During her four days in jail, Madison Jensen begged for help that never came.
Jensen, 21, was taken to the Duchesne County Jail at the request of her parents, hoping to keep her safe. Instead, she died in a jail cell covered in green vomit after an agonizing decline, according to other inmates.
Jensen's cellmate, Maria Hardinger, said she brought her food and water when Jensen could no longer stand. But after awhile Jensen lost the ability to swallow.
Hardinger blames jail officers for Jensen's death, saying they ignored pleas for medical care and were often hostile to drug users.
On Dec. 1, 2016, Jensen became one of at least 416 Utahns to die in custody since 2000, according to records The Salt Lake Tribune obtained from all county jails and the state prison system.
Amid a lack of uniform guidelines set out by state law, records show agencies vary in how they track and release information related to inmate deaths.
But setting aside those who died of natural causes and those the jails and prison have not yet categorized, suicide was by far the No. 1 cause of death for inmates. At least 96 people took their own life while incarcerated. Five others were killed, two were executed by the state, six died of suspected drug overdoses.
And then there were the harder to quantify deaths. Those that were labeled "unknown" or involved a medical condition or accident.
A flurry of questions • In many cases such as Jensen's, deaths remain clouded by a lack of information, often due to lengthy investigation that make it difficult for families to heal.
Jared Jensen still doesn't know exactly what happened after he called the Duchesne County Sheriff's Office on Nov. 27 seeking to help his daughter.
Deputy Jared Harrison responded to the family's home where Madison had been yelling and threatened to commit suicide four days after using heroin, according to an arrest report released by Uintah County, which looked into her death.
The report shows Harrison warned Jensen that jail wasn't an alternative to rehab. Jared Jensen wanted his daughter in jail "for her safety," he wrote in a witness statement two days later. He told Harrison about the three medications she was taking, including one for her heart, and Madison was taken to jail.
Harrison arrested her for possession of paraphernalia and a urine test at the jail showed she used heroin and marijuana.
The only details available, from other inmates, portray a jail that takes a hardline against narcotics and users and that may have ignored pleas for help.
Hardinger said she and Jensen repeatedly sought assistance, pushing a button that allows inmates to communicate with staff, because Jensen was sick and afraid.
"The jail wouldn't even acknowledge her or take her seriously," said Hardinger, who said she was the last inmate to see Jensen alive. "She'd thrown up all over and she needed to see a nurse. They kept telling her it's withdrawals."
Hardinger knew what withdrawals felt like.
A body that's addicted to the chemicals released by opiates cries out for drugs in strange ways. Without fueling the brain with more pain pills or heroin, addicts get twitchy and restless.
"Your nerve endings are just screaming out for drugs. It's terrible," Hardinger said.
When Jensen joined Hardinger in their cell, the two expected an excruciating first night as they continued to go through withdrawals. But as the first days passed, Hardinger improved while Jensen got worse. The vomiting and the pain didn't stop.
"Two nights before she died she asked me to check on her and to make sure she was breathing," Hardinger said. "She was so scared."
Jensen would spend her final night alone. Hardinger was moved the day before to the A-Block, a holding area where female inmates stay in a common area.
The county has declined to release much information that might help explain her death in anticipation of a lawsuit Jared Jensen intends to file.
Lt. Jeremy Curry, a spokesman for Duchesne County Sheriff David Boren, disputes much of Hardinger's account. He said the two women were together, but only for a few hours, and that Jensen was instead held alone in a medical observation cell.
"If Hardinger was housed with her it would have been on initial intake," he said.
While Curry said surveillance video from Jensen's time in jail disputes Hardinger's account, the jail declined to provide the footage that would show the conditions of Jensen's confinement, who she was with, and whether she received medical care as her health declined.
"We're obviously not going to release that to the public," he said, adding it would jeopardize the security of the facility.
A wait for answers • Three weeks after Jensen's death, an inmate with a severely damaged spleen lay on a cell floor in the Davis County Jail, over a liter of blood pouring through her insides.
