The Nassau County jail’s former medical vendor failed to provide adequate health care treatment, directly resulting in the deaths of three inmates last year, a state oversight agency has found.
The New York State Commission of Correction’s critical findings in the three fatalities come as the county and the vendor, Armor Correctional Health Services, are fighting four federal lawsuits connected to other Nassau inmate deaths. The Florida-based, for-profit company’s more than six-year role at the jail ended Aug. 31, before Nassau University Medical Center resumed control of inmate health care under a two-year contract.
The state commission concluded after investigating the 2016 deaths of three Nassau County jail inmates that Armor was “incapable of providing competent medical care.” It found one of the fatalities preventable, that a doctor didn’t recognize another inmate was suffering from cancer and that medical staff committed “professional misconduct” and acted with “gross incompetence” while treating the other late inmate, records show.
Documents obtained under the Freedom of Information law also show Nassau Sheriff Michael Sposato and county Legislature Presiding Officer Norma Gonsalves were aware of the commission’s then-preliminary findings in the trio of deaths when County Executive Edward Mangano’s administration pitched a three-month Armor contract extension in May that a legislative committee then approved.
The state commission came out with three final reports after investigations into the 2016 deaths of William Satchell, 63, Emanuel McElveen, 20, and Michael Cullum, 62. State officials heavily redacted portions of the reports, including some of the medical information, claiming privacy exemptions under the law.
But in each case, the agency’s final reports on the fatalities cited “systemic deficiencies in the delivery of adequate medical care,” and Armor’s “continued failure and unwillingness” to address problems after the commission’s probes into inmate deaths since mid-2011.
“The Board has found in each instance that failures of Armor Inc.’s staff to perform to minimally accepted community medical standards has directly resulted in these terminal outcomes,” commission Chairman Thomas Beilein wrote in a March letter to Gonsalves (R-East Meadow), referencing the then-preliminary findings.
Records related to the reports also show the recent investigations led the commission’s chairman to conclude that the Sheriff’s Department shares responsibility with Armor for failing to initiate meaningful reforms after previous jail custody fatalities.
Nassau County Attorney Carnell Foskey released a statement Friday in response to Newsday’s requests for comment from the sheriff and county executive.
“As there is presently litigation of certain inmate deaths it is best that the ongoing legal process address these issues. The county takes the death of inmates seriously,” Foskey said.
He added that Mangano’s administration believes the county “will be found to have acted in the best interest” of inmates “to ensure their health and safety.”
The commission has found Armor provided inadequate care in at least eight of the 14 Nassau inmate deaths during the company’s tenure. The commission found four of the fatalities, including Satchell’s death in March 2016, may have been prevented. The panel still is probing four of the deaths. The commission found no treatment inadequacies in two of the deaths — one involving a natural death by stroke and one a deadly assault by another inmate.
Armor has contested the commission’s findings, insisting its staff showed no negligence or incompetence in connection with its care of Satchell, McElveen and Cullum.
“As in the past on other matters, we believe our staff took appropriate action and their care and treatment in these three matters did not contribute to the demise of the patients,” Armor executive Karen Davies wrote in a May letter to the commission.
Armor spokeswoman Teresa Estefan said Friday that the company stood by its responses to the commission.
The report on Satchell’s death said the inmate died March 24, 2016, from cardiac arrest due to an artery blockage in his lungs while getting treatment at Nassau University Medical Center. The Hempstead man, a retired janitor, was in jail after an arrest a week earlier on marijuana and weapon charges.
The commission concluded the death of the father of four “was preventable if not for the shocking level of inadequate medical care and negligence of the medical staff” of Armor. It said Armor repeatedly failed to recognize “life-threatening manifestations” of “a new onset medical condition” — or diabetes.
Armor also made a “definite medication error,” giving Satchell an antipsychotic known to increase blood sugar level and possibly sparking the onset of his “unstable condition,” the commission found.
It further said Armor “grossly mismanaged” Satchell’s high blood pressure and delayed seeking emergency hospital care for “a critically unstable” patient, which was “contributory to his death.” It requested state offices to investigate an Armor doctor for gross incompetence and an Armor nurse practitioner — whose identities were redacted — for gross incompetence and professional misconduct.
Satchell’s family couldn’t immediately be reached for comment on the findings.
As part of a now-settled lawsuit against Armor, New York Attorney General Eric T. Schneiderman alleged in 2016 that Satchell didn’t get medication until three days after his jailing and the company’s failure to do a routine screening led to a delay in Satchell’s diabetes treatment.
That investigation alleged wide-ranging deficiencies in inmate care. Armor settled the suit by paying a $350,000 fine, agreeing to a 3-year ban on new business in New York and admitting no wrongdoing.
The commission’s report on McElveen said the inmate died July 5, 2016, of respiratory failure. It concluded the former Hempstead and Roosevelt man’s death was caused by a pre-existing medical condition, but Armor’s failures “were contributory to his worsening health.”
The report said Armor didn’t adequately identify and treat his illnesses, recognize and treat serious changes in McElveen’s condition, follow up properly on medication issues or adequately answer his sick call requests. The report shows one of the illnesses McElveen had was large cell lymphoma, or cancer, involving multiple organs.
The commission also concluded an Armor doctor — whose identity was redacted — failed to provide proper medical supervision, didn’t do thorough exams and missed follow-ups on lab tests and exams, failing to detect McElveen’s developing cancer. Records show McElveen had been serving a one-year jail sentence after a February 2016 guilty plea to a misdemeanor charge of unauthorized vehicle use.
