At the time of his death, following a violent altercation with guards, Karl Taylor was one of thousands of mentally ill inmates who are confined to institutions that are supremely ill-equipped to handle them.





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On the morning of April 13, 2015, a guard at Sullivan Correctional Facility, a New York State maximum-security prison nestled deep in the woods of the western Catskills, ordered a prisoner named Karl Taylor to clean his cell. By all accounts, the cell, in the prison’s E North housing block—a special unit for inmates classified as mentally ill—was a rancid mess, strewn with papers and clothes, and soaked with shampoo and other liquids. Taylor, however, had balked for weeks at cleaning it. He insisted that as part of an ongoing campaign of harassment, guards had trashed his cell and stolen his belongings while he was being held in a mental-health observation unit in a separate wing of the 550-inmate prison. To hear more feature stories, see our full list or get the Audm iPhone app. Taylor had been in prison since 1995, serving a minimum sentence of 27 years for a rape conviction in his hometown of Troy, New York. After his arrival in state custody, he was diagnosed with delusional disorder and paranoid personality disorder. By 2015, he had already made two trips to the state’s prison psychiatric hospital, where he’d received medication to quiet his symptoms. And while he had periods of relative calm, he had spent almost half of his time behind bars—nearly 10 years—in solitary confinement, a debilitating experience that experts say disorients even the sanest of prisoners.

Most witnesses to what followed on that April morning agree that after a guard opened Taylor’s cell door, the stocky, 51-year-old African American inmate walked away, shouting that he wanted to be left alone and sent back to the observation unit, where those in crisis are monitored by doctors and nurses. The witnesses differ entirely on what happened next: Guards say Taylor wheeled around without warning and punched the officer, a muscular, 27-year corrections veteran named Bruce Tucker, in the face. Inmates on the cellblock say Tucker, who is white, struck first, cracking Taylor over the head at least twice with his heavy wooden baton. “You heard two loud bangs,” an inmate named Malik Thomas recalls, “like you would hit a hardball in baseball.” Regardless of who started the violence, it ended badly: Tucker suffered a badly fractured arm after Taylor grabbed his baton and chased him across the cell tier, striking him repeatedly. Another officer had a serious concussion after also being struck and falling while trying to wrestle the baton from the prisoner. Things went much worse for Taylor. As he was being subdued by a throng of officers who had responded to the emergency, inmates heard him rasp that he couldn’t breathe. Handcuffed, he was frog-marched down a series of corridors to the prison’s clinic. Within minutes of his arrival there, he was declared dead. Investigations of the incident by the state correctional department, state police, and the local district attorney, who put the case before a grand jury, found that Taylor’s death, while technically a homicide, was primarily caused by his own poor health. He’d suffered the effects of cardiac arrhythmia—an abnormal heart beat. In layman’s terms, he’d had a heart attack. It had been brought on by hypertension, which Taylor had a history of, following the altercation with the officers, according to the district attorney. In a press release, the DA said the guards had acted in self-defense, using a justified level of force against a violent prisoner. The DA declined to answer further questions from reporters.

The statement noted that Taylor had resided on a cellblock for inmates with “behavioral issues.” But that was the only official nod to the underlying circumstances of his death—that this fatal collision between the keepers and the kept involved one of the many people with a tortured mind who wash up on the shores of America’s prisons, institutions supremely ill-equipped to handle them. Nor did any authority state the obvious: that absent the presence of a deadly weapon—in this case, a long wooden stick—and but for a guard’s stubborn insistence that even a mentally ill inmate must clean his cell, this was an avoidable tragedy. Illustration by Cam Floyd; animation by Andrew Embury “Jails and prisons are among the least therapeutic environments in the world,” says Alisa Roth, who toured facilities across the country for her recent book, Insane: America’s Criminal Treatment of Mental Illness. “You’re not bringing out the best in their behavior; you’re bringing out the worst in their behavior,” Roth told me. At the time of his death, Taylor was one of nearly 10,000 people in New York’s state correctional facilities diagnosed with a mental illness—one out of every five prisoners. Roughly half are, like Taylor, considered “seriously mentally ill,” suffering from schizophrenia or another psychotic disorder. They are men and women who have trouble coping with daily living needs, often unable to follow orders in a setting where a military-style strictness governs every movement.

