On Nov. 28, 2016, 21-year-old Madison Jensen was booked into Duchesne County Jail after her parents reported their daughter was suicidal and acting erratically. She told police she had done heroin days earlier and was in the process of detoxing.

From the time she was booked, Jensen’s condition was concerning. According to a state investigator report, Jensen was “very ill with both vomiting and diarrhea” on her first day in custody. The following day, a jail deputy noted that “[Jensen’s] condition was deteriorating.”

On Nov. 30, a deputy visited Jensen’s cell and observed she could not move from her bed. Still, the on-staff nurse, Jana Clyde, made no effort to assess Jensen’s condition.

Jensen begged for help; on Dec. 1, the last day of her life, she wrote on a medical request, “I know my bad and it is not [detoxing]. I am completely detoxed. My roomate [sic] caught the stomach bug … from me.”

By the time a medical examiner arrived to see Jensen later that day, it was too late. Four days after being booked into the Duchesne County jail, Jensen died from dehydration; she had lost 17 pounds, according to The Salt Lake Tribune.

Jared Jensen blames Clyde and Duchesne prison officials for his daughter’s death. On Sept. 25, 2017, Clyde was charged with negligent homicide for failing to intervene and possibly save Jensen’s life.

“I was waiting for this day,” Jensen’s father reacted. “The bottom line for me is that we’ve known all along. Duchesne County would not recognize at all the incompetence of their jail. They sat idly by and made our family sit here and wonder what’s wrong with the system.”

Needless Deaths

Jensen’s death was unnecessary; she died at the hands of incompetent and noncompliant state employees. Tragically, Jensen is not the only one to suffer such a fate. In 2014, the state ranked number one in the country for in-custody deaths.

In many cases, inmates die waiting for a mental health screening by the Utah State Hospital, one of the only hospitals in the state that treats inmates.

In late 2015, Matt Hall, a man diagnosed with schizophrenia, was arrested after knocking a taser away from an Ogden police officer.

For the next 15 months, Hall was held in Weber County Correctional Facility after a pair of psychiatrists and a judge ordered he be treated at Utah State Hospital before his trial could proceed.

As Hall waited for a hospital bed to open up, his condition worsened and he displayed disturbing behavior. Guards reported witnessing Hall strip naked and discard his clothes, throw food at inmates and pace around his cell for days at a time.

Hall never made it to the hospital. On Feb. 24, 2017, the schizophrenic inmate slammed his head against his concrete cell wall before climbing onto a handrail and diving off head-first. He was 31 years old.

A Deseret News investigation into Utah State Hospital found that Utah leads the Western region in average inmate wait time for treatment at the state psychiatric hospital. As of May, the wait is 149 days (about five months); in Colorado and Nevada, the waits are 17 and 16 days, respectively; in Idaho and Oregon, it is eight and six days; Arizona has no wait time.

John Snook, executive director of the Treatment Advocacy Center in Arlington, Virgina, told the Deseret News that budget cuts are to blame for unnecessary inmate deaths.

“It is a crisis of unimaginable proportions,” Snook said. “If more people were aware of just how awful this situation is, people would be up in arms.”

Faults With the System

But Hospital backlog is hardly the only thing leading to the deaths of Utah prisoners.

In March 2016, Jeffrey Ray Vigil, an inmate at Utah State Prison and member of the Ogden Trece gang, was ordered to be transferred to the Oquirrh 1, Section 2 housing unit — home of the rival Titanic Crip Society.

Knowing the danger her husband would be in, Vigil’s wife alleges in a federal lawsuit that she warned prison authorities and begged them not to place him in rival gang territory. They did not listen.

On March 14, Vigil was cornered by two Titanic Crip-affiliated inmates, Ramon Luis Rivera and Albert Collin Fernandez. As Fernandez prevented Vigil from escaping, Rivera stabbed and choked the rival gang member before stomping and kicking him more than 70 times. There were no guards around to break up the brutal attack which went on for eight minutes. Vigil died in the hospital the following day.

Why does Utah lead the nation in inmate deaths? Part of the answer may be a lack of transparency and public awareness of what happens in Utah jails and prisons. The prison standards for Utah were written by Gary DeLand, former director of the Utah Department of Corrections, who refuses to publicize his “playbook” out of fear that doing so will neutralize his techniques.

DeLand has defended inhumane corrections practices, including tying inmates to hitching posts. In the 2000s, he worked as a contractor for the Abu Ghraib prison in Iraq where American military officials tortured Iraqi prisoners. He has been named in hundreds of lawsuits, including one involving a mentally ill inmate who was kept naked in a solitary confinement cell without a bed or toilet.

DeLand now works with the Utah Sheriff’s Association as jail operations director.

“I ran the Department of Corrections and a jail, and right now I oversee about 26 jails,” DeLand bragged to The Salt Lake Tribune. “I’ve got a fair grasp of what goes on.”

For a state with low crime and unemployment rates, there is no justification for Utah leading the country in inmate deaths. Whether dying from dehydration, committing suicide while waiting for a mental health screening or being placed in rival gang territory, Utah inmates are dying at an alarming rate.

Prisoners are already deprived of a variety of rights. Convicted felons are unable to vote in local or national elections, purchase firearms or leave the country while on probation. There are enough consequences involved with getting wrapped up in the legal system without involving the possibility of death as a result of state negligence.

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