A woman died at the Salt Lake County jail after her pleas for help went ignored.

Another lost her baby while pregnant and incarcerated there after complaining for weeks that she was bleeding.

A man died by suicide after asking for help — and receiving nothing more than a handout.

A stroke killed another woman after she pleaded for medical treatment for two weeks.

Four families are mourning the loss of their loved ones, and now they’re looking for change.

They want Salt Lake County inmates taken seriously when they seek medical care, and not brushed off as just addicts coming off drugs or people complaining of fake illnesses. They want those who end up in jail to be treated compassionately — which they say didn’t happen for their family members.

“I’m so sad for the other families,” said Jontue Chavez, whose mother died in 2018 of a stroke. “I’m sad for my family. And I’m sad for the families that are going to come after. Nothing has been done. Nobody cares. They aren’t even trying to change the way they handle things.”

Some have sued. Some have settled their lawsuits, like Lisa Ostler’s parents, who were paid $950,000 earlier this year after they sued over their daughter’s 2016 death. The others say they’d like to take legal action.

They’re also pressuring local officials to step up. Attorney Rocky Anderson, a former Salt Lake City mayor, sent a lengthy letter in recent weeks to every legislator and County Council member detailing these cases, asking for these elected leaders to push reforms and launch an investigation and audit of the jail.

In response, Salt Lake County jail officials say they have worked to provide better medical care for inmates since Rosie Rivera took over as sheriff three years ago. Their medical charting system is better, and they have altered how they treat people who are experiencing drug withdrawals.

But these families don’t think it’s enough.

‘She was reaching out for help’

Lisa Ostler had pressed the intercom button in her cell at least 16 times the night before she died. Each time, she told the jailer she was in pain.

In a deposition, the jailer testified that he had been told to ignore Ostler’s pleas. She had already been checked by a nurse, he was told, who concluded she was likely reeling from heroin withdrawals.

Ostler, who had Crohn’s disease, was actually dying from peritonitis. The jail nurses hadn’t given Ostler her prescribed over-the-counter acid blocker, so an ulcer had perforated her bowels and digestive fluids were leaking into her body.

She had been arrested in Draper when officers approached her in a parking lot and found several syringes she allegedly used to inject heroin and meth. The 37-year-old spent four days behind bars, and pleaded in pain during the last days of her life.

Lisa Marie Ostler

Other inmates sought help for her or complained that she was being too noisy.

When Ostler refused to eat, Stephanie Noble was one of those inmates who asked the jailers for help.

She watched Ostler, who was just a few cells away, moaning in pain. She saw how gray Ostler’s skin was, how she crawled on the ground instead of walked and how she had difficulty speaking. Noble watched as Ostler pushed her hands through the cuff-port of her cell door, her hands grasping the air.

“She was reaching out for help, literally,” she said. “No one did anything.”

Ostler finally was taken to a hospital after inmates found her unconscious and alerted the guards, Noble said. She was taken out of the jail on a stretcher, her feet hanging out below a sheet that covered her. They were blue.

“It’s something I’ll never forget,” Noble said. “I think about it often. And I wish I could have done more.”

Ostler died at the hospital the next day, April 3, 2016. She would be one of at least 31 inmates to die while incarcerated at the Salt Lake County jail in the five-year period before January 2019, according to documents the county gave Ostler’s parents after they sued in 2018.

They eventually settled their lawsuit in March, with most of the money going to Ostler’s children. But Ostler’s father, Cal, said their goal wasn’t to get money. They wanted changes in the jail, but he said every time they met to discuss a possible settlement, attorneys for the county wouldn’t consider anything other than how much money they would agree to pay. After the case dragged on for years, Cal Ostler said they felt pressured to reach a deal because the lawsuit was becoming too expensive to keep going.

“The deaths are going to continue,” he said. “But here’s the question: Does anybody give a damn?”

A lost baby, a stroke and a suicidal man

Meagan Deadrich had been serving a sentence in the Salt Lake County jail for most of her pregnancy. She came in at eight weeks along, and, by February 2018, she was at 27 weeks — but something wasn’t right.

“The minute I started bleeding, I knew something was wrong,” she said. “I complained over and over and over again. I would even wait for the shift to change. I knew there was something wrong with my baby.”

Deadrich says she bled vaginally for two weeks and begged the jailers to take her to a doctor. As she pleaded with the jail nurses, she told them she couldn’t feel her baby move anymore.

At one point, a doctor looked at her at the jail but dismissed Deadrich’s concerns after she didn’t see blood during the examination.

Later that evening, Deadrich says jailers came to her cell and told her she was being taken to the hospital. A doctor there told her that her baby had died, and the bleeding was so severe she needed to have her uterus removed.

She was able to hold her daughter for a few minutes. The tiny body looked normal, and she wondered if the baby would have survived if she would have gotten help sooner. Deadrich herself was born early and had been in a neonatal intensive care unit. Maybe her baby could have done the same.

“I had to bleed for two weeks until they finally got [medical care,]” she said. “We may be addicts or whatever, but we’re human beings. They should treat us just like how they want to be treated.”

(Leah Hogsten | The Salt Lake Tribune) In 2018, Meagan Deadrich's daughter died in utero while Deadrich was an inmate at the Salt Lake County jail. Deadrich began bleeding vaginally and repeatedly asked jail staff to see a doctor. Finally, she was taken to a hospital, where it was discovered that her baby had died.

A few months after Deadrich’s baby died, Angie Turner went into the Salt Lake County jail. She was a 52-year-old mother and grandmother, who struggled with a drug addiction.

Turner had a family history of strokes, according to her daughter, Jontue Chavez. So when Turner died June 28, Chavez was not initially concerned about her mom’s medical treatment at the jail.

