Placed in prone restraint by his jailers, he said, ‘I can’t breathe.’ The cause of death was asphyxia.

John Neville’s bunkmate at Forsyth County Law Enforcement Detention Center heard a “loud bang in his cell” after they went to sleep on the night of Dec. 1, 2019 and looked down to see Neville on the cell floor, shaking.

Jail personnel responding at 3:26 a.m. found Neville, a 56-year-old Greensboro man in jail on a warrant for assault on a female, laying on his cell floor with vomit on his clothing, sweating and blood around his mouth, according to an autopsy completed by Dr. Patrick Lantz at Baptist Hospital.

The autopsy said a nurse — subsequently identified as Michelle Heughins, an employee of WellPath, the medical provider for the jail — noted that Neville was snoring and unresponsive, but his pupils were reactive to light, and that she “applied a sternal rub (application of painful stimulus by knuckles of closed fist to center of patient’s chest…).”

Neville reportedly regained consciousness, but was “incoherent, seemed confused, uncooperative and became aggressive — he tried to sit up, kick and swing his arms.” The summary of findings in the autopsy, which is based on investigative reports, detention center documents, videos and medical records, also said jail staff told Neville “he was not in trouble, but he was having a medical emergency and needed to calm down and stop resisting.”

Members of the jail’s special response team restrained Neville on his back with his arms and legs held down. The autopsy said Neville became unresponsive again and the Heighins had to apply the sternal rub a second time, and when he regained consciousness he tried to kick, jerk his arms away and thrash his body side to side while mumbling, “Let me go,” “Help me up,” and “Mama.”

The special response team members applied metal restraints to Neville’s ankles and rolled him onto his stomach to handcuff his wrists, prompting Neville to say, “I can’t breathe.” Then, the jail staff helped Neville to his feet and secured him to a restraint chair with his hands cuffed and his ankles still in metal restraints.

The jail staff wanted to move Neville to a single cell where they could observe him, and the autopsy says that at that point Neville “followed instructions getting out of the restraint chair” and “walked with assistance into the cell.”

The course of action taken next by five detention officers and the nurse remains inexplicable considering Neville’s apparent cooperation while he was being transferred. The autopsy says when they reached the new cell, Neville knelt “and was lowered down prone (face down on stomach) onto a mattress that had been removed from the bunk and placed on the floor of the cell.” The autopsy describes him as “writhing, moving his torso and tensing his arms and legs,” and says the detention officers handcuffed his hands behind his back and applied the metal restraints to his ankles. Then the detention officers removed the ankle restraints, and Neville’s “legs were flexed into a trifold position with his heels near his buttocks.” He said, “Please,” “I can’t breathe,” “Help me,” and, “Let me go.”

What happened next was a tragic series of mishaps.

Two and a half minutes after being placed in the prone position, the handcuff key broke off in one of the keyholes, presumably while they were attempting to free him.

They tried another key, but it didn’t work.

Neville uttered his last intelligible phrase three-and-a-half minutes after being placed in the prone position.

The detention officers unsuccessfully tried using a pair of bolt-cutters to remove the handcuffs five minutes after he was placed in the prone position.

Neville stopped moving.

Twelve minutes after he was placed in a prone position, they successfully cut the left handcuff with a second pair of bolt-cutters, and then they removed his blue jumpsuit.

Nurse Heighins checked Neville, according to the autopsy, and they left him lying prone on the mattress and closed the cell door.

Next, the autopsy says: “The nurse indicated she could not see him breathing or moving so FCDC personnel re-entered the cell, rolled him supine (on his back) and secured his arms and legs. Unable to obtain a pulse, external chest compressions were given, then about 19 minutes after placed prone, cardiopulmonary resuscitation was begun after a CPR mask was placed over his mouth.”

Neville died two days later at Baptist Hospital from “complications of positional and compressional asphyxia during prone restraint,” according to the autopsy.

Forsyth County District Attorney Jim O’Neill announced felony involuntary manslaughter charges against five detention officers and the nurse on Wednesday. Those charged are Sgt. Lavette M. Williams, Cpl. Edward J. Roussel, Detention Officer I Sarah E. Poole, Detention Officer I Christopher B. Stamper and Detention Officer I Antonio M. Woodley, along with Michelle Heughins, a nurse employed by WellPath.

O’Neill explained during the press conference on Wednesday that guilt in a case of involuntary manslaughter requires a finding by a judge or jury of “careless negligence,” meaning “a carelessness or recklessness that shows a thoughtless disregard of consequences or a heedless indifference to the safety and rights of others.”

It remains to be explained why the detention officers placed Neville in a prone restraint after he apparently demonstrated cooperation while being transferred to the observation cell. It’s also unclear whether the restraint is allowed under the Forsyth County Sheriff’s Office’s Standard Operating Policies.

