3 corrections employees placed on leave as inmate death investigation continues


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UTAH STATE PRISON — The Utah Department of Corrections has placed three additional employees on administrative leave as it investigates the death of an inmate who didn't receive his dialysis treatment.

On April 5, 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 to the prison. But that person did not show up on either April 3 or April 4.

Estrada died 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.

"The department's preliminary internal review indicates that the failure to provide Estrada with dialysis at the prison's on-site clinic could be a contributing factor in his death," the prison said in a prepared statement Thursday.

The three employees placed on leave are members of the prison's Clinical Services Bureau who were on duty between April 3 and April 5, said corrections spokeswoman Brooke Adams.

"The status of the department employees is still under review and their names will not be released," she said.

The clinic's director, Richard Garden, was placed on leave immediately following Estrada's death and remained on administrative leave Thursday.

Prison officials also announced Thursday that the Department of Corrections had retained WELLCON, "a nationally recognized corrections health care consulting firm based in Utah," to conduct an independent investigation into Estrada's death, the prison's dialysis program, the overall health care delivery system at the prison as it relates to dialysis patients, mental health issues, and to make recommendations on how to improve.

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The Corrections Department is also conducting its own internal investigation.

As of Thursday, University of Utah Health Care had not publicly disclosed the identity of the contractor. A spokeswoman said two technicians had made arrangements to switch multiple shifts that weekend at the Utah State Prison. The switch was recorded on a communications log kept at the prison, but the technician who agreed to cover the weekend shifts failed to record the changes on his own calendar.

In April, she said the man was still employed, but wouldn't comment about any possible discipline.

The prison made several procedural 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 pleaded guilty in 2005 to raping a 13-year-old girl. He was sentenced to five years to life in prison. He was scheduled to be paroled just a week after his death, at which time he would have been taken into custody by U.S. Immigration officials regarding his citizenship status.

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Pat Reavy

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