Hours before Ardit Billa was found dead on Rikers Island, officers and medical staff noticed a smell coming from his cell and sprayed what appeared to be air freshener into the housing area, according to the jail’s federal oversight monitor.
Video reviewed by the monitor shows three officers and a supervisor using a broomstick and sliding it under the door to poke at Billa’s body. When they finally entered the cell, they found the man naked with his head submerged in the toilet and covered in feces.
His death was one of at least 12 last year that Steve Martin, the court-appointed monitor, says involved “poor operational and security practices.” In a sweeping, nearly 600-page report released this week, Martin found that while not every death of a person in the city Department of Correction’s custody can be avoided, most of the 15 recorded in 2025 stemmed from issues like access to drugs, lapses in security and medical care, and inadequate supervision.
Billa, whom officers found unresponsive in his cell at Rikers’ George R. Vierno Center last August, had spent the days before his death isolating himself and refusing social services and his prescribed medication, according to the monitor’s report. One captain and three correction officers were suspended as a result of the incident.
The report lands at what the monitor describes as a “critical and uncertain” moment for the jail and Department of Correction. Mayor Zohran Mamdani has yet to name his new correction commissioner, and the appointment of a court-ordered remediation manager with broad authority over jail operations is imminent.
The report also appears to mark a shift in the monitor’s assessment of current department leadership. The monitor writes a “disturbing pattern” has re-emerged across DOC administrations, accusing the department of slowing reforms, attempting to limit transparency, minimizing serious problems and, in some cases, providing false or misleading information. Ten years after a landmark federal settlement required the city to overhaul dangerous conditions inside its jails, the monitor concludes, the system remains profoundly unsafe.
“The reform effort continues to progress at a glacial pace,” the report states, repeating language the monitor used in his last report, issued in May. While violence and use-of-force metrics have fallen from the peak of a 2021 staffing crisis, nearly all key indicators remain substantially worse than they were in 2016, when federal monitoring began.
The Correction Officers’ Benevolent Association did not return requests for comment and the Department of Correction declined to make a statement. Advocates told Gothamist they hope this may be the moment when something finally changes.
“ This moment represents an opportunity for New York City,” said Kayla Simpson, a staff attorney with the Legal Aid Society’s Prisoners’ Rights Project and part of the litigation team that prompted federal oversight of Rikers. “Do we double down on this status quo that … has produced dysfunction and death? Or are we willing to do something different even if it's hard? Because I think it will be hard.”
The report, which is the monitor’s 20th, covers the first half of 2025 but describes more recent incidents and the full-year tally of deaths. Taken as a whole, it paints a familiar picture of routine dysfunction including officers abandoning posts, cell doors left unsecured, supervisors failing to conduct basic tours and staff repeatedly neglecting to enforce fundamental rules. The result is a number of violent incidents involving both prisoners and staff, described in words and photographs throughout the report.
In one case, just last month, an officer sprayed a chemical agent onto the sole of his boot inside a closet then placed the contaminated boot near the face of a fully restrained man while other officers pretended no chemical agent had been deployed, according to the monitor, who reviewed body-camera footage of the incident. After the man began convulsing, “staff turned him on his side and moved him closer to the sanitation closet and nearer to what appeared to be orange boot prints on the floor in front of the closet,” the report states.
In another incident from October, a prisoner was seriously injured after an officer allowed prisoners to move freely and enter cells on an upper tier without supervision, according to video reviewed by the monitor. Footage shows multiple individuals entering the victim’s cell before another person alerted the officer. When the officer opened the door, one man exited with blood on his clothing. Body-camera footage described by the monitor showed the victim, who suffered facial fractures, a swollen eye, bruising and cuts that required hospital treatment.
Advocates said the latest report underscores what years of oversight have already made clear.
“Rikers continues to be an egregiously violent, dysfunctional place, and it is dangerous — profoundly dangerous — for staff and for incarcerated people,” said Zachary Katznelson, executive director of the Independent Rikers Commission, which issued a report last year outlining how to close the jail, as the City Council voted to do by 2027. “The status quo cannot continue.”
Last year, U.S. District Judge Laura Taylor Swain found the city in civil contempt for violating key provisions of long-standing court orders governing use of force, supervision and safety inside the jails and announced she would appoint a “remediation manager” for the system. She’s taken months to review potential candidates.
The remediation manager, unlike the monitor, who audits and reports, will have authority on par with that of the correction commissioner to direct reforms across the department. If progress remains stalled, the judge has warned that she may move to place the jail system into full receivership, stripping control from the city altogether.
Katznelson said the judge’s decision to impose a remediation manager reflects the court’s conclusion that incremental change has failed. “No matter who’s in charge — a commissioner or a remediation manager — the mission is very clear,” he said. “We cannot accept what’s happening at Rikers.”
At a press conference earlier this week, Mamdani pledged to cooperate with the monitor. “We are deeply troubled by the conditions at Rikers Island,” he said.
While the mayor has yet to name a commissioner to oversee the jail system, he has issued an executive order directing the correction department to end the use of solitary confinement, one of the most controversial practices at Rikers.
The bigger challenge, however, is Rikers itself. Progress toward the required 2027 closure slowed considerably during Mayor Eric Adams’ term. Throughout his mayoral campaign, Mamdani vowed to get that plan back on track.
Darren Mack, cofounder of the Freedom Agenda, which has led the push to close Rikers, said he was heartened by some of the early signs coming from the new administration, including the mayor’s choice of Dean Fuleihan as first deputy mayor and the order to end solitary. He said he hopes Mamdani will now turn his attention to reducing the population at Rikers, beginning with “the most vulnerable populations,” before closing it for good.
“ The reports have always highlighted what members of Freedom Agenda already know about Rikers Island,” Mack said. “That it's dangerous, it's dysfunctional, and it's a human rights crisis that cannot be fixed or reformed.”
