Dashawn Carter Missed Nearly 100 Clinic Appointments at Rikers Before Dying, Records Show

When the pandemic hit, Dashawn Carter struggled to get his medication for mental health issues as he was awaiting trial on Rikers Island. 

“During corona it’s hard to get my medication regularly,” he said during a desperate cold call to a THE CITY reporter in April 2020. “We are on lockdown right now. We can’t really go nowhere. Period. They bring our food to the dorm.” 

All told, Carter missed 92 medical appointments during his three stints in jail dating back to 2018, according to records from the city’s jail oversight board obtained by THE CITY via a Freedom of Information Law request. 

Most of the no-shows — likely for mental health appointments — were because correction officers failed to escort Carter to clinics located outside of the main housing areas, a Board of Correction review revealed. 

The 25-year-old Staten Islander was found hanging from a bedsheet attached to a window in the corner of a housing unit in the Anna M. Kross Center on Rikers in an apparent suicide on May 7.

Carter’s spotty medical history and lack of basic care is not an anomaly

There were 11,789 missed appointments in April, a 67{fc1509ea675b3874d16a3203a98b9a1bd8da61315181db431b4a7ea1394b614e} spike compared to December, according to jail records. There were 10,968 missed meetings in May, the latest month available. For the earliest month available, June 2020, there were only 2,083 missed visits.

An initial review of Carter’s death by the Board of Correction revealed he was put in a general population housing unit — with bars that were used for the hanging — despite a long history of mental illness. 

The Board also noted Carter had just returned from a state psychiatric hospital two days before his death. 

At the time, he was the fourth person to die in Rikers this year — following 16 deaths in 2021, the highest total in more than a decade. 

Seven more inmates have since perished, including Michael Lopez, who died inside a mental health observation cell inside the Kross Center last Friday morning. That puts the city correctional system on pace to surpass last year’s grim milestone.

Jail insiders say they believe Lopez overdosed on drugs, noting he was seen the night before smoking a substance and snorting pills, but no official cause of death has been determined yet by the city’s Medical Examiner. 

‘The Definition of Insanity’

Carter’s life and death touched on several fronts — extreme poverty, homelessness, mental illness and a lack of steady medical care behind bars — that criminal justice reformers say often leads to a spiral of arrests and jail time, for which the city has offered few alternatives.

“Dashawn Carter is the epitome of why people with mental illness, especially someone with serious mental illness, should never be incarcerated,” said Cheryl Roberts, executive director of the Greenburger Center for Social and Criminal Justice, a nonprofit based in Manhattan. 

Carter appeared to suffer from schizophrenia and began to show symptoms after he finished high school in 2015, according to friends, family and his defense lawyer. 

In April 2020, he told THE CITY it was hard to get his “psych meds” at the jail — where he was being held on robbery charges — in part because his housing area was on lockdown as the pandemic started.  

As for all the fatalities behind bars this year, at least eight of the 11 either had mental illness or substance use disorder, according to jail records and insiders. 

An aerial look at the sprawling jail complex on Rikers Island.

formulanone/Flickr Creative Commons

None of them “got the treatment they needed,” Roberts said, adding, “incarcerating people with serious mental illness is the definition of insanity and criminal in itself.” 

Carter’s odyssey through the criminal justice system was heavily influenced by a particular lack of resources on Staten Island for people with mental illness accused of committing a crime. 

“Staten Island being the forgotten borough, we do not have the other resources that the other boroughs have,” District Attorney Michael McMahon said during a “Reckonings & Reforms: A Conversation about Serious Mental Illness” online forum held by the Greenberger Center in October 2021. 

Cases are only moved to the borough’s specialized felony mental health court — put in place on Staten Island in 2010 — after a plea is made. Even that never happened in Carter’s case.

His defense lawyer also never requested a diversion program as the mental health assessment was being conducted, according to the DA’s office. 

“Staten Island’s judicial system, carceral apparatus, as a general matter, is a throwback to the 50s,” said defense attorney Ron Kuby. “And I don’t mean the 1950s.” 

“The progressive reforms that have created enlightened justice in so many other places don’t exist there,” he added.

Carter was also never offered any meaningful housing assistance, alternative to incarceration, or long term mental health treatment, according to his family and defense lawyer. 

