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UTAH STATE PRISON — A University of Utah Health Care investigation into an inmate's death released Wednesday indicates that the prison didn't call a university dialysis center until two days after a medical technician initially failed to show up to treat inmates.
Two technicians who work for the university's South Valley Dialysis Center made arrangements in March to switch multiple shifts at the Utah State Prison, including those scheduled for April 3-4, according to information released by University of Utah Health Care spokeswoman Kathy Wilets.
"This switch was recorded on a communications log kept at the prison," Wilets said. "While both technicians noted the change in the log, one of the technicians — the one who agreed to cover the shift on April 3-4 — failed to record the change on his personal calendar."
Ramon C. Estrada, 62, who was just two weeks from his parole date, died Sunday, April 5, from apparent kidney failure. Department of Corrections spokeswoman Brooke Adams said Estrada required dialysis and his lack of treatment may have been a contributing factor in his death.
The technician failed to show up at the prison to provide dialysis to inmates on Friday, April 3, and again failed to show on Saturday, April 4.
But no one apparently called the South Valley Dialysis Center until Sunday, April 5, when a nurse at the prison called to ask about the missed dialysis appointments at 4:36 p.m., according to Wilets. No one answered, so the nurse left a message. Wilets said the center is closed on Sundays and that message was not immediately received.
The university wasn't notified of Estrada's death and the missed dialysis appointments until Monday, April 6, she said.
This switch was recorded on a communications log kept at the prison. While both technicians noted the change in the log, one of the technicians — the one who agreed to cover the shift on April 3-4 — failed to record the change on his personal calendar.
–Kathy Wilets, University of Utah Healthcare spokeswoman
"We deeply regret the scheduling error leading to delayed dialysis for these patients," Wilets said in a prepared statement. "The relationship between the missed dialysis session and the unexpected death of Mr. Estrada remains under investigation."
Wilets told the Deseret News on Wednesday that the dialysis technician who missed their shift is "still employed" by University Hospital. However, she couldn't comment on whether the employee was otherwise disciplined.
Estrada, imprisoned for a 2005 rape conviction, died about 10:30 p.m. while prison workers were preparing to transport him to University Hospital for off-site dialysis treatment.
Six other inmates who require dialysis treatment but hadn't received it were transported to the hospital after Estrada died. Four of them were hospitalized overnight.
Adams told the Deseret News that barring Estrada's death, the inmates would not have been hospitalized as a result of the missed appointments. Rather, their dialysis treatment would have proceeded as regularly scheduled in the coming days, she said.
Prisoners are on rotating treatment schedules and typically receive dialysis three times per week, according to Adams. The prison offers treatment Monday through Saturday.
Richard Garden, the clinical services bureau director for the Department of Corrections, was put on administrative leave following Estrada's death, pending an internal investigation.
"Our investigation is ongoing and involves interviews with 30 to 40 different individuals, review of various policies, procedures, logs and other documents," Adams said in a statement Wednesday. "Like the university, we expect to issue a statement about our findings once that investigation is completed. We appreciate the fact that University of Utah Health Care moved quickly to investigate what happened on its end. We also appreciate that University of Utah Health Care is taking steps, just as we are, to ensure this communication failure doesn't happen again."
Wilets said Wednesday that University of Utah Health Care will do a better job of communicating with the prison in the future.
"Changes in our procedures include the implementation of an improved scheduling notification and alert system, as well as clearer communication channels with prison staff," she said.
Among those changes is an increased emphasis on making sure prison workers are comfortable with which numbers to call — including one that is operational 24 hours a day, seven days per week — to reach University of Utah Health Care at any time, Wilets said.
The 24/7 number has always been available to prison staff, according to Wilets, but the two sides are working to make it clear which numbers should be called and when in the event of a problem.
Contributing: Pat Reavy
