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Ramon Cruz Estrada was grateful for his life-saving dialysis treatment in Utah State Prison.

"I'm getting very sick and very ill, and if I hadn't gotten into that program I wouldn't be here right now," Estrada said in a 2008 parole hearing.

But last week, the prison's dialysis technician failed to show up Friday or Saturday, and Estrada died Sunday. The 62-year-old had been scheduled to be released in about two weeks after a decade of incarceration.

If Estrada suffered like a typical dialysis patient, his potassium accumulated while he waited.

Potassium is the mineral that controls nerve and muscle function, but too much of it causes problems. Someone waiting for dialysis would appear to have shortness of breath in the lead-up to congestive heart failure, said Debbie Cote, a nephrology nurse for more than 30 years.

When the kidneys cannot pass potassium, a person's heart can fail — as Estrada's did Sunday night, as medics were getting him ready to go to the hospital.

Multiple investigations were underway Wednesday to figure out why he did not receive dialysis treatment as scheduled. A technician — employed by Sandy's South Valley Dialysis, which is operated by University of Utah Health Care — did not show up as anticipated Friday and also did not show Saturday, said Brooke Adams, a spokeswoman for the prison.

Meanwhile, Richard Garden, the prison's medical director, has been placed on administrative leave pending results of the investigations. The Utah Department of Corrections is investigating what occurred and so is U. Health Care.

Unified Police, who typically investigate inmate deaths at the Draper prison, also are trying to determine what occurred.

"There was nothing suspicious at the scene," said Unified Police Lt. Justin Hoyal, "and we are now awaiting autopsy results."

What actions have been taken or are anticipated related to Estrada's death by South Valley Dialysis were not known. However, spokeswoman Kathy Wilets confirmed that supervising U. Health Care, too, is conducting an internal investigation into the matter.

"Until we have more information," Wilets said, "I don't have anything more I can add at this time."

Earlier, Wilets had issued a statement expressing sorrow, along with concern "about the scheduling error for dialysis services provided at the prison," which she characterized as an " unacceptable mistake" that will result in "whatever steps are necessary to improve communications and procedures."

In the wake of Estrada's death, six other inmates who also had missed planned dialysis treatments were taken to University Hospital for evaluation. Two were found to be in good condition and returned to the prison. Four inmates were admitted for treatment; all of them had been returned to the prison by late Tuesday.

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"It is unacceptable the inmates did not receive the medical care they needed when they needed it," said Marty Carpenter, spokesman for Utah Gov. Gary Herbert, said in a statement. "The governor has called for a full investigation by the Dept. of Corrections Law Enforcement Bureau, so we can fully understand what went wrong, who was responsible and determine the appropriate actions to make sure it never happens again."

And the Disability Law Center is investigating Estrada's death for potential civil rights violations, said Aaron Kinikini, the center's legal director.

"This is a pretty obvious case of neglect," Kinikini said. "We are really concerned. ... People with disabilities, who reside in our institutions — especially our correctional institutions — are very vulnerable. They're not very popular or even on anyone's radar screen unless something like this happens."

The center is authorized by federal law to investigate deaths of inmates with disabilities — in Estrada's case, kidney disease — for evidence of abuse or neglect.

The center will review all of Estrada's prison records, focusing on his medical records, to find whether Estrada had missed treatments before this weekend.

Evidence of neglect "could signal a civil rights lawsuit against the state and the Department of Corrections," Kinikini said.

Corrections records show that Garden, the prison's medical director, has been employed by the prison since 1994, when he worked as a staff physician before earning promotions to assistant clinical director and then clinical director. He also has served as a medical care consultant for other prisons and jails, and frequently has spoken at various conferences regarding care issues in correctional settings.

The Department of Corrections investigation will evaluate the prison medical staff's response, actions or lack thereof by South Valley Dialysis, and what inmate medical care policies and procedures may need to be revised.

Adams said prison officials already have "taken immediate action to improve communication with and oversight of the dialysis contract provider." Those actions include improving scheduling and record-keeping; collecting contact telephone numbers for dialysis technicians; requiring that nursing staff assigned to the Olympus facility make contact with and receive post-treatment reports from the on-duty technician on dialysis days; making better 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.

Adams confirmed that Estrada, who began serving time in August 2005 for a rape conviction, was to be paroled April 21. However, after his release, Estrada — a Mexican national — was to be taken into custody by federal immigration officials.

The Salt Lake Tribune on Wednesday was unable to reach Estrada's family.

Twitter: @remims