In New York, the number of inmates with mental-health issues has risen even as the overall number of people held in the state’s prisons has fallen, from a high of 72,000 in 1999 to some 48,000 currently held in the state’s 54 correctional facilities. And New York is not alone. “It is almost everywhere,” Roth says. “Even as the number of prisoners goes down, the number of people incarcerated with mental illness goes up.” Read: America’s largest mental hospital is a jail. In an earlier era, many of those now incarcerated might have been committed to large public mental hospitals, most of which were shuttered decades ago amid reforms and the increased use of psychotropic drugs aimed at allowing patients to remain in their community. “Where did a lot of these people end up? They ended up in prison,” says James Walsh, who, as the superintendent at Sullivan from 1999 to 2007, saw much of his facility become a de facto mental ward. The rising ranks of inmates with a serious mental illness has made the job of those charged with managing the prison population infinitely harder, says Brian Fischer, who served as New York’s correctional commissioner from 2006 to 2013. “We’re not designed for it,” Fischer told me. “We can do crisis management, but that’s not treatment.” Inmates with a mental illness constantly bump up against rules, he said. “A guy who acts out, do we know what to do?” Fischer asked. “If he is hearing voices and along comes a guard and gives him an order, which voice does he listen to first? The one in his head, or the one on the other side of the bars?”

In the months after Karl Taylor died, I tried to learn what had happened on the cellblock in E North. Details were few: Bruce Tucker had a reputation for treating inmates roughly. A prisoner named Vance Jackson showed me a letter he had written to the superintendent days before the fatal incident. Officer Tucker, he wrote, “needs to be stopped before he kills someone.” Taylor’s prison disciplinary record, obtained in response to a state Freedom of Information request, shows that he was a steady challenge to manage. His scores of infractions included the kind of behavior that often results from long periods of isolation. In 2001, while housed at Southport prison, a so-called super-max facility near the Pennsylvania border, Taylor had an additional two and a half years added to his sentence after he was convicted of throwing feces at a staff member. In Manhattan, I located a former E North resident named Raymond Bird. Taylor, he said, was a target for officer harassment. “The slower guys,” Bird said, “those are the ones they’d pick on.” Stammering with emotion, Bird acted out the scene he had witnessed the day of Taylor’s death: “I seen Tucker hit him and I seen him hit him again.” The only clue about Taylor’s family was an online obituary notice, and in October 2015 I drove to the Albany funeral parlor that had posted it. It was in a battered neighborhood just a few blocks from the state capitol. After an attendant there agreed to pass on my phone number to Taylor’s relatives, I got a call later that day from Julia Ramsay-Nobles, Taylor’s sister. When we met at a Dunkin’ Donuts outside Albany a few days later, she was dubious about my intentions. “How many Caucasians really value Afro-American lives?” she asked. Julia Ramsay-Nobles in Albany in September. (Nathaniel Brooks for The Marshall Project) Eventually, she opened up. Her mother, who had died the year before, had been in close contact with Taylor. Ramsay-Nobles had last visited “Butch,” as he was called, two years earlier. He had been okay then, she said. She showed me a letter he had written from prison in 2014. “I think the white people are really very angry and mad because there’s a black president,” he’d written in capital letters. “You should see some of the things these crazy ass people do sometimes.” The day he died, Ramsay-Nobles received a call from the facility telling her that her brother had “expired.” He’d gone “code blue,” she was told. When she asked about picking up his things, officials told her not to bother: There were none. She received a check for $13.67, the amount left in his commissary account. Unable to afford his burial alongside their mother, she had him cremated. “I’ve got the box in the car,” she said.

