‘The system failed her’ – Questions remain following deadly year at the DeKalb County Jail

Her brother, Matt Colman, said his sister had been in and out of mental health facilities since Memorial Day 2022.

“That’s when she started having what seemed to us like manic episodes,” Colman said.

Things escalated when Colman, 55, showed up at the Tucker home of her fiancé, Corey Jones.

“I had told her she couldn’t live at the house anymore, and I had actually changed all the locks in the house,” Jones said. “Just because she was always in my face. I loved her but it was too much living with her.”

Colman managed to get inside the home through the garage door. Jones asked Colman to leave several times, but she refused. Following an argument, she physically pushed Jones through the house’s back door before leaving in a Lyft.

Colman returned later that evening, demanding to be let in, but Jones refused. A police officer arrested Colman on charges of stalking, criminal trespass and simple battery.

Colman had Bipolar disorder, according to family members and friends. Police were aware of this when they arrested Colman, the arrest report shows.

The contractor for the jail is supposed to conduct a mental health intake screening, but records show that wasn’t done in Colman’s case because she had COVID-19 and was moved to isolation.

On July 25, 2022, Colman became one of nine inmates who died while in custody at the DeKalb County Jail in 2022, the deadliest year for inmates since 2012. She didn’t die because of COVID.

She had an undetected hole in her intestine, which caused her death. Colman’s friends and family feel the death was preventable, and records show the Sheriff’s Office found an employee did not follow proper procedures in the hours leading up to her death.

The Sheriff’s Office of Professional Standards investigated all inmate deaths in 2022, meaning the Sheriff’s Office was investigating itself. The sheriff invited the GBI to investigate two deaths at the jail, but the GBI declined.

Several of the inmates who died in 2022 had a history of mental illness, records show.

Sheriff Melody Maddox has repeatedly refused Decaturish.com’s requests for an interview about inmate deaths in 2022. The Sheriff’s Office and Medical Examiner provided numerous documents in response to our records request that shed new light on how the nine inmates died.

‘Someone needs to be looking into it’

The DeKalb County Jail has so far not reported any inmate deaths for 2023. The DeKalb Sheriff’s Office declined to provide a statement about what may have changed at the jail since 2022 that would’ve reduced the number of deaths. A spokesperson said, “The issue simply cannot be addressed that generally.”

Michele Deitch, a professor at the University of Texas at Austin who is considered an expert on jail conditions, said the reality is more often than not there are no outside agencies taking a hard look at deaths in local jails.

“But where you’ve got a situation where there’s been a whole lot of deaths… someone needs to be looking into it,” Deitch said. “The other issue is whether they are looking at the deaths or are capable of looking at the deaths with an eye toward preventing future deaths.”

None of the sheriff’s office investigations touched on systemic issues that could’ve contributed to the high number of deaths last year. Instead, the Office of Professional Standards’ investigations of each death focused on whether staff followed all policies and procedures.

In two of the inmate deaths, investigators found employees didn’t follow them.

In Colman’s case, the Office of Professional Standards concluded that an employee of the jail saw her naked in her cell and staring at the wall.

A nurse asked to check Colman’s blood pressure, but the employee told the nurse he couldn’t open the cell door because he was the only security officer in that section of the jail. The investigator found the jail employee did not notify his supervisor, a violation of jail policy.

Matt Colman, Nina Colman’s brother, said the finding that the jail employee did not follow proper procedures was not what bothered him the most about what happened to his sister.

“That’s a safety thing,” Matt said. “The thing that stands out to me is they never seem to address what appeared to be a mental health issue. That was troubling to me.”

The other case where an officer did not follow proper procedure involved the death of Vernon Head, 48, who died because of a build-up of scar tissue in the heart, a condition known as myocardial fibrosis. Head had been arrested in 2021 and was accused of making terroristic threats. Head died on July 22, 2022, a few days before Colman died.

Head, like Colman, had a mental illness. He had a history of schizophrenia and substance abuse.

The OPS investigation into Head’s death concluded that an officer lied about going on a watch tour during her shift. The OPS investigation into Head’s death also found that another jail employee was sleeping on the job.

‘Significantly cold’

The last inmate deaths of 2022 were Anthony Walker, 34, who died on Dec. 26, and Jackson Orukpete, 57, who died on Dec. 27, remain under investigation by the Sheriff’s Office.

