Davis jail death deemed natural, despite accusation woman wasn't given medicine

Friday , April 21, 2017 - 12:39 PM

MARK SHENEFELT, Standard-Examiner Staff

FARMINGTON — Kara Noakes, her family and her friends were worried about her going without prescription medications after she was arrested on a traffic warrant and taken to the Davis County Jail June 21, 2016.

Two days later, the 46-year-old was dead.

“Case closed as a natural death,” a Weber County Sheriff’s Office investigative report filed Jan. 23, 2017, says. The conclusion was included in 66 pages of Davis County documents obtained by the Standard-Examiner with an open-records request.

RELATED: The Standard-Examiner’s investigation into jail deaths in Northern Utah

RELATED: After death in Davis County Jail, family alleges inmate wasn't given medication

Amanda Cromwell, Noakes’ neighbor and best friend, says the Sunset woman’s death was the Davis jail’s fault.

“I can’t believe they’re saying that — natural causes,” Cromwell said Tuesday, disgust in her voice.

“She had a heart problem and took all of her prescriptions to the jail with her, but they wouldn’t let her take them in,” Cromwell said. “So it wasn’t natural causes. They caused it. If they had given her her meds, she probably would be alive today.”

Noakes was one of 15 people who have died in the Davis jail since 2005, contributing to Utah’s status as the nation’s leader in incarceration deaths per capita.

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But much remains unknown about Noakes’ death. Davis County officials heavily redacted details from reports that were released, citing federal medical privacy law and concerns about jail security.

It is not known whether the jail prescribed any medications for Noakes, and if so, whether she received and took any of them.

The Davis County Sheriff’s Office declined to comment during the investigation, and efforts to talk to Capt. Jen Daley, the acting department spokeswoman, were not immediately successful Wednesday.


In an interview after Noakes’ death, sheriff’s office spokeswoman Sgt. DeeAnn Servey said inmates are not allowed to bring their own medicines or get them delivered by a relative. The jail can’t tell whether the pills are what they seem to be, she said.

Jail nurses depend on the inmate to list their medications, an intake nurse said during an interview at the jail in July 2016. The nursing staff is supposed to verify prescriptions with the inmate’s doctor and pharmacy, then the jail doctor can write a prescription to be dispensed in jail. There’s an inevitable time lag, sometimes a day or two, the nurse said.

The U.S. Bureau of Justice Statistics says 40 percent of jail deaths happen to inmates who have been behind bars for less than a week.

To avoid a conflict of interest, Davis County referred the investigation into Noakes’ death to Weber County. A Weber sheriff’s investigator said in his report he interviewed guards and inmates, reviewed medical staff reports, Noakes’ medical records and a list of medications given.

In the records released to the Standard-Examiner, a copy of Noakes’ medication sheet from the jail listed no prescriptions.

Noakes’ family members said she was taking high blood pressure medicine, antidepressants and painkillers for back injuries suffered in a car crash.

Cromwell said Noakes and her three adult children were worried the woman could go into withdrawal if she didn’t have the pain medicine.

“Going into withdrawal could cause more stress on her heart,” Cromwell said Noakes told her once after visiting her doctor.

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Noakes was arriving home from giving a friend a ride to work when she was arrested by Sunset police for failure to appear on a citation for driving without a license. The Sunset officer was there after investigating a squabble between Noakes and a neighbor, and he ran her name through a police database, finding multiple warrants for failure to appear.

After Noakes was taken to jail, her family could not meet the $1,925 bail requirement to get her released.

The Weber detective reviewed recordings of numerous phone calls between Noakes and her relatives from June 21 to 23. They spoke about the bail problem and her need for medications.

“There was talk of outrage that Kara was not receiving her medication and being forced to ‘detox,’” the detective wrote.

He said a review of surveillance video shows Noakes went to the medical unit at 7:47 a.m. June 23, returning to her cell at 9:01 a.m. She was last seen entering her cell at 10:43 a.m. — about three hours before she was found unconscious.


The investigative reports portrayed a chaotic scene in the Kilo pod where Noakes died.

Noakes’ cellmate was sick, withdrawing from heroin, the report said. When jailers called in by speaker to tell Noakes to get ready for her video court appearance, she did not respond, and the cellmate got down from the top bunk to rouse her.

Noakes was cold and her face blue, the inmate noticed. She screamed for help. It was 1:48 p.m.

Jailers’ reports said an inmate on the ground floor heard the screams and rushed into the cell. She checked for breathing and pulse, found neither and began chest compression CPR.

“The paramedics walked in, and that’s when they said ‘Get downstairs,’” the inmate said in her handwritten report of the incident.

While sheriff’s personnel were moving Noakes from her bunk to the floor to continue CPR, her head hit the concrete floor, three individual staff reports said. Two nursing students who were in the jail for training were summoned to help with chest compressions until paramedics arrived, reports said.

An initial attempt to call for a Farmington ambulance and paramedics failed, one jail staff member said in his report.

“I tried calling for an ambulance and paramedics and was unsuccessful,” the report said. “I had someone else call for one.”

The reports don’t provide more detail about why the initial attempts failed.

After paramedics got to the cell, one called Davis Hospital and Medical Center to discuss the case. Soon after, resuscitation efforts were ended and Noakes was pronounced dead at 2:08 p.m.


The inmate who ran upstairs and started CPR later told the investigator said she had several conversations with Noakes during her two days in jail.

“She had been complaining of back and chest pain, and had been taken off her prescribed medications cold turkey,” the inmate said.

The Weber detective found no signs of foul play in Noakes’ death.

“Because it was unclear, I suggested to jail staff that this could be an overdose,” he wrote in his initial report. “I suggested they search the pod and have all inmates drug tested.”

Jailers later reported no drugs were found in the cell pod. Several inmates tested positive for illegal drugs, “but it is unclear whether the drugs were used prior to coming to jail or after,” the report said.

The case was closed in January after the Weber detective received autopsy and toxicology reports from the Utah Office of the Medical Examiner.

The natural causes were due to “atherosclerotic and hypertensive cardiovascular disease (high blood pressure and heart disease), and other significant conditions,” the detective’s report said. Those other conditions were redacted from the released investigative report.

Toxicology tests for methamphetamine and heroin were negative, the report said.


After Noakes’ death, the jail brought in mental health counselors for the 26 other inmates in Noakes’ cellblock. Many of the inmates were emotional or crying, and a few wrote down their thoughts for investigators.

“I was kind of watching out for her,” one said. “I was worried. She had told me of … all of the medications she was on that would not be administered to her. I felt this was wrong, being as some of her meds were to currently control her (redacted) to be taken daily. She could not just stop taking them. She could die if not given them.”

The inmate said she and Noakes went to church services the night before.

“She got a blessing after it was over. I asked her how she was feeling, and she said terrible. She told me she had a lot of pain in her back and going through to her chest.”

After Noakes’s body was taken away, her fellow inmates asked a guard what had happened.

“The officer said she had died of natural causes. A heart attack,” the inmate said.

You can reach reporter Mark Shenefelt at mshenefelt@standard.net or 801 625-4224. Follow him on Twitter at @mshenefelt and like him on Facebook

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