In one case, a mentally ill New York City inmate hanged himself from a shower pipe on his third try in three days. During that stretch, orders to put him on 24-hour watch were apparently ignored, along with a screening form that said he was "thinking about killing himself."
Another inmate hanged himself with a bedsheet from an air vent in a solitary-confinement cell after repeatedly telling guards he was suicidal. The last time he said so, one of them replied, "If you have the balls, go ahead and do it."
In yet another case, an inmate hanged himself from a metal bed that he stood on end to create a scaffold, despite a year-old jailhouse directive to weld all beds to the floor. The directive was issued after another mentally ill man committed suicide in exactly the same way.
Investigative documents obtained by The Associated Press on the 11 suicides in New York City jails over the past five years show that in at least nine cases, safeguards designed to prevent inmates from harming themselves weren't followed.
"Is there a procedure? Yes. Did they follow it? Absolutely not," said a tearful John Giannotta, whose 41-year-old son Gregory used a jail jumpsuit to hang himself from an improperly exposed bathroom pipe last year even though he, too, was supposed to be on suicide watch. The psychiatrist's order wasn't entered into the computer system until hours after his death.
"What did he need? He needed his medication and follow-up care. He got nothing in jail."
Communication breakdowns between mental health staff and guards, sloppy paperwork, inadequate mental health treatment and improper distribution of medication were frequently cited by investigators as factors in the deaths, according to the city and state documents obtained by the AP via public records requests.
Suicide is the leading cause of death in jails nationally after illnesses such as heart disease and cancer, and New York City's rate — 17 suicides per 100,000 inmates — is well below the average for the nation's jails of 41 per 100,000.
But the documents suggesting that most of the 11 suicides since 2009 could have been prevented raise new questions about the city's ability to deal with a burgeoning population of mentally ill inmates.
The mentally ill account for about 40 percent of the roughly 11,500 men and women in New York City's jails on any given day, up from 24 percent in 2007 — an increase attributed in part to the closing of large mental institutions over the past few decades in favor of community-based treatment.
Officials estimate a third of those inmates suffer from serious mental illnesses such as schizophrenia and bipolar disorder.
Previous AP disclosures about the deaths of two other mentally ill inmates — one who essentially baked to death in a 101-degree cell in February and another who sexually mutilated himself last fall — have prompted oversight hearings and promises of reform.
Mayor Bill de Blasio said in a statement that like many other jails and prisons across the country, New York City's have become "de facto mental health systems." He noted that his administration has appointed a task force to come up with better ways of treating the mentally ill, and has also recently secured $32.5 million in the budget for new housing for mentally ill inmates, more training for guards and more staff.
"It is our job to keep every New Yorker safe while they are in our care, and inmates are no different," he said.
Experts say such breakdowns are particularly egregious in New York City's jail system, the nation's second-largest behind Los Angeles County's, because it may be better equipped than any other to deal with the mentally ill, with 400 mental health staffers employed by the city or its contractor, Corizon Health Inc.
Nine of the suicides took place at Rikers Island, the city's huge jail complex near LaGuardia Airport.
Daniel Selling, a psychologist who until two months ago headed mental health services in the jails, said that failures at Rikers can often be traced to conflicting missions: Mental health workers want suicidal inmates under constant watch, while jail guards often believe prisoners threaten suicide to gain better treatment.
"The challenge then is that they're transferred into an authority whose mission is not aligned," Selling said. "And so people fall through the cracks."
The city Department of Correction said in a statement that it "views every suicide in its custody as a tragedy that should have been prevented, and we are taking many steps ... to prevent these incidents going forward."
The city Health Department noted that suicide watches are conducted about 3,800 times a year in New York's jails, which hold defendants awaiting trial as well as those serving short sentences or awaiting transfer to prisons for longer stretches.
According to the documents, the safeguards broke down spectacularly in the case of Horsone Moore, 36, who had struggled with depression since his 20s, according to his family.
Moore had served time on assault and weapons charges and was taken to Rikers last October for missing appointments with his parole officer.
He committed suicide in a shower pen in the early hours of Oct. 14 after trying three times in quick succession. He was pepper-sprayed by guards after his first attempt, never saw a psychiatrist, never received medication and wasn't watched constantly despite two such orders and a screening form that warned he was a suicide risk.
Video footage of the last 15 hours of his life, detailed in an email by a city official, shows an agitated, handcuffed Moore fashion his shirt into a noose. He is stopped by guards while attempting to string himself up, but the cuffs are removed and he is left alone. He then tears his underwear into strips and uses them to hang himself.
"There was so much time and opportunity, and nobody took any action whatsoever," said his sister, Felicia Moore-Grant, who lives in Varnville, South Carolina. "It hurts a lot because now all we have is memory and pictures. We can never talk to him again. We can never hear his voice."
After the May 2012 suicide of sexual misconduct suspect Jamal Polo, investigators found the 23-year-old wasn't properly evaluated to pick up "what clearly was a significant risk for suicide attempt."
Polo hanged himself from a metal bedframe he stood upright in his cell, prompting an order to secure all beds to the floor.
That work wasn't fully carried out until after the September 2013 death of 26-year-old Gilbert Pagan, who killed himself the same way.
Quanell Offley, 31, who had been sentenced for robbery, hanged himself with a bedsheet last fall. Investigators found that he had repeatedly threatened suicide and that his requests went unheeded by guards, including one who dared him to do it.
"People make mistakes and they go to jail, but that doesn't mean they have to be treated so cruelly," said his mother, Desdemona Offley. "I need this situation to be fixed."