NEW YORK STATE COMMISSION OF CORRECTION

In the Matter of the Death
of Bruce Morgan, an inmate of
the Ontario County Jail
------------~~-~~-----------------

TO:

Sheriff Philip C. I?overo
Ontario County Sheriff's Office
74 Ontario Street
Canandaigua, NY 14424

FINAL REPORT OF THE
NEW YORK STATE COMMISSION
OF CORRECTION

FINAL REPORT OF BRUCE MORGAN

PAGE 2

GREETINGS:
WHEREAS i the Medical Review Board has reported to the NYS Commission
of Correction pursuant to Correction La.w, section 47 (1) (d), regarding the
death of Bruce Morgan who died on December 25, 2009 while an inmate in
the custody of the Ontario County Sheriff at the Ontario County Jail, the
Commission has determined that the following final report be issued.

FINDINGS:
1.

Bruce Morgan was a 43 year old white male who died on 12/25/09 at
2:28 a.m. from suicidal hanging at the Ontario County Correctional
Facility (CF) while in the custOdy of the Ontario County Sheriff.
Despite nearly 'constant complaints of mental disorder symptoms while
incarcerated, he received no mental health diagnosis, evaluation or
treatment due to negligent supervision of non-clinical mental health
care providers and a failure to observe, i.e., ·constraints of
licensure.

2.

3.

4.

Morgan had been admitted to the Ontario County CF on

FINAL REPORT OF BRUCE MORGAN

5.

PAGE 3

On 9/16/09 at 9:25 a.m.: Officer C. completed Morgan's initial
booking process and suicide screening upon admission to the Ontario
County CF.
Morgan scored one point on the suicide screen, giving
an affirmative answer to "Detainee has a history of drug or alcohol
. abuse. ff
In the comment section, "alcohol" was lis"ted.

6.

NP D.H. stated she had a movement and activity log
completed by the security staff observing inmates who state they are
on. pain medication on admission.
The purpose of this ,log is to
determine whether the inmate's pain is interfering with his/her
activities of daily living. Morgan's movement and activity log kept
by his housing officer from 9/29/09 to 10/5/09 indicated he did not
have any fun",tional limitations. The movement and aptivity log also
reported Morgan did not attend daily exercise.

7.

There does not
appear to be a timely review of these forms by mental health. There
is no mental health screening completed for Morgan's incarceration
commencing on 9/16/09.
This is a violation of the Ont~rio County

FINAL REPORT OF BRUCE MORGAN

PAGE 4

CF staff operations procedures entitled Suicide Prevention (IV.E)
dated 2/3/09 which states:
The provisions of all related Bureau Directives
including, but not limited to "Inmate Supervision
Mental Health/Developmental Disability Screening"
and "Admission and Discharge' of inmate" shall be
complied with at all times:
8.

9.

10.

FINAL REPORT OF BRUCE MORGAN

11.

12.

PAGE 5

FINAL REPORT OF. BRUCE MORGAN

PAGE 6

LMSW, stated he spends
5 to 10 hours a week at the Ontar~o
Correctional Facility
interviewing and evaluating inmates.
K.D.,. LCSW, spends about 20
hours at the correctional facility reviewing the mental health
screens anq. evaluations and 11lental heal th referralS. These services
are provided for an avera.ge daily population of approximately 210
inmates at Ontario County CF.
K.D., LCSW,wi;LI also evaluate
inmates as needed. Both mental hea.lth clinicians stated they review
the irunates.' suicide prevention screens f however ,the suicide
screenS are not included in the Ontario Courtty CF.mental health
records. J.M., LMSW, reported about one hour a week in supervision
with K.D., LCSW, but K.D. is available on an as-needed basis to
discuss an mental health concerns that arise with the inmates.

The social worker indicated that i t may take
two weeks to address a mental health referral or request.
13.

14.

FINAL REPORT OF BRUCE MORGAN

PAGE 7

15.

On 12/24/09, Morgan made a number of phone calls to the telephone
number listed for his wife.
According to the Ontario County
telephone log, the first call was made at 2:18 p.m. at which time
he conversed with someone at his home number for fifteen minutes.
\Morgan made three other telephone .calls at 4:55 p.m., 4;56 p.m. and
6:27 p.m. to the same home number. Morgan connected with the same
telephone number at 6:29 p.m. and spoke for fifteen minutes. Morgan
made eight attempts to connect at 8:26 p.m., 8:27 p.m., 8:41 p.m.,
8:42 p.m., 8:43 p.m. ,8:50 p.m. (twice without success) and 8:54
p.m.
The visitor's log indicated that Morgan's wife visited him
regularly in jail with the last visit listed on 12/20/09.
Documentation by the Ontario County Sheriff's Department stated that
when Morgan's wife was. notified of his death, she stated she spoke
to Morgan twice on 12/24/09 and he gave no indications of s1.lici.dal
thoughts. Morgan's wife stated that Morgan had phoned her a third
time but she did not answer the phone as she had spoken to him twice
earlier.

16.

On 12/24/09 at 9:08 p.m., Officer M.B. contacted the Pod #4 housing
officer and asked if Morgan was available .for a work detail.
Officer M.B. stated he usually requested Morgan as he was a good
worker.
The OffiCer went to Pod #4 and retrieved Morgan from his
cell. Officer M.B. and Morgan went to Pods #7 and #8 and emptied
the laundry bins there.
Officer M.B. stated he had engaged in
conversation with Morgan for the entire time of the work detail.
Officer M.B. stated Morgan had said his wife had gotten into an
accident with their minivan and she waS charged with AUO 3 rd • The
officer stated that Morgan was not particularly upset about the
accident. Officer M.B. stated Morgan did not appear anymore angry
or distressed than any other husband would be if they found out
their wife had an accident with the car, but was somewhat annoyed
with the incident.
On the way back to Morgan's housing pod, he
asked Officer M.B. if they could stop in the supply room to piCk up
a book. Officer M. B. agreed and Morgan picked up two books. Morgan
told the officer that he was reading a novel a night. Morgan also
suggested that he and another inmate be assigned to the supply room
to organize the books there. Officer M.B. stated he told Morgan he
thought it was a great idea. Officer M.B. returned Morgan at 9:40
p.m.
Officer M.B. stated he had used Morgan for work detail at
least six times in the last two months and he never appeared
depressed to the officer.

17.

On 12/24/09 at 11:00 p.m., Officer A.M. reported to duty as the Pod
#4 housing officer.
Officer D. W. briefed Officer A:M. on the
previous shift. Officer A.M. stated Officer D.W. did not speak of
Morgan during the briefing. At the beginning of the night shift,
Officer A.M. stated that Morgan had asked him if there was any work
for him that night). At 12:27 a.m., Officer M.S. made a supervisory
round and stated Morgan looked like he was asleep. At 12:56 a.m.,
when Officer A.M. was making his supervisory round, he observed

FINAL REPORT OF BRUCE MORGAN

Morgan sitting up reading a book.
up at him and nodded to him.
18.

PAGE 8

Officer A.M. stated Morgan looked

On 12/25/09 at 1:27 a.m. when Officer A.M. was making his
supervisory round, he observed Morgan sitting on the floor with his
back facing the cell door. The officer stated Morgan did not look
right.
Officer A.M. stated he rattled the door and called out
Morgan's name but there was no response.
Officer A.M. opened
Morgan's cell door, and called a Code Blue, pod 4.
Code blue is
specific for ~Officer needs rover and medical assistance." Officer
A.M. stated once he was able to open the cell door he was able to
observe a piece of sheet around Morgan's neck. The sheet was tied
to the handicap bar ~on his sink.
It was tied up like a figure
eight. Officer A."'l. reported he wrapped his arms around Morgan and
lifted him in an attempt to take the pressure off Morgan's neck.
Officer V.H. arrived moments later and placed her fingers in between
the sheet and his throat.
Officers S.C., F.V. and O. arrived at
Morgan's cell.
Officer F.V. used his keys to cut the sheet from
,Morgan's neck.

19.

