NEW YORK STATE COMMISSION OF CORRECTION

In the Matter of the Death FINAL REPORT OF THE
of Richard Metcalf, an inmate of NEW YORK STATE COMMISSION
the Erie County Holding Center OF CORRECTION

a - a 

To: Sheriff Timothy Howard
Erie County Sheriff?s Office
10 Delaware Ave.
Buffalo, NY 14202

 REPORT OF RECHARD METCALF Page 2

GREETINGS:

WHEREAS, the Medical Review Board has reported to the NYS Commission of Correction

pursuant to Correction Law, section regarding the death of Richard Metcalf who died on
11/30/12 as a result of circumstances which occurred while an inmate in the custody of the Erie
County Sheriff at the Erie County Holding Center, the Commission has determined that the
following final report be issued.

1.

FINDINGS:

Richard Metcalf was a 35-year-old Caucasian male who died on 11/30/12, at 5:17 pm. at
Erie County Medical Center (ECMC) while in the custody of the Erie County Sheriff.
Metcalf was hospitalized after a prolonged use of force and an improper restraint by Erie
County Sheriff?s Deputies while incarcerated at the Erie County Holding Center (ECHC)
on 11/28/12. Metcalf's cause of death was listed by the Erie County Chief Medical
Examiner, Dr. D.V., as Acute and Subacute Myocardial Infarction with the manner of death
listed as a Homicide. The Medical Review Board has concluded that Metcalf's death was
a Homicide caused by the restraint methods used by the Erie County Deputies. A thorough
review all of the records, photos, and evidence including videography of the restraint
episode, pictures of a spit mask tied in ligature fashion around Metcalf?s neck, a pillow
case over Metcalf's head, blood in Metcalf's airway, and the transport of Metcalf in a prone
position on the ambulance gurney are evidence of the classic elements of a death that
was caused directly by traumatic with compression of the torso and neck. The
Board unilaterally rejects the conclusion of Medical Examiner Dr. D. V. that Metcalf died
from Acute and Sub-Acute Myocardial Infarction. Had Metcalf received appropriate crisis
level mental health care for his acute with proper restraint methods and
pharmacologic interventions, and had been the subject of a properly supervised use of
physical force, his death could have been prevented.

Metcalf's criminal history began on 11/5/99arrest of Unlawful
Dealing with a Child 1st and Unlawful Possession of Marihuana. On 11/27/15, Metcalf was
arrested by the Depew Police Department for Criminal Mischief 15?, Burglary Menacing
2nd, and Possession of Burglar Tools.

On 11/9/12, Metcalf had an esophagogastroduodenoscopy (EGD) completed at Buffalo
General Hospital (BGH). The procedure findings were esophageal varices and congestive
gastropathy. On 11/24/12, Metcalf went to the Millard Fillmore Suburban Hospital?s
Emergency Department (ED) due to coughing up blood for the past week and a sore
throat. He was evaluated by Dr. J. P. who gave him the medical diagnoses of: Biliary
Atresia with Kasai Procedure; cirrhosis; thrombocytopenia; and bronchitis. His
sputum was described as bloody and his stool color was blood-tinged with a positive occult
blood test. Metcalf reported that he was taking omeprazole 20 mg qd po and nadolol 20
mg qd po. A chest x?ray was completed which showed Metcalf?s lungs were clear.
Metcalf?s vital signs were reported as: 98.4 temperature, 86 pulse, 18 respirations, and a
blood pressure of 155/104. Pertinent laboratory blood work reported abnormalities of:

RBC 4.44 x10"9/L (4.70-6.00)
Abs 1.4 x10"9/L (1 
Albumin Level 3.1 

Bilirubin 3.5 mg/dL (0.2-1.2)

ALT 73 (5-50)

Prothrombin time 18.1 (11.0-15.0)
40.6 (42.0-52.0)

RDW 15.3 (11.5?14.0)

Platelet 70 x10"9/L (150-450)

Metcalf's blood pressure was 134/84 on recheck, and upon his discharge, he was
recommended to follow?up with his gastroenterologist. Dr. J.P. cited that Metcalf did not
meet the medical criteria for a hospital admission.

 

Metcalf reported he used marijuana daily with his last
use on 11/27/12. He stated he had used cocaine daily with his last use in August, 2012.
According to the NYSP Investigative Report, Metcalf's family and friends reported that he
displayed increasingly bizarre and erratic behavior for approximately a week before his
arrest on 11/27/12. The precipitating event identified for Metcalf?s mental health change
was difficulties working with his co-workers after he reported one for stealing merchandise.
Metcalf was noted to have a paranoid thought process and believed there were people
following him. Metcalf's friend also cited an incident approximately on 11/25/12, that
Metcalf went to his father's house and jumped through the glass window, suffering cuts
on his hands and arms.

 

According to the NYSP Investigative Report on 11/26/12, before Metcalf?s arrest, his
girlfriend, J.N., reported that Metcalf requested her to pick him up at his place of
employment. He told his girlfriend he thought people were out to get him. Metcalf had
also sent J.N. several phone texts which he cited that people in the store were going to
stab him. Additionally, it was noted that Metcalf would not go in his bathroom, as he
believed that a person was waiting for him there. Metcalf urinated on himself rather than
go into the bathroom. According to J.N., on 11/27/12, at approximately 2:00 am, Metcalf
ran out of his apartment, which he shared with her. Metcalf was wearing only his sweatshirt
and shorts when he ran to a local catering establishment with his girlfriend following him.
Later, Metcalf stated his rationale for going to the business and into its walk-in cooler was
he felt hot and wanted to cool off.

F-ENAL. REPORT OF RECHARD METCALF Page  4

On 11/27/12, at 2:29 Depew PD Officer RS. responded to a call for of a possible
burglary at a local catering business with a suspect entering through the back door with
access to the walk-in cooler. When Officer RS. arrived at the scene, he stated that the
catering business? cooler door was Opened and he observed blood on it. Officer RS.
entered the business establishment. Officer RS. also stated that he saw a white male,
who was later identified as Metcalf, holding cardboard boxes. Officer RS. told Metcalf ?not
to move.? Metcalf threw the boxes on the floor and started to run away from the officer.
Officer RS. reported that Metcalf stopped and then came after him with a metal wrench
in his hand. Officer RS. deployed a Taser hitting Metcalf in the stomach/torso area. Officer
R. S. stated that Metcalf got back up on his knees. The officer ordered Metcalf to lie on
the floor face down and to crawl towards him. Metcalf did not comply and Officer RS.
deployed a second Taser which hit Metcalf?s chest. Officer RS. stated he believed that
this Taser was not effective, as it partially hit Metcalf?s sweatshirt. Depew PD Officers R.
P. and NT. arrived on the scene. Both officers stated that Metcalf was resisting arrest and
would not follow Officer orders to be handcuffed. Officers RS. and NT. stated that
Metcalf had refused to release his arms and was lying on the floor on his stomach with his
hands beneath his chest. Officer N.T. took Metcalf?s left arm to assist with restraining him
for placement of the handcuffs. Officers R.P., RS., and RT. stated after a brief struggle,
they were able to place handcuffs on Metcalf in spite of him fighting and resisting. Officers
R.P., RS, and NT stated that Metcalf became cooperative once the handcuffs were
applied. Officer RS. stated he removed the Taser barbs from Metcalf?s person. Metcalf
was placed under arrest by Officer RS., who escorted him to a Depew PD vehicle for
transfer to the police station. Officer RS. stated that Metcalf was yelling that he ?loved the
boys in blue? when he was walked to the patrol car. Officers RP. and RS. stated that
Metcalf had urinated and defecated on himself. When Metcalf arrived at the police station,
he was placed in holding cell 

Depew PD Lt. J.G. ordered an EMS medical evaluation for Metcalf due to the Taser usage
which was consistent with Depew policy. Lt. J.G. stated that Metcalf only had a pair
of shorts and shirt on with no shoes or socks in spite of very cold weather and snow on
the ground. According to the Lancaster Volunteer Ambulance Corps (LVAC)
documentation, the EMTs were summoned at 3:05 am. and arrived at the police station
at 3:14 am. LVAC EMTs 6.0. and J.H. reported that they found Metcalf sitting on the
cell?s toilet, and they were told that Metcalf had a physical altercation which required Taser
usage. EMT J.H. also stated that Metcalf was only wearing his shirt, shorts, and
underwear. LVAC Paramedic MC. was called to conduct a medical assessment due to
his qualifications as a paramedic. The LVAC protocol requires a paramedic to evaluate a
patient. The EMTs GO. and J.H. observed that Metcalf had fecal matter on his hands
and lower back area. They assisted in cleaning Metcalf so an adequate assessment could
be made. When Paramedic MC. arrived, he stated Metcalf was able to articulate his
thoughts, was orientated to all three spheres, and denied any pain. Paramedic MC. stated
that Metcalf was sober during the interview and denied any drug or alcohol use.
Paramedic MC. noted a small hematoma above Metcalf?s left eye. Metcalf denied any
falls or pain recently. Metcalf?s pupils were described as PERRLA (pupils, equal, round,
and reactive to light/accommodation) and upon auscultation lungs sounds were noted as
clear. EMT J.H. stated that he observed no signs of injuries with the exception of Metcalf?s
left eye. A physical exam noted that Metcalf had a puncture site on his right upper chest
and an abrasion to the left side of chest and left ankle. A 12-lead EKG was obtained which
reported that Metcalf had a sinus tachycardia with a pulse of 114. Paramedic MC.
reported he called Dr. 30., ED physician at ECMC, and informed the physician of his
assessment. Metcalf initially refused further examination at however, Dr. B.C.

