Chemung County reaches settlement with family of suicidal inmate after report found multiple failures by jail staff

Local News
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ELMIRA, N.Y. (WETM) – Chemung County and the family of Nicole “Justy” Matkosky have reached a settlement worth $100,000 after Matkosky died by hanging in the Chemung County Jail on July 14, 2017, after a state report found failures by the jail staff to properly help Matkosky.

The settlement must be approved by the Chemung County Legislature with $50,000 being paid by the County and $50,000 from Family Services. The budget committee is scheduled to meet on Tuesday night to approve the settlement before it goes to the full legislature.

According to the Commission of Correction’s final report into Matkosky’s death, obtained by 18 News in a 2019 FOIL request, The Medical Review Board found failures by the jail staff to refer Matkosky to Mental Health, consider his extensive mental health history, schedule follow up appointments, sign mental health appointment refusal forms, and follow up on “suspicious behaviors.”

Several paragraphs of the report surrounding Matkosky’s prior history and mental status were redacted. A line on page three of the report, the only section not redacted on the page, says the “Medical Review Board questions the accuracy of Matkosky’s psychiatric diagnosis of only Opioid dependence with Opioid-Induced Mood Disorder given his symptoms required three different psychotropic medications to manage.”

On at least one occasion Matkosky was found snorting his medications.

Following a June 25, 2017, arrest, a folded piece of white paper with a yellow strip, identified by Matkosky as Suboxone, was found in Matkosky’s wallet by a corrections officer. Matkosky was placed in administrative segregation and received disciplinary charges.

Matkosky’s disciplinary hearing resulted in him having 90 days in keeplock plus the loss of one visit per week for 30 days for the possession of contraband items, possession of narcotics or narcotic paraphernalia, and attempting to smuggle items into the facility.

Matkosky’s Intake and Suicide Screening Report found Matkosky with a score of 4 out of 19 and that he denied any thoughts of hurting himself or others. Matkosky also reported using marijuana, heroin, and a drug that was redacted in the report.

Following a heavily redacted paragraph in the report, the “Medical Review Board has found that the nursing staff failed to refer Matkosky to Mental Health for a view” following an admission, the nature of which was redacted.

On July 3, 2017, Matskosky was observed by a corrections officer with a bedsheet around his neck. Matkosky told the officer he was “practicing tying a tie” and he was screened again for suicide risk.

Once again the Medical Review Board “found that clinician’s evaluation of Matkosky’s behavior failed to consider his extensive mental health history when assessing his risk and failed to schedule for further follow up with Mental Health after this incident.”

Two paragraphs on page six of the report were also redacted leading up to another finding by the Medical Review Board that “a refusal form for a mental health appointment should be signed by an inmate that refuses a mental health appointment.”

On July 5, officers found a broken light fixture, and Matkosky was placed in administrative segregation.

On July 7, an hour and half before he was found hanging in his cell, Matkosky was brought medications for him to take, but he refused to swallow them. After swallowing them he apologized for not following orders. The Medical Review Board found that the cell damage and medication diversion attempt were “both suspicious behaviors and warranted notification to a mental health clinician for further follow up.”

On July 7, 2017, a correctional officer found Matkosky with a blue sheet tied around his neck and his feet one to two inches off the ground.

Officers responded to the cell and removed the sheet to begin performing CPR and the administration of an AED. Officers continued CPR until an ambulance assumed care of Matoski. Several lines of the report were redacted leading up to Matkosky’s death on July 14, but the report findings say Matkosky was placed on life support and released by court order prior to his death.

The commission report outlined the following actions were required:

Office of the Chemung County Sheriff (at the time, Christopher Moss)

  • The Sheriff shal take note of the Medical Review Board’s findings that Matkosky had engaged in suspicious and potentially self-injurious behaviors prior to his suicide attempt. A review of the policy and procedures shall be conducted to assure that incidents like these, with inmates who have extensive mental health histories, generate a notification to mental health clinicians for review.

In a response dated Nov. 16, 2018, Chemung County Sheriff Moss indicated that the requested review was completed.

Chemung County Jail Physician

  • The Jail Physician shall conduct a quality assurance review regarding the process of obtaining documented refusals for mental health care. If a process is not in place, a plan for documenting refusals should be established.
  • The Jail Physician shall conduct a quality assurance review regarding why Matkosky was not referred to mental health upon return to the facility despite being an active patient receiving services.

The report does not disclose whether those reviews were completed by the jail physician.

Director of the Family Services of Chemung County

  • The Director shall conduct a quality assurance review with the facility clinical staff regarding why the psychiatrist was not informed that Matkosky had returned to custody on June 25, 2017 and why Matkosky was not referred to the psychiatrist despite having his medication regimen continued.
  • The Director shall conduct a quality assurance review with the facility’s clinicians and crisis services clinicians as to why the psychiatrist was not informed of Matkosky’s suicidal gesture on July 3, 2017 and why further follow-up was not scheduled.
  • The Director shall conduct a quality assurance review regarding why psychiatric progress notes were incomplete as there was no documented clinical reasoning regarding Matkosky’s medication charges on two occassions.
  • The Director shall arrange for a peer review of the psychiatrist regarding Matkosky’s diagnosis and the appropriateness of the prescribed medication regimen.

The FSCC Mental Health Clinical Director provided results of the requested reviews on Nov. 16, 2018, according to the report.

The final report was released on Dec. 18, 2018, by the New York State Commission of Correction In the Matter of the Special Investigation into the Cre and Treatment Provided to Justy Matkosky.

As of Sept. 2019, there have been three settlements between the county and the families of inmates who died by suicide between 2017 and 2019.

A similar report on the suicide of Curtis Burrows, convicted in the 2017 murder of Timothy Webster, found that the psychopharmacologic treatment of Burrows by a doctor was “inadequate.” That report required the director of Family Services to arrange a peer review of the psychiatrist regarding Burrows’ diagnosis and the appropriateness of the prescribed medication regimen, which the director reported on Feb. 19, 2019 as completed.

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