Locked away in a Nevada county jail for failing to take care of her traffic tickets, 27-year-old Kelly Coltrain asked to go to the hospital. Instead, as her condition worsened, she was handed a mop and told to clean up her own vomit. She died in her jail cell less than an hour later.
Despite being in a video-monitored cell, Mineral County Sheriff’s deputies did not recognize that Coltrain had suffered an apparent seizure and had not moved for more than six hours. When a deputy finally entered her cell and couldn’t wake her, he did not call for medical assistance or attempt to resuscitate her. Coltrain lay dead in her cell until the next morning when state officials arrived to investigate.
Details of Coltrain’s death 13 months ago came to light this week with the release of a 300-page report compiled by state investigators. The investigation found that Coltrain’s jailers violated multiple policies when they denied her medical care after she informed them she was dependent on drugs and suffered seizures when she went through withdrawals.
The investigators also asked the Mineral County District Attorney to consider criminal charges in the case, after finding evidence the Mineral County Sheriff’s Office may have violated state laws prohibiting inhumane treatment of prisoners and using one’s official authority for oppression.
To avoid a conflict of interest, the investigation was forwarded to Lyon County District Attorney Stephen Rye for review. Rye declined to press charges in the case.
“The review of the case, in our opinion, did not establish any willful or malicious acts by jail staff that would justify the filing of charges under the requirements of the statute,” Rye said.
Coltrain’s family feels otherwise.
On Wednesday, Coltrain’s mother, father and grandmother filed a wrongful death lawsuit, accusing the sheriff’s office of ignoring her life-threatening medical condition despite knowing that she was suffering withdrawals and had a history of seizures.
“(Jail staff) knew Kelly Coltrain had lain for days at the jail, in bed, buried beneath blankets, vomiting multiple times, refusing meals, trembling, shaking, and rarely moving,” lawyers Terri Keyser-Cooper and Kerry Doyle wrote in the lawsuit. “Defendants knew Kelly Coltrain was in medical distress.”
“Kelly Coltrain’s medical condition was treatable and her death preventable,” the lawyers wrote. “If Ms. Coltrain had received timely and appropriate medical care, she would not have died. Kelly Coltrain suffered a protracted, extensive, painful, unnecessary death as a result of defendants’ failures.”
‘The worst I have ever seen’
Keyser-Cooper, who has a decades-long career of successful civil rights lawsuits against Northern Nevada police agencies, said this case is “the worst I have ever seen in 33 years. I’ve never seen anything like this.”
Mineral County Sheriff Randy Adams referred questions to the county’s lawyer but did say he is in the process of updating the jail’s policies.
“Obviously it’s terribly unfortunate and it’s tragic,” Adams said. “That’s really all I can say.”
The county’s lawyer, Brett Ryman of Reno, also described Coltrain’s death as a tragedy, and said the sheriff has hired the Legal and Liability Risk Management Institute to update the jail’s policies and provide training for deputies. He declined to answer any specific questions about the investigation because of the family’s lawsuit.
“It’s just really difficult for a small rural county like this to handle what is just a massive problem,” Ryman said. “There are so many people addicted to substances who end up going through withdrawal in the jail.”
Mineral County is a tiny rural county southeast of Washoe County. Its population is just under 4,500.
Keyser-Cooper described Coltrain as a “successful student, a friendly outgoing girl, and an exceptionally talented soccer player,” who was close to her family. She developed depression and a drug addiction after a knee injury as a teenager living in Las Vegas, the lawsuit said.
The day she was arrested
Although she was living in Texas, Coltrain had visited Reno and Lake Tahoe for a family reunion to celebrate her grandmother’s 75th birthday.
After the celebration, Coltrain was pulled over for speeding outside Hawthorne on July 19, 2017, according to the investigation by the Nevada Division of Investigation. Because she had failed to take care of previous traffic violations in Clark County, the officer who stopped her decided to book her into the Mineral County Jail.
While being booked, Coltrain initially refused to answer questions about her medical history and next of kin. But soon after she learned she wouldn’t be able to make bail, she informed Sgt. Jim Holland that she was dependent on drugs and had a history of seizures when she went through withdrawals, according to the investigative report.
After Coltrain came forward with her medical history, Holland did not follow a jail policy that requires inmates with a history of seizures to be cleared by a doctor before being held at the jail. Nor did jail staff follow medical protocol of carefully monitoring the vitals of a person undergoing withdrawals.
In fact, the jail had no on-site medical care, relying instead on the hospital across the street to attend to inmates’ medical needs and prescriptions.
Deputy denied her access to hospital
About four hours after she was booked into the jail, Coltrain told the night deputy she needed to go to the hospital right away for medication. Instead of following the jail’s medical care policy, he told Coltrain she couldn’t get help unless he determined her life was at risk.
“Unfortunately, since you’re DT’ing (referring to the detoxification process), I’m not going to take you over to the hospital right now just to get your fix,” Deputy Ray Gulcynski told Coltrain, according to the investigation report. “That’s not the way detention works, unfortunately. You are incarcerated with us, so … you don’t get to go to the hospital when you want. When we feel that your life is at risk… then you will go.”
Coltrain spent the next three days in her cell, eating almost nothing and drinking a little bit of water. She spent most of her time curled in the fetal position underneath blankets.
Early on July 22, 2017, her third day in the jail, Coltrain began vomiting, trembling and “making short, convulsive type movements,” according to the investigative report. A little after 5 p.m. that day, Holland brought Coltrain dinner and water and tried to talk her into eating a little bit of food. She ate a few bites.
Holland then brought her a new set of jail clothing to replace her soiled uniform and a mop, asking her to clean the vomit from her floor, according to the investigative report. Coltrain sat still for a few minutes until Holland returned and asked her again to mop.
According to video reviewed by the Reno Gazette Journal, Coltrain then began mopping her floor while still sitting on her bed. She was trembling during the process and stopped often to rest. A few minutes later, Holland returns to point out the spots she had missed. Coltrain wipes up the spots and Holland leaves with the mop.
Holland later told an investigator that he thought it was odd Coltrain didn’t get out of bed to mop the floor.
“Sgt. Holland advised he thought Coltrain was just ‘lazy’ and that she just didn’t want to stand up to clean the floor,” the report said. “Sgt. Holland advised he just wanted the floor to be cleaned and he didn’t care how it got done, just that it got cleaned up.”
This was the last time Coltrain was seen alive.
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Source: USA Today