CATSKILL — The Greene County Jail, which had a peak population of 85 inmates in 2013, had four suicides, with two under state investigation, and one overdose death in the last 12 years.
The state Commission of Correction included the facility on its 2018 Worst Offenders report that cited the Greene County Jail as one of the worst — second to New York City’s main jail Rikers Island — for improper policies and procedures.
Two years before the jail was put on the commission’s list as the second-worst in the state for 2018, inmate Robert Knisell Jr. was found dead of an overdose in his cell in the Greene County facility.
Knisell’s family, of Saugerties, has many unanswered questions into his 2016 overdose death at the jail, his stepmother Terry Lasher said last fall.
“How did it [the drugs] get in there?” Lasher said Sept. 23, 2019. “How did he get it? Somebody wasn’t doing their job.”
The investigation conducted by the sheriff’s office was unable to determine how the drugs entered the facility, according to the report.
“There are not any confirmed methods of heroin introduction into the Greene County Sheriff’s Office Jail at this time,” according to the sheriff’s office’s report. “Random tier checks with K9 units and corrections officers have been conducted, but had negative results.”
The case was closed May 9, 2016.
Knisell, of Saugerties, had struggled with addiction, Lasher said.
“He was no angel, but he didn’t deserve to have that happen to him,” she said.
Knisell was found dead in his cell Feb. 22, 2016, from an overdose of heroin and fentanyl. Knisell was charged July 22, 2015, with second-degree burglary, a class C felony, following investigation of a burglary at a Palenville home; and unlawful possession of marijuana, a violation.
Lasher said she wondered why no one at the jail saw warning signs or tried to revive her stepson.
By September 2019, Knisell’s body had not been returned to his family for a burial.
“We are still paying the funeral off,” Lasher said last year. “We don’t have his ashes yet and it’s been three years.”
Knisell’s father, Robert Knisell Sr., died Oct. 8, 2019, after a terminal battle with cancer.
Before his death, Knisell’s father said he hoped his son’s funeral costs were paid off before he died so the father and son could be buried together, she added.
Robert’s father made the final payment to the funeral home, Seaman-Wilsey in Saugerties, before his death, Robert’s sister Jody Teator said Feb. 21. Father and son were brought home and were laid to rest together.
Lasher said last year the financial burden of Robert’s funeral expenses should not have solely been on the family because he died while incarcerated.
The Daily Mail has conducted a year-and-a-half investigation into the deaths and submitted a Freedom of Information request July 22, 2019, to the state Commission of Corrections to review all records associated with suicides at the Greene County Jail from 2007 until the jail’s closure April 20, 2018.
The commission’s report on Knisell’s death, released in June 2018, found faults with how the jail handled his incarceration and his death.
The Medical Review Board cited failures with the jail’s admission and classification process, providing care for an inmate with a history of hypertension, mental health and substance abuse issues and use of an automated external defibrillator while trying to resuscitate an inmate.
Additionally, the board discovered that the jail’s security and supervision, classification and health minimum standards policies were not in compliance with state guidelines, according to the report.
A corrections officer, who was not identified by name in the state report, said Knisell appeared to be intoxicated when he was booked into the jail, but he did not notify his supervisor or place Knisell on increased supervision. Notifying a supervisor or placing an inmate on increased supervision is required under state corrections law if an inmate appears to be under the influence of drugs or alcohol at admission, according to the state report.
The report cites a licensed clinical social worker and a doctor, whose names were redacted, for not conducting a follow-up mental health check on Knisell when he had been receiving mental health and substance abuse services and medications in the community, and for not monitoring the inmate’s withdrawal treatment and symptoms.
Knisell was reported to be sitting on his bed during 3:30 p.m. supervisory rounds Feb. 22, 2016. A subsequent round was completed at 4:10 p.m., according to the report. At 4:35 p.m., an inmate alerted a corrections officer to call for medical aid for Knisell.
