On the day that he arrived at Rikers Island last October, Steven Morales was a major suicide risk.

He was just 17 years old, charged with murder, accused of suffocating his infant daughter. He was a product of the city's foster-care system, his mother having abandoned him at birth. He had no money, little or no ties to family, and few friends. His only solid relationship—with his girlfriend, the mother of the dead infant—was collapsing.

Morales's lawyer considered the suicide risk so great that he recommended to a judge that the teen be housed in protective custody—where, the lawyer presumed, someone would keep a closer eye on him.

Ken Garduno

Protective custody, where inmates are locked in their cells up to 23 hours a day, was introduced to Rikers by jails boss Martin Horn in 2005 to house dangerous or vulnerable inmates, who would be safer there than in the general population.

But on April 27, something went terribly wrong when Horn's supervision system broke down.

That afternoon, Morales spoke to his girlfriend on the telephone and learned that she was breaking up with him, severing his last tie to the outside world. Devastated, he returned to his cell, secured a towel to the top of his cell door, wrapped the other end around his neck, and ended his life.

The officers assigned to the unit didn't notice until one of their bosses visited the floor and found him. By then, of course, it was too late.

"Someone needs to be held accountable," says Morales's lawyer, Javier Solano, a former Brooklyn prosecutor. "Based on his history and the fact that this kid, at age 17, was accused of a horrific crime, there certainly should have been much more supervision. I don't understand how he was able to do it in that setting."

The suicide in the Robert N. Davoren Center— occurring in the very place where inmate safety is supposed to be the highest priority—raises new questions about security issues at the jails under Horn's supervision, which the Voice has been reporting on for several months.

While conditions in the jails are certainly better than they were at the height of the crack epidemic, documents and interviews have revealed that violence is still a problem in the system. A series of Voice stories, for example, disclosed a spate of cases of correction officers using inmates as enforcers.

Correction Department spokesman Steve Morello declined to comment on the suicide, pending the results of several investigations.

The city Health Department, which is supposed to oversee the jails' for-profit medical and mental-health contractor, Prison Health Services, also declined to comment, citing federal and state patient-confidentiality laws.


Morales was born David Chow. After his mother left, he lived with his father. But child-welfare officials placed him in foster care when he was still quite young. He bounced from one abusive home to another until he eventually landed with a family who adopted him at age 14. (See also "The Jail Interview Steven Morales Gave to Columbia Grads" by Molly Messick and Sarah Morgan).

About three years ago, his adoptive mother took him to Spain, for reasons that are still unclear. There, he met his girlfriend, Olga. They fell in love, and before long she was pregnant.

But Olga's family didn't approve of Morales—he was too dark-skinned for their tastes—and so they kicked their daughter out of the house, says Stephanie Heredia, Morales's adoptive sister. The couple lived for a short period on the street, getting by with money from odd jobs and family members.

In mid-2007, their daughter, Sophia, was born, and the couple decided to move to New York City. They arrived with their baby, unemployed and without prospects. They took a cheap room in a Bronx building, and Olga found a job in a New Jersey bar.

For a while, things seemed OK. "The baby had a stroller, a playpen, everything she needed," Heredia says. "They weren't doing so bad."

On the night of October 7, with Olga out at work, Morales was trying to put Sophia to bed, but the infant was crying. She wouldn't settle down.

What happened next is a matter of dispute between Morales's lawyers and Bronx prosecutors.

The indictment charges that Morales threw Sophia repeatedly into the crib face-down with such force that he left fingerprint marks and bruising on her scalp and "severe bruising" on her bottom. Then he covered her face with a blanket, suffocating her.

Morales told Solano that he gave Sophia a bottle, then wrapped her in a blanket so she wouldn't fall off the bed. Then he took a shower. When he returned to the baby's side, she was blue. Morales called 911 immediately and tried to perform CPR. It was too late.

The police began to interrogate Morales at the hospital. The interview continued throughout the night and the following day. By the end of it, Morales was admitting to throwing Sophia in the crib and placing the blanket over her head.

In all, Morales was interrogated without a lawyer for 22 hours and gave seven different statements, including three that were videotaped.

The deeply regretful Morales later told Solano that he didn't remember how many video statements he had made. "This is a situation where the kid is being classically coerced," Solano says. "The kid is not sleeping, and every three or four hours they come in and want something else."