10.

FINAL REPORT OF RICHARD ilelCAl-F Page 5

stated that Metcalf would have to be transported to the hospital. Metcalf agreed to go to
the hospital for an evaluation. Metcalf was placed on to the stretcher in a semi-fowler?s
position with his hands cuffed in front of him. At approximately 3:47 am, Metcalf was
transported from the Depew PD to ECMC ED. The LVAC ambulance arrived at ECMC at
3:59 am, and Paramedic M.C. gave a report regarding Metcalf's condition to the ECMC
ED staff. Metcalf was supervised in the ED by Of?cer N.T.

On 11/27/12, at approximately 4:20 am. while at ECMC ED, Metcalf was evaluated by Dr.
SR. The attending physician was listed as Dr. 30. Metcalf denied that he any problems.
Metcalf?s EKG was abnormal with sinus tachycardia with possible ventricular hypertrophy.
His vital signs were blood pressure of 140/100, pulse 112, respirations 18, and
temperature 98.2. A chest-ray and head CT-scan without contrast was ordered and
reported within normal limits. His urine toxicology was positive for cannabis and opiates.
Dr. SR. observed Metcalf as alert and fully orientated. The physician reported Metcalf had
diffuse abrasions, and lesions in various stages of healing. According to the
NYSP Investigative Report, Dr. S. R. described Metcalf as polite but acting ?weird.? The
physician believed that Metcalf may have been "either high, on drugs, or crazy. Dr. SR.
reported she observed a Taser injury from a probe and multiple small scrapes and bruising
on his arms. Dr. BC, the attending physician, described some bruising on Metcalf which
appeared to be older and possibly had occurred prior to 11/27/12. An line was initiated
on Metcalf for hydration. ECMC Laboratory Report showed abnormalities on 11/27/12
were as follows:

Glucose 113 mg/dL (74-99)
Neut# 8.4 k/cumm (1.4-7.0)
0.1% 
Neut 91.0 (40.0-75.2)

5.0 (16.0-51.0)

MPV 10.4 fL (7.4-10.4)

0.5 k/cumm (1 .0-4.0)
Platelet Count 276 k/cumm (130-400)
(normal) - no platelet count 11/24/12
was abnormally low

Officer N.T. was relieved by Officer R.P. in the early morning hours of 11/28/12, at the
ECMC .ED. Both Officers NT. and Officer R.P. stated Metcalf was cooperative in the ED
with no incidents of aggressive or unusual behavior. Officer R.P. stated that Metcalf ate
his breakfast without incident. Metcalf?s vital signs before his ED discharge were listed as:
blood pressure 154/88, pulse 77, respirations 18, and temperature 98.2.

According to the Depew PD documentation on 11/27/12, at approximately at 9:21 am,
Metcalf'was returned to the Depew PD without incident. At approximately 10:51 am,
Metcalf was escorted to his arraignment by Depew PD Detective T.P. and Lieutenant J.

M. Detective T.P. reported that when he met Metcalf, he observed a red mark on Metcalf?s

forehead, and his face had a pinkish color around his eyes and cheeks. Per NYSP
documentation, Depew Court Clerk J.F. reported that during Metcalf's arraignment, he
appeared very quiet but did speak to his father and an attorney. J.F. reported that she saw
no injuries on Metcalf. Lieutenant J.M. and Detective T.P. stated Metcalf conversed with
his father in-the court room, Metcalf was relevant and had appropriate conversation.
Depew Town Justice G.W. reported that Metcalf appeared to understand where he was
and what he was arrested for. Justice G.W. described Metcalf?s faCe as appearing 
redden, but he did not remember any cuts on it. Justice G.W. reported that he ordered a
evaluation due to the police officers? reports of Metcalf?s behavior during the
arrest. Metcalf was held without bail pending a court ordered mental health exam. At

11.

12.

13.

14.

approximately 10:58 am, following his arraignment, Metcalf returned to the holding cell
at the Depew PD.

Officer C.W. completed supervisory rounds when Metcalf was housed in a Depew PD
holding cell at intervals approximately every 20 minutes. Detective T.P. observed Metcalf
sitting in the corner of the cell, and he had placed his shirt over his head like a tent. The
detective asked Metcalf if he was okay, and Metcalf replied that he was scared. Officer T.
P. asked Metcalf what he was scared of and he replied that he was ?just scared.? On
11/27/12, at approximately 1:50 pm, Detective T.P. stated he observed Metcalf putting
food into the holding cell's toilet and that he instructed him not to do it. Metcalf was
apologetic, stating he would not do it again. However, several minutes later Detective T.
P. observed Metcalf repeating this action. Detective T.P. reported that he thought that
Metcalf was on some type of drug or was mentally ill. The detective stated that Metcalf
smeared feces on himself and on the cell?s floor. Detective S.H. stated that Metcalf was
not booked at the Depew PD with the routine procedure with a photo and fingerprints taken
due to his abnormal behavior.

Detectives T.P. and S.H. were assigned to transport Metcalf from the Depew PD to ECHC.
Detective S.H. stated that he placed a blanket on the back seat of the patrol vehicle to
prevent contamination from the feces. Detective T.P. observed Metcalf as non?combative
and cooperative but was not acting normally. Metcalf was described as distant and
unconcerned about sitting in the feces. Detectives T.P. and Detective S.H. reported that
he observed a small cut over Metcalf?s left eye, and his facial skin was pinkish during the
transport to ECHC.

According to ECHC video?recording on 11/27/12, at approximately 3:34 pm, Detectives
T.P. and S.H. arrived in the ECHC intake/booking area. Detective T.P. stated that one
deputy was The ECHC deputies stated that they would be taking Metcalf directly to
the shower area and would return the police department's handcuffs to the detectives.
Detectives T.P. and S.H. stated the ECHC deputies told them that Metcalf ?freaked out?
after he was taken to the shower area. Additionally, Detectives T.P. and S.H. stated that
the ECHC deputies reported that they ?had to take him (Metcalf) down.? Detectives T.P.
and S.H. stated they were not able to see Metcalf in the shower area. They also stated
that they did not see when he left the shower area. The Depew PD handcuffs were
returned to the detectives by the deputies.

According to ECHC video?recording on 11/27/12, at approximately 3:38 pm, Metcalf was
taken to the shower area by Deputies RS. and 8.8. due to being covered in feces and
urine. Deputy S.S. reported that he observed bruising on Metcalf?s face. Sgt. M. 0., who
was assigned in the intake/booking area, did not initially observe Metcalf?s arrival due to
an interaction with another inmate. Sgt. MC. reported that he was on his way back to the
booking area when he overheard a disturbance in the shower area. Sgt. MC. observed
ECHC Deputies RS. and SS. attempting to take Metcalf into the shower due to soiling
himself. Sgt. MC. stated that he observed Metcalf crying, yelling, and mumbling. Sgt. M.
C. reported that when Metcalf straighten himself, he observed that Metcalf had left sided
facial swelling and an abrasion on his forehead. Sgt. MC. reported Metcalf acted
disorientated and attempted to talk to Metcalf-to calm him down. Sgt. MC. ordered Metcalf
to be escorted to the isolation area by the two deputies. Sgt. MC. reported he had Metcalf
sit on a bench and continued to talk to him. Sgt. MC. stated that he told Metcalf that he
would be taken to medical and would receive attention. The sergeant reported that he did
this because Metcalf appeared delusional or had something wrong with him. Once Metcalf

15.

16.

appeared calm, Deputies RS. and SS. escorted Metcalf directly from the isolation room
to the medical unit. According to the NYSP Investigative Report, Sgt. MC. stated Metcalf
was in the isolation room for 45 minutes until he went to the facility nurse.

On 11/27/12, during the evening shift from 3:00 pm. to 11:00 pm, RNs BL and MM.
were assigned to the medical intake area to assess newly admitted inmates. At 4:50 pm,
while at ECHC, RN D. L. documented the following regarding Metcalf:

?Patient arrived with multiple abrasions and confusions upon exam, patient has
diminished right lower lobe lungs, oxygen saturation 99%, 156/110, and heart
rate 105. Patient?s right great toe is missing several layers of skin, his ankles are
+3 pitting edema, head has several swollen contusions with left orbital swelling.
Patient recently seen at Buffalo General, consent signed and faxed for release of
information. 

At 5:00 pm, ECHC RN MM. completed a Correctional Medical Intake Screening with
Metcalf and noted that he had a right toe abrasion. Metcalf reported that he had chronic
bronchitis,- hypertension, and a ?problem with bile duct.? Metcalf stated to the
registered nurse that he drank one to two beers or liquor on weekends with his last drink
being over a week ago. Metcalf admitted to using marijuana. His vital signs were listed as:
a pulse of 92, a blood pressure of 164/110, and 18 respirations. At 5.05 pm, RN MM.
reported that she called ECHC NP BC. and advised him of Metcalf?s status. On 11/27/12,
at 5:10 pm, RN MM. completed Metcalf's admission Suicide Prevention Screening form.
Affirmative answers were given for the following questions:

~Detainee is very worried about major problems other than legal situation 
serious financial or family problems, medical condition, orfear of losing job) with a
comment listed as -and substance abuse problems. 

