The Erie County Holding Center's top staff concealed details about the treatment of inmate Richard Metcalf Jr. when a state agency began to inquire about his grave medical condition.
The Buffalo News obtained reports and correspondence that suggest the Commission of Correction's staff went days without knowing that jail deputies had knotted a "spit mask" around Metcalf's neck and pulled a pillow case over his head, preventing him from taking a breath.
The Commission of Correction now says jail deputies suffocated Metcalf, and he was in full cardiac arrest when wheeled into an ambulance around 11 p.m. Nov. 28, 2012. He did not die of a heart attack, as a former medical examiner found, the commission says. It urges the Erie County district attorney to begin a criminal probe and the U.S. Justice Department to begin a civil rights investigation.
Sheriff Timothy B. Howard and his staff have said little about the death, except that they dispute the commission's findings. Records show they were similarly guarded as the Commission of Correction, the state agency that regulates local jails and investigates inmate deaths, began to inquire about Metcalf's status four years ago. The commission's personnel began asking questions after The Buffalo News contacted them in a search for information about a life-threatening event involving a Holding Center inmate.
Eighteen hours after ambulance medics cut off the tightly bound spit mask and found Metcalf's face bloated and cherry-red, here's what the commission's staff knew from Holding Center officials about the inmate's swift transition from jail to coma:
"At some point it was decided that he needed to be hospitalized," one commission official says in an email to the top echelon in Albany. "I am unclear about what precipitated this decision. Erie [Holding Center] had him transported by ambulance and while in route, ECHC medical staff think he may have gone into cardiac arrest..."
The commission's staff seems to know nothing about the spit mask or the pillow case, or that Metcalf has four broken ribs and bruises around his body.
Holding Center personnel could have revealed more in a brief report dated Nov. 29, 2012, and sent to the Commission of Correction because an inmate had been hospitalized. But that "incident report" also did not mention restraint devices.
On Nov. 30, Metcalf still showed no brain activity as he lay in Erie County Medical Center. Jail officials then released him from their custody. He was pronounced dead at 5:17 p.m. that day, a Friday.
The following Monday, Dec. 3, 2012, Holding Center Superintendent Thomas Diina called a Commission of Correction contact to say Metcalf was dead. Facility Specialist Cynthia Diaz then relayed Diina's information to her supervisors:
"During the ambulance ride an 'event' occurred," she wrote. "...Diina did not know all the details but believes it was a cardiac issue." Diina assured her that an autopsy showed the inmate died of a heart attack. Again, there was no apparent mention of the restraint devices.
As state regulations were written at the time, Diina technically did not have to report Metcalf's death to Albany because Metcalf had been released from custody. Diina also would argue in a letter that he shouldn't have to file the standard death report because, as his preliminary investigation showed, Metcalf died of a heart attack caused by an existing medical condition.
But when the commission's operations director, James Lawrence, directed Diina to produce the form for an inmate death, he complied within hours.
A Holding Center captain filled out the form and described the circumstances: "Inmate acting bizarre. Picking at scabs, slamming head into bars, spitting blood." The captain wrote that the inmate was taken by ambulance to a hospital and that he "reportedly suffered heart attack and died..."
The captain did not mention use of a spit mask or a pillow case.
In total, there were two conversations with commission employees, two official reports and a letter from Diina to Lawrence - five occasions - when he or some jail official could have revealed, early on, that restraint devices might have played a role in Metcalf's demise. But the record shows those facts were not disclosed.
A Commission of Correction spokeswoman said the agency did not want to comment on whether Erie County officials were candid with its employees in November and early December 2012. The commission prefers to let its 25-page report serve as its comment on Metcalf's death, spokeswoman Janine Kava said.
An attorney for Metcalf's family believes the Holding Center officers are doing damage control.
"There is no question," said Jim Brown of the Brown Chiari law firm, one of the lawyers handling a wrongful death lawsuit against the county. "Obviously they don't want anybody to know. This was not a full disclosure of his condition."
Deputies were bent on blaming Metcalf for everything, Brown said. Minutes after Metcalf was carted off in the ambulance, jail deputies were preparing papers to charge him with spitting blood on one of their trousers, Brown said.
Investigations by the State Police and the Commission of Correction revealed that Metcalf went through an ordeal at the hands of his jailers, and his death could not be simply attributed to a heart attack. The 35-year-old store clerk was being held on a burglary charge after breaking into a restaurant to cool off in its walk-in refrigerator. In the Depew Police Department's lockup, he smeared feces and he had to be showered when he arrived at the Holding Center on Nov. 27, 2012. Some kind of altercation occurred during the shower, and he was soon taken to ECMC for an evaluation and treatment.
When back at the jail, he went into a general population cell. On the night of Nov. 28, 2012, a jail deputy saw him stabbing at himself with a plastic fork. Deputies also told investigators he was throwing himself against the bars. He was repeating the words "radioactive" and "slaughterhouse." Deputies, intending to get him some help, tried to bring him to the medical unit but he refused. So they began a "cell extraction."
As they forced him from the cell and wrestled him to a medical examination room, he began spitting blood, investigators were told. Deputies put him face down on an examination table and wrapped a spit mask around his head, binding it at the neck, the commission said. When Metcalf chewed through the mask, a pillow case was placed over his head, even though pillow cases are not to be used for such a purpose, the commission said in its report on the death.
The deputies then placed Metcalf face down on an ambulance stretcher, making it even harder for him to breathe. Rural/Metro medics asked that the masks be removed so they could examine him, but jail deputies refused, the commission said in its report. They also insisted Metcalf remain face down on the stretcher, according to the report. But when questioned by investigators weeks later, some deputies tried to say the Rural/Metro medics wanted Metcalf face down. The commission said it did not believe the deputies.
At some point, as deputies wheeled Metcalf to an elevator, then to the ground floor and finally out to an ambulance, he stopped breathing. Inside the ambulance, the two medics were allowed to remove the pillow case and cut off the spit mask. They found Metcalf in full cardiac arrest and rushed him to the nearest hospital, Buffalo General Medical Center. He was later transferred to ECMC.
While the medical examiner at the time, Dr. Dianne Vertes, found that Metcalf died of a heart attack, she also said the traumatic injuries he received, the stress and a liver condition contributed to the death. She eventually labeled it a homicide, but then-District Attorney Frank A. Sedita III decided not to press charges. His temporary successor, Acting District Attorney Michael J. Flaherty Jr., is considering whether to begin a criminal investigation.
A county legislator, Democrat Pat Burke of Buffalo, wants the sheriff to speak to the Legislature about what happened. But it's doubtful Howard will show. His team has cited the wrongful death lawsuit as pending litigation that prevents them from answering questions about the episode. A Howard spokesman, when delivered a list of questions for this article, said that "on advice from counsel, the Sheriff's Office cannot comment."