OGDEN — BreaAnn Carlin steadily lost weight during her nine-day stay in the Weber County Jail. At the end, she was dead, collapsed after crawling from a medical observation cell toward her scheduled shower.
Carlin was “gaunt, cheeks sunken, appeared to have aged tremendously,” a sheriff’s detective described in a report, having viewed the 26-year-old Plain City woman’s body in the initial moments of the death investigation.
“She looked nothing like her initial booking photo,” the detective said in his Weber County Sheriff’s Office investigative report.
Carlin was arrested late on the evening of Aug. 29, 2020, on a Harrisville misdemeanor shoplifting allegation. She was booked into the Ogden jail, also ordered held for failure to appear in at least two other Utah misdemeanor cases and on an extradition request from West Wendover, Nevada, according to jail records.
She died Sept. 7, succumbing to severe dehydration, according to her younger sister, Allyson Carlin of Tremonton, quoting from the Utah Office of the Medical Examiner autopsy report.
Allyson Carlin said a Sheriff’s Office news release at the time of her sister’s death was misleading. It said that the woman became unresponsive as jail personnel were helping her to the shower.
“She was not assisted,” Allyson Carlin said. “Basically she was observed crawling to the shower.”
With a public records request, the Standard-Examiner last week obtained copies of the investigator’s report plus those of other sheriff’s personnel and nurses for the jail’s medical contract provider, VitalCore Health Strategies.
Allyson Carlin said she saw the same reports and has talked to sheriff’s staff members. She said she believes her sister was mistreated.
Apparently, the older Carlin was withdrawing from narcotics.
“She was detoxing in jail and I guess they thought the whole idea was that she was just detoxing for the time she was in there,” Allyson Carlin said.
BreaAnn was “a free-spirited, very caring person who would do anything to help others,” her sister said.
CHRONOLOGY Individual reports by a VitalCore registered nurse and several jail corrections deputies said BreaAnn Carlin had to be coaxed to leave her cell to go take her scheduled shower.
At 10:22 a.m. Sept. 7, she had opened the door and was “lying on the floor, half in and half out,” the nurse wrote.
Carlin crawled on her hands and knees toward the shower door.
“She was moving her finger around the floor in circular motions,” the nurse said. Carlin then “crawled over to the entrance of the shower and leaned against the wall. She fell to her right and hit her head on the floor.”
It was 10:28 a.m. The nurse said she and a deputy agreed Carlin “should not shower herself and we should help her.”
Four minutes later, they had Carlin sitting on a chair in the shower, still clothed.
The nurse wrote that Carlin at that point “falls backward toward the wall. She does not hit her head. It is a controlled movement.”
In her report, the deputy there said Carlin did hit her head on the floor in that fall, but apparently any injury was minor.
At 10:34, the nurse noted the appearance of Carlin’s pupils was “concerning.” The pupils were “dilated and sluggish to respond” and her breathing was labored.
The nurse got equipment to check Carlin’s vital signs. The inmate vomited and the nurse said she had to hold the woman’s arm down because her body had become “very tense.”
At 10:37, the nurse left the shower to ask the VitalCore nurse practitioner for permission to have Carlin taken to a hospital. She began paperwork for the transfer then returned to the shower.
By then, Carlin was “pale, limp, and appeared unresponsive.” The nurse left again to grab an oxygen bag.
At 10:41 a.m., Carlin was moved to the floor, personnel begin resuscitation measures and paramedics were called. The individual reports said the efforts were complicated because Carlin was repeatedly vomiting during CPR.
Ogden Fire Department paramedics arrived at 10:54 a.m. Carlin was pronounced dead at 11:20 a.m.
SEIZURE, VOMITING According to deputies’ reports, Carlin had been vomiting regularly for at least two days. Reports said Carlin was seen by deputies trying to make herself vomit on at least two occasions.
A deputy reported on Sept. 5 that Carlin had been vomiting “all night on our shift.” The deputy called the medical unit.
“I stated that she had been vomiting and that her clothing and bedding had been changed several times.”
The deputy continued, “Medical asked me what she wanted. I told them that she had not asked for anything but that I was concerned about her constantly vomiting and they needed to decide what to do with her.”
Personnel then took Carlin to the medical unit for observation. It was the second time she had been taken there. On Aug. 31, Carlin slumped over in a hallway while being escorted to the medical wing for a regular visit. She had a seizure and was moved by wheelchair to the medical unit.
“It was decided that due to the extreme withdrawal symptoms as well as a large history of health problems that she would need to be kept for medical watch,” a deputy’s report said.
Another report, on Sept. 3, said nurses gave Carlin two bags of intravenous fluids “due to her coming down off drugs and being extremely dehydrated.”
Carlin was returned to a regular jail pod on Sept. 4. A report that day said she was “very pale and unsteady. They put her on an all-liquid diet.”
SHERIFF’S RESPONSE A Sheriff’s Office spokesperson declined to answer questions about Carlin’s health care, citing medical privacy laws.
He was asked why Carlin was not given IV fluids more often and whether hospitalization should have been considered sooner because she was losing weight every day.
If Carlin was inducing vomiting, why was there not more mental health intervention?
“When our staff realizes something, we report it and leave it to the professionals to see to the health care of the individual,” Lt. Joshua Marigoni said.
He said policies are extensively reviewed after every death in the jail and changes are made if needed. None were changed after Carlin’s death.
Carlin’s was the second drug withdrawal dehydration death in the Weber jail in five years. Marion Herrera, 40, of Ogden, died 3 1/2 days after her arrest on a check forgery allegation in May 2016.
Herrera was withdrawing from heroin. Her death — and 24 others in county jails around the state that year — resulted in legislative mandates for more study and resources for protecting drug-addicted inmates.
Herrera’s husband sued in federal court, but the case was dismissed.
“Every death in the jail is tragic and we feel for the families,” Marigoni said. “We do the best we can and we’re always trying to get better. That’s probably not much comfort to those who lose a loved one, but we are always working on it.”
‘STILL HUMAN’ Allyson Carlin said improvements are needed still, now that she’s learned some details of her sister’s last days.
“I want to make a change,” she said. “I don’t want other people to be treated like that in the medical unit.”
She added, “I am very heartbroken that she wasn’t assisted. That’s what they told us, but that is incorrect.”
People who go “down the wrong path,” Carlin said, “are still human. They deserve to be treated like it.”