The state Commission of Correction criticized the Erie County Holding Center's staff this month over the deaths of two inmates, saying one "may have been preventable" but there were "serious deficiencies" in the medical care provided.
The commission said the 2022 death of Sean C. Riordan "may have been prevented" if a registered nurse had properly screened Riordan for alcohol withdrawal detoxification when he was booked in the Holding Center and sent him to a hospital for an evaluation, or if Riordan had been given appropriate medical care when his condition deteriorated.
Riordan, 30, died from complications of chronic alcoholism on June 14, 2022, at Buffalo General Hospital - nine days after he collapsed at the jail.
"The Medical Review Board has found that there were serious deficiencies and absences in Riordan's medical care during his incarceration that may have contributed to his death. The Medical Review Board opines that had established medical policy and procedures been properly followed and had Riordan been promptly sent to a hospital for treatment, his death may have been preventable," the commission said in a report made public this month.
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In a second report, on the 2022 death of inmate William B. Henley due to injuries Henley suffered in an assault before he was arrested, the commission questioned why a registered nurse at the Holding Center did not notice the injuries when she interviewed Henley as he was being booked.
"The Medical Review Board has found that the manifestation of injuries on Henley, which were ultimately terminal, were not identified by the facility nursing staff who performed Henley's intake assessment on 11/26/22. The Board opines that had these injuries been able to be potentially identified the necessary medical treatment could have been obtained," the commission said in its report.
While the commission did not say Henley's death was preventable, it directed the jail's physician to conduct a quality assurance review with the nurse who assessed Henley at booking and review why significant traumatic injuries were not identified and addressed.
The Buffalo News requested comments from Erie County Sheriff John Garcia, who oversees the Holding Center and its medical and security staff. A spokesman said, "We have no comment."
The commission noted that Erie County's attorney, Jeremy Toth, sent the commission a response to its reports on the two deaths.
Toth refuted some of the report's findings and stated that the Sheriff's Office conducted an in-depth investigation into the deaths of Riordan and Henley and found no violations of policy by security or correctional health staff, the commission said.
The commission noted that the county attorney did not provide any specific response to detailed quality-of-care issues it had raised about Riordan's care.
The commission's Medical Review Board "remains affirmed in its findings and actions required," the commission said in both cases.
In 2023, The Buffalo News reported that an Erie County medical examiner had partly faulted medical personnel at the Holding Center for Riordan's death, saying they did not properly respond to his withdrawal from addictive drugs, primarily alcohol.
Dr. Stacey Reed, the county's associate chief medical examiner, wrote in an autopsy report on Riordan that she found a "failure to adequately treat" Riordan's withdrawal and said it stemmed from the way jail personnel interpreted his symptoms for the Clinical Institute Withdrawal Assessment, a protocol used to assess and treat patients in withdrawal, primarily from alcohol.
"While the medical care that the decedent received prior to his admission to hospital was inadequate, it does not rise to the level of criminal neglect," the doctor wrote, but she suggested more training for the jail's staff.
Garcia responded at that time that Reed had failed to consider many facts and circumstances of the case.
"Simply put, her investigation was either incomplete or based upon an inaccurate assessment of the information that was made available to her," Garcia said in a statement to The News.
In both the Riordan and Henley deaths, the Commission of Correction called on the Erie County Legislature to review the commission's findings and conduct an inquiry into the fitness of the county's designated health services provider at the jail.
Erie County Legislature Chairwoman April Baskin, who is leaving the Legislature at the end of the month to take her State Senate seat, said it will be up to the next Legislature chairperson to decide whether to hold a public inquiry into the reports on Riordan and Henley. Baskin held a public inquiry into the 2016 death of Holding Center detainee India Cummings so that lawmakers could ask Sheriff's Office officials questions.
Neither Democratic Majority Leader Timothy Meyers, who is expected to be voted in as Legislature chairman next year, nor John Gilmour, chairman of the Public Safety Committee, responded to requests for comment regarding any future inquiry.
