The obituary ran six days after the death of Madaline Christine Pitkin. It recalled the sunny early October evening she was born. It told stories from her childhood, the time she wanted to jump rope like the older girls, the way she loved all animals except spiders.



It said she spent her time taking black-and-white photographs. It described her as spunky, candid, independent.



It didn't say how or where she died -- only that she "passed away unexpectedly."



Her parents didn't know much more then.



On the afternoon of April 24, 2014, a chaplain and deputy had come to the door of the family's tan-and-brick bungalow in North Portland's Overlook neighborhood. Mary Pitkin was alone, cleaning in the dining room. Russell Pitkin was at work, so the deputy met him at his office, told him the news, then drove him home.

The Pitkins' 26-year-old daughter had dropped dead inside a jail cell earlier that day. No one could revive her.



The parents remember thinking: There had to be a mistake. How could this happen?

They envisioned their dark-haired daughter dying alone on a cold floor. Without anyone to hold her hand. Without last rites.



They would find out later that's exactly what happened.

Madaline Pitkin, 26, died April 24, 2014, at the Washington County Jail.

Madaline Pitkin, a heroin addict, had spent seven days detoxing at the Washington County Jail before she died.

Medical files, police reports and autopsy results obtained by The Oregonian/OregonLive show serious breakdowns in the way Pitkin received medical treatment inside the jail. The case also reveals scant accountability for the people responsible for her care.

Pitkin had made four written pleas for help that the medical staff with the jail's health care contractor Corizon Health mostly discounted or mishandled.

At least seven nurses, a physician assistant and a doctor evaluated Pitkin or signed off on her treatment as her condition deteriorated, records from the criminal investigation show.

Pitkin detailed her intensifying weakness on jail forms and twice wrote that she felt near death. Yet the medical staff repeatedly ranked her withdrawal symptoms as mild. Even when nurses did become concerned about Pitkin in the later stages of her jail stay, they failed to track her low blood pressure.

No one on the medical staff explained to investigators why Pitkin didn't get medicine by injection when she couldn't keep food or medicine down. No one explained why she didn't go to the hospital. No one called 911 until she had collapsed.

Near the end, Pitkin could barely stand.

She heard voices. She saw lights.



Then she was gone.

***

Weeks before their daughter went to jail, Madaline Pitkin's parents had suspected she was back on drugs. She was out of touch. She had been living with them, but she often didn't come home.

Mary Pitkin was angry. She worried. She wanted to know that her daughter was OK.

Jail deaths in Oregon

Madaline Pitkin was one of

nine Oregon jail inmates who died in custody in 2014

, according to data compiled by The Oregonian/OregonLive.

Besides Pitkin, one other Washington County Jail inmate died in a local hospital. The Sheriff's Office didn't release his specific cause of death. He didn't undergo an autopsy, according to the state medical examiner's office.

Several other inmates died from health issues - one in the Clackamas County Jail of a cardiac arrhythmia and another in the Linn County Jail from bacterial pneumonia. One inmate died in the Deschutes County Jail of a methamphetamine overdose. His family filed a wrongful death lawsuit against the county sheriff and staff claiming jail deputies allowed the man to die.

One woman died in the Douglas County Jail from defects in her blood vessels associated with methamphetamine use. Her death was ruled accidental.

Three of the inmates strangled themselves with bed sheets in the Multnomah, Clackamas and Marion county jails.

At least 80 inmates died in 19 jails in Oregon from 2004 through 2015,

the figures show. At least a quarter of them died at the Multnomah County Jail and the next largest total, 10, died at the Washington County Jail. Of the statewide total, 40 percent committed suicide in their cells, most by using a bed sheet to strangle themselves.

The Oregonian/OregonLive surveyed jails

throughout the state to get the numbers. The statistics include data from all but Klamath County, which requested more than $550 to search and provide the names, ages, date of death and cause of death for jail inmates from 2004 through 2014. No other county requested a fee more than $15. Most provided the information for free. The Multnomah County Department of Health declined to release the same information between 2004 and 2008, citing the federal heath records privacy law.

-- Everton Bailey Jr.

Before heroin, Madaline Pitkin had earned mostly A's and B's in school, first at Holy Redeemer in North Portland, then at St. Mary's Academy downtown. She was the younger of two children, five years behind her big brother. Growing up, she made close friends.

