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NEW YORK – Layleen Xtravaganza Cubilette Polanco died alone in a jail cell last year at the Rose M. Singer Center on Rikers Island.

A scathing new report from the New York City Board of Correction states that institutional failures – including the Department of Correction’s decision not to house Polanco, who was transgender, in general population with other women – contributed to her death from an epileptic seizure.

“There are facts laid out in the report that suggest that the idea of housing Ms. Polanco in a general population dorm for women was not seriously considered,” Jackie Sherman, chair of the Board of Correction’s Prison Death Review Board, told NBC News.

Polanco was also transferred to solitary confinement over the objection of at least one psychiatrist who was aware of her medical history, the board found. Her death, along with others over recent years, has led to calls to end solitary confinement in jails across the country.

Polanco, 27, was found dead in her cell June 7, 2019, in the Restrictive Housing Unit, which is a form of punitive segregation, or PSEG, at the Singer Center on Rikers. Rikers Island, located in the East River, is home to New York City’s jail complex.

The Singer Center houses the city’s female inmate population.

Rikers Island

The Rikers Island jail complex is seen in 2014, with the New York City skyline in the background. Layleen Polanco, a 27-year-old transgender inmate, died of an epileptic seizure June 7, 2019, in a solitary confinement cell while left unobserved by staff.

Footage that NBC News obtained earlier this month shows guards inside PSEG trying for about 90 minutes to wake Polanco before physically checking on her or calling for medical help. In the video, they could be seen peering into her cell, chatting and laughing at times.

Polanco was also left unobserved for long stretches of time, which goes against a Department of Corrections policy that requires inmates in solitary confinement be observed every 15 minutes.

By the time anyone physically checked on Polanco, she was dead.

According to investigative reports, she was not breathing, had no pulse, was blue and her face was covered with vomit. Her body was already cool to the touch.

“The video is the last piece of the puzzle,” said David Shanies, an attorney representing Polanco’s family in a wrongful death lawsuit against the city and several members of the Rikers staff.

Watch the footage of Layleen Polanco’s last day below.

The report by the Board of Correction, an independent board that oversees the city’s jails, also points to the lack of observation as a factor in Polanco’s death. The board found that no one went near Polanco’s cell for a 35-minute stretch of time and a 41-minute stretch, as evidenced by the motion-activated Genetec camera system that records activity in the RHU.

Polanco was last seen alert at 12:02 p.m., when an observation aide refilled her water cup and put it through the meal slot in her door.

“This is the last point in time the BOC investigation can definitively state Ms. Polanco was still alive,” the report stated.

The Bronx District Attorney’s Office and the New York City Department of Investigation this month released a report in which investigators determined the staff at the Singer Center is not criminally liable for Polanco’s death.

At least one report from the district attorney’s office also “deadnamed” Polanco, or referred to her by the name she was assigned at birth. Transgender advocates argue that the practice of misgendering trans people who have died is a sign of disrespect.

From misdemeanors to solitary

The Board of Correction’s report and an investigative report from the Bronx DA’s Office go into great detail of the nearly two months Polanco spent in jail before her death.

According to the DA’s office, Polanco’s family described her as “loving and gentle, citing her love of animals and the care she provided them.” She was also heavily involved in the transgender community.

Polanco was a dancer with the House of Xtravaganza, a prominent house in New York City’s underground ballroom scene.

“Ms. Polanco was heavily involved in performances with Xtravaganza,” the DA’s office report stated. “She frequently performed in ballroom events and took home first prize.”

Polanco, who had a number of prior misdemeanor arrests and convictions, was arrested April 13, 2019, on two misdemeanor charges, failure to pay a taxi fare and assault, in Manhattan. At the time of her death, she was being held on bail of $500 from an outstanding misdemeanor case from 2017.

Her bail in the 2019 case had been reduced to $1, according to the DA’s office.

“The total amount of bail that resulted in Ms. Polanco’s confinement on Rikers Island on June 7, 2019, was $501.00 cash, $501 insurance bond and $501 partially secured bond,” the DA’s report said.