-Detainee has a history of drug or alcohol abuse with a comment listed as ?alcohol.?

-Detainee is incoherent, disorientated, or showing signs of mental health illness
with a comment of: ?sergeant notified, disorientated, discharge from Buffalo
General Hospital on 11/26, and patient unsure if CA T-scan of head was done.
Awaiting fax .of medical information from Buffalo General Hospital. 

Additional notes written by RN M. M. were ?cooperative denied suicidal ideation.? RN M.
M. ?det0X-?
Medical documentation cites that RN D. L. completed a Correctional Health Housinq Form
for Metcalf indicating that Metcalf required Special Housing Needs for detoxification. RN
D. L. reported that Metcalf was having shortness of breath and neurological changes.
Metcalf?s oxygen saturation was 95 to 96% and his blood pressure was 150/110.

On 11l27l12, at 5:05 pm, RN M. M. documented the following:

B. C. aware of patient status, alert and orientated 3 with lethargy. Patient
states ?having hard time concentrating.? Difficulty tracking finger through visual

17.

18.

19.

fields. Waiting for tax return from BGM. At 6:20 pm, it was documented that 
C. NP down to see patient 174/109, HR 100, 98.1 RA, lungs CTA, weak hand
grip noted on right, "patient to be transferred to ECMC by ambulance, medical
paperwork sent from BGH, no CT of head (was) done, Alert and orientated X3
with intermittent lethargy. 

NP 30. completed a medical evaluation with Metcalf who had an oxygen saturation of
98%. Also cited was a recent (two days prior) assault with a head injury. RN MM reported
Metcalf was confused with his eyes opened, had slow speech, and difficulty with word
finding. NP B.C. observed Metcalf's left as with swelling. Metcalf's chest
and abdomen were within normal limits. NP 8.0. also observed Metcalf with 3+ pitting
edema bilaterally with several varicosities. Metcalf had patellar and brachial hyperreflexia
3+ to 4+ bilaterally. NP B.C. ordered Metcalf to be transported to ECMC ED for an intra-
cranial pressure (ICP) evaluation for a post head trauma secondary to assault. RN D.L.
documented ?Patient at 6:30 pm still experiencing SOB and neurological changes patient
with at 95% to 96% oxygen saturation and hypertensive at 150/110. Several calls placed
to Buffalo General for medical and at this time with urgency from nursing staff, patient is
being transported to ECMC by ambulance. NP B.C. ordered clonidine 0.3 mg stat p0,
which was administered before Metcalf left ECHC.

The NYSP Investigative Report states that RN D.L. reported Metcalf had a hematoma
over his left which looked ?fresh? and noted abrasions on his back as well as on his
abdomen that looked recent. When Metcalf was asked questions, he gave answers that
didn?t make any sense. Metcalf stated to RN D.L. that the Depew PD had ?whipped his
ass.? According to the NYSP Investigative Report, RN MM. contacted her supervisor, RN
D.M., by telephone at home regarding her concerns about Metcalf?s injuries and believed
he had been seriously injured prior to his arrival to ECHC. RN D.L. also spoke to RN D.
M. and indicated that he thought Metcalf had been beaten priorto his arrival to the holding
center. Rural Metro Medical Services ambulance was called.

According to the Rural Metro Medical Services documentation on 11/27/12, at
approximately 6:40 pm, EMTs CM. and R.L. arrived at the medical unit. Rural
Metro Ambulance documentation reported the EMTs were dispatched to the ECHC for an
assault. According to the NYSP Investigative Report, Metcalf told EMT C.M that he had
been assaulted two days prior but did not report who did it. EMT C.M stated he observed
that Metcalf had cuts and bruises all over his face and stated he had pain in his face. EMT
C.M noted that Metcalf's facial bleeding had been controlled prior to his ambulance
transport. His blood pressure was listed as 128/82 and pulse was 86. At 7:04 pm, EMT
C.M reported that Metcalf was transferred to ECMC ED. According to the NYSP
documentation on 11/27/12, Deputy D.H. rode in the Rural Metro ambulance with Metcalf,
and Deputy E.S. followed in the patrol car transporting Metcalf to ECMC ED.

According to the NYPD Investigative Report on 11/27/12, at 7:10 pm. upon arrival to
ECMC, RN D.L., who was the triage nurse, reported that Metcalf was ?from the Holding
Center for assault from (to) arrest. Patient does not know when it occurred, has multiple
c/o facial rib pain, SOB, chestpain, and neuro-deficits. Per the NYSP Investigative Report
on 11/27/12, at 7:17 pm. while at ECMC, RN D.G., who was treating Metcalf, conducted
his initial assessment. Metcalf complained of rib pain, facial pain, with arms both painful.
Metcalf told D.G. that he was assaulted but did not say by who or when. It was noted that
Metcalf was oriented to perSon, place, and time. RN D.G. did report that he saw abrasions
on Metcalf?s face and lesions on his arms. Dr. S.R. cited that she saw Metcalf the previous

20.

21.

night for a Taser injury. The physician noted that Metcalf stated "he had pain ?all over? with
evidence of new bruising later seen by myself this am. Metcalf complained of pain in his
right wrist and hand and had a headache. Dr. 8.R. described Metcalf?s skin as ?multiple
abrasions and lesions diffuse on all extremities and new and worsening bruises on face,
arm, and legs. The physician noted that Metcalf?s Taser site with small skin defects with
evidence of healing. Dr. 8R. documented that ?now has a black on left side. Dr. 8.
R. gave Metcalf diagnoses of ?contusions, orbital and abrasions. Dr. 8R.
reported that Metcalf complained of pain in his hands, wrists, chest, head, and his left 
was black and blue. Dr. 8.R. stated that Metcalf had bruising diffusely and an abrasion on
his toe that looked like a rug burn from being dragged. The physician also cited that
Metcalf?s wrists and hands were swollen. Metcalf stated to Dr. 8R. that he got hit, and
that he did not know who did it, or when it happened. Dr'. R.K., the attending physician,
reported that Metcalf stated to him that he "got beat up in jail. Metcalf complained of
"diffuse pain, in his head, chest, both wrists with the right greater than left. Dr. R.K. also
noted that Metcalf?s right great toe was injured. Dr. 8R. documented Metcalf?s vital signs
as blood pressure126/86, pulse 74, respirations 16, and oxygen saturation 97%. A chest
x-ray was completed which reported an enlarged heart, clear lungs with a 4.1 cm opacity
projecting from right paravertebral stripe with a CT scan of the chest recommended.
Metcalf also had X-rays completed of his right forearm, right foot, right hand, and bilateral
wrists with no fractures noted. Metcalf was discharged on 11/27/12, at approximately
10:06 pm.

The security log book reported that at 10:40 pm, Metcalf returned from ECMC. Metcalf
was transported back to ECHC by Deputies DH. and E8. A Use of Force form was
completed by Deputy D.H. The report indicated that Metcalf was ordered by Deputy 8.8.
to go to the isolation room in the booking area. Metcalf refused to walk to the isolation
room, became uncooperative, and attempted to enter another intake room. Deputies 8.8.
and R8. reported that they attempted to secure Metcalf with handcuffs and were met with
immediate resistance. At this time, Deputy 8.8. secured Metcalf?s left arm while Deputy
R.8. took his right arm. Deputy D.H. assisted with the handcuff placement and secured
them. Deputies 8.8. and R8. then escorted Metcalf to the isolation room. The deputies
did not report that Metcalf was taken down to the "ground." The deputies also reported
that Metcalf was intentionally hitting his forehead on the wall. The security log book
reported that at 11:01 pm, Metcalf was moved to isolation room. The Use of Force Report
cited that the nature of Metcalf?s injuries before the Use of Force were bruising and brush
burn on face and forehead. The nature of the injuries following the Use of Force was
opening of brush burn on face and forehead causing bleeding. Deputy D.H. reported that
a sergeant took photographs of Metcalf. Deputy D.H. stated that the injuries he reported
on the Use of Force Report were prior injuries and were not from the incident that had just
occurred.

After Metcalf returned from ECMC, he was evaluated by RN KM. in the ECHC booking
area. RN KM. documented:

?On 11/27/12 (at) 10:45 pm. returned from ECMC, CT scan and x?rays negative,

hit head against wall in isolation room, bleeding from old left temple controlled,
cleaned with normal saline, neuro checks intact, PERRLA, vital signs stable. 

Additionally, RN MM. assessed Metcalf and documented that at 10:45 pm. the following:

22.

23.

?Returned from ECMC, CT negative, chest-ray negative, right FA, right hand, right
foot, left and right wrist all negative, no fractures, hit head against wall in isolation
room,_ bleeding from abrasions, bleeding controlled, alert, orientated 3, neuro
checks intact, PERRLA, and equal hand grips. 

In reviewing Metcalf's Booking Summary Report dated 11/27/12, at 11:39 pm, RN MM.
had documented the comment of "MedicalaSpecial Needs/Notes? for the purpose of
placing Metcalf in Delta Short, a specialized inmate housing unit which was used for
inmates with mental health issues and/or undergoing detoxification. According to the
Booking/Intake Security log on 11/27/12, at 11:45 pm, Metcalf was moved to Delta Short.

