Report Finds Shortcomings In Inmate Treatment Before Death

Chautauqua County Jail. P-J file photo

A review by the state’s Medical Review Board found the Chautauqua County Jail failed to meet standards of care for an inmate who died by suicide in September 2021.

Several questions were posed in the Commission of Correction report released late last year regarding the death of 31-year-old Jose Rivera-Perez.

Click here to read the report

The board, which reviews all inmate deaths in New York’s jails and prisons and reports to the commission, found shortcomings in Rivera-Perez’s mental health and psychiatric treatment during his 145 days of incarceration.

“The Medical Review Board has found that there were significant lapses in the continuity of care pertaining to Rivera-Perez’s mental health and psychiatric care and a lack of collaboration of care between the medical and mental health staff,” the commission wrote in a 14-page report, pages of which are redacted to remove personal information.

A native of Puerto Rico, Rivera-Perez had been admitted to the Chautauqua County Jail on April 15, 2021. His booking at the Mayville facility came more than a month after he was accused of stabbing his mother’s boyfriend several times during an altercation March 11 in Dunkirk.

The victim was transported by helicopter to an Erie, Pa., hospital.

According to the report, Rivera-Perez suffered a self-inflicted, deep laceration to his left hand. He also was transported to Erie for treatment.

While still in Pennsylvania, the Dunkirk man was taken into custody on a fugitive from justice charge; back home, he was wanted by Dunkirk police on an active warrant for aggravated assault.

Rivera-Perez was eventually admitted to Erie County Prison where he spent 36 days before being extradited to New York.

In a questionnaire at the Chautauqua County Jail, Rivera-Perez reported having a history of counseling or mental health evaluation and treatment. A corrections officer notified a supervisor and a non-emergency mental health referral was made.

Rivera-Perez reported he did not have a history of suicide attempts.

In five months at the jail, he was diagnosed with five disorders; there also were multiple psychiatric medication changes ordered by a physician assistant without consultation or any assessment by a psychiatrist, the commission reported.

He was found unresponsive in his cell by a sergeant around 4 a.m. on Sept. 7, 2021. Though CPR was immediately started and local EMS was contacted, Rivera-Perez was later pronounced dead. The cause of death was suicide by hanging from a beds sheet.

An investigation by the state Attorney General’s Office found no fault by jail staff in regard to Rivera-Perez’s death.

“Anytime an incarcerated individual displays signs of self-harm or expresses concerns of self-harm they are placed on constant watch and see mental health counselors and the jail psychiatrist,” Sheriff James Quattrone told The Post-Journal in a statement.

However, the Medical Review Board concluded that the jail’s “standard of psychiatric care was not adequately met” for the 31-year-old inmate. In the report, the board believes Rivera-Perez’s increasing mental health symptoms should have been referred to the psychiatrist for review and consultation.

Rivera-Perez’s stay at the jail and his exact care are difficult to track due to pages of redacted information. The report does note that in his first two months at the jail he requested several moves.

At one point, on July 8, 2021, he asked to be placed in protective custody, only to then refuse it and later be moved to administrative-segregation protective custody. He remained there until his suicide on Sept. 7, 2021.

Among the report’s requirements to the jail physician:

A quality assurance review of the physician assistant regarding the “multiple mental health diagnoses and medications prescribed to Rivera-Perez without any consultation with the jail’s coordinating psychiatrist … and why changes to prescribed psychotropics were not released.”

An investigation why Rivera-Perez was not immediately referred to psychiatry despite “having a history of and presenting acute psychiatric symptoms.”

A review with medical and mental health staff to ensure that charts are reviewed and adequate psychiatric consultations are made for patients.

The commission also asked the Chautauqua County Legislature to review the report and “conduct an inquiry into the fitness of the currently designated provider.”

In response to the commission’s preliminary report, the Sheriff’s Office said reviews were conducted “with corrective actions taken.” Those actions were not detailed in the report.


Quattrone said the jail reports any suspected suicide attempt to the state Commission of Correction whether there is injury or not. He said the jail saw an increase in suicide attempts in 2020, 2021 and the first part of 2022.

That trend, though, appears to have subsided.

“Over the past nine months we have had a significant reduction in suicide attempts and incidents in the jail,” Quattrone said.

In the last three years, the sheriff said, the jail’s medical and mental health staff have observed more severe illnesses — both medically and mentally — among incarcerated individuals being admitted.

“This is often as a result of the incarcerated individuals not obtaining regular medical care while not in jail,” Quattrone said.

The Chautauqua County Sheriff’s Office — in partnership with the county Department of Health and Human Services, Public Health and county Office of Mental Hygiene — have been going through the process of accreditation with the National Commission on Correctional Health Care. It’s a process and accreditation that goes “far above the minimum standards required by New York State Commission of Corrections,” Quattrone said.

He added, “Chautauqua County will be one of a handful of jails in New York state to achieve this accreditation. This has not been awarded as of yet, however, the final assessment was done and we await confirmation later in the year. In an exit interview with the assessors, we were informed that we had met the standards. After confirmation from the NCCHC Board, we anticipate being awarded accreditation.”


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