The Oregonian/OregonLive's analysis of more than 200 pages of the criminal investigation into Madaline Pitkin's death at the Washington County Jail uncovered jarring discrepancies between the medical staff's accounts of her treatment and what nurses and others had documented in medical records.

At times, it's impossible to determine what care Pitkin received and when she received it, based on the available records.

Statements medical staff made to investigators don't always match dates on reports or surveillance video footage and Pitkin herself appears to have possibly put the wrong date on one of her written requests for help.

But it's apparent in the documents that the revolving door of medical staff made a series of mistakes. They didn't track her low blood pressure. They couldn't account for exactly when they saw her. They kept sloppy records.

The Washington County District Attorney's Office didn't prosecute anyone connected to the case, citing a lack of evidence to support criminal charges.

Most of the medical staff named here declined to comment on the case, couldn't be reached or didn't return messages.

An analysis of the available investigation records by The Oregonian/OregonLive shows:

1. No coherent timeline exists of when Pitkin received treatment.

Just before 4:15 a.m. on April 17, 2014, Pitkin received her first medical evaluation while she was getting booked into the Washington County Jail. Registered nurse Nerissa Galvez assessed Pitkin, who had needle marks on her hands and had last taken heroin intravenously at 7 p.m. the day before, according to medical records and police reports. Galvez weighed Pitkin, took her vital signs and asked her questions about current problems and her health history, according to the medical records.

During an interview with investigators, Galvez said Pitkin wasn't exhibiting heroin withdrawal symptoms yet, but she ordered that Pitkin undergo a withdrawal evaluation within 48 hours of using the drug, per the protocol of Corizon Health, the Tennessee-based company that provided medical care at the jail. Experts say withdrawal symptoms generally surface within three to 12 hours after last using heroin.

Galvez told investigators that Pitkin was alert and looked normal during booking. She didn't ask Pitkin whether she was currently suffering from withdrawal, she told investigators, but inquired whether Pitkin had detoxed from heroin in the past. Pitkin told the nurse she had gone through detox a couple of years ago.

Reached by phone, Galvez told The Oregonian/OregonLive that her evaluation of Pitkin lasted five minutes - typical for an initial assessment - and that Pitkin had no withdrawal symptoms.

At 9:59 a.m. on April 18, Pitkin was first evaluated on an opiate withdrawal scale by licensed practical nurse Louisa Duru, according to medical records.

Duru took Pitkin's vital signs and asked her questions to identify her symptoms, Duru told investigators. Pitkin's blood pressure, according to Duru, was low.

Detectives noticed that Duru had incorrectly added up Pitkin's score on the evaluation, saying the inmate scored an 8 when it should have been a 10. Either score, however, categorized Pitkin's symptoms as mild. Inmates who score 11 or higher are placed in the jail's medical unit, Duru told investigators, and receive additional medication.

Duru told investigators that she started Pitkin on a detoxing plan that included three medications two times a day. Medical records indicate she gave Pitkin Tylenol for pain, Vistaril for anxiety and Phenergan for nausea that morning.

Duru told investigators she had received verbal approval from the jail's physician assistant to treat Pitkin.

But the timing of Duru's evaluation and the medical records conflict with what Pitkin later wrote on a health care request form.

The investigation

The Washington County Major Crimes Team conducted the criminal investigation into Madaline Pitkin's death.

Detectives with Beaverton, Forest Grove and Tualatin and Tigard police interviewed medical staff, jail deputies and inmates. The investigation includes jail logs and medical records from Corizon Health, the Tennessee-based corrections healthcare company that provided services in the jail at the time.

The jail holds 572 inmates and has a total of 45 medical staff members who work in shifts under the county's current contract with another health care company. The staff handled 9,804 cases from last June through February, the Sheriff's Office said. The jail held the same number of inmates when Pitkin was there, but similar staffing numbers and caseloads weren't immediately available for 2014, sheriff's officials said.

Jail surveillance video shows another inmate helping Pitkin fill out a health care request form by hand. It was turned in shortly after 3 p.m. April 18, according to reports from the investigation. The request indicates that Pitkin either wasn't receiving medication or wasn't receiving enough - it's not clear from her description which is the case.

The form is dated April 19, so it's possible Pitkin and the inmate wrote the wrong date. The request said, in part, that Pitkin was suffering from heroin withdrawal and that she "told medical intake that I was detoxing & they said I was not yet sick enough to start meds."

According to medical records, physician assistant Colin Storz signed the treatment plan that Duru had created earlier for Pitkin at 5:10 p.m. April 18.

Reached by phone, Duru declined to comment. Phone calls and email messages sent to an address associated with Storz weren't returned.

At 8:48 p.m., medical staff came to the jail pod where Pitkin was housed, according to police reports. A detective who reviewed surveillance video of that night couldn't confirm whether Pitkin got medication. Medical records, however, say she received pills then.

The next morning, on April 19, the detective, again watching surveillance video, couldn't confirm whether Pitkin received her medication. Medical records once again say she got her pills. That night, the detective believed she did see Pitkin on surveillance video receive her medication. Medical records also indicate Pitkin got the pills.

