When physician assistant Logan Clark got to the Duchesne County jail Dec. 1 for his once-a-week visit, the county's nurse on staff told him he had a patient to see.
The 21-year-old inmate was Madison Jensen, who began suffering shortly after her arrest four days earlier. She was sick, fouling her cell with vomit and diarrhea, and had lost at least 17 pounds. She was given Gatorade and water, which she couldn't keep down, and was told a doctor would see her Thursday.
As Clark and the nurse, Jana Clyde, approached Jensen's cell in the jail on a hill above Duchesne and peeked in, they found Jensen's cold, lifeless body on her cell floor.
Jensen had died of a cardiac arrhythmia, brought on by dehydration, about 30 minutes earlier. The state medical examiner said both occurred in the setting of opiate withdrawal, and medical experts say her death was avoidable, if treated earlier.
Duchesne County's inmate medical services are overseen through contract with a company founded by a Draper physician who has assembled a network of similar clients, according to The Salt Lake Tribune's review of hundreds of public documents.
A small medical team is responsible for the care of hundreds of inmates in nine county jails across a massive expanse of land in Utah and Wyoming, a business that generates hundreds of thousands of dollars.
In most of those jails, inmates are seen by a nurse — if there are any on staff — and await once-weekly visits by Clark or another physician assistant, Joseph Coombs, working for Kennon C. Tubbs MD, a limited liability company founded by its namesake, a former Utah prison physician.
The lone nurse in the Duchesne County jail at the time of Jensen's death, a licensed practical nurse who works for the county, didn't call Tubbs' team as Jensen withered in jail, Tubbs said, though his contract specifies that his team will be available by phone every day.
"If Logan Clark or myself would have been contacted, we would have made some medical recommendations," Tubbs said. "But we were never contacted by the jail about that particular patient. So we didn't make any recommendations as to how to take care of her."
Duchesne officials aren't commenting because Jensen's death set off an investigation by Uintah County and a review by the state attorney general's office that has lingered for months. The Tribune also began investigating the contracts in place that designate responsibility for medical and mental health care in jails across Utah at a time when state sentencing reforms are sending more people convicted of drug crimes to county jails rather than prison.
Prison watchdogs and groups that advocate for inmates who are awaiting trial or are serving short sentences in county jails question the setup and say hundreds are receiving a low level of medical care.
Former director of the Department of Corrections, Gary DeLand, who works with counties inspecting jails in Utah, questioned the once-a-week visits to inmates in jails hundreds of miles apart.
"If he's that spread out, how many places can he be for more than a few minutes at a time?" asked DeLand during a Tribune interview that focused on deaths in Utah jails.
DeLand, who said he wrote the state's jail standards and inspects jails in 26 of Utah's 29 counties, said he was unaware of Tubbs or his network.
A review of those contracts shows Tubbs has designed a system to fit the budgets and requirements for multiple county commissions. The counties attempt to fulfill their constitutional requirement by having a doctor overseeing medical services in their jails while keeping down costs and meeting other policy directives .
Sending one of two physician assistants once a week to jails in northeastern Utah and southwestern Wyoming keeps costs at a level counties can afford, Tubbs said.
"I would be willing to provide five days a week at a price," Tubbs said. "That's just the economics of the whole providing medical care in jails. The sheriff's department has to decide how much they want to invest in how often they want their patients seen. I'm happy to provide whatever services they want."
At one visit per week ( unless delayed for up to 10 days by inclement weather), Kennon C. Tubbs MD, LLC gave certainty to Lincoln County, Wyo., Sheriff Shane Johnson that inmates would be seen.
Johnson said the county had relied on a local doctor to attend to inmates in his free time, which was never guaranteed. The sheriff also likes Tubbs' team's strict approach to medication that stresses alternatives to prescriptions.
"Take Ambien [a sleep medication], for example. We don't want a jail full of people on Ambien, they need to get on a regular sleep pattern," Johnson said. "That's what these guys do. They say you need to get in bed at this time. It's not just giving them sleep meds."
It's written into Tubbs' contract with Utah County, the largest and closest jail he oversees, that he won't see inmates who complain of insomnia only during monthly sick calls he personally attends.
Tubbs will, the contract shows, consult patients if the jail "disagrees with the psychiatrist recommendations for medications due to cost or other reasons."
Prison watchdogs say such a level of medical care isn't exclusive to the jails Tubbs oversees and exists in jails across Utah.
The state has climbed in national rankings in recent years and had the highest rate of county inmate deaths per capita in the latest year full statistics were available, according to the U.S. Bureau of Justice Statistics. Inmates died at a rate of 258 per 100,000 in Utah jails, according to the data.
The current and former contracts and documents outlining the medical care Tubbs' team is required to provide show a framework of the system that's been set up in only one region of the state.
In others, such as Kane County, inmates who need treatment are taken to a nearby hospital and the county pays for the service, according to Chief Deputy Alan Alldredge. That system costs the county about $60,000 a year, more than most of Tubbs' contracts with his counties.
Tubbs pursued contracts and gained medical care responsibility for multiple county jails while working at the Utah Department of Corrections as a prison physician, earning about $300,000 in salary and benefits, state records show.