Additionally, while many people who can’t afford a lawyer are represented by members of the Legal Aid Society, the city’s largest nonprofit criminal defense group, that option wasn’t available to Carter. He had a co-defendant in the robbery case, so he instead got a so-called 18B lawyer, a private defense attorney assigned to indigent clients under a law requiring the city to provide representation to people who are unable to pay for their own defense. 

Legal Aid has more resources like investigators, DNA experts, and an in-house media team that has the ability to call attention to questionable cases or bad behavior by prosecutors. 

The LAS and other large defense groups have also moved to a more holistic approach for their clients by providing an array of services for housing and health needs. 

Asked about the Carter case after his death, McMahon’s spokesperson merely detailed the charges he was facing: three separate burglaries at the College of Staten Island in the summer of 2018. 

Carter was also charged with allegedly throwing a can of Red Bull at a 7-Eleven clerk while trying to steal the drink, according to court records. The incident was bumped up to first degree robbery, carrying a punishment of up to 25 years in prison, because the Red Bull can was labeled a “dangerous instrument,” the indictment said. 

Before he was arrested in the Staten Island cases, Carter allegedly flew to California where he was later convicted for an unrelated assault. When he finished his jail sentence in California he was extradited back to New York where he was arrested on Oct. 4, 2019 for the Staten Island case. 

A judge set bail at $10,000 citing his history of leaving New York while his other case was pending. He was freed on bail on Nov. 30, 2020, records show. 

As that case was pending, he was arrested again on Feb. 5, 2021 in Manhattan after he allegedly assaulted a random pedestrian on the Lower East Side. When police tried to apprehend him he jumped into the icy East River

“We remain deeply saddened by the tragic circumstances of Mr. Carter’s death and we continue to call on those in charge of Rikers to do more to ensure the safety and security of all who remain under their custody and care while incarcerated, as well as those who work there,” McMahon said in a statement. 

Stuck in Limbo

Carter’s death brings attention to extensive delays in the process prosecutors and the court system use to evaluate defendants’ mental competency.

A key point in his case came on April 12, 2021, when his defense lawyer requested a so-called 730 exam to determine if Carter was mentally fit to stand trial. 

Attorney Mark Geisser asked the judge to allow his client to remain free while the evaluation was being conducted, a process that can take weeks. 

The assistant district attorney at that hearing argued that Carter posed a danger to society and contended he needed to be locked up. The judge agreed. 

Carter spent approximately two months in jail before he was deemed unfit to stand trial — and then waited another two months before jail officials transferred him to a psychiatric facility where the evaluation was conducted. 

Carter was found dead at the Anna M. Kross Center on Rikers Island this May.

Courtesy of the Department of Correction

“So for two months, someone who’s found unfit was in Rikers at a time when Rikers is at its most violent, most understaffed,” Geisser said. 

On Jan. 13, 2022, he was moved to a state mental health hospital after he was deemed unfit to stand trial, jail records show. He was transferred back to Rikers on May 5 and instantly put into general population, according to the Board of Correction’s initial death report first reported by the Daily News.

There were 140 people in city jails waiting for similar 730 mental health evaluations in Criminal Court as of last Thursday, according to the Office of Court Administration. That figure does not include the number of cases in State Supreme Criminal Term court, where people are placed after they are indicted, which doesn’t track the data in an easily searchable manner, he added. 

Julia Solomons, senior policy social workers for the Bronx Defenders, said Carter and others with mental health issues get caught in a “devastating” cycle. 

“Their conditions are made worse while they’re incarcerated,” she said. “And they’re not only not receiving the medical and mental health services that they need, but they’re also confined, they’re surrounded by conflict and violence.”

In jail, Carter was repeatedly moved to different housing areas every few days, an old-school tactic used by jail officials to get rid of detainees who are struggling to adjust to the rigid life behind bars. 

The constant transfers likely contributed to Carter’s depression and struggle with mental health, jail insiders said. 

The constant moves also made it difficult for Carter to get proper care, according to the Board of Correction’s initial report into his death. 

Correction officers “failed to produce” him to the medical clinic 70 times over three periods in jail dating back to 2018, the Board’s review said. 

The other missed appointments were due to intervening court dates, reported “refusals,” and while he was in the state psychiatric hospital, the data shows. 

