A New York State watchdog agency overseeing jails and prisons has found that gross incompetence by medical personnel and correction officers at Rikers Island led to the death of a mentally ill inmate who was found naked and covered in feces after being locked in a cell for six days.

In a report, the agency, the New York State Commission of Correction, called for the Justice Department to investigate possible civil rights violations, saying the details of the inmate’s death “shock the conscience.” It is not clear, though, whether anyone received significant punishment.

The inmate, Bradley Ballard, died on Sept. 11, 2013, after he was deprived of insulin for diabetes and locked in his cell without food or running water for nearly a week. Though correction officers, doctors and inmates were visibly repulsed by the stench coming from his cell, none of them entered or sought help.

The commission’s report, which is dated Dec. 16, and was obtained by The New York Times, though not released publicly, describes how a warden, an assistant deputy warden, guards, doctors, mental health clinicians, nurses and others made at least 57 visits to Mr. Ballard’s cell as he slowly deteriorated over a six-day period but did nothing to assist him.