After high school, she floundered. She wasn't sure what she wanted to do. She liked listening to Portland indie bands, hiking in the Columbia River Gorge and camping on the Oregon coast.

For a term, she studied at the University of Oregon but returned to Portland because she didn't like it, her parents said. She held down part-time jobs while she took classes at Portland Community College and was interested in eventually finding work in a medical field. In the meantime, she was a barista, a waitress, an elf for Santa Claus at the downtown Macy's for a few holiday seasons in a row.

She lived on her own. She made new friends. She met a guy.

She was about 24 when she changed. She became unreliable. Evasive.

Her parents caught her in lies. They confronted her. They wanted to help.

She eventually admitted she was an addict. That she was using heroin.

Pitkin didn't want to be an addict, her mother said, and she detoxed through a program in Portland that provides 24-hour medical care for people suffering from withdrawal. She told her parents she was going to Narcotics Anonymous meetings. She seemed clean for about a year.

In 2014, her old behavior returned. She slept a lot. She lost weight. Her parents questioned her, but she didn't answer.

That January she was charged with heroin and cocaine possession after an arrest in Portland. In February, she faced more possession allegations after a Lake Oswego arrest.

Then in April, she was arrested for a final time.

A police officer stopped her for improperly using her blinker as she turned onto Southwest Boones Ferry Road in Tualatin. The officer noticed small spots of smeared blood on her feet and a glob of heroin stuck on her driver's license. He learned she had a warrant from an earlier heroin arrest and asked her to step out of her van.

On went the cuffs.

***

Just before 4:15 a.m. on April 17, 2014, Pitkin went through booking at the jail, where she had her mug shot and fingerprints taken. She also got her first medical evaluation. She stood 5-foot-7 and weighed 107 pounds. A nurse noted needle marks on the tops of her hands and more needle marks on her arms.

She told the nurse that she injected a gram of heroin a day. She last shot up around 7 p.m. the day before. Withdrawal was setting in, according to a health request Pitkin later submitted, but a nurse told investigators she didn't appear sick.

Symptoms from heroin withdrawal generally surface within three to 12 hours after the last use, experts say, and can become severe after 24 hours. For long-term users like Pitkin, detoxing is agonizing, but typically not life-threatening.

Pitkin didn't call her parents from jail to tell them what happened. They found out about her arrest when police called Pitkin's mother to say that they had impounded her silver Dodge Caravan. Pitkin had been driving it when police stopped her.

Inside the jail's courtroom hours after booking, Pitkin pleaded not guilty to a heroin possession charge, likely unaware that her parents were right outside.

They had traveled to Hillsboro for the hearing but didn't make it. The judge liked to run early, someone had told them later, and with that, they missed a last chance to see their daughter alive.

***

Inside the jail, fellow inmates knew Pitkin was dope sick. Some knew what that was like, they later told investigators.

The inmates thought Pitkin was too thin. Her lips were purple, her face pale. Over time, her complexion took on a purple and yellow hue, they noticed. She had bruises on her arms. Bags under her eyes.

She didn't leave her cell much, and when she did, she walked hunched over. Some inmates heard her vomit, even through closed cell doors, they said. One prayed for her.

Some jail deputies also thought Pitkin looked to be in rough shape. She appeared at various points "emaciated," "fragile," "tired," "very tired," "weak," "very skinny," "far too skinny," "sickly," "sick," "very sick," "very very sick," "lethargic," "unsteady" and "shaky," they told investigators later.

One deputy said he called medical staff more than once because of her appearance on the day before she died. Another said her detoxing was the worst he'd ever seen.

Deputies told a detective that Pitkin didn't ask them for help or complain about her care.

Instead Pitkin wrote it down: She followed jail protocol and filled out forms four separate times to request that someone help control her withdrawal symptoms, the criminal investigation shows.

Pitkin's first request was dated two days after she arrived at the jail, but surveillance footage appears to indicate she possibly turned it in the day before, April 18, according to the investigation. An inmate later told investigators that she helped Pitkin fill out the paperwork because she was so weak.

How we got the story

The Washington County Major Crimes Team investigated Madaline Pitkin's April 24, 2014, death at the county jail.

The team, made up of detectives from agencies across the county, launched the investigation at the request of Sheriff Pat Garrett and turned over the results to the county District Attorney's Office.

Chief Deputy District Attorney Roger Hanlon reviewed the case last spring and declined to file criminal charges against anyone.

