“Catastrophic systemic failures” at the Island County Jail led to a 25-year-old man’s death from dehydration April 8, Island County Sheriff Mark Brown said.

An exhaustive investigation by Detective Ed Wallace offers an unblinking look at how negligence and errors by both corrections deputies and jail administration contributed to Keaton Farris’ tragic death. The report was released today.

Two corrections deputies who falsified logs were placed on administrative leave and have since resigned. Lt. Pam McCarthy was placed on paid administrative leave pending a disciplinary review. Chief De Dennis, the jail administrator, was suspended for 30 days without pay and his continued employment is uncertain, Brown said.

Island County Coroner Robert Bishop reported that Farris died from dehydration, but malnutrition was a contributing factor.

Farris was suffering from mental health issues and had been both combative and non-responsive with jail staff in three different counties, Wallace’s report indicates.

Wallace 51-page report outlines a complicated series of missteps. The water to Farris’ cell in the Island County Jail was turned off for days because he put a pillow in the toilet at one point and later flooded his cell. He was given water during his meals but it was only a fraction of what was necessary to survive. The staff did not check on him as often as protocol dictated. The logs didn’t include necessary information and observations.

Medical staff wasn’t called to examine Farris until the day before he died and the nurse didn’t relate any concerns to jail staff.

“Once the nurse was notified she failed to do a proper evaluation of his condition even after Farris advised her that he was not doing well,” Wallace wrote.

The detective figured out that Corrections Deputies Mark Moffitt and David Lind had falsified their logs by comparing the entries to surveillance video.

The sheriff doesn’t excuse himself from blame. He said he failed in his supervisory role of the jail.

Brown said he immediately implemented changes at the 58-bed jail to ensure inmate safety and is planning on bringing in an expert in jail administration to do a comprehensive analysis of the facility, especially those confined to “safety cells.”

“I want to know why the problems were so glaring and why I didn’t see them,” he said.

Brown breaks down into tears when he talks about the death of the young man who once played high school football in Coupeville, the town where the sheriff’s office resides. Farris struggled with mental health issues after high school, but was remembered by friends and teachers as an athlete and a personable kid.

Brown said he brought Farris’ father into his office soon after the tragedy and had one of the most difficult conversations of his life.

“I promised him I would investigate this as if he were my own son,” he said, struggling with his emotions.

Brown said his mission is to find the truth, disseminate it to the public, repair the problems and — hopefully — regain the public trust while offering closure to Farris’ family. He said he doesn’t know if the family will sue and such an eventuality isn’t guiding his actions.

Brown concedes that larger issues are at play in the death, particularly how jails are ill equipped to deal with people with mental health issues. But at this point he said he’s focusing on the problems at his jail and what he can do to fix them.

Sgt. Chris Garden, a veteran member of the department with training in emergency medicine, has taken over as interim jail administrator.

Records from San Juan County Superior Court show that prosecutors charged Farris, a Lopez Island resident, with second-degree identity theft March 2 after a man reported that a check had been stolen, forged and cashed at a bank. A $10,000 warrant was issued for his arrest.

Lynnwood police picked him up on the warrant March 20. Officers responded to a report of a suspicious man at a bank. Farris told an officer that he was “off his meds” and that he was projecting his thoughts at people inside the bank, Wallace wrote.

Records from the Lynwood jail indicate that he had prescription Lorazepam when he arrived. Under a cooperative agreement between jails, he was transferred to Snohomish County jail, where staff members indicated in paperwork that he was “gravely disabled,” was presenting symptoms of psychosis and needed a mental health evaluation before leaving the jail. A “medical slip” of paper indicated that he tested positive for amphetamines, THC and Lorazepam and possibly suffered from bipolar disorder, Wallace wrote.

Farris was then transferred to Skagit County on March 24. He was originally supposed to be transferred the day before, but he apparently resisted and was Tasered in Snohomish County.

In Skagit, he was non-communicative and resisted jailers; he was placed is restraints. A Skagit official warned the Island County jail lieutenant that two corrections deputies would be needed to transport Farris because of his unpredictable behavior. The message wasn’t passed down and a lone Island County corrections deputy arrived but wasn’t able to transport him.

The San Juan Sheriff’s Office finally transported Farris to Island County on March 26. The Island County Jail holds inmates from San Juan County under an interagency contract.

Farris arrived without his medication or any of the medical and mental-health information that the other jails collected. Brown said he he doesn’t yet know what happened, but he hopes to work with the other agencies in the future to ensure such information is shared.

On March 27, Farris grabbed a corrections deputy by the hand and tried to pull him through the “feed slot” when the deputy was trying to give him water, the report states.

Farris was initially placed in a blue-padded safety cell but was moved to a single-person cell March 30. His cell was designated as a “safety cell,” which means heightened monitoring is required.

His water was turned off in his cell March 30 after he placed his pillow in the toilet and was “playing in the water in his sink,” Wallace wrote. It was turned off again when he flooded his cell on April 4.

In his investigation, Wallace estimated that Farris’ consumption of water and other fluids during his time at the jail to be about 185 ounces based on the the amount of liquid in the Dixie cups the jail uses. Under National Institute of Health guidelines, his intake should have been 1,563 ounces. FEMA guidelines state that 791 ounces would be necessary for survival in an emergency situation.

“The number could be lower since we cannot confirm that he consumed all the water/fluids provided,” Wallace wrote. “It could be higher as well since there were windows of opportunity where he would have been able to provide himself water.”

Farris’ inmate book states that he was supposed to be observed each hour, but the log showed long stretches of time in which nobody checked on him. The last time that a corrections deputy confirmed he was alive was at 5:30 p.m. on April 7. A deputy tapped on his door at 8:30 p.m., but Wallace wrote that it was likely he was dead at that time because of the lack of response and estimated time of death from the coroner.

Corrections deputies discovered that he was dead at 12:30 a.m. on April 8.

Wallace describes the confusion among the jail staff regarding policies and procedures. The jail administration was in the process of instituting the Lexipol manual concerning jail policies. The part of the manual regarding safety cells had been implemented, Brown said, but staff didn’t receive training and the information wasn’t adequately disseminated or explained.

Wallace details a series of instances in which the corrections deputies failed to follow the “safety cell procedures.”

He wrote that the Farris wasn’t offered fluids hourly, as required. A safety cell log wasn’t started immediately and was incomplete. Supervisors didn’t inspect the logs as required. The safety checks were not sufficient to assess the inmate’s well-being. The policy requires that his medical and mental-health status be assessed within 12 hours, but he wasn’t evaluated until his 11th day in custody.

Wallace also described confusion among jail staff about McCarthy’s alleged directive that the door to Farris’ cell should not be opened because of his combative history.

During his time in the cell, a corrections deputy observed Farris lying on his bunk with a piece of cloth in his mouth. He was concerned about the possibility of him choking and alerted McCarthy, who told him to leave Farris alone because of the possibility that he would assault a deputy.

The Sheriff’s Office contracts with Island County Public Health to provide a nurse at the jail four days a week. The nurse only interacted with him for two minutes and didn’t have a “hands on encounter.”