detention center, his grandmother, Madeline Feliciano, said.
Hours later, alone in the pen, Mr. Feliciano twisted a piece of clothing into a noose and tried to hang himself from a U-shaped piece of metal bolted to the ceiling above a toilet. The piece of metal had been left there even though it had been used six days earlier in another suicide attempt, two people with knowledge of the episode said.
For seven minutes, guards looked in on Mr. Feliciano while he tried to hang himself, but did not enter the cell. Mr. Martinez, who had been wheeled into the area on a gurney after receiving medical treatment, said he shouted at the guards, “He’s hanging!”
“They saw him hanging and did nothing,” Mr. Martinez said.
City officials have repeatedly pledged to improve conditions at Rikers Island, a sprawling jail on an island in the East River that currently houses roughly 5,180 inmates. But the harrowing events surrounding Mr. Feliciano’s suicide attempt, which left him in critical condition and on a respirator, have once again focused attention on serious mismanagement at the aging complex.
An investigation by The New York Times found that the suicide attempt came after a series of mistakes by correction officers and other staff members at Rikers, errors that suggest lapses in the supervision of people with mental health issues at the city’s jail.
As the jail population has dropped in recent years, a greater percentage of the inmates who remain at Rikers have a history of mental illness, from schizophrenia to bipolar and depression disorders. About 43 percent of the city’s inmates received mental health services while detained, including 1,100 people — or 16 percent of the jail population — who have been diagnosed with a serious mental illness, according to data from Correctional Health Services.
This account of Mr. Feliciano’s attempted suicide was based on interviews with three city officials and one former corrections official with knowledge of what happened in the holding pen, all of whom spoke on the condition of anonymity to discuss an open investigation, as well as interviews with Mr. Martinez, Ms. Feliciano and the president of the corrections officers’ union.
The New York City Department of Correction and Correctional Health Services both declined to respond to detailed questions about the suicide attempt, saying it was under investigation.
Mr. Feliciano had been sent to jail on a parole violation after serving time in a juvenile detention center for robbery. But The Times found that he was placed in the jail’s general population despite his mental health history and his previous attempts to take his life while in custody. In fact, correction officials housed him in a facility that many detainees try to avoid because it is rife with gang violence.
Then the correction officers who saw Mr. Feliciano try to hang himself assumed at first that his threat was not genuine because his feet appeared to be touching the floor, one of the city officials said.
The Correction Department has responded to the incident by suspending five correction officers and a captain. Federal prosecutors in Manhattan are also considering whether there is sufficient evidence to open a criminal investigation. Mr. Martinez said he had been interviewed by the F.B.I.
A review of the suicide attempt by the New York City Department of Investigation has expanded to include two paramedics who were with Mr. Martinez when Mr. Feliciano attempted suicide, one official with knowledge of the investigation said.
“The system failed him big time,” Mr. Feliciano’s grandmother said.
Elias Husamudeen, president of the Correction Officers’ Benevolent Association, denied that officers were slow to respond and said investigators should review the role of managers and mental health evaluators who placed Mr. Feliciano in general population.
“My guys are the scapegoats,” he said.
Last month, the City Council approved a plan to close Rikers Island and replace it with several smaller and more humane jails. But the plan does not take effect for seven years.
A search for treatment
Mr. Feliciano was adopted by his grandmother when he was 5 years old, because his mother was unable to care for him and his father had abandoned him. His grandmother raised him in a tight-knit family along side her son, Angel, who was two years older, in Brooklyn and more recently in Kew Gardens, Queens.
As a child, Mr. Feliciano was diagnosed with attention deficit hyperactivity disorder, and later with clinical depression, Ms. Feliciano said. He was placed on medication and received a variety of services over the years, including weekly psychotherapy sessions.
Mr. Feliciano was 15 when he first tried to kill himself, his grandmother said. After a fight with a classmate at a high school for students with disabilities, he ran outside and stood in front of a speeding truck. A security guard pulled him out of harm’s way.
Later, during a stint in the Horizon Juvenile Center after being accused of robbery, he attempted suicide three times, Ms. Feliciano said. He tried to hang himself and was sent to Bellevue Hospital Center. He once used a blade from a pencil sharpener to cut his arms, legs, neck and abdomen.
“He always used to say he was feeling suicidal,” Ms. Feliciano said. “He tried stuff, but he never succeeded.”
Mr. Feliciano cycled in and out of residential treatment programs, she said. He was removed from one because of a conflict with a peer. Another time, he ran away from the program and a warrant was issued for his arrest.
He was also getting into trouble on the street, though much of his criminal record remains sealed because he was a minor at the time. Mr. Martinez said he and Mr. Feliciano were members of Los Sureños 13, a Mexican street gang.
