THE BRONX — Eight years ago, Ken Loadholt was told by city officials that his identical twin brother had died of an asthma attack at Rikers Island while awaiting trial on drug possession charges.

It wasn't until this month that he learned his brother, John Loadholt, actually died as the result of systemic failures by city Department of Correction officers and the health care company contracted by Rikers Island.

“Loadholt’s asthma was inadequately managed by Prison Health Services, a business corporation holding itself out as a medical care provider,” Frederick C. Lamy, the commissioner of the State Commission of Correction, wrote in a report reviewing Loadholt's Jan. 9, 2006 death that was issued a year later.

State Investigators Flagged Medical Provider for Role in Deaths of Four Rikers Island Inmates View Full Caption

The report said Loadholt was never taken to several appointments at the jail’s medical clinic, and that staff from Prison Health Services never followed up with him. State investigators wrote that PHS routinely overbooked its clinic schedule, only seeing a fraction of the inmates who had appointments each day.

The report, shared with the DOC commissioner and high-ranking officials at the city Health Department, also found that Rikers guards failed to follow the rules when Loadholt told them he had difficulty breathing.

Instead of immediately contacting medical personnel, a guard walked him from his housing unit to the clinic, despite him having a “staggered gait” and being unable to talk. Loadholt collapsed on the walk and died.

“I’m pissed off that this was never forwarded to my family,” Ken Loadholt, a correction officer in New Jersey, said after DNAinfo New York informed him of the probe and provided him with a copy of the report. “I didn’t know there was an investigation as to what happened.”

Three other families of Rikers inmates who died in custody over the past decade were also never told the true circumstances surrounding the deaths — information that could have led to legal action against the city and PHS, which is now known as Corizon.

One of the reports calls their care “grossly inadequate” and says the provider caused the death of a Rikers inmate who died of sepsis from a skin infection. Another says it “violated chronic care guidelines” and “lacked adequate monitoring” after another inmate died of an asthma attack less than an hour after a PHS doctor told them nothing was wrong with him.

DNAinfo obtained the four reports through a Freedom of Information Law request.

A spokesman for the State Commission on Corrections told DNAinfo the families could also have obtained a copy of the report through a Freedom of Information Law request. However, none of them were ever told that investigations into their loved ones’ deaths had been opened.

"They just said that he died of an asthma attack,” Quantails Legrand, 52, said of her brother. “Somebody called me here. I wasn't home. They talked to my son. They told my son.”

That’s how Quantails learned that her brother, Devernon Legrand, had died while awaiting trial on arson charges at Rikers Island.

Devernon had asthma, but his sister said he managed it carefully and was otherwise healthy. The SCOC report says that he was never given the correct equipment or care at Rikers.

Less than an hour before his death, a PHS doctor told Legrand there was nothing wrong with him and to leave the medical area.

The state commission said Legrand received inadequate medical care from PHS. The medical provider lacked clinical continuity, violated chronic care guidelines and lacked adequate monitoring, all of which were factors in his death, the report says.

The state commission called on New York’s Department of Health to evaluate “whether PHS Inc. is competent to manage serious chronic illness such as asthma.”

Quantails said she had taken care of her brother her entire life.

“I was like a mother to my brother, raising him with me,” she said. “He didn't have anyone but me.”

Her pleas for answers about his death were ignored.

“They told us nothing, nothing. I tried to see if somebody would,” she said. “Nobody's gonna help me. So I just left him alone.”

Devernon’s brother, Lagarthucin Legrand, 41, of Crown Heights, said, “It's a shame there was an investigation that we weren't even aware of.

“They told us [he died of asthma]. We went on that. We're not doctors.”

Despite these four SCOC reports and four other reports criticizing Corizon's care of suicidal inmates, the firm still received a new three-year contract in 2012. DNAinfo reported in September that the Health Department, which oversees Rikers medical care, asked city hospitals to take the contract, but no local providers stepped up.

