Die and Disappear: New Study Rings Alarm on ‘In-Custody’ Deaths

By Stephanie Gadlin

The faces of the incarcerated dead are rarely known past the jailhouse door. Yet this year, a new national study led by Dr. Roger A. Mitchell Jr., forensic pathologist and president of the National Medical Association (NMA), forces America to confront a grim truth: people are dying in police and correctional custody at rates the government still cannot fully count, including alarming numbers of in custody deaths.

The “Strengthening the U.S. Medicolegal Investigation System: Lessons from Deaths in Custody,” co-authored by Dr. Mitchell and released this fall, details a broken system of medical, legal and data failures that obscure how and why men and women, disproportionately Black, die once detained by law enforcement. The report, published by the National Academies of Sciences, Engineering, and Medicine (NASEM), concludes that decades after Congress first ordered agencies to track these deaths, the nation still has no complete, reliable record of them.

The study defines “in-custody death” from the moment you are in contact with law enforcement, including during stops, arrests, pursuits, interrogation, overnight lockups, pre-trial detention, transport, hospitalization, and prison incarceration. The expansive review suggests that custodial deaths, including in custody deaths, are far more widespread than previously reported. This framework provides families, advocates, lawmakers, and the public with a more nuanced understanding of “state-connected” deaths beyond police-involved shootings or incidents of police brutality or torture.

“We would never try to fight cancer, not knowing how many people are dying from cancer,” Dr. Mitchell told the Crusader. “We would never want to fight maternal mortality without counting how many women are dying in childbirth.

“So, the question becomes, do we really want to stop people dying in our criminal justice system?” the NMA president asked rhetorically, “because you begin by completely tracking and accurately tracking those that are dying, either at the hands of law enforcement or in the systems that law enforcement holds.”

The NMA is the nation’s oldest and largest professional organization representing African American physicians and health professionals in the United States. It was founded in 1895 in Atlanta by Black doctors who were barred from joining the American Medical Association (AMA) because of racial segregation.

Today, the association represents more than 50,000 physicians, nurses, and other allied health professionals through over 100 affiliated chapters across the U.S.

Mitchell, who is also a tenured professor at Howard University, is NMA’s 126th president. The son of a single mother and a crack cocaine-addicted father, he said his experiences growing up in New Jersey, along with the impact of the 1999 Amadou Diallo slaying by New York police officers, illuminated his career path.

“I went into medicine looking to serve, but when I found out that forensic pathology was something I could do and that violence was affecting my community, I thought I could study violence through being a medical examiner (and) forensic pathologist,” Rogers said. “I was a first-year medical student when (Diallo) got shot and killed. He got shot at 41 times and was hit 19 times and had entrance wounds in the soles of his feet.

“I knew that I could use my medical training to (fight) police brutality or death in custody,” he explained. “These (types of deaths) are health issues too; and I wanted to spend my career bringing light and understanding how and why people are dying at the hands of law enforcement.”

Board-certified in anatomic and forensic pathology by the American Board of Pathology, Dr. Mitchell worked in the District of Columbia government for seven years, as the chief medical examiner and interim deputy mayor for public safety and justice, among other positions. He was one of the first Black men to work as a forensic scientist for the FBI and co-authored the book, “Death in Custody: How America Ignores the Truth and What We Can Do About It.”

“There has not been an undertaking by NASEM to highlight some of the needs of the medicolegal death investigation system (MLDI) in this country,” Dr. Mitchell said. “The system is compiled of two major subsystems—a coroner system and a medical examiner system. The report gave definition on where that system does not have parity. It gave voice to the fact that there is a lack of a uniformity of practice within the system. It also showed that the system is governed at state, local, county, and does not have federal oversight.”