Former Sheriff’s Office Investigator Sean McCulloch interviewed Corrections Officer Amanda Enck, who was delivering meals to the inmates at about 4:35 p.m. Feb. 16 when she heard the call for help.
“[Enck] advised me that she was assisting [corrections] officer Jaycox serve meals on D-Block when she heard an inmate yell ‘Bob OD’d,’” according to McCulloch’s report. “Enck said that when she got to the cell, she observed Knisell sitting on the edge of his bed slumped over to the right side. She said that she could immediately see that he was purple in color from head to toe.”
Enck radioed for help, but did not get a response and she notified Sgt. Chad Hock in the control room, according to McCulloch’s report.
Enck did not comply with the jail’s policy calling for staff to use the phrase “code red” in the event of an emergency, according to the Medical Review Board’s report.
Enck declined to comment on the incident.
Corrections Officers Matthew Miller and John Jarvis performed CPR on Knisell for an unspecified amount of time and called an ambulance at 4:48 p.m. They both described Knisell as cold to the touch, purple and without a pulse, in their statements to McCulloch.
Knisell was scheduled to be sentenced the following day, according to the state report. He died the day after his 36th birthday.
The Medical Review Board found that unnamed corrections officers failed to follow the jail’s policy to attach the automated external defibrillator to Knisell by placing two electrodes on his chest and following the prompts.
Knisell had been dead for over an hour when he was found at about 4:35 p.m., which was clear by his condition when he was discovered, according to the board’s report. One of the corrections officers, who was not identified by name, responded to the scene at an undetermined time and reported Knisell was sitting up on his bed with a book in his hands, according to the state’s report.
Sheriff’s Investigator Joel Rowell discovered two beige-colored clonidine hydrochloride pills, a prescription high-blood-pressure medication, inside a pen in Knisell’s cell. A powdery substance was discovered on the window sill, but the commission has not received any analysis of the substance from the jail, according to the state report.
A State Police Forensic Center analysis found no controlled substances in the sample sent from the sheriff’s office, according to the sheriff’s office report.
The investigation conducted by the sheriff’s office did not yield many details, according to the state’s report.
The sheriff’s office report contains statements from interviewed facility staff, but no details from inmates except for one sentence — a statement submitted by Sheriff’s Office Investigator Joel Rowell.
“‘I have spoke [sic] to several inmates who all stated that it is common knowledge there are drugs in the jail, but no one would state where they came from,’” according to Rowell’s statement in the sheriff’s office report.
Knisell did not have any visitors during his incarceration, according to the state report.
The board was unsatisfied with the sheriff’s office investigation.
“The Medical Review Board finds that this investigation is incomplete and inadequate in that after 22 months, it remains without update, only one officer provided a written statement for the incident and one witness remains ‘not yet interviewed’ without explanation,” according to the report. “Additionally, there was no indication that there was any investigation into how the drugs were brought into the facility to identify the sources of contraband and to prevent future drug-related deaths.”
The board requested then-Sheriff Greg Seeley conduct a review of the investigation and submit a response to the board stating why the probe was incomplete.
“This report shall also state any updated information regarding how the contraband entered the facility and any measures that have been taken to prevent such contraband from entering the facility in the future,” according to the report.
Seeley did not respond to the state’s report, said Jill Spadaro, former state Commission of Correction public information officer, on Nov. 5, 2019.
A CHANGE IN POLICY
The sheriff’s office was required to review the Greene County Jail’s mental health policy after a state investigation into an April 2018 inmate suicide. The jail’s classification policy, which outlines how inmates should be assessed for suicide risk when being processed at the jail, was updated April 24, 2018, — 10 days after inmate Matthew Leombruno was discovered hanging from a bedsheet tied to the jail cell bars and four days after the facility closed.
The state commission released a report Dec. 17, 2019, after the state board’s investigation into the death of Leombruno.
Leombruno, 43, of Coxsackie, died from his injuries at Columbia Memorial Hospital in Hudson two days later. The jail permanently closed April 20, 2018, following an analysis that revealed the south wall of the building was structurally compromised and dangerous for inmates and staff.
