Report: Death Of County Jail Inmate ‘Could Have Been Prevented’

Cells are pictured inside the Chautauqua County Jail in Mayville.

Editor’s note: This is the first of two stories regarding deaths of inmates at the Chautauqua County Jail.

It was just after noon on July 25, 2021, when Louis Rivera told a corrections officer at the Chautauqua County Jail he felt nauseous and was sweating.

The complaint from the 65-year-old inmate at the Mayville facility was documented and, by 12:20 p.m., he went to the jail’s medical center.

Twelve minutes later, according to the jail’s housing logbook, his cell was searched for drugs and contraband by the same corrections officer.

None were found.

Louis Rivera died due to acute gangrenous cholecystitis, perforation with localized peritonitis and sepsis.

A resident of Jamestown, Rivera had been jailed on a number of felony drug-related charges. He reportedly admitted his guilt and indicated that the crimes helped support his own addiction.

After entering the Chautauqua County Jail three months earlier on April 23, Rivera complained numerous times of heartburn, a problem that persisted despite medication treatment and diet intervention.

However, about 13 hours after he reported feeling nauseous the afternoon of July 25, Rivera was rushed to Westfield Memorial Hospital. His condition had worsened that day, and by 1:25 a.m. the following morning he was having problems breathing.

A sergeant who had been summoned looked in and could hear there was something in Rivera’s lungs. The sergeant would later say he knew “right away” that the inmate was in trouble.

A corrections officer was with Rivera in the ambulance ride to the hospital. But by 2:20 a.m., Rivera was dead from acute gangrenous cholecystitis, described as the inflammation of the gallbladder, as well as perforation with localized peritonitis and sepsis.

A report from the state Commission of Correction’s Medical Review Board outlined numerous failures by the jail’s medical staff to provide proper care to Rivera prior to his death.

In its findings, the board — which acts as a watchdog group to investigate deaths in New York’s correctional facilities — concluded that had Rivera “received adequate medical care, had been properly assessed, and had been timely referred to a hospital for treatment, his death could have been prevented.”

Read the report here

Further, the board noted that despite Rivera’s “significant medical history” and his ongoing complaints of heartburn he was never seen by a physician during his 94 days in the jail.

Among other findings in the 12-page report, large sections of which are redacted:

¯ Rivera had been admitted to the County Jail on April 23, 2021, after having used heroin and methamphetamine within the past 48 hours. However, he was not assessed for withdrawal or placed on a withdrawal protocol.

¯ Rivera’s initial health exam was not completed until May 11 — 18 days after arriving at the jail. In New York state, prisoner examinations are required at the time of admission, or as time permits, but no later than 14 days after entering the facility.

¯ A nurse on July 25 failed to adequately assess Rivera’s complaints of unresolved gastrointestinal issues, “dismissingly attributing his signs and symptoms to substance use without any verified indicators of such.”

As a result, “The lack of adequate assessment and referral to a physician denied Rivera access to lifesaving surgery which was needed due to an undiagnosed cholecystitis.”

¯ A corrections officer reported giving Rivera “over-the-counter” medication at 1 a.m. on July 26 after Rivera had complained of heartburn.

The officer had reviewed Rivera’s record prior to giving the medication. However, the unauthorized dose at an unauthorized time without a medical provider’s order was in direct violation of Chautauqua County Sheriff’s Office policy.

For the latter finding, the report states that the corrections officer “acted carelessly, outside his scope of duty, and in direct violation of agency policy and procedure by administering a medication to Rivera that was outside of the prescribed time and that was not authorized by a medical provider.

“The Medical Review Board further finds that critical time needed to transport Rivera to a hospital for emergency surgery was lost while the officer awaited to see if the wrongfully administered medications would have effect on Rivera.”

¯ A post-mortem review found the acute gangrenous cholecystitis indicated Rivera’s condition had been developing into an acute state over several days and he “was in need of emergency surgical intervention.”

Chautauqua County Sheriff James Quattrone said in addition to the Commission of Correction, the state Attorney General’s Office also investigates deaths of people in custody, whether in jail or while being arrested.

In regard to Rivera’s death, he said the Attorney General’s Office did not find any fault with the Chautauqua County Jail or its staff.