The Oregonian/OregonLive first asked the Sheriff's Office for records related to Pitkin's death on March 24, 2015, a week after Hanlon finished his review.

Five months later in August, the Sheriff's Office released heavily edited reports, with paragraphs, sentences and individual words blacked out. Among the redactions: the name of the drug that Pitkin had taken and her requests for medical help.

The Sheriff's Office initially turned over 12 police reports to us - part of the Major Crimes Team investigation of Pitkin's death.

In the course of reading them, we discovered 12 other reports were missing from the file. They were from investigators with the Sheriff's Office and Beaverton and Forest Grove police departments and included interviews with jail medical staff, autopsy results and surveillance video descriptions.

Sgt. Bob Ray, a Sheriff's Office spokesman, said he didn't know why the agency didn't have those reports in its investigative file on Pitkin's death.

We requested the reports from Beaverton and Forest Grove, but those, too, were edited, including blacking out Pitkin's requests for medical help.

We then asked the Washington County District Attorney's Office to review the information concealed on some of the reports.

District Attorney Bob Hermann and Deputy District Attorney Chris Quinn determined the information was exempt from disclosure under medical and personal privacy laws.

"In this instance, we do not believe that the public interest weighs in favor of disclosure," they wrote in their decision.

The Sheriff's Office, Beaverton and Forest Grove charged us $413 for the redacted records.

Ultimately, a source provided unedited copies of the reports. They show Pitkin told medical staff in writing that she felt like she was near death 68 hours before she died.

-- Rebecca Woolington

In the space labeled, "Problem (Be specific)," the request said: "Heroin withdrawal. I told medical intake that I was detoxing & they said I was not yet sick enough to start meds. Now I am in full blown withdrawals and really need medical care. Please help!"

On April 20, Pitkin had been getting medicine for at least a day, but she put in another health care request form, according to medical records. It said, "detoxing from heroin

REALLY

Bad. Can't keep any food down. Heart beating so hard that I can't sleep."

The following day, she filed a third form. It said, "vomiting and dhiarea (sic) constantly. Can't keep meds, food, liquids down. Can't sleep. Everything hurts. My stomach is so sour and filled with bright green bile that I keep puking up. Muscles cramp and twitch. So weak. Cannot stand long. Can't walk far without almost fainting. Feel near death."

On each of her first three requests, medical staff wrote that she was already on a detoxing plan that included medication for anxiety, vomiting and pain and later for diarrhea, according to records. A nurse told investigators that Pitkin's appearance didn't match what she had written on her third request. "She looked like a detoxer," the nurse said, but just didn't seem that sick.

Yet during her first five days in jail, she vomited in the night and needed new bedding, she vomited on herself in the common area and needed to get cleaned up, and she defecated in her pants and needed new ones.

A deputy saw her vomiting and dry-heaving for hours in her cell one night.

"It won't stop!" she told him.

Heroin withdrawal symptoms - body aches, tremors, runny nose, yawning, gooseflesh, nausea, vomiting, diarrhea, irritability and drug cravings - last for days, said Dr. Melissa Weimer, a physician at Oregon Health & Science University who also treats people with opioid addictions.

Withdrawal normally isn't considered dangerous but can be if symptoms aren't controlled early, Weimer said. If people can't keep anything down for a day and a half, she said, they may need fluids and medication administered intravenously.

Dehydration from unrelenting vomiting and diarrhea, Weimer said, could make people light-headed. Their heart rate would increase while their blood pressure would fall, she said.

People generally start to feel better after two to three days of withdrawal. If they don't, she said, they should get checked.

***

On the day before Pitkin died, she stood next to inmates waiting for their pills to be passed out by medical staff. She dropped to her knees, unable to stand. A deputy had already called a nurse.

Minutes earlier, Pitkin had turned in her fourth and last request form for medical care. It said: "This is a 3rd or 4th call for help. I haven't been able to keep food, liquids, meds down in 6 days ... I feel like I am very close to death. Can't hear, seeing lights, hearing voices. Please help me."

An hour later, a nurse evaluated Pitkin, according to the records. He wrote down a score that indicated Pitkin's withdrawal symptoms were mild and had subsided from days earlier.

But the nurse also told investigators that he became concerned when he couldn't record her blood pressure - apparently because it was so low. He later said part of the problem could have been that Pitkin's arm was so skinny. He wanted to use a child's cuff to get a valid reading, but it's unclear if medical staff made any attempt because no one wrote down a measurement that day, the investigation shows.