In February 2018, Mr. Feliciano was arrested in connection with a robbery and an assault, and ended up at Horizon, in the Bronx, along with Mr. Martinez.
As part of a plea deal, he agreed to a year of psychiatric treatment, records provided by Ms. Feliciano show. While at Horizon, social workers noted he had post-traumatic stress disorder from being the victim of an assault and had auditory hallucinations. A staff member was assigned to watch him around the clock.
In January, Mr. Feliciano and Mr. Martinez were charged with groping a correction officer at Horizon. Later that month, he was transferred to a state-run adolescent offender facility in upstate New York. Finally, on Oct. 23, Mr. Feliciano was released on parole, Ms. Feliciano said.
Within a month, however, Mr. Feliciano was in custody again, after his parole officer learned that he tried to purchase a gun, skipped required programs and tested positive for drugs, state prison officials said. Mr. Feliciano was sent to Rikers Island to await a hearing on Dec. 20.
There, the Correctional Health Services staff members evaluated Mr. Feliciano and, despite his history of suicide attempts, placed him in the general population with other young adults, rather than in a mental health unit, one official said.
Mr. Husamudeen, the union president, said that given Mr. Feliciano’s history, he should have been housed in either the prison ward at Bellevue or several mental health units at Rikers.
The official said Mr. Feliciano was also misclassified as a member of MS-13, a brutally violent Salvadoran prison gang, when he was actually a member of Los Sureños, a Mexican gang that has roots in Southern California. Gang affiliations are considered when placing detainees in an effort to prevent violence.
At the jail, Mr. Feliciano stayed close to Mr. Martinez. At nights, they communicated through an opening between their cells; they began each day with a tight hug. “He’s always been a little more timid, mild, nerdy,” Mr. Martinez said in an interview. “I’m more street.”
His grandmother said Mr. Feliciano called her everyday and told her, “It’s crazy in here.” She last spoke to him on the morning before Thanksgiving. A guard ordered him off the phone, and he had promised to call her later, she said.
The night he hanged himself
That evening, Mr. Martinez said he got into a fight with a member of a rival gang, and the struggle turned into a melee after Mr. Feliciano stepped in to help.
While Mr. Martinez was taken to an urgent care clinic for a stab wound, Mr. Feliciano was put in Holding Pen 11 in a section known as the “intake” at 6:23 p.m., where he waited for medical attention.
Five hours passed. Two vans available to transport inmates were tied up with other jobs. Mr. Feliciano became agitated and threw liquid or food out of the pen toward the guards, one official and a former jail official said.
Then, at 11:15 p.m., he started climbing onto benches in the holding pen, a second official said. He was topless.
Then Mr. Feliciano used his sweater to create a noose, climbed on a partition next to the toilet, tied one end around his neck and the other around the metal hook in the ceiling, and stepped off, the officials said.
Two correction officers had looked in on him, but his feet appeared to be touching the floor even as the sweater was tightened around his neck, the first official said.
Another officer saw what had happened and rushed to get a supervisor, the official said.
Mr. Martinez, who had passed through the intake area as he returned from an urgent care unit on a gurney, said a sweater was covering Mr. Feliciano’s face and his body was not moving. Alarmed, he yelled at the officers to do something. He recalled one of the officers saying to him, “Tell your buddy to come down.”
“They took it as a joke,” he said. “They let him hang there for a long time.”
Mr. Husamudeen said officers are trained to make sure a detainee is not faking a suicide attempt before entering a pen or cell on the theory they might be lured in and then attacked.
He said that if the metal piece had not been left in the cell, Mr. Feliciano may not have been able to hurt himself. “It jeopardizes security,” he said.
Six days earlier, another detainee, Angel Richards-Bailey, 26, who has bipolar disorder and had initially been housed in a mental health unit, had used the piece of metal to hang himself.
Mr. Richards-Bailey said in an interview that it took about three minutes before two guards entered the pen and cut him down.
“Nobody stopped me until I did it,” Mr. Richards-Bailey said.
In Mr. Feliciano’s case, an off-duty captain who was about to leave for the night and had been in a security booth ran into the cell at 11:41 p.m. and brought Mr. Feliciano down, according to three people with knowledge of the incident. He did not have a pulse for two minutes, a former jails official said.
It was an additional 30 minutes before an ambulance took Mr. Feliciano to a hospital, one official said.
Ms. Feliciano said she had been praying for her grandson, who remains in a medically induced coma, has seizures and a fever, and is battling pneumonia at Elmhurst Hospital Center in Queens.
“Why did they ignore him?” she asked.“