NEW YORK STATE COMMISSION OF CORRECTION

In the Matter of the Death

FINAL REPORT OF THE
NEW YORK STATE COMMISSION
OF CORRECTION

of Nikko Gambino , an inmate of
the Genesee County Jail

TO:

Sheriff Gary T. Maha
Genese.e County Sheri 'f f'
165 Park Road
Batavia, NY 14020

B

Office

FINAL REPORT OF NIKKO GAMBINO

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 Nikko Gambino who died on July 8, 2011 while an inmate in the
custody of the Genesee County Sheriff at the Genesee County Jail, the
Commission has determined that the follo~ing final report be issued.

FINDINGS:
L

Nikko Gambino was a 42 year old white male who died on 7/8/11 at 3: 05 p.m.
from untreated acute benzodiazepine and suboxone withdrawal while in the
riff's

laboratory evidence clearly rules out
this case.
Mr.
Gambino was serving an intermitte~t sentence without continuity of care.
2.

Impersonation 2 nd •
He was sentenced to 59 days of intermittent time at the Genesee County
Jail.
On 6/28/11 during his intermittent sentence at the Genesee County
Jail, Gambino was discovered to be in the possession of Xanax and
Suboxone.
Gambino was charged for Criminal Possession of a Controlled
st
Substance 5 th , Knowingly Make/Possess Dangerous Contraband in Prison 1 ,
Tampering with Physical Evidence, and Possession of Controlled Substance
in a non-original container.
He was detained in the Genesee County Jail
without bail.
3.

Gambino reported he was removed from his home as a child. Gambino stated
he lived in High Meadows Institution and Newington Children's Hospital in
Connecticut.
He. also stated he was in foster care placement.

Gambino stated he had delayed speech
walking as a c
reported attending special education classes and achieved
education while in school.
4.

FINAL REPORT OF NIKKO GAMBINO

5.

6.

7.

PAGE 3

FINAL REPORT OF NIKKO GAMBINO

8.

9.

PAGE 4

According to Genesee County Sheriff's documentation on 6/6/11, RN T.B.
received an e-mail from Superintendent R.G. who notified the nurse that
Gambino's attorney, M.W., would be in contact with her with regard to
Gambino's medical issues and medications.
Gambino was sentenced to 59
days in the custody of the Genesee County Sheriff's Department for his
charge of Criminal Impersonation 2 nd •
Gambino was to serve his sentence
on an intermittent basis.
Intermittent sentencing is an inmate serving
his jail time in blocks of days, e.g., weekends. On 6/7/11, attorney M.W.
arrived at the ai.1 with a list of presc"ription medications for Gambino,
RN T.B. informed attorney M.W. that
Gambino would not be prescribed
which are controlled
medications, during his intermittent
Genesee County Jail.
There is no jail policy to document such.
Both Genesee County Medical
Director Dr. G.S. and NP H.M. were not contacted regarding this decision.
RN T.B. acted out of her scope of practice as a registered nurse to make
such a determination.
This practice of abrupt discontinuance of a
benzodiazepine, when taken regularly, will cause a significant withdrawal
syndrome which includes tremor, headache, tachycardia, palpitations,
difficulty in ambulating, hot/cold sweats, and generalized myalgia.
As
the withdrawal progresses, hallucinations are present, full delirium with
disorientation, and seizure activity will occur~
Presently, the Genesee
County Jail does not have a benzodiazepine withdrawal protocol in place.
The Genesee Cpunty Jail's Medical Director, Dr. G.S., stated he was not
involved in the formul~tion of the jail's present withdrawal policies
which include an alcohol, opiate, and drug abstinence syndromes protocol.

FINAL REPORT OF NIKKO GAMBINO

PAGE 5

review of literature indicates
stered
(burprenorphine/naloxone) can
cause a serious drug reaction
recommends that an alternative
medication be prescribed.
Patients receiving scheduled prescribed
Suboxone maintenance with the administration of Tramadol could worsen
their opiate withdrawal.
Suboxone has a half-life from 20 to 70 hours.
Genesee County Jail's opiate withdrawal procedure is inadequate as there
is no direction on completing regular Clinical Opiate Withdrawal Scale
(COWS) assessments to keep an accurate and updated account of a patient's
withdrawal status;
10 .

