A private autopsy conducted in the case of Lashawn Thompson, who died in Georgia's Fulton County Jail last year, found that weeks of neglect caused his death.
Thompson was found unresponsive slumped over a toilet in his jail cell on Sept. 13, 2022, according to the independent autopsy, and was pronounced dead after 24 minutes of CPR. A copy of the report was provided to NBC News by attorneys for Thompson's family, Ben Crump and Michael Harper, who announced the results at a news conference Monday.
Roger A. Mitchell, a board certified forensic pathologist, concluded that a number of factors led to Thompson's fatal cardiac arrhythmia, including dehydration, malnourishment and rapid weight loss. A toxicology report appeared to show that Thompson was not receiving medication for his diagnosed schizophrenia disorder at the time of his death.
He also showed signs of "severe body insect infestation," according to the autopsy report.
"I want to go on record: This is the most deplorable death and custody case in history," Crump said Monday.
Thompson's brother, Brad McCrae, told NBC affiliate WXIA in April that his brother was in jail custody from June to September on a battery charge. He says his brother was unrecognizable in the photos he saw following Thompson's death.
“The loss was unbearable,” McCrae said. “Nobody should see those type of pictures.”
The independent autopsy report included a review of Thompson's in-custody medical records, the county medical examiner's autopsy, and the jail incident report.
During his intake on June 13, 2022, Thompson weighed 180 pounds and showed no signs of impairment, Mitchell's independent report said. He was also prescribed 5mg of Haldol, an antipsychotic used to treat schizophrenia, and 50mg of Benadryl, according to the report.
Thompson's medical report show he was checked five days later, and appeared fine. A provider checked on him again on July 14, 2022, where he "was selectively mute but without distress" and compliant with his medications.
But then there is a "significant gap" between a check-in on July 27 and Sept. 8, 2022," according to Mitchell's report.
"This represents 43 days where there was minimal documentation found within the records that show care being delivered," the report said. "The medication administration log showed that no medication was administered from August 11, 2022 – September 13, 2022."
Thompson was placed on psychological observation after a mental health provider found him in a fetal position in his unkept cell on Sept. 8, 2022. His medical notes include observation from a sheriff's deputy that he appeared to have lost a significant amount of weight.
He was seen twice over the next four days, where providers noted he was "continuing to decompensate" and was awaiting transfer to a mental health clinic, Mitchell's report said.
Thompson weighed 148 pounds at the time of his death with matted hair, dirt under her nails and at the bottom of his feet, and "severe body insect infestation," the report said.
Mitchell found that the cause of death in Thompson's case was complications due to severe neglect, with untreated decompensated schizophrenia as a contributing cause.
"Had Mr. Thompson received adequate care during his incarceration at the Fulton County Jail than he would not have died at the time that he did," Mitchell concluded.
The Fulton County Medical Examiner said Thompson's cause of death was "undetermined" but did note a severe bedbug infestation, WXIA reported at the time. The medical examiner's office did not immediately respond to a request for comment from NBC News on the independent findings Monday.
The private autopsy was made possible by NFL quarterback and social justice activist Colin Kaepernick, according to Thompson's family. Kaepernick launched the Autopsy Initiative last year to fund secondary autopsies in cases of "police-related death."
An attorney for Kaepernick did not immediately respond to a request for comment from NBC News.
The Atlanta Police Department is investigating Thompson's death, but referred media inquiries to the Fulton County Sheriff's Office.
Fulton County Sheriff Pat Labat told WXIA last month that he requested resignations from several members of the Fulton jail staff following the investigation into Thompson's death.
Labat, who took office in January 2021, also said he has told the Fulton County Board of Commissioners his concerns regarding the jail's overcrowding, facility issues, and the need for a new health vendor.
"A lot needs to happen. We need to build a new facility," Labat said. "I've been screaming this ... since before I was elected. We need a new way of thinking."
Labat did not immediately respond to a request for comment from NBC News. Neither did the clerk for the county commissioners office.
The Fulton County Jail has been plagued with issues over the course of nearly two decades and was placed under a consent order following a 2004 lawsuit was filed alleging that the conditions amounted to cruel and unusual punishment.
The order, which set population limits and staffing levels, was lifted in 2015 after nearly $1 billion was spent to remain in compliance, according to calculations by The Atlanta Journal-Constitution.
An analysis of 2022 data by the American Civil Liberties Union of Georgia recommended a series of measures to decrease overcrowding and improve conditions in the jail. The report argued that the jail will continue to face these issues without serious criminal justice reform.
The organization suggested that Fulton County eliminate wealth-based detention, release people charged only with misdemeanors, ensure timely indictment and refer eligible people to community diversion programs in order to solve its issues long term.