Kevin Desir was arrested on Jan. 13, 2021, after a traffic crash where marijuana was found in his car. He would be dead two weeks later.
Desir, 43, was held briefly in the Broward County jail that houses and treats people with mental health diagnoses, the North Broward Bureau. In a civil rights lawsuit recently filed in federal court, Desir’s family alleges that what happened to Desir while he was incarcerated there is one example of inadequate care inside the jails, of which the results are “often times deadly.”
Broward jails have been under federal oversight for decades. An expert’s report in 2018 detailed numerous issues with the treatment of inmates, calling it “absolutely inhumane.” In the years since, the Broward Sheriff’s Office has improved conditions and procedures, though problems persist, according to the mental health expert’s most recent reports in November 2020 and May 2023.
Desir was in the throes of an apparent mental crisis on Jan. 17 while inside the male infirmary unit at North Broward Bureau. He refused to leave his cell and resisted the deputies’ efforts, ultimately culminating with deputies fighting with him for nearly 10 minutes until he became unconscious and was taken to the hospital.
His family removed him from life support on Jan. 27. There are differing opinions from two medical examiners as to how and why Desir died: one said it was “undetermined” and one said it was homicide.
The Sheriff’s Office said last year that their deputies who fought with Desir would not be disciplined, saying their use of force was compliant with their policies and procedures. A prosecutor’s review said the deputies’ actions did not rise to a criminal level.
In filing the lawsuit, Desir’s family is seeking damages, policy changes and to hold the men and women involved accountable, said Lauren Bonds, executive director of the advocacy organization National Police Accountability Project, whose attorneys are working with Desir’s family.
Bonds said the fact that the Sheriff’s Office’s review determined that the deputies did not violate any policies during the struggle with Desir was part of the reason the National Police Accountability Project took on the case.
“I think that’s one of the reasons that we got involved in this case is because we think they have policies and customs that are inadequate in terms of protecting the folks that are housed in Broward County and that particular unit specifically … I think their inaction is part of the problem.” Bonds said.
Bonds said the organization also chose to take on the case partly because of what she called a “real established pattern of there being a problem” in Broward County jails.
The lawsuit points out the jails’ continued monitoring and gives numerous examples with other inmates of what they allege show a pattern of inadequate mental health and medical treatment.
Desir’s brother, Mikeco Desir, is the plaintiff in the lawsuit that names as defendants Sheriff Gregory Tony, six deputies and Wellpath Management — a private company that provides healthcare in the jails — and several of their employees. It was filed in March under seal because it contained images from the jail security video of the fight, which has not been released publicly. A version of the complaint without the images was filed Aug. 25.
“Kevin’s not coming back. We’ve accepted that … But on this side of heaven, we know we’ve lost our brother forever. I would really like to get some type of justice,” Mikeco Desir told the South Florida Sun Sentinel a few days before the lawsuit was formally filed.
Carey Codd, a Sheriff’s Office spokesperson, said in an email Aug. 30 that the agency typically does not comment on pending lawsuits.
Jan. 17, 2021
Desir was the second of five children. They were taught that their brothers were their “first friends,” Mikeco Desir said.
“He was very charismatic. I wanted to be like him, funny guy, always dressed well,” he said. “Once I got big enough, I used to go in his closet and try to take his clothes. Always been a very cool guy, stylish.” Mikeco Desir said his young son “has picked up his love for hats like his uncle.”
After their father died in November 2020, “things were very rough on Kevin,” Mikeco Desir said. Despite his grief, Desir was thinking of his brother’s children around the holidays, asking Mikeco Desir what size clothes he should buy while Christmas shopping.
“That was always the type of person he was,” Mikeco Desir said. “Even in the midst of grieving, his heart always remained big. He was a special guy.”
Desir was diagnosed with bipolar disorder in his early 20s, his brother said.
“Kevin Desir was a father to two young girls, a brother, a son, and a man who deserved to live,” the lawsuit complaint said. “Despite Kevin’s mental health diagnosis, Kevin was a productive member of society who many people looked up to and respected. With proper care and treatment, Kevin functioned well.”