The NASEM report also exposed systemic gaps that echo through Illinois, where hundreds of people have died behind bars without meaningful review. According to the Illinois Criminal Justice Information Authority’s “2022 Deaths in Custody Annual Report,” 546 people died in custody between 2019 and 2022. Nearly half were Black, despite African Americans comprising less than 15 percent of the state’s population. About 79 percent of those deaths occurred in state prisons, with the majority classified as “natural causes.”

Dr. Mitchell said the persistent labeling of such deaths as “natural” or “undetermined” perpetuates racial disparities. “The use of these undetermined [causes] when cases are not undetermined, or ‘excited delirium,’ when that diagnosis doesn’t exist, it definitely perpetuates disparity,” he said. “…People are dying behind the bars of the jail systems from cancer, from congestive heart failure, from diabetes. And what we don’t know is… are they dying prematurely because of the lack of care? Are they getting the care behind bars?”

He pointed to the case of LaShawn Thompson, who died inside Atlanta’s Fulton County Jail in September 2022. It remains one of the most disturbing symbols of America’s quiet cruelty and indifference toward the incarcerated. Thompson, 35, was discovered slumped in his cell in the jail’s psychiatric wing naked, dehydrated, malnourished, and covered in feces, lice, and bedbugs.

For weeks, he had gone without medication, food, or a shower as guards ignored his pleas and obvious decline. At his death, he was 30 pounds underweight. The Fulton County Medical Examiner initially ruled the cause of death undetermined, turning what advocates called a “slow-motion killing” into bureaucratic ambiguity.

However, an independent autopsy commissioned by Thompson’s family later exposed the truth; his death was a homicide caused by severe neglect. The U.S. Department of Justice opened a civil-rights investigation in 2023, citing “unsanitary, unsafe, and inhumane” conditions at the jail. On January 3, 2025, federal officials and Fulton County entered into a consent decree requiring sweeping reforms to protect detainees’ constitutional rights. The agreement mandates improved mental health and medical care, enhanced supervision and staffing, the elimination of unconstitutional isolation, and comprehensive pest control and sanitation measures. A federal monitor was appointed in February.

Thompson’s family received a $4 million settlement.

In 2024, Michael Broadway, age 51, died during a June heat wave while incarcerated at Stateville in downstate Illinois. The official autopsy listed bronchial asthma as the cause of death, with heat stress identified as a “significant contributing condition.” Inmates had complained of a lack of air conditioning, medical care and access to water as internal prison temperatures reportedly reached 110 to 120 degrees. Broadway had recently graduated with a bachelor’s degree from the Northwestern University Prison Educator Program just eight months earlier.

His death sparked protests and calls for justice and reform. Less than 120 days before Broadway passed away, IL Governor JB Pritzker announced Stateville, which opened in 1925, along with a sister facility would be demolished and replaced by 2029 in a $900 million construction plan.

“Cases (like these) are being reported as natural deaths but are these natural deaths preventable,” Dr, Mitchell continued. “You know, there is a law called the Medicaid inmate exclusion policy, and when Medicaid was written into law, it says ‘yes, if you meet the criteria, … you get Medicare, and if you’re young and disabled or poor, you can get Medicaid. But if you’re in jail or prison, you can’t get Medicaid. You can’t get state-sponsored health care. What you’re going to get is what is offered and given to you… You know it’s less costly to take care of healthy people than sick ones.”

Mitchell also noted that his research has found that a great majority of people who are dying are pre-trial. “Many of them have never had their day in court,” he said. “They are being held until trial and therefore haven’t been convicted of the crimes they’re accused of. This is alarming and begs the question of why many pre-trial detainees are dying in custody—be it from disease (diabetes, high blood pressure, heart disease, etc.), suicide, accidents, or something else.”

A National Crisis Hidden in Plain Sight

The federal Death in Custody Reporting Act of 2013 required states to report every death occurring during arrest, detention, or incarceration. Yet even with that mandate, the U.S. Department of Justice Bureau of Justice Statistics has repeatedly failed to produce a complete count. In 2021, the Government Accountability Office found that nearly 1,000 in-custody deaths went unreported nationwide. There have been no congressional hearings or consistent calls for accountability by members of Congress.

