COUPEVILLE — A mentally ill man’s death from dehydration at the Island County Jail in April was the result of staff failure and a “systematic” breakdown of jail operations, Sheriff Mark Brown said Thursday.

Keaton Farris, 25, of Lopez Island, died April 7. The water had been shut off to his cell, and corrections deputies falsified records saying they had been checking on him hourly. Farris did not receive medical or mental-health evaluations for days after being booked.

For the nearly two weeks he was in the Island County Jail, Farris’ fluid intake was at best 185 ounces of water — less than a quarter of the amount considered minimum for survival.

“I am truly sorry for this tragic death,” Brown said in a news release. “Mr. Farris did not receive the attention and care he needed.”

The man’s parents were provided a copy of the sheriff’s investigation Thursday, said their attorney, Kathy Goater. They have established a website dedicated to their son and raising awareness about his death.

“The family is devastated,” Goater said. “The report is shocking. There was a complete disregard for the health and safety of a mentally ill man.”

Farris, who was living with bipolar disorder, put his pillow in the toilet on March 30 and flooded his cell on April 4. Corrections officers shut off the water to his cell but failed to make sure he was adequately hydrated.

It is clear that protocols and procedures were not followed, Goater said.

“What happened to Farris is unconscionable,” she said. “His death was completely preventable.”

Goater and her colleague, Becky Roe, expect to file a lawsuit on behalf of the dead man’s parents and his estate.

Brown has ordered an overhaul and an outside review of the jail, citing “a lack of leadership and supervision.” The two corrections deputies who were being investigated for falsifying logs have resigned. They admitted to changing the logs after Farris was found dead to look as if they performed required checks.

The investigation has been provided to prosecutors for review, Brown said Thursday.

The chief deputy in the jail was suspended Thursday for 30 days without pay, and a lieutenant was placed on leave.

“We are determined to do everything possible to minimize the chances of this kind of a tragedy from occurring in our jail ever again,” Brown said.

The U.S. Department of Justice launched a criminal investigation at a North Carolina prison last year after a mentally ill man died from dehydration and malnutrition.

Corrections officers had turned off water to the man’s cell after he flooded the toilet. More than two dozen people were fired or resigned.

The Daily Herald reported in April that the Island County coroner suspected that Farris had died from dehydration. Coroner Robert Bishop on Monday confirmed his initial findings and added that malnutrition also was a contributing factor. Bishop ruled the manner of death as natural causes.

The report released Thursday shows that Farris bounced between three other jails before he was moved to the lockup in Coupeville. Staff at the different jails were aware that Farris was mentally ill and showing signs of decompensation, according to the investigation.

Farris was arrested by Lynnwood police on March 20. He had a warrant for failing to show up for a hearing in San Juan County Superior Court. He was charged there with identity theft. Prosecutors accused him of a cashing a $355 check that didn’t belong to him.

Farris told an officer in Lynnwood he was off his medication and anxious. He said the officer’s badge was “calming him down.”

He was moved to the Snohomish County Jail where staff made notes that Farris appeared “gravely disabled” and was displaying symptoms of psychosis.

He arrived in Skagit County in a restraint chair and refused to speak. Jail staff were advised that he had been shocked with an electric stun gun while at the jail in Everett.

Skagit County corrections officers restrained him and requested he be seen by a designated mental health professional. That never happened because the request was too vague and there was a question about who had jurisdiction over the man.

He ended up at the jail in Coupeville because San Juan County doesn’t have a jail and uses Island County’s under a contract. When San Juan County deputies arrived in Skagit County to take custody of Farris he refused their commands to stand up, and he began to ramble.

He was booked in Coupeville on March 26. He was being kept there in a padded safety cell but later was moved, according to the report. Water and juice was supposed to be offered to him hourly.

Farris was awaiting a mental health evaluation to determine if he was able to assist with his own defense. Initially the judge ordered Farris to be moved to Western State Hospital for his mental health evaluation. Less than a week later the order was revised, however, allowing the evaluation to take place at the Island County Jail. Long delays at Western State Hospital have been at the center of federal lawsuits and the psychiatric hospital has been ordered to make changes to fix the problems.

Farris had been checked on by a jail nurse and mental-health doctors through his cell door on April 6, according to the report. The nurse did not ask to go inside the cell because she heard staff say that Farris was violent and uncooperative.

She said he didn’t arrive at the jail with any medical history, nor was there information that he was taking any medications. There is no indication that Farris was ever given his medication, though it appears that his father called and inquired.

Corrections deputies were supposed to check on him hourly on April 7. The deputies’ logs said that happened, but security camera surveillance showed no checks took place for several hours at a time.

He was found dead at 12:40 a.m. April 8. His time of death was estimated at roughly two hours before.

In the report, the corrections chief said that under jail policies, if an inmate wasn’t taking in food or water, “we cannot manage that individual here, he has to go to the hospital.”

At the same time, the investigation raised questions about the adequacy of the jail’s policies, which reportedly were written for a bigger operation and don’t fit the reality in Coupeville.

Corrections officers around the country — including Snohomish County — have been struggling with providing care for inmates who are mentally ill, suffering from alcohol and drug withdrawal, living with medical problems, or a combination of those issues. Jails are designed to detain offenders. Medical and mental health services traditionally have been seen as having a lower priority than security.

Farris’ family is planning a demonstration outside the jail in Coupeville at 10 a.m. Sunday.

He attended high school in Coupeville and Lopez Island, where he graduated in 2008. He spent most of his life on Lopez Island and was living there prior to his death.

He enjoyed writing, walking the beach, playing basketball and hanging out with friends and family. He “planned to one day sail the world and live off the land while he continued to write,” according to the website.

“Keaton was loved by his family and friends on Lopez and Whidbey Island.”

Diana Hefley: 425-339-3463, hefley@heraldnet.com. Twitter: @dianahefley.