Susan Kiscoan refused to leave a doctor’s clinic just north of downtown on Sept. 14, 2017.

After directing her to get out several times, Omaha police arrested her for trespassing — a misdemeanor that typically results in a $25 fine or a day in jail.

For Kiscoan, it effectively became a death sentence.

Over the next two weeks, the schizophrenic 45-year-old Omaha woman sat in jail, sometimes desperate, sometimes defiant, sometimes despondent.

No one from the Douglas County Jail attempted to seek hospitalization for her ongoing physical and mental issues. Jail medical staff also apparently didn’t provide her with any of her medicine for the last three days of her life, according to a sheriff’s summary.

Upon her entrance to jail, a deputy Douglas County attorney declined to file a petition to force her into the hospital because it didn’t appear she was a danger to herself or others — the standard for a hospital commitment under state law. The county attorney then didn’t receive much more information about her.

A public defender tried to see her two times, only to have the request refused.

And the 45-year-old Omaha woman may have declined the opportunity to plead to the infraction and get out the day of her first appearance, as is typically the case in trespassing cases.

All of those choices added up to this: Kiscoan — awaiting her day in court for trespassing — died in her cell  from Addison’s disease, a rare condition that jail officials knew she had.

“Susan had been very sick since day one,” one of her fellow inmates, Lorena Contreras, wrote in a letter to The World-Herald. “She had been vomiting, and defecating all over herself for days. ... Susan (at times) wasn’t even capable of standing up on her own. Many inmates would plead to the staff to give her medical treatment because she was clearly not well.

“Susan’s death could have been avoided. (She) died because she wasn’t given proper medical attention.”

Last week, a grand jury essentially agreed. Reviewing her in-custody death as part of their duty under state law, grand jurors didn’t charge anyone with a crime.

But they did take the rare step of issuing a report, calling on the Douglas County Jail and its medical provider, Correct Care Solutions, to provide “additional training on all health issues especially deteriorating ones”; to “make more detailed documentation and communication on health issues”; and to “implement a policy on when an inmate requires hospitalization.”

“Grand jury is concerned about the lack of medical and mental health resources at the Douglas County Correctional Center,” the report concluded.

Michael Myers, who takes over Monday as the Douglas County Jail director, declined to comment on the grand jury’s recommendations “because of ongoing litigation.”

Kiscoan’s parents, Lorraine Duggin and Jack Kiscoan, have filed a wrongful death claim with the county — seeking $2 million.

The litigation comes on the heels of at least 13 lawsuits against Douglas County over inmates’ claims that the county’s medical provider, Correct Care Solutions, failed to properly treat them.

Douglas County Attorney Don Kleine and Public Defender Tom Riley — whose offices both were involved in the case — said the Kiscoan case is tragic confirmation of a former jail director’s declaration that, on any given day, the Douglas County Jail may be the biggest collection of mentally ill patients in the city.

“At one time, 30 or 40 years ago, people used to get committed and put in a mental health facility for indeterminate amounts of time. We’ve gotten away from that, which is a good thing,” Kleine said. “But I’m afraid that when people (act out) now, they’re put in a criminal justice system that is not set up to treat their mental health needs.”

Kiscoan’s case seems to fit that pattern.

According to court documents, Douglas County sheriff’s reports and interviews with authorities involved in the case:

Though suffering from schizophrenia, Kiscoan was an “extremely intelligent, high-functioning” woman who held down several jobs, according to one person assigned to her case. She graduated from college with distinction and spoke three languages.

Her mental illness seemed to further deteriorate as she endured the effects of Addison’s disease, an affliction that attacks the adrenal glands and can lead to fatigue and rapid weight loss.

On Sept. 14, 2017, she was staying at the Lydia House, an emergency shelter for women. A case worker there reported to county officials that she was taking her medicine for Addison’s disease but refusing to take her medication for schizophrenia. The case worker said they did a test for illegal drugs, but it was negative.

County officials didn’t see enough evidence to try to forcibly hospitalize her at that point.

An hour or so later, Kiscoan was at the CHI Health Clinic at 24th and Cuming Streets. She was “asked to leave the property after refusing medical attention.” Omaha police arrived and ordered her to leave multiple times. She refused. They arrested her.

At 4:49 p.m., she was booked into the Douglas County Jail.

A half-hour later, jail officials tried to interview her as they assessed placement. She refused to sign a classification sheet, though she did allow her medical records to be released to Correct Care Solutions.

On Sept. 15, Kiscoan wrote on an inmate kite — an informal request form — that she suffered from Addison’s disease and listed two medications she needed for it. A doctor authorized her to receive one of the medications — once in the morning and once in the evening. The doctor gave her the other medication three days later.

On the morning of Sept. 18, Kristin Huber, a deputy county attorney, left a message with Kim Potter, the former supervisor of the mental health unit at the jail, telling her that Kiscoan had, off and on, been a mental health board commitment since 2012. Huber asked Potter to keep her informed of Kiscoan’s behavior in jail.

After starting in general population, Kiscoan was moved to the infirmary.

About 1 p.m. Sept. 18, a mental health professional noted that “Kiscoan has been soiling herself and stating that she (is) paralyzed.” Potter emailed that account to Huber.

Kiscoan also told nurses that she was concerned she was “taking the wrong (dose) of medication.”