For African Americans, not only are “Black lives” devalued, so are “Black deaths.” Families have long decried the way their loved one’s deaths were handled by law enforcement or government officials whose reports are often vague and devoid of detail. Most of the outrage centers on the fact that many families aren’t notified at all.

Dr. Mitchell warned that many custodial deaths involved whites, a statistic that also goes unreported. “A lot of white males are dying while in custody and this is an overlooked fact,” he said. “We know the opioid crisis ravaged many communities, just like the crack epidemic primarily hit Black neighborhoods. But it wasn’t until legislators realized just as many whites were dying from the opioid crisis that the federal government, the media, and everybody started ringing the alarm and it became a public health issue.

“This is a problem that is facing the entire country, and particularly in states like Indiana and Illinois, where there is a large rural population,” he continued, “we see white men and women, particularly white men, are dying not at a higher rate because black people and brown people are dying at a higher rate, but they’re dying in law enforcement’s custody, and we don’t know why they died either.”

Illinois paints a disturbing picture. In 2022, the Illinois Criminal Justice Authority (ICJIA) documented 546 deaths in custody between 2019 and 2022; 263 victims (48.3 percent) were Black; 224 (41.2 percent) were white; 49 (9.4 percent) were Hispanic/Latino; and 8 (1.5 percent) were Asian. About 398 (72.5 percent) were officially deemed “natural causes;” 39 (7.1 percent) were ruled suicides; and 21 (3.8 percent) deaths were attributed to use of force or restraints by officers. The remainder were accidents, overdoses, or undetermined cases. But the report also revealed that some counties failed to report deaths or provided incomplete data, meaning the totals likely undercount true figures due to noncompliance or missing records.

The ICJIA researchers noted that most deaths occurred in older prison populations but also documented gaps in reporting by local agencies. Their study acknowledged that cross-checks with media coverage and the Illinois Violent Death Reporting System often revealed missing or misclassified cases, thus confirming that the true number of deaths is likely higher.

In Cook County, where Chicago’s sprawling jail complex sits, advocates have long accused officials of failing to release timely data. Between 2019 and 2024, at least 116 people died in the custody of Cook County Jail and state prisons combined, according to an analysis of public records and advocacy databases. Community groups such as the Chicago Appleseed Center for Fair Courts and the Illinois Justice Project have demanded the creation of a public fatality review board and mandatory independent autopsies.

Carlos Ballesteros is an award-winning, senior investigative reporter with the nonprofit newsroom “Injustice Watch.” In his June 12, 2024, heavily researched and groundbreaking investigation, Ballesteros revealed that 18 people died in the jail in 2023, marking the highest mortality rate at the facility in a decade. About half of those deaths, his team found, were preceded by failures in supervision or medical care, such as unchecked withdrawal symptoms from smuggled drugs, unexplained time alone in cells, and alarms that never triggered. One such case involved a detainee placed in detox who collapsed eight hours later on the toilet without staff ever entering the bathroom.

 “What we found is that in 2023 there was an incredibly high number of deaths at Cook County Jail; the most number of deaths in a decade at the jail,” he told the Crusader, “even though the daily average population that year was half that it was in 2013, which is the last time that they had as many deaths. We set out to figure out why that was. Even the most basic information was unavailable to us, unlike other jails and counties across the country.

“Cook County Jail and the sheriff’s office that runs it do not update the public every time someone dies at the jail (and) there’s no public announcement of the death of the person’s name or the fact that even happened at all anywhere on the sheriff’s website,” he continued. “And like I said, you know that’s different than other big jails across the country, like New York or LA, who do post those updates whenever they do happen, but not here.”

In seeking comment and public records from Cook County Sheriff Tom Dart his office did not respond at press deadline. The Chicago-region jail system remains among the most criticized among those with large populations, for failing to release timely death data.