11.

12.

On 6/13/11 at 4:52 p.m., Gambino arrived at the Genesee County Jail to
serve his first intermittent sentence segment.
At 6: 41 p.m., Senior
Correction Officer W.Z. completed a Suicide Prevent
scoring Gambino with a "0" for all negative answers.

FINAL REPORT OF NIKKO GAMBINO

PAGE 6

13.

14.

reviewing the Genesee County Jail Opiate Withdrawal protocol, there is no
direction on how often to complete COWS assessment by health services
staff.
15.

community as his first intermittent sentence time was finished.
16.

FINAL REPORT OF NIKKO GAMBINO

PAGE 7

17.

On 6/20/11 at 5:52 p.m., Gambino reported to the Genesee County Jail to
serve his second intermittent sentence.
He was released on 6/22/11 at
6:05 p.m.
In reviewing Gambino's housing unit log and medical record,
there is no documentation of any medical, behavioral, or security issues
for these days.

18.

According to Genesee County Jail documentation on 6/21/11 at 12:15 p.m.,
an inmate informed security staff that multiple inm~tes with intermittent
sentences were bringing in contraband in the form of prescription
medication to the Genesee County Jail.
Xanax pills were found in the
possession of another inmate. On 6/27/11 at 6:09 p.m., Gambino reported
to his third intermittent sentence at the Genesee County Jail.
The
Genesee County Sheriff's Department had obtained a search warrant for a
body cavity search on Gambino. On 6/27/11 at 9:40 p.m., Gambino was seen
at United Memorial Medical Center' for a body cavity search.
The
correction officers reported to Dr. S.C., the ED physician, that Gambino
was known to be "smuggling" drugs in the Gehesee County Jail for his
weekend stays. Dr. S.C. was info
d that Gambino
Suboxone and Xanax in his rectum.

Gambino was
arraigned in Genesee County Court for his additional charges of possession
of contraband and was held in the Genesee County Jail without bail.
19.

20.

On 6/29/11 at 8:00 p.m., Gambino's Suicide Screening Prevention Form was
completed by Officer W.Z. Gambino gave all negative answers to questions
the officer asked with a resulting score of "0" indicating he had no
suicide risk factors. However, Gambino gave negative responses regarding
having a psychiatric history and a history of drug use inconsistent with
his previous established history.
Officer W. Z. wrote a statement

PAGE 8

FINAL REPORT OF NIKKO GAMBINO
regarding Gambino's
following:

admission

interview

on

6/29/11

which

stated

the

Nikko Gambino was brought into the facility on 6/29/11 at 8:40
p.m. by Deputy D. following arraignment in Batavia Town Court
by Justice C. for Batavia City Court on a charge of Promoting
Prison Contraband 1 st •
Justice C. ordered the subject held
without bail with a return date scheduled for July 7th at 1300
(1:00 p.m.) in Batavia City Court.
21.

22.

On 7/4/11 at 6:35 p.m. according to the security log, Officer K.C.
reported Gambino was observed yelling for an "angel."
At 7: 00 p.m.,
Gambino was rattling his cell bars and going into another inmate's cell.
Senior Correction Officer K.W. was advised.
At 7:30 p.m., Officer K.W.
came to Gambino's cell and Gambino was double locked for his safety.
Officer K. C. completed a Genesee County Jail General Incident Report which
stated:

PAGE 9

FINAL REPORT OF NIKKO GAMBINO

"On 7/4/11 at approximately 7:15 p.m. while working the first floor,
Inmate Nikko Gambino was yelling out for people who were not there,
rattling the cell bars, and going into other inmates' cells.
For his
safety he was double locked without any further incident. Officer W. was
present when he was locked in.
This could be the beginning of drug
withdraw (al) ."
23.

