RENO, Nevada — 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.
Hours pass before deputies realize she is dead — paramedics not called
Less than an hour later, Coltrain was shown on the video lying in the fetal position when her body suddenly goes rigid and her legs straighten. While on her stomach, her face slowly rises toward the back wall and her arm stretches out and hangs off the bed. Her head lowers back onto the mattress and for the next several minutes her body appears to go through periodic convulsions.
Coltrain then stops moving entirely about 6:26 p.m. The video shows her lying still in the same position until about 12:30 a.m. when Gulcynski arrives to move her to a different cell and finds her unresponsive.
According to the investigation report, the 20-minute section of video depicting Gulcynski entering her cell was missing entirely from the files the state obtained for its investigation from the sheriff's office. But a Reno Gazette Journal reporter found the video in files provided by Keyser-Cooper.
The video shows Gulcynski walk into the cell and nudge Coltrain's leg with the tip of his boot. When she didn't respond he enters the cell, looks at her face, briefly touches her arm and then quickly exits the cell.
According to the investigative report, Gulcynski notified his supervisors that Coltrain appeared dead and was cold to the touch. The video then shows him re-enter the cell and check for a pulse on Coltrain's neck before leaving again.
The sheriff's office then left Coltrain's body locked in the cell until a Washoe County forensic technician arrived at 5:48 a.m. to begin the investigation.
No one on staff called for paramedics after finding Coltrain lying unresponsive and cold on her bed, according to the investigation. The lawsuit said the sheriff's office had no policy for what to do after discovering an unresponsive inmate.
The Washoe County Medical Examiner labeled Coltrain's death accidental, caused by "complications of drug use." The toxicology results showed she had heroin in her system.
Investigator: Had deputies followed policy, she may not have been in danger
Gulcynski told investigators that he had periodically looked at Coltrain from the video monitor outside her cell but thought she was asleep. The sheriff's policy requires deputies to physically check inmates under observation at least twice an hour if they are lying under blankets. That didn't occur, according to the investigation.
Holland told investigators that Coltrain "never looked good," but that he couldn't "force medical attention" on inmates.
The state investigator assigned to the case, Detective Damon Earl, noted in his report that had Gulzynski and Holland adhered to some of the department policies in place, Coltrain may have not have been in as much danger.
"There were a limited number of times where Coltrain had actual contact with the staff," Earl wrote. "This may be significant because had more contact been made with Coltrain, indicators of Kelly's medical condition may have been observed. These indicators may have alerted staff therefore prompting medical attention to be rendered to Coltrain."
At one point in his investigation, Earl timed his walk from the jail to the hospital across the street. It took "a little over two minutes."
Ryman, Mineral County's lawyer, said he couldn't comment on the specifics of the investigation, including why no one called for emergency medical help when Coltrain was discovered unresponsive. He also wouldn't comment on whether any disciplinary action was taken against either Gulcynski or Holland.
The lawsuit, however, said both men were disciplined but that Holland opted to retire early.
In June, the Mineral County Commission voted unanimously to buy Holland an additional year toward his service for a cost of $17,853. The buy-out allowed Holland to retire with a higher annual pension and health care benefits than if it had been denied.
District Attorney didn't find 'cruel, oppressive or malicious treatment'
In reviewing the case for criminal charges, Rye, the Lyon County District Attorney, said he couldn't find evidence that the two jailers acted maliciously.
"Based on my review, they did not notice any signs warranting any medical intervention based on their training or experience," Rye said. "They were provided information related to her, and it appeared to me that was taken into account in her housing and monitoring. The officers did not ignore information provided to them. And, based on the reports by NDI, it did not appear that they exhibited any cruel, oppressive or malicious treatment."
Keyser-Cooper, however, believes policies and training are less than adequate at the Mineral County Jail. The lawsuit by Coltrain's family seeks not only compensation for their loss, but also for Sheriff Adams to improve the conditions at the jail. Keyser-Cooper said the family won't settle their lawsuit without that.
Ryman said such changes are already underway, but within the small county's limited resources.
"The policies of the jail in regard to people who have addictions and are undergoing withdrawals have the full attention of the sheriff and the county, despite the fact of the lawsuit," Ryman said. "Even outside the lawsuit, the sheriff will go forward with this kind of training. Everything will be done to the best ability of this small county. They don't have the resources of someone like Washoe County."
Follow Anjeanette Damon on Twitter: @AnjeanetteDamon