Internal investigation found 'systemic breakdown' by state possible factor in death of Gynnya McMillen
Staffers repeatedly lied about checking on the teen, ate her food when she did not respond, left her lying in the same position for 10 hours without seeing if she was OK and failed to provide CPR when they learned she was not breathing, according to the investigation.
LOUISVILLE, Ky. (WDRB) -- The day after 16-year-old Gynnya McMillen died at Lincoln Village Regional Juvenile Detention Center a little before midnight on Jan. 10, the facility's superintendent told investigators "it appears we did everything right," according to recently released court records.
But despite Michelle Grady's initial claim, an internal investigation made public in a federal lawsuit filed against several Department of Juvenile Justice and Lincoln employees Wednesday lays out myriad mistakes from staffers at all levels throughout the teen's 24-hour stay.
Staffers repeatedly lied about checking on the teen, ate her food when she did not respond, left her lying in the same position for 10 hours without a closer examination to see ff she was okay and failed to immediately provide CPR when they learned she was not breathing, among other failures, according to the investigation.
While an autopsy determined that Gynnya died in her sleep from a rare heart condition known as sudden cardiac arrhythmia, the internal investigation concluded that "had staff conducted their checks as required, they might have detected a medical issue with her and provided the proper medical assistance that may have prevented her death."
A total of six staffers missed and then falsified 65 bed checks. Officials at the center admitted they do not check video to see if the bed checks are actually made. This has led to a culture where staffers often skip the checks, according to the records.
The internal investigation found that "not verifying the accuracy" of the observation logs "has caused the staff to become complacent. This in turn became a systemic practice of some staff falsifying the Room Observation Forms."
This "systemic breakdown led to staff possibly not noticing (Gynnya) in a medically stressed state," the internal investigation concluded.
Staff at Lincoln Village "did not provide appropriate supervision, medical care, food, clothing, shelter or education," the investigation concluded.
The assistant superintendent of the facility, Michael Price, told investigators staff is expected to make sure a resident is breathing. An "hourly wellness check" is expected to be "thoroughly documented," Price said, according to documents. If no movement is detected, "staff should go in the room and physically check to see if the resident is alive."
Grady also said that during hourly wellness checks, staffers are supposed to check to make sure a resident is breathing and "she would open the door if the resident has not moved or she cannot ascertain if the resident is breathing."
Staffers did not check to see if Gynnya was breathing for more than 10 hours.
Stacy Floden, a spokeswoman for the Department of Juvenile Justice, told WDRB in January that "staff is not to enter the room until wake up time unless the youth shows signs of distress" or to deliver medicine or personal hygiene items.
"Youths are required by the American Correctional Association Guidelines to have eight hours of uninterrupted sleep," Floden said. "We make every effort to ensure that the youth is sleeping and in no apparent medical distress, the head isn't covered, and nothing is covering the neck or face. That's why we require that the head and neck be exposed. Even during hours when youth are awake, staff do not generally enter youth rooms unless necessary to avoid the risk of assault."
In response to the lawsuit, the Department of Juvenile Justice released the following statement:
"We respect the family's right to bring this action and remain deeply saddened by their loss. We have also fully complied with three independent investigations, all of which confirmed that this tragedy was the result of natural causes. After reviewing all the evidence, medical examiners were clear that this child passed away in her sleep, without any signs of distress that would have prompted medical attention."
The lawsuit claims that a little before midnight on Jan. 10, Gynnya coughed a few times and seized in an "uncontrolled manner," while a guard watched.
An expert witness for Gynnya's family believes the coughing was the teen gasping and losing consciousness and that a former guard, Reginald Windham, who heard the coughing and saw the seizure, could have "in all likelihood saved the girl's life" if he had taken action, according to the suit.
Windham, according to the suit, said he checked on Gynnya "to make sure she had not thrown up and was choking or something like that." He looked through her cell door at 11:39 p.m. for 18 seconds, watching "her last gasps and dying breaths and final uncontrollable movements and seizure," the suit claims.