“I could die,” she said.

The mental health professional noted that Kiscoan had been diagnosed with schizophrenia. She recommended that Kiscoan be scheduled for a mental health follow-up.

Douglas County Sheriff’s Lt. William Rinn, who investigated her death, detailed the last 10 days of her life.

By the morning of Sept. 19, Kiscoan was lethargic, her blood pressure had dropped and her words were slurred. Dr. Jacqueline Esch ordered an IV, but a nurse couldn’t tap a vein. They encouraged Kiscoan to drink more fluids. Kiscoan ate half of her lunch and drank a Gatorade.

At 9:50 a.m. Sept. 20: Kiscoan told Potter that she needed to go to the hospital because her legs were weak. Kiscoan denied any mental illness and said she wasn’t interested in receiving mental therapy.

At 3:38 p.m. Sept. 21: Kiscoan was uncooperative with staff, stated she couldn’t walk. She refused to sit up and talk. She accused a nurse of “rewiring her brain” and demanded that the nurse leave.

At 3 a.m. Sept. 22: Kiscoan was crawling around on the floor. Staff found her under her bed and she said there were drones in her bed “watching her.” A nurse convinced her she was safe — and Kiscoan eventually crawled back into bed and went to sleep.

Over the next two days, she bounced back. She was cooperative and said she rested well both nights. She took her medicine.

Then came Sept. 25. Kiscoan started the day pleasant and cooperative. But by 4 p.m., she refused to speak with a nurse.

Sept. 26: Kiscoan said she was unable to walk or to shower until she got her salt packets.

Sept. 27: Kiscoan fell between the toilet and sink area — and touched the back of her head as if she hurt it in the fall. Two correctional officers loaded her into a wheelchair to take her to shower. As they returned, one of the officers couldn’t lift the slight Kiscoan out of the wheelchair and onto the bed. The officer left her half on and half off the bed, naked. Kiscoan wet herself.

At 1:01 p.m., Kiscoan struggled to muster enough strength to get herself completely on the bed. She covered herself with a blanket.

At 6:02 p.m., a guard set a tray of food and a glass down on her bed. Kiscoan didn’t touch it.

By 6:30 p.m., the guard had retrieved the food.

By midnight, Kiscoan was listless. Rinn, the investigator, detailed her struggling in discomfort, in bed. She moved her arms a lot, placed both hands on her chest, her right hand behind her head and then threw her head back. She was taking several deep breaths, then shallow ones.

By 12:17 a.m., Rinn wrote, Kiscoan was “not breathing and no movement.” It took another four hours before a night correctional officer found her. Rinn noted that that officer claimed to have done hourly cell checks, contrary to what video showed. Rinn ticketed the correctional officer for providing him with false information, a misdemeanor.

Rinn also noted that, according to records, Kiscoan had not received her medication since Sept. 24, 2017, three days before her death.

Cause of death: Addison’s disease.

The grand jury’s report had authorities scrambling to explain the inaction.

By law, authorities are required to seek the least restrictive care for mentally ill people. Kiscoan had been committed to hospital care more than a half-dozen times since 2012.

But in this case, Kleine said, the jail mental health director didn’t advise the County Attorney’s Office of any bizarre behavior beyond Sept. 18, when Kiscoan soiled herself.

Meanwhile, others are asking how the trespassing count was handled — and why it took so long to sort out. Typically, Omaha police simply ticket and release a person for trespassing, though Kiscoan’s refusal to leave likely led to her arrest.

After Kiscoan pleaded not guilty, Judge Craig McDermott set bail at 10 percent of $2,500 — which is the standard bail amount under city code. That meant she would have to post $250 to get out of jail for a misdemeanor that typically ends in a $25 or $50 fine. The judge set her trial for Oct. 24.

Many times, trespassing cases are disposed of the first day a defendant appears.

City Prosecutor Matt Kuhse, whose office handled the trespassing case, said it’s likely his prosecutor offered to have Kiscoan plead to trespassing in return for her release with credit for time served. (A recording of Kiscoan’s hearing wasn’t available last week.)

“Some people take it; some people don’t,” Kuhse said. “Her mental illness could have contributed to a decision not to.”

Prosecutors also would have the option of simply dropping the trespassing count in return for getting Kiscoan help.

Kiscoan’s jail stay may have been extended by her inability to see an attorney. Riley said the two attempts his office made were met with a jail note: “refused.” That means Kiscoan either didn’t want to see the attorney or that she was unable to because she was in the infirmary.

Riley said his office ethically can’t authorize a plea by a mentally incompetent person, even to something as simple as trespassing. She would have had to understand her rights — and understand the court process. Getting an incompetent defendant to that point can take weeks.

Complicating matters even further: Kiscoan didn’t list her parents as possible contacts on her jail booking sheet, so her mother and father never knew to bail her out.

The case is devastating, Riley said.

“She’s 40 before anything really starts happening to her,” he said of her court-ordered mental health commitments. “And then this happens. It’s an absolute tragedy.”

World-Herald staff writer Christopher Burbach contributed to this report.

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Reporter - Courts

Todd Cooper covers courts, lawyers, trials, legal issues, the justice system and government wrongdoing for The World-Herald. Follow him on Twitter @CooperonCourts. Phone: 402-444-1275.

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