Officer M.D. was in Pod #5 when he heard Officer A.M. calIon his
radio "Code Blue, pod 4." Officer M. D. responded to the code after
Officer M. S. came to cover pod #5. He went to the Sergeant's offige
to obtain the cut down tool (a curved shaped knife).
,In the
meantime, Sgt. T.D. stated he obtained the cut down tool from the
sergeant's office. Officer M.D. stated he looked for an AED and a
first-aid kit, and not seeing them, he ran ,over to the Illedical unit.
Officer M.D. stated both himself and Sgt. T.D. were at the medical
unit looking for the AED.
Both Officer M.D. and Sgt. T.D. stated
they could not find the AED in the medical unit. The Ontario County
Correctional Facility Medical Operations policy entitled First Aid
Kits and Emergency Bag (A.3) states:
Locations: Automatic emergency defibrillator (AED): one
in the "'ledical Officer EIllergency Supply room and one in
the AdIllinistrative Area.
Officer D.P. documented she went to the lobby area to retrieve the
AED there.
Officer M.D. stated he arrived at Pod 4 with Officers
D.P., J.S. and Sgt. T.D.

20.

CPR for Morgan was initiated by Officers A.M. and F.V. Officer A.M.
was having difficulty with the mask seal and another face mask was
obtained from the Pod 3 first aid kit which had a better seal.
Officers V.H.and F.V. attached the AED to Morgan's chest. Officers
A.M., M.D., andF.V. rotated in performing CPR until the Canandaigua
Emergency Squad arrived.
All resuscitation efforts before the
ambulance arrived were completed by security staff as the Ontario
County CF does not having nursing staff during the night shift.

FINAL

21.

REPOR~

OF BRUCE MORGAN

PAGE 9

A review of the computerized security log revealed that the only
notation that refers to this event is on 12/25/09 at 1:42 a.m. and
is documented by.Officer S.C. as "EMT responded." It was reported
that log entries can be made at the pod station checkpoint as well
as computer at the housing officer's desk in the pod.
This is a
violation of the NYS Commission of Correction's MinimUl1l Standards,
section 7003.3(j) (6) (m), Supervision of prisoners in facility
housing areas which ·states:

(j)

All written records pertaining to·facility housing
supervision required pursuant to this section shall
be recorded in ink in a
bound ledger of
consecutively numbered pages which shall be
maintained in each housing area.
such records
shall include, but not be limited to, the following
information:

arty significant events and activities occurring
during supervision, including:
(i)
the date and time of each such event or problem;
(ii) the names of all prisoners and/or staff involved;
(iii)
facility response to such event or problem,
including
a summary of what occurred; and
(iv) a description of the condition of any prisoners
involved.
( 6)

(m)

Notwi ths tanding the provisions of this section
requiring a bound ledger, records pertaining to
facility housing supervision may be recorded on a
computerized log.

22.

RECOMMENDATIONS:
TO THE SHERIFF OF ONTARIO COUNTY:
1.

The Sheriff shall direct the Ontario County Correctional Facility
security staff to fully comply with . the Commission's Minimum
Standard, section 7003.3 entitled Supervision of prisoners in
facility housing areas.

FINAL REPORT OF BRUCE MORGAN
2..

PAGE 10

The Sheriff shall direct the Ontario County Correctional Facility
nursing staff to comply with the Ontario county Correctional
Facility Staff Operations entitled Suicide Prevention (IV, E) dated
2/3/09 which states:
The provisions .of all related Bureau Directives
including, but not limited to "Inmate Supervision Mental
Health/Development Disability Screening" and "Admission
and Discharge of inmate" shall be complied with at all
times.

3.

The Sheriff shall direct the Ontario County Correctional Facility
administrative staff to iss\le a memo regarding the location of
facility AEDs in the medical area.

4.

The Sheriff shall direct the Ontario County Correctional Facility
administrative staff to assist the Ontario County Mental Health
Department.to include the inmates' suicide screens in their mental
health Ontario County records.
TO THE DIRECTOR OF THE ONTARIO COUNTY MENTAL HEALTH DEPARTMENT:

1.

The Director shall conduct a quality assurance review regarding the
mental health evaluation of patients performed by J.M., Licensed
Master Social Worker.
Such" review should include audit of a
representative sample of patient records for quality and propriety
including observation of the constraints of licensure.

2.

The Director shall conduct a quality assurance review regarding the
practice of K.b., Licensed Clinical Social Worker, in the areas of
the quality, frequency and attentiveness of supervision of LMSW's.
Additionally r there should be an examination into the clinical
approach to inmates who make repeated self~referrals and requests
for services while reporting mental health symptoms.

3.

The Director shall conduct a quality assurance review regarding the
response time for mental health Clinicians to see inmates who submit
mental health referrals ..

4.

The Director shall develop a written policy regarding referral of
inmate/patients who make repeated self-referrals for mental health
services citing persistent signs and symptoms of mental health
disorder as a basis for referral by social workers to higher levels
of care, either a psychologist or psychiatrist.

5.

The Director shall develop a patient education tool wi th associated
in-service
colloquia
regarding
the prescription of
common
psychoactive
l

medications,

their

usage,

actions,

benefits,

and

disadvantages as a basis for patient education during the social
workers' evaluations and encounters with inmates at the Ontario
County Correctional Facility.

FINAL REPORT OF BRUCE MORGAN

PAGE 11

6.

The Director shall develop a policy and procedure regarding informed
Refusal of Treatment forms to be implemented at the Ontario County
Correctional Facility when an inmate refuses further mental health
treatment 'and/or psychotropic medication after patient education.

7.

The Director shall provide the documented results of the above
requested quality assurance reViews, the patient education tool and
colloquia and thE! policy and procedure ,regarding the use of the
Refusal of Treatment Form to the Commissioner of the NYS CommissiOn
of CorrectiOn's Medical Review Board by May 25, 2011.

WITNESS, HONORABLE PHYLLIS HARRISON-ROSS, M.D., Commissioner, NYS
Commission of Correction, 80 Wolr Road, 4 th ,Floor, in the City of Albany,
New York 12205 this 24 th day of December, 2()10.

,--~-~~--_I

_-'-i'l-

Harrison~Ross,

ComIilissioner

PHR:mj
09~M-18l

8/10
cc:

,William Swingly, Director of Community
Services, Ontario County Mental Health Dept.

M.D.

NEW YORK STATE COMMISSION OF CORRECTION

In the Matter of the Death
of Gary Pfleuger, an inmate of
the Clinton CF

TO:

FINAL REPORT OF THE
NEW YORK STATE COMMISSION
OF CORRECTION

Honorable Brian Fischer
Commissioner
NYS Department of Correctional
Services
State Campus, Building #2
Albany, New York 12226

\

FINAL REPORT OF GARY PFLEUGER

PAGE 2

GREETINGS:
WHEREAS, the Medical Review Board has reported to the NYS Commission
of Correction pursuant to Correction Law,
section 47(1) (d),
regarding the death of Gary Pfleuger, who died on September 22, 2009
while an inmate in the custody of the NYS Department of Correctional
Services at the Clinton correctional Facility, the Commission has
determined that the following final report be issued.
FINDINGS:
1.

Gary Pfleuger was a 38 year old male who died on 9/22/09 from a
suicidal hanging that occurred On 9/18/09 while in the custody of
the NYS Department of Correctional Services (DOCS) at the Clinton
CF.
Pfleuger was a mental health- patient on the active case load
at the time of his death.
His mental health was characterized by
inattentive case management with multiple changes in treatment
regime at a distance without clinical encounters.

2.

Gary Pfleuger was born in Buffalo, NY. He was married and had three
sons. Due to his arrest and conviction, he was separated from his
wife of 19 years and going through a divorce. Pfleuger was employed
as a correction officer for DOCS at the time of his. arrest.

3.

Pfleuger had no prior criminal record. In the instant offense,
Attempted Criminal Sexual Act l't
to 17 to 20 years in DOCS.

4.

5.

6.

Pfleuger was sentenced on 4/6/09 and received at Wende CF on' 419/09.
Pfleuger was transferred to Elmira CF on 4/17/09.
Due to his
employment as a correction officer, Pfleuger was considered in need
of long term protective custody and was placed in the Assessment and
Program Preparation Unit (APPU) at Clinton CF on 7/2/09. Pfleuger
had no incident reports or disciplinary infractions during his
incarcE?:ration.

FINAL REPORT OF GARY PFLEUGER

PAGE 3

7.

