NEW YORK (AP) -- Federal prosecutors should launch a civil rights probe into the 2013 death of a mentally ill New York City jail inmate who was locked in his cell for six days without care or medication, a state oversight panel concluded in a review that called the treatment "so incompetent and inadequate as to shock the conscience."
Bradley Ballard, a 39-year-old paranoid schizophrenic with diabetes, died shortly on Rikers Island, the city's main jail complex, after a doctor finally went into his cell and found him naked, covered in feces and badly infected from a piece of cloth he tied tightly around his genitals.
The review by the New York State Commission of Correction, obtained by The Associated Press, said the lapses by the city and its medical provider, Corizon Health Inc., violated state law and "were directly implicated in his death."
"Had Ballard received adequate and appropriate medical and mental health care and supervision and intervention when he became critically ill, his death would have been prevented," the report said. "The medical and mental health care ... was so incompetent and inadequate as to shock the conscience."
The AP first reported the details of Ballard's death last year soon after it reported another mentally ill inmate, Jerome Murdough, died last February after he was left unattended for hours in a cell that sweltered to 101-degrees Fahrenheit because of malfunctioning heating equipment.
The two cases prompted calls for reform, an oversight hearing and contributed to Mayor Bill de Blasio's recent pledge to spend $130 million over four years to divert people with behavioral disorders to treatment instead of Rikers.
Officials estimate about 40 percent of the roughly 11,000 daily New York City inmates have a mental health diagnosis.
"Every day I'm thinking about him," said Ballard's mother, Beverly Ann Griffin. "I'm so angry with what they did to him."
City officials said in statements that since Ballard's death mental health workers and jail guards have received more training on how to communicate better.
Dr. Sonia Angell, a deputy commissioner with the city Health Department, said a Corizon mental health unit chief in charge of the mental observation unit that housed Ballard was transferred to a smaller facility with fewer responsibilities after the death. And jails Commissioner Joseph Ponte said a new housing unit where mentally ill inmates get therapy, along with more training for guards in how to work with mentally ill inmates, would improve conditions.
Corizon spokeswoman Susan Morgenstern said an internal investigation was launched after Ballard's death but declined to provide details, citing legal reasons.
The medical examiner ruled Ballard's death a homicide and said he was killed by diabetic ketoacidosis which occurs when people don't have enough insulin and the liver breaks down fat instead.
Dr. Phyllis Harrison-Ross, the commissioner of the state oversight panel, recommended in the report that the U.S. Department of Justice open a criminal investigation into Ballard's death, as well as more comprehensive investigations into both the 2,300-bed Rikers facility where Ballard was held and Corizon.
A DOJ spokeswoman said officials would review the report. Federal prosecutors in Manhattan are currently suing jail officials to quell what they've called pervasive violence in Rikers facilities. State prosecutors in the Bronx are still reviewing Ballard's case.
Jonathan Chasan, one of the lawyers representing his family in a civil wrongful death lawsuit, called the state's review "profoundly devastating."
Ballard had a long history of mental illness and had an earlier assault conviction in New York. He was brought to Rikers from Texas in 2013 for changing his address without notifying his parole officer.
State investigators called Ballard's treatment at Rikers "incompetent" even before his fateful final lockup, noting that his psychotropic medication had been mistakenly switched, which made him more irritable, and he didn't receive regular insulin for his Type 2 diabetes.
After making a lewd gesture at a jail guard, investigators found that Ballard was locked up alone in his mental observation cell for six days and eight hours, a more detailed accounting than in earlier reports. Water was turned off after he flooded his cell and he was visited only twice in brief, minute-long episodes by health workers making rounds. At one point a jail guard sprayed deodorizer outside his cell, but did not get him help.
The review found that at least three top jail officials passed by Ballard's cell during the six-day stretch though none ever summoned medical staff. One official, then-deputy warden Turhan Gumusdere, is seen on video outside Ballard's cell in that time, according to two city officials familiar with the footage who spoke on condition of anonymity because of the ongoing criminal probe.
Gumusdere has since been promoted to warden of the facility.
Associated Press writer Eric Tucker in Washington, D.C., contributed to this report.