The inmate health care provider at Nassau County's jail may have prevented an Oceanside man's 2014 death if not for "incompetent and deficient" medical treatment, according to a state commission, which also found a pattern of negligent care at New York facilities where the company has contracts.

Those findings from the State Commission of Correction came in a report focused on the death of inmate John Gleeson, 40, an electrician and father of two. He suffered from angioedema, a condition in which bouts of swelling can escalate into breathing emergencies.

After the probe into his July 14, 2014, death, the commission has now also broadly criticized Armor Correctional Health Services, the Miami company that first won a multimillion-dollar Nassau contract for inmate medical care in 2011.

"Had John Gleeson been provided with competent medical care by Armor Inc. in a timely manner, been properly referred to a specialist, received a correct diagnosis, and received proper medical treatment, his death may have been prevented," says the report Newsday obtained Monday.

The report also questions Armor's ability to meet the health care needs of inmates where it holds contracts in New York, saying the company "has engaged in a pattern of inadequate and neglectful medical care." The agency also directs Nassau's legislature to do its own inquiry into the company, including its pattern of "failing to provide hospitalization" for patients who need it.

James Pascarella, an attorney for Gleeson's family who previously filed a notice of claim against the county and Armor, said the "disturbing" findings in Gleeson's case weren't a surprise.

"It's what our investigation has led us to conclude," the Mineola attorney said. "It's disturbing to hear that this could have been prevented had Armor been diligent."

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The late inmate's father, retired FDNY battalion chief John Gleeson, said the report "was like a stab in my heart," adding: "What I can get from it is what we felt all along, that if they had taken proper action, there's no doubt in my mind my son would be alive today."

In response, an Armor spokeswoman said the company has a record of providing quality health care to more than 40,000 inmates in eight states, but couldn't discuss a specific inmate case due to a privacy law. The company said it has averaged 56,000 annual patient encounters in Nassau.

Its website shows it has a contract with Niagara County.

Armor's statement

"Unfortunately, health care providers in the corrections setting are subject to significant and frequently unfounded allegations and legal actions. During our 11 years of service the overwhelming majority of allegations made against Armor have been unfounded. No jury has ever found Armor guilty of medical malpractice," it said.

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Capt. Michael Golio, a spokesman for Nassau Sheriff Michael Sposato, said Armor's contract enhanced jail security and public safety by significantly increasing the health services provided on site, adding: "It is our understanding that Armor provided a detailed response to the [state] regarding their allegations in this case."

Gleeson pleaded not guilty to burglary on the day he died. Other Nassau jail inmates had said Gleeson's throat swelled dramatically in the hours before his death, and one said he complained of serious breathing trouble, Newsday reported in August. That story said Gleeson had told inmates he got Benadryl in the medical unit before being sent back to be locked in his cell for the night.

Gleeson's family, and one of those inmates, also told Newsday that Gleeson made repeated trips to the medical unit on the day he died. His father had accused officials of letting his son "suffer and die," despite having treated Gleeson for swelling earlier in his incarceration and knowing about the deadly risk of angioedema.

Gleeson's death certificate shows he died at nearby Nassau University Medical Center at 11:20 p.m. after his throat swelled shut; that he couldn't breathe; and that his heart and lungs failed. But the state's report, while heavily redacted, confirms he did seek care hours earlier. It says Armor officials "lacked the medical knowledge" that the treatment they gave Gleeson at 3 p.m. would be ineffective, and Gleeson could have gotten a proper diagnosis and treatment if sent then to a hospital.

The report says Gleeson returned to his jail unit at 9:25 p.m. after another medical visit, and says "unresolved symptoms" should have prompted a doctor exam and for medical staff to consider an "immediate transfer" to a hospital.

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Witnesses previously told Newsday that the jail tier erupted with noise about 9:45 p.m., with inmates trying to summon correction officers after Gleeson apparently signaled for help from his cell after the tier's lockdown. The state report says a correction officer told officials Gleeson's head "was all swollen and blue" when he walked to the medical unit at 10:16 p.m. It also shows an ambulance arrived at the jail at 10:40 p.m., taking him to the hospital at 10:56 p.m.

Incomplete records

The commission concluded that problems with Armor's treatment of Gleeson included deficient medical knowledge on the part of its doctors and midlevel clinicians, compounded by problems created by unorganized and incomplete health care records.

The report follows the state's criticism of Armor after one Nassau inmate died in 2011 and another died in 2012.

It directs Norma Gonsalves, the county legislature's presiding officer, to have lawmakers do an inquiry into Armor's fitness to provide inmate medical care, something it advised the county executive's office to do after the 2011 inmate death.

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"Specific attention shall be directed to Armor's pattern of failing to properly manage patients' chronic medical needs, failing to maintain proper and organized patient records, and failing to provide hospitalization for patients when clinically indicated," the report says.

Speaking for Gonsalves, GOP legislature spokesman Frank Moroney said officials had asked the commission for more information, including background materials related to Gleeson's case "to make a determination as to what steps, if any, we're going to take next."

But Legislative Minority Leader Kevan Abrahams called for an immediate suspension of Armor's contract -- just renewed in June -- followed by a public hearing and an audit of state findings. "I don't see how, in good conscience, we can continue to have Armor knowing full well the findings of the state," he said.