Coltrain, who was jailed for outstanding traffic tickets, lay dead for more than six hours before a deputy found her body, the Gazette Journal reported. The deputy did not call for medical help or try to revive her.
Coltrain’s final hours are detailed in the investigative report released this week by Nevada Division of Investigation officials, who found that deputies violated several of the jail’s own policies when they denied her medical care. Coltrain had told jail workers that she was addicted to drugs and suffered seizures when she went through withdrawal.
The investigators also requested that Mineral County prosecutors consider criminal charges against the deputies involved. The Gazette Journal reported that the case was forwarded to the Lyon County District Attorney to avoid a conflict of interest.
Lyon County officials declined to prosecute.
"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," Lyon County District Attorney Stephen Rye told the newspaper.
The lawsuit filed by Coltrain’s family alleges jail personnel deprived her of her constitutional right to adequate medical care and, ultimately, caused her death. The suit specifically names Mineral County Sheriff Randy Adams and two deputies, Sgt. Jim Holland, a supervisor at the jail, and Deputy Ray Gulcynski.
The lawsuit states that jail officials ignored their own medical policies for when inmates come in suffering from drug withdrawal symptoms. According to the filing, the policies require that inmates with a history of seizures be taken to a hospital and medically cleared before being jailed.
The jail designates “max cells” for inmates at risk because of drug abuse, the lawsuit states. Deputies are supposed to monitor those inmates every 15-20 minutes, with a physical check to be done twice an hour if the inmate is lying down.
The deputy placing the inmate into the security cell must also start an incident report and protective custody watch sheet, which should include details of the circumstances of the inmate, as well as observations and actions of deputies. A sergeant is supposed to act as a medical liaison to schedule appointments, maintain the inmate’s medical records and fill and refill medications as needed, the suit states.
Read the entire lawsuit filed by Kelly Coltrain’s family below.
The jail policies also require that the hospital be called any time an inmate requests a visit to the emergency room. The inmate is supposed to fill out a request form describing the illness.
The medical liaison is also supposed to start a medical file on all inmates requesting a trip to the hospital, the lawsuit states.
The report from state investigators indicates that none of those policies were followed, according to the Gazette Journal and the lawsuit. The probe found that Coltrain, who was arrested after she was stopped for speeding, initially refused to answer questions about her medical history.
When she realized she would not be able to make bail, she told Holland she was opioid-dependent and suffered seizures if she went through withdrawal, the Gazette Journal reported. Holland failed to have her taken to the hospital to be medically cleared.
Jail staff also failed to monitor her vital signs as required by the medical policies, the the newspaper reported.
About four hours into her jail stay, Coltrain told Gulcynski, the night deputy, that she needed to go to the hospital for medication. He told her she could not go to the hospital unless he determined her life was in danger.
"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," Gulcynski told her, according to the Gazette Journal. "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."
The lawsuit filed by Coltrain’s family states that Gulcynski admitted to investigators that she told him, as she had told Holland, that she suffered from seizures.
“Gulcynski replied: ‘The next time you have a seizure, since you’re prone to them, hit the button and I’ll come in here right away,’” the lawsuit states.
The deputy also told investigators that he did not believe she was in withdrawal the first night because she had only been in jail for a few hours, according to the lawsuit.
For the next three days, Coltrain spent most of her time curled in the fetal position on her bunk, eating and drinking very little, the lawsuit states. She could occasionally be seen moving around restlessly and yawning, which are signs of opioid withdrawal.
The lawsuit states the video shows she also appeared to have “full-body convulsions” July 20, two days before the final, fatal seizure.
On July 22, she began vomiting, trembling and making “short, convulsive-type movements,” the investigative report said.
Holland brought her dinner shortly after 5 p.m. and, at his urging, she ate a few bites. The sergeant also brought her a clean black and white jail uniform because she had vomited on the one she was wearing.
At that point, Holland brought her a mop.
The jail video obtained by the Gazette Journal shows Coltrain mopping the floor as she sits on her bunk, trembling. Holland, who returned to point out spots she had missed, later told state investigators that he thought it was strange that she stayed in 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 investigative 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."
When Holland left with the mop, it was the last time Coltrain was seen alive, the Gazette Journal said.
"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," the Gazette Journal reported. "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."
She stopped moving completely around 6:26 p.m., the newspaper said. She was in the same position when Gulcynski arrived around 12:30 p.m. the following morning to move her to a different cell.
The investigative report indicated that a 20-minute portion of video during which Gulcynski finds Coltrain dead was not provided to state investigators. The Gazette Journal obtained the footage from one of the lawyers representing Coltrain’s family.
