The late John Patrick Walter.
The late John Patrick Walter.
Estate of John Patrick Walter

Coroner: John Patrick Walter Died in Jail Because He Wasn't Given His Meds

Update: The conclusion of an amended autopsy report for John Patrick Walter, who died in Fremont County jail on April 20, 2014, has been changed from "undetermined" to acute withdrawal from benzodiazepine, a prescribed medication that was withheld from him by staff during his incarceration. The findings echo claims made in a lawsuit filed about Walter's death, and Erik Heipt, an attorney for his family, feels the results would have been known years ago if not for obstruction by Fremont County officials.

"We have alleged in this case that the Fremont County Sheriff's Office engaged in a coverup following the death of John Patrick Walter," Heipt says. "Because of that, the coroner's office was unable to determine the cause of death until now."

Our previous coverage of the Walter case, published in January, is on view below in its entirety. Also accessible are the two autopsy results from the El Paso County Coroner's office — the original analysis and an amended version whose "Final Diagnosis" begins like so:

1. Acute benziodiazepine withdrawal:

A. Decedent withdrawn from clonazepam without taper.

B. Extensive contusions, abrasions, rib fractures and right hemothoraz (50 ml) in the setting of reported history of multiple incidents of self-injurious and combative behaviors and multiple incidents of "Use by Force" by jail staff.

The doctor who penned the amended autopsy adds that the change in manner of death was made "to reflect new information provided to me in this case to include pharmacy records, medical records and deposition transcriptions including one stating that benzodiazepines were not administered despite written orders to taper the medication." However, the note adds, "The manner of death remains undetermined, as any intent behind not providing the medication taper is not clear."

In other words, the autopsy makes no determination about whether the withdrawal of the medication, shorthanded as "benzo," was done maliciously or through oversight, neglect, incompetence or an effort by Correct Care Solutions, the company with which Fremont County contracted for health care at the jail, to save money.  Whatever the case, Heipt argues that "had a law enforcement agency conducted a rudimentary death investigation, the coroner's office would have known all along about Mr. Walter's medication history, and that his medication was cut off abruptly without tapering, resulting in the symptoms that led up to his death."

Because that information wasn't initially provided, Heipt continues, "the medical examiner couldn't determine the cause of death. It took this civil-rights litigation to bring out the truth of what happened. Our belief when we first looked at this case was that John died of acute benzodiazepine withdrawal, and now we have official confirmation of that."

At this writing, Fremont County hasn't made a public offer to settle the lawsuit. But Heipt says, "From the perspective of the civil-rights case, this is a major development. And what happened to John is emblematic of what happens across the country in our county jails. Often pretrial detainees who haven't been convicted of a crime or even had their day in court are denied medications they need or see their often serious medical conditions go untreated — and they end up dead."

Click to read the amended John Patrick Walter autopsy report and the original version. Below, find our previous coverage.

"Atrocity": The Agonizing, Unnecessary, 18-Day Jail Death of John Patrick Walter
WEDNESDAY, JANUARY 25, 2017 AT 5:29 A.M.

The death of John Patrick Walter in Fremont County jail was absolutely unnecessary, according to a lawsuit filed by his family. The complaint contends that Walter was allowed to slowly, painfully expire as a result of withdrawal from a prescription medication by representatives of a private, for-profit company under contract to provide health-care services for inmates.

That includes those, like Walter, who had not been formally charged with a crime. He'd been taken into custody after getting into a fight with an acquaintance and couldn't afford to pay his bond.

The lawsuit, accessible below, contends that Walter died of withdrawal from benzodiazepine — "benzo" for short.

Patients who quit taking benzo immediately, rather than going through a medically supervised weaning process, can suffer from hallucinations and other psychic traumas that Erik Heipt, an attorney representing the Walter family, describes as a "mental horror movie." He dubs the resulting death of Walter after eighteen days of suffering an "atrocity" — one marked not by the proper treatment of his symptoms, but by punishment.

On multiple occasions, Walter was strapped into a restraint chair, where he was tased and pepper-sprayed over his histrionics. But he did even greater damage to himself, kicking and hurling himself against walls with such force that Heipt believes he broke several bones.

Clonazepam, the generic name for Klonopin, a popular benzodiazepine.
Clonazepam, the generic name for Klonopin, a popular benzodiazepine.
CBS4 file photo

Heipt's Seattle-based law firm, Budge and Heipt, filed the suit in U.S. District Court in Denver last year. Defendants include Correct Care Solutions, the corporation that was also named in a lawsuit filed by the family of Jennifer Lobato, who died of opioid withdrawal while in Jefferson County jail in 2015. Jeffco agreed to pay $2.5 million to settle the Lobato case, but the complaint against Correct Care Solutions was still pending at last report.

