NEW YORK STATE COMMISSION OF CORRECTION --------------------------------- In the Matter of the Death of Kevin Schmitt, an inmate of the Ulster County Jail ---------------------------------TO: Sheriff Paul Van Blarcum Ulster County Sheriff's Office 380 Boulevard Kingston, NY 12401 FINAL REPORT OF THE NEW YORK STATE COMMISSION OF CORRECTION FINAL REPORT OF KEVIN SCHMITT PAGE 2 GREETINGS: WHEREAS, the Medical Review Board has reported to the NYS Commission of Correction pursuant to Correction Law, section 47(1) (d), regarding the death of Kevin Schmitt who died on September 4, 2009 while an inmate in the custody of the Ulster County Sheriff at the Ulster County Jail, the Commission has determined that the following final report be issued. FINDINGS: 1. Kevin Schmitt was a 50 year old white male who died on 9/4/09 at approximately 9:22 a.m. from blunt force trauma as a result of a suicide attempt at the Ulster County Correctional Facility. Schmitt was in custody of the Ulster County Sheriff when he jumped to his death from the upper tier of his housing area. The failure of the Ulster County Sheriff's Office to provide adequate supervision and a comprehensive mental health assessment and psychiatrist refe.rral based on significant risk information reported to the jail was implicated in Schmitt's death. Ulster County Correctional Facility's medical and mental health services are provided pursuant by contract by Correctional Medical Care, Inc .. (CMC) , a business corporation holding itself out as a medical care provider. 2. 3. 4. Schmitt was a self-described "workaholic" who was self employed running a landscaping/snow removal business with his ex-wife. FINAL REPORT OF KEVIN SCHMITT PAGE 3 5. 6. 7. Schmitt had no known significant medical history. 8. In the in.stant offense, Schmitt confronted his ex-wife and her male acquaintance with two loaded . 308 caliber rifles. He allegedly struck the woman with a rifle butt and scuffled with the man inside her house before barricading himself in his own nearby home with three weapons. He surrendered some 10 hours after .the start of the incident and was taken into custody. 9. Schmitt was arraigned by Judge M.W. on 9/1/09 who ordered in the Special Orders/Instructions of the securing order, a CPL 730 (competency) exam, a mental health referral and under additional comments, "Suicide Watch!" He was remanded to the Ulster County Correctional Facility in lieu of $50,000/$100,000 cash/bond bail. 10. Upon admission, Schmitt was screened by Officer S.R., scoring a "6". (high risk) on his Suicide Prevention Screening Guidelines including: Observations of Arres,ting/Transporting Officer #1 Arresting or transporting officer believes that detainee may be ? a suicide risk, i f YES, noti?Y supervisor: with a general comment by the screening officer, "Made suicidal statement!> to police." This question is a shaded area on the screening form designed for FINAL REPORT OF KEVIN SCHMITT PAGE 4 automatic notification to the supervisor and the institution of constant supervision. Schmitt answered affirmatively to: #3 Detainee has experienced a significant l.oss within the l.ast six months (e.g., l.oss of jcib, l.oss of reLationship, death of cl.ose famil.y member): stating "brother died." #6 Detainee has history of drug or aLcohol. abuse: Sunday." stating, "beer #7 Detainee has history of counseLing or mental. heaLth evaLuation/treatment: reporting Benedictine Hospital Psych. #lOa Detainee hak previous suicide attempt: reporting he cut his wrists in 1998. #11 Detainee is expressing feeLings of hopeLessness (nothing to l.ook forward to): stating "work." It should be noted that this box was checked "no" in error as Schmitt responded he was concerned about work. #12 This is detainee's first incarceration in Lockup/jail.: reporting first time. In the Officer's Comment Section, Officer S.R. documented, "States no thought of suicide at this time." 11. Sgt. A.T., the intake supervisor, was notified and signed the Suicide Prevention Screening Guidelines. Schmitt was assigned constant supervision with a conunent, "pendi:t:lg medical screening." The referral section was marked by Officer S.R. for referrals to Medical/Mental Health as non-emergencies. 12. 