 

The Medical Review Board opines that LMHC RM. failed to
recognize Metcalf?s signs and of acute and failed to initiate an
appropriate treatment plan including immediate referral to 

According to medical documentation on 11/28/12, at 11:45 am, NP J.C. completed a
history and physical examination with Metcalf. The nurse practitioner noted that Metcalf
was seen at the ECMC ED last night secondary to an assault with head injury two nights
ago. NP J.C. observed Metcalf had contusions on his face and had orbital 
Metcalf's skin was noted by NP J.C. to have ?multiple abrasions and contusions? and
ordered a medical follow-up in one week. Metcalf appeared very sleepy and stated he had
not slept for the last two nights as he was scared about what was happening. Metcalf?s
past medical history was noted by the nurse practitioner as hypertension and biliary
atresia. Anxiety was listed under Metcalf?s past history. It was documented by
the nurse practitioner that Metcalf was prescribed nadolol 20 mg po qd, Prilosec 20 mg po
qd, and hydroxyzine 25 mg qid pm for anxiety. Metcalf stated that his last ethanol drink
was one week ago with 4 to 5 mixed drinks and marijuana use one week prior. Metcalf?s
blood pressure was noted to be 146/106 and a pulse of 106. NP J. C. noted the CIWA

24.

25.

26.

27.

REPORT OF RSCHARD METCALF Page  11

score was a ?zero,? and Metcalf had no need for detoxification as his last alcohol use was
one week ago. It was ordered that Metcalf was to have blood pressure checks for five
days with a follow-up in two weeks. Prilosec 20 mg po qd was prescribed for GERD. NP
J.C. also The Medical Review Board
opines that with two hospital emergency room admissions within a 48-hour period and
continued complaints of unresolved acute anxiety should have prompted the NP to
immediately refer Metcalf to for an evaluation.

On 11/28/12, at approximately 1:00 pm, Deputy S.H., who the assigned classification
officer, completed the security Initial Classification Instrument. Deputy S.H. documented
that Metcalf had a violent felony, this was first incarceration and was over age 35. Under
the section that asked ?Has medical or mental health staff requested special needs
housing?? Deputy S.H. circled Metcalf?s total score was Metcalf was approved
for general supervision with no special needs. According to the NYSP investigative report,
Deputy S.H. stated that he Was walking Metcalf to his cell after his classification and
noticed that Metcalf kept looking behind him. Deputy S.H. stated that Metcalf told him that
he 'did not Want to get beat up again. Deputy S.H. reported that Metcalf stated that the
Depew PD officers had beat him up. Deputy S.H. had Metcalf lift his shirt and Deputy S.H.
stated he saw Taser marks and dozens of black and blue marks on Metcalf?s chest,
stomach, back, and face. Deputy S.H. stated that Metcalf answered all his questions and
appeared to be coherent. Deputy S.H. stated that Metcalf?s biggest concern was getting
beat up again. Deputy S.H. reassured Metcalf that he would be okay, and he appeared to
become calm. Deputy S.H. did not take any photographs of Metcalf?s injuries or notify a
supervisor. 

On 11/28/12, at 1:45 pm, there was a security log entry that Metcalf was moved to Echo-
Long cell On 11/28/12, at 2:32 pm, there was a notation that ?Metcalf was complaining
of pain, medical notified. "There is no documentation that indicates that medical personnel
saw or evaluated Metcalf for this complaint.

At approximately 4:30 pm, Metcalf asked Deputy MO., who was an Housing
Officer, to be lock-in because he felt scared. Deputy MO. stated that this was not a usual
request from an inmate. Deputy MO. stated he locked?in Metcalf, and Metcalf ate his
dinner without incident.

On 11/28/12, at approximately 10:15 pm, Deputy MO. observed Metcalf acting in an
irrational manner in his cell. Deputy MO. stated Metcalf was biting and punching himself
as well as picking at scabs on his arms with a plastic fork. Deputy MO. reported that he
tried to speak to Metcalf and asked him for the fork. Metcalf responded by throwing the
fork at him. Deputy MO. notified Deputy R.F., an Housing Officer, about
Metcalf?s behavior. Deputies RF. and MO. stated they heard Metcalf making statements
that made no sense. Metcalf was saying he was ?radioactive? and ?slaughter house."
Deputy R.F. notified Sgt. R. D., who was on different a housing unit, regarding Metcalf?s
behavior. Sgt. R.D. was the supervisor for Metcalf?s housing unit. Sgt. RD.
and Deputy E.K. initially responded to the disturbance with Metcalf. Deputy E.K. reported
that he observed Metcalf biting his fingers and toes, as well as hitting himself. Sgt. R.D.
went to the cell and attempted to talk to Metcalf to calm him down. Sgt. R.D. told Metcalf
to follow his order to place his hands behind his back so that he could place handcuffs on
Metcalf's wrists. Metcalf did not comply with Sgt. order. Sgt. R.D. repeated the
instructions; however, Metcalf ignored them. Sgt. R.D. decided to complete a cell?

28.

29.

30.

31.

extraction. The restraint chair could not be Used, as it was not functioning correctly and
needed to be repaired. Sgt. R.D. called for a response team.

At approximately 10:20 pm, deputies responded to Metcalf?s cell. They were Sgt. MC.,
Deputies RS, and SE. Deputy S.E. stated that he went to MetCalf?s cell but did?not enter
it due to the space limitations. Sgt. R.D. was in charge of the use of force for Metcalf.
Deputy was ordered by Sgt. R.D. to go to controls and open Metcalf's cell. Deputy
MO. then stayed at the controls to operate the gate. Sergeants RD. and MC. stated that
Metcalf was self?injurious and was banging his head against the wall and floor. He was
also biting his arms and smearing the blood on the walls. Sgt. R.D. stated that Metcalf was

.taken down to his bunk. Metcalf resisted by placing his hands under his chest while in the

prone position. Sgt. R.D. stated that the deputies moved Metcalf to the cell floor so that
his hands could be restrained and then placed into handcuffs. Sgt. MC. reported that he
secured Metcalf?s legs. Metcalf's right arm was secured behind his back by Deputy E.K.
Metcalf's left arm was positioned behind his back by Deputy R.S. Metcalf was handcuffed
and removed from the floor. Metcalf was taken out of his cell. Metcalf ambulated to the
hallway escorted by Sgt. MC., Deputy E.K., and Deputy R.S. The intent of this transfer
was to have Metcalf examined by the nursing staff. Sgt. MC. stated that during the escort
to the Delta medical examination room, Metcalf began to spit large amounts of blood at
the deputies, and he continued to resist.

According to the ECHC video?recording on 11/28/12, at approximately 10:22 pm, Metcalf
was seen entering the elevator. Metcalf was handcuffed behind his back with three officers
restraining him. Metcalf was resisting the officers. There were three officers who placed
Metcalf on the wall of elevator in the corner with his head down. There were also three
different deputies in attendance in the elevator who did not restrain Metcalf, for a total of
six deputies in the elevator. Deputy E. stated that he heard a commotion coming from
the elevator area. He then saw Metcalf exiting the elevator with the deputies. Deputy C.
E. stated Metcalfwas out of control and spitting blood everywhere. Deputy R.S. stated
that Metcalf was uncooperative during the escort to the medical unit. Metcalf was taken to
the Delta medical examination room by three deputies, and the three other deputies were
walking behind them.

The ECHC video-recording shows that on 11/28/12, at approximately at 10:23 pm,
Metcalf was observed in the Delta medical examination room. The video?recording shows
the door of the examination was closed shortly at 10:23 pm. A deputy opened the
examination room door at 10:25 pm. Metcalf was observed to be struggling with the
deputies. The Delta exam room has two entrances in which both were used by the
deputies to gain access. Sgt. MC. stated that Metcalfwas spitting blood in the exam room,
which hit the medical equipment and the officers? clothes. Metcalf was placed face down
in the prone position on the medical table due to this behavior. Sgt. MC. reported that he
was at the head of the exam table controlling Metcalf's head. Sgt. MC. stated he secured
Metcalf?s head in the downward position so the other staff would not be struck by blood.
Sgt. R.D. reported that it took four deputies to restrain Metcalf on the table.

On 11/28/12, at 10:24 pm, RN K.M was observed entering the Delta medical
examination room to evaluate Metcalf. RN K.M reported that he observed Metcalf face
down in the prone position on the examination table surrounded by multiple deputies who
were restraining him. The registered nurse described Metcalf as resisting, combative,
kicking his legs, and spitting blood at the deputies. RN K.M reported that he was notified
by Sergeants RD. and MC. that Metcalf had been self-injurious and combative including

32.