The Medical Examiner’s report says Walker died of hypothermia, and his death was ruled an accident.

Walker was arrested on Dec. 18 on charges of aggravated assault and possession of a firearm by a convicted felon.

Walker had schizophrenia and a substance abuse problem. Jail staff found him naked and dead in his cell on Dec. 26, according to a record provided by the Sheriff’s Office.

The Medical Examiner’s report said, “Investigative reports indicate that the ambient temperature was significantly cold (not measured), and the decedent’s skin was reportedly wet due to flooding in his cell resulting from his reported obstruction of the toilet outflow with his clothing, which was subsequently confiscated.”

The autopsy findings in Walker’s death were “consistent with fatal hypothermia associated with a qualitatively cold environmental ambient temperature compounded by moist skin surfaces and absence of overlying clothing.”

Emails reviewed by Decaturish show that Walker was the son of a former employee of the Sheriff’s Office.

When a chaplain and Sheriff’s Office employees notified his mother about her son’s death, she told them that all Walker needed to do was take his “shot and medication.”

Like Walker, Orukpete was found dead in his cell by jail employees. He was arrested in July 2022 on a charge of family battery and violence.

It’s not clear from the records whether Orukpete had a mental health diagnosis, but records provided by the sheriff showed he was ordered to undergo a mental health evaluation in November 2022 to determine his competency to stand trial.

The medical examiner ruled that Orukpete died from “Cardiac Dysrhythmia due to Atherosclerotic Coronary Artery Disease.” It was also cold in Orukpete’s cell.

“The ambient temperature within the cell was qualitatively described as being very cold; the decedent was covered with a blanket but was otherwise unclad,” the Medical Examiner wrote.

The Medical Examiner said cold temperatures may have contributed to Orukpete’s death, but it couldn’t be proven.

“The potential influence of the reportedly cold environment upon the development of a fatal cardiac dysrhythmia due to severe coronary artery stenosis must be considered …,” the Medical Examiner wrote. “However, antemortem hypothermia can be neither conclusively verified nor excluded by postmortem examination due to the universal tendency of corpses to gradually assume environmental ambient temperatures.”

‘Ain’t going to make it too much longer’

Three of the nine deaths at the jail were ruled to be suicides.

The first death at the jail in 2022 occurred on Feb. 6. Jaquay Smith, 20, of Stone Mountain, hanged himself in his cell. He had been arrested on Feb. 1, accused of aggravated assault with a weapon and armed robbery.

The Sheriff’s Office did not provide any other records about Smith’s death, but Decaturish has followed up to ask if an Office of Professional Standards Investigation had been completed.

Michael Assevero, 65, hanged himself in his cell on Aug. 14, 2022. He had been arrested on Aug. 11 on a warrant for failure to appear in court to face a charge of violating the Georgia Rico Act. Assevero, a doctor, was accused of being part of a “pill mill” distributing pain medication.

Before his suicide, Assevero told another inmate, “I’m 65 years old man. I ain’t going to make it too much longer,” according to records provided by the Sheriff’s Office.

Anna-Maria, Assevero’s sister, questioned the circumstances of her brother’s death.

“How it could be allowed to happen is a real big question mark,” she said.

She believes her brother received “shabby care” while in custody at the jail and believes jail staff were negligent.

Records provided by the Sheriff’s Office show Assevero had wounds from a previous suicide attempt when he was admitted into the jail.

Viktor Ivanov Radunchev, 27, was found hanging in his jail cell on Aug. 16, 2022. He’d been at the jail since Aug. 13, 2022, on a charge of simple assault and family violence.

He was born in Bulgaria and lived in Snellville. An administrative review of the death said, “very little is known about his life or the catalyst for this suicide.” During intake, he said he had never been diagnosed with a mental illness and his responses did not trigger any red flags indicating he was a suicide risk.

He was given a mental health referral after a nurse noted “odd” behavior. It appears that the evaluation was not completed before his death.

‘Not for me to answer’

Two deaths at the jail occurred within days of each other due to heart conditions.

Ivory Kelly, 35, died at the jail on May 16, 2022. The official cause of death was listed as a heart attack.  He was found unresponsive in his jail cell and died at Grady Hospital 12 hours later.

