It began with a 9-1-1 call and ended with the death of a 16-year-old Black girl in a youth facility in Kentucky.

Little has been written about the girl’s case, but advocates and organizers say it is illustrative of failures at multiple points in the state’s juvenile justice system.

Gynnya McMillen was found unresponsive in her room at the Lincoln Village Regional Juvenile Detention Facility in Hardin County, Kentucky, on January 11, where she had been taken the previous morning following a domestic altercation with her mother.

In the three months since, there’s been a state investigation into her death, lawmakers have proposed legislation to investigate in-custody fatalities, and several staff members at the facility have quietly left their posts.

And yet the teenager’s untimely death continues to be shrouded in mystery.

One of the most pressing questions among advocates, attorneys, and McMillen’s family is whether there is a link between a scuffle that took place during her intake at the facility and her death several hours later.

By Kentucky officials’ own admission, multiple adult staff members physically restrained McMillen using an “aikido” hold—a modified martial arts move—after the teen allegedly refused to remove her sweatshirt as part of a routine check-in procedure. As Graham Kates has reported for CBS News, surveillance camera footage shows staff bringing McMillen to the ground and holding her there for four minutes and 15 seconds. However, the footage fails to capture the full extent of the incident since the girl was brought down behind a counter and remains hidden from view for much of the incident, according to Kates.

In a February email to Rewire, a spokesperson for Kentucky’s Justice Cabinet (which oversees the state police, the Department of Corrections, and the Department of Juvenile Justice, among others), described the martial arts hold as a “nationally-approved system called Aikido Control Training, which is utilized by various juvenile justice agencies and mental health facilities throughout the country [and] designed to prevent injury to the child and staff.”

“Since strength of the employee is not a factor, only balance, injury to the child and staff is almost nonexistent,” Lisa Lamb, a spokesperson for the state Justice Cabinet, explained. “This control method does not use any type of strike, punch, choke, wrist lock or throw.”

But experts with decades of experience working on inmates’ rights and conditions of confinement tell a different story.

One of them is Paul DeMuro, a senior consultant at the Annie E. Casey Foundation and the current federal court monitor for a juvenile justice settlement in Mississippi. He told Rewire in a phone interview that in all his 44 years of experience he has never once heard mention of this “aikido” hold or known of any facility that has employed it as a form of restraint.

“From what I know of the case, there was no reason to use this particular restraint on this young woman,” he said. “To use that kind of force to resolve an issue as simple as a teenager saying she didn’t want to take her sweatshirt off goes against both the letter and spirit of most policies regarding physical restraints,” he added.

According to DeMuro, employees at Lincoln Village appear to have dealt with a frightened young girl as though she were a violent offender, escalating her anxiety instead of talking her through it. “Add the race and class elements,” he said, “and you have a situation in which several adult staffers are taking down a 16-year-old kid. This never should have happened—she was essentially going through a simple booking process and she wound up dead.”

Kentucky officials have vehemently denied the allegation that the girl suffered some deadly trauma or injury as a result of being tackled to the ground by multiple adult males. On March 16, the state medical examiner announced at a press conference that McMillen had died of a rare genetic disorder, called inherited long QT syndrome, which can cause “life-threatening arrhythmias [irregular heartbeats] and sudden cardiac arrest,” according to the Centers for Disease Control and Prevention.

But McMillen’s family rejects those findings. Shortly after Gynnya’s death, her sister created a Facebook page to gather and share information about the case. A series of posts, presumably written by a family member who manages the page, suggested that the “aikido” hold caused or contributed to her death.  The family has also consistently drawn attention to the fact that staff members at the facility failed to conduct mandatory 15-minute bed checks throughout the night, and were slow to perform CPR on the girl when at last she was found to be unconscious in her room.

State officials cannot refute this allegation. Investigators said at the press conference earlier this month that Lincoln Village employees acted unprofessionally by neglecting to provide adequate supervision and falsifying documents such as observation reports. After reviewing 60 hours of footage from the facility, Kentucky Justice and Public Safety Cabinet Secretary John Tilley said, “Some of the misconduct smacks of outright indifference,” pointing to one incident caught on video in which a staff member offers McMillen a sandwich and, receiving no reply, later eats the meal himself.

