A state commission asked the Chautauqua County Sheriff’s Office to review its handling of a 23-year-old inmate who died by suicide inside the County Jail.

The death of Andrew Maybee in December 2022 marked the third person to have died while incarcerated at the Mayville facility in a 16-month span. His death is detailed in a heavily redacted 10-page report recently released by the state Commission of Correction.

Maybee, who had a reported history of mental health issues, was booked into the Chautauqua County Jail on Nov. 17, 2022, on a reckless driving and driving while intoxicated conviction. The 23-year-old underwent a suicide prevention screening during his booking.

In its report, the commission noted that Maybee was “properly followed by psychiatry and mental health” while at the jail. However, a review of the inmate’s care found that a full medical assessment and physical examination had not been completed within 14 days of his admission as required.

Jail staff were alerted to a medical emergency inside Maybee’s cell the evening of Dec. 7. He was later pronounced dead.

Though not identified by name at the time, Chautauqua County Sheriff James Quattrone confirmed to The Post-Journal that an inmate had died.

“Correction officers and nursing staff responded immediately and began emergency care,” he said shortly after the incident. “(The) Mayville Volunteer Fire Department responded and also administered emergency care. However, all attempts were unable to revive the individual.”

A corrections officer later reported that Maybee had not exhibited any signs of distress or displayed any sort of unusual behavior.

Further, the report states that the inmate “had not expressed or displayed any suicidal ideations or behaviors that would have indicated the terminal event.”

The Commission of Corrections, which acts as a watchdog group to investigate deaths in New York’s correctional facilities, questioned the lack of a full medical assessment conducted on Maybee.

The jail physician told the state’s Medical Review Board that he is updated on the condition of inmates who are under constant observation. Portions of the report that are not redacted do not indicate whether Maybee, at any time during his stay at the Chautauqua County Jail, had been under observation.

As noted in the report, the jail physician said he typically requests inpatient medical records. Nonetheless, the doctor said such records “would not have aided him in his decision made for Maybee’s treatment.”

A review of Maybee’s chart showed no request had been for his past medical records.

“The Medical Review Board opines (that) had these records been requested and reviewed in a timely manner, Maybee’s extensive mental health history including his hospitalizations and suicidal ideations could have been more appropriately assessed,” the report states.

Maybee is the third inmate to die inside the Chautauqua County Jail between July 2021 and December 2022 and the second by suicide.

The death of Louis Rivera, 65, due to inflammation of the gallbladder resulted in a scathing report by the commission that cited numerous failures in the inmate’s ongoing care. It concluded that had Rivera “received adequate medical care, had been properly assessed, and had been timely referred to a hospital for treatment, his death could have been prevented.”

Shortcomings also were documented after another inmate, Jose Louis Rivera-Perez, died by suicide in September 2021.

In five months at the jail, Rivera-Perez was diagnosed with five disorders; there also were multiple psychiatric medication changes ordered by a physician assistant without consultation or any assessment by a psychiatrist, the commission reported.

Regarding Maybee, the commission asked the jail physician to conduct a “comprehensive quality assurance review” of the care provided to Maybee to include why he was not seen for his admission medical history and physical assessment within the 14 days of his admission.

A directive to the county director of Chautauqua County Mental Health Services is included as well. It asks that a quality assurance review be made with mental health staff and providers to assure that individuals who have “known psychiatric histories” are presented for services. It also asks that “thorough attempts” are made to request available records from community providers and hospitals.

A note in the report states that the Chautauqua County Sheriff’s Office had implemented changes to assure compliance with admission health assessment requirements. In addition, the department said a plan had been developed to ensure inmate records are requested and reviewed when necessary.

Quattrone has previously commented on the number of inmate suicide attempts inside the jail. He said individuals who express concerns of self-harm are placed on constant observation and see mental health counselors and jail psychiatrist.

Quattrone said the jail saw an increase in suicide attempts in 2020, 2021 and the first part of 2022. He attributed a spike in attempts to the restrictions imposed during the COVID pandemic and due to New York’s bail reform law.

“Throughout the pandemic we had complaints from incarcerated individuals regarding the lack of visitors as well as on programs,” Quattrone said in December 2022. “We also heard from our counseling staff that individuals were having difficult times.”