The number of people who died in Colorado's jails more than doubled in four years, following a national trend of a rising death toll among inmates in city and county jails across the country.
Jail deaths in Colorado grew from 11 inmates in 2011 to 24 in 2015, according to data compiled by The Denver Post. During the same period, Colorado's jail population declined.
Colorado does not require county jails to track their in-custody deaths, and there is no statewide reporting system. The federal government has a law instructing jails to report their in-custody deaths, but the number of Colorado counties that report the information annually is inconsistent.
Unlike prisons, jails often house suspects who have not been convicted of a crime, and sheriffs and their deputies are responsible not only for protecting the public from inmates but for keeping inmates safe — from themselves and others.
"These people are in public custody and when they're dying the public has a right to know: A) it's happening and B) why it's happening," said Eric Heipt, a Seattle lawyer who has sued jails across the country over inmate deaths, including in Colorado. "How can the public ask for change for injustices if they're kept in the dark about these things?"
After a series of deaths inside Front Range jails in early 2016, The Denver Post sent open-records requests to Colorado's 64 sheriffs in an attempt to answer the question of how many people die behind bars in Colorado's jails and why they die.
Experts suggested a variety of factors, including a heroin epidemic, jails filled with mentally ill people, inadequate training for deputies, private health care companies motivated by profits, and state and federal laws that have few requirements when it comes to protecting those who are incarcerated.
Those who follow criminal justice issues said if no one knows the basic information of how and why people die in jails, it is difficult to fix persistent problems with inmate care. In Colorado, county sheriffs are responsible for the jails and the inmates inside, most of whom are awaiting court hearings and have not been convicted of their charges.
Sheriffs and deputies interviewed by The Denver Post said they do their best to care for inmates, despite the challenges of mental health issues, addiction and an overall lack of health care many have experienced on the outside.
"We do everything possible so when you come in you don't leave worse than when you came in," said Jeff Goetz, jail division chief at the Boulder County Sheriff's Office. "When you have someone that dies on your shift, that's pretty significant. The people that work in here take it very personally. They're people under their watch that they're supposed to be caring for."
The analysis found 116 people died in jail between January 2010 and June 22, 2016. Of those, 58 died of medical or health issues and 48 died by suicide. Others had undetermined causes of death or died by homicide.
A death because of a medical issue can be deceiving. For example, the Arapahoe County Sheriff's Office reported that Jeffrey Lillis, 37, died of sepsis caused by bacterial pneumonia, but a lawsuit filed by his family in December says he died because the jail's medical staff denied care.
The Denver Post's open-records request asked for details such as age, race, gender, cause of death and booking date.
Eight counties do not operate jails — Cheyenne, Delores, Hinsdale, Kiowa, Mineral, Ouray, Phillips and San Juan. Archuleta County Sheriff Richard Valdez was the only sheriff in charge of a jail who did not respond to repeated attempts from The Post to release the information.
It's also possible some deaths are not reported by sheriffs because there is not a specific definition of "in-custody." And, sometimes, inmates who are sick or injured in jail are given a personal recognizance bond, and their deaths are not recorded as in-custody.
That's what happened in March 2016 to 41-year-old Joseph Jaramillo. He fell ill inside the Pueblo County Detention Center after being jailed on probation violations and a burglary charge. His family could not afford a cash bond.
While he was hospitalized in critical condition and on life support, he was given a personal recognizance bond and was released from custody. He died a day later.
"Why would he get a PR bond?" said his mother, Syliva Jaramillo. "It's because they don't want responsibility."
The federal Death in Custody Reporting Act of 2000 requires local jails to report in-custody deaths to the federal Bureau of Justice Statistics. But those statistics lag for several years.
In 2014, 56 jurisdictions in Colorado reported their jail deaths to the Bureau of Justice Statistics. Since 2000, when reporting became mandatory, the number of jurisdictions reporting has fluctuated between 50 and 56. The federal report does not break down jail deaths by county.
And the death numbers calculated by The Post, based on the sheriff's responses, did not always match statewide in-custody deaths reported to the federal government.
Here is what The Post's analysis found:
- 116 people died in custody during the 6 1/2-year period.
- Of those, 58 died of medical issues such as cancer, obesity and sleep apnea.
- Another 48 people took their own lives, most often hanging themselves with bed sheets in their jail cells.