In that footage, Gulcynski is seen nudging Coltrain’s leg with his boot to wake her. When she doesn’t respond, he goes in the cell and, after looking at her face and touching her arm, quickly exits.
State investigators said that Gulcynski went and notified his supervisor that Coltrain was cold and appeared to be dead. The footage shows him re-enter her cell, feel for a pulse and leave again.
Paramedics were not called for and Coltrain was left in the cell for another five hours until a Washoe County forensic technician arrived to begin processing the scene, the Gazette Journal reported.
The medical examiner who conducted Coltrain’s autopsy found heroin in her system, the family’s lawsuit said. Her death was classified as accidental, with the cause of death listed as “complications of drug use.”
Gulcynski told state investigators that he looked at Coltrain on the video monitor several times overnight, but thought she was sleeping. He did not perform a physical welfare check as required by jail policies, the Gazette Journal reported.
Holland told them that Coltrain “never looked good” and said he could not “force medical attention” on the inmates.
The lawsuit filed in Coltrain’s death states that Holland told investigators he did not recall if she had requested medical care. Coltrain’s mother, Carol Fesser, claims in the suit, however, that she called and talked to the sergeant July 20, the day after her daughter was booked.
“Good, I can get verification of this,” Holland said, according to Fesser. “Kelly stated she was drug dependent and had seizures, so she needed to go to the hospital.”
Fesser said she verified what her daughter had told the jailer, who said that was one reason they were keeping Coltrain under observation.
“Kelly had mentioned she might as well die,” Fesser claims Holland told her. “Kelly said she needed medical care. I explained to her we could take care of her since we have a fine medical facility.”
Fesser said Holland told her he has four daughters and promised to keep her daughter safe.
“Kelly will be taken good care of,” Holland said, according to the lawsuit.
Fesser told investigators that her daughter had also told her she should “just go kill herself” because she was arrested again.
"Carol stated Kelly's first words to her were, 'I never thought I'd call you from jail again, mom,'" the report said, according to the Houston Chronicle. "Kelly told Carol to just pack up their stuff because they were going to lose their apartment."
Rye told the Gazette Journal that he did not find any evidence that the deputies acted with malicious intent in their treatment of Coltrain. He said his review indicated that the deputies did not see any signs that the inmate needed medical intervention, based on their training as deputies.
The family’s lawsuit states, however, that “reasonably trained correctional policymakers and officers” are aware of the opioid epidemic in the United States and are “particularly attuned to patterns of heroin and opiate abuse due to the disproportionately high number of heroin and opiate abusers typically present in a correctional population.”
They were also aware of the risk of seizures and other symptoms of withdrawal from those drugs, the lawsuit states.
“(Deputies) 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,” her family’s lawyers, Terri Keyser-Cooper and Kerry Doyle, wrote in the suit. “Defendants knew Kelly Coltrain was in medical distress.”
The attorneys pointed out that the jail had no policy on what to do when an inmate is found unresponsive. They wrote that the deputies were “deliberately indifferent” to her medical needs, which caused her death.
“Kelly Coltrain’s medical condition was treatable and her death preventable,” the lawsuit states. “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.”
Earl seemed to agree in his report, pointing out that Coltrain might have been saved if Holland and Gulcynski had followed jail policies and made more contact with her in her cell, where they might have noticed the indications of withdrawal that were seen on the video.
“These indicators may have alerted staff, therefore prompting medical attention to be rendered to Coltrain,” Earl wrote, according to the lawsuit.
The Gazette Journal reported that county officials declined to say what, if any, discipline the deputies received following Coltrain's death. Holland has since retired early, with the county commission offering him a $17,853 buy-out in June that allowed him to retire with a bigger pension and better health care benefits, the newspaper said.
The lawsuit against those involved seeks compensation for Coltrain's death, as well as changes to the way people undergoing withdrawal in the jail are treated. Mineral County Attorney Brent Ryman told the Gazette Journal that those changes are already underway.
Coltrain’s family said in the lawsuit that despite struggling with addiction, she had been upbeat and happy during the family’s time together prior to her arrest. A massage therapist, she had hopes of going back to school and becoming a nurse.
“Kelly had a life of promise and potential,” the lawsuit states.
Her aunt, Catherine Wise, recalled the last few days with her niece for the Chronicle.
"We had gone on hikes, swam and relaxed by the lake together," Wise said. "Most importantly, we were able to hug, have a laugh and share the exciting things going on and plans for the future. I miss my niece's sweet laugh."
Coltrain’s high school friend, Katie Adreano, remembered her friend’s sweet spirit.
"She was so full of life, even in her deepest points of addiction," Adreano said. "She was someone you wanted to be around and the best friend you could ever ask for. She was my biggest cheerleader and I will miss her support and positivity for the rest of my life."