A state commission has found another inmate death at Nassau's jail may have been prevented, issuing a report criticizing jail officials and the private health care contractor that lately has come under fire.

It follows a series of jail custody fatalities and what the oversight agency has called a pattern of neglectful inmate medical care.

The Commission of Correction's findings in the Feb. 10, 2014, death of Kevin Brown mark at least the fourth time the state found Armor Correctional Health Services' care inadequate after probing a Nassau inmate's death.

StoryFar Rockaway man, 47, dies in Nassau jail

The findings say the death of Brown, 47, of Far Rockaway, may have been prevented if he received "proper medical care and supervision." The report noted his body was in full rigor mortis when found in his cell -- a sign he'd been dead more than four hours and not properly checked on.

The commission's findings, obtained Thursday through a prior Freedom of Information request, say Brown died of heart failure. It says Armor's deficient care resulted in a mismanaged mental health diagnosis, a failure to diagnose or manage heart disease and inadequate psychiatric care and management of Brown's seizure disorder.

The report also says Armor was negligent because Brown wasn't seen by a doctor or taken to a hospital after two seizure episodes days after his arrest. And despite evidence of hallucinations during Brown's jail admission and increasingly agitated behavior, he never received a full mental health assessment, the commission found.

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Miami-based Armor took over Nassau inmate treatment in mid-2011 when the county privatized the jail's medical contract to cut costs -- a savings County Executive Edward Mangano put at $7 million a year.

"They really need to get rid of them," Kevin Brown's mother, Marcella Brown, 78, said Thursday from her Far Rockaway home. "They cost four people's lives . . . It's not right and I feel my son is worth more than what they are saving."

Kevin Brown, 47, of Far Rockaway, died in the Nassau County jail, authorities say. Photo Credit: Brown family

The mother said she's considering legal action after hearing about the report's findings of medical negligence and lack of supervision by jail officials -- something she said a separate witness account supported. A Legal Aid attorney previously wrote her a letter saying another inmate had heard Kevin Brown "banging on the wall of his cell" from 11 p.m. to 1 a.m. -- hours before he was found dead -- and asking for water that he never received.

The Brown report's release follows news of the state attorney general investigating Armor, which Newsday reported last week.

It also comes after the commission's recent finding that the July 2014 death of inmate John Gleeson, 40, of Oceanside, may have been prevented if not for "incompetent and deficient" care. In both the Gleeson and Brown reports, the commission broadly criticized Armor's treatment of state inmates.

Both the Brown report and the Gleeson report -- made public in October -- ordered Nassau's legislature to conduct an inquiry into Armor's fitness to provide inmate medical services. That sparked inmate advocates and the Nassau Legislature's minority leader to call on Mangano to suspend Armor's multimillion contract -- just renewed for two years in June.

County Attorney Carnell Foskey said in a statement Thursday that Mangano's administration "takes these allegations seriously," and Mangano had ordered a review of the Brown report and Armor's contract. However, Foskey said his office "opined that the county cannot cancel the contract without subjecting taxpayers to significant liability as the allegations have not been substantiated to date."

Marcella Brown holds a photo of her son Kevin Brown, who died at the Nassau County jail. She spoke about him at her Far Rockaway home on Thursday, Nov. 5, 2015. Photo Credit: Howard Schnapp

He said the county last month began drafting a request for proposals for jail medical services. The timing of the completion of that process was unclear.

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Armor said in a statement Thursday it couldn't comment on specific patients due to a privacy law, but had statistics showing the extreme volume of patients "our providers serve with skill and dedication." A spokeswoman said the company appreciated feedback of the Sheriff's Department "as to the vast improvements they have noted" under Armor.

Authorities said at the time of Brown's death that he'd been arrested Jan. 13, 2014, and held on a petty larceny conviction. A Nassau courts spokesman said recently a record of that case is not in court files, and Brown actually was being held on a Queens warrant when he died. A Queens district attorney's spokeswoman said that case is sealed.

The Brown report says correction officials found his body shortly after a 6:15 a.m. inmate count. It recommended disciplinary proceedings against an officer who allegedly didn't check on Brown, but noted officers said Plexiglas plates were scratched and hard to see through in the area.

Brown's mother said he battled seizures stemming from a 1998 car accident, and a doctor had prescribed the drug Dilantin for him. She said her son grew up in Far Rockaway, was a car service dispatcher for decades, and loved to party and cook Italian food.

"He's supposed to be here with us. Somewhere along the line, somebody has to answer for it," Saleem Brown, the late inmate's older brother, said Thursday. "Why not have justice?"