The emergency-room doctor who examined Sophia told police that he didn't see signs of foul play, the police records show. Moreover, the medical examiner's report described Sophia as a well-nourished infant. Her body didn't show signs of abuse, except for two small bruises on her head and buttocks.

"The saddest part of the case is, we believe we had a viable defense," Solano says. "Everything corroborates his story. At most, this was a case of reckless endangerment or endangering the welfare of a child. Now, everyone will just remember him as a monster."

Morales arrived at Rikers following his arrest and was placed in the protective-custody unit. He should've had a mental-health evaluation as well.

"I thought he needed additional monitoring because of the charges and his grief—plus I wasn't sure how other inmates would treat him," Solano says.

Early in his stay at Rikers, Morales spoke of suicide, but he seemed to adjust and seemed a little more comfortable after a while, Heredia says.


After two months, Morales asked to be taken out of protective custody, and Solano says he made this request to the Correction Department. But officials there declined to do so, for reasons that are still unclear.

Heredia visited Morales. He told her during the visit that he didn't intentionally kill Sophia, and he also complained that he was having trouble reaching his girlfriend. He said he wanted to fight the charges.

"He became more optimistic," Heredia says. "But he had no communication with Olga. He couldn't reach her."

Morales finally did find a number and called her. It was then, according to Heredia, that Olga told him she was pregnant by another man. Olga told Heredia that she felt she needed another child to replace the one she'd lost.

On April 27, after that awful phone call, Morales returned to his cell and hanged himself.

By one account, after the phone call with Olga, Morales was screaming and banging on his cell door. One inmate, the sources said, screamed for an officer, but the officer told the inmate to be quiet.

Under DOC rules, Morales should have been monitored every half-hour. But sources tell the Voice that officers assigned to the unit sometimes shirk their required rounds.

"It's not clear that the regulations were followed in this case," a correction source said.

In addition, Morales covered the window in his cell door with a sheet, and the officers either didn't notice it or didn't act when they saw it, sources said.

Morales was finally discovered at 4:30 p.m. by a correction captain who was making a visit to the floor, rather than by the assigned officers, sources said. The time of death was listed as 5:20 p.m.

"If he was supposed to be under extra supervision, somebody was not doing their job," says Heredia.

It remains unclear how often Morales saw mental-health counselors during his time at Rikers.

Morales's suicide was the second in two years in the protective-custody unit at the Robert N. Davoren Center. In November 2006, Matthew Cruz, a 38-year-old New Jersey man charged in a stock-manipulation case, hanged himself by a sheet woven through his bars. The suicide was the second in recent months for one of the officers assigned to the unit, sources said. It is unclear whether that officer has been disciplined.

A State Commission of Correction report on the Cruz death concluded that the mental-health treatment he had received was inadequate, flawed, and crippled by poor decision-making and poor record-keeping that violated department policy. The commission blamed Prison Health Services Inc., a company that provides health care at Rikers under a huge Department of Health contract.

The health-care workers dismissed clear signals that Cruz intended to commit suicide, the state report said. Cruz had been placed in "close custody" after his life was threatened by another inmate. Six days before his death, he slashed both his wrists in an initial suicide attempt.

The heavily redacted report also suggests that DOC staff did not have a defibrillator on hand, as required, and that may have contributed to his death.

Last December 20, a third inmate, David Mercado, 17, of Mount Vernon, New York, hanged himself at the Davoren Center.


Jail officials had placed Mercado in a dorm with 50 other inmates, even though a Queens judge, Gene Lopez, had ordered, both in writing and from the bench, that the teen should be placed on suicide watch, according to the family's lawyer, Andrew Stoll.

For some reason, however, correction officials and PHS decided to ignore the judge and place Mercado in the general population. It is unclear whether officials even did a thorough mental-health screening of the teen. Mercado killed himself less than 24 hours after being admitted to Rikers.

Even more troubling, state reports on a series of other suicides at city jails show lapses by both correction staff and PHS medical personnel dating back to 2001.

Horn created the "close" or protective-custody program in 2005 as a way to house those inmates considered either too dangerous for the general population, or too vulnerable to other inmates because of their high-profile status or the crime they committed. For that reason, the unit is supposed to have a higher staffing level than other jail areas.

Inmates are locked in their cells up to 23 hours a day, allowed out singly for exercise, and receive an escort to other areas. They're allowed to watch television, but in plexiglass cubicles designed to prevent any physical contact with other inmates.

