Death at Orange County Jail investigated
GOSHEN — The Orange County Sheriff’s Office has released more information about the death of an incarcerated man at the Orange County Jail on Sunday, which is being investigated by the sheriff’s and state attorney general’s offices.
Samantha Pascal, a senior investigator at the sheriff’s office, said the county Medical Examiner’s Office completed an autopsy Tuesday morning of 30-year-old Jairo Navarro. Preliminary results showed no signs of physical trauma or foul play, she said. His official cause of death will be released once the results of the toxicology reports are available.
At this stage, the attorney general’s investigation into Navarro’s death is preliminary, which is not unusual.
Under state law, the attorney general’s Office of Special Investigation assesses every reported incident where a police officer or peace officer, including a corrections officer, may have caused the death of a person. These investigations may proceed whether the officer is on-duty or off-duty, and the person who died may be armed or unarmed. The person who died may or may not be in custody or incarcerated.
A full investigation may be opened if the initial assessment indicates an officer caused the person’s death, according to a spokeswoman in the attorney general’s office.
Navarro’s death is the third reported at the Orange County Jail since 2021. The state Commission on Correction reviewed the deaths of Troy Conklin, a 26year-old man who died in 2021, and Ricky Mack, a 65-year-old man who died in 2022. In the heavily redacted public reports, the commission said a lack of adequate medical care may have contributed to both deaths.
Commission: inmate’s suicide risk was not fully recognized by contractor
Conklin, a Honesdale native and tattoo artist, died on June 10, 2021, after he was released from jail, according to the state Commission of Correction’s report from June 28, 2022. He was survived by his two children, his parents and three siblings. According to the report, he died by suicidal hanging on June 1.
By the time officers found Conklin, he was unconscious and lacked a pulse. But the Medical Review Board found that although he had received mental health and psychiatric services at the jail, his overall risk for suicide — with three attempts within 30 days — was not fully recognized by Wellpath, a contract service provider.
A month before his death, Conklin had been arrested and charged in Port Jervis with several offenses related to kidnapping, assault and criminal mischief. While he was in a holding cell at the Port Jervis Police Department, Conklin had attempted to strangle himself, which officers had reported to the jail, according to the commission’s report. He was put through a suicide prevention screening at the jail by an officer who submitted an emergency referral for mental health and a non-emergency referral for medical attention. He was also placed under constant supervision.
But at some point, it appears Conklin was taken off the oneon-one watch, according to the report, which said he should have received a psychiatric evaluation before he was removed from constant supervision.
On April 1, 2021, Wellpath took over mental health services at the jail, which Orange County’s
Mental Health Administration previously provided. During this transition, the patient’s mental health records were not readily available to Wellpath and the records had to be requested from the county, according to the report.
The report notes several subsequent failures in medical protocols, including not giving Conklin a full assessment after he tried to cut himself, not submitting an official referral after he refused medication, and not placing him at an elevated risk for suicide during the time it would take for the prescribed medications to achieve therapeutic efficacy.
The commission asked the Orange County Legislature to conduct an inquiry into the fitness Wellpath as a service provider.
New York Correct Care Solutions, a subsidiary of Wellpath, said in its response to the commission that it has given staff training related to the issues cited in the report and has updated policies to ensure patients’ refusals of medications are better monitored.
Commission says Mack’s death could have been prevented
About a year after Conklin’s death, Ricky Mack, a Bunnell, Fla., native, died at the jail after suffering from several ailments, including COVID-19. He was survived by his four children and five siblings.
He died from hypernatremic dehydration, poor oral intake, chronic kidney disease complicating diabetes mellitus, hypertensive cardiovascular disease, esophagitis, and a contributory COVID-19 infection, according to the commission’s report on his death released in December 2023.
The Medical Review Board found “gross failures in the medical assessments and treatment of Mack during his incarceration that were contributory to his death.” Wellpath was also providing medical services in this case. The board indicated his death may have been prevented if Mack had been properly assessed and taken to the hospital for diagnosis and treatment.
Mack was incarcerated after being charged in December 2021 for third-degree criminal possession of a controlled substance.
The report noted multiple violations of state health services law concerning Mack’s medical treatment at the jail, including that he was not properly assessed within two weeks of being admitted and that his medical chart didn’t have a proper medical history. A doctor was also not notified that Mack had refused to have blood drawn for lab tests.
Notes on him not eating for three days and drinking minimal fluids were not properly documented. There were also several findings related to a lack of proper neurological assessments and issues with medical notes related to these tests after he injured his head when he passed out.
Based on postmortem results, Mack had tested positive for COVID-19. For three days in January, his medical chart did not show he had his vital signs tested. The Medical Review Board believes that if he had received these tests, along with a daily assessment, his medical deterioration would have been identified.
The board further said that the lack of these assessments indicates the jail’s physician was not adequately overseeing the nursing staff.
On the morning of Jan. 16, 2022, Mack asked a corrections officer to bring him a cup of water. The officer returned to Mack’s cell a few minutes later and found him lying on the floor. When the officer asked Mack if he was OK, he said, “No,” according to the report. Emergency services were called and paramedics arrived a halfhour later.
Most of the report’s information about the medical response is redacted, but the Medical Review Board said it believed Mack’s death could have been prevented if he had been properly assessed and taken to the hospital sooner.
Like in the review of Conklin’s death, the commission directed the Orange County Legislature to conduct an inquiry into Wellpath.
New York Correct Care Solutions said in its response to the commission that it fired a licensed practical nurse cited in the report, conducted a quality assurance review and gave its medical staff training on the issues noted in the report.