FAIRFIELD, Calif. (KTVU) - At 83 years old Kenneth Utterback from Vallejo was a survivor. He had survived serving in the Vietnam War. He had survived a massive seizure on a Navy ship in his 20s, and he had survived a life-threatening allergic reaction when doctors then prescribed him the common anti-seizure medication Dilantin.
"I remember him being swollen up. He was peeling as if he had been burned," said Utterback's son Eric Utterback who was a child at the time. "His skin was thin like a balloon."
But on April 15, Kenneth Utterback did not survive what should have been a temporary psychiatric hold at the Solano County Jail, according to his two sons.
Jail records obtained by 2 Investigates reveal that during the jail intake process a correctional officer confiscated Kenneth Utterback's medical alert tag while the elderly man was in a confused state of mind.
Jail medical staff then gave him the very medication he was deathly allergic to, according to medical records.
The result: an allergic reaction so gruesome it left his skin breaking down internally and externally.
"I said ‘Doctor, that is just what my father looked like 50 years ago when they gave him Dilantin!" Eric Utterback told 2 Investigates.
Eric Utterback said he instructed doctors to request his father's Veteran Affairs medical records, and it was only then that they realized he was clearly allergic to the medication he had been prescribed.
"Their jaws dropped," Eric said.
Records show Kenneth Utterback had been given Dilantin for at least a month by staff at Solano County Jail and Northbay Medical Center in Fairfield.
According to his death certificate, he died of septic shock, multiple organ failure and Steven's Johnson Syndrome. Steven's Johnson Syndrome is a rare and serious skin reaction that resulted, in his case, from the Dilantin.
"I want Solano County Jail to be held accountable," said Kenneth Utterback's youngest son Trent Utterback. "I'm angry right now because their neglect killed my father."
Postmortem photos show the elderly man's body peeling and his face blackened as if scorched in a fire. He was transferred to two hospitals before ultimately being sent to UC Davis' burn center where he died in April.
Doctors repeatedly wrote "No known allergy" on medical records.
TIMELINE OF KENNETH UTTERBACK'S TREATMENT:
As a result of 2 Investigates' reporting, the Solano County Sheriff's Office, which oversees the jail, immediately launched an internal investigation and changed its inmate property handling policy.
On July 9, a custody division captain sent an internal memo alerting staff that employees who come across inmate medical information, like a medical alert tag or paperwork, must notify medical staff.
That policy was not as clear before, according to Solano County Sheriff's spokesman Deputy Cully Pratt.
"We were led to believe it was common practice. You could say it fell under common sense," Pratt said "But there are a lot of things that may have happened."
Pratt said his department was unaware of what happened to Kenneth Utterback until 2 Investigates reached out. Their investigation, he said, is currently looking into who processed the veteran into the jail and how staff handled his medical information.
According to Pratt, Kenneth Utterback passed the jail's 10-page medical screening process and told jail staff that he was taking Dilantin. His sons were shocked to hear that response.
"That's sickening! That is a slap in my face and a slap in my father's face," Eric Utterback said. "My father has known he was allergic to Dilantin for 50 years, and he had his medical alert tag that said he was allergic to it."
"We are doing everything we can to make sure this never happens again and to find out what exactly happened," Pratt said.
Pratt said his agency's internal investigation could take several weeks, and he is committed to releasing the results to the public. He said there could be more policy changes as the investigation continues.
Both NorthBay Medical Center in Fairfield and Mercy General Hospital in Sacramento, where Kenneth Utterack was transferred, declined on-camera interviews with 2 Investigates citing patient privacy laws.
"NorthBay Medical Center physicians followed evidence-based protocols and adhered to NorthBay's procedures related to the care of Mr. Utterback," Steve Huddleston, Public Affairs VP of NorthBay Healthcare, wrote in an email.
Dignity Health, which oversees Mercy General Hospital, wrote, "[We] would like to express our deepest sympathy to the family for their loss. The care and safety of our patients is our top priority."
Kenneth Utterback's sons said even though they had recently lost contact with their father, no one should die the way he did.
"It's too late to say ‘I'm sorry' or ‘I love you'," Eric Utterback said. "That's all gone."
Candice Nguyen is an investigative reporter for KTVU. Send her comments and story tips at firstname.lastname@example.org.