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Back-to-Back Jail Deaths Rock Small Utah County

Two women died at the Duchesne County Jail in the span of about one week in 2016. Now their families are suing in federal court.

Tanna Jo Fillmore (left) and Madison Jody JensenPhoto illustration by Anagraph. Photos via Starks Funeral Parlor (left) and Jared Jensen

On Nov. 23, 2016, Melany Zoumadakis received three distressed phone calls from her daughter, Tanna Jo Fillmore. She had been incarcerated in Utah’s Duchesne County Jail a little over a week and called Zoumadakis for days, each time sounding more fearful than the last. Fillmore told her mother she hadn’t taken her medication for her anxiety and attention-deficit/hyperactivity disorders because jail officials refused to give them to her.

A rodeo queen with a knack for reciting cowboy poetry, Fillmore loved riding horses and telling jokes. She had a history of mental illness but was improving just before she was locked up, largely because of her medications. During her calls from the jail, Fillmore begged her mother to bring them to her. On the final Nov. 23 call with Zoumadakis from the jail, Fillmore threatened to die by suicide and then abruptly hung up.  The next day, Fillmore was found hanging her in cell.

Between 2013 and 2016, at least four people died at the jail in Duchesne County, a tiny part of the state approximately 100 miles southeast of Salt Lake City that is home to only about 20,000 residents. Three of those deaths were suicides—the leading cause of death at Utah’s jails and jails across the country. This year, in late November, Fillmore’s family filed a civil rights lawsuit in federal court naming the county, two of its medical providers, and Duchesne County Sheriff David Boren as defendants. In The Fillmore lawsuit came just weeks after the family of Madison Jody Jensen, who died in 2016 from dehydration due to heroin withdrawal at the jail, filed an amended civil rights complaint in federal court. Zoumadakis said of Fillmore: “Her being gone at 25 years old is a pain that is not explainable. My daughter did not want to die.”

The Duchesne County Sheriff’s Department declined to comment, citing the ongoing litigation.

“They should treat people with love and respect…when they have people in the jail they’re human beings.”

On Nov. 15, 2016, Fillmore, who had just moved to Salt Lake City, was arrested there on a probation violation stemming from a misdemeanor drug charge in Duchesne County. The violation was for failing to call her probation officer, but she was booked into the Salt Lake County Jail and held overnight nonetheless.

The next day, Fillmore was moved to the Duchesne County jail where she told the booking clerk she was prescribed Xanax for anxiety and D-amphetamine sulfate for ADHD and also had post-traumatic stress disorder and major depressive disorder. Because she had previously been incarcerated there, her psychiatric records were already in the jail’s system. According to the lawsuit, Fillmore was then sent to her cell without ever being examined by the jail nurse, asked to sign a release so that personnel could obtain her medical records, or given her medications.

In addition, Zoumadakis, who is a registered nurse, repeatedly called her daughter’s probation officer, Steve Hooley, to warn him that she would destabilize if she was not given her medications. According to the lawsuit, Hooley assured Zoumadakis that he would inform the jail of her daughter’s psychiatric needs. But on Nov. 22, Fillmore had not received her medications, so she submitted a medical request form and met with jail nurse Jana Clyde. Clyde told Fillmore that she wouldn’t be provided with her medications because she was a “drug addict,” according to the lawsuit. Clyde did not respond to a request for comment from The Appeal.

As problems with Fillmore getting her prescriptions persisted, her phone calls to her mom sounded increasingly urgent—and hopeless. Zoumadakis pleaded with Hooley to tell the jailers to put Fillmore on suicide watch. “Hooley advised Zoumadakis that Fillmore had been placed in an observation cell,” according to the lawsuit, “and told her not to worry.”

On Nov. 24, Zoumadakis’s daughter Calley Clark gasped after receiving a Facebook message from a friend that her sister had died. Fillmore’s family told The Appeal that they learned of her death from Thanksgiving Day Facebook messages from people around town, rather than the sheriff’s office. “Even after she was dead they still didn’t even respect us,” Clark said. “We have to find out in this awful message on Facebook. She was already at the morgue being autopsied by the time we found out.”