Heather Ashton Miller's death, too, has many open questions that have family members – and attorneys – wondering what happened. She was arrested on Dec. 20 on possession of a bag of heroin. She died the next night.
"It is so strange," said Rocky Anderson, an attorney and former Salt Lake City mayor who is looking into the matter for the 28-year-old woman's family.
Anderson called inconsistent notes from first responders and the state medical examiner "classic excuses in child abuse/death cases." One report said Miller fell from a stool. Another said she fell from the top bunk of a bed in her cell.
The autopsy report showed Miller had a cut on her chin smaller than an inch. Other than that, there was no sign of external trauma. An autopsy revealed a "near complete transection of the spleen."
A toxicology report showed there was methamphetamine and marijuana in her blood as well.
Other than the reports that say Miller either had a seizure and fell off the top bunk of her cell or off a stool, there has been no explanation of what could have caused her injury.
The county has declined to release information to The Tribune about the investigation into Miller's death.
Cindy Farnham-Stella, Miller's mother, believes jail staff may have mistreated her daughter because she was arrested for a drug crime.
She is relying on an investigation from the Utah attorney general for answers.
"My intention is to maintain a relationship with Utah and to make sure that all people have the opportunity to be taken care of and respected until they're judged when they go to court," Farnham-Stella said, "instead of being punished and treated badly before they even get that opportunity."
A search for others • It's hard to determine how many in-custody deaths have aspects similar to that of Jensen's and Miller's.
No state law requires detailed disclosures about an inmate death. As a result, there's a patchwork of local policies.
Weber County, for example, released the names, reason for arrest and times of death of 31 inmates who died in the county jail but not how they died.
Neighboring Davis County, meanwhile, released only the inmates' causes of death, time of arrest and gender but declined to identify any of the 18 people it knew had died in jail since 2005, saying releasing the names was prohibited by state law.
In Beaver County, a lieutenant named in a lawsuit filed by the family of Troy Bradshaw, an inmate who committed suicide, told The Tribune the records were off-limits.
Bradshaw's family is suing in federal court alleging his constitutional rights were violated after his arrest on June 13, 2014. Despite knowing of Bradshaw's history of mental illness, the family said in court, jailers failed to properly monitor him before he apparently hanged himself in his jail cell two days after his arrest.
A search for justice • Women who were former inmates in the Duchesne County Jail say they're speaking with The Tribune because they want changes that would prevent future deaths.
One week before Madison Jensen died alone, another young inmate, Tanna Jo Fillmore, hanged herself on Thanksgiving Day. It was the third death in the county's jail in just over a year, the records show.
Laurie Ames-Morris, who said she was the last inmate to reside with Fillmore, said the jail denied Fillmore anti-anxiety medication when she arrived.
Curry, the sheriff's spokesman, said the jail is a "narcotic-free facility."
"If it's a narcotic [a doctor at the jail] will deny it and will give them other things that are similar," he said.
Another woman who was an inmate when Fillmore and Jensen died also described hostility toward drug users.
"Unfortunately, there's, I don't want to say many of them, but there's been a few of the girls [who] will come through, and if they're coming off of heroin, then yeah they're pretty sick their first couple of days," said Megan Palmer, a former inmate who was in general population when Jensen died. "But to [jail staff] it's, 'Hey, that's your fault. You did drugs, you go through the withdrawals.' "
Sheriff David Boren said in a news release Thursday "statements by anyone which purport to be based on facts are misleading at this point," saying the Uintah County investigation was still pending.
He said the jail followed best practices and, "I want to assure everyone that myself and my staff are committed to the care and safety of individuals once they enter the Duchesne County Jail, regardless of the surrounding circumstances."
Jared Jensen received Madison's death certificate Friday. It says she died after having a probable cardiac arrhythmia caused by dehydration and opiate withdrawal. The state classified Madison Jensen's death as natural.
He doesn't see it that way and plans to fight in court to prove the jail played a role in his daughter's death.
"For me, we're going to vindicate my daughter," Jared Jensen said. "Somebody else's child isn't going to die in there. That's what we need."
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