Lawsuits filed
The families of both Riordan and Henley have filed lawsuits against Erie County and Garcia over their deaths.
Second inmate death lawsuit filed in a week against Erie County
William B. Henley died in 2022 in the Erie County Holding Center. His daughter sued Erie County, Sheriff John Garcia and the city of Buffalo on Monday accusing them of causing his death by failing to provide adequate medical services to him.
Riordan's mother, Christine Riordan, filed her lawsuit in June 2023 in State Supreme Court. The case was moved by Erie County to U.S. District Court.
The lawsuit says Riordan was booked in the Holding Center on June 2, 2022, after being stopped for a traffic violation.
(The Commission of Correction said he had outstanding warrants from several municipalities and was booked on charges of first-degree aggravated unlicensed operation of a motor vehicle and second-degree criminal impersonation.)
"Over the following days, he exhibited classic and severe symptoms of acute ethanol (alcohol) withdrawal, including persistent nausea and vomiting, anxiety, agitation, tremor, paroxysmal sweats, and seizure activity. He had at least two documented falls," the lawsuit says.
But the jail staff failed to provide Riordan with the medical attention he needed.
"Defendants' willful and deliberate indifference to Sean Riordan's serious medical needs directly led to his untimely, easily preventable, and unjustifiable death," the lawsuit alleges.
The lawsuit, filed by attorney Melissa Wischerath, is pending.
Henley's daughter sued Erie County, Garcia and the City of Buffalo on Nov. 25. She alleges that Buffalo police and Holding Center staff did not provide any medical treatment to Henley, even though he had visible injuries, could not remain standing during his court arraignment and had complained to Buffalo police and Sheriff's Office staff at the jail that he was injured.
Buffalo police arrested Henley on Nov. 25, 2022, on burglary and gun charges in connection with a break-in the day before at an apartment in the building where he lived.
Deputies discovered Henley dead in his cell at the Holding Center on Nov. 27, 2022, nearly six hours after he failed to get up for breakfast and about 24 hours after he was booked in the jail, according to the lawsuit filed by Johneya Henley.
Henley died from an undisclosed neck injury that he suffered in an assault on Nov. 25, 2022, hours before he was arrested by Buffalo police, then-District Attorney John Flynn said last year. He said Henley did not voice any medical concerns or complaints regarding pain to the jail medical staff when he was booked.
If Buffalo Police or Erie County Sheriff's Office staff at the Holding Center had initiated appropriate medical intervention or requested medical attention on his behalf, he would be alive today, the lawsuit claimed.
Attorneys Ryan Johnsen and Robert Corp filed the Henley lawsuit, which is pending.
Medical examiner faults Erie County Holding Center staff for inmate's death but sees no 'criminal neglect'
Sean Riordan's family has been working with a lawyer to gather his medical records and videos of him compiled over his final hours. The autopsy is one piece of a larger puzzle, said Tracie Riordan, his sister. "It's very apparent my brother was sick and needed medical attention and did not receive it," she said.
Inmate deaths costing taxpayers
Earlier this year, Erie County was ordered by a State Supreme Court justice to pay $20 million in damages, plus more than $6 million in lawyer fees and interest, for causing the death of Erie County Holding Center inmate Richard J. Metcalf Jr. in 2012. Sheriff's Office deputies forcibly restrained Metcalf because he was in a mental health crisis and they put a spit mask and a pillowcase over his head - which the Commission of Correction said asphyxiated him. A jury initially awarded Metcalf's estate $100 million in damages, but a judge cut the award by 80%.
Erie County also agreed in September to pay $3.8 million to settle a lawsuit over the 2016 death of Holding Center inmate India Cummings, 27. She died 20 days after she was booked in the jail. Cummings had showed obvious signs of severe mental illness, and the Commission of Correction said the medical care she received was "so grossly incompetent and inadequate as to shock the conscience."
Staff reporter Sandra Tan contributed to this story.
Contact Mike McAndrew at [email protected]
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