Dr. Kennon Tubbs is responsible for the medical and mental health care of incarcerated people at the Duchesne County Jail. Under the contract, Tubbs or one of his physician assistants conduct sick calls on Thursdays and provides phone consultations as needed. Critics say the weekly visits fill the bare minimum of the constitutional requirement to provide medical care for inmates. “I think he does provide the care that he’s contracted to do, but he fashions the contracts in such a way that doesn’t meet the needs of the inmates,” said Zoumadakis’s attorney, Tyler Ayres.  

Tubbs, who has contracts with more than half a dozen Utah county jails and a 2016 deal with the Teton County Jail in Wyoming that netted him $200,000 per year, said jail officials never contacted him about Fillmore before her death. He added that he would not have given Fillmore her medications; he insisted that Xanax and ADHD medication D-amphetamine are “not for suicidal behavior.” ” Studies have found, however, that abruptly stopping the use of amphetamines is strongly associated with extreme dysphoria and suicidal ideation. Tubbs also argued that not much could have been done to save Fillmore because she only told her mother and not the jail’s medical staff that she would kill herself. “Suicide is not easily preventable,” he said. “The problem with suicide is a lot of times the patients who commit suicide don’t notify anyone.” Tubbs said that had he known that Fillmore threatened to die by suicide, he would have put her under 24-hour watch.

Zoumadakis alleges in the lawsuit that that jailers and medical staff were negligent when they failed to provide proper medical care to her sick daughter.  “They should treat people with love and respect and they should get them help no matter what they have to do,” she said. “When they have people in the jail they’re human beings.”

“Puking for 4 days straight, runs, diarrhea, can’t hold anything down not even water.”

On Dec. 1, 2016, not long after Fillmore’s death at the Duchesne County Jail, Madison Jody Jensen was found dead in her cell. When an investigator examined her emaciated body, he noted crusty pieces of vomit in her hair. She had been throwing up as she went through heroin withdrawal. Just days earlier, when she was booked at the jail, the 21-year-old, who stood at 5’11”, weighed 129 pounds; when she died, she weighed 112 pounds. The medical examiner later determined that Jensen died from dehydration due to opiate withdrawal.

Deaths from withdrawal are common in jails and prisons; in June, the ACLU sued Whatcom County, Washington, over its failure to provide access to medication-assisted treatment to incarcerated people with opioid use disorder, arguing that such policies violate the Americans with Disabilities Act.

Like Fillmore, Jensen was booked into the jail on minor charges—in her case, drug possession—and she also struggled with mental health issues. She told her father, Jared Jensen, that she had suicidal thoughts and her drug possession arrest stemmed from an argument between the two about her escalating drug use and mental health problems. When Jensen was arrested at her family home on Nov. 27, 2016, a Duchesne County Sheriff’s corporal told her that “jail would help her detox” and she would be free in a week, according to the lawsuit.  Jensen and her father also believed that she would go to drug court the next day and then be admitted to a treatment program. But because of conflicts with the judge’s schedule, her court date was moved from Monday to Friday.

Within 10 minutes of entering her cell, Jensen began vomiting and excreting diarrhea. The next day, she and her cellmate pressed the call button several times to ask for help but were simply told that the jail was aware that she was sick. At one point, Jensen vomited and defecated on herself. When she asked to take a shower, the jailer allegedly refused to allow her to do so.

Jensen continued to suffer and eventually filled out a medical request form. “Puking for 4 days straight, runs, diarrhea, can’t hold anything down not even water,” she wrote in late November 2016, dating the form Dec. 31 out of delirium. But she was not seen by Clyde, the nurse, and Dr. Tubbs said he was never contacted. Tubbs declined to comment on the matter because of a lawsuit filed this year by Jensen’s family. In 2017, the Utah attorney general’s office charged Clyde with negligent homicide in Jensen’s death. But last February, a Utah judge dismissed the case, ruling that there was not enough evidence to proceed.

On Sept. 20, Jensen’s family filed an amended civil rights complaint in federal court against Duchesne County, Sheriff Boren, Clyde, Tubbs, and others.

“I have a hard time reconciling the fact that a jail takes a person in knowing that they’re withdrawing from drugs,” Ryan Hancey, Jensen’s father’s attorney told The Appeal, “and in the course of the jail stay know that the person is exhibiting symptoms consistent with bad withdrawals … and still that inmate is allowed to die from dehydration of all things.”