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Utah Jail Nurse Faces Negligent Homicide Charge in Death of 21-Year-Old Woman

In 2016, Madison Jensen died from opiate withdrawal at the Duchesne County jail. New court filings allege that jail staff, including its nurse, ignored her rapidly deteriorating health.

Photo illustration by Kat Wawrykow. Photo from Getty Images.

A criminal case against a Utah jail nurse in the death of a 21-year-old woman has been revived after a state appellate court found that there was sufficient evidence that she “grossly deviated from the standard of care.” 

Jana Clyde now faces a negligent homicide charge in the case of Madison Jody Jensen, who died from dehydration at the Duchesne County jail in December 2016 after she went into opiate withdrawal and violently vomited and excreted diarrhea for four days. The Utah Court of Appeals decision reversed a lower court’s February 2018 dismissal of the case. 

The three-judge panel noted that evidence presented in a 2018 preliminary hearing represented Clyde’s “near complete indifference” toward Jensen that “grossly deviated from the standard of care for treating severe dehydration, especially when the result of a failure to treat is death.” The evidence described a care regimen that consisted of a single check of Madison’s blood pressure and a sports drink for dehydration. 

Clyde—along with the Duchesne County jail, its medical staff, and jailers—is also named as a defendant in a federal civil rights lawsuit filed by Jensen’s family in September 2018 for “deliberate indifference” to her medical needs. An amended complaint was filed on Feb. 15 and it details the final four days of her life, alleging that staff members refused to administer opiate medication and ignored her rapidly declining health. 

“Everything for my poor daughter went to crap on her,” Jensen’s father, Jared Jensen, told The Appeal. “Every wall that should have been there to save her life failed.”

On Nov. 27, 2016, Jensen was admitted to the 166-bed Duchesne County jail, about 100 miles southeast of Salt Lake City. Earlier that day, Jared said his daughter told him that she wanted to kill herself. In the days prior, he told The Appeal, she told him she had taken a hit of heroin and gone to the emergency room, where doctors gave her Clonidine, a blood pressure medication often used for acute opiate withdrawal symptoms, and then released her. Unable to reach the local counseling center, Jared called the Duchesne County Sheriff’s Department and told the dispatcher that his daughter threatened to die by suicide. He said he called the sheriff’s office because he had no other options: “There’s no place here to help people who have them problems.”

Boren sent a deputy to Jared’s house. There, according to Jared, the deputy called Duchesne County District Attorney Stephen Foote, who said the treatment center would only see Madison if it were court ordered. The Jensens said they reached an agreement with Foote that she would be taken into custody and appear before a judge the next morning so she would be seen by a treatment center.

(In an e-mail to The Appeal, Duchesne DA Foote wrote that “we are not going to make any statement regarding the case based on pending litigation. I will let you know that there was no agreement between myself or my office in regards to Madison’s incarceration. Further that we couldn’t make such an agreement to get her into any rehab center as we have no access to any rehab. Defendants in our courts that go into rehab do so on their own or through the state of Utah’s Department Of Corrections. Which couldn’t happen until the case was resolved and she would have had to be put on probation with them.”)

But first, they needed a reason to take Madison Jensen into custody and asked if she had anything illegal in the house. Jensen then produced a small piece of aluminum foil from her purse. The deputy said the foil qualified as drug paraphernalia. She also told him that she had used heroin four days earlier and was booked into the jail on a possession charge. Jensen told the deputy she was prescribed Tramadol, an opiate for pain related to endometriosis, Wellbutrin for anxiety and depression, and Clonidine for blood pressure. Users of Tramadol can experience withdrawal symptoms within 12 hours of their last dose, according to American Addiction Centers. These are often “flulike” and include vomiting, diarrhea, and loss of appetite. The deputy said that she would be able to take the medications to the jail with her, according to the family’s lawsuit. 

Due to conflicts with the judge’s schedule, Jensen’s court date was moved from Nov. 28  to Dec. 2. Court records show that Clyde told Logan Clark, a physicians’ assistant about Jensen’s medications. According to Clyde, Clark only approved the Clonidine. Clark said that Clyde never mentioned the other two medications. 

Jensen listed Tramadol on the medical intake form she filled out upon admission the jail; she also noted noting that she used heroin four days earlier. In an interview with state investigators, Clyde denied ever receiving the form; Elizabeth Richens, who was responsible for intake duties at the jail, insisted she left the form for her.

The next day, on Nov. 28, Jensen told Clyde that she felt unwell and had been vomiting. Clyde told her to save her vomit and diarrhea by not flushing the toilet—a request that Clyde said was standard practice—for observation and gave her a Gatorade. In the preliminary hearing, Clyde testified that upon seeing Jensen she thought, “Chick, you do some serious drugs and I know you’re lying to me.” In lieu of the Tramadol, Clyde offered Tylenol, Diamode (used to treat diarrhea), or ibuprofen, which Jensen declined to take. 

That same day, according to Jensen’s father, a sheriff’s deputy came to his house and told him that his daughter had stopped vomiting, and she was doing well and working with staff at the jail. But over the next two days, Jensen’s condition continued to deteriorate, according to the lawsuit. Her cellmate repeatedly pushed the call button to alert staff that she was ill, but one staffer allegedly told her to stop pushing the button because it was “interfering with jail staff’s duties.” Jensen declined her meals and was unable to keep liquids down, and at one point her request to shower after she excreted diarrhea on herself was refused. 

