Jail deaths substantially higher than reported

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At least 57 Erie County jail inmates have died since 2005, a much higher number than previously reported.

The death rate has barely budged in nearly a quarter century. Indeed, it has ticked up since Sheriff John Garcia took office, taking over from a predecessor widely criticized for the number of jail deaths on his watch.

Forty-four prisoners, or one inmate every 4½ months, died under former Sheriff Timothy Howard, who became sheriff in June 2005, after five inmates had already died earlier that year under the previous sheriff, Patrick Gallivan. With eight deaths since Garcia took office in January 2022, the death rate has been one inmate every four months. That’s even though the jail population plummeted by 35 percent between 2014 and 2023. 

Media reports for years have understated the number of deaths. Last year, for example, The Buffalo News set the number at 34 between June 2005 and January 2023. The actual number was 47.

Half the time, the state Commission of Correction, which investigates jail deaths, has found fault with medical staff, guards or both, and recommended changes to jail policies and operations. 

Of the 57 deaths since 2005, 40 were holding center inmates and 13 Alden correctional center prisoners. In four cases, official reports didn’t say which facility the inmate was at.

Twice, the commission has referred cases to the U.S. Department of Justice for possible criminal charges. In three other cases, the commission determined that deaths were likely preventable if inmates had gotten proper medical care.

Mortality reports are grim.

• Two inmates died four years apart, in 2015 and 2019, from perforated intestinal ulcers gone undiagnosed and untreated. 
• An inmate deemed in urgent need of mental health care hanged himself in 2018. He was one of more than five dozen inmates waiting at the time for mental health care. 
• A 63-year-old prisoner with heart problems died of a blocked lung artery at the Alden correctional facility in 2017 after medical staff failed to monitor his blood pressure as directed by a nurse practitioner. 

The county’s two jails have improved, according to Garcia. Last year, the U.S. Department of Justice agreed to end a 2011 consent decree aimed at improving medical and mental health care. The sheriff last spring touted accreditation by the National Commission on Correctional Health Care, a nonprofit group based in Chicago.

“I promised … the people of Erie County that I would modernize the sheriff’s office,” Garcia said in a May press release. “Seeking and achieving accreditation is a key component of that.”

Garcia didn’t respond to interview requests for this story, but medical care isn’t a problem, according to Sandra Amoia, first deputy superintendent for compliance for the sheriff’s office.

“We’re giving them really good medical care,” said Amoia, a former assistant commissioner for the state Department of Corrections and Community Supervision who Garcia hired to help get county lockups accredited. “You’re going to see people die — every jail in America has deaths. You can’t control that. Some die of cancer or old age.” 

Former Erie County Sheriff Tim Howard. Photo provided by WKBW.

Concerns remain, however.

Erie County Legislature Chair April Baskin last spring asked the county’s Correction Specialist Advisory Board to review all jail deaths that have occurred during the past four years. The request came after the state Commission of Correction told Baskin in March to review the fitness of jail health care providers following an investigation into the death of James Ellis, whose cancer went undiagnosed during the nine weeks he spent at the holding center three years ago.

The March order for legislative review marked the fifth time since 2016 that the commission has told the Legislature’s chair to determine the competency of jail health care providers.

Buffalo attorney Melissa Wischerath, who represents two families who are suing the sheriff over jail deaths under Garcia, said she read state Commission of Correction mortality reports in sequence after obtaining them through a state Freedom of Information Law request.

“It made me feel sick,” Wischerath said. “Has the county health commissioner read these in totality? Has the sheriff? Does anyone care enough to do something about the death rate?”

Incomplete counts

Erie County operates two jails, which house inmates awaiting trial or serving sentences of less than a year. 

Built in 1938, the downtown holding center has a capacity of 638 prisoners. Its population in July was 325. 

The correctional facility in Alden was built in 1985 and has a capacity of 884. It held 435 inmates in July.

The two jails this year are budgeted to employ 740 people with an operating cost of $115.4 million. In addition, taxpayers this year are scheduled to spend $17 million for jail health care, which employs 72 people.

Tracking jail deaths isn’t simple.

The sheriff typically doesn’t issue press releases when inmates die. Reporting standards to state agencies have changed over time. An inmate pronounced dead outside jail now triggers a report to the state Commission of Correction, but that wasn’t always the case.

Partly as a result, top Erie County officials have gotten numbers wrong.

