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Inmate dies after his dialysis tech fails twice to show up at prison

Ramon C. Estrada, 62, died Sunday, April 5, 2015, at the Utah State Prison.
Ramon C. Estrada, 62, died Sunday, April 5, 2015, at the Utah State Prison.
Utah Department of Corrections

UTAH STATE PRISON — An inmate scheduled to be paroled in two weeks died Sunday after a medical contractor responsible for performing his dialysis treatments failed to show up at the prison on Friday and Saturday.

Ramon C. Estrada, 62, died from apparent cardiac arrest that was the result of kidney failure, according to a statement from the Utah Department of Corrections. His body was sent to the state medical examiner to determine an exact cause of death.

"A preliminary review indicates that the lack of dialysis treatment could be a contributing factor in Estrada’s death," said Department of Corrections spokeswoman Brooke Adams.

Richard Garden, the clinical services bureau director for the Department of Corrections, was placed on administrative leave while the circumstances leading to Estrada's death are investigated.

A dialysis technician who works for University of Utah South Valley Dialysis Center, based in Sandy, "failed to show up as anticipated" at the Utah State Prison on both Friday and Saturday to provide dialysis treatment for inmates, Adams said. Estrada was to receive kidney dialysis on Friday. He died Sunday night while prison staff and others were preparing to take him to University Hospital to be treated.

Six other inmates, all men, also went without their scheduled dialysis and were taken to the hospital Sunday night. Four were admitted for an overnight stay. One man remained hospitalized Tuesday.

Adams would not comment on why the technician failed to show up or why it took prison officials until Sunday night to get treatment for the inmates.

"Obviously, we are aware that he didn't (show up)," Adams said, but she would not say when prison officials discovered that the inmates hadn't received their scheduled treatment.

The spokeswoman also declined to comment on the circumstances surrounding Garden being placed on leave. An internal investigation is underway.

"The delayed response in ensuring that the inmates received needed medical care is unacceptable," Adams said.

Estrada's parole date was just two weeks away, on April 21. He was sent to prison in August of 2005 after being convicted of rape. Estrada was a citizen of Mexico.

Aside from the Department of Corrections' internal investigation, the Unified Police Department is also investigating Estrada's death, which is standard procedure. Lt. Justin Hoyal said his department is primarily interested in finding out Estrada's cause of death from his autopsy.

"(Criminal culpability in Estrada's death) is one of the things that could play into this and one of the things we will look into," Hoyal said. "But as far as the investigation as to what took place there at the prison, as far as his medical care and what may or may not have been taken care of, is being conducted internally by prison officials."

A spokeswoman for the University of Utah Health Care said it would also investigate the "unacceptable mistake."

"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," Kathy Wilets said in a prepared statement.

Adams said several changes will be put in place at the prison "to improve communication with and oversight of the dialysis contract provider."

"Those steps include getting a schedule calendar with contact telephone numbers for dialysis technicians; requiring nursing staff assigned to the Olympus (prison) facility 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 when the dialysis schedule changes or a technician fails to show up," she said.

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