33.

banging his head against his cell walls and floor. The sergeants stated to RN KM. that
Metcalf was biting and stabbing himself in the forearm with a plastic fork. RN K.M. stated
Metcalf was handcuffed behind his back and was shackled at the ankles by the deputies.
RN KM. stated that he was unable to gain close proximately to Metcalf to assess his
injuries due to his combativeness. Sergeants RD. and MC. requested an EMS
ambulance be called to transport Metcalf to ECMC for his injuries and behavior. RN K.M.
agreed with this and reported he called Rural Metro for an ambulance. The registered

Mt he also called Dr. H., who told him to notify Dr. 
Dr. B. agreed that Metcalf should be transported to ECMC as soon as

possible. RN KM. stated that he asked Dr. B. about ?pm? sedation for Metcalf?s behavior.
Dr. B. info'rmed RN K.M. that these medications would have to be ordered by the forensic
department at ECHC, The Comprehensive Emergency Program
(CPEP) requires an emergency encounter and triage before mental health medications
are ordered. The ECHC Use of Force Report dated 11/28/12, at 11:20 pm, was competed
by Sgt. R.D. reported that the nature of Metcalf's injuries before the use of force were
?multiple cuts/abrasions and bruising. "The nature of the injuries following this use of force
was listed as: ?unknown transported to the hospital.? The Medical Review Board opines
that the Erie County Holding Center and Erie County Mental Health failed to have an
adequate crisis intervention plan for inmates who are experiencing acute with
violent behavior and revisits prior Medical Review Board concerns from the Matter of
Michael Bennett (DOD: 7/5/02), who died while in custody at ECHC in a similar manner in
2002, under a prior sheriff's administration. Had an appropriate plan been established and
an emergent chemical restraint ordered and administered, Metcalf's violent behavior may
have been managed safely.

According to the ECHC video?recording, at approximately 10:28 pm, Sgt. MA. entered
the examination room and he saw Sergeants D.K., M.C., RD, and Deputy R.S. holding
Metcalf down on the examination table. Sgt. M.A. stated that someone requested a spit
mask. Sgt. M.A. stated that he obtained one from another room. At 10:29 pm, a deputy
was observed with a spit mask in his hand and entered the exam room. Sgt. M.A. reported
that he handed the spit mask to someone but could not recall who it was. Deputy C.E.
stated that he entered the examination room and reported someone gave him a spit mask.
Deputy C.E. gave the spit mask to Sgt. M.C. According to the NYSP Investigative Report
and Sgt. M.C., Sgt. M.C. secured the spit mask loosely over Metcalf?s head and face but
did not tie the mask. Sgt. R.D. reported that the spit mask was placed over Metcalf?s head
with the blue part in the front. Deputies E.K. and CE. reported that they did not see
anyone tie the spit mask. Metcalf chewed a hole through the mask and began to spit blood.

According to the ECHC video-recording, at 10:42 pm, a deputy was observed bringing a
pillow case in the exam room. According to the NYSP Investigative Report, Sgt. M.C.
stated he placed the pillow case loosely over Metcalf's head securing it when Metcalf?s
head was in the downward position. Sgt. M.C. stated that he had previously received
retraining on the use of a spit mask. This is a violation of Erie County Sheriff?s Office Policy
and Procedure #04?09-02 entitled Restraint Chair; Section (B) Use of Spit Mask which
states:

?Hoods, bags, or other devices covering the head and face, which may interfere

with normal breathing are prohibited.?

spit mask maybe used when an inmate is attempted to spit on staff placing the

inmate in a restraint chair. Only a mask speci?cally designed as a spit mask is

authorized. NO improvised masks are permitted. 

34.

35.

36.

?The spit mask should be placed over the inmates head and tied in the back. It
should not be tied around the inmates face or neck. At all times the inmates
ability to see and ability to breath comfortably must not be obstructed. 

RN KM. stated that he was unable to observe the spit mask or pillow case applied to
Metcalf's head as he was talking by telephone to the physicians.

The Medical Review Board opines that Sergeant M.C. applied a dangerous and
unauthorized restraint device on Metcalf that, from the physical post mortem findings,
caused Metcalf to have severely restricted breathing. Additionally, Erie County Sergeant
R.D. who oversaw the use of force was immediate responsible for the care, custody, and
treatment of Metcalf and failed to properly supervise staff and prevent dangerous and
unauthorized restraint methods. The failures of both sergeants to properly oversee
Metcalf?s condition and supervise staff directly resulted in Metcalf's demise and is in
violation of Correction Law 500-C. 

On 11/28/12, at 10:24 pm, Rural Metro EMTs RM. and-M.J. were contacted for the
transport of a patient with a emergency from ECHC to ECMC. According to
Rural Metro Medical Services documentation, at 10:46 pm, EMTs RM. and M.J. arrived
at ECHC. According to the ECHC video?recording at approximately at 10:49 pm, the
Rural Metro EMTs were observed with their stretcher at the medical exam room where
Metcalf was located. Per the ECHC video-recording at 10:50 pm, EMTs RM. and M.J.
were observed pushing their stretcher into the exam room. EMT M.J. came out of the
exam room less than a minute later. Both EMTs RM. and M.J. stated that a deputy gave
an order for EMT M.J. to leave the exam room due to Metcalf?s behavior. She was
observed standing by the door until 10:51 pm. and then goes back into the exam room.
RN KM. stated that he gave the Rural Metro EMS a report on Metcalf and observed the
deputies securing Metcalf on the EMS stretcher. At 10:52 pm, Metcalf?s stretcher exited
the medical exam room. A deputy was observed at the top of the stretcher where Metcalf's
head was located and pushing the stretcher in the hallway. Metcalf?s head was covered.
EMT RM. was observed at the foot of Metcalf's stretcher. EMT M.J. came out of exam
room and followed the stretcher.

Rural Metro Ambulance EMTs M.J. and RM. provided statements to the NYS Department
of Health; Bureau of Emergency Medical Services as part of their investigation for this
incident. The EMTs also supplied supporting depositions to the NYSP for their
investigative report of Metcalf?s death. EMTs RM. and M.J. stated that the deputies told
them Metcalf was combative, belligerent towards the staff, and spitting blood. EMTs M.
J. and RM. stated that they observed the patient face down on the examination table, with
his hands handcuffed behind him and his feet also cuffed with a chain. EMT RM. stated
that he entered the examination room with the stretcher and observed the inmate moving
and making noise. EMTs M.J. and RM. stated that Metcalf had a pillow case over his
head, and there were five to seven deputies holding him down. EMT RM. stated that he
asked the deputies why it was necessary for a pillow case over Metcalf?s head he was told
by the deputies that they needed to cover Metcalf?s head to prevent him spitting blood.
EMT RM. stated that he asked to move to Metcalf?s head in order to assess him. The
deputies told EMT RM. they needed to hold Metcalf down for safety reasons. EMT RM.
stated that he was unable to gain access to Metcalf's head to assess him. EMT RM.
stated that Metcalf was not actively resisting while he was present.

37.

38.

39.

EMT R.M. stated that the deputies lifted and put Metcalf on the stretcher with his face
down. The deputies told EMT RM. that Metcalf was going to be moved onto the EMTs
stretcher the same way he was on the examination table. EMTs RM. and M.J. reported
that they asked if Metcalf could be placed on his back for health reasons. The deputies
denied this request and told EMTs RM. and M.J. that Metcalf needed to be on his stomach
for control as he had been fighting the deputies and spitting blood. Metcalf was placed on
the stretcher by the deputies. EMT R.M. reported that the deputies would not let him place
the stretcher restraint belts on Metcalf with the exception of one belt on the stretcher in
the torso area. Sergeants R.D., MO, and Deputy E.K., reported that the EMTs had asked
the deputies to leave Metcalf on his stomach for theistretcher transport. According to the
NYSP investigative Report, Sgt. R.C. stated that the EMTs told him to leave the pillow
case on Metcalf and to place Metcalf face down onto the stretcher. EMT R.M. reported
that the deputies would not let him or EMT M.J. control the stretcher where Metcalf's head
was located. However, after asking, the deputies allowed EMT RM. to push Metcalf?s
stretcher at the feet.

According to the ECHC video-recording, at approximately at 10:52 pm, the EMTs
stretcher was seen leaving the medical exam room. Metcalf was in the medical
examination room for approximately twenty nine minutes from 10:23 pm. to 10:52 pm.
Approximately seven deputies exited the medical examination room after Metcalf?s
stretcher was moved in the hallway towards the elevator. A correction deputy was seen
pushing at the end of the stretcher where Metcalf?s head was located. EMT R.M. was
observed walking at the stretcher where Metcalf?s feet were located. EMT M.J. was
walking behind two deputies as Metcalf?s stretcher was exiting the medical exam room.
The ECHC video?recording showed that throughout the entire transfer to the Rural Metro
ambulance a deputy was pushing the stretcher where Metcalf?s head was located. EMT
R.M. was pushing the stretcher at Metcalf?s feet. EMT M.J. followed behind the stretcher.
Additionally, a deputy was pulling on the shoulder restraint strap over Metcalf's right
shoulder. At 10:52 pm, Metcalf?s stretcher was wheeled inside the elevator with EMT R.
M. located at the middle of the stretcher. An officer was still pulling the shoulder strap
buckle of the stretcher at the head of the stretcher. Deputies are observed at Metcalf?s
head as the stretcher was removed from the elevator. According to the NYSP
Investigative Report, EMT RM. stated that Metcalf's breathing became shallower during
the transport to the ambulance. EMT R.M. stated that Metcalf?s movements and noises
decreased while in the elevator and stopped when they left the elevator and went down
the hallway to the ambulance.

