After spending nearly a quarter-century behind bars, John McMillon was counting down to the day that he would be eligible to be released on parole.

“I’m going home,” a fellow inmate recalled him saying.

Mr. McMillon suffered from mental illness and had had disciplinary problems over the years. He was punished for assaulting a guard and for fighting with another inmate, but had then vowed to stay out of trouble, and was looking forward to his parole board hearing.

He never made it there.

One day in January, Mr. McMillon, 67, was involved in a struggle with guards at the Great Meadow Correctional Facility in upstate New York. According to the official account, he once again attacked a guard and resisted efforts to control him. He died of a heart attack, the official autopsy said.

As far as state investigators were concerned, the case was closed.

But several inmates who witnessed the struggle told a much different story.

Four inmates, all of whom were interviewed separately and in person by The New York Times, said they witnessed Mr. McMillon being harshly beaten by guards.

An additional five inmates provided similar accounts to prisoners’ rights groups.

“They killed that man,” one of the inmates, Pernell Griffin, told The Times. “There was a lot of blood. He was screaming in pain.”

It is unusual for inmates to speak out so forcefully about allegations of brutality behind bars. Many fear retaliation by guards.

The inmates differed with respect to some details, but they all offered the same basic narrative: Mr. McMillon was returning from dinner and asked to go back to his cell. He then began behaving erratically, though not violently, the inmates said.

The inmates said that in response, a female guard approached and punched him in the face. Several other guards also responded and beat him, the inmates said. One inmate said he saw Mr. McMillon being choked.

State investigators independently interviewed the same inmates, who made similar assertions that Mr. McMillon was beaten, according to an inquiry by the Washington County district attorney, J. Anthony Jordan.

But guards told state investigators that they merely tried to restrain Mr. McMillon, and the inquiry said the guards’ body camera footage supports their statements. State prison officials have not released the footage.

Several of the inmates who spoke to The Times and prisoners’ rights groups said guards retaliated against them because they spoke to state investigators.

The starkly conflicting accounts of the struggle deepened the questions surrounding Mr. McMillon’s death.

Government watchdog agencies and nonprofit groups have long expressed concern about what they say is a culture of brutality at Great Meadow, a troubled maximum-security prison with 1,415 inmates in Comstock, more than 200 miles north of New York City.

Gov. Andrew M. Cuomo toured Great Meadow last year in response to the turmoil there. On the day of his visit, the prison was on lockdown following fights among inmates — the third violent incident at the prison that week.

A correction officer there had also been suspended for beating an inmate. The governor said the problems at the prison demonstrated the need for statewide prison reform.

Great Meadow ranked third highest of all the prisons in New York for rates of assaults on inmates and assaults on staff in 2016, according to the most recent data collected by the Correctional Association of New York, a nonprofit group that has the authority under state law to monitor prisons.

The association found that of the state’s maximum-security facilities, the prison had the highest incidence of guards using force against inmates.

Last year, several inmates filed lawsuits against the prison charging brutality by guards.

Mr. McMillon’s family has sharply criticized the official determination of his death. His sister, Carolyn Hodge, said that when she first called the local coroner’s office for information about the cause of death, she was told Mr. McMillon had been strangled.

A photo that family members took of his body when it was brought to a funeral home shows visible marks around his neck and face.

“I don’t think I will be able to forgive them for what they did to my brother,” Ms. Hodge said.

Thomas Mailey, a spokesman for the state department of correction, said in a statement that investigators’ conclusions were based on an extensive review of body camera footage and interviews with guards and prisoners.

“Any story claiming that John McMillon was beaten by correction officers before his death would fly in the face of the Washington County medical examiner’s findings, as well as the preliminary results of the investigation by the department’s Office of Special Investigations,” Mr. Mailey said. “Such a baseless assertion would be a blatant abdication of the truth.”

“I’m here, I’m alive.”

Mr. McMillon had been in the state prison system since he was convicted in 1995 of two armed robberies of stores in Buffalo, during which he shot and wounded a store manager.

His defense lawyer at the time said Mr. McMillon had “a longstanding mental illness” and an “inability to piece together facts.”

He was one of nine children, the son of a bar owner in Buffalo, said Ms. Hodge, 62. Her brother began stealing cars and doing burglaries as an adolescent, she said.

“As long as he was taking his medication, he was fine,” she said.

In 1993, he married a woman he had met at a gift shop in a local bus depot. But before they could have a honeymoon, Mr. McMillon was in trouble with the law again, facing charges of attempted murder, robbery and related offenses.

“He apologized so many times in that visiting room,” recalled his wife, Victoria McMillon. “He knew he messed up.”

In prison, each day when the alarm went off in the morning, Mr. McMillon would shout: “I woke up another day. I’m here, I’m alive,” one inmate recounted.

Outside his cell, he was known for giving younger prisoners facing lengthy sentences tips on how to survive.

Mr. Griffin, one of the inmates who said he witnessed the conflict between Mr. McMillon and the guards, said Mr. McMillon used to recommend books for him to read, including “The Making and Breaking of a Ghetto Mind,” by Lloyd H. Williams.

In recent years, Mr. McMillon worked in the kitchen and the laundry room, but he continued to be plagued by mental illness.

His medical history included anxiety, schizophrenia, epilepsy and substance abuse, according to a report on his death by the Washington County district attorney’s office.

According to his disciplinary history, he twice assaulted prison staff at other facilities — once in 2012, and again in 2017. After the latter incident, at the Washington Correctional Facility, Mr. McMillon was placed in isolation for six and a half months.

He had also been involved in five fights with other inmates during stays at other prisons including an incident last year at the Clinton Correctional Facility, officials said.