Polanco’s behavior at the 13th Precinct, where she was booked on the April 13 charges, led to officers escorting her to the emergency room at Bellevue Hospital, where she remained for three days, the BOC’s report said.

While at Bellevue, Polanco was prescribed Keppra, an anti-convulsant taken by people with epilepsy. When she was discharged April 16, her medication was recorded on an NYPD Medical Treatment of Prisoner Form, which was provided to the court and DOC officials, who gave a copy to Correctional Health Services.

The first misstep in Polanco’s treatment while jailed was Correctional Health Services’ failure to follow up on that information, the board found.

According to the BOC report, Polanco was taken to the Singer Center, where she underwent medical and mental health screenings. During her intake, she informed jailers that she suffered from a seizure disorder.

“Ms. Polanco applied for transgender housing, and on April 18 moved into one of the two Transgender Housing Unit (THU) dorms at RMSC,” the report stated. “On April 30, Ms. Polanco suffered a seizure in the middle of the night in her dorm and was transported to the facility clinic.”

She was transferred to the other THU dorm May 2 due to a conflict with another inmate. Two days later, she suffered another seizure and was again taken to the clinic, the report stated.

Polanco got into a fight with someone from her former transgender dorm May 6 and was charged with an infraction. Following a disciplinary hearing May 14, she was sentenced to 20 days in PSEG.

The day of the hearing, however, she got into another fight. A corrections officer noted that she was “showing radical changes in behavior” and referred her to the jail’s mental health services, according to the BOC report.

Polanco was housed in an area for inmates awaiting transfer into one of the transgender units.

Read the Board of Correction’s entire report about Layleen Polanco’s death below.

Layleen Polanco NYC Board of Correction Report by National Content Desk on Scribd

“On May 15, in THU New Admissions, Ms. Polanco declined to come out of her cell for breakfast or services,” the report stated. “When she eventually came out at medication time, she refused to take her medication and began rolling around on the floor in the dayroom, talking to herself, and growling.”

She was given a second referral to mental health. Some of the behavioral traits indicated on the form included changes in behavior, expressing a desire to commit suicide, poor personal hygiene and randomly crying and shouting.

After lunch that day, Polanco was accused of charging at an officer and striking the officer’s arm. She was sent to Elmhurst Hospital for nine days, eight of which she spent in the hospital’s prison psychiatric ward.

When she was returned to Rikers Island, jail officials had a hard time figuring out where to house her. Her conflicts with other inmates in the THU meant she needed to be placed elsewhere.

In emails reviewed by the board, jail officials debated whether to place Polanco in a male facility, in protective custody or in PSEG to serve her 20-day punishment for the May 6 infraction, the report noted.

Read the Bronx District Attorney’s Office’s report on Polanco’s death below.

Bronx DA Report on Layleen Polanco's Death by National Content Desk on Scribd

They ultimately chose PSEG, despite DOC standards in place since 2015 that barred inmates “with serious mental or serious physical disabilities or conditions” from being placed in solitary confinement, the BOC stated in the report. Under those restrictions, if jailers want to place an inmate with physical or mental issues in PSEG, a psychiatric provider has to review their medical history and sign off on the placement.

The psychiatrist who reviewed Polanco’s history refused to clear her for PSEG. Authorities began the paperwork to have her placed in protective custody.

“Early the next morning, on May 25, DOC’s Operations Security Intelligence Unit (OSIU) denied, via email, a protective custody placement for Ms. Polanco, citing a lack of evidence or documentation to validate any threat to her safety,” the report stated. “While the Department continued to deliberate over where to house her, DOC sent her back to THU New Admissions where she was housed alone in the unit for five days.”

On May 29, a different psychiatrist allowed her to be placed in a restrictive housing unit, another form of segregation, pending medical clearance. The next morning, Correctional Health Services determined that her epilepsy was under control and she could be placed on the unit.

From solitary to the morgue

Polanco was placed in one of 21 small cells in the RHU. Outside the doors of the cells is a dayroom and beyond the dayroom is a raised observation room surrounded by plexiglass.

On each cell door is a small window through which jailers can observe the inmate held inside. DOC policy requires that officers observe each inmate every 15 minutes.