- Fifty-three people died within a week of being booked.
- Twenty-four Hispanics died in custody.
- Twenty-four sheriffs reported zero jail deaths during the period analyzed by The Post.
- The Denver Sheriff Department, which operates two of the state's largest jails, was the only department to report in-custody deaths due to use-of-force. They had two during the past five years — Marvin Booker in 2010 and Michael Marshall in 2015.
- Adams County had the highest number of suicides (nine).
- Of the 48 people who committed suicide, at least 15 were in jail for sexual assault or domestic violence.
- Denver accounted for the highest number of deaths at 20. Adams County was second with 13.
The rising number of jail deaths in Colorado matches a national trend.
In 2014, 1,052 people died in jails across the United States, an 8 percent increase from 2013, according to the most recent data available from the U.S. Bureau of Justice Statistics.
Colorado's mortality rate inside jails was 164 per 100,000 inmates in 2014, according to the federal data. Eleven other states had higher jail inmate mortality rates that year.
Nationally, suicides are the leading cause of death in jails, the federal report said. Those increased 13 percent between 2013 and 2014 to 372 deaths.
Sheriff's department's have suicide protocols for their jails. Inmates should be questioned about their mental health at intake. Most jails have special cells and smocks for those who are suicidal, and deputies have instructions to monitor those who are at risk for killing themselves.
In Boulder County, deputies are trained on how to watch for signs of suicidal thoughts and behavior, Goetz said. Boulder County reported nine deaths; six were suicides.
"We try to assign our deputies to work in the same modules as much as possible because that builds relationships," Goetz said. "Inmates can come to a deputy and they build that rapport."
In Pueblo County, the sheriff recently hired a staff psychiatrist and created a "watcher" program that requires deputies to have a direct line of sight on suicidal inmates, Undersheriff J.R. Hall said.
The county's suicide rates have dropped and Hall credited the changes. But he also said an overcrowded jail also led to fewer deaths by suicide. Pueblo reported seven in-custody deaths. None were due to suicide, although one person's cause of death was not reported.
"It is very difficult to commit suicide with two other people in the room," Hall said. "On the other hand, being overcrowded and with mentally ill people is not ideal."
Training deputies to communicate with inmates is crucial.
"In the jails, how you communicate is your most effective tool," Hall said. "You might see an individual that becomes self-centered, not going to be talking to other folks, not purchasing commissary, not social networking and then mostly you see them just kind of withdraw. You have got to be able to go and ask them what's going on."
Most Colorado sheriffs contract with outside medical providers to care for the sick. The jails often are filled with the poor, the addicted and the mentally ill — all people who may not have regular health care coverage outside of incarceration.
"It's really a bad place to be sick," said Christie Donner, executive director of the Colorado Coalition for Criminal Justice Reform.
For Lillis, the Arapahoe County Detention Facility was the worst place to come down with pneumonia.
A married father of five children, Lillis died Dec. 14, 2014, of sepsis caused by untreated bacterial pneumonia after nurses failed to respond to his cries for help, a bloody cough and his increasingly dire vital signs, according to a lawsuit filed Dec. 12 in U.S. District Court in Denver.
Lillis' family has sued Arapahoe County and the private health care contractors who work inside the jail for "deliberately indifferent" care.
The lawsuit also blames the private health care company — Correct Care Solutions and its subsidiaries and business partners — that provides medical staff in jails across the country. Those companies often sacrifice quality care for high profits, the lawsuit said.
"The only medical care jails provide is Tylenol and Gatorade, and that's just not constitutional," said Erica Grossman, one of the attorneys representing Lillis' children in the lawsuit.
Arapahoe County Sheriff Dave Walcher and the health care companies declined comment.
Arapahoe County had 12 in-custody deaths. Five were due to suicide, and five were because of medical issues. One cause had not been determined, and another was a homicide.
Part of the problem with jail medical care is the medical staff inside a jail is not bound by the same legal standards as doctors who practice on the outside, said Denver civil rights attorney David Lane, who repeatedly has sued jails over inmate abuse and deaths.
A doctor who neglects a patient on the outside faces malpractice complaints and lawsuits. Not so for a medical staff treating inmates, he said.