Registered nurse Molly Johnson signed Pitkin's health care request form, indicating she had reviewed it at some point. Johnson, who never examined Pitkin, noted that Pitkin already had begun treatment, according to Johnson's interview with investigators and Corizon medical records.

Johnson told investigators that licensed practical nurse Courtney Nyman had told Johnson that she saw Pitkin and that Pitkin was receiving treatment.

Nyman, the reports say, told detectives she only saw Pitkin one time more than a day later and she didn't remember talking to Johnson about Pitkin.

So, it's unclear in the investigative records whether any nurse saw Pitkin on April 19 in response to her plea for help.

Reached by phone, Johnson declined to comment. Nyman declined comment about any details of the case, citing patient privacy rules. "It was a horrible, horrible experience and I'm really sad about it," she said.

2. Pitkin may have gone at least one more day without seeing any medical staff about her complaints.

Pitkin turned in her second health care request at 4:10 p.m. on April 20, according to medical records. She wrote, "detoxing from heroin

REALLY

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

Nyman evaluated Pitkin at 8:30 p.m. April 20, according to medical records. But Nyman later told investigators she wrote the wrong date on her evaluation and believed she actually saw Pitkin on April 21.

Yet Johnson told investigators that she put in an order on the night of April 20 for Pitkin to start receiving loperamide, a medication used to treat diarrhea, based on Nyman's assessment. Pitkin started receiving that pill on the morning of April 21, according to medical records.

Johnson didn't work April 21, she told investigators.

Given the differing accounts, it's possible no one saw Pitkin on one of those days. That's important because Pitkin said she was still suffering from severe withdrawal symptoms.

The morning of April 21, Pitkin walked down from her upstairs cell to get breakfast, but had to stop apparently to rest, according to a detective's account of surveillance footage. Once in the food line, Pitkin squatted down, indicating that she couldn't stand long, the detective wrote in a report. Soon after breakfast, jail staff moved Pitkin from an upstairs cell to a downstairs one.

A statue and other mementos sit in front of Madaline Pitkin's photo in her parent's home in North Portland's Overlook neighborhood.

Pitkin told a deputy that day that she needed new pants because she had defecated in hers. The deputy thought Pitkin looked "very, very sick" and believed Pitkin should have been in the jail's medical unit, according to an interview with a detective.

At 2:10 p.m. on April 21, Pitkin put in her third health care request, stating, in part, that she was experiencing "vomiting and dhiarea (sic) constantly" and that she felt "near death."

Six hours later, according to Nyman's statement to investigators, Nyman evaluated Pitkin's withdrawal symptoms. The evaluation, which Nyman said she conducted at a deputy's request, indicated that Pitkin had slightly improved from days earlier. Nyman explained to investigators that Pitkin scored "a little high" for pain and stomach upset symptoms. According to the evaluation, Pitkin's score indicated she had recently experienced vomiting and diarrhea, but not multiple episodes.

Nyman told investigators that she didn't see Pitkin's latest health care request until later on the night of April 21. Pitkin hadn't seemed as sick as what she described on the request, Nyman said. Pitkin's pulse had been elevated, but her blood pressure was normal, she said.

"I had seen her and this didn't match the person I saw," Nyman told investigators. "I've seen people who are behaving what she's written here and those people will get moved immediately to the (medical unit). They are dripping in sweat. They're very very sick. They can't get up. And you know, she was sitting up. She wasn't in her room. She had come out on her own accord. I didn't call her out."

Nyman wrote on Pitkin's request that the inmate was already receiving treatment for withdrawal symptoms. Nyman saw no reason to be alarmed, she told detectives.

A deputy saw Pitkin vomiting and dry-heaving for hours in her cell the night of April 21, he later told investigators.

3. Pitkin probably missed a dose of medication as her condition worsened.

On the morning of April 22, surveillance video shows Pitkin having to sit down on the way to get breakfast in the general population unit, then continuing the rest of the way slightly hunched over and walking slowly.

After breakfast, medication assistant Cindy Bosvelt brought in her cart. It was Bosvelt's duty to pass out medication to inmates that day.

Bosvelt recorded that Pitkin refused her morning dose of medication, according to medical records and Bosvelt's interview with investigators.

The deputy working that day told investigators that she believed Pitkin had gotten the dose. She hadn't noted a pill refusal from Pitkin in her notebook. It's standard procedure for deputies to record when inmates refuse or miss medication, the deputy said. She didn't explain the discrepancy with Bosvelt's account.

Bosvelt later told investigators that Pitkin looked better that day and appeared to be feeling better, but the report doesn't indicate if Bosvelt saw Pitkin in her cell or in the medication line. Bosvelt typically doesn't make notations on medical records about why inmates refuse pills and didn't in this case, she said.

A detective watching surveillance video from that morning didn't see Pitkin come out of her cell while Bosvelt was there to pass out medications. The two deputies working that day told investigators they believed Pitkin came out for her medications and said she looked sick.