On 7/5/11 at 10:45 p.m., Officer B. assumed duty of Gambino's housing
unit.
On 7/6/11 at 3:30 a.m., Officer B. completed an entry in the
security log which reported Gambino was talking incoherently.
At 5:30
a.m., Officer B. made a security log notation which stated "Gambino
refused his medication" and "was talking incoherently."
If an inmate
complains or is observed having auditory or visual hallucinations, having
tremors or "shakes," sweating, nervous, pacing and/or fidgety behavior and
is disoriented, an immediate referral to medical staff should be made and
the inmate placed on constant supervision.
Prudent actions required for
Gambino would be lmmediate placement on constant supervision, the facility
physician notified, and arrangements made to transport to the hospital.
This is a violation of the NYS Commission of Correction's Minimum
Standards, §7003.3(h) which states:
(h)

The chief administrative officer and/or the facility physician shall
determine whether a prisoner requires additional supervision based
on the prisoner's condition, illness or injury, and the chief
administrative officer shall order such supervision if warranted.
Additional supervision may include:
(1) more frequent supervisory visits;
. (2) active supervision when only general supervision is required; or
(3) constant supervision.

24.

On 7/6/11 at 7:00 a.m., Officer P.M. reported to Gambino's housing unit,
1 N/E housing, to assume his duty. O·fficer P.M. stated that, between the
hours of 7:00 a.m. and 9:00 a.m., he observed fecal matter on Gambinois
clothes and toilet. There was also some type of stain on his cell walls.
Gambino was sitting upright on his bed.
Senior Correction Officer R.Z.
told Officer P.M. -to move Gambino so his cell could be cleaned.
Gambino
reported to Officer P.M. that he was at a house on the beach. He reported
to the correction officer he didn't want to leave, as the "sand" would get
him.
Officer D.K. was assigned'to escort Gambino to Housing Unit 1
south/east (S/E), cell #1, his newly assigned housing unit. When Officer
D.K. entered Gambino's cell · to retrieve him, he observed Gambino lying on
the floor, with feces on him, talking to himself, with his clothes in the
toilet.
Officer D.K. also observed Gambino speaking into an "imaginary"
cell phone. Officer D.K. asked Officer P.M. to assist him. Officer P.M.
was able to speak to Gambino, got him on his feet and walked him to S/E
cellblock. Officer P.M. observed Gambino walking slowly and methodically.
The officer observed Gambino talking about being sucked into the sand.
Officer P.M. reported Gambino was obviously hallucinating.
The security
log noted that on 7/6/11 at 8:30 a.m. Gambino was moved to 1 S/E cell #1
with the comment "double-locked." Inmate T.H. was in cell #2 and in cell
#3 was inmate M. Z.
Officer P.M. stated he notified RN T. B. about
Gambino's mental status while she was administering medications on the

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FINAL REPORT OF NIKKO GAMBINO
25.

PAGE 10

According to the security log on 7/7/11 (Thursday), Officer P.M. was the
day officer for Gambino's housing unit.
His security log book entry
reported at 10: 30 a.m. that Gambino was transported to court.
Officer
P.M. stated Gambino was escorted by Deputy J.H.
Gambino returned from
court at approximately 12:00 p.m.
Deputy J.H. stated Gambino became
incoherent and agitated during his court appearance and Deputy J.H. called
and asked for assistance with Gambino who was returning from court.
Deputy J.H. stated that Gambino walked up the stairs where his cuffs and
shackles were removed. Senior correction Officer R.Z. requested that the
nurse, RN T.B., be notified. Officer D.K. stated that he saw RN T.B. get
Gambino into a wheelchair and Officer P.M., RN T.B., and himself wheeled
Gambino back into the S/E housing area.
Officer P.M. stated that when
they returned to Gambino's housing unit door, Gambino started to brush
away spiders he thought were crawling on his body.
Gambino was saying
"get them off of me."
He continued to swat at the imagined spiders.
Officer P.M. stated that Gambino slowly slouched to the floor, then fell
on the floor. Gambino continued to brush away the spiders. Officer P.M.
stated he pretended to step
rs to kill them and
Gambino then calmed down.

26.

27".

28.

On 7/8/11 at 7:00 a.m., Officer D.K. reported to duty as the housing
officer on Gambino's (South/East) housing unit.
Officer D. K. stated

FINAL REPORT OF NIKKO GAMBINO

PAGE 11

Gambino was in his cell and was sleeping on his bunk when the officer
completed his supervisory rounds in the morning. Officer D.K. stated his
first verbal interaction with Gambino occurred during the noontime
medic.Cition pass . . At approximately 12:15 p.m., Officer D.K. spoke to
Gambirto through the catwalk bars and then proceeded to enter Gambino's
cellblock and went directly to his cell door. Gambino did not speak with
Officer O.K. but gestured that he was alright and got up from his bunk.
Officer D.K. stated that it was not unusual for Gambino not to speak.
walked to his cell door.
Officer
eeli

ed when .he left Gambino's cell,

observed

him sitting on
29.