One of the agency’s directives states that “restraining devices or techniques that have been proven to contribute to serious physical injury or death, e.g. ‘positional asphyxiation’… shall be prohibited,” but the directive applies specifically to “transport of detainees and arrestees” by the enforcement bureau. The directive was obtained by Triad City Beat in November 2018, two weeks before Sheriff Bobby Kimbrough took the oath of office. TCB requested the directive as part of a review of policies on use of prone restraint by Triad-area law enforcement agencies after Marcus Smith, a 38-year-old man, was killed by Greensboro police while being hogtied during a mental health emergency at the North Carolina Folk Festival. TCB has a pending request with the Forsyth County Sheriff’s Office for all directives that reference the use of prone restraints.

After reviewing the police body-camera video of the incident with Marcus Smith’s father, attorney Graham Holt described how Smith was placed in a prone restraint in a written narrative that bears striking similarities to the recent autopsy for John Neville.

“While multiple officers held him down, one officer cuffed Marcus’ hands behind his back,” Holt wrote. “Another officer then grabbed Marcus’ ankles and pushed up on his feet forcing Marcus to bend his knees. The officer pushed his feet all the way to the point that Marcus’ feet were touching his handcuffed hands on the small of his back. Then they hogtied him. Using a strap of some kind they bound his feet behind his back. He was still face down. The officers tightened the straps so tight that Marcus’ shoulders and knees were suspended above the ground.”

A medical examiner ruled Smith’s death a homicide caused by “sudden cardiopulmonary arrest due to prone restraint; n-ethylpentalone, cocaine and alcohol use, and hypertensive and atherosclerotic cardiovascular disease.” No officers involved in Smith’s death have faced discipline or received criminal charges.

Beyond a pithy account of the events leading up to John Neville’s death and explanation of the elements of the involuntary manslaughter charges, District Attorney O’Neill and Sheriff Kimbrough have offered few additional details about the events that transpired at Forsyth County Law Enforcement Detention Center on the night of Dec. 1, 2019. At the conclusion of the 28-minute press conference, O’Neill and Kimbrough left the room without taking questions from reporters.

Michael Grace, the lawyer who represents Neville’s estate and surviving family members, said at the press conference that he has asked the family members to refrain from speaking publicly about the case.

“Early in this process, I asked Sheriff Kimbrough to not share the video that you’ve heard so much about with the public and with anyone until the family has a chance to see it and digest it,” said Grace, who was retained by the family shortly after Neville’s death. “He promised me he wouldn’t. He promised me that he would fall on his sword in whatever criticism comes his way for being un-transparent or non-transparent; he’d accept it. And he kept his word and did not make it available. And it has not leaked out, and no one has seen it but the people who ought to see it. The family has seen it, and they’re quite devastated by it, as are all who have seen it. But we are grateful to the DA’s office and to the sheriff for keeping their word.”

Grace added: “I will not talk about the facts, neither will [my partner] Mr. [Chris] Clifton, and we have urged the family not to. This matter is a court matter now. It’s a criminal court matter. She should respect that. We should respect that there are some things that will come out in the course of both criminal and civil trials, if there are such, and that the public will get the information that they need as soon as it’s available, and as long as it does not hinder the ability of the six men and women who were charged to get a fair trial.”

O’Neill said Neville’s children support his position that the video should not be released until the case reaches trial in criminal or civil court.

Kimbrough said when he escorted the five detention officers to the magistrate’s office on Wednesday morning, they told him to tell Neville’s children: “Sheriff, tell them that we meant their father no harm. We were trying to assist and help.” Kimbrough added, “And so, that is my message is that we’re sorry that the mistakes were made that day. I take responsibility for that as sheriff.”

None of the law enforcement and court officials involved in the case have missed the significance that the killing of another Black man who pleaded, “I can’t breathe,” has sparked a global uprising against systemic racism.

O’Neill, who is the Republican challenger in the November election for state attorney general in North Carolina, used the Wednesday press conference as a platform to push back against calls to transform law enforcement.

“I understand that there have been calls to reduce funding for law enforcement, but I’m here to tell you that would be a mistake,” he said, “because we need funding. In fact, we need more funding to be sure that the training can still be done in a manner that it should be.”

O’Neill issued a warning to protesters, while also addressing Neville’s children.

“I would be remiss in my duties if I did not provide this message to the citizens of this community, of this state and of this country,” he said. “We have all been witnesses to the unrest that has gripped our world over the last several weeks. As it relates specifically to your father, Mr. Neville, his death was avoidable, and that is a tragic, singular fact. Consequently, charges have been brought forth. I have stood with the victims of crime for almost 25 years now, and today I stand firmly with your family.”

O’Neill continued that while he and Neville’s children support the right to peacefully protest, “We will not support protesters who cross the line and break the law. For you, too, will be prosecuted.”

True to his word, during a protest outside the jail, five people protesting Neville’s death were arrested by Winston-Salem police on Wednesday and charged with impeding traffic.