Corizon spokeswoman Susan Morganstern said the company could not discuss individual cases, but said they work closely with the city and state.

"Any reports we receive get careful consideration and action, if appropriate, so we can fulfill our mission of delivering quality care," she said.

The Health Department and the Correction Department did not respond to requests for comment about why the reports weren't shared with the families.

Another inmate Edwin Ruiz, 44, was also turned away from medical care at a PHS clinic a day before he died of sepsis, according to an SCOC report.

At 10 p.m. on Nov. 4, 2007, a Rikers guard took Ruiz to the clinic because “he was sick, not looking well, and appeared to be in pain.”

But the PHS staff said they couldn’t see him because of the high number of emergency patients already there, the report says.

The following morning, guards described Ruiz as “going in and out of consciousness.” He died a day later.

In the report, state investigators recommended that the city Health Department review and address why medical staff didn’t see Ruiz.

“The Division should use this case to re-evaluate the overall quality of medical care provided by PHS,” Daniel Stewart, the then-commissioner of SCOC, wrote in the December 2008 report.

In another report, investigators slammed PHS for its treatment of David Caban, an inmate suffering from schizophrenia who died on Jan. 25, 2009, after being restrained by prison guards during a psychotic episode.

After restraining him, guards took Caban, 38, to the clinic, where a psychiatrist briefly examined him. But the psychiatrist didn’t follow protocol for a restrained prisoner in a highly agitated state, according to the report.

Instead Caban was placed in a holding cell with his hands cuffed behind his back. About a half hour later guards found him unresponsive and not breathing, the report said. An autopsy said he died of a sudden heart problem due to agitation from his mental illness.

The SCOC report recommended that the Correction Department review its policy for supervising inmates under restraints and called for a probe of the officers who watched Caban.

It also told the state Health Department to investigate the conduct of a psychiatrist who had administered an emergency anti-psychotic medication to Caban two days before his death. The report says that the psychiatrist failed to monitor the effects of the drug on Caban.

Ken and John Loadholt grew up in East New York. Starting at age 10, they worked odd jobs at a tire shop on Eastern Parkway.

Ken joined the Army. John stayed in Brooklyn, working at the tire shop seven days a week for more than 30 years, his brother said. Ken said that’s where his brother developed a drug habit that repeatedly landed him in jail.

“No matter what he did as far as drugs, if you needed something he was there,” Ken said. “And people loved him.”

At 2:30 a.m. on the night he died, John was in the bathroom in his cell block fumbling with his asthma pump, according to the SCOC report.

“Having a little difficulty,” he told a prison guard.

After 10 minutes, a corrections officer walked John out of the cell block and toward the clinic.

John staggered along the walkway. The guard asked him to speak, and he couldn't respond. He then slumped to the ground.

The guard felt for John's pulse and listened for breath. At 3 a.m., the DOC captain zoomed up on a battery-powered cart, passing the medical staff who were heading to the scene. He found Loadholt unresponsive.

“I could really imagine that you can’t breathe, your chest is tightening up and you can’t walk,” Ken said while reading the report on his brother. “All they had to do was give him a breathing treatment.”

For two decades, Ken has worked as a corrections officer in Cumberland County, N.J. He knew Corizon’s failings first-hand.

“I know the size of the neglect,” he said.

He called Rikers in 2006 looking for the real story.

“I was trying to get ahold of the New York DA’s office, anyone who might know,” he said. "I just followed that loop."

Then he went to the morgue to see his brother.

“I went there because I wanted to know exactly what happened,” Ken said. “Let me see his face, his hands, his body.”

The coroner later provided Ken with a death certificate that said his brother died of an asthma attack with complications from methadone he was receiving for his drug addiction. Ken said he thought the methadone treatment was odd, since his brother used crack, not heroin.

He wishes he had tried harder to find the truth years ago.

“I allowed my association with the law enforcement community to get in the way of that,” he said. “It really saddens me because it’s not that hard to give someone adequate medical treatment.”