Tilley dismissed two employees in connection with McMillen’s death—Victor Holt and Reginald Windham, both of whom have previously been reprimanded for using excessive force on youth.

“Why Was She Arrested in the First Place?”

While much of the limited reporting around McMillen’s case has focused on events that transpired inside the detention center, juvenile justice advocates are equally concerned about why the girl was arrested in the first place.

“There is a much larger story here, about each of the points in the process where the system failed this child,” Liz Ryan, president and CEO of the Youth First Initiative, told Rewire. “For instance, why was she detained and arrested in the first place?”

Ryan believes McMillen’s case is indicative of the impacts of mandatory arrest laws, and later pro-arrest laws, that were introduced under the Violence Against Women Act (VAWA) in a bid to curb intimate partner violence, by instructing or encouraging police officers responding to domestic violence calls to remove a possible abuser from the household.

Though designed to protect women from spousal or partner abuse, the laws have had the perhaps unintended consequence of driving vast numbers of girls into the criminal justice system for altercations with their families.

According to Francine Sherman, clinical professor and director of the Juvenile Rights Advocacy Project at the Boston College Law School, girls comprise 40 percent of youth arrested for domestic assault, even though they account for just 29 percent of overall arrests nationally.

“Girls are disproportionately arrested for domestic assault, largely for altercations with their mothers,” Sherman told Rewire in a phone interview. “So the events that led up to McMillen’s arrest are not at all unusual nationally.”

Sherman, who co-authored a recent study on girls’ increasing share of the burden of youth incarceration, said that although Kentucky does not have mandatory arrest laws on the books, the state follows what are known as officer discretion laws, which have been susceptible to reliance on arrests as a means of resolving domestic disputes.

It is one of just many “pathways” that are still funneling girls into the juvenile justice system, despite an overall decrease in the national youth incarceration rate. Sherman’s research shows, for instance, that while the Juvenile Justice and Delinquency Prevention Act bars judges from jailing girls for simple status offenses (offenses that apply only to minors, such as violating a curfew), girls who fail to comply with a valid court order (VCO) regarding these offenses can still be detained. In 2014, Kentucky used the “VCO exception” 1,048 times—more than any other state.

And as multiple researchers have pointed out, Black girls are disproportionately represented in every stage of the justice system. By Sherman’s estimates, using justice department data, girls of color comprise 61 percent of incarcerated girls. “In 26 states and the District of Columbia, the placement rate for Black girls surpassed the rate for all other race and ethnic groups,” Sherman told Rewire.

Set against this backdrop, McMillen’s arrest and detention are hardly unusual; in fact, the circumstances surrounding her death are indicative of a long history of policing and punishing Black girls that advocates say has been largely sidelined.

“For decades society has placed huge pressure on Black girls: either by sexualizing their bodies, or portraying them as having ‘superhuman’ strength,” explained Chanelle Helm, a Kentucky-based organizer and researcher who has been mobilizing community support for Gynnya McMillen’s case.

“We’ve repeatedly seen Black girls being detained in violent and highly sexualized—we saw it with the officer in Texas using his entire body to restrain a Black teenager in a bathing suit; we saw the same thing with an officer assaulting a Black girl at the Spring Valley high school in South Carolina,” she added.

“If you listen to the 9-1-1 call that McMillen’s mother made right before her arrest, you see this same pattern—of the girl being called degenerate, sexualized names,” said Helm, who is a former board member of the Kentucky Alliance Against Racist and Political Repression and a member of Stand Up Sundays, part of Black Lives Matter-Louisville. “And then you see her being bodily detained by employees at the detention center.”

Helm added that Black girls going through the child welfare system often have health conditions that go undetected “due to an overall culture of negligence when it comes to [their] health.”

“Heart arrhythmias are hard to detect, especially for people who can’t afford that kind of medical care,” Helm said. “And if you’ve gone through as much as Gynnya was going through—being in the child welfare system, getting into a fight with her mother, sitting alone in that detention center—how are you going to know it’s something more than anxiety?”

