"Confused" jail staff infrequently checked on Layleen Cubilette-Polanco, the 27-year-old transgender woman who died on Rikers Island from epileptic seizures while she was in solitary placement the day she died, according to a new report from the city's jail oversight agency.

The Board of Correction also found that the NYC jail system's doctors' process for identifying people with medical conditions who should be excluded from solitary units is "insufficient, inconsistent, and potentially susceptible to undue pressure from" the Department of Correction.

Polanco spent nine days in the restrictive housing unit. The day she died, jail staffers failed to check on her every 15 minutes as required by policy; many staff were "confused" about the policy, the report found.

It also found that the Department of Correction's decision to house a transgender woman in a different area than cisgender women resulted in "increased pressure to place" Polanco in a restrictive housing unit that was "unsuitable to manage both her medical and mental health needs."

Polanco died on June 7th, 2019 while awaiting trial on misdemeanor charges. She was held on $500 bail. Earlier this month, the Bronx District Attorney found no criminality in her death.

"As Ms. Polanco's family and friends continue to mourn her death and thousands of members of her community protest in the streets, the Board's report presents a path forward for the City to make significant changes to protect the safety and care of people in custody," the chair of the BOC's Prison Death Review Board Jackie Sherman said in a statement.

The new report details her weeks incarcerated—her mental anguish, her transfer to a unit alone, and the failure to properly check on her condition. In the weeks leading up to her death, an officer noted she had refused breakfast, was talking to herself, and was "randomly crying, shouting."

While in a housing area for transgender inmates, Polanco allegedly had an altercation with someone, which spurred her transfer to a solitary unit as a means of discipline. She spent nine days in the hospital for psychiatric conditions while in custody, and then returned to Rikers.

The DOC struggled to determine where to place her after that.

“We tried very hard to get Inmate [Polanco] cleared [for segregation] but [Mental Health] just won’t clear her," a tour commander wrote.

On May 24th, a psychiatrist declined to clear Polanco for a solitary unit due to her seizure history, but six days later, a CHS doctor reversed the decision and she was moved into a restrictive housing unit.

She died nine days later.

The report notes: "The officers and captains in the Unit that afternoon [June 7th, when she died] whom BOC interviewed reported that they were never informed that Ms. Polanco had a seizure disorder, and nothing in the DOC housing area records that BOC reviewed referenced Ms. Polanco's propensity for seizures."

Staff left Polanco unchecked for periods of 57, 47, and 41 minutes between when she was confirmed alive and pronounced dead.

At one point, Polanco was seen lying face down under a blanket with headphones on—though an officer told the BOC that it was "not unusual for people to be sleeping with headphones," according to the report.

An hour before Polanco was pronounced dead, officers stood at the doorway of her cell for two minutes "talking and laughing to each other, calling out to Ms. Polanco before closing her cell door again." A mentor captain told the officers to reopen the door to physically check her, upon which the officers called for medical emergency, began chest compressions, and discovered her face was purple and blue.

She was pronounced dead at 3:45 p.m. on June 7th, 2019. Her death would soon after spark cries for justice for Polanco, as well as demands to close Rikers. The City Council has since passed plans to relocate facilities to four borough-based jails as a part of a longterm strategy to close the remaining facilities on Rikers Island and reduce the jail population.

The oversight agency released the report on Polanco as mass demonstrations have swept New York City—calling for defunding the police and an end to systemic racism and police violence. Among the dozens of marches in recent weeks, thousands packed Brooklyn's downtown streets, dressed in white, chanting "Black trans lives matter" in a show of solidarity. Polanco's family joined the demonstration in front of the Brooklyn Museum.

In the report, the oversight agency issued a laundry list of recommendations for DOC and CHS: creating additional controls to ensure patients are getting and taking medications, ensure medical information is thoroughly reviewed when someone's incarcerated, placing transgender women in general population with cisgender women when transfer is required after an altercation with another inmate, require officers to check for signs of life during rounds, among other changes.

DOC Commissioner Cynthia Brann said the department is reviewing the recommendations.

"Our deepest condolences are with Layleen Polanco's family and friends and we thank the Board of Correction for their time and diligence in preparing this report," Brann said in a statement: "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."

The department touted the 80% reduction of punitive segregation housing since 2014. Punitive segregation is not supposed to be for seriously mentally ill individuals or anyone under 22 years old. In 2019, being locked up for 23 hours a day was prohibited.

The DOC did not answer a question about what reforms or training regarding the 15-minute rounds policy has been done or other reforms made after Polanco's death. The department noted transgender, intersex, and gender non-binary people can elect where they're placed—with other gender-non-conforming individuals or with cisgender inmates. Polanco elected to be moved into transgender dorms before she was punitively placed into a restrictive housing unit.

Correctional Health Services [CHS] strongly disagreed with the conclusions the oversight agency reached.

"As part of NYC Health + Hospitals, the nation’s largest and leading municipal health care system, Correctional Health Services (CHS) is guided by best clinical practices in patient care," CHS spokesperson Jeanette Merrill said in a statement. "We disagree with the conclusions the Board reached in the report, as well as their misguided recommendations regarding the clinical care that was provided."

"Our doctors, nurses and other health care professionals consistently provide the highest quality health care to all of our patients," Merrill added. She did not specify which conclusions and recommendations her statement referenced.