Ramsay-Nobles said she wanted to learn what had happened, too. “Nobody deserves to die like that,” she said. “I prayed and asked the Lord to give me the truth.” I wrote down the phone number of a prison-reform advocate and gave it to her. More than three and a half years after Taylor’s death and three years since that meeting, a federal civil suit filed on Ramsay-Nobles’s behalf by lawyers from a major Manhattan law firm, Patterson Belknap Webb & Tyler, is nearing trial. The suit names the prison’s two top administrators, 11 correctional officers, and the doctor who oversaw Taylor’s treatment as having contributed to his death. It accuses state mental-health and prison officials of ignoring recommendations—made just weeks before he died—that Taylor be sent back to Central New York Psychiatric Center, a special prison hospital near Utica, to receive court-ordered medication. The lawsuit also cites the conclusions of the leading forensic pathologist Zhongxue Hua, who consults for several metropolitan-area counties, that the medical examiner who conducted the autopsy overstated evidence of Taylor’s hypertension, while downplaying indications that the inmate had been choked to death. In a deposition, the medical examiner was asked to look at autopsy photos and count the tiny red marks dotting the inner lining of Taylor’s eyelids. Known as petechial hemorrhages, the marks are considered by forensic investigators to be a telltale sign of choking. In her autopsy report, the examiner noted “several” such marks. At the deposition, she counted 56.

It’s unclear when mental illness first disordered Taylor’s mind. No record exists of him receiving any treatment prior to his conviction, and glimpses into his life before prison are few. There is a childhood photo, a picture of wide-eyed innocence in a plaid jacket, taken by relatives down South; another snapshot, from a Thanksgiving dinner in 1977, shows him at 14 years old, nattily dressed in a white turtleneck and looking confidently into the camera. “He was very handsome, a smiler,” Ramsay-Nobles said. Their mother doted on Taylor, who was one of seven children. “It was always ‘Butch, Butch, Butch,’” Ramsay-Nobles said. She married and moved away, and saw little of him over the years. She knew he dropped out of high school and worked as a truck driver and a cook. She never learned the name of the woman her brother was convicted of raping, but said her mother had told her that the woman later changed her story. If she did, there’s no record of it. Police reports state that on the night of October 16, 1992, a then-28-year-old Taylor brought a 38-year-old woman he’d met at a bar in Troy to his rooming house to smoke pot. Taylor held the woman, whose identity has been redacted from records, captive for hours, forcing her to have sex multiple times, she told police. “What do you mean?" Taylor said when he was told he faced charges of rape, according to his arrest report. “We had sex, but I did not force her at all.”

Held in jail for the next two and a half years, he underwent competency hearings and psychological evaluations. As in most such cases, he was eventually found competent to stand trial, a much lower standard than whether he was sane. “There was no question he was competent,” said Paul Engster, the defense attorney assigned to Taylor’s case after three prior lawyers withdrew, citing his disruptive behavior. “He knew who he was and where he was, and insisted upon creating a defense that was not defensible.” Against Engster’s advice, Taylor took the stand. “It was a total train wreck,” Engster told me. “He went out of his way to piss off the judge. It was almost like he wanted to go on this journey.” After Taylor’s conviction on charges of rape, sexual abuse, and unlawful imprisonment, Albany County Judge Thomas Breslin sentenced him consecutively on each count. It added up to a minimum of 27 and one-third years and a maximum of 55 years. Such sentences are normally served concurrently, but given Taylor’s behavior in the courtroom, the judge’s decision wasn’t a surprise, Engster said. “I wondered what happened to him,” Engster told me. “I knew whatever it was, it wasn’t going to be good.”

Taylor, in the white turtleneck, in 1977. His sister Julia is to his left. (Courtesy of Julia Ramsay-Nobles) In state prison, Taylor was quickly diagnosed with delusional disorder and paranoid personality disorder. “He does nothing but stare out the window,” staff at Downstate Correctional Facility wrote in a memo. After being sent to Central New York Psychiatric Center, he was prescribed Haldol, an antipsychotic. It calmed him for a while, but he later refused to take it. For the next 20 years, records show, he ping-ponged around the maximum-security prisons in northern and western New York, often landing in mental-health units. In 2009, while serving another lengthy term in solitary at Southport Correctional Facility, Taylor was observed “on all fours and barking like a dog.”