8.

9.

10.

11.

12.

Pfleuger was transferred to Clinton CF to be housed in

13 .

14.

----~-------_
• . . . . . . . . . . . . . . . . . . . . ._._-_ •...

FINAL REPORT OF GARYPFLEUGER

15~

16.

17.

18.

19.

20.

21.

PAGE 4

FINAL REPORT OF GARY PFLEUGER

22.

23.

24.

25.

26.

27.

PAGE 5

FINAL REPORT OF GARY PFLEUGER

PAGE 6

.28.

Commission staff noted during the investigation
that Dr. S.G. Was the only psychiatrist assigned Clinton CF, (2900
total beds) at the time of Pfleuger's death. The clinical staffing
deployment to the facility is grossly inadequate and argues strongly
for adjunct services such as telepsychiatry.
29.

On 9/17/09 at approximately 10:17 a.m., inmate block porter D.H.
found Pfleuger hanging in his cell LH-4-27. Pfleuger had tied off
to the front cell bars with a sheet and was in a kneeling position.
Inmate D.H. reached through the bars and attempted to hold Pfleuger
up·while calling for·help. Inmate T.K. heard D.H. yelling for help
and assisted holding Pfleuger up until help arrived.

30.

Officers T.V. and C.H. heard the yelling from ·4 gallery and
responded to the area.
Officer D. opened the cell block and the
officers entered the cell.
Officer C.H. lifted Pfleuger up while
Officer T.V. removed the sheet from around Pfleuger's neck.
The
officers then laid Pfleuger on the floor outside the cell.

31.

Sgt. T.W. responded to the area and called fora medical response.
Officers C.H. and T.V. placed Pfleuger on a stretcher and escorted
him out to the hallway between galleries three and four.

32.

33.

FINAL REPORT OF GARY PFLEUGER

PAGE 7

RECOMMENDATIONS:
TO THE NYS OFFICE OF MENTAL HEALTH, DIVISION OF FORENSIC SERVICES:
1.

The Division
assurance/im
Pfl'euger.

Services should
s chiatric

2.

3.

conduct a quality
rovided to Gar

Services should conduct
the clinical care

The Division should address the inadequate availability of
psychiatry at Clinton CF with consideration of adjunct services such
as telepsychiatry.

WITNESS, HONORABLE PHYLLIS HARRISON-ROSS, M.D., Commissioner, NYS
Commission of Correction, 80 Wolf Road, A th Floor, in the City of Albany,
New York 12205 this 24 th day of December, 2010.

PH-R.:mj
09-M~131

8/10
cc:

Superintendent Thomas LaValley, Clinton cF
Dr. Carl Koenigsmann, Chief Medical Officer
Elizabeth Ritter, Assistant Commissioner
Richard Miraglia Division of Forensic Services
NYS Office of Mental Health
Don Sawyer, Executive Director, Central
New York Psychiatric Center
Jayne VanBrarner, Director, Bureau of
Quality Managem~nt, OMH
l

I

NEW YORK STATE COMMISSION OF CORRECTION

In the Matter of the Death
of. Jesse Ramirez, an inmate of
the Anna M. Kross Center

TO:

Commissioner Dora Schriro
NYC Departmetit of Correction
75-20 Astoria Blvd, Ste. 100
East Elmhurst, NY 11370

FINAL REPORT OF THE
NEW YORK STATE COMMISSION
OF CORRECTION

FINAL REPORT OF JESSE RAMIREZ

PAGE 2

GREETINGS:

WHEREAS! the Medical Review Board has reported to the NYS Commission of
Correction pursuant to Correction Law, section 47(1) (d) 1 regarding the
death. of Jesse Ramirez who died on August 5,2009 while an inmate in the
custody of the NYC Department of Correction at the Anna M, Kross Center,
the. Commission has de'termined that the following final report be issued.

FINDINGS:

1.

Jesse Ramirez was a 34 year old male inmate who died on a/S/09 from a
suicidal hanging while in the custody of the NYC Department of Correction
(NYCDOC) at the Anna M. Kross Center. Ramirez was under the mental health
care of Prison Health Services, Inc. (PHS, Inc.), a business corporation
holding itself out as a medical care Jprovider.
Ramirez received
inadequate mental health care, without continuity of care characterized
~ t i n gdiagnoses, none of which
_ w e r e supported by clinical evidence.
Additionally,
Ramirez did not receive a~ adequate suicide risk assessment from a mental
health clinician after being referred by correction staff on the date of
his death.

2.

Jesse Ramirez was born and raised in the Brooklyn, NY area. He completed
the 10~ grade but obtained his GED during a prior incarceration. Ramirez
was engaged to be married and had one child.

a. recent family loss when his·father died on l/lB/09.

3.

4.

5.

Jesse Ramirez was admitted into NYCDOCcustody at AMKC on 2/8/09. He was
ini tially housed on 2/10/99 in DOrin 4 Main for new admissions.
On
2/17/09, he was reass~gned to ,Quad 6 Upper, general population. His last
move was to Quad 15 Upper cell #3 on 4/29/09.
Ramirez had an uneventful
incarceration with no unusual incidents. or disciplinary infractions.

FINAL REPORT OF JESSE RAMIREZ
6.

7.

8.

9.

10.

11.

PAGE 3

FINAL REPORT OF JESSE RAMIREZ

PAGE 4

12.

i~appropriate

approach to the

13.

14.

15.

16.

noted elsewhere herein, this represents a reckless and cavalier
approach to this patient.

FINAL REPORT OF JESSE RAMIREZ

PAGE 5

17.

18.

19.

20.

On'8/5/09, Correction Officer G.C. was assigned the A post on Quad Upper
13/15 for .the 11:00 p.m. to 7:00 a.m. tour.
At approximately 5:00 a.m.,
Officer G.C. observed Ramirez pacing back and forth in the tier. Officer
G.C. called Ramirez overah~asked him what was going on. Ramirez stated
that he was upset due to family problems, was not sleeping weIll and was
being seen by mental health for depression. Ramirez.began crying and said
that his girlfriend didn't want to be with him anymore.

Officer G.C.

talked with Ramirez and assured him that she would get him sent down to
the mental health clinic as'soon as she coUld.
21.

Officer'G.C. filed a Referral of Inmates to Mental Health Services form on
Ramirez noting "unable to sleep," "being depressed" and documenting
~inmate is crying profusely and is continuously stating he needs to speak
to a psych."
Officer G.C. was relieved by Officer L.R. at 7:00 a.m.
Officer G.C. debriefed Officer L.R. and informed her of the need to have
Ramirez sent to the mental health clinic. Officer L.R. made notification
to area Captain A.-who took responsibility for processing -the--referral-.

FINAL
22.

~PORT

OF'JESSE RAMIREZ

PAGE 6

Ramirez was' observed by Officer L. R. to follow his usual housing unit
routine for the rest of the morning. After the count, Ramirez went to the
dayroom to use the phone. At approximately 9:30 a.m., he went out to the
recreation yard.

23.

24.

25.

health evaluation and
26.

represents flagrantly
by PHS, Inc. staff.

Offider K.P. was assigned supervision of the Bpost on 8/5/09 for ~he 3:00
p.m. to 11:00 p.m. tour.
OfficerL.R. remained the A post officer for
overtime. OfficerK.P. conducted the count at approximately 3:20 p.m. and
had all inmates accounted for. Officer K.P. then conducted a supervisory
tour at 3:45 p.m. with all appearing--secure.

27.

Officer K.P. proceeded to hand out soap supplies to the inmates and began
on the 15 side of the unit.
At approximately 4:10 p.-m., he approached
Ramirez' cell (#3) and observed that a sheet was covering the bars on the
cell door. Officer K.P. pulled the sheet away and observed Ramirez on the
floor with a ligature around his neck and affixed to the cell door.
Officer K.P. called to OfficerL.R. and ordered cell #3 opened.

28.

Officer K.P. had difficulty opening the cell door as the sheet was jammed
in the door mechanism.
Officer K.P. ordered Officer L.R. to release a
nearby inmate to assis~ him.
Officer K.P. and an in~atefinally 'forced
the door open and were able to enter the cell. Ramirez was found seated
on the cell floor with his back against the cell door.
Officer K. P.
utiliz~d his cut down 'tool to remove the ligature from Ramirez'
neck.
Ramirez was checked fora pulse and breathing, found none, and started
CPR.