“There have been 31 deaths in Erie County’s jails since Timothy Howard became sheriff in 2005,” Baskin said in a 2019 written statement after Robert Ingalsbe hanged himself in the holding center. “These deaths are a stain on our community, and a burden to taxpayers.” 

In fact, at least 41 inmates had died under Howard’s watch when Baskin blistered the sheriff.

Since 2021, sheriffs have been required to report jail deaths to the state attorney general’s office, which publishes a statewide list once a year. Sheriffs have long been required to notify the state Commission of Correction when inmates die. Until 2014, sheriffs weren’t always required to make reports if stricken inmates lived long enough to be moved outside jail, according to a commission spokeswoman.

Consequently, a list of deceased inmates and copies of mortality reports obtained by Wischerath via her FOIL request isn’t complete. For instance, the commission had no records on Kristian Woods or Patrick Yale, who both died in 2012 months after being released — Woods after his heart stopped when he was injected with psychotropic drugs after guards sent him to Erie County Medical Center, Yale after he was beaten by an inmate — and so the commission wasn’t notified. 

A list of dead inmates the commission gave Wischerath’s office is missing an additional two prisoners whose families Wischerath is representing in lawsuits against the sheriff’s office. The names weren’t included in the agency’s response because death was pronounced outside jails, so they weren’t considered inmates, even though the commission is reviewing the deaths, a commission spokeswoman wrote in an email to Investigative Post.

Wischerath said she isn’t confident that the state has a complete list.

 “It’s missing two that we know of,” said Wischerath. “There may or may not be more out there.”

“It should be publicly reported”

Investigative Post tallied deaths by looking through media reports and state records obtained by Wischerath. Acting on a tip, Investigative Post also confirmed that Ramon Frazier, a holding center inmate died on June 1. Frazier, 49, succumbed to cancer, according to a GoFundMe page set up by his family. 

Amoia, of the sheriff’s office, declined comment on Frazier’s death. The state Commission of Correction refused to provide any details.

“In several years of following the issue, several people have quoted different figures,” said Colleen Kristich, a senior community researcher with Partnership for the Public Good, a nonprofit think tank that’s advocated for better health care in county lockups. “There never has been a concrete reporting of all the deaths. A lot of times, they’re not reported at all.”

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The death of Shaun Humphrey last year wasn’t publicly reported until six months afterwards, when it was ruled a homicide due to asphyxiation. The attorney general’s office issued a press release announcing that Humphrey had died after holding center guards tried handcuffing him while he was lying prone.

The sheriff should be required to make public all jail deaths, not just report fatalities to the state, Kristich said.

“I’m actually shocked that it’s not,” she said. “That should be a law, that it should be publicly reported.”

Howard, the former sheriff, told Investigative Post that he couldn’t talk about deaths because there might be pending litigation. Nor would he talk about cases that didn’t result in lawsuits.

“I’m not interested in talking about any of them,” Howard said during a brief phone call.

State finds problems

When an Erie County inmate has died, the state Commission of Correction found fault with guards, health care providers or both in 22 of the 44 deaths that occurred while Howard ran the county’s jails. Problems ranged from long waits for mental health care to twice failing to treat perforated intestinal ulcers that likely were survivable.

Of the eight deaths under Garcia’s watch, the commission has completed one investigation. The rest are pending.

Under Howard, the death of Joseph Balbulzoski, who died from a stroke in 2007, “was hastened by a grossly inadequate medical care delivery system at the Erie County Correctional Facility,” the commission wrote in its report. 

Lapses included:

• Failure to transfer medical records from the holding center to the correctional facility in Alden.
• Failure to take vital signs after Bulbulzoski began vomiting six days prior to death.
• A licensed practical nurse changing Balbulzoski’s chart after he died.

Twice, inmates died from ulcers that, if properly treated, would have been survivable, the commission found.

David Liddick’s 2014 death from a perforated intestinal ulcer could have been prevented, the commission found, if he’d been taken to a hospital. Instead, he was sent back to his cell after a brief visit to the holding center’s medical unit when he complained of chest and severe abdominal pains. It’s not clear from the commission’s redacted report where or when Liddick died, but the commission reported that he remained at the holding center for 16 hours while his condition worsened.

Five years after Liddick’s death, Joseph Bialaszewski died from complications of a perforated intestinal ulcer. As with Liddick, the state commission determined the death was preventable. Instead of taking Bialaszewski to a hospital when he said his abdominal pain was a nine on a scale of one to 10, he was kept at the holding center, where he was found unconscious in his cell two days before he died, the commission reported in 2020.

