Report Released on Inmate Left to Die in Jail Cell

September 3, 2018 Updated: September 3, 2018

Nevada state authorities have released a 300-page report detailing how a 27-year-old woman held for overdue traffic tickets ended up dead in her jail cell.

According to the reports, Mineral County Jail personnel violated multiple policies when they denied the woman medical care, even though she informed them that she was withdrawing from addictive drugs and prone to seizures, the Reno Gazette-Journal reported.

The woman, Kelly Coltrain, eventually did have a seizure—a fatal seizure. Despite being in a video-monitored cell, it took more than six hours for anyone to notice that she wasn’t moving.

Then, when a Sheriff’s deputy finally realized something was wrong, he didn’t call for a medical team and didn’t try to resuscitate the woman. He left her until morning.

In their report, state investigators opined that the Mineral County Sheriff’s Office may have violated state laws prohibiting inhumane treatment of prisoners.

The case was submitted to Lyon County District Attorney Stephen Rye—it was not sent to the Mineral County prosecutor, to avoid potential conflict of interest.

District Attorney Rye declined to press charges, saying, “The review of the case, in our opinion, did not establish any willful or malicious acts by jail staff that would justify the filing of charges under the requirements of the statute,” according to the Gazette-Journal.

Kelly Coltrain died in a Nevada jail cell
Kelly Coltrain died in a Nevada jail cell while her jailers ignored her. (A family photo of Kelly Coltrain. Courtesy of Carole Fesser)

‘Medical distress’

Kelly Coltrain’s mother, father, and grandmother filed a wrongful death lawsuit on Aug. 29.

In the filing, lawyers Terri Keyser-Cooper and Kerry Doyle wrote: “Defendants knew Kelly Coltrain was in medical distress.”

Coltrain had been in the cell for several days. She told her jailers that she was withdrawing from addictive drugs, and was prone to seizures while withdrawing. She refused food, and vomited repeatedly.

Her jailers gave her a mop and told her to clean up her mess. She died about an hour later.

“Kelly Coltrain’s medical condition was treatable and her death preventable,” the complaint further stated.

“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.”

Terri Keyser-Cooper, who has a long history of successful civil rights lawsuits against Northern Nevada police agencies, told the Gazette-Journal, that Coltrain’s case was “the worst I have ever seen in 33 years. I’ve never seen anything like this.”

Mineral County Sheriff Randy Adams said he could not discuss details of an ongoing case, but that he had instituted an update of jail policy.

“Obviously it’s terribly unfortunate and it’s tragic,” Adams told the Gazette-Journal. “That’s really all I can say.”

Kelly Coltrain tries to mop up her own vomit
Kelly Coltrain tries to mop up her own vomit on orders from her jailer, Sergeant Jim Holland , despite being too sick to stand. (Mineral County Sheriff’s Office)

Death Sentence for Traffic Tickets

Kelly Coltrain lived in Texas but traveled to Nevada to help celebrate her grandmother’s 75th birthday.

Coltrain was pulled over for speeding on July 19, 2017, according to the investigation by the Nevada Division of Investigation, the Gazette-Journal reported.

Because she had other unpaid tickets on her record, the officer who stopped her took Coltrain to the Mineral County jail.

At first, Coltrain refused to answer questions about her next of kin or her medical history. However, when she was told that her bail would be higher than the cash she had available, Coltrain told mineral County Sheriff’s Sergeant Jim Holland that she was dependent on drugs and had a history of seizures when she went through withdrawals, according to the state report.

Also, according to the state’s report, Deputy Ray Gulcynski told Coltrain, “Unfortunately, since you’re DT’ing (detoxifying), I’m not going to take you over to the hospital right now just to get your fix.

“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.”

On July 22, 2017, according to the report, Coltrain began vomiting, trembling and “making short, convulsive type movements.”

Around 5 p.m. on July 22, Sergeant Holland brought Coltrain food, a clean jail uniform, and a mop, and ordered her to clean her cell. Coltrain stayed in bed and moped as best she could. Sergeant Holland pointed out places she had missed—she tried to reach those spots.

Sergeant Holland said he considered Coltrain to be “lazy” but not sick.

The report stated, “Sgt. Holland advised he thought Coltrain was just ‘lazy’ and that she just didn’t want to stand up to clean the floor.

“Sgt. Holland advised he just wanted the floor to be cleaned and he didn’t care how it got done, just that it got cleaned up.”

Kelly Coltrain lays motionless on her cot.
This still from Mineral County Jail surveillance video shows Deputy Ray Gulcynsk checking on Kelly Coltrain who is laying motionless on her cot. (Mineral County Sheriff’s Office)

Convulsions, Then Stillness

About an hour after Sergeant Holland left the cell, Coltrain can be seen on video going through continued convulsions for about half an hour. She stopped moving entirely at 6:26 p.m.

Coltrain lay in her cell until 12:30 a.m., when Deputy Ray Gulcynski came to move her to a different cell. He found her unresponsive. He nudged her with his boot, looked at her face, touched her arm, and left the cell.

He then returned and tried to find a pulse. He could not.

Coltrain lay in her cell until 5:48 a.m., when a Washoe County forensic technician arrived to deal with the body. Paramedics were never called, and no attempt was ever made to resuscitate Coltrain.

Also, jail policy requires jail personnel to physically check on inmates who are motionless under covers twice an hour.

In his report, state investigator Detective Damon Earl stated that had jail staff followed its own policies, the incident might not have ended so tragically.

“There were a limited number of times where Coltrain had actual contact with the staff,” Earl said in his report, according to the Gazette-Journal.

“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.”

Missing Video

According to the state report, the twenty-minute section of video, which included the time when Deputy Gulcynski found Coltrain unresponsive and tried to find a pulse, was removed from the video sent to the investigators.

The Sheriff’s department was responsible for supplying the edited video to the state investigators.

The missing segment of video, which establishes when jail personnel first learned that Coltrain needed medical assistance, did not turn up until the civil lawsuit was filed.

The missing video was included in the evidence the state turned over to the two lawyers filing the civil suit.


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