A spokeswoman for the Cook County Medical Examiner Office (MEO) decline to comment on the NASEM findings. “The MEO did not author or publish the article and cannot provide comment,” Maria Phelan said via email. She did respond to an inquiry about number of custodial deaths between 2020 and 2025 with links to it online portal and a spreadsheet.

Based on verified data from the Cook County Medical Examiner’s Office, between January 2020 and November 2025, 61 people died while in custody in Cook County, accounting for approximately 88 percent of all 69 in-custody deaths statewide under the MEO’s jurisdiction included in the dataset. The overwhelming majority of these deaths (80 percent) occurred in the 60608 zip code, encompassing the Cook County Jail complex on South California Avenue and associated facilities.

The racial data tell an unmistakable story about inequity behind bars: of those who died in custody, 33 were Black, 20 were White, and 8 were Latino or Hispanic. Over half of the deaths (54 percent) involved a Black detainee, mirroring the county jail’s long standing racial disparities. The majority of deaths (64 percent) stemmed from non-natural causes, including accidents/overdoses (18), suicides (16), and homicides (5). Natural causes, such as heart disease or respiratory failure, accounted for 22 deaths. The medical examiner cautions that these figures depend on law enforcement reporting, meaning the true number of custodial deaths could be higher.

It should go without saying, Illinois mirrors the rest of the country, lacking a centralized medical examiner system. According to the 2022 U.S. Census Bureau there are 2,720 cities, towns, and villages, represented by nearly 1,300 municipalities and 102 counties. Each of those counties uses its own mix of coroner or medical examiner models, making consistent, federal review and classification impossible.

It should also be noted; there is a stark difference between a coroner and a medical examiner. Coroners are mostly comprised of elected officials with little to no forensic training. In many states, coroners are only required to be registered voters or have backgrounds in law enforcement or administration. Their job is to determine cause and manner of death, but because they may lack medical training, they sometimes contract pathologists or rely on external autopsy services.

On the other hand, medical examiners are usually appointed by a county board, mayor, or state agency. They must be a licensed physician, typically trained and board-certified in forensic pathology. They determine cause and manner of death based on medical evidence, rather than politics or gut instinct.

Ninety-two Illinois use an coroner system. Cook County, and seven other municipalities, however, operate under a medical examiner system.

In the Crusader report, “Lynchings By Suicide,” activists investigating the Trey Reed case at Delta State University (DSU) complained that the “suicide” ruling in his hanging death lacked professional oversight and was rooted in politics.

Marquell Bridges, a spokesperson for the Reed family and a nationally recognized human rights activist, said in September, “We had serious concerns about conflicts of interest with the coroner and his possible ties to DSU in (Reed’s) ruling,” he said. “In Mississippi, anyone can be a coroner if they pass a basic test or win a race. They don’t have to have a medical background. This makes it hard for families here to receive answers and justice when you can’t trust the coroner.”

A second, independent autopsy commissioned by the family came back inconclusive; however, a relative told the Crusader Reed had signs of “blunt force trauma,” a fact that was not disclosed in the original report. The case is pending, according to activists, although the Mississippi state examiner has backed the official ruling.

Illinois has no statewide medical examiner system that oversees the 92 county coroners and 10 medical examiners, each with their own rules, resources, and local politics.

“Illinois should put a death-in-custody checkbox on local death certificates,” Dr. Mitchell said. “There needs to be a statewide fatality review committee… so that anyone who dies in custody gets reviewed in a multidisciplinary way—so we can identify where care could have been improved, where policy could have been improved, where conduct could have been improved—for the purpose of saving people’s lives. This is just one of the reforms that should be implemented at the state level across the country.”

