SALT LAKE CITY — Advocates are calling the death of a Utah State Prison inmate who was not given a scheduled dialysis treatment a "completely preventable tragedy."

"This is egregious, to the extent that it was completely avoidable," said Aaron Kinikini, legal director of the Utah Disability Law Center.

The center is investigating the death of Ramon Estrada, 62, who died at the prison Sunday after a University of Utah South Valley Dialysis Center contractor didn't show up Friday or Saturday to provide the treatment.

An autopsy has been ordered to determine Estrada's cause of death, which Department of Corrections officials said appears to be cardiac arrest resulting from kidney failure.

"These are presumably inmates who are on a regular list of patients receiving dialysis, and if the dialysis contractor doesn't come in on a Friday, it seems alarm bells should have been going off somewhere. If he doesn't come in on a Saturday, louder alarm bells. To wait until Sunday night to transport (Estrada) to a hospital seems inexcusable," Kinikini said.

The Disability Law Center's investigation, beginning with a request of Estrada's health records, will focus on whether neglect on the part of prison staff led to the inmate's death.

Investigations by the Unified Police Department, a standard procedure for deaths at the prison, and the Department of Corrections Law Enforcement Bureau, as ordered by Gov. Gary Herbert, are underway. An internal probe by the South Valley Dialysis Center has also been announced.

Estrada was one of seven male inmates scheduled to receive dialysis on those days, the Department of Corrections confirmed. The remaining six men were treated at an area hospital Sunday, where four remained overnight. One inmate remained at the hospital until Tuesday.

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Utah Dept. of Corrections: Prison inmate dies after lack of dialysis treatment

An inmate at the Utah State Prison died Sunday as the result of apparent cardiac arrest due to renal failure, officials said.

The Department of Corrections has not specified when it was discovered that the men had not been treated. Richard Garden, the Department of Corrections' clinical services bureau director, has been placed on administrative leave while the circumstances leading to Estrada's death are investigated.

The governor called Estrada's death "a tragedy" on Wednesday, saying that the Department of Corrections investigation must be used to determine future problems may be prevented.

"It's hard to comprehend," Herbert said Wednesday. "I would expect even the inmates themselves would say, 'I'm supposed to have a treatment. Where's the guy? Why is he not here?' We'll do a complete investigation to find out what's happened and who's responsible."

Utah's American Civil Liberties Union will also be "watching with great anticipation" as the probes progress in order to determine what additional action may be needed, legal director John Mejia told KSL Newsradio's Doug Wright on Wednesday.

Estrada, a Mexican national, pleaded guilty in 2005 to rape, a first-degree felony, and was sentenced to five years to life in prison. According to court records, Estrada admitted to raping the 13-year-old daughter of a woman he was living with in Brigham City.

Estrada was two weeks away parole, at which time he would have been released to federal immigration officials.

Despite his crimes, Kinikini emphasized that Estrada warranted adequate and timely medical treatment while he was in the care of the Department of Corrections.

"Regardless of how Mr. Estrada ended up at the prison, he's still a human being," Kinikini said. "Evolving standards of human decency as well as Constitutional law mean that somebody in his position needs to have his medical needs met, and that is true whether he is a jaywalker or, in his case, if he is a sex offender. Extending to prisoners a lower level of human regard, I think, is immoral."

Estrada had been receiving dialysis treatments since at least the first of the year, Department of Corrections spokeswoman Brooke Adams confirmed. She could not confirm how long Estrada had been receiving the treatments, but said that they had not begun recently.

There are currently no female inmates receiving dialysis treatments, Adams said. Those prisoners who require dialysis are located at the Draper facility in order to receive the treatments in-house, which the South Valley Dialysis Center will continue to provide, she said.

Changes being put in place at the prison following Estrada's death include 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.

"There are some things there that we're re-emphasizing, some things that we're instituting newly — and I think those will be in place moving forward — and there may be additional steps taken in addition to these," Adams said.

Prison officials are in contact with Estrada's next of kin, including as they work to determine what will happen to his remains, but Adams would not specify whether Estrada's relatives are in Utah or even the United States.

The Department of Corrections will stay in contact with the family as the investigation progresses, she said.

Contributing Mike Anderson

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