On 11/28/12, at 10:54 pm, Metcalf?s stretcher exited the facility through the ECHC intake
sally port with a deputy still at the head of the stretcher. EMT R.M. was at the foot of the
stretcher with EMT J.M. walking behind the stretcher. Approximately five additional officers
also exited the sally port behind EMT M.J. EMT R.M. reported that as the deputies
transferred Metcalf?s stretcher to the ambulance, he Went to Metcalf?s head to begin to
assess him. EMT R.M. removed the pillow case from Metcalf?s head. EMT M.J. and EMT
R.M. stated that they observed a spit mask tied very around Metcalf?s neck, in
flagrant violation of Erie County Sheriff?s Office Policy and Procedure #04?09-02 entitled
Restraint Chair; Section (B) Use of Spit Mask . EMT M.J. and EMT R.M. reported the spit
mask was tied so tight that R.M. had to use his scissors to cut the spit mask off. EMT R.
M. assessed Metcalf and found no carotid pulse or respirations. EMT M.J. also checked
for a carotid pulse and respirations and finding none concurred with EMT R.M.'s findings.

40 16

EMT R.M. told the deputies to give him a handcuff key as he was ?working a code. The
deputies gave him the key. EMT R.M. had difficulty removing the handcuffs. A deputy
jumped in the ambulance and took the cuffs off. EMT R.M. turned Metcalf to the supine
position. Both EMTs M.J. and RM. stated that Metcalf?s face was. discolored. They
described it as cherry and purple colored. EMT R.M. stated Metcalf?s head was abnormally
large from swelling and his face had small broken blood vessels stated that they saw visible marks around Metcalf?s neck. Additionally, EMT M.J. stated
that Metcalf had enlarged veins in his neck area. EMT R.M. used the BVM and gave
Metcalf two breaths. EMT M.J. applied the AED which advised no shock. EMT R.M. told
EMT M.J. to drive to the nearest hospital which was BGH. EMT R.M. initiated chest
compressions. Deputy M.P., who was assigned security transport for the ambulance
completed respirations with the BVM. EMT R.M. stated that he asked the deputies what
else happened to Metcalf due to Metcalf?s facial bruising. According to the Rural Metro
ambulance report, the deputies stated "to our knowledge we did not see it but according
to other of?cers, he (Metcalf) was punching himself and banging his head against the bars
in the cel.? EMT R.M. attempted to call for ACLS back up but could receive any signal
from dispatch. Metcalf had no pulse or respirations during the transport to BGH. An
annotation with the Rural Metro Medical Services documentation completed by EMT R.
M. indicated that Metcalf had bruising on his left and bruising on his lower back.

According to Rural Metro Medical Services documentation, the ambulance arrived at the
BGH ED at 11:09 pm. The EMT's wheeled Metcalf?s stretcher into ED and hospital staff
assumed Metcalf?s care. Dr. A.P., the attending physician, stated that EMT told him
that EMT RM. and she did not get told all of the information regarding Metcalf until they
were in the back of the ambulance. Dr. A.P. stated that RM. and M.J. reported they
asked the officer who accompanied Metcalf in the ambulance about the contusion on the
left side of Metcalf?s eye, along with other lacerations and bruising. The officer told EMT
M.J. that Metcalf was banging his head against the bars in the jail cell. EMT M.J. stated
Metcalf had numerous bruises on his abdomen, back, and chest. Dr. A.P. stated that both
EMTs M.J. and RM. were visibly upset about the emergency call, and he advised them
to notify their supervisor.

BGH medical documentation reported that Metcalf had a witnessed cardio?pulmonary
arrest with the total time from the point of arrest to arrival at BGH ED was ten minutes.
Metcalf had received CPR forthe entire time. According to the NYSP Investigative Report,
BGH RN E.O., who was assisting another nurse with Metcalf?s care, 'stated that on
11/28/12, at about 11:00 pm, Metcalf was brought in the BGH ED in cardiac arrest by
ambulance. RN E.O. stated?that the EMT advised her that Metcalf was transported to the
hospital for self-inflicted wounds. RN E.O. reported that the EMT stated to her that Metcalf
had a spit mask on him, and the EMT found that the mask was so applied that he
had difficulty getting one finger under the ties. EMT R.M. confirmed that he stated such.
RN E.O. stated that the EMT stated he had to cut the mask off of Metcalf. RN E.O. recalled
that Metcalf had bruising on his arms, legs, torso, and facial area. RN E.O. reported that
Metcalf had one swollen shut, and she could only open it for an exam.

While in the BGH ED, the cardiac monitor reported that Metcalf had a PEA (pulseless
electrical activity). Metcalf received two rounds of epinephrine 121000 and was intubated.
After ten minutes of resuscitation, Metcalf had a spontaneous return of respirations and
circulation. He was placed on ventilator. A right femoral central line was inserted and the
hypothermal protocol was initiated. Metcalf was admitted to BGH at 11:15 am. It was cited
by Dr. AP. that Metcalf had significant over large portions of his trunk and

FINAL REPORT or METCALF Pagel17

face. Also noted in Metcalf?s BGH medical recorded, ?patient suffered significant trauma
with diffuse on torso, head, and face (it) is unclear what the origin of these
injuries were. BGH medical documentation for Metcalf completed by Dr. M.B., an ECMC
resident, reported ?head: contusion to face and head, Chest Wall: Multiple areas of
and Back: multiple large areas of Metcalf?s eyes were
described as: ?pupils 4 mm and fixed bilaterally, Left periorbital and edema,
and right subconjunctival hemOrrhage. "According to the NYSP investigative report, Dr. A.
P. cited that Metcalf had severe bruising on the left side of his face and he was cyanotic.
Dr. A.P. stated that he had difficulty examining Metcalf?s left due to the swelling and
bruising of the eye. Metcalf had diagnostic testing completed which were reported as:

- CT Facial lSinus without Contrast was completed and findings listed: ?left greater
than right facial soft swelling with left periorbital hematoma. No acute facial
fractures?

- CT Head/Brain without Contrast reported ?large left scalp hematoma, No acute
intracranial hemorrhage, mass effect or edema.?

- CT Torso Study with Contrast listed; ?There are three contiguous right
anterolateral lower rib fractures (a fourth, fifth, and sixth rib fracture) identified
along a left posterior 11th rib fracture. Additionally findings were compatible with
severe cirrhosis with portal hypertension and splenomegaly. Numerous varices
identified. There is no significant ?ow in the portal vein which may be thrombosed. 

Laboratory Blood Gases reported at BGH on 11/29/12 at 12:17 am. were as follows:

pH 6.90 (normal 7.35-7.45) BE -15.9 

VOZsatcalc 89.0 (70.0?76.0) p002 91 (35?45)

p02 92 (30?50) 21 mmollL (23-27)

HCO3 18 mmollL (20-26) Hematocrit Blood Gas 36.0 (42.0-52.0)

Laboratory gases reported on 11/29/12 at 1:40 am. were as follows:

Percent oxygen 100 A HCO3 17 mmollL (20-26)
AOZSatcalc 100% (95.-98.0) A BE -7.6 (-3.0-3.0)
Hematocrit Blood Gas 39% (42.0-52.0) A TCO2 18mmollL (23-27)
PEEP 5 cm H2O A CO2 33 (35-45)
A p02 371 (80-100) A pH 7.33 (7.35-7.45)

Laboratory blood work was completed on 11l28l12 at 11:22 pm. with abnormalities, with
the exception of Troponin levels, were reported as:

Sodium 148 mmol/L (135-145) Creatine Kinase 1156 unit/L (0-118)
WBC18.3 x10"9lL (4.0-10.5) Creatine Kinase MG 10. 

PT Prothrombin Time 21.1 sec (11.0?15.0) INR 1.93

APTT 46.1 sec (25.0?34.0) Troponin 0.02 0.06)
Carbon Dioxide 7mmollL (18-30) ALT 95 unit/L (5-50)

Platelet 96 x10"9lL (150?450)
Chloride 112 mmol/L (96-110)
RDW 15.9 

Bilirubin 5.1 (0.2-1.2)
AST 131 unit/L (5?50)

44.

45.

46.

47.

On 11/29/12, at approximately 5:38 am, Metcalf was transferred to ECMC for further
medical treatment. The ECMC medical record completed by Dr. K.C. noted upon
admission that MetCaIf had an approximate 3mm left periorbital and
his skin was described as having extensive and bruising, along his back,
neck, head, truck, chest, and extremities. According to the NYSP Investigative Report,
Dr. S.R., who had previously treated Metcalf on 11/27/12, in the ED, reported that she saw
new bruising on Metcalf and noticed that the old bruising was larger than the last time she
treated him. Dr. S.R. stated that Metcalf's left also stuck out because it was a lot larger
this time and was bleeding. Dr. S.R. stated that Metcalf had organ failure, which she noted
caused excessive and spontaneous bleeding and lead to previous injuries becoming
larger. ECMC attending physician Dr. B.C. reported he had treated Metcalf after Metcalf
was admitted to ECMC ICU. The physician cited that he observed bruising on Metcalf?s
face which was not there on the first hospital visit to ECMC on 11/27/12. Dr. C. reported
the most notable was the swelling in Metcalf?s facial area. Also cited in Metcalf?s ECMC
medical record was extensive on his extremities and 1.5 1.5 cm abrasion
on the right planter aspect of great tOe. Metcalf received numerous blood transfusions.
On 11/29/12, at 7:00 pm, ECMC RN J.L. documented the following on Metcalf's medical
record:

?Bilateral sclera/ edema and redness noted. Left entirely, right 
lid to right corner, multiple areas of noted on face and left
ear. Left flank and side large area noted, Bilateral knees multiple spots
of noted. Right thigh large noted, bilateral inner thighs
with multiple areas of noted. Right flank with multiple areas of
noted right second digit and right first toe with first layer of skin
removed.?

