The New York State Commission of Correction has urged the Onondaga County Legislature to investigate the suitability of the county jail’s health care provider.

The directive came in a report, released by the commission Wednesday, into the death of Angela Peng, who was found to have died by suicide at the jail in September 2021.

While the commission can require the Legislature to investigate, the commission has little enforcement authority.

Peng, 27, did not receive adequate care before her death, the report determined. The report acknowledged that NaphCare, the jail’s current health care provider, had disputed the findings.

“The Medical Review Board remains affirmed in its opinion that there were serious deficiencies in the standard of care provided to Angela Peng that require corrective action and will be subject to further review by the Commission,” the report says.

The commission’s report outlines the jail’s alleged mismanagement of Peng’s medical conditions. When Peng was being held at the jail, she suffered from withdrawal from fentanyl and methamphetamines, according to the report.

Peng was never seen by an onsite medical provider — only remotely — the commission says in the report. At least one nurse practitioner employed by NaphCare who handled Peng’s care was not licensed to practice in New York State, the report also notes.

Peng’s family has filed a $10 million lawsuit in federal court, suing NaphCare and Onondaga County.

Hers is one of three reported deaths at the jail in the last 15 months. The others are Paul Watkins, 38, who died by suicide, and Ayanna Byrd, an infant who was born prematurely at the Onondaga County jail in her mother’s cell.

Byrd’s family has so far filed a notice of claim, preserving its right to sue the county and NaphCare.

During his bid for Onondaga County Sheriff, the jail’s current chief, Esteban Gonzalez, said NaphCare’s contract as the jail’s medical provider should be put out to bid. His opponent Toby Shelley, the presumed winner of the race, said health care professionals should review care at the jail.

The report, released Wednesday, provides a timeline of Peng’s time and the care she received at the jail.

Peng was booked at the Onondaga County Justice Center on Sept. 1, 2021 for violating her probation in a separate case, the report said.

During a preliminary screening, Peng told deputies she did not have mental health treatment, suicidal ideations or a history of addiction, according to the report. Deputies put her in a general supervision cell that requires a check every 30 minutes, the report said.

About a day after being booked, a deputy found Peng lying on her back with her arms spread out in her cell during a count, according to the report. Peng had vomited and defecated on herself, the report said. She was suffering from withdrawal while being held at the jail, according to the report.

The deputy asked to a nurse to see Peng but that the nurse gave the deputy the “run-around” and did not immediately see Peng, the report said.

Peng began frothing and gargling at the mouth, leading a deputy to call for a medical emergency, according to the report. Peng was taken to an area hospital, the report said.

Among the issues outlined in the report are:

  • The emergency room referral should’ve been more specific as to which substances Peng was detoxing from, the report said. The report notes that if hospital staff had known Peng was suffering from fentanyl withdrawal, they might have ordered a different pain management treatment.
  • Peng should have had a toxicology completed to identify any drugs potentially in her system, according to the report. After Peng was taken to the hospital, a buprenorphine hydrochloride pill was found in her cell, according to the report.

When Peng was brought back to the jail from the emergency room, she was neither seen by a mental health professional nor was she placed on increased supervision, according to the report.

“During Peng’s incarceration, Peng was never seen or evaluated onsite by any medical provider but instead had all of her orders completely remotely through the corporate headquarters at NaphCare,” the report read.

On Sept. 3, 2021, at about 9:10 a.m., about two days after she was booked, deputies found Peng throwing up and alerted a nurse that she needed to be seen, according to the report.

Two minutes later, deputies escorting nurses to Peng’s cell found Peng had attempted suicide, the report said. Deputies began giving Peng chest compressions while the nurses did not give hands-on care, the report said.

The facility also did not have some of the required equipment readily available to treat Peng, who was suffering from cardiac arrest, the report said.

The commission found that NaphCare medical staff “was not properly prepared to respond to a medical emergency,” according to the report.

Peng died three days later on Sept. 6.

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Chris Libonati covers government, accountability and equity. Have a tip? Contact Chris at 585-290-0718 or