Medical staff put Pitkin in a wheelchair. She sat, with her knees drawn up to her stomach, as they wheeled her to the jail's medical office.

At least one other nurse and the nursing director there tried to record Pitkin's blood pressure a short time later, they told investigators. One said Pitkin's blood pressure was "very low" but never wrote down the actual reading. The nursing director said she tried to get a reading, but it's unclear from the police report if she did.

After Madaline Pitkin's death, her parents say they're now left with memories and photographs of their daughter. They have her belongings that they can't look through. And her fat white cat.

During the check, Pitkin received some ice chips and water. A doctor saw her and also checked her blood pressure, according to medical records. A "progress note" in the file indicates the reading was low, but gives no number.

At the doctor's direction, one of the nurses started her on a withdrawal plan similar to one that Pitkin started five days earlier but had complained wasn't working, medical records show. The nurse later told investigators she didn't remember whether she had checked Pitkin's chart and wasn't aware of the earlier treatment.

The doctor also ordered nurses to check Pitkin's blood pressure at every shift, but the nurse on duty didn't carry out the orders for the checks, according to records from the Oregon State Board of Nursing. The nurse, later reprimanded by the board, said she wished she would have done more for Pitkin, the state records say. She told police investigators that she had taken Pitkin's blood pressure and it was low, but she didn't remember writing it down.

The state reprimanded no one else involved. The Sheriff's Office and Corizon Health, the Tennessee-based contractor that provided medical staff at the jail, wouldn't say if they disciplined anyone, citing potential litigation.

After Pitkin got the ice chips, the medical staff sent her to a cell in the jail's medical unit for the first time.

Inside the medical unit, Pitkin's deterioration stunned a deputy who had seen her the day before in the general population, he told investigators. That afternoon, Pitkin couldn't sit up on the bed inside her cell to receive her medication. A nurse helped lift her upper body, but she fainted when she rose, according to the deputy.

She came to and took her pills, the deputy said later.

Around 8 p.m., another nurse arrived to give Pitkin powdered Gatorade and told another deputy, "She doesn't look good at all." But the nurse didn't check her vital signs, the deputy told investigators.

Within an hour, Pitkin asked to get out of her cell. For 30 minutes, she sat alongside the deputy in the small common area of the medical unit. The Blazers played the Rockets on TV. The two talked about her drug use, the deputy recalled. She told him she was feeling better.

At 9:30 p.m., he locked Pitkin back inside her solitary cell in the unit. That night was her last.

***

On the morning of April 24, 2014, two nurses saw Pitkin through the glass of her cell window for about 30 seconds, one nurse told investigators. They gave Pitkin pills; she thanked them and washed the dose down with water, the nurse said.

No one took Pitkin's blood pressure during the visit at about 6:10 a.m., the nurse told investigators.

An hour later, the deputy working that day peered into Pitkin's cell. She appeared to be awake.

Every 15 minutes, the deputy would look in on Pitkin because she was housed next to a suicidal inmate, who needed quarter-hour checks. Nothing major changed until 9:30 a.m.

That was when the deputy saw Pitkin standing, leaned up against a wall. She wore only some of her jail-issued clothing: a pink sports bra, green-and-white striped pants and pink socks.

She stared at the floor. Her skin shined with sweat.

With an exhausted expression, Pitkin turned and looked at the deputy. Minutes later, a nurse arrived in the medical unit to check on a diabetic inmate, and the deputy urged her to look at Pitkin as well, the deputy told investigators. The nurse, the deputy said, resisted his request, but they still went back to see Pitkin.

Her body lay on the cell floor. Her eyes were open. Her mouth moved slightly as if she had to cough, while one of her arms twitched. A brown fluid pooled beneath her.

The deputy called for help in Cell 20. He locked other inmates back up. The nurse yelled at Pitkin, trying to rouse her.

More medical staff entered her cell. They searched her neck, wrist and groin for a heartbeat, but found none. The deputy and nurses pushed down on her chest to restart her heart. They tried to shock her back to life.

Too late.

Firefighters pronounced her dead at 10:09 a.m. Other inmates watched as deputies and investigators took pictures inside the cell before Pitkin's body was wheeled out on a gurney.

A medical examiner combing through her cell found a pink jail-issued shirt, a book and a handwritten copy of the Lord's Prayer.