The Lobato case is one of several stories we've covered about jail deaths that allegedly resulted from inadequate medical care. Note also the experiences of Christopher Lopez, whose jailers joked and laughed as he slowly died (that matter was settled for $3 million), as well as the still-pending heroin-withdrawal-death lawsuit involving Tyler Tabor. And there are plenty more like it.

"We're working on eight jail-death cases in five different states right now," Heipt says. "We feel there's absolutely a major problem across the country, particularly in county jails, with pre-trial detainees who are being denied medical care or medications before they're even convicted of a crime. John's case is a perfect and egregious example of that and of how the public is kept in the dark about what's happening in our county jails."

Below, read Heipt's account of what happened to Walter, as culled from an extensive interview with Westword. That's followed by the video deposition of Fremont County Sheriff James Beicker and the lawsuit itself. Readers of the Denver Post's fine recent report about Colorado jail deaths more than doubling from 2011 to June 2015 — a piece that incorporated an account of what happened to Walter — will get much more information about this startling case. Those entirely unfamiliar with it may find many of the details disturbing.

The Fremont County Detention Center.
The Fremont County Detention Center.
Google Maps

"This incident happened back in April of 2014. John was arrested on April 2nd and was taken to the Fremont County Jail, which is in Cañon City. During his intake, he informed them that he was on some prescription medications, including, most significantly, Klonopin. It's generically known as Clonazepam and commonly referred to as being in a class of medication called benzodiazepines. They are anxiolytics, meaning that they're used to treat anxiety. They're also sometimes called sedative hypnotics, and they're prescribed to people with fairly severe anxiety disorders, seizure disorders or insomnia.

"Any medication in the benzodiazepine class is an addictive medication. If you take the medication long enough, you can become physiologically dependent on it. Often what happens is, someone is prescribed this medication, and after a period of time, that prescribed dosage doesn't have the same therapeutic effect. So the dosage is increased, and that sets off a chain of events where that person slowly increases the dosage to get the therapeutic benefit of it. But once that person becomes physiologically dependent on the medication, they're at risk of life-threatening withdrawal if they stop taking it. It's the same as if you're taking something like Xanax. You can't suddenly go cold turkey without risking your life — and ending the medication has to be done slowly, through a tapering regimen under the guidance of a qualified physician.

"The two most serious forms of withdrawal are alcohol and benzodiazepine withdrawal. With just about any other kind of narcotic or drug withdrawal you can think of, including opiate withdrawal, people in the medical community would say they're not directly life-threatening, because you're not going to die from the withdrawal itself. It's going to be extremely uncomfortable, but if your life is threatened, it's going to be collateral damage from things like dehydration, because you can't keep fluids down, for example. But alcohol and benzodiazepine withdrawal are directly life-threatening, which is why jails, and especially county jails, that are dealing with people who are being taken straight to jail absolutely have to screen people for them, just as they have to screen for any medication they're taking for things like epilepsy or a heart condition. If someone presents with a prescription of benzodiazepine, that person needs to be continued on the same dosage of the medication or be gradually tapered off that medication with another benzodiazepine .

"Fremont County does not do this. They have a practice of not continuing benzodiazepine prescriptions and making people who are benzodiazepine-dependent go cold turkey. And John wasn't someone just claiming that he was taking a certain medication. He had his medications with him, in his pocket, at the time of his arrest. He wasn't abusing street drugs. He was on prescriptions for Klonopin and also for methadone from his longtime medical provider. But at the time of his arrest, his medications were confiscated, and while they tapered him off his methadone, they totally and completely discontinued his Klonopin and didn't give him a substitute benzodiazepine.

"Following the discontinuance of Klonopin, the withdrawal typically peaks somewhere between two and three weeks, and there is nothing worse or more torturous than benzodiazepine withdrawal. Alcohol withdrawal is the only thing that can compare to it. Shaking, profuse sweating, an inability to eat or sleep, abnormal vital signs, gastrointestinal distress: In addition to all of these horrible symptoms, a person slowly loses touch with reality and begins going into a state of delirium or withdrawal psychosis. They will start hallucinating, and ultimately, they will go into seizures and die.

"Like many counties, Fremont County made the decision to contract out its jail medical services to a for-profit corporation. This is a corporate medical provider that has contracts throughout Colorado and also across the United States. They weren't there 24/7. Instead, they were there for twelve hours a day — not at night, but during the daytime. This is the company that made the decision to abruptly discontinue John's benzodiazepine prescription, and over the course of the next two weeks, he went through extreme withdrawal.

"At first, John was in a group pod, but because of his steadily declining health and his mental deterioration, he was moved out of that pod and into a single cell in the same pod. He was moved to that cell on April 14, and by then, he was no longer operating in a world of reality. He was profoundly anxious, severely agitated, disoriented, confused.