Out of 14,000 inmates at Rikers, 50 are currently held in protective custody, three of them involuntarily, and 19 because they are considered "predatory."

"We use close custody as a last resort when other means do not provide the requisite safety," Correction Department spokesman Morello says.

But jail observers have long objected to protective custody as an overly punitive and psychologically harmful practice. And Morales's suicide certainly raises concern that oversight of the program is not what it should be.

The Correction Department often has suicide-prevention aides on hand in the jails, but there were none in Morales's unit. Some observers suggest that the aides—who are specially trained inmates—could have acted as another set of eyes to prevent the tragedy. But the close-custody policy bans any outside inmates from entering the unit.


And some question whether it was a good idea to place Morales in such an isolated setting, given his age and the stresses weighing on him.

Teenagers are especially susceptible to mental illness in that environment, says Stuart Grassian, a psychiatrist with Harvard Medical School and an expert in the effects of special confinement. Indeed, Morales told people who visited him that he felt "abandoned and alone."

Grassian says that Morales had many of the major risk factors for suicide: his age, the charge he faced, the minimal support from outside, and the type of housing he was in. "This kind of thing is going to continue until people recognize that the people who end up in places like Rikers are mostly people whose emotional lives are out of control," Grassian says. "Placing them in solitary confinement is going to massively increase the chance they may commit suicide."

Monitoring an inmate, Grassian adds, doesn't mean just walking by and looking at him. "If the behavior isn't dramatically agitated and disorganized, you're not going to pick it up," he says.

Meanwhile, Lawrence Berg, a former upstate commissioner of mental health who is now a lawyer assisting Solano, says: "Putting someone in lockdown is the last thing you want to do with someone who has mental-health issues, and it's even worse for a teenager. And there is no reason for a suicide to take place in a controlled setting like a protective-custody unit in a jail."

Morello counters that inmates often request protective custody, and thus might feel more relaxed and safer than if they were in the general population. Once they are in the unit, he says, few ask to be transferred out.

Norman Seabrook, the president of the correction officers' union, said his understanding was that the officers in the unit did everything by the book.

To Seabrook, the broader issue is the decline in the number of officers staffing the jails. There are about 2,500 fewer correction officers today than there were 10 years ago, he says. It is common to have a single officer watching both wings of a unit, where there used to be two officers, he says.

"We just don't have enough correction officers in the department," he says. "I'm not attributing this death to that, but the point needs to be made. It's just a matter of time before something else happens, and people will try to blame the officers when they're being asked to work short-handed."

The PHS and DOC, Seabrook continues, could do a better job of screening inmates and making sure that they get the mental-health care they need. "The mental-health unit should be more diligent in ensuring that a 17-year-old be placed in a hospital where he can get the attention he needs," he says. "We may see signs of illness here or there, but we're not trained to do that."

In response to Seabrook, Morello says the staffing change was made by a prior commissioner. "Mr. Seabrook's comment here is irrelevant, since in this unit, there was more than one officer assigned," he says.


In general, Morello says, there are additional officers assigned to the close-custody unit. Plus inmates are screened by mental-health professionals on entry into the system and during subsequent periods as necessary. Additional consideration is given to candidates for close or protective custody. Also, chaplains visit such units on a daily basis, and, he says, correction officers are trained to observe suicidal behavior.

Some observers have questioned the practice of placing both adults and adolescents in the same close-custody housing. But Morello says that it's within the rules because the inmates have no direct contact.

Morello also argues that the age of the inmate and his placement in protective custody doesn't necessarily increase the odds of suicide. Of the last 20 suicides in the city's jails, only three were inmates 19 or younger, and two were in close custody, along with a third in punitive segregation.

Morello says that the 23-hour lock-in doesn't necessarily mean that the inmates are in their cells 23 hours a day. They receive the same out-of-cell activities as other inmates, and they're allowed to watch television in adjoining plexiglass cells.

"The suicides that have occurred since Commissioner Horn took office at the beginning of 2003 total 25 percent fewer than in the equal number of years prior to the start of this tenure," Morello says. But he declined to state the exact number of officers assigned to a given shift in the protective-custody unit on security grounds.

For now, the investigation into Morales's death at Rikers continues. Heredia is mulling whether to file a notice of claim against the city.

"Everyone failed this kid, and now the correction system has failed him too," Solano says.

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