In addition, inmate observation aides, sometimes called “suicide prevention aides,” are required to conduct a minimum of six patrols of their assigned area each hour, according to the report.

“These observation aides are people in custody who are trained and employed by the jails to conduct visual observations of people in their cells, recognize signs of decompensation, and prevent suicide,” the document stated.

Rikers Island

File photos show the sign near the gate of New York City’s Rikers Island, left, as well as barbed wire fencing around the jail complex. Layleen Polanco, a 27-year-old transgender inmate, died of an epileptic seizure June 7, 2019, in a solitary confinement cell while left unobserved by staff.

On the day Polanco died, she was one of six women being held in the segregation unit, spread out across the cells on the bottom tier.

“Ms. Polanco was in cell #6, located more than halfway down the left wall of the unit,” the report indicated. “Her cell door contained a 20-inch by-5-inch window (as opposed to seven cells in the unit with larger cell door windows for people on suicide watch). Inside the 12-foot-by-7-foot cell, there was a small window to the outside, a ceiling light, a bed, two plastic storage bins stacked to function like a table, and a metal mirror, toilet, and sink.”

Polanco began her final morning with breakfast at 5:15 a.m., according to the report. She was taken for a shower and just before 8 a.m., she was given her medication by a Correctional Health Services staff member.

Despite Polanco telling jail officials of her epilepsy when she was first processed into the facility, the jailers on the unit the day she died told board investigators that they were never informed she had a seizure disorder.

“Nothing in the DOC housing area records that BOC reviewed referenced Ms. Polanco’s propensity for seizures,” the board wrote in the report.

Throughout the morning, the jail’s surveillance system caught footage of the comings and goings on the unit. Polanco went to recreation for an hour. One of the women on the unit was released, reducing the number of inmates there to five.

At about 9:49 a.m., a janitor had “what appeared to be an animated interaction” with Polanco through her cell window. About an hour later, Polanco was taken to the clinic so she could discuss her hormone therapy with medical workers.

Polanco was returned to the unit at 11:20 a.m.

“According to Genetec, Ms. Polanco’s demeanor appeared normal and healthy at the time she reentered her cell,” the report stated.

Over the next 40 minutes, the normal lunchtime routine took place. Polanco appeared to request a second serving and an observation aide gave her the lunch tray from the woman in the cell next door, who had refused the meal.

When the aide removed the two trays and refilled Polanco’s water cup minutes after noon, it was the last interaction the inmate had with anyone.

For the next 90 minutes or so, various employees glanced in on Polanco, though “no one walked near Ms. Polanco’s cell in the 35-minute stretch between 12:51 p.m. and 1:26 p.m., as evidenced by a lack of Genetec footage indicating motion in front of her cell during that time period,” the report stated.

At some point during that time frame, the observation aid left the unit for the day, though her departure was not recorded in any of the unit’s logbooks. The next footage shows two mental health clinicians appear at 1:26 p.m.

“The first clinician went straight to Ms. Polanco’s cell, knocked on her door, and, getting no response, proceeded to knock on the cell door for another two minutes, leaning on the glass at times to peer inside as she knocked. She left word search puzzles in the meal slot,” according to the report.

That moment appeared to be the first indication that something was wrong, though one of the jailers noted in a logbook at 1:30 p.m. that a tour of the unit was conducted and there was “nothing unusual to report.”

The mental health clinicians kept looking into Polanco’s cell window, tapping on the glass but getting no response. One of the clinicians is seen talking to one of the officers, who also looks in on Polanco but walks off to another cell.

“Officer G. later explained to BOC investigators that Ms. Polanco appeared to be sleeping face down under a blanket with her hair wrapped in a cloth, and that it was not unusual for people to be sleeping with headphones,” the report stated.

Officers and the clinician continue to peek in on Polanco multiple times over the next several minutes. None made “affirmative contact” with the inmate, however.

An officer glanced in at Polanco at 1:46 p.m. while group therapy was taking place in the dayroom, feet away from the dead or dying inmate.