Taylor was sent back to Central New York, this time with a court order for psychiatric medication; he was injected with Risperdal, another antipsychotic. He spent nine months in the hospital, a lengthy stay for a facility with just 220 beds and thousands of mentally ill prisoners to serve. But his time there left him relatively stable for several years. Malik Thomas, who ended up in Sullivan’s E North with Taylor, told me that the two men became friendly in 2012, when both were housed in a unit for the mentally ill at Great Meadow prison, north of Albany. “He was in excellent shape,” Thomas said. “He would go out to the yard or work out in his cell.” He also listened to music. “He loved Donna Summer and Barbra Streisand; he’d sing their songs,” Thomas said. Read: The prison mental-health crisis, viewed from the inside A social worker at Elmira prison noted in March 2014 that Taylor’s “mood vacillated. He would be calm and talkative at times, then angry or frustrated.” He talked at length about “the system and racism,” proclaiming himself an innocent man. That same month, Taylor’s mother died. It was just “a natural part of life,” he told the social worker, according to investigation records. In a letter to his sister about their loss, he wrote: “Today I’m happy and healthy and I cry tears of joy when I think of how good things are for me compared to a lot of other people.” He didn’t need any more medication, he wrote, adding: “I won my dream.”

A few weeks later, Taylor was scalded by hot water in his cell, causing blisters to form on his chest and neck. He accused another inmate of throwing the water at him, but no charges were filed. Afterward, social workers reported, he grew hostile and isolated, refusing to come out of his cell. A “change of venue” was ordered in hopes of improving his behavior and mood. Taylor arrived at Sullivan two days before Thanksgiving in 2014. Placed in cell 148 on the second tier of the residential mental-health unit in E North, he seldom emerged. A social worker described him as agitated and “ranting about discrimination.” But others found him congenial. Raymond Bird struck up a relationship with his new neighbor as he watched sports on a TV located just outside Taylor’s cell. “We would talk,” Bird told me. “Sometimes he would drift off. Something was messed up with him in his head.” Malik Thomas found Taylor to be the same “laid-back, happy guy” when he reencountered him at Sullivan. Taylor’s primary entertainment, the men said, was reading auto magazines he collected. He’d pull out the pages and line the floor of his cell with photos of cars. Jeffrey Hunt, a correctional officer who worked in the unit’s “bubble”—a control booth where gates to the cellblock and individual cells are opened and closed—also liked gabbing with Taylor. “He was crazier than a loon, but I humored him,” Hunt said in a deposition. An Air Force veteran who has worked at Sullivan for 26 years, Hunt said Taylor insisted that he had been a colonel in the Army. “I’d go over there, salute him. ‘Karl, Master Sergeant Hunt reporting for duty, sir.’” The two were Yankees fans and talked about their team. On a few occasions when Taylor got loud, Hunt said he brought him a cup of coffee to calm him down. “Honestly, I never had a problem with Karl,” the officer said. Malik Thomas (Christopher Gregory for The Marshall Project) Under their union contract, officers get to select their posts based on seniority. Even if prison supervisors feel that a particular officer is a bad fit for a job, there is little they can do about it unless the officer is found guilty of serious misbehavior. Bruce Tucker had worked in the special-care unit for more than 20 years. It was an odd choice for an ex-marine known as a strict, by-the-book officer.