29.

FINAL REPORT OF JESSE RAMIREZ

PAGE 7

RECOMMENDATIONS;
TO
THE
DEPUTY
COMMISSIONER,
DIVISION
OF
HEAITH
CARE
IMPROVEMENT, NYC DEPARTMEN'r OF HEAITH AND MENTAI HYGIENE;

1.

ACCESS

AND

The Division shall require PHS, Inc. to conduct a comprehensive quality
improvement review of the psychiatric care provided to' Ramirez by PHS,

Inc.

while

in

the

custody

of

the

NYC

Department

of

Correction.

Specifically, the review shall focus on:
a.

b.

c.

2.

The Division shall require PHS, Inc. to cohduct a comprehensive quality
improvement review of the mental health care provided to Rami~ez by the
mental healt~clinidians while in the custody of the NYC Department of
Correction;
Specifically, the review shall focus on:
a.

Verification of continuity for patients who are

recommended for

group therapy as part of their treatment plan have been afforded the
opportunity to attend such programs;

b.

3.

The Division shall require PHS_, Ilic. to conduct trainilig for all clinical
staff on suicide risk assessment, as C\pproved by the State Commission of-,
Correction.

4.

The Deputy Commissioner, in consultation with the Health .Commissioner,
shOUld-ask the NYC Corporation Counsel's Office to inquire into the status
of PHS, Inc. to lawfully hold itself out as a medical care provider in New
York State.

FINAL REPORT OF JESSE RAMIREZ

PAGE 8

WITNESS,
HONORABLE
PHYLLIS
HARRISON-ROSS,
M.D.,
Commissioner,
NYS
Commission of Correction, 80 Wolf·Road, 4 th Floor, in the City of Albany, New
York 12205 this 24 th day of December, 2010.

PH-R:mj

09-M-114
8/10
ce:

Eric Berliner, Executive Director
of Health Services
Lewis Finkelman, General Counsel
Archana Jayaram, Chief of Staff
Louise Cohen! Deputy 'Commiss1oner
Correctional Health Service~, NYC
Department of Health & Mental Hygiene
Robert Berding, Deputy Executive Director
Policy and Planning, NYC Department
of Health & Mental Hygiene
George Axelrod, Deputy Executive Director,
NYC Department of Health & Mental Hygiene

NEW YORK STATE COMMISSION OF CORRECTION

--~--------~------~----------~---

In the Matter of the Death
of Clifford Renshaw, an inmate
of the Chautauqua County Jail

TO:

FINAL REPORT OF THE
NEW YORK STATE COMMISSION
OF CORRECTIoN

Sheriff Joseph Gerace
Chautauqua County Sheriff's Office
15 E. Chautauqua Street
Mayville, NY 14757

FINAL REPORT OF CLIFFORD RENSHAW

PAGE 2

GREETINGS:
WHEREAS, the Medical Review Board has reported to the NYS Commission
of Correction pursuant to Correction Law, section 47(1) (d), regarding the
death of Clifford Renshaw who died on July 2, 2009 while an inmate in the
custody of the Chautauqua County Sheriff at the Chautauqua County Jail,
the Commission has determined that the following final report be issued.

FINDINGS:
1.

Clifford Renshaw was a thirty year old white male who died on 7/2/09
at the Erie County Medical,Center from a suicidal hanging at the
Chautauqua County Jail while in the custody of the Chautauqua County
Sheriff.
His mental health evaluation, care and treatment was
characterized by gross incompetence and professional misconduct as
part of an overall systemic failure of care at the Chautauqua County
Jail. The Board found that had Mr. Renshaw received adequate care,
his death may have been prevented.
Medical and mental health
services at the Chautauqua County Jail are deficient and violative
of State regulations to an extent that makes the Chautauqua County
Jail unsafe for some or all of its inmates.

2.

3.

In the instant offense, Renshaw was arrested on one count of
Criminal Contempt 2 nd , a misdemeanor, and one count of Trespass, a
violation.
His bail was set at $5,000/$1.0,000 cash/bond.
This
charge involved a complaint filed by an ex-girlfriend.

4.

Renshaw was separated from his wi~e and was the father of three
children.
He completed special education classes up to Bili grade.
He was collecting social security disability and was working as a
handyman for his landlord.

5.

6.

Renshaw had· been'·
for a

by various

community

FINAL REPORT OF CLIFFORD RENSHAW

PAGE 3

7.

8.

In the month prior to Renshaw"s incarceration, he had established
a relationship with a former girlfriend.
Renshaw stated ,that the
girlfriend had a child a few years ago that may have been his or his
brother's.

9.

On 6/9/09, Renshaw was arrested by the Jamestown PD for HarasSment
2 nd •
~he charges were filed by his girlfriend who alleged that he
had assaulted her.
She had obtained an Order of Protection.

10.

11.

FINAL REPORT OF CLIFFORD RENSHAW

12.

Clifford Renshaw was arrested by the Jamestown Police Department on
6/21/09 on one count of CriminalContelllpt 2 nd and one count of
Trespass following a violation of the Order of Protection. He was
arraigned by Judge P. in the Jamestown City Court and remanded to
the Chautauqua County Jail in lieu of $5,000 cash/$10,000 bond.

13.

Renshaw was booked into the facility by Officer L.B. who completed
Renshaw's Suicide Prevention Screening Guidelines. Renshaw scored
_a "5" givit:lg affirmative answers to:
4.

5.

6.

7.

#4 Detainee is very worried about major problems other than
legal situation: stating he was worried about his family's
well being.
#5· Detainee's family member or significant or other has
attempted or committed suicide: stating his brother committed
suicide 15 years ago.
#7 Detainee has history of counseling or mental health
evaluation/treatment:
Renshaw was
currently
an
active
participant in the ACT Program.
#10 a,b, Detainee has previous suicide attempt/attempt within
the last month: stating he took a drug overdose three weeks
ago.

Question #10 is a shaded area on the screening form designed as an
automatic notification to the supervisor and for the imposition of
constant supervision.
The supervisor was notified and Rensha¥ was referred to medical and
mental health. Renshaw was not placed on constant supervision and
was not evaluated by a mental health clinician until 6/23/09.
This practice is not in accordance with either the written suicide
prevention screening guidelines or the associated training.
Moreover, since it was clear that Renshaw needed additional
supervision, the failure by jail managers and staff to order and
implement it is a violation of 9 NYCRR section 7003.3(h) ,
Supervision of Prisoners ~n Detention Areas.

FINAL REPORT OF CLIFFORD RENSHAW
14.

PAGE 5

Th~

Chautauqua County Jail's medical policy and proc~dur~ stat~s
imm~diat~ly following recognition that an inmat~ is at risk for
suicid~, placem~nt in a housing ar~a' that affords th~ closest
that

moni taring., i. e., constant surveillance, is appropriate until the
inmat~ can be
psychiatrist.

furth~r ass~ssed

by a

m~ntal

h~alth prof~ssional

or

15.

This laps~ by jail managem~nt and staff also shows th~ Chautauqua
County Jail's op~rations policy and proc~dur~ to b~ inad~quat~, in
that it fails to r~quir~that thos~ inmat~s scoring high and/or
having a scor~d shad~d ar~a on th~ scr~~ning guid~lin~ shall b~
aU,tomatically assign~d constant sup~rvision until th~ inmat~ can b~
~xamin~d by an appropriat~ly lic~ns~d m~ntal health professional.

16.