The commission requested the sheriff’s office, along with the jail physician Dr. Walter Hubicki II, of Greenville Medical Associates, and county Director of Mental Health Services Jason Fredenberg, review the jail’s mental health policy following the board’s review released in the December report.
“A special focus shall be placed on ensuring that all suicide screenings are reviewed by mental health staff and include guidelines for placing inmates on constant watch,” according to the report. “The policy should also include a plan for training jail employees responsible for inmate supervision.”
Seeley was directed to determine why Corrections Sgt. Christopher Statham, who served as the jail’s watch commander the day of Leombruno’s death, did not place the inmate on constant watch — a violation of state corrections law — and send the commission the corrective actions taken.
The sheriff’s office responded to the Sept. 24, 2019, preliminary report Nov. 21, 2019, indicating administrative action had been taken. The report does not elaborate on the consequences or action taken by jail administrators.
The established protocols were followed in Leombruno’s case, former Greene County Jail Superintendent Michael Spitz said in September 2019. Spitz declined to comment further on the matter and referred further questioning to the county attorney.
The Columbia County coroner, who was not identified by name in the report, was directed to determine why an autopsy was not performed on Leombruno, as required by state law. The coroner’s office was also directed to submit its reasoning and any corrective actions in a report to the Medical Review Board. No deadline to respond to the state’s review was listed in the board’s report.
The commission has not received a response from the coroner’s office, state Commission of Correction Public Information Officer Janine Kava said Aug. 3.
“We can’t compel the coroner to respond,” she said, adding the commission has no legal oversight over county coroners.
The Daily Mail submitted an inquiry Aug. 5 to the Columbia County Coroner’s Office requesting the name of the coroner assigned to the case, why an autopsy was not performed and why the office had not responded to the commission’s report. Columbia County Coroner Michael Blasl referred the request to the Columbia County Attorney’s Office.
On Aug. 10, Blasl said he had not received a response from the attorney’s office. Requests to the attorney’s office were referred back to the coroner’s office.
Greene County Legislature Chairman Patrick Linger, R-New Baltimore, was directed in 2019 to assess the quality of inmate health care services and to determine if the jail physician should continue to provide services to the facility or a new provider would be appointed.
The Legislature authorized a contract with Hubicki in November 2017, which was set to expire in December 2018. The county contracted work from Hubicki, who worked at the former jail, Linger said Jan. 29, adding the physician was not a county employee.
No decisions have been made regarding who will be named the physician at the new jail, Linger said.
“It will be both a cost-benefit analysis as well as looking at what other services we are going to provide,” he said.
Linger said he has reviewed the commission’s report on Leombruno’s death, but declined to comment, citing the pending litigation.
Leombruno’s death occurred one week before the jail was forced to shutter due to structural concerns.
The jail administration failed to report incidents — one of several violations listed in the 2018 Worst Offenders Report. Reportable incidents include assault, sex offense, contagious illness, contraband, maintenance/service disruption, disturbance, natural/civil emergency, escape/abscondence/erroneous release, fire, discharge of firearm, group action, hostage situation, physical injury/hospitalization and death.
A minimum standards evaluation by the commission in November 2017 found Greene County jail staff failed to report discoveries of contraband on several occasions, such as a golf ball-sized bag of marijuana, a syringe, heroin, a garbage bag of ingredients to ferment alcohol and hoarded medications, according to the evaluation.
In June 2017, less than a year before the jail closed and before Leombruno’s death, Seeley told county lawmakers at a Public Safety Committee meeting the jail was “unsafe” and “unfit.” The following month, in the sheriff’s July 24, 2017, letter to the Commission of Correction, Seeley argued this was not the case.
Two suicides occurred at the jail in the last 12 years, according to the commission: Leombruno and Donald Houghtaling, who died in 2009.