“You have to have some skills to navigate these inmates,” Walsh, the former Sullivan superintendent, told me. “Some officers are black-and-white and the rule is the rule, and that was the case with [Tucker]. You have to be able to deal with a little bit of gray with these populations.” Tucker’s name came up in a “fair amount” of reports involving use of force against inmates, Walsh said, but no disciplinary charges were ever leveled. “I think he realized he was being looked at more closely, and I think that upset him. He believed he was a good, dedicated officer who did things the way they were supposed to be done.” Inmates on the cellblock, however, viewed Tucker as volatile and menacing. Tucker, who worked the 7 a.m.–to–3 p.m. shift on E North, “was a mental bully to guys” in the unit, said Gregory Judge, who was housed there at the same time as Taylor. Tucker called inmates “stupid” and “assholes,” Judge said. There were harsher words, too, inmates claimed, both in interviews with me and in depositions. Bird remembered Tucker calling Taylor a “nigger, telling him he’s a piece of shit.” Hunt said in his deposition that inmates had complained to him “several times” about Tucker using racial epithets with them. Unlike other officers on the cellblock, Tucker carried a baton, and prisoners said he was quick to wield it threateningly. Thomas recalled pausing to look out a window on his way back to E North one day. Tucker, he said, “immediately pulled out his club,” asking him, “What the fuck are you doing?”

In his deposition, Tucker said he carried the two-and-a-half-foot wooden baton because “you can protect yourself and save someone’s life with it.” He denied using slurs or abusing anyone. “I treated them all the same,” he said. Taylor was “just a typical inmate.” Related Stories A Mental-Health Crisis in Alabama’s Prisons

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The Deal Prosecutors Offer When They Have No Cards Left to Play When a new superintendent, William Keyser, took command of Sullivan, in June 2014, he was alerted by officials in Albany to keep an eye out for incidents involving Tucker and one other officer. “They just said, ‘Watch, these are people we are concerned about. They’re involved in a lot of use of forces,’” Keyser said in his deposition. Still, he never found cause to discipline Tucker. He had a reputation, Keyser said, for following the rules. Hunt said Tucker’s run-ins with inmates were well known. “Officers would talk about it,” Hunt said. “It was ‘Oh, Tuck got into another one, huh?’” It was “common knowledge,” he said, that Tucker had the most instances of use of force in the facility. Pressed for his opinion of Tucker, Hunt said, “I don’t think he was cut out for corrections, that’s all. “We wouldn’t be here right now,” he added. Two months after Taylor got to E North, Tucker referred him to Sullivan’s Residential Crisis Treatment Program, saying the inmate hadn’t showered in weeks. Operated by the state’s Office of Mental Health, the observation unit holds eight spartan cells. Patients are allowed only slippers and a tear-resistant smock, to protect against suicide attempts; inmates call it the “Barney Rubble suit” because it resembles the Flintstones character’s outfit. Taylor told staff that he was “the victim of one of the officers here, who was harassing him … trying to jump him,” according to their notes. Garrick Jackson, a nurse on the unit, had heard similar complaints before. Tucker’s name, he said in a deposition, “did come up quite a few times” with inmates.

But Taylor otherwise refused to engage when social workers and doctors sought to draw him out. In her notes, Kristie Sneckenberg, a psychologist in the crisis treatment program, described Taylor sitting on his bed, talking to the wall. “If you are black, you’re in more trouble than if you’re white,” she heard him mumble. Other times, he would stand at the gate talking loudly to himself “as if he was teaching a class.” Concerned that Taylor was steadily deteriorating, Sneckenberg recommended that he be sent back to Central New York to receive medication under a court order. Most of the mental-health staff concurred. When nothing happened, Sneckenberg sent an urgent email—later produced as an exhibit for her deposition in the lawsuit—to the unit’s doctors. “What are we doing with this????” she wrote. The transfer decision was up to Seung Ho Lee, a psychiatrist at Sullivan since 2011. Lee didn’t see Taylor until five days after Sneckenberg’s email. During his visit, Lee wrote that Taylor said he felt “good … beautiful,” but that he didn’t feel safe on the cellblock. “They beat me up,” Taylor told him. A week later, on February 25, Lee saw Taylor again. The prisoner repeated that he felt “beautiful,” and claimed to have been showering, although there was no evidence that he had done so. He said he wanted protection against an officer who he claimed had assaulted him. Immediately after the visit, Lee ordered Taylor returned to E North. The patient should have been safe, he said in a deposition, because he was on medical “keep lock” status: Taylor had refused an annual testing for tuberculosis, so he wasn’t allowed out of his cell. Asked whether he had been concerned about Taylor’s claims of harassment, Lee said, “I always believe the officers protect the patient.” Illustration by Cam Floyd; animation by Andrew Embury “The doctor has the final say,” Jackson, the nurse, later told state investigators. “Ninety-nine percent of the time, we would’ve admitted the patient to Central in this case.”

