Report: Jail death “may have been preventable”

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Story updated Dec. 8.

Sean Riordan’s death might have been prevented if he was given proper medical care while an inmate at the Erie County Holding Center in 2022, a state oversight commission has concluded.

Instead, the holding center staff failed to transfer Riordan to a hospital for alcohol withdrawal treatment, and failed to provide adequate care while he was in the jail, the state Commission of Correction concluded in a newly released report.

There were “serious deficiencies” in Riordan’s medical care during his incarceration that might have contributed to his death, according to the report.

“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 report states.

In a second report released last week, the commission questioned why medical staff didn’t recognize inmate William Henley suffered from “significant traumatic injuries” when he was admitted to the holding center in November  2022.

“Injuries on Henley, which were ultimately terminal, were not identified by the nursing staff who performed Henley’s assessment,” the Commission of Correction wrote in its report on Henley’s death.  “Had these injuries been able to be potentially identified, the necessary medical treatment could have been obtained.”

Sean Riordan

Riordan and Henley were the second and third of eight inmates to die since Erie County Sheriff John Garcia took office in January 2022. At least 57 Erie County jail inmates have died since 2005, with the most recent June 1, 2024, according to an Investigative Post report. 

Riordan was arrested in the Town of Tonawanda June 2, 2022, on an outstanding warrant for driving without a license and criminal impersonation. He was remanded to Erie County Holding Center in lieu of $5,000 bail.

Riordan was dead less than two weeks later, on June 14, his 30th birthday.

“It’s another shocking example of medical and deliberate neglect of inmates,” said Melissa Wischerath, an attorney representing Riordan’s family. “If Sean had been seen by any other medical provider, he would have been alive. What’s shocking about this document is how many times they had the opportunity to get him to a hospital.” 

Henley, 57, was arrested by Buffalo police Nov. 26, 2022 on burglary and weapon possession charges. He was remanded to the Erie County Holding Center later that day without bail. Henley was found dead in his jail cell the next morning.  Henley’s family also filed a lawsuit,  alleging Henley would still be alive is he received proper medical care from Buffalo police and the holding center staff.

The Erie County Medical Examiner’s office previously ruled Henley’s death resulted from a compression fracture to his neck caused by “blunt force injuries.” The Erie County District Attorney’s office said Henley received those injuries in a fight prior to his being arrested. Henley’s assailant was convicted last year of assault.

Because Riordan and Henley died at the holding center, their deaths become the purview of the state Commission of Correction. With its Medical Review Board, the commission  is charged with investigating the causes and circumstances of all inmate deaths in New York. The commission is also tasked with making recommendations to improve quality and availability of medical care inmates receive.

The commission is requiring the Erie County sheriff as well as the jail physician review the way the Riordan and Henley cases were handled in jail, and  report back to the commission as well as the chair of the Erie County Legislature. In Henley’s case, the commission is also calling for a review of EMS procedures.

The sheriff’s office did not respond to a request for comment.

Erie County Attorney Jeremy Toth declined comment, citing ongoing litigation. But in its report on Riordan, the Commission of Correction said the county attorney refuted some of the commission findings, although the commission mentioned no specifics.  The county attorney also said the sheriff’s office had conducted its own independent investigations into the Riordan and Henley cases, and found no policy violations, according to the commission reports. The commission’s Medical Review Board, however, “remains affirmed in its findings and actions required.”

Riordan’s time at holding center

Here’s what happened when Riordan was at the holding center, according to the commission report:

• Riordan complained of being nauseous and vomiting when brought to the holding center on June 2, but the jail staff underscored his detox screen, which kept him from being transferred to the Erie County Medical Center for alcohol withdrawal assessment and treatment. Instead, he was placed in a housing unit at the holding center.
• The following morning, Riordan was transferred to a detox unit within the holding center. A deputy there reported Riordan was very agitated, and could be heard throwing up. That evening, Riordan reported he was throwing up blood. He was taken to the jail medical unit, and later seen by a nurse, who said he was fine.
• Riordan didn’t sleep that night. One of the deputies reported that Riordan was disrupting other inmates, so he was transferred out of the detox unit.