Attorney Erik Heipt.
Attorney Erik Heipt.
YouTube file photo

"At this point, it was literally a medical emergency, and in response to his mental-health crisis, which was brought about 100 percent due to the withdrawal, force was used on him. He was strapped into a restraint chair, he was pepper-sprayed, he was tased. He would be screaming or banging on the walls or saying incomprehensible stuff, and they'd tell him to knock it off and calm down. And when he wouldn't, they'd strap him into the restraint chair for several hours or pepper-spray him or tase him.

"Then, on the 15th, John was removed from that cell and brought to a holding cell in the booking area with a large, see-through window, so that everyone walking through the booking area for the next five days could see him at all times. Don't confuse this with some sort of medical unit. It was more of an observation cell where you might put a suicidal inmate you wanted to keep a close eye on. But the significance of this is the sheer number of people who saw him in his dire condition over the next five days. We're talking about more than twenty people over that period of time, and while he was in there, he didn't sleep, he didn't eat, he drank very little water, and for the vast majority of the time, he was completely naked.

"His medical condition was obvious and apparent for everyone to see, and he was growing weaker, suffering from severe malnutrition and dehydration. When he came into the jail, he weighed more than 200 pounds, and we believe that he lost between thirty and fifty pounds. And because he was hallucinating, he was banging on the walls, trying to get help because of the people who were inside his cell — people who weren't really there. He was in a mental horror movie during this time. He was acting very strangely, speaking nonsensically about events that didn't take place, was disoriented as to where he was and what month it was, and at times, he was rolling on the floor and yelling. At other times, he was shaking and probably seizing. And in addition to everything else he was going through, he had serious physical injuries that appear to have been self-inflicted — not because he was in a cogent state of mind trying to hurt himself, but because he was in this state of terrifying withdrawal psychosis.

"He would be banging and kicking on the walls and doors and trying to escape whatever was haunting him. And so he had visibly broken bones, at least as described by certain corrections officers. His toes, for example, were bruised and swollen. One of the defendants, Sarah Lightcap, said that new bruises would show up on his body every day, including a potentially broken bone on his foot and bruises on his hip. And in the autopsy report, they found at least nine broken ribs that couldn't be explained by doing CPR on him. Sometimes when people are doing CPR, they can break certain ribs on the front side. But as the medical examiner wrote in her autopsy, John had multiple broken ribs in his back that couldn't be attributed to resuscitation efforts after his heart stopped beating.

"This went on for days on end, and as he got worse and worse and worse, many corrections officers were extremely concerned about his deteriorating mental and physical health and thought he should be taken to the hospital — thought that his medical providers weren't doing enough for him. This went up the chain of command to sergeants, lieutenants, the commander of the jail, the undersheriff and all the way up to the longtime sheriff, James Beicker. These people would go to the corporate medical staff, but they weren't doing anything. Everyone was passing the buck to the medical providers, even though they knew the medical providers weren't doing their job, not effectively treating this person. No one was getting on the phone and calling 911.

"And don't get me started on the medical providers. They had the power from the get-go to prevent this medical crisis by either continuing John on his prescription or starting him on a cross-tolerant replacement benzodiazepine — and if they felt, for whatever reason, that they needed to discontinue the medication, they could have put him on a medically effective or safe tapering regimen. They knew what they were doing when they cut him off his medications — or if they didn't, it's a level of incompetence that would be unheard off. But the staff cut him off his medications and watched him descend into an extremely dire state of benzodiazepine withdrawal in which he was manifestly experiencing life-threatening symptoms — and they didn't arrange for hospital transport or do anything to reverse the withdrawal process. There's an off-site doctor who's one of the defendants in the case; I don't believe he ever showed up at the jail. But at one point, a nurse called him to describe John's condition, and the doctor's response on the phone was that they were doing everything they needed to do for his withdrawal.

Two milligram Clonazepam tablets.
Two milligram Clonazepam tablets.
United States National Library of Medicine file photo

"On the morning of April 20 — Easter Sunday — John was lying naked on the floor, twitching, shaking and convulsing. But even though multiple corrections officers and a nurse saw him on that final day, no one called 911 or arranged for him to be transported to the nearest hospital. In a report, one officer wrote that 'I could visibly see Inmate Walter laying underneath the sink.... He was laying on his right side with his hands shaking above his chest.' And later in the day, he observed that John was 'laying underneath the sink shaking as he normally does.' He was lying on the ground in the fetal position, shaking and jerking and twitching, but no one did anything. Then, on the evening of April 20, he was found dead in his cell.

"That part of the story was over. But there's an equally disturbing chapter two, which is what happened in the aftermath of this. And that chapter goes to the heart of why and how the public is often kept in the dark about deaths of pre-trial detainees in county jails. Because there was a coverup, a totally sham investigation.