On 11/30/12, at 12:16 pm, Dr. N.T. documented that Metcalf?s EEG and neurological
evaluation revealed no cortical activity." On 11/30/12, Metcalf was released from the
custody of Erie County Sheriff?s Department. Metcalf?s prognosis was discussed with his
family and at 3:10 pm, Metcalf's family signed a DNR with comfort measures ordered
and administered. Metcalf was pronounced dead on 11/30/12, at 5:17 pm. by Dr. N.T.

The NYS Department of Health: Bureau of Emergency Medical Services received an
incident report completed by J.R., the supervisor at Rural Metro Medical Services. T.F. of
NYS Department of Health Bureau of EMS Investigation provided the DOH EMS
Reportable Incident Report to the NYS Commission of Correction after Metcalf?s death.
NYS DOH: Bureau of Emergency Medical Services conducted their own investigation into
the Metcalf incident and determined that there was no negligence or violations of Public
Health Law or Regulations on the part of the EMTs. This incident was also reviewed by
Rural Metro Medical Services Medical Director, Dr. BC. The Bureau cited that the Rural
Metro EMTs acted appropriately given the circumstances of the emergency.

A forensic examination was conducted by the Medical Review Board?s forensic pathologist
of the microscopic slides obtained during Metcalf?s autopsy which reported no evidence
of an acute myocardial infarction. Significantly the results of Metcalf?s autopsy did not
demonstrate that he had any coronary artery disease or atherosclerosis heart disease that
would support the pathological diagnosis of Acute Myocardial Infarction. Additionally,
Metcalf had a normal Troponin level on admission to BGH.

48.

49.

50.

51.

52.

Metcalf?s initial blood testing taken on his admission to Buffalo General Hospital ED on
11/28/12, reported laboratory finding consistent with respiratory acidosis including a lower
than normal PH (6.9) and a higher than normal P002 (91). These findings support that
Metcalf's respiratory acidosis and ultimate cause of death was suffocation due to airway
obstruction and compression of the chest.

On 11/29/12, at 1:31 am, a CT scan of Metcalf?s torso completed during his admission
to reported lower right anterolateral rib fractures. Metcalf?s fourth, fifth, and sixth ribs
were fractured on the right side and on the left side there was a posterior fracture of the
11?h rib. These fractures were indicative of traumatic injury and not consistent with
resuscitative efforts. Also noted was that prior radiologic studies of Metcalf?s torso done
on 11/27/12, showed no current or prior evidence of a rib fracture.

The NYSP crime scene photographs of the spit mask used on Metcalf showed several
knots that tied the strings of? the mask together. Photographs taken of Metcalf at his
autopsy show visible striations across his face further indicating that the spit mask was
tied inappropriately around his neck.

A review of the statements given to the NYSP for their investigation into Metcalf?s death,
as well as those from the NYS Department of Health Bureau of Investigation, reveal
that there are conflicting accounts of this incident. The correctional deputies reported that
the Metro Rural EMTs asked to keep Metcalf on his stomach during the transport;
however, statements given by the Metro Rural EMTs indicate that their request to turn
Metcalf on his back to the supine position was refused by the deputies. Additionally, the
EMTs stated they were told that they could not access Metcalf?s head nor direct the
stretcher during Metcalf's transport to the ambulance. A review of the ECHC video-
recording gives credibility to this claim as a deputy was observed controlling Metcalf?s
stretcher where his head was for the entire transport from the Delta medical examination
to the exit doors of ECHC. Additionally, deputies reported that Metcalf was yelling and
moving during the entire transport to the ambulance. The EMTs disputed this report stating
that there was no noise or movement from Metcalf when the stretcher was going to the
ambulance after exiting the ECHC elevator. The ECHC video-recording supplies no sound
to determine such. A review of the ECHC video-recording by 8000 staff observed no
movement from Metcalf on the Rural Metro stretcher from approximately 10:52 pm. to
10:54 pm. when exiting the ECHC sally port on 11/28/12.

From the crime scene photographs it was learned that the spit mask used on Metcalf was
a product from ?The Safari/and Group? named ?The Spit A review of the
conditions/instructions in the enclosed protective wrapping that comes with the spit mask
state:
?Do not use on anyone that is having difficulty breathing. Or is bleeding profuse/y
from mouth or nose area
Bring the straps under the armpits and through the loops in the back
Tie the two straps together to secure the Spit Net in position. The straps should be
snug to keep the Spit Net in place, but should not interfere with circulation or
breathing.?

Since this incident ECHC has changed their policy that only now sergeants can apply spit
mask on inmates.

53.

54.

55.

56.

57.

:?triElC?aLF Pagi?  20

Eight inmate witnesses, who were incarcerated at ECHC at the time on Metcalf?s housing
unit for his use of force on 11/28/12, stated the following to NYSP Investigators:

Witness V.K. stated in part that he never saw the inmate but could hear the inmate yelling
and acting crazy. He heard an officer say something to the inmate about not wiping blood
on the walls of his cell. V.K. stated that inmate was yelling slaughterhouse. V.K. stated
that a short time later he could hear several officers enter the cell block area and give the
inmate commands that he did not appear to be following. V.K. reported that one of the
officers said something to the fact that the inmate must be on bath salts or something,
V.K. also stated the deputies should just have sedated the inmate because it sounded like
he was getting out of control. V.K. stated that the inmate kept screaming ?Slaughterhouse.?
V. K. reported that he did not see any type of physical alteration take place between the
officers and the inmate.

Witness A.S. reported that he recalled seeing the white male in cell 2 and spoke to him
briefly. He noticed that the inmate had a black and some bruising on his face. A.S.
stated the inmate asked him when he (A.S.) was walking by his cell what he was there for.
A.S. stated he then asked an officer why the guy was in jail, and he was told for burglary.
A.S. went back to the inmate and told him why he was in jail. A.S. reported thatthe inmate
didn?t seem right and said it seemed like the inmate was high on something or had
something wrong with him. A.S. said Metcalf was seen by the forensic staff at the holding
center and then kept in his cell, A.S. said that they gave Metcalf his food in the cell then a
short time later when he walked by the cell he saw the inmate poking himself with a
plastic fork and wiping the blood on his bars of his cell. The officer went to the cell and told
the inmate to stop picking at his arms with the fork. A.S. then stated that when the inmate
didn't stop, the officer told the inmate to give him the fork. A.S. thought the inmate threw
the fork toward the bars and it may have hit the officer. A.S. then said the officers ordered
all the inmates into their cell and a few minutes later a group of officers came on the block
A.S. stated he could not see anything but said that it sounded like the officers went into
the cell and took the inmate to the ground and handcuffed him. A.S. said he saw a lot of
blood on the bars before the officers secured the inmate.

Witness PR. stated that he remembered a white kid (Metcalf) coming on the block. PR.
also remembered seeing the kid with blood over all over his arms and that he was picking
at his arm with a fork then sticking it into his arms causing more bleeding. PR. stated that
Metcalf was writing his name on the cell wall with his blood, that the kid was banging his
head on the bars or the wall, and yelling slaughter house, get me out of here. PR. stated
there was an obvious mental issue going on with this kid. PR. stated he could see into
the cell and could hear the officers telling the kid to knock it off, and there was no one in
his cell. PR. also stated it seemed like the guy was tripping or something similar. After a
while, a bunch of officers came on to the block to take him out because he was being very
disruptive. PR. heard one officer keep telling him (Metcalf) to stop sticking himself with a
fork. PR. stated that more officers were called in because he would not stop, and then
the inmates were told to lock in their cells so they could get him out. PR. said about six
officers came into the block and PR. stated he could not see from his cell but could hear
them fighting to get him out of the cell. PR. stated that he heard the kid was carried out
of his cell from another inmate. PR. reported that the officers were trying to get the kid to
stop in a nice way with the blood, but he would not listen.

Witness T.W. stated shortly after Metcalf was brought into the facility, all of the inmates in
the area were given free time to go outside of their cells. Metcalf did not leave his cell and

58.

59.

60.

seemed scared. He said Metcalf stayed in the cell and kept saying that he was innocent,
and he did not know why he was inside of the cell. He continued by stating Metcalf also
thought that someone was going to take his food and hurt him. Metcalf was in his cell for
about two hours, and most of the time he just sat in his cell being quiet. T.W. then stated
Metcalf started cutting and biting the scabs on both of his arms. Metcalf was cutting himself
with a plastic fork and then wiped and spit blood all other the walls and bars of his cell.
Metcalf was yelling "slaughter house? over and over. T.W. reported after a short period of
time, the guards locked everyone down and tried to go in and clean up the cell. After being
looked back into his cell, T.W. could not see what was going on but could hear the rest of
the incident. T.W. stated he heard a guard ask Metcalf why he was doing that to himself,
and then he heard a guard say something to Metcalf about Metcalf trying to cut him with
a knife. T.W. stated he heard this guard call for assistance from other guards to come in
and take Metcalf out of his cell. While Metcalf was in his cell, he was saying things like he
was a political refugee, he was innocent and did not do anything, and things about the
slaughter house. T.W. reported that Metcalf was really acting crazy and demented and
noticed that Metcalf had a busted up that was purple in color and appeared to be
swollen but did not notice any other marks on Metcalf's face or body. T.W. reported he did
not see Metcalf get assaulted by any inmate or guard at the facility.