"In a jail or a prison, you can be negligible all day long and there's no malpractice," Lane said. "They have to show ‘deliberate indifference.' Sometimes, their defense is, ‘Yes, we're idiots and we're negligent, but we're not malicious.' "
Chris Johnson, executive director of the County Sheriffs of Colorado, said most sheriffs run their jails under more stringent standards than what is set by state law. Rural counties rely on private health care providers because of limited medical resources in their communities.
Johnson said the rising number of jail deaths reflects the increasingly challenging situation sheriffs face in managing inmates, who often suffer from mental and physical illnesses.
"If anything, I think it's getting more and more challenging," he said.
Johnson blames the prevalence of heroin in Colorado as part of the problem.
"Have you ever seen anybody on heroin?" he said. "You don't stop being an addict when you come into jail. It's becoming more taxing on jail medical needs everywhere."
An inmate withdrawing from heroin often requires multiple visits to an emergency room and sick calls with medical staff inside a jail, Johnson said.
Lane, the Denver civil rights attorney, said heroin addiction is no excuse for people dying behind bars.
"All you need to do is keep these people hydrated," Lane said. "If you can't keep Gatorade down, you get an IV. It's simple."
For families who lose loved ones in a jail, questions always surface about what could have been done differently. Finding answers can prove difficult, in part because there are no laws in Colorado that require independent investigations into in-custody deaths.
On Easter Sunday in 2014, John Patrick Walter died naked on the floor of a cell in the Fremont County Jail with broken bones, bruises and internal bleeding. He weighed 30 pounds less than when he had been booked 18 days earlier.
A lawsuit filed against Fremont County and Correctional Healthcare Companies said Walter died of severe drug withdrawals after the jail staff and its health care provider failed to administer Klonopin, a strong anti-anxiety medication. Those who discontinue the drug cold turkey suffer from seizures, hallucinations and body tremors.
Walter, who grew up in an Air Force family with six siblings, had brushes with the law throughout his adult life. But when he was jailed April 3, 2014, on assault and menacing charges, no one in the family was aware, said his sister, Desiree Klodnicki.
Walter had brought two prescription bottles with him to the jail and listed his medications on a form during intake, the lawsuit said. As symptoms of Klonopin withdrawal worsened, Walter was unable to call them and was too ill to attend a court hearing to set a bond, she said.
Those symptoms include abnormal vital signs, weight loss, disturbed sleep, gastrointestinal distress, anxiety, mood swings, paranoia, hallucinations and seizures.
Walter lost control of his bladder and bowels and experienced seizures, the lawsuit said.
"Mr. Walter's psychotic break from reality was so profound that he was often heard screaming and seen kicking, punching and clawing at the walls and door in an apparent effort to escape imaginary people in his cell," the lawsuit said.
Klodnicki said she learned of Walter's death when their oldest brother called her while she was washing dishes the Monday after Easter. The family began asking questions.
But information was hard to come by as an investigation dragged for months, she said.
"I felt stonewalled," Klodnicki said. "No matter which way we turned for answers, they gave us none."
The family hired Budge & Heipt, a Seattle law firm that specializes in police brutality and civil rights. They filed suit in April and are asking for an unspecified amount in damages.
Sheriffs have an obligation to care for those in their custody, no matter their health conditions, Klodnicki said.
"Since they don't have their freedom, they're supposed to care for them medically, that's for sure," she said. "It probably was a simple fix if they would have given him his medication. This whole thing could have been avoided. It's sad. It's hard to put your mind around it."
Klodnicki is critical of Fremont County Sheriff Jim Beicker, whose office produced a six-page death investigation report on Walter. The sheriff's office never should have investigated itself, she said.
Beicker did not respond to repeated phone calls from The Denver Post. Fremont County reported two other deaths besides Walter. The others were because of natural causes.
But in a video-taped deposition, Beicker said he had relied on his deputies to conduct a thorough investigation in Walter's death. He admitted it could have been more thorough, and he said he had no plans to investigate policy violations committed by deputies or medical staff.
When asked what he had done to figure out why Walter died, Beicker answered, "Personally, nothing."
Klodnicki, who lives in Colorado Springs, believes the state needs to provide more oversight into investigations of in-custody deaths. It is wrong for a sheriff's office to investigate itself, she said.
Klodnicki also said it would be informative for the state to collect data so people could fully understand how their sheriffs were carrying out their duties.
"That would be helpful to the public to know, come election time, who is doing their job and who isn't," Klodnicki said.