Twice, the commission has referred cases to the U.S. Department of Justice for potential criminal prosecution for civil rights violations.

The commission asked federal prosecutors to review the 2012 death of Richard Metcalf, who died after jailers put a spit mask and a pillowcase over his head while he was in a prone position. Both the county medical examiner and the state Commission of Correction concluded it was a homicide, with the state determining that Metcalf was suffocated. An Erie County jury last spring awarded his estate $100 million. The county had rejected a $17 million settlement offer.

There is no statute of limitations for civil rights violations resulting in death. Aryele Bradford, a U.S. Department of Justice spokeswoman, declined via email to comment on the Metcalf case, refusing to say whether the department reviewed the death or why criminal charges haven’t been filed.

Bradford also refused to comment on the case of India Cummings, which the state commission referred to the Department of Justice for possible criminal charges after concluding that her 2016 death after 16 days in the holding center was “homicide by medical neglect.” The county has agreed to pay $3.8 million to settle a lawsuit filed by her mother.

Cummings was denied water while incarcerated and died from a pulmonary embolism, according to the commission, which also found that she suffered acute renal failure, dehydration, thrombosis of leg veins and rhabdomyolysis, a condition in which muscle tissue breaks down and enters the bloodstream. A broken arm suffered during her arrest also went untreated at the holding center, the commission reported.

Commission investigations can stretch years. Ingalsbe’s 2019 suicide that prompted Baskin to lambaste Howard remains under review. Ingalsbe was the last county inmate to commit suicide, according to commission records that document 18 suicides since 2005.

Deaths prompt lawsuits

Of the eight deaths since Garcia became sheriff, the commission has closed one case, determining that Edward Bald, who died in 2022 after extended hospitalization, succumbed to unspecified natural causes. The commission found no fault with anyone affiliated with the jail.

The remaining seven deaths since 2022 have prompted two lawsuits, one from the family of Sean Riordan, who died in 2022 after losing consciousness while withdrawing from alcohol at the holding center, and another from the daughter of Humphrey, whose 2023 death after guards attempted to handcuff him was deemed a homicide by the county medical examiner.

Lawyers for two other families say Garcia should expect more litigation.

Brittany Penberthy, attorney for the family of William Hager, said via email that she’s gathering medical records and soon will sue over Hager’s death last November in the correctional facility, where he succumbed to water intoxication.

Ryan Johnsen, lawyer for the estate of William Henley, who died in 2022 from a fractured neck suffered outside jail that wasn’t diagnosed until he was found unresponsive in his holding center cell, said that he’s finished gathering records and expects to sue soon.

Henley reportedly complained of dizziness and was allowed to sit during his arraignment, according to a 2023 press release from the district attorney’s office, but didn’t complain of pain during a medical exam at the holding center.

“He never said, ‘I have a headache, I feel weak,’” Amoia said. “He was on the phone that night. He never mentioned it to people on the phone.”

“It clearly isn’t working”

Garcia has said that he’s committed to improvement.

At the request of the county and the U.S. Department of Justice, a judge last year terminated a 2011 consent decree created to improve mental health services and medical care. The decree ended after court-appointed monitors in 2020 and 2021 declared that county lockups had met standards for at least 18 months.

“We are adhering to the best practices as identified by experts around the country,” Garcia said in his May press release when the department won accreditation from the National Commission on Correctional Health Care.

Erie County Sheriff John Garcia. Photo by Garrett Looker.

Accreditation came after the sheriff fixed problems found by commission inspectors last October, according to inspection reports.

Inspection reports obtained from the sheriff’s office under the state FOI Law reference only the holding center. Amoia said the reports also cover the correctional facility in Alden. Inspectors found deficiencies that were later corrected, including inadequate medical and mental health screenings of inmates and failure to fully vet health care providers.

“We had to run everybody that we had,” Amoia said. “We didn’t find anything, thank God.”

Accreditation and consent decrees and oversight from afar don’t go far enough, said Kristich, of the Partnership for the Public Good. 

“It clearly isn’t working,” she said. “It isn’t something that should have to go to the attorney general or the federal government. It should be something local.”

Patterns are apparent, Wischerath said.

“When someone dies alone in the jail from a preventable disease based on inadequate care or treatment, when they’re there for a small, minor crime, which so many are, that’s just a systemic problem that everybody should know about and everybody should care about.” 

Bruce Rushton