Back in E North, Raymond Bird told me, he’d watched Tucker and other officers turn Taylor’s cell upside down in his absence. “The officers trashed his books, his legal work, his clothes all thrown on the floor,” Bird said. “His stuff was all torn up.” In his deposition, Tucker explained that cell searches are never neat. “I have to go through everything,” he said. Upon his return, Taylor told Bird, “They did it, so they gonna clean it up.” Taylor’s refusal to clean his cell himself aggravated Tucker, inmates said. The officer would start his shift by banging on Taylor’s gate with his baton, demanding that he get up and clean his cell, Bird said. From his own cell, Malik Thomas said he witnessed an angry Tucker pointing his finger and yelling at Taylor. “It went into a heated debate,” he said. On April 7, Taylor filed a grievance, the only formal complaint he appears to have made. “All property missing, gone, stolen … or thrown away,” it reads. He neatly signed his name and his inmate identification number, and attached two pages of scrawled, disjointed notes. “Fraud” he wrote repeatedly, along with a reference to the “Central Park Five,” the Harlem teens whose 1990 rape convictions were later overturned. He told the sergeant assigned to investigate his claim that he feared Officer Tucker. The grievance was dismissed. Two other investigations of Tucker were conducted in early April. In one, an unnamed inmate said he was “in fear of his life” following an incident with the officer. That report, too, was dismissed. But one filed by Tucker himself—in which he claimed that an inmate had struck him in the head as he was conducting a “pat frisk”—raised concerns in the central office in Albany. Three prisoners who had witnessed the incident said Tucker had thrown the inmate to the floor and punched him. None of the witnesses confirmed Tucker’s account of being struck first.

Officials in Albany asked Keyser, the superintendent, to tally all use-of-force reports on cellblocks where Tucker had worked over the previous two years. Of the 23 total incidents, Tucker had taken part in more than half, an even dozen. All inmates involved were classified as disabled, either mentally or physically. Asked at his deposition to account for his many clashes, Tucker responded, “I was probably unlucky.” The morning Taylor died, Tucker banged on his cell and ordered Jeffrey Hunt, working in the bubble, to crack his cell gate open. Hunt was hesitant. “I just had a feeling,” he said in his deposition, “maybe things ain’t going to work out too good.” Malik Thomas heard Tucker yelling at Taylor to start cleaning up or he was “going to have some serious fucking problems.” Taylor walked out of his cell, bellowing that he wanted to speak to a sergeant and go back to the observation unit. Tucker said in his deposition that he calmly ordered Taylor back to his cell to “lock in.” He said he didn’t realize that Taylor was upset until the inmate turned and “hammered” him with a punch that knocked him back several feet. Two other officers on the block at the time, Shane Topel and Steve Witte, both described the inmate’s blow as a “sucker punch” in their depositions. Hunt was inconsistent about what he saw from the control booth. In a statement to investigators, he said he saw Taylor swing first. At his deposition, under oath, he told a different story: “Tucker took the first swing with his baton.”

