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Utah State Prison inmate dies after failure to receive scheduled dialysis treatments, officials say

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DRAPER, Utah — An inmate at the Utah State Prison died Sunday after failure to receive scheduled dialysis treatments, officials confirmed Monday.

According to the Utah Department of Corrections, Ramon C. Estrada, 62, was scheduled to receive kidney dialysis in the prison’s onsite treatment center in the Olympus Facility on Friday, but a technician never showed up Friday or Saturday.

“It’s unacceptable. We’re looking at everything to help us understand better what happened and how we can prevent it from happening again,” said Brooke Adams, spokeswoman for the department.

Estrada died at about 10:30 p.m. on Sunday, as prison medical staff and outside responders prepared to transport him to the University Medical Center for treatment. Early reports suggest the cause was cardiac arrest, due to renal failure.

“Everything from the response and the actions of the treatment provider, our medical leadership’s staff response, is under investigation,” Adams said.

The prison works with South Valley Dialysis through a contract with University of Utah Healthcare.  The clinic referred all questions to the university.

Spokeswoman Kathy Wilets said they are now conducting a “thorough review” of what happened and will take any necessary steps to improve communication and practices.

“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,” said Wilets, in a statement.

Following Estrada’s death Sunday evening, six other inmates who need ongoing dialysis treatment but had not received it were taken to University Medical Center for evaluation.

Two were found in good condition and sent back to the prison, while four others were admitted. Only one remained at the hospital Monday evening.

“The 8th Amendment of the constitution guarantees prisoners with adequate medical assistance, and what happened is a tragedy,” said John Mejia, legal director of the ALCU of Utah.

While the investigation is only in its early stages, Mejia believes it could very likely end in a courtroom.

“If there is reason to believe the prison has fallen short of its 8th Amendment duties, there is a right of action under the constitution to bring a civil suit against the prison,” Mejia said.

In the meantime, the Department’s Clinical Services Bureau director has been placed on administrative leave, pending the outcome of the investigation.

According to Adams, the department has also taken immediate action to improve communication with an 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 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 for the charge nurse when the dialysis schedule changes or a technician fails to show up.

Estrada was convicted of rape and has been incarcerated since Aug. 10, 2005. He had an upcoming parole date of April 21.  The federal Immigration and Customs Enforcement Service had an active detainer on Estrada, who is a Mexican National.