A week before he died, McElveen said in a jail grievance that Armor staff hadn’t seen him after several requests and he had pain all over, hearing loss, swollen feet, facial numbness and an allergic reaction, the report shows.
Pamela Gales, the maternal grandmother of McElveen’s toddler son, said Friday she has believed all along that he didn’t get proper medical care at the jail. “They wouldn’t let him see the doctor,” she said.
Attorney Nicholas Warywoda, who represents Gales’ family, said the inmate didn’t have to die and that Armor staff diagnosed McElveen’s symptoms of cancer as being “moderate malnutrition.”
“This is just another example of Armor getting paid to provide medical care, and they fail to do it, again resulting in someone losing their life,” said the Port Washington lawyer, who in April won a nearly $8 million lawsuit verdict against the county and Armor while representing the family of military veteran Bartholomew Ryan after the inmate’s 2012 jail suicide.
“Manny had a type of cancer which was treatable when he was making the complaints to the doctors and because of their incompetence, he lost his life for something that was treatable and curable,” Warywoda added.
Cullum died Sept. 5, 2016, after a blood clot formed in leg veins and went to his lungs, according to the commission, which said pancreatitis and opioid dependency also were contributing factors to his death.
The commission found Cullum’s death was “impacted” by Armor’s failure to adequately treat chronic illness, recognize and treat serious changes in his condition, provide proper follow-up on treatment refusals and promptly transfer him to a higher level of care.
After the inmate’s death, his sister Dorothy Cullum said he would be alive if Armor “gave him his medication like he should have had.” The family’s attorney, Frederick Brewington, said then that the inmate went more than a week without “his lifesaving medication.”
Brewington said Friday after seeing the commission’s conclusions that the agency’s findings are consistent with the family’s belief that Cullum got poor medical care at the jail. “I’m shocked at the level of neglect and violations that are documented,” he said.
Cullum told authorities after his Aug. 26, 2016, arrest by Glen Cove police on drug charges that he was in a methadone treatment program, records show.
The commission found an Armor doctor showed gross incompetence by failing to see the need to send Cullum to the hospital after significant changes in his condition, and an Armor licensed practical nurse showed unprofessional conduct by breaking detoxification protocol.
The commission also noted an “unacceptable delay” of 4 hours and 40 minutes before a doctor saw Cullum despite his unstable vital signs, and said Armor staff failed to send him to the hospital in a timely manner when he needed emergency care.
The panel asked other state offices to investigate the Armor doctor for gross incompetence and multiple nurses for professional misconduct, and for a probe into Armor’s use of LPNs without proper supervision. The names of the Armor staffers were redacted.
In all three reports on the deaths, the commission said the county should hire a medical contract monitor with the power to penalize the jail’s health vendor for missed performance standards — a position written into the county’s Armor contract, but that New York’s attorney general previously found hadn’t been filled since 2013.
In the Satchell report, the commission also advised the county to appoint an independent medical authority to do a thorough review of jail health care and provide oversight of it.
The three-month extension of Armor’s contract included a 66 percent increase in the company’s monthly rate and came at a time when the county was facing a potential jail health care crisis. Armor had taken legal action to try to enforce the May 31 end of its contract, while the county hadn’t lined up a new vendor.
At a May 22 meeting, the legislature’s Republican-controlled Rules Committee, led by Gonsalves, approved the Armor extension.
The approval happened without any mention from Mangano officials or Gonsalves about the state’s preliminary findings in the three deaths — conclusions that wouldn’t be publicly available until several weeks later after the state’s reports became finalized.
Five days after the contract extension approval, a 58-year-old Nassau inmate died after her lawyer said she complained about not getting blood pressure medication for several days after her jail booking. That fatality remains under probe.
Frank Moroney, a spokesman for Gonsalves, said in a statement Friday that the Armor extension was granted “to effectuate the transition to NUMC” and “there was no other health care provider that could step in during that transition and provide such services.”
The spokesman said the preliminary reports stated that the commission’s reports weren’t final and weren’t available for public dissemination until they were final. “Gonsalves wasn’t allowed to discuss those cases,” Moroney said.
However, records show a letter the commission sent to Gonsalves that accompanied the preliminary reports didn’t prohibit her from releasing some of the information in them.
“You should check with your county attorney or legal adviser prior to releasing any information contained in this report or its attachments, if any,” the letter advised.
Sposato, an appointee of Mangano who runs the jail, responded to the commission’s then-preliminary findings on the three deaths in three nearly identical letters on May 12.
In each, he said the county was “in the process of transitioning facility inmate health care to another provider” because Armor’s contract would expire at month’s end. Sposato also told the state that the county was searching for a candidate to fill a health care contract monitor position, and a Health Department employee was filling the role in the meantime.
In his letters, the sheriff noted that he had attached a copy of the May 12 letter that Davies — the Armor executive — wrote to the commission. Her letter to the commission challenged specifics of the agency’s findings in the Satchell, McElveen and Cullum death reports.
In Satchell’s case, Davies said Armor disagreed that treatment he got at the jail contributed to his death while he was hospitalized.
The Armor official also said the company disagreed that the company’s treatment of McElveen contributed toward his declining health, and added that he got appropriate treatment in jail.
Davies further said the company also denied that Cullum’s death was impacted by care he got at the jail.
“We stand by the work of our caregivers as meeting and exceeding the required standards of care for the patients that we serve at the jail,” she wrote.