A lengthy lawsuit alleging the Garfield County Sheriff’s Office caused an inmate’s death by over-administering and mixing certain prescription drugs was filed in federal court Sunday.

On behalf of the estate of 19-year-old Oscar Canas, a Garfield County inmate who died on April 18, 2021 while in custody, the suit accuses Sheriff Lou Vallario, two deputies and the Garfield County Commission, as controllers of the Sheriff’s Office budget, of causing through various means Canas’ fatal drug toxicity by combining prescription drugs olanzapine and buprenorphine, while neglecting to check his well-being.

Olanzapine is a depressant used to treat methamphetamine-associated psychosis. On the flipside, buprenorphine — widely known as Suboxone — is used to treat opioid addiction. Medical standards maintain that any patient who is given both drugs be also administered bloodwork and an electrocardiogram, a measurement of any potential cardiac irregularities within the body.

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The civil action was filed by Maxted Law LLC’s David Maxted, a Denver-based civil rights attorney. In the official complaint, Maxted argues that not only was Canas never given an electrocardiogram or other Medication-Assisted Treatment (MAT) safety protocols by jail staff, correctional officers allegedly failed to act when Canas began exhibiting overdose symptoms in his cell.

“In November of 2021, several months after Mr. Canas entered the jail, medical staff, including Nurse Practitioner (“NP”) Joanna Kluender and other medical staff employed by private contractor Correctional Health Partners LLC (‘CHP’), prescribed Mr. Canas high doses of olanzapine for mental health symptoms he was experiencing,” the complaint states. “Olanzapine is a depressant well-known to cause side effects of cardiac arrhythmia, respiratory depression, and other symptoms which can result in death — particularly when combined with Suboxone.”

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“The County failed to ensure these and other MAT safety protocols were followed in its jail, and these failures killed Mr. Canas,” the complaint further states.

The Garfield County Sheriff’s Office reported in 2021 that Canas, already a father of two children, was arrested for violating a restraining order. Throughout his stay Canas went without any opiate use yet Kluender and CHP medical staff started him on a “dangerously high initial dose of Suboxone” even though “he was already on a high dosage of olanzapine,” the complaint states.

Upon his admission to Garfield County Jail in September 2020, Canas reported to staff that he was struggling with meth abuse as his primary substance use challenge. But he also did not request and was not admitted to any MAT treatment or any other medications for opiate dependency.

By November 2020, however, Canas requested mental health treatment after experiencing symptoms of anxiety, insomnia and more. On or near Nov. 20, 2020, Canas was prescribed his first 2.5-milligram dosage of olanzapine. By March 2021, Canas’ daily dosage of olanzapine had increased to 15mg, and it was at this point he had been taking the drug daily for five months.

On April 16, 2021, the complaint alleges that “in deliberate indifference to these deadly risks,” Kluender prescribed Canas Suboxone at multiple dosages of 8mg/2mg without “performing any of the necessary safety protocols.”

Maxted told the Post Independent on Monday that his office has reviewed all Garfield County Jail safety procedures — as well as video surveillance footage — through CORA requests and that “we see no indication that the jail had in place any safety protocols for MATs.”

In addition to administering what the complaint is referring to as a fatal drug cocktail, the complaint alleges that Garfield County Correctional officers Vanessa Bujanda and Michael Lathi, both on duty at the time, failed to adequately monitor Canas on the night of his death.

“This part of the lawsuit is directly against jail deputies,” Maxted said. “With these drugs, you have to monitor them to see how they respond. In jail, at least when this happens, that responsibility is going to fall to these deputies.”

The complaint states that Canas was housed at the time in isolation, in a single cell without a cellmate. No cameras monitored his safety inside his cell. His cell door was solid steel, without bars. A small window in the cell door allowed a visual into the cell. A food tray slot also allowed the ability to speak into the cell from the hallway. 

“In fact, written jail policies required that Defendants Bujanda and Lathi conduct random checks for the safety of persons in the jail, including Mr. Canas, at approximately 30-minute intervals,” the complaint states. “These safety checks were required, per written policy, to be ‘very thorough, spending enough time to fully inspect each individual cell to ensure the inmate is safe and the cell condition does not pose a safety hazard to the inmate or employees. Any issues or problems must be dealt with in a timely manner and/or a supervisor notified.'”

The complaint also alleges that Canas, while in his cell, started to suffer from respiratory depression, cardiac symptoms, early pneumonia and other symptoms of drug intoxication, while bleeding and foaming at the mouth, “as he died from the fatal drug cocktail prescribed to him by the jail.” 

Plaintiffs allege that Mr. Canas was experiencing these visible symptoms of obvious distress for hours prior, including at the times Defendants Bujanda and Lathi conducted their cell checks, which would tell any reasonable person he needed emergency help right away, throughout the night, the complaint states.

“During one cell check at about 1:47 a.m., Defendant Bujanda peered into Mr. Canas’s cell through the window at his door, and then began to turn away,” the complaint states. “As she turned her head and began to walk away to the next cell, Defendant Bujanda suddenly stopped and did a ‘double take’: she stopped, turned back toward Mr. Canas cell, looked into his cell a second time.” 

Plaintiffs allege that Defendant Bujanda did that because she observed signs of distress or cause for concern, the complaint states. However, in “deliberate indifference to Mr. Canas’s safety and life,” Defendant Bujanda did nothing to confirm Mr. Canas was safe, failed to attempt to speak to him or check his breathing, failed to open the cell door to check on him, and failed to take any other action to ensure he was safe.

It wasn’t until 4:30 a.m. that correctional officers and medical staff attended to Canas’ body.

“Had Defendant Bujanda acted on what she observed which caused her concern, and actually checked Mr. Canas’s well-being, the fatal drug interaction which was killing him that night through respiratory depression would have been interrupted, and his life saved through emergency medical care,” the complaint states. 

Maxted said Garfield County, Vallario and the two deputies are included in the lawsuit because they were directly responsible for Canas’ care. The subcontracted medical company CHP, however, is not being sued because they have already been receptive to questions.

“With the county jail, it doesn’t matter who they contract, the county is ultimately responsible,” he said. “Otherwise, jails can hire somebody and wipe their hands clean, which obviously would not be lawful.”

Maxted said Garfield County has so far refused to answer any inquiries put forth by Maxted Law LLC. The Post Independent reached out to Vallario for comment but has yet to hear back.

Maxted has specifically filed multiple claims for relief, which allege Garfield County and its staffers deprived Canas of various Federal and Colorado constitutional rights. The case is currently awaiting discovery and litigation.

“Based on an in-depth review of the records, we believe it’s a very strong case based on what we know,” Maxted said.

Maxted said jails around Colorado are unfortunately “black boxes,” and that people typically don’t know what’s going on within their walls, which is a crucial component of this case.

“This really was a preventable death,” Maxted said. “It should’ve never occurred.”