DRAPER, Utah – Three more employees at the Utah State Prison have been placed on administrative leave based on the preliminary findings of two investigations sparked April 5 when an inmate died after he didn’t receive scheduled dialysis treatments.
A press release issued Thursday by the Utah Department of Corrections states the autopsy report for Ramon C. Estrada, 62, has not been completed yet but 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.”
Estrada's children filed a lawsuit in June that accuses the Utah Department of Corrections and University of Utah Health Care, which oversees the contract provider for dialysis services at the prison, of negligence and cruel and unusual punishment in the death of their father, who was due to be paroled shortly.
“They knew he had a serious medical condition that he needed this life-saving dialysis,” Estrada family attorney Alyson McAllister told FOX 13 News in June. “He didn’t get it on Friday and they knew he didn’t get it. He didn’t get it on Saturday and they knew he didn’t get it, and he didn’t get it on Sunday.”
Estrada died around 10:30 p.m. that Sunday as medical personnel were preparing to transport him to University of Utah Medical Center.
“It’s definitely negligence, but it’s more than negligence,” McAllister said in June. “It’s deliberate indifference.”
The Department of Corrections employees placed on leave worked for the Clinical Services Bureau and were on duty between April 3 and April 5, and it is during that timeframe that a scheduling error meant technicians from South Valley Dialysis, the contract provider for dialysis services at the prison, did not arrive to give Estrada dialysis as scheduled.
The release states that because the status of these employees remains under review, their names will not be released. The Bureau Director for clinical services was put on administrative leave immediately following the fatal incident, and the director remains on leave pending the outcome of the ongoing reviews.
The Department of Corrections retained WELLCOON, described in the press release as a nationally recognized corrections health care consulting firm based in Utah, to conduct an outside review of Estrada’s death, the dialysis program at the prison and the overall health care delivery system at the prison as it relates to dialysis patients as well as mental health issues. WELLCON will make recommendations following the review.
The department’s Law Enforcement Bureau is also “engaged in an extensive internal investigation into the events leading up to Estrada's death."
Both reports will be reviewed by the Utah Department of Health before they are finalized. The press release sates the department has already made several changes to procedures after Estrada’s death to improve communication as well as oversight of the contract provider for dialysis services.
According to the press release, the department and South Valley Dialysis have also added additional measures to improve care, which include “provision of weekly summary sheets of inmate dialysis treatment; a procedure for monitoring and tracking inmates who refuse or stop scheduled dialysis treatment; sharing of treatment protocols and notes/orders between the Department and South Valley Dialysis; holding quality assurance protocol reviews every six months; and mandatory joint training of Department and South Valley Dialysis staff who work in the Olympus Facility (where the dialysis clinic is located).”