It’s common knowledge that once an individual is in custody of the authorities, it’s their responsibility to see to it that the detained individual is safe and well. Unfortunately for Gynnya McMillen, 16, that wasn’t the case at any point during her stay at a juvenile detention center that led to her death.

McMillen was being held in the Lincoln Village Juvenile Detention in Elizabethtown, Kentucky on the morning of Jan. 10 to await a court hearing for a misdemeanor assault in a domestic incident at her mother’s house, according to New York Daily News.

When a deputy arrived at the detention center the next morning to take McMillen to her hearing, she was found laying down in a “sleeping position” cold and unresponsive. An entire nine minutes later, staff called 911. CPR wasn’t started until two minutes after that, according to a recording of the call that was obtained by CBS.

Original reports from the facility claimed that McMillen died in her sleep, but they later added that they used aikido techniques to restrain her at one point because she refused to take off a hoodie.

“The staff performed an Aikido restraint hold to safely conduct a pat-down search and remove the youth’s hoodie,” wrote Stacy Floden, a spokesperson for the Kentucky Department of Juvenile Justice, in a statement. “The purpose of having multiple staff involved in a controlled restraint is to ensure the safety of the youth and staff.”

Based on reports, Lincoln Village Juvenile Detention didn’t do anything they were supposed to do at any point, before and after McMillen’s death. For starters, juveniles are supposed to be checked on by staff every 15 minutes, which McMillen didn’t receive for hours. Guards made verbal offers for food and a telephone call at multiple points – at 6:30 a.m., 8:17 a.m. and 8:53 a.m.– but got no response and still didn’t check on her.

Staff didn’t attempt to get a response from her until the next morning when she was due for court.

As a one-time practitioner of aikido, I can say that using certain techniques at the wrong time with the slightest adjustment – even one small enough to be completely accidental and go unnoticed – can have fatal consequences.

Rules are in place to check on juveniles every 15 minutes for obvious reasons. Finding out that McMillen went hours without one is shocking and it’s devastating to think that just one of those could’ve been the difference between her being carted off to a coroner the next morning and going on to live a full life.

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