Witness D.L. stated that he remembered that a white guy (Metcalf) was being in and put
in a cell just a couple of cells down from his. D.L. indicated he couldn?t see this subject
very?good and could not tell if he was injured when he came in. As soon as the guy got
into his cell, he was yelling for help and acting crazy. D.L thought that the guy had a mental
issue and they would eventually take him out. According to D.L., later in the day Metcalf
was pounding on the and he (D.L.) did not know what he was pounding them with, his
head or his hands, but there was a bunch of blood on the bars of the cell. D.L. stated he
did not remember the officers going in to get him.

Witness D.M. stated he was housed on Echo Block cell when a white male, Metcalf,
was brought into cell 2. D.M. did not see the inmate very well and did not notice any
injuries on him. D.M. indicated that after the inmate was in his cell for about a half an hour,
he started yelling that he needed help. After a while, the inmate was not getting the help
he wanted, he started banging. D.M..was not sure if Metcalf was banging his head or his
fists.- D.M. stated that the inmate was also yelling things like slaughterhouse. About an
hour later approximately five officers came to the block and went into cell D.M. stated
he heard what sounded like someone hitting the floor, and then he heard the inmate say
?stop, you?re hurting me.? D.M. stated it was clear that there was an altercation going on
in the cell, and then the officers had the inmate handcuffed, and they carried Metcalf out
of the cell. D.M. thought that three officers carried Metcalf out and on the way to the
elevator, the inmate was still yelling for ?help.?

Witness RF. stated that he was in cell and a white inmate (Metcalf) was in cell He
saidthat the inmate was yelling for help, and he asked him what was wrong. The inmate
told him what had happened, and the inmate told him that he had been beaten up the day
before by the officers in the jail. R.F. reported that the inmate kept yelling for help and kept
saying "this is slaughter house. little while later, all the inmates were locked down, and
he could hear the inmate in cell #2 banging the cell bars with something. According to
RF, a few minutes later an officer walked up in the front of cell #2 and told the inmate
that was yelling to stop banging and to stop picking his arms. When the guy did not stop,
the officer called for help and said that they were going to have to go in and get him. R.F.
said about 7 to 8 officers showed up and told the inmate to get to the back of his cell. The

61.

62.

REPORT OF RECHARD METCALF Page 22

inmate was not listening and kept yelling for help. The officers opened up the cell and went
in to get the inmate. R.F. reported it sounded like they were fighting inside of the cell and
added that he saw one of the officers holding a spit mask that they used to put over his
head to keep him from spitting. R.F. said that the officers carried the inmate out of the cell
and in the opposite direction of his cell. R.F. said that he did not see any blood on the
inmate.

Witness H.B. recalled seeing a white male acting strange while he was there (at ECHC).
He did not recall the inmate?s name but stated it was a white male with a medium build.
H.B. indicated he was in one of the middle cells of the row, and the subject in question
was a few down from him. H.B. recalled looking at the subject while the subject was still
in his cell and said that it appeared that the inmate was just dazing off into space. H.B.
said that he witnessed the inmate picking at his arms with a plastic fork. H. B. stated that
he thought the inmate should have been placed in a forensic unit or a medical unit,
because he seemed strange like something was wrong with him. H.B. stated that late that
evening, all of the inmates were told to lock in their cells, and no one knew why. They
realized it was because they were going to have to deal with the inmate that was acting
strange. H.B. heard the officers giving the inmates commands like ?put your hands behind
your back. He believed that they were going to hand cuff the inmate. He then heard the
inmate yelling ?help me? and slaughterhouse? before being taken off the unit. H.B. said
that he heard one of the officers say ?this fucker just threw blood on me. H.B. also said
he heard the Officers telling the inmate to give them the fork he was picking at himself with.
H.B. stated that at no time did he witness any officer hit or touch the inmate.

The Erie County District Attorney's Office requested that the New York State Police:
Bureau of Criminal Investigation conduct an independent investigation of circumstances
surrounding Richard Metcalf's death. At the completion of the investigation, the Erie
County District Attorney?s Office did not bring forth any criminal charges, and a Grand Jury
was not convened to review the matter.

RECOMMENDATIONS:
TO THE OFFICE OF THE SHERIFF OF ERIE COUNTY:

The Sheriff shall develop a Crisis Intervention Training for the Erie County deputies
specific to identify and safely manage inmates with mental illness who are in a crisis state.

The Sheriff shall develop a policy and procedure to photograph inmates who enter the
Erie County Holding Center who are observed with injuries.

The Sheriff shall establish a policy that corrections staff should not interfere with
emergency medical services when they are attempting to assess and administer medical
care to inmate in need of such unless there is a serious and immediate threat to the safety
and security of the facility.

The Sheriff shall mandate compliance with Erie County Sheriff?s Office Policy and
Procedure #04?09?02 entitled Restraint Chair; Section (B) Use of Spit Mask which states:

"Hoods, bags, or other devices covering the head and face, which may interfere
with normal breathing are prohibited. A spit mask maybe used when an inmate is
attempted to spit on staff placing the inmate in a restraint chair. Only a mask
speci?cally designed as a spit mask is authorized. NO improvised masks are
permitted. The spit mask should be placed over the inmates head and tied in the
back. It should not be tied around the inmates face or neck. At all times the
inmates ability to seetand ability to breath comfortably must not be obstructed.?

The Sheriff shall continue with mandatory annual training on the use and application of
spit masks and other restraints with continued compliance.

The Sheriff shall monitor the status of the restraint equipment used to control inmates?
behavior. Attention should be given that if deficiencies exist that the prompt repair should
be initiated.

The Sheriff shall conduct an investigation into the conduct of Sgt. M.C, who violated Erie
County Sheriff's Office Policy and Procedure #04?09?02 entitled Restraint?Chair; Section
(B) Use of Spit Mask and dangerously applied an unauthorized restraint to Metcalf. At the
completion of the investigation, administrative action shall be taken for any identified
misconduct.

 

The Sheriff shall conduct an investigation into the conduct of Sgt. R.D. who failed to
properly supervise staff during the use of force of force on Metcalf and failed to maintain
a correctional facility in a safe, stable, and humane manner and in violation of NYS
Correctional Law. At the completion of the investigation, administrative action shall be
taken for any identified misconduct.

TO THE DIRECTOR OF ERIE COUNTY FORENSIC MENTAL HEALTH SERVICES:

The Director shall develop a comprehensive response plan with the Erie County Sheriff.
for humane response and safe management of inmates who are in mental health crisis.
The plan should include procedures for restraint, referral for hospitalization, crisis
intervention techniques and emergency pharmacologic interventions.

The Director shall conduct a thorough investigation and review of Richard Metcalf?s mental
health care while incarcerated at the Erie County Holding Center. The review shall focus
on why clinicians failed to recognize a patient with acute and in need of
immediate referral to a provider.

TO THE ERIE COUNTY MEDICAL EXAMINER:

That the Erie County Medical Examiner review the forensic pathology of this case in light of the
findings of the Medical Review Board with an toward a restatement of the cause of death to
better reflect the circumstances and the autopsy findings that Metcalf died from traumatic
and that heart disease was not a factor in this case.

TO THE ERIE COUNTY DISTRICT ATTORNEY OFFICE:

That the District Attorney take official notice of the findings of the Medical Review Board in the
case cited herein, with the newly revealed evidence that supports Metcalf?s cause of death was a
homicide due to traumatic and initiate a criminal investigation into the matter.

TO THE CHAIR OF ERIE COUNTY LEGISLATURE:

As the governing body responsible under Correction Law section 501 to appoint a physician to
the jail of the county, the Erie County Legislature shall take notice of the findings of the Medical
Review Board, and review the continued service of the current appointee.

TO THE ASSISTANT ATTORNEY GENERAL FOR CIVIL RIGHTS, US. DEPARTMENT OF
JUSTICE:

That the Assistant Attorney General for Civil Rights take official notice of the findings of the
Medical Review Board in the case cited herein and initiate both individual criminal civil rights
investigations and a CRIPA investigation into the Erie County Sheriff?s Office confinement and
treatment of Richard Metcalf.

WITNESS, HONORABLE M.D., Commissioner, NYS
Commission of Correction, Alfred E. Smith State Office Building, 80 South Swan Street, 12?h
Floor, in the City of Albany, New York 12210 on this September 27, 2016

27%,
Harrison?Ross, MD.
Commissioner

 



9/16

Cc:

FINAL REPORT OF METCALF Page 25

Gail Burstein M.D., Commissioner
Erie County Department of Health
Dr. Tara Mahar, Chief Medical Examiner
Erie County
Frank A. Sedita, District Attorney
Erie County
John J. Mills, Chair
Erie County Legislature
Michael A. Siragusa

Erie County Attorney
Benjamin C. Mizer, Assistant Deputy Attorney General for Civil Rights
US Department of Justice