Inmates said the same thing. Thomas was on the cellblock’s second tier looking down at the two men, who were standing in an area known as “the pit,” a few steps down from Taylor’s cell. As Taylor turned away from Tucker, “the officer drew his club and repeatedly struck Mr. Taylor to the head,” Thomas told me. “You could hear the stick hit his head,” Raymond Bird said in his deposition, “and then he hit him a few more times.” Another inmate, Silburn Spence, said he heard Tucker yelling at Taylor right before the officer “just hit him with the stick.” According to inmates’ individual accounts, all watched in astonishment as Taylor grabbed the baton and began chasing Tucker, flailing at him and the other guards who had rushed to Tucker’s aid. Near a set of steps, the inmate and the officers collapsed in a heap. Officer Witte, stunned by a blow from Taylor, struck his head on a brick wall and was briefly knocked unconscious. Officer Topel pulled the “pin,” an alarm on his radio signaling an officer in distress. Read: Does bad health care constitute cruel and unusual punishment? Amid the brawl, one of the officers had his knee on Taylor’s back and was choking him, Bird said. “He’s telling the officer, ‘I can’t breathe.’” “Everybody could hear” Taylor saying he couldn’t breathe, Gregory Judge said. As guards swarmed the cellblock, inmates saw Taylor disappear beneath a knot of blue uniforms. They described seeing blows—punches and kicks—as Taylor was subdued. When officers stood him up, his hands were cuffed behind him. Bird said Taylor looked like “a rag doll” as he stumbled out of E North. On the way to the prison’s clinic, Taylor refused to walk any farther and asked for a cart, according to the depositions of sergeants who had accompanied the escort. Instead, guards carried him, spread-eagle and face down, the rest of the way.

In the clinic, a nurse named Laura Greener heard the emergency code broadcast. “The voice sounded panicked,” she said. Although she estimated that the clinic was about a five-minute walk from E North, she said Taylor didn’t arrive until 20 minutes later. Handheld video cameras are usually employed when inmates are escorted away after violent incidents, but none was fetched that morning. Superintendent Keyser said there wasn’t time. “This is a fluid incident,” he said in his deposition. “You don’t run and get a camera.” Bruce Tucker during a deposition for the lawsuit filed by Julia Ramsay-Nobles. (Stills from a deposition of Bruce Tucker) Officers on the escort said no force was used on the inmate once he was shackled. None reported seeing more than a few drops of blood. Hunt wasn’t on the escort. But in his deposition he acknowledged that when “an officer gets assaulted, well, you know, it’s payback time to the inmate that did it.” Such beatings are known as “tune-ups,” Hunt said. The retaliation, the officer said, is often explained away as “They tripped and fell,” or “They kissed one of the gates.” A prisoner named Kurtis Lamar Williams told investigators that he witnessed such a tune-up when he watched Taylor and the officers escorting him through a window in a hallway door. “They was kicking him, punching, brutally beating him in the head,” Williams said. Stacy Liggan, one of two inmates assigned to clean up the blood spill in the corridors later that morning, said in an affidavit that he mopped up “a lot of blood in the hallway … thick drops from clinic to E block.” When they got to E North, they saw only specks of blood on the floor, he wrote. Officers had already cleaned the rest up, inmates there told them.

After Taylor arrived at the clinic, Greener, the nurse, was the first to examine him. She couldn’t get a pulse, and Taylor wasn’t breathing. For half an hour, three nurses and a doctor tried to revive him using CPR and a defibrillator. He was pronounced dead at 9:25 a.m. Greener relayed the news to the prison chiefs, who were gathered nearby. There was “kind of a shock laid over” the rest of the day, she said in her deposition. Late that afternoon, an autopsy was conducted by a veteran medical examiner named Margaret Prial, who’d been engaged by the local coroner. Sullivan County District Attorney James Farrell and two investigators looked on as she worked. In her deposition nearly three years later, Prial couldn’t recall who had told her about Taylor’s history of hypertension. But she acknowledged that her examination had showed that he lacked some symptoms normally associated with the disease, including an enlarged heart and a thickened ventricle wall. The bleeding and bruising of muscles along Taylor’s neck, as well as fractures of the cornuae—small bones protruding from the Adam’s apple—were consistent with sustained pressure from an arm or a baton, she said. And the petechial hemorrhages she noted on Taylor’s eyelids had likely resulted from force applied to the jugular vein. There were also no contusions on his knuckles of the sort that would result from punching someone hard with a fist. Yet he’d suffered at least eight blunt impacts to his head and numerous others to his body, injuries that could not have resulted from a fall. Asked whether those blows and the wounds to his neck could have triggered cardiac arrhythmia, Prial said they could have. She had listed hypertension as the first cause of death, she said, because “you generally put the natural disease first.”

