Pulled over for speeding and booked into Mineral County Jail because of unpaid traffic tickets, 27-year-old Kelly Coltrain died days later from withdrawal symptoms after her requests for medical attention went ignored.

After a 13 month long investigation into Coltrain’s death, state investigators just released a 300-page report which described in detail the neglect suffered by Coltrain at the Mineral County Jail.

The state’s investigation found jailers violated policy by denying her medical attention and suggested the Mineral County District Attorney consider criminal charges. Lyon County took over the investigation to avoid a conflict of interest but ultimately refused to press charges. Coltrain’s family, however, disagrees and has filed a wrongful death lawsuit.

Arrested for Traffic Tickets

Originally based in Texas, Coltrain came to Reno and Lake Tahoe for her grandmother’s 75th birthday celebration. Following the party, traffic officers arrested her for speeding outside Hawthorne on July 19, 2017. The officers found Coltrain had outstanding traffic violations in Clark County, and so booked her into the Mineral County Jail.

At first, Coltrain would not say anything about her next of kin or medical history. But on learning she was not eligible for bail, Coltrain told Sgt. Jim Holland that she was drug dependent and prone to suffer terrible seizures during withdrawal.

Holland failed to adhere to jail policy which required that inmates with a history of seizures be cleared by a doctor before being remanded at the jail. Also in violation of policy, no jail employees closely watched Coltrain’s vitals as she went through withdrawals.

A surveillance video installed her in cell recorded everything that then would follow and lead to her death.

“When We Feel That Your Life Is At Risk…Then You Will Go To Hospital”

A few hours after landing at the jail, Coltrain pleaded with the night officer to go to a hospital because she needed immediate medication. The officer that night, Deputy Ray Gulcynski, told Coltrain he wouldn’t allow her visit the hospital since she was detoxing.

“Unfortunately, since you’re DT’ing (referring to the detoxification process), I’m not going to take you over to the hospital right now just to get your fix,” Gulcynski told Coltrain. “That’s not the way detention works, unfortunately. You are incarcerated with us, so … you don’t get to go to the hospital when you want. When we feel that your life is at risk… then you will go.”

Over the next three days Coltrain became very sick and could not eat, barely drank water and spent almost all of her time curled up in a fetal position under her blankets.

On the morning of the third day, things got even worse for Coltrain and she began vomiting, trembling and making short convulsive like movements.

A little after 5 p.m. that evening, Holland brought her some food but Coltrain could only eat a few bites despite him urging her to eat. Then the officer saw that Coltrain had vomited and soiled her prison uniform. He brought her another uniform and a mop, asking her to clean her vomit – according to a video recording of events in her cell.

Coltrain was too weak to mop her vomit, but managed to do so with one hand while remaining seated on her bed. Holland who said later he thought she was just being lazy, forced her to clean up other spots on the floor even though she was barely able to move.

By 6:30 p.m. that evening, Coltrain was dead in her cell. Despite the live video feed of Coltrain’s cell, no one entered again until Gulcynski arrived at 12:30 a.m. to move her to a different cell. Instead, he found her completely unresponsive after kicking her lightly with his foot. He ventured further into her cell and touched her gently before quickly leaving.

Gulcynski says he informed his superiors that Coltrain was cold and appeared dead. Video shows him going back into her cell to check for a pulse and then leaving again. Noone called for paramedics upon finding her unresponsive in her cell.

Coltrain was left in her cell until around 6 a.m. when a forensic technician from Washoe County arrived to begin an investigation. The Washoe County Medical Examiner called Coltrain’s death accidental and caused by “complications of drug use.” Toxicology results showed she had heroin in her system.

Jailers Violated Prison Policy, but No Charges Pressed

Prison policy dictates that officers must visit inmates twice every hour if they are lying under blankets, but Gulcynski and the other jailers never did this. Gulcynski said he watched Coltrain from the video monitor and thought she was asleep the night she died.

According to a Reno Gazette report, Holland told state investigators that Coltrain “never looked good,” but that he couldn’t “force medical attention” on inmates.

Detective Damon Earl, the state investigator for the case, noted that had Gulcynski and Holland adhered to some of the jail’s policies Coltrain likely would not have died.

“There were a limited number of times where Coltrain had actual contact with the staff,” Earl wrote. “This may be significant because had more contact been made with Coltrain, indicators of Kelly’s medical condition may have been observed. These indicators may have alerted staff therefore prompting medical attention to be rendered to Coltrain.”

Despite state investigators determining that deputies violated several policies in regard to Coltrain’s medical needs, the District Attorneys for both Mineral County and Lyon County refused to press charges. After jurisdiction was given to Lyon County, the D.A. determined officials did not commit any willful or malicious.

“Based on my review, they did not notice any signs warranting any medical intervention based on their training or experience,” the Lyon County D.A. said. “They were provided information related to her, and it appeared to me that was taken into account in her housing and monitoring. The officers did not ignore information provided to them. And, based on the reports by NDI, it did not appear that they exhibited any cruel, oppressive or malicious treatment.”

But Coltrain’s family is filing a lawsuit for wrongful death. Terri Keyser-Cooper and Kerry Doyle, both lawyers, are representing the family in the litigation.

“Defendants knew Kelly Coltrain was in medical distress,” the lawyers wrote. “Kelly Coltrain’s medical condition was treatable and her death preventable. If Ms. Coltrain had received timely and appropriate medical care, she would not have died. Kelly Coltrain suffered a protracted, extensive, painful, unnecessary death as a result of defendants’ failures.”

A Bonus and Early Retirement for Officials Responsible for Kelly Coltrain’s Death

The family’s lawsuit claims that both Holland and Gulcynski were disciplined but Holland opted for early retirement.

Then last June, Mineral County voted to give Holland an additional year towards his service and granted him $17,853. According to the Reno Gazette, that decision allowed Holland to retire with a higher annual pension and health care benefits than he would have received otherwise.

Meanwhile, the family’s lawyers said they would not settle for compensation only and that they wanted a guarantee of an improvement in the conditions at the jail.

During the whole ordeal, a hospital was just across the street from the jail and Coltrain. Detective Earl timed his walk from the jail to the hospital and said it took “a little over two minutes.”

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