Th~Chautauqua County

Sheriff, Chautauqua County Director of Health
and the ChautauqUa County Dir~ctor of Mental Health failed to
d~v~lop and/or
implem~n.t adequat~ polici~s and procedures
for
inmates ent~ring th~ facility who are consider~d to be at high risk
for s~lf harm. No coher~n.t syst~m ~xists at th~ ChautauqUa County
Jail wh~r~by all departm~nts ar~ trained according to th~ suicid~
pr~vention and crisis int~rv~nt10n and to comply with all suicide
prev~ntionand risk ass~ssment polici~s and procedur~s.
Th~

lack of adequate polici~s and proc~dur~s for inmat~s ~nt~ring
the facility who ar~ consid~r~d to b~ at high risk for s~lf harm is
a violation of 9 NYCRR §70l3 CLassification, §7013.3 ,FaciLity
Policies and Proc~dur~s which states in p~rtin~nt part: The chief
administrative offic~r of each correctionaL faciLity shaLL deveLop
and impLement written poLicies and procedur~s which provide for the
assessm~nt and
cLassification of inmates and co.mpLy with the
requirements of this Part.
Such poLici~s and procedure shaLL
incLud~, but are not Limited to
(2)

(3)

c0Il!PL~tion of initiaL screening and risk assessment incLuding,
but not Limited to, the determination of security and
superVision reqUirements and inmate speciaL needs;
use of fo:rrnaL risk assessment instructions and other
appropriate admcissionsfoxms in the classification process;

Section 7013.7 InitiaL Screening and Risk
in part:
" (b)

Assessm~nt,

which

stat~s

Each inmate upon admission to a faciLity shaLL undergo an
initiaL screening and risk assessment which shaLL consist of
a screening in te;rview, visual assessment, and review of
commi tment docUIllents.
Such screening and risk assessment
shaLL occur immediateLy upon an inmate's admissiQn.
A
screening insti:UIllent (s) ShaLL be utiLized to eLicit and record
info:rrnation on ~ach inmate reLating to, the foLLowing:

FINAL REPORT OF CLIFFORD RENSHAW

PAGE 6

(4)
(6)

history of mental illness or treatment
prior attempts at self-Oinjury or suicide;

(b)

immediate decision concerning the disposition of each
inmate shall be made on the basis of inforIllation
gathered during initial screening and risk assessment.
Such disposition may include, but is not limited to,
referrals
to 'outside medical
and mental health
providers.
An

17.

18.

Renshaw was admitted to B block on active supervision to await
primary classification.
Officer L. B. noted on Renshaw's initial
Classification that Renshaw was cooperative, claiming that he was
not suicidal or a past behavioral problem in the facility.
She did
mark under "Special Conditions" that Renshaw was "m,entally slow.

(f

19.

20.

The Chautauqua County Jail does not maintain an integrated
medical/mental health record. There is no documentation that this
information was forwarded to the mental health providers.

21.

The clinical enCounter that should have resulteod in a thorough
medical history and physical exam pursuant to state regulations was
inadequate.

FINAL REPORT OF CLIFFORD RENSHAW

PAGE 7

This represents an inadequate and poorly documented history and
physical.
There are no recorded vital signs or any recorded
physical assessment.
The review of systems was inadequate.
The
signature on the note is not legible.
When interviewed regarding this exam, the FA incorrectly stated that
the nurses generally" have completed an extensive history and
physical when he conducts his clinical encounter.
The nurses had
not completed the history and physical. According to the FA, his
sole objective was to prescribe mental health medications until
Renshaw was seen by the psychiatrist.
The gross inadequacy of this examination is a violation of 9 NYCRR
section 7010.2(b) (1), Hea~th Services.
22.

The PA was not able to recall whether a Suicide Prevention Screening
Guideline was available in Renshaw's medical record.
It was
subsequently learned that the Suicide Prevention Screening
Guidelines are not placed in the medical record at all, only in the
mental health record.
The jail administration stated that this
information is readily available to the medical staff on the jail's
computer management system. Use of the jail management system is
not contemplated in either the jail's written suicide prevention
screening guidelines or the associated training.
This is also a violation of§7013.2(j) Hea~th Services which states
in part, Adequate hea~th service and medica~ records sha~~ be
maintained which sha~~ inc~ude but sha~~ not necessari~y be ~imited
to such data as: dat;e, name (s) of inmate (s) concerned; diagnosis of
comp~aint medication and/or treatment prescribed.
A record sha~~
a~so be maintained of medication prescribed by the physician and
dispensed to a prisoner by a staff person.
The Chautauqua county ,jail was previously cited for violation of
this standard in health care evaluations conduc,ted by the Commission
in 2007 and 2009.

23.

The Chautauqua County Jail's mental health services are provided by
the Chautauqua County Mental Health Services., The service providers
include K. N ., a Baccalaureate level social worker employed full time
at" the jail, and Dr. C.T., psychiatrist, who is allotte,d 3-4 hours
weekly at the jail during which time she sees approximately 15
patients. Approximately one-third of the Chautauqua County inmates
are prescribed psychotropic medication.

FINAL REPORT OF CLIFFORD RENSHAW

PAGE 8

24.

25.

26.

27.

28.

29.

On 6/25/09, Inmate B.S. reported to Officer B.S. that Renshaw was
"talking about hanging up."
An incident report states that at
approximately 1:07 p,m. on 6/25/09, Officer B.S. was making a
supervisory round and overheard Renshaw say that he waS going to end
i t all by hanging up.
Renshaw was escorted to booking and placed
on constant supervision.

FINAL REPORT OF CLIFFORD RENSHAW

PAGE 9

30.

reference

31.

to

No physician had seen Renshaw in
his continuance from suicide prevention precautions.

The facility failed to establish a supervisory log for Renshaw's
constant supervision.
This is a violation of 9 NYCRR §7003.3(j),
Security and Supervision which states in part:
(j)

ALL written records pertaining to faciLity housing supervision
required pursuant to this section shaLl. be recorded in ink in
a bound Ledger of consecutiveLy numbered pages which shaLl. be
maintained in each housing area. Such records shaLl. incLude,
but not be Limited to, the foLLowing information:
(1)
(2)
(3)
(4)

(5)

(i)

the name of the faciLity hous,ing area in which the
supervision is being maintained;
the
name(s)
of
faciLity
staff
conducting
the
supervision;
when active supervision is conducted, the date and time
supervision is initiated and the date and time it ends;
when· general. supervision is conducted, the date and time
each supervisory visit is performed pursuant to the
requirements. of subdivision (b) of section 7003.2 of
this Part and the signature of faciLity staff conducting
the supervisory visi t;
when the chief administrative officer and/or the
faciLity physician determine
a
prisoner requires
additional. supervision pursuant to subdivision (h) of
this section:
the reaspns underLying such determination;

FINAL REPORT OF CLIFFORD RENSHAW

PAGE 10

made requiring such additiona~ supervision,
the dates and times when the supervision is to
be initiated and end;
(iii) the
name (s)
of
the
individua~ (s)
making
such
determinat~on and/or ordering the supervision;
(iv) the dates and times when supervision was initiated and
ended;
(v)
the
name (s)
of
faci~ity
staff
conducting
the
supervision; and
(vi) periodic faci~it:y staff observations of. the prisoner's
condition or behavior;
(6)
any significant ~vents and activities occurring during
supervision, inc~uding:
(i)
the date and time ·of such event or prob~em;
(ii) the names of a~~ prisoners and/or staff invo~ved;
(iii) faci~i ty staff response . to such event or prob~em,
inc~uding a summary of what occurred; and
(iv) a description of the condition of any prisoners
(ii)

orders

inc~uding

invo~ved.

32.

FINAL REPORT OF CLIFFORD RENSHAW

33.

34.

35.

PAGE 11

FINAL REPORT OF CLIFFORD RENSHAW

PAGE 12

36.

On 6/27/09 Officer B.S. was scheduled to work a double shift that
started' at 3: 00 p. m.
He was assigned to the first floor where
Renshaw was housed for both shifts. He stated he recalled speaking
to Renshaw at approximately 6:00 p.m., 7:50 p.m. and 8:55 p.m.,
concerning repeated loss of wristband, bail bond and exercise the
following day . . According to Officer B.S., Renshaw showed interest
in the next day's activities and made good eye contact.

37.

At approximately 9:15p.m., while making a supervisory visit,
Officer B. S. discovered Renshaw hanging from a bed sheet tied
through the bars of his cell. Officer B.S. stated that he called
for assistance, then unlocked the A-Block doors for responders.
Officers S., G., F., K., A. and P responded.
Officers S. and F.
held Renshaw up while Officers A. and K. tried unsuccessfully to get
the knots out of the ligature. The sheet had been wetted and tied
through the bars and double knotted at the front of his neck. Sgt.
M. arrived and cut the
knot with a pocket knife.
Renshaw was
without pulse and apneic. CPR was immediately started and the AED
applied with no shockable rhythm.