13. FINAL REPORT OF KEVIN SCHMITT PAGE .5 14. 15. 16. The social worker failed to conduct a comprehensive mental health K .. B. 's findings contradict the intake screening results, K.B., LCSW-R, improperly released Schmitt from constant supervision. Schmitt was not referred to a psychiatrist for further evaluation prior to his release from constant supervision.. The. social worker would have had access to the. nurse's notes, the nursing referral, the judge's security order and the Suicide Prevention Screening Guidelines. In an interview, K.B. could not recall if she had reviewed this information prior to seeing Mr. Schmitt. The-assessment performed by K.B., LCSW-R, was grossly incompetent, flagrantly substandard and missed abundant signs of suicide risk. 17. According to K.B., LCSW-R, there is no CMC policy and procedure in place for conducting mental health and risk assessments. K.B. stated that, although she didn't know the extent of what happened with Schmitt, she did know he was in more trouble than he was admitting to. She reported that she knew he would find out the reality of his situation when he went to court on 9/3/09. Commission staff inquired as to whether she planned on seeing him following his court appearance and she stated that she had planned FINAL REPORT.OF KEVIN SCHMITT PAGE 6 to see him but "did not have time that day." not shared with correctional staff. 18. This information was Schmitt was transferred to H-Block, the classification following his release from constant supervision. unit, 19. 20. On 9/2/09 at approximately 10:30 p.m., Officer K.D. received a phone call in reception from a female stating she was a family member and expressed concern for Schmitt's mental stability and ?his past psychiatric history. She asked that he be checked on. She did not wish to identify herself. Cpl. G. S. immediately sent his . task officer to Schmitt's housing? area and had him escorted to the medical department. He reported this to Cpl. R.T., the oncoming supervisor. 21. 22. At approximately 11:46 p.m., Cpl. R.T. was notified by RN M.T. that Schmitt was not a danger to himself or others and he was cleared for general population. RN M.T. was not interviewed as she is no longer employed at the Ulster County Correctional Facility. 23. On 9/3/09, Schmitt made a court appearance, leaving the facility at approximately 1:30 p.m. and returning at approximately 3:30 p.m. His bail was not reduced. 24. On 9/4/09, Officer A.M. started his B-line shift by entering H-pod at approximately 7:55 a.m. He relieved Officer P.R., who had briefed him on the prior shift's issues, none of which included Schmitt. Officer A.M. conducted a supervisory round, called in his count? and signed the log .book. H-pod is split into two sides, the right side used for classification inmates where Schmitt was housed. The left side of the? pod is for inmates on keeplock, i.e., inmates locked in for 23 hours/day. Officers R.F. and P.J. entered .the pod to start running showers and recreation. for keeplock inmates. 25. During the recreation, time that inmates were Schmitt called Officer being run for showers A.M. via the intercom and and FINAL REPORT OF KEVIN SCHMITT PAGE 7 requested a phone call. Officer A.M. told Schmitt he would have to wait a minute due to the movement on the other side. Officer A.M. also needed to check to see if Schmitt was allowed to have a call at the time requested. 26. ? A short time later, Officer A,M. informed Schmitt he could have a ten minute phone call and opened Schmitt's cell. Officer A.M. watched Schmitt walk down the stairs, turned the phones on, and then turned away to sit and record his log entries. Officer A.M. was still writing his entries when he heard a loud noise. He stated that no more than two minutes had passed since he saw Schmitt descend the stairs and walk to the phones. He initially thought the noise was the phone slamming and stood up looking towards the phones and not seeing Schmitt at the phones, scanned the pod and saw Schmitt lying on his left side on the floor in front of the shower with a large amount of blood around his head. 27. Officer A.M. called a medical emergency at approximately 8:28a.m. Cpl. R.C., Officers G. H., M.B., R.F., and P.J. responded. Officers G.H. and M.B. and RN T.A. conducted a quick assessment. 