Two Colville women were booked into a rural Washington jail. It became a death sentence

When guards found LaCrisha Cate unresponsive on the floor of a shower in the Okanogan County jail in August 2023, she was cold to the touch. Cate, a mom and a dancer, had been there for hours lying in a pool of her own vomit, an unopened Gatorade bottle by her side. She never woke up.

She was the second citizen of the Confederated Tribes of the Colville Reservation to die in that jail within three months. 

That April, Amber Marchand died by suicide after she repeatedly asked jail staff for help with serious opiate withdrawal-related symptoms, which went untreated for five days, a lawsuit by her family claims.

Okanogan County had received a state grant under a program meant to ensure its jail provides FDA-approved medications for people incarcerated with opioid use disorder that have been shown to be effective at alleviating severe withdrawal symptoms. But records show at the time of Cate and Marchand’s deaths, the county instead provided their own de facto “opiate withdrawal protocol” method that medical experts say is not proven to effectively treat withdrawal symptoms: Gatorade, ibuprofen, an antihistamine, an anti-nausea medication and a blood pressure medication. 

“They are supposed to be adhering to those standards to get that funding,” said Mandy Owens, a clinical psychologist and assistant professor at the University of Washington School of Medicine’s Addictions, Drugs and Alcohol Institute. Owens worked with the state’s health authority and other corrections health experts to develop the treatment standards for the grant program.

The deaths of Cate and Marchand — who were both in jail awaiting trial — expose repeated failures by the Okanogan County jail to provide appropriate care for opioid withdrawal and suicide prevention, increasing pressure on state lawmakers to implement statewide standards and oversight of jails, lawyers for the family say. Washington has the fourth-highest rate of jail deaths in the nation, according to federal data as of 2019, and is one of 12 states without enforceable statewide oversight of its jails, relying instead on facilities to voluntarily adopt jail policy guidelines. 

Cate left behind three children and many extended relatives who miss her, her family says. Joleen McKinney, her stepmother, says she feels strongly about preventing the deaths of more Indigenous people inside the Okanogan County jail, calling for the state to pass a law increasing oversight of local jails, especially around addiction treatment.

“I never want this to happen to anybody’s child the way it happened to my little girl,” McKinney said.

The Okanogan County Sheriff’s Office declined to comment on the deaths, citing pending litigation, and did not respond to a list of questions sent by InvestigateWest. State law requires jails to publish reports following unexpected deaths within 120 days. More than two years since the two deaths, the Okanogan County Sheriff’s Office has not done so, according to a state database.

The families of Cate and Marchand have filed separate federal lawsuits alleging their loved ones’ civil rights were violated by Okanogan County and jail staff for not providing adequate treatment — and in Marchand’s case, using physical restraints while offering insufficient suicide prevention measures. According to the lawsuits, they are among at least nine people — including five Colville Tribal members — who have died or been seriously injured due to similar failures at the jail since 2011. 

Shelby Stoner, the families’ lawyer working for Indigenous rights law firm Galanda Broadman, said biased policing against Colville Tribes citizens is an ongoing issue in Okanogan County, which borders the Confederated Tribes of the Colville Reservation. Native Americans in Washington are more likely to face arrest and less likely to be offered opportunities to avoid jail during sentencing. 

The lawsuits say both women were left alone while detoxing from opiates in areas of the Okanogan County jail where it was difficult to monitor inmates for safety — an issue county officials had been aware of since 2017, when an audit by the state Department of Corrections raised the issue. The recommendations of the audit, including to verify inmate welfare during checks, had not been implemented in the six years between the audit’s publication and the deaths of Cate and Marchand, according to law enforcement records and the lawsuits.  

After Marchand’s death, public records show Okanogan County Sheriff Paul Budrow requested that the chief jail administrator of the Island County Sheriff’s Office, more than 100 miles west of Okanogan County, review the circumstances that led to Marchand’s death. It’s unclear if any report was conducted on Cate’s death, as none was published. The Island County investigation found that Okanogan County didn’t have a formal policies or procedures manual in place when Marchand died, and called for Okanogan County to immediately implement a host of changes at the jail, including the development of policies for inmate safety checks, medical screening, detoxification and withdrawal, suicide prevention, use of restraints and force, and reporting in-custody deaths. The recommendations were similar to those in the 2017 Department of Corrections audit, a review showed.

“Unfortunately, the previous administration buried the report and did not take action on any of the recommendations provided,” the report by the Island County Sheriff’s Office said.

The draft report, obtained through a public records request, was never published publicly to the state Department of Health’s website as required. 

Without a manual

On April 23, 2023, Amber Marchand, a Colville Tribes citizen and mother of three, found herself in the Okanogan County jail for theft and possession of stolen property. 

According to her family’s lawsuit, Marchand told the jail she wasn’t on any substances but soon began experiencing opioid withdrawal symptoms and refused to return to her original cell. Guards placed Marchand on lockdown — meaning she could only leave her cell for one hour a day — and moved her to a different area. 

