Locked & Loaded | Cover Story | Salt Lake City Weekly

November 07, 2018 News » Cover Story

Locked & Loaded 

Inmate deaths plague Salt Lake County jail.

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  • Derek Carlisle

Inmate safety at Salt Lake County Jail isn't guaranteed, even for those incarcerated for minor infractions, such as DUI or possession of drug paraphernalia. They can be beaten to death, die by suicide or die in their cells of medical complications.

It's not the only jail with such problems, as inmate deaths plague lockups across the country. Still, Utah led the nation in per-capita jail deaths in 2016 with 24. That number dropped to seven in 2017, but four of those deaths occurred at the Salt Lake County Jail.

The facility is inundated by arrests throughout the county, particularly those for minor offenses, such as possession or sale of small amounts of drugs. Often, suspects are booked and released on the same day, or spend one or two days locked up. Annually, the Salt Lake County jail records some 36,000 bookings. Some defendants are booked into the jail more than once a year.

More serious offenders, about 18,000 annually, spend significant time behind bars. But the facility has only 2,200 beds, meaning there is significant turnover. On any day, more than 2,000 inmates are housed there.

Some are violent offenders. But most are convicted of non-violent crimes, such as burglary, theft, larceny or drug offenses. Many are drug users, who can arrive at the jail with health issues. Providing security, health and safety is a challenge, even with an annual budget of about $100 million.

The operation, critics say, is hampered by employee turnover and resulting staffing shortage, a culture that doesn't always put inmate well-being as the top priority and a health-care system that is less than perfect.

Among those dead are:


Scott Osterkamp, 32, died in his cell while serving a 62-day sentence for DUI. He contracted Hepatitis A at the jail and also suffered a broken arm after falling from his bunk. He went untreated and died of liver failure, despite his and his ex-wife's pleas for medical assistance.


Lisa Marie Ostler, 37, died of an abdominal infection after being jailed for possession of drug paraphernalia. She begged for medical aid as she lay dying in pain but was denied because the guards and medical personnel believed she was faking it—"gaming" the system.


Daniel Davis, 39, arrested after a domestic dispute, was beaten to death by another inmate as guards looked on. The assailant, a "unit worker" with special privileges, was being held on charges of aggravated assault before the deadly attack.


David Walker, 48, accused of child molestation, was said to have taken his own life. But for days leading up to his death, he told his mother over the phone that, "They are going to kill me. They are going to kill me." His accusers had already left the state and his Mazda Miata convertible disappeared at the same time. There is little information on the complainants or the car.

About half of Utah jail deaths are the result of suicide. The second-leading cause of death is illness.

Since 2005, 149 deaths have been reported in Utah county jails. (Not all deaths are reported.) But under state law, neither county jails nor the Utah State Prison can be held liable for "negligence" when inmates die.

In order for families to seek redress, they must demonstrate "deliberate indifference," which is an exceedingly difficult legal burden. In most cases, it cannot be met, according to the 1996 Utah Supreme Court case of Ross v. Shackel.

A dissenting opinion by Justice Daniel Stewart put it this way: "Incarcerated persons are not entitled to competent medical treatment and have no legal remedy for negligent treatment that may endanger one's health or life, unless the malpractice is either so extreme as to constitute 'cruel and unusual punishment' or is fraudulent or malicious," he wrote. "In effect, prisoners are treated as a subspecies of the human race who are not entitled to reasonable, competent medical care."

Further, Utah is one of 20 states that does not require jail inspections or independent oversight.

The lack of transparency makes it difficult to track the effectiveness of health-and-safety protocols, said Leah Farrell, staff attorney for the Utah affiliate of the American Civil Liberties Union. The outcome, she says, is that county jails lack accountability for inmate well-being.

Salt Lake County Sheriff Rosie Rivera oversees the jail. She was appointed to the position on Aug. 15, 2017, by the County Council after Sheriff Jim Winder resigned and became Moab's chief of police.

In interviews, Rivera, as well as veteran jail chief deputies Matt Dumont and Kevin Harris, contend the jail provides excellent health services, as well as mental-health care for inmates.

"They get better care here than they would in the hospital," Dumont says.

A significant number of inmates are drug and alcohol users who have health issues when they're booked, Dumont explains: "For some folks who come into the jail, this medical care is the only medical care they get."

Medical and mental-health care are accredited by the National Commission on Correctional Health Care, which recently audited the jail, Dumont says, adding the organization gave it a positive evaluation.

The well-being of inmates is the focus of the administration, the chief deputy adds. "We train all our staff to treat people with dignity and respect."

But according to families, as well as current and former jail employees, the systems can break down at times, with serious consequences. Beyond that, two insiders allege the culture among the deputy sheriffs who run the jail has become more callous in recent years, leading to a lack of compassion and humanity toward inmates. And family members contend they've been treated poorly when visiting, and later received only sketchy information about the deaths of their loved ones.