“(The) Chautauqua County Sheriff’s Office along with its medical and mental health providers provide the best care possible to all incarcerated individuals,” Quattrone said in a statement to The Post-Journal. “The jail houses a health clinic and mental health clinic that are staffed with (registered nurses), (licensed practical nurses), Social workers, Substance abuse counselors, Care Coordinators, a psychiatrist, and as of October 2022, two physicians who personally provide services on a regular basis.

“Also late in 2022 we developed a single medical record system that better serves the incarcerated individual’s needs. Any service that the in-house staff are unable to provide get provided by outside medical or mental health providers.”


Born in Chicago, Rivera was divorced and did not have any children. He did have two siblings, a brother and a sister; however, The Post-Journal was unable to locate the pair and no obituary matching Rivera’s information could be found online.

Rivera entered the Chautauqua County Jail at 7:27 p.m. on April 23, 2021. Earlier that day, and while out of state prison on parole, he was taken into custody on three counts of third-degree criminal possession of a controlled substance and one count of second-degree criminally using drug paraphernalia.

A copy of the felony complaint obtained by The Post-Journal indicates that New York State Parole, with police assisting, recovered 4.6 grams of fentanyl compound, 5 grams of fentanyl and 4.7 grams of methamphetamine alleged to have been possessed by Rivera. Also located inside his West Sixth Street lower apartment were digital scales and plastic bags.

According to the report, Rivera was unemployed and “made money from selling drugs.” A review of online state inmate records shows he had numerous drug possession convictions dating back at least 25 years.

Rivera was arraigned on the latest felony charges where, court records note, bail was set at a nominal $1. However, he was kept in jail on a detainer due to his parole violation.

In September 2021, just weeks after Rivera’s death, Gov. Kathy Hochul signed into law the “Less is More Act” that largely eliminated New York’s practice of incarcerating people on technical parole violations. It fully went into effect in March 2022.

Examples of technical violations include missing curfew or failing a drug test.

Under the law, those accused of “non-technical violations” — instances in which new criminal charges are brought — are given a recognizance hearing within 24 hours of an arrest to determine whether they will stay jailed pending the outcome of the violation proceedings.

The Less is More Act followed implementation in 2020 of bail reform in New York in which cash bail was eliminated for many nonviolent felonies charges.


At 5:08 p.m. on July 25, about five hours after Rivera first reported feeling ill, another inmate told an officer that the 65-year-old was “feeling nauseous.” A sergeant was notified, though nothing was documented in the logbook that medical staff had been contacted.

Rivera received medication at 7:44 p.m. that evening.

At 10:55 p.m. that night, another corrections officer began his overnight shift. He told the Medical Review Board he was not made aware that Rivera had been feeling ill and could not recall if his condition had been noted in the logbook.

About two hours later, at 1 a.m., Rivera complained of having heartburn. It was at that time the corrections officer reported giving the inmate over-the-counter medication.

About 25 minutes later, the officer saw Rivera sitting in a “tripod position, struggling to breathe.” Per the Medical Review Board, “Rivera reported to (the corrections officer) that he was feeling worse. (The corrections officer) saw that Rivera was having trouble breathing and called (the sergeant).”

By 1:45 a.m., local volunteer firefighters arrived at the jail and later transported Rivera to Westfield Memorial Hospital.


Included in the report are a number of actions required of the Sheriff’s Office, jail physician, director of county Mental Health Services and the county Legislature. Among them:

¯ A review and retraining of the corrections officer who administered the over-the-counter medication to the inmate. “Administrative action should be taken if determined to be appropriate,” the commission wrote.

Not including Rivera, the report only identifies individuals by their position — such as “correction officer” or “PA” for physician assistant — and what is likely their initials.

¯ A review and retraining of staff on the importance of immediately alerting a supervisor when an inmate is in need of medical care.

¯ An investigation and review why Rivera’s “continued complaints of heartburn” from April 23, 2021, until his death “were not adequately addressed by medical staff.”

¯ A quality assurance review of patient charting at the County Jail to ensure “clinical notes are properly made and maintained.”

Quattrone said medical and mental health screening are performed on new inmates, with a more thorough assessment completed within 14 days. He said there also is a process in place where incarcerated individuals can request to see medical or mental health staff.

“We have continued to provide various medical and mental health trainings for our correctional staff,” Quattrone said. “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.”

Monday’s story will focus on the September 2021 death of Jose Louis Rivera-Perez, an inmate at the Chautauqua County Jail.


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