Over the next six days, Marchand, who was 35, experienced ongoing, uncontrolled bowel issues and constant pain, which wasn’t normal for her, according to her family’s lawsuit. 

The lawsuit says that on April 27, as she continued experiencing symptoms, she complained that guards refused to take her to the hospital. That night, Marchand swung a broom around and attempted to assault deputies with it. She was handcuffed to a restraint chair and placed on suicide watch by jail deputies. One deputy summoned a professional from the county behavioral health department to meet with Marchand.

Marchand then explained she smoked 30 fentanyl pills a day, requesting to be put on buprenorphine, one of the FDA-approved medications used to treat opioid use disorder. She told the county worker that she was scared and apologized for her behavior, according to a deputy’s notes, which are included in the lawsuit. They referred her to a medication-assisted treatment program, and that night, she was taken out of the restraint chair and suicide watch, the lawsuit says. 

But the next day she still had not received medication, according to the lawsuit. The jail conducted virtual medical visits only twice a week — and since the drug counselor couldn’t prescribe the medication directly, the earliest she could begin buprenorphine, known by the brand name Suboxone, was the following week, May 2, the lawsuit says.

By April 29, Marchand was pressing her intercom call light to ask for help multiple times per hour, the lawsuit says. Still on lockdown, she was still unable to control her bowels and complained that she felt she was “choking and going into shock,” but her calls were “largely” ignored, the lawsuit says.

Around 1:40 p.m. that day, guards decided to let Marchand get some “fresh air” and left her unsupervised in the outdoor recreation area, the lawsuit says. Twenty-two minutes later, jail staff found her unresponsive in an enclosed bathroom at the recreation area. She had hanged herself. Jail staff attempted to resuscitate her, but she died three days later, on May 4, 2023, after several days on life support, according to the lawsuit. 

Three months after Marchand’s death, Cate would also die unsupervised in the same facility.

When Cate was arrested by the Colville Tribal Police and handed over to Omak Police Department alongside her boyfriend on the afternoon of July 31, 2023, her boyfriend told the Omak officer that he’d just consumed five fentanyl pills and methamphetamine in the hours prior to his arrest, police reports show. The officer took him to a local hospital but didn’t do the same for Cate, who was instead booked on an outstanding county warrant for escape from community custody and failure to appear for a court date, according to the lawsuit. 

Cate reported during her jail intake that she too had consumed fentanyl and that she had a medical problem because she was suffering from “withdrawal,” according to the lawsuit.

National guidelines for managing substance detox say that inmates believed to be under the influence of a substance should be assessed for dependence and acute withdrawal. Upon intake, it’s common for jails to conduct a type of fitness exam, particularly those who report medical issues to the jail, for analysis by or in conjunction with a medical professional to see if they are fit to be in jail or if they require medical attention. Cate received no such exam, according to the family’s lawsuit.

Instead, Cate, who was 34, was sent to a dormitory-style bunk with other inmates, where she began vomiting and had difficulty staying awake, the lawsuit says. Other inmates reported she was going through detox and had vomited on herself, but jail staff didn’t respond until late that evening, when a deputy without medical training came to take her vital signs, according to the lawsuit. 

After a consultation by the jail’s off-site physician, Bradley Craig, the lawsuit says Cate began the jail’s standard treatment for opioid withdrawal symptoms that included Gatorade, ibuprofen, clonidine and other medications — none of which treat opioid withdrawal symptoms as effectively as the FDA-approved medications that include methadone, buprenorphine and naltrexone. Craig did not respond to a message seeking comment.

The following morning, Cate was covered in her own vomit, the lawsuit says. Two guards decided to put her in a shower, but she was so weak they physically moved her down a hallway to a shower room, according to the suit. One of the staff members observing Cate, Carine Wood, was a pharmacy technician and filled the role of the jail’s sole “medical officer.” 

Wood left Cate in the shower room unattended, with Cate lying on the floor of the shower “finally getting some rest” after she had stopped vomiting, according to Wood’s reports which are a part of the lawsuit. Wood then “went upstairs to complete tasks,” according to the lawsuit. Wood reported that she checked on Cate several times over the next couple hours — though the checks were not recorded in official documents, and the reports didn’t say whether Cate was conscious and breathing, said Stoner, the families’ lawyer. No jail staff physically entered the shower room to ensure Cate was breathing for more than three hours, the lawsuit says. 

At 9:30 am, another deputy found Cate face down, unresponsive on the shower floor, her head in an “unnatural position” according to the lawsuit. The shower was dry. Her skin was cold. She wasn’t breathing. 

“She would have been so embarrassed lying there on the cold concrete, I can’t get it out of my mind,” said McKinney, her stepmother. “It’s terrible — that’s not how you treat human beings.”