28. 29. Officer A.M. reported that he never saw Schmitt go back up the stairs and that the phones are not visible when seated in the officer's booth. No other inmates were out of their cell at ?the time of the incident and the other officers had left the pod with Inmate Q. 30. A review of facility phone records revealed that Schmitt did not make a phone call that morning. 31. Officer P.R. was assigned shift prior to Schmitt's approximately 6:00 a.m. Officer P.R. when "chow" to Schmitt's housing area during the night suicide. He stated in interview that at Schmitt came to his cell door and asked was coming. He recalled Schmj_tt ate all PAGE 8 FINAL REPORT OF KEVIN SCHMITT of his food and asked for a second beverage. He reported that Schmitt had? slept all night and acted very normal. 32. Immediately following Schmitt's suicide, CMC reviewed their Suicide Prevention Policy whereby, "Regardless of who places the inmate on constant supervision, only a psychiatrist may release the inmate back to general population." 33. Following the incident, Inmate D.T. gave ?oetective ?o.L. a statement regarding a conversation he had with Schmitt on 9/3/09 during recreation. He reported that Schmitt told him he had nothing to live for. and stated that he would not be here tomorrow, that he was going to jump off the railing. Inmate D.T. stated that he told Schmitt that he didn't believe him. "He said he was going to kill himself." Inmate D.T. stated that he never told anyone because?he didn't believe Schmitt. Inmate D.T. repo.rted th.,.t he saw the officer let Schmitt out and Schmitt walked downstairs towards the phone, then came back up the stairs and w.,.lked over to the railing and "after that all you heard was a thump." 34. Video was forwarded to the Commission which clearly reveals Schmitt diving head first off the upper floor. RECOMMENDATIONS: TO THE ULSTER COUNTY SHERIFF: 1. The Ulster County Sheriff shall direct that a review be conducted by the mental health contract provider, Correctional Medical-Care, Inc., of the mental health services afforded Schmitt during his incarceration. Specific attention should be focused on the failure of the social worker to conduct a comprehensive mental liealth exam? and risk assessment on a patient with a high level of risk factors and failure to refer Schmitt to the psychiatrist. Also, the discontinuance of constant supervision without a psychiatric evaluation, remarkably as the judge had ordered 730 exam and noted "suicidal" on the securing order. The results of this review shall be reduced to writing and forwarded to the Medical Review Board upon completion. Any delay or denial by CMC, Inc. respecting this recommendation should result in termination of their contract for cause. a 2. The Ulster County Sheriff shall develop policy/procedure in cooperation with classification, and medical and mental health services at the Ulster County Correctional Facility whereby all inmates .,.re re-screened/classified following significant changes in the inmate's status and/or notification from family or friends regarding concerns of an inmate's risk for suicide. Other events to be considered for re-screening include conviction 9f FINAL REPORT OF KEVIN SCHMITT PAGE 9 serious/heinous charges, .elevation of charges, heavy sentencing, or other stressful events. 3. The Sher;i.ff shall post signs in jail lobby, the visiting room, inmate housing area, the booking area, ?interview rooms and any other area of your facility where inmates or visitors are permitted informing them .of the need to report knowledge of inmates threatening self harm. This information should also be included in inmate handbooks. TO THE NYS EDUCATION DEPARTMENT, OFFICE OF THE PROFESSIONS: That the Office of the Professions undertake an inquiry into the status of Correctional ? Medical Care, Inc. , a Pennsylvania corporation, as a lawful medical practitioner in. New York State. WITNESS, HONORABLE PHYLLIS HARRISON-ROSS, M.D., Commissioner, NYS Commission of Correction, 80 Wolf Road, 4~ Floor, in_ the City of Albany, New York 12205 . this 18th day of March 3, 2011. PHR:mj 09-M-124 12/10 -----------------