ALBANY, N.Y. (AP) — The final two months of Cachin Anderson’s life in New York’s prison system were filled with warnings he was a man in crisis.

He climbed on a sink and dove headfirst at the floor, saying he “wanted to end it and go home.” He urinated on guards. He hurled a can at one corrections officer and punched another in the face, knocking him out.

That behavior landed him in solitary confinement, a setting experts say is often unsuitable for people who are mentally ill or trying to hurt themselves. And there, Anderson killed himself on June 28, 2017, a death a state oversight board later said could have been prevented.

Prisoner advocates say Anderson’s death and others illustrate how New York’s prison system fails to ensure the safety of inmates who might hurt themselves if left alone in a cell.

New York state prison inmates in solitary confinement or long-term “keeplock” units, in which inmates are isolated, were over five times more likely to kill themselves than prisoners in general confinement, according to a report from the Department of Corrections and Community Supervision.

The report said that of the 130 inmate suicides from 2004 to 2013 in New York prisons, 30 were by prisoners in solitary or isolated housing, or a special treatment program.

New York has tried to curtail the use of solitary confinement. Earlier this year, Gov. Andrew Cuomo and legislative leaders announced a plan to restrict the isolation practice further by capping solitary confinement time to 30 days.

The state prison system has set out procedures designed to prevent suicides, too.

Correction officers watching over solitary confinement are required to make rounds every 30 minutes on an irregular basis.

Prisoners are also supposed to undergo a suicide prevention screening and a mental health assessment when they enter solitary confinement. During the screening process, prisoners found to be at an imminent suicide risk are put in the Residential Crisis Treatment Program, a separate unit inside the prison where correction officers make their rounds every 15 minutes, and each inmate is monitored under video, according to the Office of Mental Health.

Inmates in the program also have a private daily session with a mental health clinician. The program is used to find out which inmates need to be moved to the Central New York Psychiatric Center in Marcy, New York, for inpatient care.

But the rules aren’t always followed.

In its review of Anderson’s death, the Commission of Correction concluded that the 33-year-old, who was serving a 10-year sentence for involvement in an assault on a parking attendant, should have been put under a “one to one constant watch” until he could be seen by mental health staff.

“Had appropriate safety measures been taken, given Anderson’s recent suicidal threats and behavioral changes, his suicide may have been preventable,” the commission wrote in its report, obtained by The Associated Press through the Correctional Association of New York.

Anderson’s uncle, Larry Evans, a retired corrections officer in Connecticut, said his nephew should have been under closer supervision.

“If they knew that something was going on with him, he’s supposed to (be) in the unit where he’s supposed to be watched — period,” Evans said.

Prison suicides received national attention after Jeffrey Epstein, the millionaire accused of sex trafficking, killed himself at a federal jail in New York City.

Two jail guards responsible for monitoring Epstein the night he died have been indicted on charges that they falsified jail records to show they were checking on prisoners every 30 minutes, when they were actually sleeping and browsing the internet.

Those lapses occurred even though Epstein had only recently returned to his cell after a stint under psychological evaluation in a jail medical wing after a previous, apparent suicide attempt.

Higher suicide rates for prisoners in solitary confinement is a pattern seen across the country, according to prison experts.

Suicide screenings, access to mental health units and restrictions on who can be put in isolation have placed New York ahead of some other states in addressing solitary confinement suicides, said Martin Horn, a lecturer at John Jay College of Criminal Justice who previously led Pennsylvania’s prison system and New York City’s jails.

“New York has a very robust effort to identify people with mental illness and deal with their misbehavior,” he said.

But he noted New York has not gone so far as Colorado, which prevents inmates from being held in solitary confinement for more than 15 days.

In New York, some of the prison system’s procedures for handling mentally ill inmates were set out in the state’s Special Housing Unit Exclusion law.

The law outlines various timelines for when inmates in solitary confinement should be checked on by mental health clinicians. For example, at prisons geared toward dealing with major mental health disorders, inmates are supposed to be seen by a clinician within one business day after being put in solitary confinement.

The Justice Center, a state watchdog agency, has repeatedly found that prisons it inspects aren’t abiding by the rules.

Eight of the 25 prisons it visited last year failed to meet existing solitary confinement regulations because mental health and suicide assessments, along with follow-up visits, were not completed in certain time frames.

The year before, the agency found that nine of the 24 facilities it visited were not in compliance.

One report from the Justice Center found that psychiatric staff were supposed to follow up with a prisoner at the Elmira Correctional Facility within two weeks but actually did not meet with the inmate until four months later.

In another report, the center said an inmate was not provided monthly sessions with a therapist.

In a third report, the oversight agency uncovered seven instances at one prison where a suicide prevention screening was not completed when people were put in isolation.

The state prison agency, the Department of Corrections and Community Supervision, did not make someone available to answer questions for this article.

The agency, in a statement, argued that the Justice Center found “minor instances” in which procedures were not followed, saying the situations are often clerical mistakes and changes were made to remedy the issue.

The department said it takes the physical and mental health of prisoners seriously and is preparing to implement the 30-day cap on solitary confinement announced this year.

The correctional officers’ union has opposed restrictions on solitary confinement.

Michael Powers, president of the New York State Correctional Officers Police Benevolent Association, said in a statement that housing units separate “dangerous” people from the general population “and only when they commit serious infractions.”

“Those residing in special housing units are afforded most, if not all, of the same comforts as those in general population,” he said in a statement.

Anderson’s death followed others in solitary.

In 2009, Amare Seltun killed himself while in solitary confinement at Attica Correctional Facility. Like Anderson, he had previously tried to kill himself.

Less than a year later, Amir Hall, who had borderline personality disorder and PTSD, was sentenced to seven months in solitary confinement after a series of confrontations with officers and other inmates. Less than two weeks later, he killed himself.

Anderson’s family has filed a wrongful death lawsuit against the state.

His mother, Joyce Hemingway, said she wants justice for her son’s two children.

“He wanted to be a father to his children,” she said of Anderson’s plans after prison.

Another development caused them even further pain.

When his body was returned to the family, Evans said, it came with a paper bag containing the noose they believe he used to kill himself.

___

Ryan Tarinelli is a corps member for Report for America, a nonprofit organization that supports local news coverage in a partnership with The Associated Press for New York. The AP is solely responsible for all content.