A Data Divide

The Illinois data painfully intersects with national cases that shaped the public consciousness. Sandra Bland, a Chicago-area activist, died in a Texas jail in 2015 after a traffic stop that went viral. Her death, officially ruled a suicide, sparked a movement questioning how so many Black men and women die after minor police encounters or while in jail detention. The “Lynching by Suicide” investigation published by this newspaper also reported on hundreds of jail and erroneous death rulings in Mississippi and throughout the country.

The NASEM report places such cases within a continuum of state violence that stretches from plantation patrols to present-day jail cells. “We have to stop pretending that the devaluation of Black life is a historic problem,” Dr. Mitchell said. “It’s an ongoing condition.”

The ICJIA’s report, like Dr. Mitchell’s study, finds that data itself can be a weapon. Illinois officials acknowledged that missing or incomplete records, especially from county jails, made it impossible to track how many deaths were preventable or connected to the use of force. The state began requiring additional data fields under the SAFE-T Act, but compliance remains uneven.

Black America’s doctor argues that in custody death is both a public health and human rights issue. “No one gets to abdicate their responsibility,” he said. “The criminal justice system doesn’t count who dies. The public health system counts who dies just as it counts who is born.”

So, what’s the solution? The report has several recommendations: Congress must treat these deaths as preventable public health failures, not incidental outcomes of law enforcement. It also urges coordination between the Department of Justice, the Centers for Disease Control and Prevention (CDC), and the Department of Health and Human Services to build a unified national database of custodial deaths.

Civil rights organizations, faith leaders, and watchdog journalists, such as Ballesteros and the team at Injustice Watch, have echoed those demands. In Chicago, the Better Government Association, the Invisible Institute, and the Illinois Legislative Black Caucus have each launched data transparency campaigns since 2023, arguing that incomplete reporting violates the spirit of both federal and state law.

“If I wanted to know how many people died this year (in Cook County Jail), I wouldn’t be able to find that out without asking for records,” Ballesteros said. “ Let’s imagine the person is just a normal person, not a reporter, having to find that out. It’s just mind-boggling. And then the other thing is, there is no independent supervision of the jail (compared to) the Chicago Police Department. There’s a Civilian Office of Police Accountability, but there’s no comparable agency for the county sheriff’s office for the jail. So, every single aspect around discipline and investigations into things that happened at the jail happens within the Cook County Sheriff’s Office, which also runs the jail, and so that presents an issue around transparency as well.”

Solutions and the Moral Imperative

Dr. Mitchell is clear about what comes next. “Congress can take a lot of this on themselves and make those requests of agencies within the government,” he said. “The CDC has responsibilities. HHS has responsibilities. The DOJ and the Bureau of Justice Statistics have responsibilities. There are several criminal justice and health agencies that have a role and responsibility—both on the federal level and on the local level—to improve this medicolegal death investigation system.”

He also called for ordinary citizens to act. “This report calls on Congress and asks Congress to do something. It calls state and local government to do something,” he said. “I’m hoping they get some ear—and I’m willing to go anywhere in this country and talk more about it. I encourage people, especially those who have lost loved ones who were in custody, to contact their representatives and to raise their voices.”

Dr. Mitchell stressed, “I want people to understand that the manner in which people die, and the cause of death is instructive for the living,” he said. “If patterns show that people in custody need increased health care needs, or that the standard of medical and mental health care is not available to people, then we must demand systemic change.

“We need a checkbox on the U.S. standard local and state death certificate that says, ‘death in custody,’” Dr. Mitchell reiterated. “That is a very simple thing that your local Black Legislative Caucus, your local Progressive Caucus, and the local legislature in total can do as a nonpartisan issue. It makes sense.”

For communities like Chicago’s South and West Sides, where faith, family, struggle and survival intertwine, the fight for human rights and a just appraisal value of Black life persists. The way to correct wrongs, Ida B. Wells, the original Crusader, once wrote, is to turn the light of truth upon them. If Congress heeds Dr. Mitchell’s call, perhaps this time, the counting will lead to caring. a lack of