It's grown into a lucrative side business for Tubbs, who maintains a practice in Draper, one that at its peak grossed over $500,000 a year. While he lost a contract worth $4,800 per month in Uintah County this year, Tubbs expanded his portfolio last year to include Teton and Lincoln counties in Wyoming and Juab County in Utah.
The framework has caught the attention of outside groups working to improve conditions in jails across Utah.
"Medical services should be provided ideally by someone who's accessible," said Aaron Kinikini, legal director of the Salt Lake City-based Disability Law Center. "If you're doing sick call once a week, that's probably not enough."
Tubbs countered that he's trying to treat a high-needs population.
"I want to improve medicine in the county jails and provide a good service for this underserved population," Tubbs said. "I do try and do my best for the counties and patients."
But Tubbs conceded that the business had a heavy workload when it served 11 counties before it lost the Uintah contract and the Daggett County jail closed this year.
"This is as much as one man can do," said Tubbs, who added that eastern Utah's Uintah County chose a cheaper doctor to provide service.
Uintah County Sheriff Vance Norton said the new jail doctor is a local resident who visits frequently.
"Since [he] has started, he has been over twice a day and has been working with us on how he feels we can make things better for the care of our inmates," Norton said. "We are very excited about the level of care he is providing."
While Tubbs' business is unique in the region for the expansive geographic area the small team covers, there are businesses nationally that provide correctional health care to multiple facilities. And, elsewhere in Utah, one doctor, John Wood, is the medical director for the jails in Davis and Weber counties.
Ongoing efforts to improve mental and medical health care in jails come as the state has enacted reforms to send people who are convicted of drug crimes to county jails rather than prison and a crowded Salt Lake County jail has leaders searching for extra beds in other counties.
Many of these Utahns are being booked into jails that struggle to offer treatment. Some, including within Tubbs' network, have no nursing staff and it's up to corrections officers to determine whether an inmate's illness or injury warrants a trip to the hospital.
Cache County has registered nurses on staff and works with an area doctor who comes by when needed, according to Lt. Doyle Peck, the jail's commander.
Policies that leave it up to jail staff to determine whether an inmate needs treatment outside a jail can lead to errors — potentially fatal ones — if a jail staffer misses warning signs and an inmate doesn't receive necessary medical care, said Karen Russo, founder of the Wrongful Death & Injury Institute.
"This is literally where [the system] goes off the rails," Russo said.
Jensen's family is preparing a lawsuit and wondering how inmates could be left to die untreated in a county jail.
"Why would you not protect your citizens?" asked Jared Jensen, Madison's father. "When you know that people have problems in jail, why don't you have somebody who can actually do a lifesaving technique as simple as putting a needle in her arm?"
Counties, especially rural ones, say they often can't afford expanded medical services or find professionals willing to work in a correctional setting at an affordable rate. Even Salt Lake County, which recently approved an expansion of its mental-health services, has struggled to find a staff psychiatrist.
"There's only so much money," said DeLand, who once was the Salt Lake County jail commander before overseeing the state prison system. "When you look at what it costs to put a full-time staff of doctors, nurses or whatever together, if you're doing all that for 30 inmates or all that for 300 or 3,000 inmates, obviously the economies of scale make that impossible to do."
After Jensen's death, the Duchesne County Commission voted for funding to hire a registered nurse. It also hopes to create a medical wing that could help with inmates who are withdrawing from drugs.
"It's in no way a reaction to what's happened in the past," said Ron Winterton, the commission's chairman, referring to the death of Jensen and two others in the past two years in the jail. "We've had it in the works for a couple years, but we'd run out of money."
Wasatch County, as elsewhere in Utah, for years left it up to jail staffers to determine when an inmate's medical needs required attention outside the jail.
That jail, also overseen by Tubbs, hired a nurse last month, said Tubbs, which he attributed to the events in Duchesne. The county also hired Tubbs as an employee last year for $43,000. He made about $26,000 as a contractor but now receives benefits as a county employee.
Jails in Utah's Juab County and Lincoln County in Wyoming, have no nurse on staff, and Tubbs said when officers contact him about inmates who need help, he often recommends getting them out of the jail.
"We're stuck doing what we can do, giving the best medical care that we can," Tubbs said. "When the officers call me with a patient, I am very reluctant to treat those patients conservatively not seeing a nurse. So I send almost all of those to the emergency room to get seen by a nurse and doctor. I agree that an officer can't make that call."
Tubbs also said medical changes in Duchesne happened after he talked to the office overseen by Sheriff Dave Boren, who has declined to comment about conditions in his jail on the advice of his attorney.
The changes recently adopted in Duchesne and Wasatch counties will bolster medical capacity at those jails. But Tubbs, along with DeLand and jail commanders across the state, conceded counties don't have adequate medical services in-house. It's simply too expensive for small, rural counties.
"In an ideal world, we would have round-the-clock nursing in every jail in the state," Tubbs said. "The state doesn't provide these smaller counties with any type of financing or any type of subsidies for nursing staff at the county jails in these smaller counties."