Tonya Brown-Osterkamp is a nurse who works at Intermountain Medical Center (IMC) in Murray, which treats inmates in critical condition. She and her late ex-husband, Scott Osterkamp, have two sons, ages 8 and 11. The couple remained close after their divorce and Tonya called or visited Scott daily while he was serving his 62-day sentence.

Over and over again, Scott and Tonya asked jail officials to provide him medical care, she explains. On numerous occasions, Tonya called the jail's nurse line and left messages, which never were answered. On Jan. 7, several days before his death, Tonya approached a deputy sheriff after visiting her ex-husband. "I told one of the guards that my husband is confused and is turning yellow and he's not getting any medical care. The guard said Scott might have to turn in multiple requests before getting seen."

On Jan. 10, she was told she couldn't visit Scott because he was in the infirmary. The following day, Tonya was at work when her mother called to say that deputies came to their house and said Scott was done with his sentence and they could pick up his belongings at the jail.

"I'm thinking, something is wrong," she recalls. "I called the operator at IMC and asked if Scott was in the hospital. They told me he was in shock-trauma. I immediately ran over there and he was on life support."

He was pronounced dead when he was removed from the respirator.

Tonya and her sons are traumatized from his death. "My kids are without a father," she laments. "I think it's horrible. The jail is inhumane. People in jail have rights. They are human beings."

Sheriff Rivera says she cannot comment on specific cases for various reasons, including that some remain under investigation and others are in litigation. But she contends that her staff treats the families of deceased inmates with courtesy and offers as much information as possible.

Every life is important, Dumont adds. "We don't want anyone to die—these are people," he says regarding inmates. "When something happens to anyone under our custody, our staff takes it personally."

The Salt Lake County Jail contracts with a private firm called Wellcon for medical services at a cost of $1.4 million annually. The county pays the firm an additional $735,000 for mental-health services. Wellcon did not respond to a request for an interview. But according to the company's website, "Dr. Todd R. Wilcox has served as the medical director of the Salt Lake County Jail System for 16 years. During his tenure, he has assisted Salt Lake County in transforming its health-care system into one of the most modern and technologically advanced correctional systems in the country."

Nurses are on duty 24/7 at the jail. Wellcon physicians make regular rounds during daytime and evening hours. Doctors are on call on a 24-hour basis. But insiders and inmate family members contend medical and mental-health care is sporadic, even when inmates display serious symptoms.

On March, 29, 2016, Lisa Marie Ostler, 37, was arrested for possession of drug paraphernalia but was not intoxicated when she was booked into jail, according to an intake exam. (Winder was then sheriff.) Ostler had suffered from Crohn's Disease, a serious gastrointestinal disorder. A decade earlier, she had undergone gastric bypass surgery to help alleviate symptoms. An autopsy revealed that her intestine began leaking into her abdomen at the site of the surgery.

Ostler began to complain of abdominal pain on the afternoon of April 1, 2016, according to a jail report. One inmate interviewed for this story said Ostler was in agony and crying out for help. Inmates around Ostler's cell began asking for assistance—each cell has an emergency button—only to be told: "Mind your own fucking business and shut the fuck up," by the guard on duty, according to her father, Cal Ostler.

The deputy apparently believed the inmate was going through heroin withdrawal, though her medical intake exam determined she was sober. Cal Ostler, a former investigator for the Utah State Medical Examiner, recently interviewed four inmates housed near his daughter. One told him that the guard said, "It feels like you're going to die, doesn't it?" At one point the deputy threatened to "write up" the woman for continuing to push the emergency button in her cell, Cal Ostler says.

Nurses on duty did not check her pulse, blood pressure or temperature, according to a lawsuit filed in federal court on behalf of Cal Ostler by attorney Rocky Anderson. Nurses on duty apparently did not inform physicians of Ostler's requests for help.

Shortly after 8 a.m. on April 2, she was found unresponsive in her cell and pronounced dead. Lisa Marie Ostler leaves three children, ages 7, 13 and 14.

Anybody believing their loved ones are safe in the Salt Lake County Jail is fooling themselves, Cal Ostler declares. "Your child is going to die in jail ... These aren't the Ted Bundys, these are kids who made mistakes."

Ostler's suit alleges deliberate indifference by guards, nurses and a doctor. The action also cites the deaths of inmates Carlos Umana, 20, Alexa Hamme, 25, Lindsey Goggin, 25 and Dustin Bliss, 29, who died in jail from health complications due to a lack of medical attention.

Many troubling health and safety issues at the jail are a direct result of a lack of effective leadership, according to a deputy sheriff, who spoke on the condition of anonymity. At best, working at the jail is a difficult job and many veteran deputies are leaving. More and more, the facility is staffed with relatively young and inexperienced jailers. New recruits, the deputy said, can be influenced by older colleagues who take an act-tough attitude when dealing with inmates.

Many staff members do not communicate with inmates in a civil manner, the deputy explains. Inmates react according to how they are treated. When they are bossed around or bullied, they can become angry, the deputy says.

"If you don't have a compassionate nature and aren't there to serve your community, you're not going to be happy there," the deputy believes.

