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Utah State Prison nurses apparently did not try to contact a dialysis center for at least two days after the center's dialysis tech began missing appointments at the prison in April — and then left a voice mail at the center on a Sunday, while the office was closed, according to an investigation into the death of 62-year-old prisoner Ramon Estrada.
But perhaps the most startling detail in the report by University of Utah Health Care is what investigators say happened after a prison nurse left the message at 4:36 p.m. in an empty office on Sunday, April 5: Prison officials did not seek treatment for six other inmates who missed dialysis treatments until after Estrada died, nearly six hours later.
Preliminary medical reports indicate Estrada died of renal failure after he missed scheduled dialysis treatments on April 3 and 4.
The investigation by University of Utah Health Care, which contracts with the prison to provide dialysis to inmates, found that the tech had agreed to switch shifts with a co-worker and take the April 3 and 4 appointments. Although the techs both noted the change on a communications log at the prison, the tech who agreed to cover the April 3-4 shift failed to note the change on his personal calendar, investigators found.
He did not report for work at the prison on those two days.
As a result, Estrada and six other inmates did not receive dialysis treatments.
Estrada died on the evening of April 5 while medics were preparing to take him to a hospital, "prompting the prison to send all six other inmates who missed dialysis … to University of Utah Hospital's emergency room for evaluation," according to a summary of the university's investigation.
The summary does not indicate why prison staff waited to seek evaluations of the other inmates until after Estrada died at 10:30 p.m..
Investigators found that a prison nurse left a voice mail with the University's South Valley Dialysis Center almost six hours earlier, at 4:36 p.m. Investigators did not report whether prison staff sought treatment with other health care providers before sending the inmates to the university's center.
The investigation also does not say when prison officials began taking action to move Estrada to a hospital; what, if any, other care was given; or the extent to which his condition had deteriorated before care was sought.
Of the six inmates who were taken to the emergency room, one was hospitalized overnight, three received dialysis and returned to the prison, and two were found to not need dialysis immediately.
"We deeply regret the scheduling error leading to the delayed dialysis for these patients," University Health Care spokeswoman Kathy Wilets wrote.
University Health Care has implemented "an improved scheduling notification and alert system, as well as clearer communication channels with prison staff," Wilets wrote, adding that the "disciplinary process" for the employees involved was still ongoing.
Prison officials are conducting their own investigation into Estrada's death and the missed appointments.
"Our investigation is ongoing and involves interviews with 30 to 40 different individuals, review of various policies, procedures, logs, and other documents," wrote Brooke Adams, spokeswoman for the Utah Department of Corrections. "Like the university, we expect to issue a statement about our findings once that investigation is completed."
When Estrada died, he was just weeks from being released on parole after nearly a decade in prison on a rape conviction. He had spoken of the importance of his dialysis treatments in a 2008 parole hearing.
"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.
Twitter: @erinalberty