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An attending nurse in the Davis County jail failed to do a routine blood-pressure check when 28-year-old Heather Ashton Miller fell almost 5 feet from her top bunk in late December, causing fatal internal injuries, newly released records show.
The severity of Miller's injuries, including a nearly severed spleen that led to her death a few hours after her fall, may have been detected earlier with a more thorough medical examination, indicate attorney general's office investigation records obtained by The Salt Lake Tribune through an open-records request.
Deputies in charge also didn't request that she be sent to the medical ward even after she showed signs of incoherency and couldn't walk.
She was instead sent to a cell with an open bottom bunk, where, unknown to anyone, her damaged spleen continued to pour blood into her abdomen until she was near death. The next time the jail's nurse saw her nearly three hours after the first medical check she "looked dead."
Jail staff chalked up Miller's strange behavior to drug withdrawal, documents from the investigation by Attorney General Sean Reyes' office show. The woman, who had moved to Utah two months before her death, had been arrested in Clearfield for possession of methamphetamine and heroin.
Eventually, "Once they arrived near the medical treatment area and nurse Marvin [Anderson] saw [Heather], he immediately remarked, 'We got to get her out of here,' " Sgt. Roberta Wall told investigators.
Miller first fell at about 5:55 p.m. Wall called dispatch at 8:43 p.m. Paramedics left with Miller at 8:58 p.m. She went into cardiac arrest en route to McKay-Dee Hospital in Ogden, where she was pronounced dead at 10:26 p.m.
After the first medical check, Miller was moved by wheelchair to a new cell, where deputies and inmates passing by peeked through her window and saw her as she moved from the bed to the floor, stripped off most of her clothing and descended to near death.
At about 8 p.m., a deputy called one of two nurses on staff at the time and told him Miller was lying on her back in her cell, was not fully clothed and had some blood on her chin. The deputy was told not to worry about Miller's condition, according to a clerk at the jail who heard the conversation.
Erik Christensen, the state's chief medical examiner, later told state investigators that the injured spleen attempted to heal itself by clotting.
"The severity of the injury made it impossible to clot completely," Christensen told investigators, according to the report. "Without medical care, the injury was fatal."
Civil rights attorney Rocky Anderson, who has been working with Miller's family, said "We're taking a very close look at" a lawsuit.
"I don't think there is any doubt there was utter neglect and a callous disregard of Heather's obvious medical needs. From its record of inmate deaths, that jail should be shut down and a major investigation conducted." Five inmates have died in the Davis County jail since June 2016, The Tribune found.
A.G.'s investigation • The report by Tyson Downey, an investigator in the attorney general's office, provides a more thorough look into the circumstances leading up to Miller's death.
The office had released only a terse statement April 28 notifying the public it wouldn't pursue criminal charges against anyone at the jail, which is run by Davis County Sheriff Todd Richardson.
Investigators weighed whether criminal negligence was involved in the case but didn't find enough evidence that would support a conviction at trial, the records show.
Weber County sheriff's investigation reports, previously obtained by the newspaper, revealed that investigators were upset that the two cells Miller occupied had been quickly cleaned up, destroying potential evidence, despite their status as crime scenes based on what is considered Miller's in-custody death. The attorney general's investigative report doesn't show whether Downey questioned staff about the quickly cleaned cells.
Richardson didn't respond to a request for comment Wednesday about the attorney general's report. A spokeswoman said last week the state's decision not to prosecute vindicated jail staff.
"In this case, it was found that there was no fault at the sheriff's office," Sgt. DeeAnn Servey, a spokeswoman for Richardson, said.
After Miller fell nearly 5 feet from her top bunk to the cell floor and then fell into a table when she tried to get up, the jail's nurse checked on Miller, who seemed fine on the outside and didn't show she was in pain when touched. Miller told staffers she was dizzy and having trouble walking. They decided to move her to a unit where she would be under closer scrutiny and helped her to the top of a stairway.
The "part that got weird," according to Austen Rogers, a clerk working in the jail that night, was when Miller had to "scooch on her butt" to get downstairs to a wheelchair awaiting her.
Rogers "said she couldn't stand or walk but 'they apparently didn't think she was fit for medical,' " the report says.
Had the nurse checked Miller's vital signs, including her blood pressure, he may have seen her blood pressure dropping, which could have indicated internal bleeding from her injury, according to another registered nurse who was working in the jail the night Miller died and the jail's nurse supervisor.
Falls from top bunks in the Davis County jail happen a few times a month, nurses said. When medical staff respond to requests for treatment, they "always do first responder things."
"If the person is walking around, they won't [call paramedics], but will check for vital signs and for injuries," the James Ondricek, the nurse supervisor, told investigators, according to the report. "When they check vitals, they check blood pressure, pulse and respirations."
Anderson, an 18-year corrections system nurse, later said he usually checks vitals after responding to inmate falls, "and he said he should have done it when he saw her," the report said.
"I asked James if it would be his expectation, as a supervisor, for a nurse to bring an inmate to medical or provide further observation if an inmate can't walk or if the inmate needs to be wheeled or carried out of a unit," the investigator wrote. "He said 'absolutely.' "