Four other deaths, aside from Leombruno’s, were uncovered that were linked to the Greene County Jail over the past 12 years: the suicides of inmates Carrie Cotrone, 36, in 2017; Daniel Medici, 52, in 2013; and Donald Houghtaling, 30, in 2009; and the overdose of Robert Knisell Jr., 36, in 2016, were discovered during The Daily Mail’s investigation.
When asked for comment on the jail’s suicide prevention policies Aug. 4, former Sheriff Greg Seeley said, “You never gave me any good press while I was there, why are you digging this up now?”
When asked why there was an increase in suicides during the last five years the jail was open, Seeley hung up the phone.
Comparing suicide data since 2007 at similar-sized jails in Columbia, Cortland, Delaware, Essex, Herkimer, Orleans, Otsego, Seneca and Tioga counties, Herkimer and Tioga counties reported one suicide each during that time period, while the other county jails had none, state Division of Criminal Justice Services Director of Public Information Janine Kava said Dec. 5.
One Seneca County Jail death remains under investigation. Kava declined Aug. 4 to disclose what type of death, citing the pending investigation. None of the facilities reported any overdose deaths since 2007, Kava said March 6.
The Greene County Jail population peaked at 85 inmates in 2013 and dipped to a low of 40 in 2017. While the jail was closed in 2019, it reported 35 inmates, which were transferred to other jails in Columbia, Ulster and Albany counties.
“Greene is one of the smaller counties and has historically operated one of the smaller jails, so it is unusual to have five deaths in a decade,” said Insha Rahman, director of strategy & new initiatives with VERA Institute of Justice, a nonprofit organization focused on improving the justice system.
“Especially an overdose, which is wholly avoidable and shouldn’t be happening in custody,” Rahman said.
In addition, the five deaths at the Greene County Jail are serious, she added.
“When the numbers are small, they tend to get overlooked,” she said. “This is not an insignificant number and it’s actually quite surprising. It’s alarming not only because of the sheer number of deaths, but the causes of death as well.”
The state’s review of Knisell’s overdose death released in June 2018 noted several failures in the way the jail administration handled the incident, describing the sheriff office’s investigation as inadequate and incomplete.
Medici was charged January 27, 2013, with two counts of criminal sexual act, a class B felony; first-degree sexual abuse and attempt to lure a child to commit a crime, both class D felonies; and endangering the welfare of a child, a class A misdemeanor, according to state police.
Medici, 52, of Catskill, attempted to take his life Jan. 29, 2013, while on suicide watch by hanging himself with a bed sheet, according to The Daily Mail archives. The first 72 hours of incarceration is the most critical time for inmates who are contemplating suicide, according to jail documents regarding the facility’s mental health policies.
The investigation conducted by the sheriff’s office states Medici was discovered during by Corrections Officer Jeremy Bear “during his normal rounds on the tier” and does not refer to a suicide watch.
In a 2013 Daily Mail interview, Seeley indicated that Medici was on watch.
“He was on watch,” Seeley said at the time. “We knew of his condition, we were aware that he was upset and those guys did everything that they should have.”
Medici was scheduled to appear in court for a preliminary hearing Jan. 31, 2013. While hospitalized at Columbia Memorial Hospital, Medici was released from custody of the jail by the Catskill Town Court on Feb. 4, 2013, according to jail documents. The suicide rendered Medici brain dead and he remained on life support at Columbia Memorial Hospital for nine days, until his death Feb. 7, 2013, according to The Daily Mail archives.
The commission does not have records pertaining to Medici’s death, according to its Oct. 15, 2019, response to The Daily Mail’s Freedom of Information request.
Kava would not comment on the jail staff’s handling of Medici’s death, or if she feels the jail’s administration followed proper protocols. The commission does not comment on pending investigations, she said.
In 2013, state corrections law did not require police to report an inmate’s release from custody while hospitalized. But, in 2014, the commission updated its policy requiring jails to report any time an inmate is released from custody while hospitalized, making it possible for the commission to investigate deaths that occur after an inmate is released from custody, Kava said.