Moving Riordan was “detrimental in the continuity of care,” according to the commission report, which states Riordan was experiencing signs of alcohol withdrawal and should have been transferred to a hospital for evaluation and possible treatment.

• The following day, on June 4, he fell after complaining of dizziness, dehydration and nausea.

The commission’s medical review board found that “nursing staff failed to appropriately respond and manage Riordan’s obviously worsening symptoms” and should have notified the jail physician or sent him to the hospital, the report states.

• The next morning Riordan refused breakfast, and fell over again. The deputy called for a medical emergency, and a nurse checked his vitals. Riordan said he didn’t know what happened. 

“I was talking to the nurse and all of the sudden I passed out,” he reportedly told staff. A few seconds later he fell a second time, and staff brought a wheelchair to take him to medical; he couldn’t get dressed himself, fell a third time, and his body began to stiffen.

• Medical staff called EMS and put Riordan down on a mattress. They gave him an oxygen mask but he was still not responsive to staff. 

“At this time, Riordan should have been assisted with his respirations,” the report states, and a defibrillator should have been used. The next part of the report is heavily redacted, but describes EMS responding and taking him to an ambulance.

The commission report provides no further details on Riordan’s condition.

However, a lawsuit filed by Riordan’s family states he was declared brain dead at the hospital and removed from life support nine days later, on his 30th birthday. 

Henley’s time at holding center

One of Henley’s neighbors called police about 11 p.m. on Nov. 25, 2022 to report an attempted burglary. Before police arrived, the commission reported, Henley got into a  fight with another of his neighbors, who picked Henley off the floor and pitched him headfirst into a metal electrical wall panel about three feet off the ground.  The attacker then hit Henley in the head and torso with steel-toed boots. When the fight ended, Henley was seen getting up off the ground and walking away, according to the commission report.

Henley was arrested at 2:35 a.m. Nov. 26. The Commission report makes no mention of it, but then-Erie County District Attorney John Flynn previously said Henley “allegedly reported dizziness and was permitted to sit “ when arraigned in City Court later that day,  but that Henley did not report any medical concerns or complaints during his jail admittance assessment exam. The publicly released commission report — parts of which are redacted — does not detail what occurred in the entrance screening when Henley arrived at the holding center, except to note that nursing staff did not identify any injuries, and that Henley told jail staff he was having financial problems because he was not collecting his unemployment. He was assigned to a unit with security tours every 15 minutes, the report says.

Here’s what the commission report says occurred after Henley arrived at his holding center housing unit:

• Henley made a 10-minute phone call at 4:35 p.m. on Nov. 26. He didn’t mention having any injuries or being in any pain during the conversation.
• Deputies reported Henley refused a meal tray at 5 a.m. the next morning. When lunch was delivered at 10:45 a.m., a deputy noticed Henley didn’t get up for his food tray. The deputy tried several times to wake Henley, but was unable to. A medical response, including an EMS ambulance, was called.
• The ambulance arrived at 11:05 a.m., and began performing life-saving measures. At the time, Henley had signs of advanced rigor mortis indicating his death occurred at least four hours prior to their arriving at the scene.

“ACLS (Advanced Cardiac Life Support)  measures along with the LUCAS (chest compression) device should not have been initiated on Henley who had obvious sigs of death,” the commission wrote.

The Henley and Riordan lawsuits are among several currently filed against Erie County by families whose loved ones died while inmates at the Erie County Holding Center in downtown Buffalo or the Erie County Correctional Facility in Alden. Three lawsuits were filed last month alone by the families of  Henley as well as James Ellis, 58, who died in November 2021, and William Hager, 44, who died in November 2023.

The jail has been criticized for not making improvements to address jail deaths. Last month Erie County rejected a plan to build a new jail, citing the $700 million cost. 

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

But lawsuits filed by the Riordan and Henley families argue not enough has been done to prevent jail deaths.

“The big picture is that individuals are dying,” said Wischerath, the Riordan family attorney. “We’re seeing a pattern that [the review board] is telling the county to do better. But nothing is changing.”

I'Jaz Ja'ciel