“According to Genetec, no one (officers or the observation aide who had apparently left the unit) looked in Ms. Polanco’s cell to check on her for the next 41 minutes,” the report stated. “Although the logbooks report an active supervision tour with ‘nothing unusual to report’ at 2 p.m., Genetec does not show anyone checking on Ms. Polanco until 2:27 p.m., at which time Officer W. conducted rounds by peering into Ms. Polanco’s cell before walking away.”

Still, the logbooks all reported that nothing unusual was going on.

It was not until 2:45 p.m. that a corrections officer opened Polanco’s cell door. Even then, no one went into the cell to check on her.

“Without entering her cell, the officers stood at the threshold for two minutes, from 2:45 p.m. to 2:47 p.m., talking and laughing to each other, calling out to Ms. Polanco before closing her cell door again,” the report said. “At that moment, a mentor captain arrived in the unit and immediately directed the officers to reopen the door and physically check on Ms. Polanco.”

An officer went into her cell and came out nine seconds later. She and the captain immediately called over the radio for a medical emergency, and the captain retrieved a defibrillator.

“The housing area officers reentered Ms. Polanco’s cell and turned her body over, reportedly discovering that her face was purple and blue,” the report stated. “The officers began chest compressions and the captain and one of the officers employed the defibrillator. In response to a radio call of a medical emergency, two other captains arrived and assisted until 2:55 p.m., when medical staff arrived and took over.”

Fire medics arrived and worked on Polanco for about 15 minutes before a doctor pronounced Polanco dead at 3:45 p.m.

Layleen Polanco

Layleen Polanco is among the transgender dead memorialized June 20, 2020, on the wall of the Stonewall Inn in Greenwich Village. Polanco, 27, died June 7, 2019, in a solitary confinement cell on New York City’s Rikers Island.

Institutional failures

The Board of Corrections identified several key areas in which Polanco’s treatment while in jail was lacking. Correctional Health Services staff failed to follow up on Polanco’s medical information she provided at intake, the report stated.

That information would have alerted the staff to the fact Polanco had just been hospitalized at Bellevue and they would have been able to pull those records.

Secondly, the report stated, “CHS’s current process for identifying people for medical and/or mental health exclusion from PSEG/RHU is insufficient, inconsistent and potentially susceptible to undue pressure from DOC.”

Jeanette Merrill, a spokesperson for Correctional Health Services, told NBC News that the agency disagrees with the Board of Correction’s findings.

“We disagree with the conclusions the Board reached in the report, as well as their misguided recommendations regarding the clinical care that was provided,” Merrill said in a statement. “Our doctors, nurses and other health care professionals consistently provide the highest quality health care to all of our patients.”

The board also criticized the DOC’s decision to not house Polanco in general population.

“DOC’s determination not to house a transgender woman in general population housing areas for cisgender women in May 2019 resulted in increased pressure to place Ms. Polanco in the RHU – a unit unsuitable to manage both her medical and mental health needs,” the report stated.

Jailers not only failed to conduct rounds every 15 minutes per policy, they also left Polanco unobserved for multiple lengthy stretches of time, the longest being 51 minutes. When they did observe her, they were not properly trained in how to confirm signs of life, the board found.

The Board of Corrections made a total of 25 recommendations to the DOC, including housing transgender women in general population with cisgender women. Other recommendations included medical staff providing better communication to jailers about inmates’ medical needs and providing more adequate training on how to confirm signs of life.

The board also recommended written protocols for allowing a clinician to override a colleague’s previous decision to keep an inmate out of solitary confinement.

Department of Correction Commissioner Cynthia Brann thanked the board for its work, according to NBC News.

“We have worked tirelessly to create a correctional system that is safer, more humane and fairer, fundamentally reforming our housing structure to ensure that all people, regardless of their gender identification, have the access to the resources they need,” Brann said in a statement. “We are committed to working with our partners at Correctional Health Services to keep all individuals in custody safe and we are carefully reviewing all of the board’s recommendations.”

Shanies, the attorney representing Polanco’s family, said he will be watching the DOC to see if the recommendations are taken to heart.

“The board’s fittingly scathing report marks the first time government officials have acknowledged that Layleen’s death was the result of the city’s unsafe and discriminatory policies and public servants’ reckless decisions,” Shanies told the network.