The spike in missed medical visits throughout the city’s jail system comes a few months after the issue became so pronounced that the Legal Aid Society asked a judge to hold the Correction Department in contempt of court. The lawyers for detainees argued the department failed to follow an earlier court order requiring proper medical care for everyone behind bars.

In December, Bronx Supreme Court Judge Elizabeth Taylor ordered jail officials to make sure that there are enough officers to escort detainees to medical visits when requested. 

The Legal Aid Society said Carter’s death and the 92 missed appointments are proof the department is failing to provide adequate medical care — and has been for years. 

“This failure results in daily suffering, sickness, and pain. DOC has admitted that they would be better able to serve a smaller jail population,” said Legal Aid spokesperson Redmond Haskins, urging the “courts, prosecutors, and elected officials ”to reduce the number of people locked up. 

Critics of the department contend the process for asking for medical help is deeply flawed. 

People in jail can seek a medical appointment via a so-called Sick Call Triage phone in each facility. People with chronic conditions typically have follow up appointments automatically scheduled. 

In the 1980s, detainees were able to walk themselves to the medical clinic area in each housing unit. But at some point in the 2000s jail officials concerned about security began requiring officer escorts

Officers are often unavailable due to staffing shortages or unwilling to make the trek multiple times each day, according to several detainees. 

As a result, the officers either never call the people before their scheduled appointments, make the transport announcement in a low voice, or in an area where few, if any, people are congregated, insiders say.

“It’s a long walk to the main clinic and the COs are busy and it’s chaotic,” said Anne Petraro, who worked as a jail clinician from 2013 to 2018. “The officers claim that (the detainees) never want to go. But that’s not accurate. Everyone wants to leave their dorm.”

Jail officials contend they are doing the best they can and that most of the missed appointments are actually due to detainees refusing to go. 

“Seventy percent of the medical appointments that are missed are the result of the people in custody refusing to go,” Correction Commissioner Louis Molina told WNYC earlier this month. 

“They could refuse to go for a number of reasons, because they might have a court date that same day, they may have a family visit that they don’t want to miss, they may be participating in some educational programming or workforce development programming, or they may simply no longer want to see a doctor.”

As for Carter’s death, two jail captains and two correction officers were suspended, according to the Correction Department. Multiple officers were not at their assigned posts when Carter took his life, according to a jail source familiar with the ongoing probe.

‘He Was a Good Dude’

Before jail, Carter’s life drastically changed for the worse after his mother passed away while he was in high school, according to friends from school. 

His two brothers helped but he was placed in foster care. 

When he graduated Evander Childs High School in The Bronx, he struggled to find work and housing and began to exhibit signs of serious depression and confusion with reality, according to friends and family. 

Criminal justice reform advocates protest in Lower Manhattan against conditions at Rikers Island, May 17, 2022.

Hiram Alejandro Durán/THE CITY

“He had no support system,” said high school friend Ray Robinson. “He just had to really rely on himself and those close to him.”

“He probably felt he couldn’t go nowhere,” Robinson said, noting that Carter had previously asked him for cash.  

His friends remembered him as someone who always shared his snack and liked to whisper trash talk when he played basketball. 

“He was a good dude,” Robinson said. “He was pretty reserved.” 

Carter struggled in school and graduated the “summer after” most of his classmates, said Robinson. 

They last spoke two years ago at a summer cookout before Carter briefly moved to California. 

Robinson found out about the death through a Facebook group set up by former classmates. 

“I didn’t realize how important he was in my childhood,” he said. “I didn’t sleep all night and the last death I didn’t sleep was my grandmother’s two years ago.”

“Life is really just not promised,” he said. “And those who you had a close relationship with might just disappear.” 

Roberts, who has spent eight years and counting trying to create an alternative to incarceration mode for people like Carter, said his death is one more tragic reminder of how society fails to properly treat people with mental illness. 

“Dashawn Carter represents everything wrong with trying to confine someone with mental illness in an incarceral system rather than a mental health system,” she said. 

“This is not just about the failings of Rikers, it’s about a decades long failure of our mental health system and a refusal to acknowledge that when it comes to mental health treatment, we need it all — community based resources and treatment, supportive housing and more in-patient treatment beds.”