38.

39.

The Medical Review Boa.rd found that Hr. Renshaw's medical and mental
heal th care was grossly and flagrantly inadequate, stemming from the
nearly complete systemic failure of the Chautauqua county Jail's
health and mental health care delivery'system.

FINAL REPORT OF CLIFFORD RENSHAW

PAGE 13

a.

b.

Correction officers deliver all medications at the Chautauqua
County Jail with the exception of controlled substances. The
Commission requires that the jail's registered nurses manage
the medication delivery system within the jail, however, it
would appear that there is a fundamental breakdown in that
system as illustrated by this case. The Commission has in the
past recommended that a registered nurse make the initial
medication passin the morning which would alert the medical
providers of the effectiveness of medication, medications not
available, refusals, etc;
This practice has never been
implemented.

c.

The jail currently employs only two full~time registered
professional nurses through the Chautauqua County Health
Department for a population of approximately 300 inmates,
including 65 boarded-in federal inmates.
A 2006 health Services staffing analysis for the Chautauqua
County Jail requires at a minimum three full time RN
positions. Two RNs are reqUired on the 7:00 a.m. to 3:00 p.m.
shift and a full time RN position is required for the 3:00
p.m. to 11:00 p.m. shift. The analysis does not prescribe a
formal coverage factor but clearly indicates that the facility
make the necessary arrangements to ensure these positions are
covered at all times .seven days a week (additional full-time ,
part time, per diem coverage)
The jail does not meet this
staffing requirement.
e

Consequently, the Chautauqua County.Jail is in violation of 9
NYCRR §7041. 2 Staffing Requirements which states in part:
FaciLitv functions and formuLation of daiLy staffing needs.

(a)

The state Commission of correction shalL, in determining
the minimum faciLity .staffing requirement for each LocaL
correctionaL faciLity, ascertain the functions to be
performed by faciLity staff incLuding, but not Limited
to:

(5)

medicaL services;

FI~AL

REPORT OF CLIFFORD RENSHAW
(b)

The State Commi.ssidn of· Correction shall, in determining
the minimum facility staffing requirement for each local
correctional facility, consider the following factors,
among others:
(1)
(2)

(3)

(c)

d.

PAGE 14

the physical plant of the facility;
the maximum prisoner capacity of such facility
established pursuant to Part 7040 of this Subtitle;
and
any other· factors including those unique to a
particular facility.

The
State
Commi.ssion
of Correction
shall,· upon
compliance with subdivisions
(a) and (b). of this
section, determine the number of man hours necessary to
perform each facility function during each shift
regularly scheduled within a 24-hour period.
Upon
making such determination, the State Commission of
Correction shall determine the total number of persons
necessary to perform such functions during each such
shift.

Currently a contracted physician's assistant examines inmates
at the facility twice a week. The two contracted physician's
as·sistants work under the supervision of Dr. R.B., former
Commissioner of Public Health and currently a medical
consultant for the Chautauqua County Health Department.
During an interview withConunission investigators, it was
determined that Dr. R.B, only reports to the facility on
limited occasions in· his capacity as a public health
consultant for TB control matters. He does not review charts
nor is he involved in the day~to-day supervision of the
physician's assistants or any health services operations at
the jail.
Consequently, this is·a violation of New York state Correction
Law §501 and 9 NYCRR §7010.2(a) Health Services requiring the
county legislature, board of supervisOrs, or similar county
gOverning unit appoint a properly registered physician for the
local correctional facility.
It should be understood that
this contracted appointee is the health authority responsible
for all aspects. of inmate health services as well as
supervising all facility hl"althcare professionals.
The
appointee is required,
in conjunction with the chief
administrative officer t·o develop and implement medical/mental
health policies and procedures consistent with this part.

e.

During the investigation, the Commission questioned R.H., PA,
as to the supervising physician's review of the PA's practice

FINAL REPORT OF CLIFFORD RENSHAW

PAGE 15

at the jail.
He reported that he occasionally takes records
from the jail to the doctor for review but "that hasn't
occurred in a few years."
In consultation with the Executive Secretary for the NYS Board,
of Medicine, the Board found that, although there are no
specific requirements regarding physicians; supervision of
physician's ~ssistants, it is accepted community practice for
supervising physicians to periodically review the records and
performance of a supervised physician'S assistant.
f.

During the investigation, i t was determined that on 6/27/09,
the day Renshaw died, he had a physician's assistant
appointment. This is documented in the supervisory log and on
a printed callout list. According to the supervisory l'og and
the housing officer, Renshaw and two other inmates were sent
from A-Pod to the medical unit, returning ten minutes later.
The PA has no recollection of this encounter and there is no
docUlllentation of an encounter in the record.
No sick slips
were maintained and the Commission was unable to verify what
occurred when Renshaw went to the medical department callout
that day. No medical record was made.

g.

Renshaw had five clinical encounters with medical providers
from 6/22/09 through 6/24/09, yet his history and physical was
never completed.

RECOMMENDATIONS:
TO THE SHERIFF OF CHAUTAUOUA COUNTY; THE CHAUTAUQUA COUNTY
EXECUTIVE, THE CHAUTAUQUA COUNTY PUBLIC HEALTH DIRECTOR AND THE
CHAUTAUQUA COUNTY DIRECTOR OF MENTAL HYGIENE:
The Sheriff of Chautauqua County should enlist the assistance of the
Chautauqua County Commissioner of Health as the chief pUblic health
officer in the county, together with the Chautauqua County Director
of Mental Hygiene, with the Chautauqua County Executive directing
the provision of such assistance, to undertake a top-to-bottom
review of the quality and availability of medical and mental health
care and of the qualifications and, professional conduct of the
health care professional entrusted with the care of jail inmates in
the Chautauqua County Jail.
A comprehensive overhaul of
organization and administration, from both the structural and
process standpoints, health and mental health services support
elements, a credible integrated medical records system, effective
procedures for the safety of those inmates admitted to ,the facility
who are at risk of self-harm, quality improvement, professional
staffing levels, personnel qualifications and credentialing and
quality and availability of direct care services should take place,
with priority implementation of recommended improvements,

FINAL REPORT OF CLIFFORD RENSHAW

PAGE 16

TO THE SHERIFF OF CHAUTAUQUA COUNTY:
1.

The Sheriff shall conduct a review of admission screening at
booking, specifically the process of administering the ADM 330
Suicide Prevention Scrceening Guidelines with focus on the failure
of the supervisor to institute the appropriate level of supervision
until Renshaw was evaluated by a
qualified mental health
professional in accordance with both the written suicide prevention
screening guidelines and the relevant training.

2.

The Sheriff shall comply wi th 9 NYCR.R §7041. 2 Staffing ReqUirements,
specifically, the required February 2006 Health Services Staffing
Analysis.
'

3.

The Sheriff shall comply. wi th 9 NYCRR §7003. 3 (j) Securitv and
Supervision, specifically, the establishing of supervisory logs for
constant supervision.

4.

The Sheriff shall comply with 9 NYCR.R §7010.2(j) Health Services,
specifically adequate health service and medical records shall be
maintained.

5.

The Sheriff shall establish a credible, accountable and verifiable
medication delivery system at the Chautauqua County Jail.

6.

The Sheriff shall comply with 9 NYCRR Part 7013 Classification,
§7013.3 Facility Policies and Procedures and §7013.7 Initial
Screening and Risk Assessment.
TO THE CHAIRMAN OF THE CHAUTAUQUA COUNTY LEGISLATURE:
The Legislature shall comply with 9 NYCR.R §7010.2(a) Health
Services, specifically, requiring the county legislature, board of
supervisors, or similar county governing unit to appoint a properly
registered physician for the local correctional faci·li ty.
TO THE CHAUTAUQUA COUNTY DIRECTOR OF MENTAL HEALTH:

1.

As part of the quality and availability review on conjunction with
other county officials set forth herein, the Director of Mental
Health should undertake a qu&lity assurance review of the adequacy
of the mental health evaluation and treatment of Clifford Renshaw,
specifically the failure to evaluate him in a timely manner for a
medication regimen in view of his history of .mental health
treatment, anxiety and depression.
In addition, the propriety of
deferring. any consideration of a medication regimen until records
of prior treatment are received should be revised.
Finally,
provisions for on-call emergency services should be established.