Ivory had been arrested in April 2021 on a charge of disorderly conduct and terroristic threats.

In 2021, he had been deemed incompetent to stand trial. On the day before he died, Kelly had been in a fight with another inmate, records provided by the Sheriff’s Office show.

While at Grady, Kelly became combative with staff and resisted medical treatment, which caused staff to restrain him to his bed. He died later that morning after fighting with medical staff trying to treat him.

The Office of Professional Standards’ investigation of his death found that jail staff had followed all policies and procedures.

Taneeka Holmes, 43, died at the jail on May 18, 2022, and the cause of death was ruled to be cardiovascular disease. She was arrested on May 12, 2022 and was accused of driving without a license, failure to yield and a probation violation.

Holmes was arguing with another inmate before her death.

Rowena Holmes, Taneeka’s mother, said her daughter wasn’t supposed to be in jail at the time of her death.

Her arrest stemmed from charges out of Avondale Estates and the order and she was supposed to be released on a signature bond within 72 hours, according to her mother and records provided by the Sheriff’s Office.

“She was supposed to get out, but whoever was supposed to tell the county to let her out in three days, they weren’t at work in Avondale Estates,” her mother said.

Avondale Estates City Manager Patrick Bryant said at the time of Holmes’ arrest, the city court clerk was out on extended medical leave.

“So, while she was gone she had our judge issue a standing order to the jail to release all persons in their custody on one of our warrants after 72 hours on their own recognizance if they haven’t bonded out with cash,” Bryant said.

Bryant said the sheriff got that order and acknowledged receiving it. Holmes should’ve been released before her heart attack, and he’s not sure why she wasn’t.

“That’s not for me to answer,” Bryant said.

Rowena questioned whether it took too long for her daughter to get medical attention.

Holmes first fell to the floor at 7:11 a.m. on May 18. A sheriff’s office employee arrived on the scene at 7:15 a.m. A paramedic arrived shortly before 7:17 a.m.

The Office of Professional Standards’ investigation into Holmes’ death found that staff followed all jail policies and procedures.

‘The system just failed her’

While Sheriff Maddox has declined to speak to Decaturish about inmate deaths at the jail, she did answer questions submitted via email to the Atlanta Journal Constitution, but it’s unclear if she sent those answers back to the reporter.

She compiled her answers in October 2022, after seven of the nine inmates had died.

The AJC reporter asked Maddox to explain the high number of deaths and asked whether COVID-19 had been a factor.

In response, Maddox said, “There is no blanket answer to the question of why individuals die while in custody or why there are more of these occurrences in some years than in others.”

“Statistically, the ratio of custodial deaths to the surviving inmate population is likely comparable to what occurs in the greater community outside the detention facility, as are causes of death,” the Sheriff wrote in her answers to the AJC.

“As the coronavirus persists as a health care issue, medical professionals concur that it will have an impact on deaths in general, due to complications from the illness and related additional health challenges.”

Based on the records provided by the Sheriff’s Office and Medical Examiner, there is no indication COVID-19 caused any deaths at the jail in 2022. But several of the inmates, including Colman, had mental health issues, records show.

In response to the AJC reporter’s questions about mental health, Maddox said that mental health issues can put a strain on the jail. She told the AJC that 40% of the jail’s yearly admissions enter the jail with a mental health and/or substance abuse diagnosis.

A contract provider for the jail conducts a mental health assessment during the inmate intake process and follows a mental health suicide prevention plan of action in coordination with jail security to monitor the behavior of inmates, Maddox wrote in her response to the AJC.

“Detainees with longer legal stays tend to have more serious mental health challenges that may exceed jail service capacity, and discharge planning is difficult because of limitations in community-based resources, housing, health care coverage and related factors,” she wrote.

Colman was familiar with the challenges faced by people with mental health issues, her brother said. In addition to being Bipolar, Colman was working for disABILITY LINK, an advocacy organization for people with disabilities based in Tucker. Before her arrest and death, she had left the organization prior to her death to take care of her mental health.

“It sucks. My sister spent her life helping other people and … it seems like the system just failed her,” Matt Colman said.

The National Suicide Prevention Lifeline is a hotline for individuals in crisis or for those looking to help someone else. Dial 988 to speak with a certified listener.