***

According to the autopsy, Pitkin's death occurred naturally. She died of complications from intravenous drug abuse, the doctor ruled. Lab tests later showed no drugs - not even medication - in her system.

After her death, the Sheriff's Office initially launched its own investigation but four days later asked for an outside agency to conduct a criminal review. Sheriff Pat Garrett told detectives he received calls from executives with Corizon Health after Pitkin's death. Garrett said the executives told him the company would review her case and would make sure something similar didn't happen again, according to the reports.

Madaline Pitkin, pictured right in a childhood photograph with her brother.

By fall 2014, seven months after Pitkin's death, Washington County's auditor completed a review of the county's handling of its contract with Corizon Health.

The audit concluded that the county had failed to monitor its agreement for inmate health care. For example, the audit said, payroll records from fiscal 2012 showed that the jail went without a registered nurse for nearly one-fifth of the time when one was supposed to always be there.

The audit didn't address specific cases, including Pitkin's. The sheriff and county administrator took issue with some of the findings, but are moving to complete most of the audit's staffing and management recommendations.

Five months after the audit's release, county commissioners voted to change the jail healthcare provider from Corizon to NaphCare, a correctional healthcare company based in Alabama. Most of the old Corizon employees are now gone from the jail, a county spokesman said. Corizon currently provides jail medical services for Clackamas County, its only contract in Oregon.

Corizon said it couldn't comment on the details of Pitkin's care for privacy and other reasons, but released a statement that extended "our sincere condolences for their loss to Madaline Pitkin's loved ones."

The Sheriff's Office said it has a policy of not commenting on pending or possible litigation, but a detective wrote shortly after Pitkin's death that an initial review of her case indicated the inmate's health requests "were not addressed adequately."

Last year, Pitkin's parents met with the Beaverton detective and a Washington County prosecutor at a library in Southwest Portland.

Chief Deputy District Attorney Roger Hanlon told them he couldn't charge anyone criminally in their daughter's death. Too many people were involved across too many shifts over too many days, her parents remember him saying.

In a letter to the sheriff last March, Hanlon wrote only that he and the detective had answered many of Mary and Russell Pitkin's questions, but couldn't answer their most important one: "Why their daughter died in custody when medical attention was available."

That same week, the Pitkins sent a letter to county officials, telling them that they plan to file a wrongful death suit. Their attorney, Tim Jones, said his investigation is continuing.

"Madaline pleaded for medical help for the better part of six days before dying alone on the floor of a jail cell," Jones said in a statement to The Oregonian/OregonLive. "Her death was entirely preventable had she received the medical care required of the county and their medical contractor, Corizon Health."

***

Mary and Russell Pitkin are left with their memories of their daughter. Flashes of her smile. Camping in Waldport. Hiking around Timothy Lake.

They're left with her fat white cat. Her bedroom in the home where she grew up. Her belongings in boxes they can't look through. Her upright piano in their dining room, its keys left untouched and hidden by a wooden cover.

Holidays are hard. Birthdays, too.

Mary Pitkin (left) and her husband, Russell, struggle to understand how daughter Madaline Pitkin of Portland died in the Washington County Jail.

They have photographs of her. A trip down Splash Mountain at Disneyland. School portraits. Her brother's wedding.

They have a card they sent to her in jail. The picture on the front shows flowers on a blue-and-white checkered tablecloth.

"Dad and I wanted you to know that we love you very much and we would like to come and see you," Mary Pitkin wrote inside. "You would have to put us on your visitor's list."

She included the couple's full names, dates of birth and driver's license numbers - information the jail requires to screen its visitors. She also tucked inside photographs of her daughter's newest nephew, born the day she was arrested.

"I have put some money in your account at the jail in hope that you will give me a call soon and to get some things at the commissary if you need anything. I will keep my cellphone on. I'm hoping you will call.

"Please call, we love you, Mom."

Madaline Pitkin never called. Never wrote. Never spoke to her parents again.

Mary Pitkin hadn't written her full name in the return address on the card's envelope. One simple omission. But it was enough to violate the jail's strict letters policy.

So, instead of delivering the card to Madaline Pitkin, the jail sent it back. The Pitkins found it in the mail two days after their daughter died.

"Just a missed connection," her father said. "Pretty heartbreaking."

READ: Who treated Pitkin and what they did

-- Rebecca Woolington

503-294-4049; @rwoolington