FINAL REPORT OF CLIFFORD RENSHAW

PAGE 17

2.

The Director of Mental Health should establish a service delivery
plan whereby a psychiatrist is directly responsible for all mental
health patients' medication orders, monitOring and follow ups.

3.

The Director of Mental Health should provide adequate psychiatry and
social worker services with appropriate licensuresto meet the
mental health needs of the inmate population at the Chautauqua
County Jail.
TO THE CHAUTAUQUA COUNTY PUBLIC HEALTH DIRECTOR:
As part of the quality and availability r~view in conjunction with
other county officials as set forth herein, the Director of Health
shall review the nursing duties and practices at the Chautauqua
County Jail relevant to medication delivery practices, transcription
of physician's orders, nursing documentation and the completion of
Histories and Physical Assessments· in a timely manner.

WITNESS, HONORABLE PHYLLIS HARRISON-ROSS, M.D., Commissioner, NYS
Commission of Correction, 80 Wolf Road, 4~ Floor, in the City of Albany,
New York 12205 this 24 th day of December, 2010.

PHR:mj
09~M"C97

8/10
cc:

Gregory Edwards, Chautauqua County Executive
Keith D. Ahlstrom, Chair, Chautauqua County
Legislature
Christine Schuyler, BSN, MHA; Public Health
Director, Chautauqua County Health Department
Patricia Brinkman, Director of Mental Hygiene,
Chautauqua Count~ Mental Health Department

NEW YORK STATE COMMISSION OF CORRECTION

In the Matter of the Death
of Adam Wheeler, an inmate of
the Downstate CF

TO:

Honorable Brian Fischer
Commissioner
NYS Department of Correctional
Services
State campus, Building #2
Albany, New York 12226

FINAL REPORT OF THE
NEW YORK STATE COMMISSION
OF CORRECTION

FINAL REPORT OF ADAM

~HEELER

PAGE 2

GREETINGS:
WHEREAS, the Medical Review Board has reported to the NYS
Commission of Correction pursuant to Correction Law, section
47 (1) (d)., regarding the death of Adam Wheeler who died on
March 12, 2010 while an inmate in the custody of the NYS
Department of
Correctional
Services at
the Downstate
Correctional Facility, the Commission has determined that the
following final report be issued.
FINDINGS:
1.

2.

3.

Adam Wheeler was a 19 year old white male who died on 3/12/10
at 9:35 a.m. at St. Luke's Hospital from a suicidal hanging.
while in the custody of the NYS Department of Correctional
Services (DOCS) at Downstate Reception Center.
Wheeler
received grossly
inadequate mental
health evaluation,
treatment and case management characterized by a nearly
complete breakdown in continuity of care between two
successive incarcerations August 2007-0ctober 2009 and
February 2010-March 2010 in which. his mental health status
changed from seriously mentally ill to not in need of services
with an associated failure to examine extensive documentation
of his history and prior courses of treatment.
Had Adam
Wheeler received adequate and appropriate mental health care
and treatment, his death may have been prevented.

FINAL REPORT OF ADAM WHEELER
4.

5.

6.

,.

PAGE 3

FINAL REPORT OF ADAM WHEELER

PAGE 4

8.

9.

10.

11.

12.

13.

10/1/07, Wheeler was transferred from Downstate Reception
Great Meadow CF.

FINAL REPORT OF ADAM WHEELER

PAGE 5

14.

15.

16.

17.

18.

19 ..

On 8/7/08, Wheeler was transferred from Great Meadow CF to
Mid-State CF's Sex Offender Program (SOP). Wheeler remained
in Mid-State CF's Sex Offender Program (SOP) until his
discharge to parole on 10/23/09.

FINAL REPORT OF ADAM WHEELER

PAGE 6

20.

21.

On 10/23/09, Wheeler was granted a conditional release to the
custody of the NYS Division of Parole.
According to Parole
records, Wheeler's parole was violated when, he failed to
follow directives from Washington County Department of Social
Services to secure housing. Specifically, Wheeler failed to
provide adequate housing contacts violating his Independent
Living Plan Program. Documentation states attempts were made
by parole Officer T.to seek alternative housing for Wheeler
without success; The Salvation Army program located in Glens
Falls does not accept sex offenders.
Wheeler was a undomiciled sex offender and posed a threat to the community.
A warrant was issued on 11/10/09 and Wheeler was taken into
custody without incident.

22.

Wheeler was placed in custody at the Washington
a arole violator.

Wheeler was
county jail on 2/9/10.
23.

On 2/9/10, Wheeler was admitted as a parole violator to
Clinton Reception CF from the Washington County CF.

FINAL REPORT OF ADAM WHEELER

PAGE 7

RN

R.L. From Washington County CF verified that. Washington county
CP completes the Health Transfer Information Form in
triplicate as advised by the NYS Commission of Correction.
24.

However, the current OMH
policy entitled Referral, Admission, Transfer & Discharge
Processes, (A) presently dictates that all inmates who arrive
in a reception center are initially screened within two days
,of arrival by OMH clinicians who completed the CNYPC Mental
Health Screening-Structured Interview Form and a Suicide
Prevention Screening Form. Additionally,RN J.C. stated she
leaves questions 3, 5, 8 and 14 blank as she stated this was
what she was told to do when she was originally trained many
years ago on the suicide screening form.
However, she is
trained on a yearly basis on suicide prevention with DOCS.
25.

FINAL REPORT OF ADAM WHEELER

PAGE 8

26.

L. L., OMH Assistant Psychologist III, stated she had been
employed in her OMH position for less than a year, though she
had been employed by other mental health organizations
previously.
Additionally,' she stated she did not receive
training on completing the CNYPC Mental Health Screenin Structured Interview form.

27.

transferred from Clinton Rece tion to

FINAL REPORT OF ADAM WHEELER

PAGE 9

The DOCS
nursing staff at the correctional facilities, including the.
reception centers, do not have the knowledge or access of the
incoming incarcerated populations' crimes and unless the
inmate chose to disclose a child sex abuse crime to a DOCS
nurse, the question would be answered with a "no" answer, when
the question should have been answered with a "yes."
If RN
C.S. had knowledge of the inmate's crime and had given Wheeler
an affirmative answer to question #3, which would have
indicated the inmate's crime was shocking in nature, a mental
health referral would have' been generated to the OMH
clinicians. The OMH clinicians would have had to re-evaluate
Wheeler and would have been able to identify him as a sex
offender, which is a well-known high risk factor for suicide.
The current practice of having DOCS nurses completing and
rescreening incoming inmates with the Suicide Screening Form
without knowledge of their crime is completely ineffective and
was shown to skew the results of Wheeler's suicide screen.
OMH clinicians who have access to the FPMS screen that reports
the inmate's crime would be better suited to re-complete the
suicide screen and obtain more accurate results with the firm.
28.

29.

Downstate Reception OMH Unit Chief T.U. stated that once an
inmate is screened by an OMH clinician with the Suicide
Screening Form and CNYPC Mental Health Screening-Structured
Interview. form and are classified as an OMH Level 6. this
procedure does not have to be repeated at the second reception
processing by OMH.
He stated he receives an e-mail
notification from other reception areas with the names and the
OMH levels of incoming inmates. If an inmate is classified as
an OMH Level I through 4, an appointment is made on the same
day they arrive with an OMHclinician. Also, pMH Unit Chief
T. U. stated all completed CNYPC Mental Health ScreeningStructured Interview forms are available to review as they are
copied on the OMH computer system. OMH unit Chief T. U.. could
not recall specifically Wheeler's Health Transfer Information
form completed by Washington County CF'S mental health staff.
OMH Unit Chief T.U. stated he reviews all the mental health
inforlllation that comes to the faci~ity with the inmate.

FINAL REPORT OF ADAM WHEELER

PAGE 10

30.

31.

32.

On 3/4/10, Officer M.M. was the assigned 2D housing officer
for the day shift. At this time, Officer M.M. had less than
one month of on-the-job training and reported it was his third
day as day housing officer.
At approximately 11: 45 a. m. ,
Officer M.M. reported he completed an inmate count and
observed Wheeler as "healthy and breathing at this time."

