Felix Jorge was caught on tape screaming while guards physically removed him from his prison cell in the throes of a full psychotic breakdown. Less than 72 hours later, he committed suicide.
This is the story of how he got here.
In 1992, at age 22, Jorge was arrested for holding up a woman with a toy gun. He was sent to prison for three to six years.
Despite a history of psychiatric hospitalizations dating back to his childhood, it took seven months before prison officials realized the full extent of Jorge's mental illness.
According to prison documents obtained by ABCNEWS, after a psychotic episode in which he "barricaded himself in his cell" and "said his mother was calling him," Jorge was diagnosed with paranoid schizophrenia and sent to the Central New York Psychiatric Center.
After treatment, the doctors sent Jorge back to Auburn State Prison with a warning to officials there that he "could have the potential for imminent danger to himself."
"At Auburn, the first day he's back, he's made to stand trial for having had a psychotic episode before he left," recalls Jorge's attorney, Ed Miller, "and he's punished for it."
Jorge was found guilty of "creating a disturbance" and "refusing a direct order," and he was then sent to solitary confinement or the "hole."
Treatment Discarded, Lucidity Detoriated
In the hole, Jorge soon began refusing his medications as paranoid schizophrenics often do.
And despite the fact that the doctors had recommended "continual daily counseling…to encourage him to accept" the drugs, Jorge never got such counseling.
"Without that, he was lost," explains Miller. "He was a dead man."
After three months without medication, Jorge tried to kill himself by swallowing 150 Tylenol pills. After he got back from the hospital, he was again punished: He was found guilty of "self-inflicted bodily harm." He was sent back to the hole.
One month after that, he was transferred to the Clinton Correctional Facility. But his medical file evidently got lost in the shuffle.
And when the prison psychologist at Clinton evaluated Jorge, she decided he didn't require any services. Without medication, he once again deteriorated.
Videotape Documents Forcible Removal
Prison guards made a videotape of their actions because they are required to document every forcible removal of an inmate. In the video, one can see the guards removing Jorge from his cell, while they beat his hands in order to get him to let go of the bars.
Jorge had barricaded himself inside. He had started a fire, cut himself, soiled himself and was screaming at imaginary voices. Guards were ordered to extract him to take him in for psychological treatment. As they subdued him, Jorge cried for help.
On the tape, one can hear Jorge say, "My name is Felix Jorge. Number 93A-3824. They're going to kill me."
(Incidentally, the guards were actually following procedure and were not charged with excessive force. New York state officials refused comment, but they have agreed to settle a lawsuit brought by Jorge's family for $250,000.)
After this incident, Jorge was then seen by a doctor and put under observation.
"They put him in what's ironically called the Observation Unit," says Miller, "where in the end, he was left unobserved for 50 minutes, though he was on a suicide watch."
In those 50 minutes, Jorge was supposed to be checked every 15 minutes. He was not. When the guard finally did check on him, Jorge was dead. He had stuffed wet toilet paper up his nose and down his throat.
"New York State could not be clearer in sending us the message: they don't value these lives, these lives are not valued," claims Miller.
Officer Herbert Perry, who was supposed to be watching Jorge the night he died, was initially fined and suspended. But within weeks, he was reinstated. And at the end of the year, he received an excellent performance evaluation.