Naked and shivering in a Fremont County jail cell, an emaciated John Patrick Walter punched his cell door and screamed in agony.
But when he couldn't manage to fill his own cup of water, a nurse deprived him of a medication that might have eased his suffering.
"If he can't get it for himself, then he won't get his meds," the jail's head nurse, Kathy Maestas, announced before shutting his cell door.
The episode - which came days before Walter's April 20, 2014, death on his cell room floor - was recounted in an October deposition by then-detention deputy Sarah Lightcap, who witnessed the incident. It is among the latest indications of neglect uncovered by a nine-month-old federal lawsuit against the jail and its for-profit health-care provider, Correctional Healthcare Companies Inc., also known as Correct Care Solutions, alleging violations of Walter's due process rights. Maestas is one of two jail nurses named as defendants.
The medication withheld that day was likely methadone, which in Walter's case was prescribed for severe back pain, say attorneys for his estate. Though it couldn't have saved his life, depriving it could have added to his nightmarish descent, they say.
"Something went seriously wrong here," said plaintiff's attorney Ed Budge of Seattle, who filed suit in U.S. District Court in March.
During his ordeal, the 53-year-old, 200-pound Walter lost 30 pounds in less than three weeks. He was found with broken ribs, internal bleeding and bruises all over his body - injuries that remain unexplained.
Depositions show a raft of missteps by jail health providers, which went undiscovered during a "sham" Fremont County sheriff's investigation that failed to interview eyewitnesses to Walter's death, Budge said.
A different nurse acknowledged that her colleagues were responsible for 15 lapses of medical protocol in their handling of Walter, a deposition shows, and Fremont County Sheriff James Beicker acknowledged in a separate deposition the office did nothing to uncover policy violations.
Beicker, Maestas and others named in the suit couldn't be reached for comment.
The new eyewitness accounts of Walter's unraveling come as the Canon City jail pursues reforms in how it provides medical care to inmates.
In September, the Fremont County Sheriff's Office terminated its contract with Correctional Health Companies effective Jan. 1, according to a document the sheriff's office provided to the plaintiffs last week.
Although an autopsy couldn't determine the cause of Walter's death, plaintiffs' attorneys say he suffered an agonizing death from benzodiazepine withdrawal - even though he brought in a prescription and a bottle of medication upon his booking.
Deprived of his prescription Klonopin, an anti-anxiety drug also known as clonazepam, Walter went days without sleep and began to exhibit signs of delirium.
For those on small doses over a short term, clonazepam withdrawal can be uncomfortable.
But at Walter's dosage - 6 mg a day - patients must be gradually weaned under medical monitoring or face potentially deadly consequences, his attorneys say.
As withdrawals took hold within 10-12 days of Walter's booking into jail on suspicion of assault, he began to hold conversations with "imaginary people" and thrashed about his cell, prompting deputies to resort to Tasers, pepper spray and restraints to contain him, his attorneys charged in a 29-page complaint.
Attorneys say that rather than diagnose what went wrong in the Walter case, the Fremont County Sheriff's office failed to account for mistakes by deputies and two nurses working on behalf of the jail's contractor, which must cover the tab anytime a jail inmate requires hospitalization, up to an annual cap of $50,000, the contract shows.
The steep financial penalty acts as a disincentive to provide costly interventions, Budge said.
In the wake of Walter's death, a sheriff's detective produced a single six-page death investigation report that listed the cause of his death as inconclusive.
Independently reviewed by The Gazette, the report shows no evidence the detective interviewed deputies who reported concerns about Walter to their chain of command, nor the nurses who treated him.
The document doesn't disclose the contents of Walter's handwritten list of medications. Nor does it specify whether his belongings were checked for prescription medications.
The report "could have been more thorough," Sheriff Beicker acknowledged in November during a seven-hour deposition, excerpts of which were provided to the newspaper.
The 13-year sheriff took swigs from a water bottle and shifted in his seat uncomfortably while Budge questioned him over steps left unaddressed.
Although Beicker was ultimately responsible for ensuring adequate health care at the jail, he said he didn't review the detective's investigative report and ordered no probe into whether policies or procedures were violated by deputies or health-care providers.
Even after being confronted with a nurse's claims of repeated policy violations, Beicker said he had "no plans" for an internal review.
But in private, the sheriff expressed deep "frustrations" with how Walter was treated, and blamed his death on neglect by care providers, according to a transcript of a deposition by Capt. John Rankin, the jail commander.
Rankin said he was personally approached by four detention supervisors voicing concerns about Walter's continuing deterioration.
The jail commander requested that both Beicker and Undersheriff Ty Martin come to the jail to look into the situation. Both did. Rankin said Beicker told him he had received assurances from both nurses stating everything was OK.
"I would say (he was) frustrated because he was reassured that they were on it, they are following protocols, (that) he's under a doctor's care," Rankin said. "It still happened."
There is no evidence that Walter ever received clonazepam while in custody, Budge said, and toxicology reports showed no trace of it in his system.
The El Paso County Coroner's Office, which conducted the autopsy, was unable to pinpoint the cause or manner of the death, listing both as "undetermined," the report shows. Budge said the lack of information provided by sheriff's deputies prevented a pathologist from being able to pinpoint benzodiazepine withdrawal as the cause of Walter's death.
The autopsy documented numerous injuries, however, including "extensive contusions, abrasions (and) rib fractures."
Self-injury and efforts at resuscitation might have caused some of the trauma.
But some of Walter's rib fractures occurred in his back where the ribs meet the spine, attorneys say.
"Those injuries cannot be attributed to CPR or any other legitimate cause," Budge said. "It is either a case of too much force used by deputies, or it is a case of neglect."
The autopsy report also noted a "right hemothorax," or blood between the chest wall and the lung - "usually a consequence of blunt or penetrating trauma," according to MedScape.com.
The sheriff's six-page death investigation notes a final unexplained indignity - a "jail shoe imprint on Inmate Walter's lower back."