33.

On 3/4/10 at 12:15 p.m., Officer M.M. announced "get ready for
chow" over the intercom to the 2D housing unit. Officer M.M.
stated he opened all eligible cells 'and twice again announced
chow.
Officer M.M. counted 28 inmates and reported he
repeated once more. Officer M.M. stated he had five inmates
who were keep-locked
in their cells. Officer
M.M.
documented
.
.
.
"Wheeler must have been hiding because he was not visible in
his cell." Officer M.'M. stated he also believed he may have
miscounted the inmates as he was new at his job. Officer M.M.
stated he left for chow from the 2D housing unit with 28
inmates.' This is a violation of DOCS Dire,ctive #4945: A,3
dated 11/21/01, entitled Inmate Counts.
This directive
states:

\

.

An employee assigned to supervise inmates is
responsible for knowing the number of inmates
assigned and the whereabouts of the inmates
authorized to be absent, and for keeping an
accurate count of the inmates under supervision.
The Master Counts. must be performed at the
prescribed times: unscheduled Counts are to be
performed as circumstances dictate
Inmates

FINAL REPORT OF ADAM WHEELER

PAGE 11

locked in cells during the program day rnust be
counted at least hourly. The counting employee is
solely responsible for the accuracy of count, that
is, for reporting the absence of any inrnate on an
"outHcount (i.e., an inmate, normally assigned to
the ,area being counted by the employee, who is
absent for a known purpose, such as temporary
release or a Visit), and for reporting immediately
any inmate who absence is not accounted for.
A "Check Count"is an unscheduled, informal count
.... Typically Counts of this kind are made while
inmates are working, engaged in daily activities
within the housing unit, or engaged in recreational
or other activities ... When a Check Count is high
or low, indicating an absent or out of place
inmate, the fact shall be reported to the imrnediate
supervisor
and
the
Watch
Commander
for
investigation.
It is particularly important that
an employee in charge of an outside gang or
escorting or transporting inrnates check frequently
to assure that none of the inmates in his or her
charge have left the group.
34.

Officer M.M. stated that, upon returning to the 2D housing
unit about 45 minutes later, he had the inmates line up in
front of the security bubble on the numbers written on the
floor and counted 28 inmates.
At this time M.M. made a
supervisory round and discovered Wheeler hanging from a
ligature. Officer M.M. stated he immediately pulled his radio
pin.
Officer M.M. then ran down to the front door of the
housing unit-to unlock it.

35.

At approximately 1:02 p.rn., Sgt.D.V. heard a Red Dot Alarm
for 2D, responded, and was told there was a problem in cell
20.
Sgt. D:V. stated he responded irnmediately.
A Red Dot
Alarm signals that 'an officer needs immediate assistance.
Sgt. ,D. V. stated upon approaching he did not see an inmate in
the cell.
Sgt. D.V. stated that Officer A.J. was also a
,responder and assisted the sergeant with Wheeler. Wheeler had
tied a shoelace on the door closer mechanism and then had made
a ligature. Sgt. D.V. called a Code Blue at 1:05 p.m. A Code
,Blue is an immediate medical emergency and the officer needs
rovers' assistance. Upon entering the cell, Sgt. D.V., cut the
ligature with his personal pocket knife resulting with Wheeler
falling behind the door. sgt. D.V. stated he and Officer A.J.
moved Wheeler from behind the cell door to get a better look
at him.' It be,came apparent that Wheeler was not breathing nor
had a pulse.
Sgt. D.V. stated he also cut the ligature from
around Wheeler's neck.
Then the sergeant called to Officer

FINAL REPORT OF ADAM WHEELER

PAGE 12

M.M. to get the AED. At this time, Officer T.C. entered the
cell and checked for a pulse. Sgt. D.V. and Officer T.C. both
stated neither could palpate a pulse for Wheeler ..
36.

stated he was just
and Officer P.D.

start CPR when PA N.D.,
the cell.

37.

38.

39.

40.

There was no suicide note found, through a letter found in
Wheeler's cell was addressed to his correction counselor
asking for a. unit with less inmate traffic or protective
. custody. He had indicated in the note that other inmates from
his county knew about his crime.

FINAL REPORT OF ADAM WHEELER

PAGE 13

RECOMMENDATIONS:
TO THE NYS DEPARTMENT OF CORRECTIONAL SERVICES, DIVISION OF
HEALTH SERVICES, AND THE NYS OFFICE OF MENTAL HEALTH, DIVISION
OF FORENSIC SERVICES:
1.

The Department and the Division shall review the practice of
the NYS Department of Correctional Services' nurses completion
of the Reception Suicide Screening Form on incoming inmates
with limited information available to them.
The OMH
clinicians should be considered to perform this screen as they
have access to additional crime information for a more
accurate scoring and identification of inmates' with high risk
suicide factors.

2.

The Department and the Division should conduct a comprehensive
review of reception suicide risk assessment regarding actual
policies, practices, and procedures at the New York State
Reception Centers with particular attention to high risk sex
offenders and patient information provided by the county
mental health clinicians On the Bealth Transfer Information
Form.
TO THE NYS OFFICE OF MENTAL HEALTH,
SERVICES:

1.

DIVISION OF FORENSIC

The Division of Forensic Services should conduct a peer
quality review regarding the mental health treatment of
patients u~der the care of L.L., OMH Assistant Psychologist
III, specifically focused in the areas of initial evaluations,
the completion of CNYPC Mental Health Screening-Structured
Interview format, and assignment of OMH service classification
levels of those inmates.

FINAL REPORT OF ADAM WHEELER
2.

PAGE 14

The Division should provide the documented results of the
above quality assurance review to the Commissioner and Chair
of the State Commission of Correction's Medical Review Board
by April 30, 2011.
TO THE COMMISSIONER OF THE NYS DEPARTMENT OF CORRECTIONAL
SERVICES:
The Department should review the conduct of Officer M.M. who
failed to comply with DOCS Directive #4945: A,3 dated
11/21/01, entitled Inmate Counts which states:

An employee assigned to supervise inmates is
responsible for knowing the humber of inmates
assigned and the whereabouts of the inmates
authorized to be absent, and for keeping an
accurate
count
of
the
inmates
under
supervision.
The Master Counts must be
performed at the prescribed times: Unscheduled
Counts are to be performed as circumstances'
dictate
Inmates locked in cells during
the program day must be counted at least
hourly.
The counting employee is solely
responsible for the accuracy of count , that
is, for reporting the absence of any inmate on
an "out" count
(i.e., an inmate, normally
assigned to the area being counted by the
employee, who is absent for a known purpose,
such as temporary release or a visit), and for
reporting immediately any inmate who absence
is not accounted for.
TO THE NYS DEPARTMENT OF CORRECTIONAL SERVICES, DIVISION OF
HEALTH SERVICES:
The Department will conduct in-service training on completion
of the Suicide Screening Form to their professional nursing
staff for the duration of their responsibility to complete
such.
TO THE NYS COMMISSION ON OUALITY OF CARE AND ADVOCACY FOR
PERSONS WITH DISABILITIES:
The Commission is asked to conduct an investigation into the
mental health evaluation and mental health classification
provided to Adam Wheeler through the NYS Office of Mental
Health while at the NYS Department of Correctional Services.

FINAL REPORT OF ADAM WHEELER

PAGE 15

WITNESS, HONORABLE PHYLLIS HARRISON-ROSS, M.D., Commissioner,
NYS Commission ot Correction, 80 Wolf Road, 4 th Floor, in the City
of Albany, New York 12205 this 24 th day of December, 2010.

/J
Harrison-Ross, M.D.
Commissioner
PH-R:mj
10-M-40
8/10
cc:

Superintendent Ada Perez, Downstate CF
Dr. Carl Koenigsmarm, Chief Medical of.ficer
Elizabeth Ritter, Assistant Commissioner
Richard Miraglia, Division of Forensic Services,
NYS Office of Mental Health
Don Sawyer, Executive Director, Central
New York psychiatric Center
Jayne VanBramer, Director, Bureau of
Quality Management, OMH
Jane C. Lynch, Chief Operating Officer, NYS
Commission on Quality of Care & Advocacy
for Persons with Disabilities