Paramedics revived Cate, who was taken by ambulance to a hospital nearly 40 minutes after she was found unconscious. For three days, she remained on life support, her family at her side, McKinney said. She never regained consciousness. Her death certificate listed her cause of death as polysubstance abuse, cardiac arrest and brain hypoxia. McKinney said it has been completely devastating to the entire family, including Cate’s young children.

“I wouldn’t wish this on my worst enemy,” McKinney said. 

Standard of care

Tribes and independent groups have called on the state to address the risk of death that people with opioid use disorder face in jail, particularly for Native Americans. 

Reports show a lack of state data accounting for jail fatalities across the Northwest, although Oregon recently passed a law to track jail fatalities. One 2019 report from the nonprofit Columbia Legal Services found that drug and alcohol withdrawal and suicide were leading causes of death, with withdrawals often playing a factor in the suicide deaths.

In a 2024 resolution, the Affiliated Tribes of Northwest Indians, a coalition representing the interests of more than 50 Native American nations in the Northwest, called on Washington legislators to pass minimum enforceable standards in jails for substance withdrawal management and suicide prevention. They also urged lawmakers to require that the Washington Criminal Justice Training Commission implement mandatory substance withdrawal management, suicide prevention, and Indigenous and tribal cultural competency training for its correctional officer training program by this year.  

The lack of statewide mandates or oversight means most of those guidelines are a suggestion for jail administrators, according to a state report on jail standards and advocates for more oversight.

In the case of Okanogan County, auditors have identified specific failures that contributed to the circumstances of Cate and Marchand’s deaths, yet the sheriff’s office had not implemented any of those recommendations by the time the women died, according to the lawsuit. 

The 2017 audit of the county’s jail identified a host of issues from incident reporting to lax security measures. It found corrections staff failed to adequately check on inmate welfare, which the audit said caused a risk of “untimely discovery of offender death or injury.” Okanogan County jail officials checked on inmates roughly every 90 minutes, which is far below the national standard of conducting inmate welfare checks every 30 minutes, the lawsuit says. 

The auditors also found inmates using bed sheets in their cells, shower and bathroom areas to create privacy, which the audit said “limits staff visibility and creates dangerous opportunities for concealment.” The report recommended removing all hanging bedsheets and other items hung by inmates in the jail.

Both Cate and Marchand died in areas of the jail — a shower and a bathroom — that were dinged by the report for issues of undue privacy. 

Also in the report on their external investigation, Island County officials recommended that Okanogan County make its medications for opioid use disorder and alcohol use disorder treatment programs as accessible as possible. Inmates had been required to request and fill out a form to receive those treatments, then wait for one of the twice-a-week appointments to begin a program, according to the lawsuit.

“It’s sad that there continues to be barriers for people with opioid use disorder to receive the care that they want and should get,” said Owens, the University of Washington psychologist. “There certainly is the need for more research and systematic overview of what is actually happening in jail.” 

The Island County report echoed a need to make the treatments more accessible.

“If (medication-assisted treatment and medication for opioid use disorder) programs are not low barrier, then custody staff may need to monitor subjects more closely as they go through the withdrawal process in order to prevent suicide or intervene during a medical emergency,”  the Island County report said. “Unfortunately, that did not happen with Marchand, and she succumbed to suicide as the final option in her mind.”

Lacking transparency

In 2019, the Washington Legislature sought to increase transparency surrounding jail deaths by mandating a committee of county experts review any case where the death of an incarcerated person is “unexpected,” generally meaning any death that isn’t the result of a documented illness, according to the statute.

The reports are required to be conducted and published on the Washington Department of Health’s website within 120 days and should result in a corrective action plan to address any conditions that allowed for the death to occur. The reviews are meant to develop recommendations to the department and Legislature about how to prevent fatalities — and improve safety, the law says.

Okanogan County has yet to publish a single unexpected fatality report since the law’s passage, according to the department of health database of reports. In Cate’s case, Okanogan County declined to publish a report on her death because she died after several days on life support, Cate’s family lawyer says — but the law states that the death of any person under their care and custody, regardless of where the death actually occurred, is covered.

McKinney, Cate’s stepmother, still plays scenarios in her head where it goes differently. McKinney and her daughter were extremely close, she says, their birthdays just a day apart. Cate was by McKinney’s side almost everywhere she went, as McKinney helped raise Cate’s children, she said.

“She was just fun, giggly, she had a funny little laugh,” McKinney said. “Hanging out with her felt like sitting at the cool kid’s table.”

McKinney and Cate had planned to travel to Idaho, where they’d have a fresh start together, she said. Cate was arrested the day they were supposed to leave. McKinney tried to bail her out of jail the very same day, she said. 

“I would not let her go on through all that, where it hurt so bad and she’s crying,” McKinney said. 

She was told that she’d have to wait two days until Cate went to court. 

The next morning, she got news that Cate was in the hospital, on the verge of death, she said. She dropped to her knees.