Niagara County Coroner Joseph V. Mantione had never seen anything like what he encountered in the emergency room of DeGraff Memorial Hospital on the night of Oct. 10, 2014.
He was summoned that night to the North Tonawanda hospital to officially pronounce the death of a 46-year-old Amherst man who had been stricken with a heart attack while shopping at a Tops supermarket in the City of Tonawanda.
A hospital doctor had declared Michael E. Cleveland dead. But Mantione saw Cleveland breathing with his eyes open despite an oxygen tube in his mouth, according to his deposition transcript obtained by The Buffalo News.
"He's been doing this for an hour," Tammy Cleveland, the man's wife, told Mantione.
"It was something I hope to never see again," Mantione said in a brief interview with The Buffalo News.
State Supreme Court Justice Frank Caruso is scheduled to hear arguments Thursday from attorneys for Kaleida Health and Dr. Gregory C. Perry, the emergency room doctor that night, to throw out Tammy Cleveland's malpractice lawsuit. A trial is scheduled for April in Tammy Cleveland's lawsuit against Perry and Kaleida Health.
Kaleida Health owns both DeGraff Memorial and Buffalo General Medical Center, where Michael Cleveland died the next morning.
Perry's attorney, Brian Sutter, declined to comment for this story, as did Kaleida Health.
"This issue is currently in litigation, so we cannot discuss it at this time," Kaleida spokesman Michael P. Hughes said.
The suit claims that Michael Cleveland's life could have been saved if better or more prompt treatment had been provided.
"Michael Cleveland was a living, abandoned patient for two hours and 40 minutes," charged Charles F. Burkwit, Tammy Cleveland's attorney.
Instead, Perry didn't act on several requests to check Cleveland again for almost three hours, the suit alleges. Some of those requests came from Mantione.
"Dead people don't move. He needs to go in there and check his pulse," Mantione told the ER staff, according to his deposition.
After he was confirmed to be alive, Michael Cleveland was transferred to Buffalo General Medical Center. He died the next morning.
Dr. William M. Morris, a cardiologist who treated Cleveland at Buffalo General, also was named as a defendant in the original malpractice lawsuit, but all sides agreed in December to delete him from the case.
"The doctor had done everything appropriately and wasn't able to salvage the patient," said Morris' attorney, J. Mark Gruber.
Morris' affidavit said that when Michael Cleveland arrived at Buffalo General, he was "unconscious but agitated."
Morris wrote that the patient was in shock. He had a fully blocked coronary artery, a collapsed lung and fractured ribs. The latter two injuries apparently stemmed from attempts at cardiopulmonary resuscitation by first responders.
"There was nothing I could do with regard to the fact that before the patient had ever come under my care, he had suffered a major heart attack, had undergone a prolonged period of resuscitation and had suffered a prolonged period of cardiogenic shock," Morris wrote. "Only time would tell if the help we had provided his body would be sufficient to overcome those shocks to the system."
Mantione said he did not see Tammy Cleveland confront the ER team. The coroner said he did that himself.
"She wasn't irate. She was calm and fine," Mantione said of Tammy Cleveland's demeanor in the emergency room, as she held her husband's hand.
He testified that Tammy seemed most angry that Michael, a diabetic, hadn't taken better care of himself.
Burkwit, her attorney, denied that.
"My client never, ever told the coroner that," Burkwit said.
He said depositions from other witnesses state that Tammy was indeed angry and upset.
In Tammy Cleveland's deposition, she testified that she asked Mantione, "Are you here to prove my husband's dead? Because look at him."
The coroner testified that he confronted Perry and other members of the staff.
"I was loud. I thought it was an emergency situation," Mantione said.
But no one went to check on the man, so Mantione went back into the room himself.
He saw that Cleveland's skin, which had been grayish, became paler, and his chest was red. He also saw Cleveland gasping and moving his arm.
After he saw that, Mantione said that he declared, "Dead people don't move," and Perry went into the patient's room. The doctor returned about 15 minutes later and said there was no pulse, Mantione testified.
Mantione also testified that he talked to Perry about the breathing he had seen.
"He said that eventually the drugs will wear off and then he would stop," Mantione said in his deposition.
Mantione said he told the ER team twice that he was not going to take Cleveland's body until he stopped moving, and he left.
After he received a call a short time later from a nurse that Cleveland had "awakened," Mantione said he drove back to DeGraff.
"The reason I came back was I wanted to see what had happened," he said in an interview.
When he returned to the emergency room, Mantione said, he was confronted by Michael Cleveland's brother-in-law, who slammed him against a wall and demanded answers about what had happened. Mantione said he convinced the man the situation wasn't his fault.
He then went into the ER and saw Michael Cleveland "thrashing" on a gurney as a nurse's aide tried to hold him down.
"He was like literally trying to get up," Mantione testified.
He said he heard Cleveland "screaming" through the tube that was still in his mouth.
"I can't believe this is happening," a nurse said, according to the coroner.
Mantione said he then left, because his services were no longer required. But he went home and immediately wrote down what he had seen.
"I had a feeling this was going to happen," he said during his deposition. He said in an interview that was a reference to likely litigation.