In all, there are 39 incidents on his record, including some minor — all enough to make getting paroled an uphill battle.

The parole board had repeatedly denied Mr. McMillon’s request for early release, citing his disciplinary history, his sister said and records showed.

Starkly different accounts of the struggle

In the weeks after Mr. McMillon’s death, word of what inmates described as a violent attack on him had spread beyond the prison’s towering brick walls.

The four inmates who spoke with The Times were housed in two different prisons, but all were at Great Meadow at the time of the struggle.

One of the inmates said he was hesitant at first to speak to a reporter during a visit because a guard had peppered him with questions and warned him “to be careful.”

On the evening of Jan. 22, Mr. McMillon returned from dinner in a cafeteria, went to retrieve medication and later returned to a gallery area in section B8 of the prison, the inmates said.

He asked a guard if he could go back into his own cell. He became upset when he was told he could not, an inmate said.

One inmate in a statement to investigators described his outburst as an “episode.”

It was then that Mr. McMillon either bumped into or touched a female guard, who wheeled and punched him, witnesses said. He went down under her blows. He reached up to block the blows, and one inmate heard her shout, “He touched my breast.”

The inmates said they saw at least five guards piled on top of Mr. McMillon. One guard wrapped his hands around Mr. McMillon’s neck and choked him, his knees pressed into the prisoner’s back, one inmate said.

The floor, a nearby phone area and a guard station were spattered with his blood, the inmates recalled.

Ricardo Rosado, another inmate, said that from his cell window, he saw what he described as an assault by guards that continued in the infirmary.

“They were stomping him out,” Mr. Rosado said. “They continued stomping him until he stopped moving. They were all over him.”

Inmates told state investigators in written statements obtained by The New York Times that guards had punched, kicked and stomped Mr. McMillon until he stopped moving.

But the district attorney, in its report, concluded that other evidence undermined the inmates’ accounts.

“In reviewing the body camera footage, there is no indication of any use of batons, no choking of Mr. McMillon or any other evidence of excessive use of force,” the report said.

The report includes a first-person account of a guard who said the struggle started when Mr. McMillon was “screaming incoherently” but would not follow an order to return to his cell.

“Inmate McMillon was walking toward myself flailing his arms and making bobbling noises at which time I gave inmate McMillon several direct orders to back up and stop approaching officers,” the guard, Paige Londrigan said. “Inmate McMillon lunged at me, attempting to grab me and as a result physical force became necessary.”

Ms. Londrigan and another guard, Eric Rich did not respond to requests for comment.

The New York Times filed a Freedom of Information Request for body camera and other video footage in order to evaluate the state’s assertion that Mr. McMillon was not beaten.

After initially denying the request, the department later agreed to provide very limited and redacted footage, but did not indicate when.

The struggle occurred at 5:25 p.m. Prison staff administered CPR, but emergency medical responders did not arrive until 6:40 p.m., records show. The ambulance arrived at Glens Falls Hospital 34 minutes later. Mr. McMillon was dead.

Jennifer Scaife, executive director of the Correctional Association, said she believed that the accounts of the inmates who described a deadly beating of Mr. McMillon were highly credible. Inmates have everything to lose if they speak out, so they most likely would not fabricate what they say they witnessed happen to Mr. McMillon, Ms. Scaife said.

“People should not die at the hands of people who are there to protect them,” she said.

State investigators who questioned inmates about the death focused on whether Mr. McMillon had used drugs and who in the prison sold drugs, the inmates said.

“There was nothing about the police brutality,” one inmate said.

The autopsy did not show any drugs in Mr. McMillon’s system.

The medical examiner, Dr. Michael Sikirica, said in an autopsy report that “without the decedent’s significant underlying cardiovascular disease the death would not have occurred.”

There were fractures and moderate bleeding on Mr. McMillon’s ribs, but the medical examiner wrote that was consistent with attempts to resuscitate him. The autopsy report also noted that the only significant injury was “a small area of hemorrhage along the soft tissue of the neck.”

Through his lawyer, Dr. Sikirica declined to discuss the marks around Mr. McMillon’s neck, which were visible in a photo his family provided to The Times.

“Dr. Sikirica cannot legally comment on the specifics of this autopsy,” his lawyer, John W. Bailey, said. “He is sure that he performed his duties thoroughly and professionally.”

Claims of retaliation

Some inmates said they were punished after speaking to investigators and to their defense lawyers about Mr. McMillon’s death.

Mr. Griffin, who spoke with investigators about what he saw, said he was beaten by high-ranking guards and then placed in solitary confinement.

Another inmate who spoke with investigators said in a letter to Prisoners’ Legal Services of New York that he was also placed in isolation on what he claimed were fake charges of misbehavior.

Others were moved to different parts of the prison, two inmates said, a common tactic used to make it difficult for investigators and prisoner rights groups to locate witnesses.

One inmate who had requested a transfer months ago was suddenly moved to another prison after speaking with investigators associated with the Correctional Association.

Another inmate said prison officials confronted him and said they had heard him talking about the attack over the phone.

Mr. Mailey, the state corrections’ spokesman, declined to comment about the inmate’s allegations that they had been punished for speaking out.

Officials from the Correctional Association toured Great Meadow after receiving a letter from an inmate about Mr. McMillon’s death.

But the prison’s superintendent and correction captains joined the group’s investigators as they attempted to speak with inmates.

Fearful, some inmates declined to talk.

Doris Burke contributed research.

Jan Ransom is a reporter covering criminal courts and jails in New York City. Before joining The Times in 2017, she covered law enforcement and crime for The Boston Globe. She is a native New Yorker. @Jan_Ransom

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