Preliminary medical reports indicate Estrada, 62, then died of renal failure, but the final autopsy results are not complete, Adams said.

Richard Garden, the prison's medical director, was previously placed on administrative leave pending results of investigations by the Department of Corrections; University of Utah Health Care, whose employees at South Valley Dialysis missed the appointments; and the disability law center.

Estrada's family last month filed a lawsuit in connection to his death.

The University of Utah Health Care investigation found that a technician with South Valley Dialysis had agreed to switch shifts with a co-worker and take the April 3 and 4 appointments. But although the techs both noted the change on a communications log at the prison, the tech who agreed to cover the shifts failed to note the change on his personal calendar, investigators found, and did not go to the prison.

Prison nurses apparently did not try to contact the dialysis center for at least two days after the tech began missing appointments, according to the investigation.

Then, after leaving a phone message in the dialysis center's empty office on the afternoon of Sunday, April 5, prison workers did not seek treatment for six other inmates who missed dialysis treatments until after Estrada died, nearly six hours later, according to the investigation.

Those six inmates were taken to a hospital for evaluation: One was hospitalized overnight, three received dialysis and returned to the prison, and two were found to not need dialysis immediately.

Estrada died while medics were preparing to transfer him to a hospital, Adams has said.

When Estrada died, he was just weeks from being released on parole after nearly a decade in prison on a rape conviction. He had spoken of the importance of his dialysis treatments in a 2008 parole hearing.

"I'm getting very sick and very ill, and if I hadn't gotten into that program I wouldn't be here right now," Estrada said.

The Department of Corrections in April hired WELLCON, a Utah-based consulting firm, to investigate Estrada's death, dialysis treatments at the prison, and overall prison health care. The department's Law Enforcement Bureau also is conducting an internal investigation. The Utah Department of Health will review both investigations.

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