But at Turner’s wake, a former cellmate approached Chavez and handed her a stack of papers. The cellmate told her that her mother had suffered before her death and that she held Turner’s head in her lap until jailers finally called an ambulance.

Among the papers were at least nine written grievances that Turner’s fellow inmates had filed on her behalf, each detailing how Turner cried out and asked for help for two weeks before she died.

Her words were slurred, they wrote. But the jailer she sought help from was dismissive and swore at her. He later wrote in his own report that he closed the cell door on her after she yelled at him, telling her “not to act like an a--hole” while he figured out what was going on.

One inmate wrote in cramped handwriting: “I woke up to Angie crying and yelling for help. … There are too many deaths in this jail. I personally will make sure there is justice for Angie.”

Chavez read the grievances at the wake — and broke down.

“They really treated her like an absolute piece of garbage,” she said. “Like a nonhuman.”

(Courtesy Jontue Chavez) Angie Turner died from a stroke at the Salt Lake County jail in 2018.

The same month that Turner died, David Walker was booked into jail, accused of sexually assaulting a young girl who had been at his home one evening.

Walker maintained his innocence but had told his mother in phone calls that he was concerned for his safety because other inmates had learned of the allegations against him. He also worried about harming himself, according to his brother, John Walker.

David Walker reached out to a medical staffer at the jail for help in late July, saying he was suicidal. He was given “some handouts to help with his mood,” a jail worker wrote on his medical form, but Walker said he didn’t think it would help.

No one checked back with him, according to his medical records.

He tried to end his life months later and was eventually declared dead at a hospital on Sept. 7, 2018.

“I can’t put my head around it,” John Walker said. “He said, ‘Hey I need help, I am thinking things,’ and your response is to give him a brochure and send him back to his cell? He’s sitting there and had no one to talk to, no one to communicate with.”

(Courtesy John Walker) David Walker was at most at peace when he was working with his hands and creating, according to his brother. Walker died by suicide at the Salt Lake County jail in 2018.

He was 51 years old when he died. David had come to Utah for work and had often told his brother, who lives in Virginia, how much he liked it here, how he loved the big sky.

John never really understood what he meant, until after his brother had died and a friend took them to watch a Utah sunset from David’s favorite mountain overlook.

He has the words “Big Sky” tattooed on his side now, to remind him of his brother — a man who never saw the bad in people, who loved his children fiercely and whose life was cut short.

Medical treatment

The Salt Lake County Sheriff’s Office declined a request for an interview for this story, and instead released a statement in response to Rocky Anderson’s letter.

People who come into the jail have “unique medical challenges,” officials wrote, and policies and procedures are in place to address those medical needs.

“We continually review and improve our policies and procedures to ensure we are operating consistent with current best practices,” the statement reads.

Officials say they have a review process anytime someone dies at the jail, which includes both an outside criminal investigation and an internal review.

There’s been a “positive change in culture” since Rivera took office in 2017 and appointed a new deputy chief to oversee daily jail operations, the statement says. Jail officials have also taken steps to prevent self-harm, like swapping sheets for blankets.

“For our inmates who are dealing with the effects from withdrawal, we have provided hydration stations in each of the quarantine units to help encourage drinking fluids,” officials said, adding that they recently began providing “medically assisted treatment” to those who are withdrawing.

But Anderson said written policies mean little if staffers don’t follow them. In Ostler’s case, a guard should have contacted a nurse when it became clear she was having an emergency. That didn’t happen, he said.

According to jail policy, Ostler should have had her vital signs checked twice a day for at least five days — but that also didn’t happen consistently. Her blood pressure was recorded as low one day, and her heart rate was so high that it should have prompted a nurse to contact a physician if staffers had followed the jail’s policy. The following day, a nurse had written down that Ostler’s heart rate and blood pressure were normal, but Ostler was found unresponsive and not breathing less than 24 hours later.

“Failing to perform those mandatory assessments was fatal for Lisa,” Anderson said, “and will almost certainly be fatal for other detainees without significant changes to the practices at the jail and accountability for the gross violations of detainees’ rights to medical treatment.”

Anderson noted that no one was ever disciplined for how Ostler was treated, despite the sheriff’s office assertion that workers who engage in misconduct would be.

Chavez, whose mother died of a stroke, said the guard who was dismissive of her mom was never disciplined either.

Rebecca Thomas, who worked as a deputy at the jail for nearly nine years, said deputies who were callous and tough often were mentored or given promotional opportunities. Those who showed compassion toward inmates often did so in secret, she said, to avoid being ridiculed. The culture there, she says, needs to change.

“It takes all different personalities and all different strengths to run the jail efficiently,” she said. “There’s a time to use muscle and a time to use your heart.”

Thomas recalled instances when fellow deputies teased inmates who were mentally ill, talking to them in their cells at night through the intercom speaker. Once, a nurse gave an inmate the wrong methadone medication, causing him to overdose — but she says a supervisor told her not worry, and hoped that the man had done enough drugs in his life that he wouldn’t remember the incident.

The families say their loved ones were treated like they weren’t real people. But they were more than just inmates.

Turner was a doting grandmother. Walker was creative and made eccentric artwork. Ostler loved her children and never ended a conversation with her own mother without expressing her love. Deadrich will never know the daughter whom she lost.

When the Ostlers settled their lawsuit a few months ago, they vowed to keep fighting for more policy changes at the jail. But Cal Ostler said it’s been frustrating so far.

"It’s the indifference that we’re fighting,” he said. “The jail doesn’t care because the Salt Lake County Council isn’t pushing. And the citizenry doesn’t seem to care. Their medical system is broken. The problem we run into is that nobody cares.”

Correction: A previous version of this story incorrectly stated how many days Lisa Ostler had been at the jail before she died.