Unlike times past, there's a dearth of positive reinforcement from jail administrators, the deputy complains. There was a time when "we felt valued. But the current administration treats us worse than the inmates. Everyone is scared to death of getting into trouble."

Families of deceased inmates say they have been treated poorly by jail staff. Among them are John and Deborah Walker, whose son, David Walker, 48, had been brain dead for 20 hours before jail personnel contacted them. On Sept. 6, they rushed to IMC where David was on life-support and shackled to a bed. Upon their arrival, a deputy sheriff told them they could not enter his room without an appointment.

"I said, my son is brain dead and I can't go in there to say goodbye? You've got to be kidding me," Deborah Walker recalls. She described the deputy as "callous and sneering."

After a phone call to a second attorney, who alerted county authorities, the Walkers were allowed to enter the room. "When we finally got in there, he was shackled on both legs and arms, as though he was a danger to someone," she says.

David Walker was arrested on June 19, after an 8-year-old girl who was staying in the house where he lived said he had touched her inappropriately. Walker was renting a room in the house where a woman and her daughter were visiting a relative who was the lease holder. He remained in jail pending a hearing but his accusers had left the state. His Mazda also had gone missing. Walker maintained his innocence, telling his mother, "I don't know what's going on."

Complicating matters, law enforcement authorities had confused David Walker with a man by the same name who had been convicted of aggravated assault in Indiana. The Utahn was mistakenly treated as a dangerous felon.

In telephone calls to his mother, David said he feared for his safety in jail, where he was known as a child molester. "He'd call me four times a day and say he was afraid of the inmates and the staff," Deborah Walker said. "He said they were going to kill him."


With each passing day, David Walker grew more desperate. On Sept. 4, he told his mother, "I don't know how this happened but they are going to kill me and this is fuckin' real." Two days later, the Walkers got a call from a lieutenant at the jail. "He said David has been transported [to IMC] and it doesn't look good," Deborah Walker says.

Jail officials say David Walker hanged himself with a bedsheet. The family, however, does not believe he took his own life. They have yet to receive autopsy results from the medical examiner.

"He didn't deserve to die," Deborah Walker says. "Nobody deserves for this to happen."

Mental-health care for jail inmates is lacking, says a former employee, who, fearing reprisals, spoke on the condition of anonymity. "We are therapists but we had no office and there is no therapy being done," the former employee says. "They only call us when someone is acting out."

Among the duties of the mental health-care workers is to distribute medications prescribed previously by personal physicians or doctors at the jail. "But inmates were not always given their meds," the therapist admits. "The refrain in the jail was that the inmates were gaming the system and would sell their drugs."

Jail policy forbids the use of some medications, including methadone, a replacement therapy for heroin addiction. In many cases, heroin addicts are left to go through painful and potentially harmful withdrawals.

Most people booked into the jail are not there for violent offenses. Many are charged with crimes somehow related to drug or alcohol use. But it also houses violent criminals.

Thirty nine-year-old Daniel Davis had a volatile, off-and-on relationship with his girlfriend. He was arrested July 15 after a domestic altercation—he had violated a court protective court order. Davis was incarcerated awaiting a hearing date when he was beaten to death Aug 4. After exchanging verbal barbs with another inmate, he was decked with a sucker punch, according to his mother, Judy Davis. The assailant then put his foot on the right shoulder of the prone inmate and punched him in the head 22 times. The assault was captured on the jail's video system. A guard responded with pepper spray but did not otherwise physically intervene, according to policy. The assailant was a "unit worker," given extra privileges for responsibilities inside the lockup.

Daniel Davis' sister, Ashlie McCracken, said the family was provided with few details following the attack. "They called me and said something has happened to your brother," McCracken said. "They told us he'd been released from all charges and we should go to the hospital and make some decisions."

Daniel Davis suffered traumatic brain injury. When his mother and sister arrived at the hospital, he had a tube in his head to drain fluid and was comatose. He soon succumbed to the injuries. He leaves a 10-year-old son.

Although Daniel Davis would verbally joust, he wasn't a fighter, his mother explains. "Daniel was more of a it's-not-worth-a-fight guy," she says. "What happened to my son—it felt like my heart was being ripped out."

McCracken wonders why the jail would have an inmate charged with assault acting as a unit worker. "Daniel is a victim. He didn't ask to be killed in jail," she says.

In an interview on Fox 13, Sheriff Rivera says Davis' death is an inherent risk of incarceration. "There are times when inmates are going to get in altercations," she explains.

Judy Davis finds the explanation hurtful and it leaves her angry. She wonders why the sheriff didn't accept any responsibility. "My goal is to expose the jail for how rotten they are," she says. "They should not treat families like this. Daniel was a son, father and uncle. The jail made him out to be a thug."

Todd Weiler, a Republican state legislator from Davis County, is pushing for better oversight of jails, but it's been a challenge to get such legislation passed, he says. It's important to have transparency and accountability, he adds.

But legislators feel little pressure to make changes because the general public is not concerned with inmate well-being and doesn't want more tax dollars spent on jails. Until Utah lawmakers determine that independent oversight could improve conditions and save lives, accountability will go wanting.

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