"Their 'investigation' — and I'm putting that in quotes — culminated in between a five- and six-page document finding no impropriety. There were over twenty corrections-officer witnesses that went all the way up the chain of command to the sheriff. But the detective assigned to the case didn't interview any of them. There were multiple witnesses to his last five days in the observation cell, when he wasn't secluded by himself and there was a large window. Dozens of people saw him: other inmates, trustee inmates, inmates being booked. Yet no member of the Fremont Sheriff's Office was interviewed by this detective, who was also a member of the department.

"That's not all. No medical providers were interviewed for even five minutes. His medical records weren't looked at or analyzed. No video footage was looked at or analyzed. One inmate was interviewed, but it wasn't an inmate with information about the last five days of his life, when the withdrawal symptoms were peaking; it was someone who was in the group pod with him earlier. And the autopsy report listed the cause of death as undetermined.

"When someone dies of withdrawal, there are no physical markers left if you don't know the history. The medication history of the person is absolutely essential. But in this case, the medical examiner was not provided with anywhere remotely sufficient information from the jail to make the determination that John died of benzodiazepine withdrawal. The cause of death was somewhat of a mystery to her, which is why she said the cause of death was undetermined.

"So what do you do if you're a family member? What do you do if a member of your family goes into jail and you get word that he or she has died? You want answers. But you're told there's an ongoing investigation, and you're not given any information for months. Then you're told that the medical examiner has ruled that the cause of death was undetermined, and that's it. At that point, the vast majority of people do nothing, and the incident is swept under the rug.

Sheriff James Beicker, center, in a photo from the Fremont County Sheriffs Office Facebook page, is one of the defendants in the case.
Sheriff James Beicker, center, in a photo from the Fremont County Sheriffs Office Facebook page, is one of the defendants in the case.
Facebook

"In this case, the family didn't know what happened in the days and weeks leading up to John's death, but what they were told didn't sit right with them. They weren't given answers, they weren't given much information at all. So shortly before the statute of limitations was set to expire, they called us. They basically said, 'All we have is the autopsy and a few records from the jail: 23 pages of records.' They didn't even have the six-page investigation. Now, we field calls every week from family members of people who die in jails, and we often turn down the cases because we just don't see anything to firmly convince us that there's a legitimate constitutional violation or civil-rights case to pursue, even though there very well might be. But this was a case where we looked and, by a stroke of luck, someone just happened to notice some barely legible words on a report that said he'd gone into the jail on a prescription of Klonopin — and we knew right away that we were looking at benzodiazepine withdrawal. We were able to see that he'd been taking that medication for a long time, and taking it at a fairly high dosage. We couldn't tell from the records that they'd cut him off, but reading between the lines, we strongly suspected that they had. So we decided to take the case.

"We filed in March, and it wasn't until around November that the county finally terminated its contract with this corporate medical provider. Even without a thorough investigation, you would think that given the concerns of the sheriff, the undersheriff, the jail commander and many others over the treatment of this detainee and the medical provider not doing anything to help, and the detainee dying, they would have terminated the contract before then. But from April 2014 until November 2016, this same corporate medical provider was allowed to treat Colorado citizens detained in that jail. That strikes me as disturbing.

"When counties decide to contract away their jail health services, various for-profit corporate correctional health-care corporations will submit bids for how much they're going to charge for these services, and counties will invariably select the lowest bidder. These companies are operating on a pretty razor-thin margin in order to make any kind of profit because of the amount they've bid to run this jail medical-services contract, and as was the case in Fremont County, these corporate medical providers are responsible for the cost of outside hospital visits up to a certain amount — a cap within a designated time period. In this case, it was $50,000. Now, you can imagine, in a jail population that has hundreds of inmates coming in and out every year, how quickly that amount would be eaten up. These for-profit medical providers were also responsible for prescription medication costs, and there wasn't a cap on them. So every dollar they saved on that was another dollar in the pockets of these corporations.

"You can look at a case like John's and see it as one of pure cruelty. But you have to ask yourself, what was the motivation? Was it just a cruel, callous nurse — a sadistic person, you might say — who was motivated purely by a lack of humanity? Or was it something else? And if you're looking for other explanations, one of them is about money and choosing profits over people. It would have cost money to take John to the hospital. It would have cost money to give John his benzodiazepine prescription. If there had been no lawsuit filed — which came very close to happening — it wouldn't have cost them a dime. His death, a death that was clearly an atrocity, would have been free.

"This case is not about money for the family. It has been very important, extremely important for them to get answers. So rather than focusing our efforts on trying to enter into quick settlement negotiations, we've been focusing all of our efforts on doing the investigation that was never done and piecing together what happened. And that's what we're doing right now."

Click to see highlights from the videotaped deposition of Sheriff James Beicker, as well as the unedited version and the lawsuit itself.

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