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UTAH STATE PRISON — "An obvious breakdown in communication" resulted in the death of a Utah State Prison inmate who failed to receive his dialysis treatment, according to a statement from the Utah Department of Corrections.
But as of Friday, there were still many unanswered questions pending multiple investigations about who may have failed to talk to whom or who might have failed to relay a potentially life-saving message.
"There were people who were aware the technician had not shown up and what they did next and why is a key question in our internal investigation," said Corrections spokeswoman Brooke Adams. "We'll be better able to answer this question when our investigation is completed."
On Sunday, Ramon C. Estrada, 62, died from apparent cardiac arrest resulting from kidney failure. Estrada and six other inmates were scheduled to receive dialysis on April 3 from a University of Utah South Valley Dialysis Center contractor who was supposed to go out to the prison. But that person did not show up on either April 3 or April 4.
Estrada died Sunday night while officials were preparing to take him to University Hospital to be treated.
It was unknown if or how long Estrada was exhibiting signs of being in distress prior to his death.
There were people who were aware the technician had not shown up and what they did next and why is a key question in our internal investigation. We'll be better able to answer this question when our investigation is completed.
–Corrections spokeswoman Brooke Adams
As of Friday, University of Utah Health Care had not publicly disclosed the identity of the person who was supposed to be at the prison, why that person didn't show up, or whether they had been placed on administrative leave or fired.
For now, the group is sticking with its original prepared statement: "We are saddened to learn of this prisoner’s death and are concerned about the scheduling error for dialysis services provided at the prison by University of Utah technicians. We have a responsibility to provide quality care for patients. We will now conduct a thorough review of the circumstances that led to this unacceptable mistake and will take whatever steps are necessary to improve communications and procedures."
The Corrections Department has placed its clinical services bureau director, Richard Garden, on administrative leave pending an investigation into the incident. Investigations were being conducted by the Corrections Department and Unified police.
"Our medical staff have the discretion to make determinations of what is necessary to treat a patient, whether that is receiving care in the infirmary, getting a second opinion from an off-site specialist or having an inmate transported off site. Part of our internal investigation will be looking at what decisions were made and why," Adams said.
The prison has made several changes immediately following Estrada's death, including getting a schedule calendar and contact information for dialysis technicians; requiring facility nursing staff to make contact with and receive post-treatment reports from the on-duty technician on dialysis days; improving chart notes about each inmate's status and condition; and requiring timely notification to the charge nurse if the dialysis schedule changes or a technician fails to show up.
Estrada, a Mexican national, pleaded guilty in 2005 to raping a 13-year-old girl. He was sentenced to 5-years to life in prison. He was scheduled to be paroled in a week, at which time he would have been taken into custody by U.S. Immigration officials regarding his citizenship status.