Zhongxue Hua, the independent forensic pathologist retained by the attorneys who brought the civil suit, drew his own conclusions. If Taylor had hypertension, it “was neither significant nor fatal,” he said. “The primary cause of death,” he wrote in his findings on the case, “was physical injuries sustained during an altercation(s) with correctional officers.” Such intense outside scrutiny is rare in prison-abuse cases. High walls, remote locations, and a reluctance to talk borne of fear and secrecy make what happens inside correctional facilities difficult to pierce. Such scrutiny is rarer still for the likes of Karl Taylor, a man convicted of an awful crime and ravaged by mental illness, whose demise was mourned by few. What befell Taylor needn’t ever have happened, says Jack Beck, who has spent decades monitoring prison mental-health units for the Correctional Association of New York, a 174-year-old nonprofit with legislative authorization to inspect the state’s prisons. Taylor was “a kind of throwaway prisoner,” Beck told me, someone whose psychoses rendered him resistant to treatment, and who was at the mercy of officers relying on threats rather than on communication. “Had there been adequate mental-health intervention, he would not have been back on the cellblock,” Beck said. Culpability aside, the tragedy had repercussions for officers, too. Due to their own injuries, Bruce Tucker and Steve Witte both retired. Tucker said the day left him with mental-health issues as well. “I suffer from post-traumatic stress disorder and it is very difficult,” he said in his deposition. “I don’t want to discuss the incident with anybody.” He did not respond to requests for further comment. A private attorney representing the officers in the civil case has filed a counterclaim against Julia Ramsay-Nobles, citing the damage the officers suffered in the fight with her brother. In a recent letter to the court, the attorney, Kirk Orseck, wrote that Taylor’s injuries were incurred while “officers were defending themselves and each other from his deadly baton assault.” His clients had no “specific recollection of any contact with Taylor’s neck,” he wrote, but “concede that such a strike or grab could have inadvertently occurred” during the struggle. Only “a few mentally ill inmates” say otherwise, he stated, referring to the eight inmate-witnesses who have given depositions in the case. Illustration by Cam Floyd; animation by Andrew Embury Defense attorneys from the state attorney general’s office who are representing the prison administrators have maintained that there was no wrongdoing on the administrators’ part, as has a lawyer for Lee, the psychiatrist who allowed Taylor to return to E North.

Representatives of the state’s correctional department and mental-health office declined to discuss the case with me, citing the ongoing litigation. But they pointed to policy changes since Taylor’s death three years ago. Officers now receive additional training in “de-escalation” techniques. They’ve been given pepper spray as an alternative to physical force. Both steps, officials said, have reduced the number of injuries throughout the state’s correctional facilities. Additional staff and beds have also been added to mental-health units, with more to come next year for prisoners deemed seriously mentally ill. Ramsay-Nobles said she’s glad the lawsuit has provided some answers about her brother’s death, as troubling as those answers are. “It’s made me wonder, what about the others like him in prison?” she told me recently. “The ones we don’t hear about?” This summer, officials cleared up at least one mystery tied to the case: They discovered a bag of Taylor’s property that Ramsay-Nobles had been told didn’t exist after his death. There wasn’t much to see. It contained two bars of soap and his magazines, many covered with scrawled notes in the margins. A few months ago, she was finally able to bury her brother’s ashes beside their mother’s grave. Her next plan, she said, is to get him a headstone. This investigation was published in partnership with The Marshall Project, a nonprofit newsroom covering the U.S. criminal-justice system.