“Catastrophic systemic failures” at the Island County Jail led to a 25-year-old man’s death from dehydration April 8, Island County Sheriff Mark Brown said.

An exhaustive investigation by Detective Ed Wallace offers an unblinking look at how negligence and errors by both corrections deputies and jail administration contributed to Keaton Farris’ tragic death. The report was released June 18.

Island County Coroner Robert Bishop reported that Farris died from dehydration, but malnutrition was a contributing factor.

Farris was suffering from mental health issues and had been both combative and non-responsive with jail staff in three different counties, Wallace’s report indicates.

Wallace’s 51-page report outlines a complicated series of missteps. The water to Farris’ cell in the Island County Jail was turned off for days because he put a pillow in the toilet at one point and later flooded his cell. He was given water during his meals but it was only a fraction of what was necessary to survive. The staff did not check on him as often as protocol dictated. The logs didn’t include necessary information and observations.

Medical staff wasn’t called to examine Farris until the day before he died and the nurse didn’t relate any concerns to jail staff.

“Once the nurse was notified she failed to do a proper evaluation of his condition even after Farris advised her that he was not doing well,” Wallace wrote.

The detective figured out that the two corrections had falsified their logs by comparing the entries to surveillance video.

At this point, it’s unclear whether anyone may face criminal charges. Brown said Wallace’s report has been sent to the Island County Prosecutor’s Office. Prosecutor Greg Banks said he will review it carefully.

The sheriff said he doesn’t excuse himself from blame. He said he failed in his supervisory role over the jail.

Brown said he immediately implemented changes at the 58-bed jail to ensure inmate safety and is planning on bringing in an expert in jail administration to do a comprehensive analysis of the facility, especially those confined to “safety cells.”

“I want to know why the problems were so glaring and why I didn’t see them,” he said.

Brown breaks into tears when he talks about the death of the young man who once played high school football and was a track star in Coupeville, the town where the sheriff’s office resides.

The sheriff said he brought Farris’ father into his office soon after the tragedy and had one of the most difficult conversations of his life.

“I promised him I would investigate this as if he were my own son,” he said, struggling with his emotions.

Brown said his mission is to find the truth, disseminate it to the public, repair the problems and — hopefully — regain the public trust while offering closure to Farris’ family. He said he doesn’t know if the family will sue and such an eventuality isn’t guiding his actions.

Brown conceded that larger issues are at play in the death, particularly how jails are ill equipped to deal with people with mental health issues. At this point, however, Brown said he’s focusing on the problems at his jail and what he can do to fix them.

Sgt. Chris Garden, a veteran member of the department with training in emergency medicine, has taken over as interim jail administrator. He will be working closely with Undersheriff Kelly Mauck.

Missing from Wallace’s report is the family’s interaction with the jail, according to Keaton’s father, Fred Farris. He said he and other family members went to the jail just about every day to see Keaton Farris, but were turned away.

The reasons cited were unclear, conflicting and sometimes simply false, he said.

He said family members would have noticed something was wrong and gotten him help; he said his son lost more than 20 pounds during his short time in jail.

“It wouldn’t have happened if we were able to see him,” he said. “That’s the whole thing.”

Brown said that the jail policy doesn’t allow visitations when an inmate is in crisis or at risk. He said such individuals can’t be moved to visitation rooms and visitors aren’t supposed to be brought to cells.

Brown said he’s interested in looking at policies at other facilities. He said it might make sense to allow visitors to visit certain inmates at their cells, especially if it would calm them.

Keaton Farris was diagnosed with bipolar disorder two years ago after experiencing a sudden onset of symptoms, his dad said.

It was difficult to deal with, Fred Farris said, but he was convinced his son would figure it out and live a happy life.

He noted that Keaton Farris had never been in a jail before this incident and had no criminal record.

Records said San Juan County Superior Court show that prosecutors charged Farris, a Lopez Island resident, with second-degree identity theft on March 2 after a man reported that a check was stolen, forged and cashed at a bank. A $10,000 warrant was issued for Farris’ arrest.

Lynnwood police picked him up on the warrant March 20. Officers responded to a report of a suspicious man at a bank. Farris was transferred to Skagit County on March 24. He was originally supposed to be transferred the day before, but he apparently resisted and was tasered in Snohomish County.

In Skagit County, he was non-communicative and resisted jailers; he was placed is restraints. A Skagit official warned the Island County jail lieutenant that two corrections deputies would be needed to transport Farris because of his unpredictable behavior.

The San Juan Sheriff’s Office finally transported Farris to Island County on March 26. The Island County Jail holds inmates from San Juan County under an interagency contract.

Farris arrived at Island County Jail without his medication or any of the medical and mental-health information that the other jails collected. Brown said he doesn’t yet know what happened, but he hopes to work with the other agencies in the future to ensure such information is shared.

Farris was initially placed in a blue-padded safety cell but was moved to a single-person cell March 30. His cell was designated as a “safety cell,” which means heightened monitoring is required.

On March 30, water to Farris’ cell was turned off after he placed his pillow in the toilet and was “playing in the water in his sink,” Wallace wrote. It was turned off again when he flooded his cell on April 4.

In his investigation, Wallace estimated that Farris’ consumption of water and other fluids during his time at the jail was about 185 ounces based on the amount of liquid in the Dixie cups the jail uses.

Under National Institute of Health guidelines, Farris’ intake should have been 1,563 ounces. FEMA guidelines state that 791 ounces would be necessary for survival in an emergency situation.

“The number could be lower since we cannot confirm that he consumed all the water/fluids provided,” Wallace wrote. “It could be higher as well since there were windows of opportunity where he would have been able to provide himself water.”

Farris’ inmate book states that he was supposed to be observed each hour, but the log showed long stretches of time in which nobody checked on him. The last time that a corrections deputy confirmed he was alive was at 5:30 p.m. April 7. A deputy tapped on his door at 8:30 p.m., but Wallace wrote that it was likely he was dead at that time because of the lack of response and based on the estimated time of death determined by the coroner.

Corrections deputies discovered Farris was dead at 12:30 a.m. on April 8.