On April 5, 2015, Ramon C. Estrada, 62, incarcerated since 2005, died at the Utah State Prison due to an apparent heart attack related to renal failure. His death was preceded by two days of missed dialysis treatments because a medical technician had failed to show up for work. Estrada was scheduled to be paroled within three weeks.
At the time of his death, University of Utah Health Care had been providing dialysis services at the prison for seven years. The university operates 17 dialysis clinics in Utah, Idaho and Nevada.
After Estrada died, prison officials transported six prisoners, who had also missed dialysis treatments, to a local hospital for evaluation. Two were deemed in good condition and returned to the prison; the others were admitted for observation.
University of Utah Hospital spokesperson Kathy Wilets released a statement saying, “We have a responsibility to provide 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.”
According to Utah Department of Corrections (UDC) spokesperson Brooke Adams, those steps include providing prison staff with the technicians’ phone numbers, ensuring prison staff are notified when technicians report to provide treatment and requiring nurses to make more detailed notes regarding prisoners’ medical conditions.
Following an autopsy by the Utah State Medical Examiner’s Office, the Unified Police Department launched an investigation into Estrada’s death. Dr. Richard Garden, the prison system’s Clinical Services Bureau (CSB) director, was placed on leave pending an internal investigation. He was later reinstated – but as a “medical doctor,” not as CSB director.
Other staff members involved in Estrada’s death faced disciplinary action. Prison officials fired a physician’s assistant and supervising nurse, while another nurse was demoted and a third was suspended for 40 hours. Shortly after Estrada died, the Utah Department of Health launched its own review of the dialysis program.
In December 2015, the UDC agreed to pay $400,000 to Estrada’s family to settle their wrongful death suit. According to the Salt Lake Tribune, state officials agreed to the settlement as a means of curtailing the cost of litigation and not as an admission of wrongdoing. See: Estrada v. Crowther, U.S.D.C. (D. Utah), Case No. 2:15-cv-00433-DS.
In March 2016 the University of Utah clinic responsible for dialysis treatment at the Utah State Prison agreed to pay $100,000 to settle the lawsuit filed by Estrada’s family. At that time, Wilets expressed regret over the “scheduling error” that resulted in Estrada’s death and said the university had made changes to ensure that such lapses do not happen again.
Sources: Associated Press, www.stltrib.com, www.news.yahoo.com, www.startribune.com, www.fox13now.com
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Related legal case
Estrada v. Crowther
|U.S.D.C. (D. Utah), Case No. 2:15-cv-00433-DS