Advocates Seek Far-Reaching Reforms

The question of who bears ultimate responsibility for McMillen’s death has not yet been answered. Once the Kentucky State Police wrap up their investigation, a prosecutor is expected to present the case to a grand jury to determine whether to bring criminal charges against possible defendants.

Advocates, taking their lead from McMillen’s family, say they want accountability. A Color of Change petition addressed to Gov. Matt Bevin (R) calls for the termination of superintendent Michelle Grady, who was responsible for the Lincoln Village facility, as well as any staff who were involved in the incident.

Local organizers, meanwhile, want further-reaching reforms.

“Our main goal is a complete overhaul of Kentucky’s juvenile justice system,” M.L. Butler, a member of a group called The Voices Unheard, which has been organizing around McMillen’s case, told Rewire. “We want to see the closure of the Lincoln Village facility and the decriminalization of Black youth.”

According to the state Juvenile Justice Department’s 2012 annual report, the 48-bed facility was slated for closure in 2013 in a bid to slash the department’s expenses by $2 million. It is unclear why these plans did not go through, and the state will likely have to answer this question under pressure from activists.

Butler told Rewire in a phone interview that grassroots groups are mobilizing for a protest outside the Hardin County Justice Center on April 8 to demand justice for McMillen. Many of these groups, including Helm’s Stand Up Sundays, were among the first to call attention to McMillen’s death, staging vigils outside the detention center from as far back as January and drawing a smattering of media to an otherwise completely overlooked case.

“We had 50 people at our first vigil and we’re hoping for as many, if not more, supporters on April 8,” said Butler, whose group works with the Oakland-based direct action training collection BlackOUT.

Those familiar with Kentucky’s Department of Corrections say activists are going up against a system that has shown little regard for inmates’ lives.

One of them is Greg Belzley, a Kentucky-based lawyer who has been inmates’ rights lawyer for more than two decades and sued state prisons and county jails “repeatedly” over detainee deaths and conditions of confinement, is not optimistic.

One of them is Greg Belzley, a Kentucky-based lawyer who has sued state prisons and county jails “repeatedly” over detainee deaths and conditions of confinement. He is not optimistic.

“Time and time again there is an inexcusable, horrifying, or grotesque inmate death in Kentucky. And time and time again no one is prosecuted and nothing happens,” he told Rewire in a phone interview, adding that in the two-year period from the beginning of 2012 to the end of 2013, there were more than 100 deaths in Kentucky jails and prisons.

He is particularly skeptical about a piece of legislation introduced in the house a month after McMillen’s death, which would create an independent panel of experts to review in-custody deaths across the state. Belzley’s biggest concern is that the panel would include 13 nonvoting members—almost double the number of voting members—who “represent organizations that have never shown the slightest interest in spending the time or money required to properly attend to inmates’ medical needs or seriously investigate or prosecute instances of inexcusable detainee deaths,” he said.

These include the Kentucky County Judge/Executive Association, the Commonwealth Attorney’s Association, and the state’s Jailers Association.

“Legislative efforts have made no difference—it’s been business as usual in this office,” Belzley told Rewire, adding that the root of the problem is the ingrained mindset among those directly responsible for detainees, whether jailers or medical personnel, that they do not warrant humane treatment.

“I’m working on cases right now that would turn your stomach,” he told Rewire, adding that he’s represented inmates who died of alcohol and drug withdrawal, covered in their own feces and urine, even though there was a hospital a few miles away.

“I’ve seen it happen so many times—a jailer will look in on an inmate who appears to be sleeping and unless there’s blood all over the floor or the inmate is hanging from a cord they will generally just make a note on their observation log that everything is okay,” he said.

While Belzley’s work has largely focused on adult jails and conditions of confinement, his analysis bears a striking resemblance to the kind of negligence that occurred in McMillen’s case.

“People need to start taking inmates’ lives seriously,” Belzley said. “Any responsible person who heard that a 16-year-old girl was put in a martial arts hold for over four minutes because she wouldn’t remove her sweatshirt and was found unresponsive the next morning, would say there was cause for a serious criminal investigation—and if there is probable cause to believe there was a violation of criminal laws in the treatment of this young woman, somebody needs to be prosecuted and if found guilty they need to go to jail.”