When it was time for lunch, a deputy let Pitkin eat it in her cell because she was so weak.

One phone number listed for Bosvelt was disconnected and she didn't return messages left at another number associated with her name. She didn't return Facebook messages for comment.

4. Nurses didn't adequately track or respond to Pitkin's low blood pressure.

On the morning of April 23, Pitkin dropped to her knees while she was standing next to a line of other inmates waiting for medication in the general population unit.

A deputy helped her to a chair, a detective saw on surveillance video. The deputy later told investigators that he had called medical staff multiple times to check on Pitkin that morning.

A short time later, Tony Wertz, a licensed practical nurse, evaluated Pitkin for heroin withdrawal symptoms, according to an interview he later had with investigators and medical records. Wertz recorded that Pitkin had no current symptoms of stomach upset. Pitkin had complained of vomiting and diarrhea in her requests for help and deputies had seen it happen. Medical records also indicated she had been taking medications for those symptoms.

Wertz sent Pitkin to see registered nurse C.J. Buchanan in the medical office. She tried to take Pitkin's blood pressure and found it was "(v)ery low, it was very hard to hear," she later told detectives. Buchanan didn't write down Pitkin's blood pressure on any records that day, according to the medical documents. Wertz and Director of Nursing Leslie O'Neil also tried to take Pitkin's blood pressure, they later told investigators. Wertz recorded a reading of 40/UA - meaning unavailable -- and O'Neil apparently didn't write anything down, according to police reports and medical records.

Reached by phone, Wertz declined comment. O'Neil said she believed she got a blood pressure reading for Pitkin and didn't think medical staff could do much more to help Pitkin.

At a doctor's direction, Buchanan started Pitkin on a detoxing regimen that was similar to one that records indicate she had just finished, but this plan included two new medications. Pitkin had only received medication for diarrhea the morning of April 23, according to medical records.

Buchanan later told investigators she didn't know about any earlier withdrawal treatment Pitkin received.

The jail physician, Dr. Joseph McCarthy, also had seen and talked to Pitkin that morning and had tried to take her blood pressure, according to medical notes that Buchanan wrote and what she told investigators.

McCarthy ordered Buchanan's treatment plan for Pitkin, Buchanan told investigators. Buchanan initially told investigators that she believed she spoke to McCarthy in person about the treatment. She then told detectives she may have spoken to him about it on the phone, before finally saying she talked to him in person.

But McCarthy, whose last day with Corizon appeared to be April 23, never signed the treatment order, according to medical records and police interviews with medical staff. Investigators never reached McCarthy for an interview. Corizon wouldn't confirm whether April 23 was McCarthy's last day with the company, citing potential litigation over Pitkin's death.

Reached by telephone, McCarthy declined to comment.

State Board of Nursing records indicate Buchanan was reprimanded for failing to document Pitkin's blood pressure the day before she died and for failing to carry out a doctor's care plan that called for repeated checks of her blood pressure. Medical and state records show nurses were supposed to take Pitkin's blood pressure every shift for seven days.

During an initial interview with a sheriff's office detective, Buchanan didn't disclose information about Pitkin's low blood pressure, according to a police report. She also didn't mention that she was the nurse who found Pitkin unresponsive in her cell and tried to revive her with the deputy, the police report says.

Buchanan later said she wished she would have done more for Pitkin, state records say. Reached by telephone, Buchanan declined to comment.

Addiction experts say a blood pressure reading of 80/40 is low enough to trigger a higher level of care and a doctor's attention. If medical staff couldn't take accurate measures, the patient could go to intensive care, one said.

5. Questionable record-keeping apparently continued until the end, with a nurse noting that Pitkin received her withdrawal pills as the inmate lay dying on the floor of her cell.

On April 24, a deputy and Buchanan found Pitkin unresponsive on the floor of her cell in the medical unit shortly before 9:40 a.m. The deputy called for more medical help, and moments later, two deputies arrived in the unit, according to a detective's observation of surveillance video. One of them ran to Pitkin's cell.

More deputies and medical staff members arrived, the video showed. Two minutes after Pitkin was discovered, licensed practical nurse Louisa Duru entered the medical unit with a cart used to pass out medications to inmates, according to the video. Duru walked toward Pitkin's cell, the video showed, then ran back to the unit deputy's desk and got on the phone.

Four minutes after entering the unit, Duru left, the detective's report says.

A minute later, firefighters arrived inside the medical unit, according to the report. Within three minutes, more paramedics came into the unit with a gurney.

At 10:09 a.m., Pitkin was pronounced dead inside her cell.

On medical records, Duru initialed that she had dispensed medication to Pitkin that morning, according to the investigation.

"I am unclear how that was possible since Pitkin was found unresponsive in her cell prior to Duru arriving in the (medical unit)," a detective wrote in a police report.

The police report detailing Duru's interview with detectives doesn't address the discrepancy.

The autopsy found that Pitkin had no controlled substances or medicine in her system when she died.

-- Rebecca Woolington

503-294-4049; @rwoolington