At this time, Gynnya rolled onto her stomach with her left leg hanging of the bed at the knee, according to a picture released. She then rolled back onto her right side and did not move again, according to the investigation.
A physician estimated this is when Gynnya died.
In a summary of his interview with investigators, Windham said Gynnya did not make any sounds that caused him to believe she was in distress. He believed she was asleep and breathing.
Windham acknowledged checking on Gynnya two or three times "at most."
Windham, who is facing misdemeanor charges along with another former staffer, Victor Holt, for allegedly lying about performing multiple bed checks on Gynnya, "did not lift a finger to help her, instead returning to his desk," according to the suit. An attorney for the men has said they were following protocol at the center. They have pleaded not guilty.
Holt initially lied to investigators about making the checks, according to the internal investigation. After being shown the surveillance video, Holt admitted he "missed multiple checks, fabricated facility documents and violated facility policy and procedure."
Holt also told investigators he should have woken Gynnya up prior to a deputy arriving to take her to court around 10 a.m. and did not attempt CPR when "he did finally realize (the teen) was in medical distress or deceased."
In addition, the assistant, Price, told investigators that staffers are expected to wake residents by 5:45 a.m. Staffers did not get help for Gynnya until about 10 a.m.
Around 6:30 a.m.,an employee pounded on Gynnya's cell door holding a tray of food. When she did not respond, the worker "callously ate her breakfast" and later lied about making a bed check, the suit claims.
The employee wrote that Gynnya "declined breakfast -- refused to acknowledge staff," the suit says.
Guards should have completed a form signed by the teen declining the food, officials said. And Grady acknowledged staffers should not have eaten the food.
A little later, according to the internal investigation, Holt told Gynnya she had a phone call. When she didn't respond, he said, "I don’t have time for this" and closed the cell door, a staffer told investigators.
At about 9:37 a.m., Holt entered the teen's cell and picked up a water bottle sitting on the bed, using it to push Gynnya's body. Holt then attempted to shake Gynnya's body. After receiving no response, Holt left the cell with the water, later noting that he performed a bed check and reporting that "resident was told to get up and change out for court and ignored staff."
At 9:55 a.m., another staffer came in and tried to wake the teen, kicking her bed frame, according to a time line in court records.
For several minutes, Holt and the other staffer try to wake Gynnya by shaking and moving her. Neither man performed CPR.
Around 10 a.m., a nurse came into the cell and began to perform CPR six minutes later.
The investigation also goes into detail about an Aikido control technique used to restrain Gynnya after she refused to remove her hoodie and was combative when she was first brought to Lincoln.
Gynnya became "belligerent" when told staffers would have to search her for weapons and contraband and refused to follow orders, according to interviews in the investigation.
When she refused to be searched, two staffers grabbed her arms and the teen began to kick, according to the officer who arrested Gynnya after she got into a fight with her mother. Gynnya was placed on the floor and continued to struggle but "staff did not harm her," Shelbyville Police Officer Austin Sasser said.
Five employees and Sasser who either witnessed or were involved in the restraint all said they noticed no injury to Gynnya during or after the incident. The restraint lasted 4 minutes and 15 seconds. Only part of the incident was captured on video as the view was partially obstructed by a counter in the intake area. A camera in that area was not working, according to the investigation.
An autopsy later concluded the restraint "was not a factor in her death," according to the internal investigation.
The lawsuit, filed in the Western District of Kentucky, claims video shows staff members physically restrained Gynnya after taking her to an isolation cell and "forcibly places her on her knees on the metal bed frame with her hands placed on the wall."
Pictures made public in the lawsuit show staffers restraining Gynnya as they take her into her cell because she was "combative," according to court records. But there is no other mention of the restraint in her cell.
So far, officials have only said they used a control technique to restrain Gynnya after she began kicking staffers when she was brought in.
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