John Patrick Walter, who suffered delusions and shed 30 pounds in less than three weeks before his April 2014 death at the Cañon City detention center, died of “acute benzodiazepine withdrawal,” according to an April 17 report by Dr. Emily Berry.

Walter, 53, brought his prescriptions with him to the jail upon being booked on suspicion of felony assault. 

Blood tests show he wasn’t provided his daily 6 mg dosage of Klonopin, even as his condition continued to deteriorate in a glass-walled observation cell in full view of numerous deputies.

“Decedent withdrawn from clonazepam without taper,” Berry wrote, referring to the generic name for Klonopin, which Walter had taken for years to manage anxiety.

The new finding bolsters allegations in an ongoing federal lawsuit that Walter’s nightmarish decline – previously documented by The Gazette in March 2016 and in follow-up reporting in December and last March – was the result of medical neglect.

It also raises new questions about the medical care provided to inmates by the jail’s former health care contractor Correct Care Solutions of Nashville, Tenn., a giant in the for-profit correctional health care industry formerly known as Correctional Healthcare Companies Inc. Fremont County terminated its contract with the company effective Jan. 1.

The forensic pathologist released her finding in a mid-April update to a 2014 autopsy in which she initially classified Walter’s death as “undetermined.”

She revised her opinion after reviewing newly obtained medical records and eyewitness accounts, she said in her report. Those materials were furnished by attorneys for Walter’s estate, who filed suit in U.S. District Court in Denver in March 2016.

The about-face by the El Paso County Coroner’s Office on the cause of Walter’s death came after a more than yearlong investigation in which attorneys for Walter’s estate pursued questions left unaddressed by the Fremont County sheriff’s death investigation.

A six-page sheriff’s report, previously obtained by the newspaper, shows that a detective failed to interview Walter’s medical providers and did not consult a list of prescriptions that Walter brought with him when he was booked into the facility, among other missteps.

“It goes to the core of our allegation that Fremont County engaged in a cover-up,” said Erik Heipt, an attorney on the case. “That made it nearly impossible for the (coroner’s office) to determine a cause of death. Now, through what’s been uncovered, they have been able to determine a cause of death, which is what we suspected it was when we first filed this case.”

Fremont County Sheriff Jim Beicker, deposed last fall for roughly seven hours as part of the case, acknowledged the report “could have been more thorough” but declined to investigate further. He admitted that the Sheriff’s Office did nothing to ensure policies and procedures were followed in Walter’s case.

Apparent missteps related to Walter’s death helped launch an ongoing citizen-led effort to recall Beicker from office.

Beicker and his spokeswoman, Sgt. Megan Richards, did not respond to a request for comment on the coroner’s revised finding.

Plaintiff’s attorneys say the county’s previous medical provider had a “blanket policy” of depriving benzodiazepines to inmates, even to those with valid prescriptions.

Such a policy “would violate every standard of care in the book,” said Ed Budge of Seattle, another of the attorneys on the lawsuit.

Benzodiazepines are commonly prescribed to combat anxiety. They include medications marketed under the names Xanax and Ativan. Although patients on small doses can experience discomfort when they try to quit, patients on high doses must be gradually weaned off them under medical supervision or face serious complications, including delusions and death.

Walter’s death shines a light on an issue that reverberates in jails and prisons across the country, said Stephen LaCorte of the Benzodiazepine Information Coalition, a fledgling nonprofit founded last year in Utah to draw attention to complications of using the drug.

“We think the fact that someone can be sent to prison and die from withdrawal is a story in and of itself, not to mention the multitude of people who have suffered a particularly debilitating and protracted illness from withdrawal,” LaCorte said in a written statement.

With opiate addiction dominating headlines in the United States, complications related to benzodiazepines have largely been ignored, he said.

The problem is particularly nettlesome because some people have little trouble weaning themselves off of benzodiazepines, while others report serious complications.

But the consequences of forcing inmates to go cold turkey is well understood by correctional health care providers, say attorneys for Walter’s estate. They cited a U.S. Bureau of Prisons detoxification guide for “chemically dependent inmates,” which recognizes the dangers of suddenly depriving inmates of their prescription benzodiazepines.

The document cites “the high risk of delirium, seizures and death” associated with sudden abstinence. “If left untreated, a delirium may develop with hallucinations, changes in consciousness, profound agitation, autonomic instability, seizures and death,” the guide says.

Those symptoms closely mirror observations of Walter’s behavior recorded by jail detention staff, according to reports and depositions reviewed by The Gazette.