The commission has requested all records related to Medici’s death and is investigating, Kava added.
“The commission is always looking at what is required to be reported and makes changes all the time,” Kava said Feb. 21. “It’s likely the change was prompted by a specific case, but I don’t have the details of that case.”
The commission determines what is considered a reportable incident and makes changes to ensure it receives useful information for the agency’s oversight capacity, Kava said.
“People who are knowledgeable of that decision are no longer with the commission,” she added.
With the 2014 corrections law change requiring jails report inmates released from custody while hospitalized, the Greene County Jail administration released Cotrone from custody while hospitalized by a judge’s order, but did not report it.
Cotrone, 36, of Palenville, was arrested Dec. 25, 2017, and charged with second-degree criminal contempt for violating an order of protection, a class A misdemeanor; and second-degree harassment, a violation. She was remanded to Greene County Jail on $20,000 cash bail or $40,000 bond. She did not make bail, according to court documents. Cotrone attempted to take her own life the following day — she died just over one week later from her injuries.
At the time of her arrest, Cotrone was, “irate and continued to scream and yell at everyone for no apparent reason,” according to the arrest report.
“During Officer [Jeremy] bears [sic] 15 minute rounds, he found inmate Cotrone with what appeared to be a bed sheet around her neck,” according to jail documents. “He notified the Sergeant [Michael Acker] who responded with [corrections] officer [Phillip] Moritz and [corrections] officer [Lacey] Hansen. Inmate was cut down, CPR was started and rescue squad was notified. Inmate was transported to Columbia Memorial Hospital for treatment.”
Cotrone did not have any known mental health issues, previous suicide attempts, substance abuse issues or history of self-harm, according to jail documents.
Cotrone was released from custody Dec. 26, 2017, with a court order from the late Catskill Town Justice William Wooten. Cotrone was scheduled to appear in court Dec. 28, 2017. She died at the hospital Jan. 6, 2018.
The decision to release an inmate rests solely with a judge, Kava said. She did not comment on a state law or commission policy about releasing inmates from custody after a suicide attempt.
A jail administration is required to notify the commission when an inmate is released from custody due to hospitalization, which Greene County did not do in Cotrone’s case, Kava said Dec. 5, 2019.
The commission requested records pertaining to Cotrone’s death and Kava said in December the incident remains under investigation.
The state Commission of Correction did not issue any citations in the case of Donald Houghtaling.
Houghtaling, 36, of Catskill, hanged himself with a bedsheet May 8, 2009. Houghtaling was arrested March 9, 2009, and charged with unauthorized use of a motor vehicle, a class A misdemeanor; and violating probation, a class E felony, according to state police.
Houghtaling scored a three out of 19 on the suicide screening when he entered the jail because he had a friend who committed suicide, according to the commission. A score of eight or more would have required constant supervision and the shift supervisor to be notified, according to state policy.
Houghtaling also had a history of using drugs and alcohol and he was experiencing withdrawal from heroin at the time of his arrest, according to the commission’s report on his death. Corrections Officer Kerry Keller was making supervisory rounds May 8, 2009, when he noticed Houghtaling sitting in the far left corner upright by the window with a sheet around his neck, according to jail documents.
Keller radioed for help and Corrections Officers Donald Schermerhorn and Steve Ross responded. Ross was not interviewed, according to the report.
Ross and Keller took turns administering CPR to Houghtaling.
“Keller described the inmate as having partial blue coloring, limp and unresponsive,” according to the report submitted by Sheriff’s Deputy Richard Selner.
When paramedics arrived approximately 10 minutes later, at 12:10 a.m., they found Houghtaling had a pulse and he was transported to Columbia Memorial Hospital.
A suicide note was found in Houghtaling’s jail cell. He was pronounced dead at the hospital at 4:44 p.m.
Tomorrow: Part 3 of Behind Bars will look into the county response to past issues at the jail.