On 7/8/11 at approximately 2:00 p.m., Officer L.A. was in the process of
escorting inmates to and from the visiting room when she was stopped by
the 1 S/E area (Gambino's housing block) inmates. Officer L.A. identified
these inmates as T.H. and M.Z., Gambino's housing unit mates. They stated
to Officer L.A. that Gambino was having a possible seizure. Officer L.A.
observed Gambino mildly shaking in his bunk. Officer L.A. observed that
Gambino's eyes were glossy as he sat up. Officer L.A. stated she notified
Officer W.Z. and reported her concerns regarding Gambino.
Officer L.A.
observed Gambino had moved from his bunk, slid to the floor, and was lying
on his stomach with his head close to the gate.
Officer L.A. also
repo'rted this to Officer W. Z.
Officer w. Z. requested Officers D. K. and
R.M. go see Gambino, to which they complied.
Officer W.Z. relieved
Officer D.K. in the control r90m while he left to see Gambino.
Officer
R.M . . stated that, since he is an advanced EMT, he, is often called on to
check on sick or injured inmates. 'Officer R.M. found Gambino lying on the
floor on his stomach.
Officer R.M. spoke with Gambino through the cell
gate and asked if he was okay.
Gambino responded with a neh."
Officer
L.A. stated she observed Gambino lift his head off the cell floor while
Officer R.M. was interacting with him.
Officer L.A. stated she observed
a yellow stain on the back of Gambino's boxer shorts when he was lying on
the floor.
Officer P.H. then relieved Officer W.Z . in the control room,
who then went to Gambino's cell . . Officer W.Z. looked into Gambino's cell
and observed him lying on his stomach on the floor.
Officer W.Z. stated
Gambino was in a position similar to a push-up with his head off the floor
and he was making sounds so he was breathing.
Officer W.Z. went back to
the control room to speak with Officer R.M. Officer R.M. reported Gambino
was acting the same as he had been for the past few days. Gambino's color
was good' and he was breathing freely.
Officer R.M. stated, due to
Gambino's withdrawals, the safest place for him was on the floor. Officer
R.M. determined that Gambino did not need any further medical assistance
and reported such to Officer W.Z.

30.

Officer D.K. reported that inmates M.Z. and T.H., who were in the cells
next to Gambino, had stated that they .did not want to be housed with him
as they felt responsible for him and were uncomfortable with that. After
Officer R.M. left the cell block, Officer D.K. asked inmate T.H. why he
had not rung the emergency bell if he felt that Gambino was in trouble.
Inmate T.H. stated he did not want to get into trouble for hitting the
button.
Officer D.K. stated he assured the inmate that he would not get
in trouble for pushing the button in the event of having a legitimate
concerh with another inmate.

FINAL REPORT OF NIKKO GAMBINO
31.

32.

33.

PAGE 12

According to the security log on 7/8/11 at 2:24 p.m., Officer "D.K. was
conducting a security round when he observed Gambino lying on his stomach
on the cell floor with his head at the door of his cell (#1) and not
moving.
Officer D.K. called Officers w.z. and R.M. for assistance.
Officers w.z. and R.M. responded almost immediately.
Officer w.z.
observed Gambino lying on his stomach on the floor.
The officers" moved
Gambino to his back. Officer W.Z. reported that Gambino was not breathing
nor was his pulse detectable.
Officer W.Z. called for an ambulance, the
AED, and a bag valve mask, which Officer D.K. retrieved from the second
floor. Officer D.K. saw Officer P.M. and offered to relieve him from his
duties to take the emergency equipment to Gambino's cell.
Officer D.K.
stated his reasoning was Officer P.M. was a ce~tified EMT and would be
more of an asset than him in the resuscitation efforts.
Officer R.M.
initiated CPR on Gambino in his cell.
Office~ P.M. arrived with the AED
and bag valve mask. He attached the AED to Gambino which reported "check
"pulse and continue CPR." Officer P.M. palpitated Gambino's carotid pulse
which he described as a brachycardia rhythm.
Officer R.M. also was able
to palpitate a weak bradycardic pulse in Gambino's wrist.