On Nov. 29, Jensen was moved to a medical observation cell, which was outfitted with surveillance cameras. Clyde told a jailer that she was moved because she was sick and “possibly had the stomach flu,” according to the federal complaint. Jensen was asked to fill out a form so that she could see physicians’ assistant Clark on Dec. 1 when he did his weekly rounds at the jail. Confused, she dated the form Dec. 31, and wrote that she had been “puking for 4 days straight, runs, can’t hold anything down not even water.” 

The next day, a jailer who saw Jensen told his wife that there was “a girl in the jail who was very sick and looked like she was going to die.” A total of three jailers alerted Clyde about Jensen’s condition, according to the lawsuit. In a June 1, 2017, interview, Clyde told investigators from the attorney general’s office that she wasn’t made aware of the seriousness of Jensen’s condition. “I didn’t get she’s throwing up. She’s having diarrhea,” she said. 

On Dec. 1, Clark arrived at the jail at around 9 a.m. Under Dr. Kennon Tubbs’s contract with the jail, Clark visited every Thursday to provide medical care. Tubbs, who has contracts with more than half a dozen Utah county jails, was responsible for overseeing medical care at the jail and sent Clark to see patients. Clark said that Clyde never gave him Jensen’s file or her request to see him, and he became aware of her condition just before he left the jail for the day, when Clyde told him that she was vomiting. Clyde, however, told investigators that she gave Clark the form that Jensen filled out. 

When Clyde and Clark arrived at Jensen’s cell around 1:30 p.m., she was dead. Video shows that Jensen was still alive that morning and then suffered a seizure and went limp at 12:56 p.m. A medical examiner determined that Jensen had lost 42 pounds during her four days at the jail and died of prolonged dehydration. At the time of her death, she weighed 87 pounds, he said. The examiner later testified that Jensen’s electrolytes results were “severely in the abnormal range” and indicative of “profound dehydration.” During the preliminary hearing in Clyde’s criminal case, a registered nurse testified that depending on other conditions, the dehydration could have been reversed with intravenous fluids “almost up to the time of death.” 

In September 2017, the Utah attorney general’s office filed a negligent homicide charge against Clyde, charging that she failed to provide the proper medical care that could have saved Jensen’s life. But Eighth District Judge Lyle Anderson dismissed the case in February 2018, ruling that there wasn’t enough evidence that Clyde had acted so poorly that the case should go to trial. 

Tubbs, Clark, and Clyde have all denied wrongdoing in Jensen’s case. In a July 11 hearing in federal court, attorneys for Tubbs and Clark argued for a dismissal of the cases against them and blamed Clyde for not properly notifying the pair about Jensen’s condition. The court ruled against them on July 22. But the family lawsuit also alleges that Tubbs and Clark failed to properly train Clyde to treat people who withdraw from opiates and suffer from dehydration. According to the lawsuit, Clark told jail staff that a person could not die from opiate withdrawal. 

Clark’s attorney, Kathleen Abke, told The Appeal in an email: “The allegations against Mr. Clark are unfounded and should be dismissed. Mr. Clark’s actions were entirely appropriate and in no way violated Ms. Jensen’s constitutional rights.”

Frank Mylar, Clyde’s attorney in the civil case, said his client didn’t know Jensen was at risk of death. “You have a situation here where nobody in jail population died of opiate withdrawal. That just didn’t happen,” he told The Appeal. “How can you fail to act when you don’t understand the significance of what’s going on?” He said Jensen’s death was “a tragedy” that “should not be laid at the feet of anyone involved.”  He added: “I think it’s just wrong as a matter of public policy to put officials that are trying to do a good job in a rural area [at risk of legal action], especially in this instance because there’s not very many medical people in rural areas.”

But opioid-related deaths have been common in county jails for years. In May 2015, Tyler Tabor died of opiate withdrawal due to dehydration at the Adams County Detention Center in Colorado, just one state east of Utah. Two months earlier, Jennifer Lobato died of heroin withdrawal at Colorado’s Jefferson County jail. And between 2013 and 2016, at least four people died at the Duchesne County jail. Three of those deaths were suicides. 

Tubbs and Clyde also face a federal lawsuit filed in November 2018 by the family of Tanna Jo Fillmore, a 25-year-old who died by suicide at the Duchesne County jail about one week before Jensen. The lawsuit alleges that Tubbs and Clyde ignored Fillmore’s desperate pleas for her psychiatric medications. According to the lawsuit, Clyde told Fillmore she wouldn’t give her medications because she was a “drug addict.” In a December interview, Tubbs told The Appeal that he wouldn’t have given her the drugs either because they were “not for suicidal behavior.” 

A trial date has not yet been set for either of the lawsuits in Jensen’s death, but her father hopes someone will be held accountable for her death.“I want somebody to stand up and say I done this to this girl and I’m sorry,” he said. “Somebody has to stand up and say they did something wrong. That’s all we have asked for ever.”