FINAL REPORT OF NIKKO GAMBINO

PAGE 13

RECOMMENDATIONS:
TO THE OFFI CE OF THE GENESEE COUNTY SHERIFF:
1.

The Office of the Genesee County Sheriff shall comply with the NYS
Commission of Correction's . Minimum Standards, §7003.3(h) which states:
(h)

The chief administrative officer and/or the facility physician shall
determine whether a prisoner requires additional supervision based
on the prisoner's condition, illness or injury, and the chief
administrative officer shall order such supervision if warranted.
Additional supervision may include:
(1) more frequent supervisory visits;
'(2) active supervision when only general supervision is required; or
(3) constant supervision.

The Office of the Sheriff shall direct the security and medical staff to
initiate constant supervision on inmat'e s who are observed having
hallucinations and/or altered mental status or seizures.
2.

The Office of the Sheriff shall cause an inquiry to be conducted and its
results, along with action taken, reported to the Medical Review Board,
into the failures of medical staff at the Genesee County Jail on the part
of the facility Medical Director, Nurse Practitioner and Registered
Professional Nurse to adequately corrununicate vital clitlical information
. to evaluate, assess and treat Nikki Gambino,
specifically:
a.

Failure of medical supervision and oversight by the long-standing
but essentially absentee physician/Medical Director;

b.

Failure of the Medical Director to develop a treatment plan . .
spite being informed specifically that

c.

Failure of the Nurse Practitioner to supervise subordinate
practitioners at the facility and to assure a quality clinical plan;

d.

Failures . to administer pres'c ribed medication
indiscriminate preparation of prescription forms
professional nurse for blanket physician
medications other than those prescribed
administration of specific medications fol

PAGE 14

FINAL REPORT OF NIKKO GAMBINO

the inmate's personal physician that they were contraindicated and
potentially harmful; nursing failure to not ~ Nurse
Practitioner that patient refused medication . . . . . . . . . . . . . in a
patient exhibiting clinical deterioration;

3.

4.

e.

Failure of the nursing staff to recognize florid signs and symptoms
of worsening acute withdrawal which were objectively measured
(COWS), clinically described and documented over several days
resulting in dea~h, and failure to provide acute treatment;

f.

Investigate the gross failure of clinical examination assessment of
an acutely ill pre-terminal seizure patient by acknowledged ALS
provider CO R.M. on 7/8/11 who admittedly exercises those advanced
provider skills in that setting.

The Office of the Sheriff shall direct Genesee County Jail medical
providers to develop a comprehensive policy and procedure specific to
benzodiazepine withdrawal with consultation of a physician with a
specialty in addiction medicine, which will include and is not limited to:

a.

To identify inmates who are high risk
withdrawal syndrome and/or seizures; and

to

b.

To develop a protocol to safely manage inmates who are at high risk
to develop sign'i ficant withdrawal syndrome and/or seizures.

develop

significant

The Office of the Sheriff shall direct Genesee County Jail medical
providers to develop a comprehensive policy and procedure specific to
opiate withdrawal protocol with attention to inmates who used Suboxone in
the community in consultation with a physician with a specialty in
addiction medicine and the completing of regularly scheduled withdrawal
assessments.
TO THE NYS EDUCATION DEPARTMENT,
PROFESSIONAL DISCIPLINE: .

OFFICE OF THE PROFESSIONS,

OFFICE OF

That the Office of Professional Discipline conduct an investigation into
the professional conduct of Registered Nurse T.B. for malpractice, gross
incompetence, gross negligence, and failure to maintain an accurate
medical record for Nikki Gambino while he was incarcerated at the Genesee
County Correctional Facility.

WITNESS,
HONORABLE PHYLLIS HARRISON-ROSS,
M.D.,
Commissioner,
NYS
Commission of Correction, Alfred E. Smith State Office Building, 80 South Swan
Street, 12th Floor, in the City of Albany, New York 12210 this 19 th day of March,
2013 .

~a~/){;JCommissioner

PHR:JJ:mj
ll-M-83
12/12