When he was booked into jail on Jan. 13, Desir reported his history of mental illness. The Sheriff’s Office Internal Affairs report, dated March 2022, said no medical issues were documented during his intake screening and his vitals were stable.
He was in the North Broward Bureau on Jan. 14 and was moved from the open mental health unit to North Broward Bureau’s infirmary unit that same day “per Wellpath medical.” The next day, he remained in the infirmary and was placed in a cell for psychiatric observation, the Internal Affairs report said.
Three hours after being placed on psychiatric observation, a mental health professional tried to evaluate Desir but he refused. Three hours later, when another mental health provider tried to see him, he was nonverbal, “and as a result remained on psychological observation,” the Internal Affairs report said.
The Internal Affairs report makes no mention of Desir’s state on Jan. 16, but the State Attorney’s Office memo said notes showed that early in the morning of Jan. 16 Desir continued to be “not receptive.”
The next contact with Desir documented in the Internal Affairs report was at 1 p.m. Jan. 17, where a mental health professional noted that he came to the cell door and talked to a nurse. “No acute distress noted,” it said. He stayed on observation.
By 4 p.m., Desir was standing naked in his cell, the close-out memo said.
By 9:40 p.m., deputies found him standing naked in his cell that was flooded with water, bleeding after cutting himself with the piece of a broken mirror, the Internal Affairs report said. Desir was not communicating clearly and throwing himself against the wall, based on deputies’ accounts to Internal Affairs.
Desir’s family in the lawsuit said it was clear by that point that he was in crisis. They allege that the force deputies used in the next moments furthered his crisis and prevented him from being treated.
By the time the fight that led from Desir’s cell to being strapped into a restraint chair was over, Desir had been punched nine times, stunned with a Taser multiple times, pepper sprayed and held by one deputy under his chin for at least two minutes while in the chair, according to the Internal Affairs report and a State Attorney’s Office close-out memo from February 2022.
The Sheriff’s Office said in a news release in May 2022 when the deputies were cleared that Desir became “extremely violent by pulling away, kicking and spitting” after deputies removed him from the cell and that he bit one of them.
“Deputies placed him in a restraint chair for his safety and the safety of staff,” the Sheriff’s Office said in their news release. “While deputies tried to restrain him in the chair, he continued to move about violently until becoming unresponsive and was removed from the restraint chair. Deputies immediately began CPR, and jail medical staff took over resuscitation efforts.”
The prosecutor wrote in the close-out memo that the force used was “entirely appropriate to remove him from his cell for his own safety.”
Desir’s family disagrees, saying in the complaint that the level of force was “unreasonable, unnecessary, gratuitous, and punitive.”
The struggle began about 10:05 p.m. By 10:12 p.m., Desir was “limp in the chair,” the close-out memo said. At 10:17 p.m., they put Desir on the floor and started CPR. The staff tried to shock him with a defibrillator, but the machine said the heartbeat was too faint. Paramedics arrived another 10 minutes later.
Desir was admitted in critical condition at Broward Health North and died 10 days later.
Medical examiners typically use blood specimens to complete a toxicology report. But in Desir’s case, the Sheriff’s Office and the medical examiner never received it from the hospital and could not determine if Desir had any medical issues that could have played a part, the State Attorney’s Office close-out memo said.
The medical screening at the jail showed Desir had no history of heart or lung conditions and was not taking medications for heart conditions or seizures, the lawsuit complaint said. Mikeco Desir said his brother was healthy, the only medication he took daily being for his mental health.
Medical records showed that Desir suffered a “cardiac incident” after the pepper spray, prior to hospitalization, according to the close-out memo. Desir suffered from seizures while hospitalized, the memo said, which could have contributed to his death. But the medical examiner could not say for certain.
The Broward County doctor who performed the autopsy ruled out that Desir died from being strangled because the bone in his neck was intact and his brain had no swelling, the memo said. And while he did suffer a heart attack, the autopsy found that was not how he died.
“The lack of testing on the admission blood specimen hindered the medical examiner from conducting all of the tests they typically do, but it was explained that in this instance, any testing would not have pointed this investigation to a finding of a homicide, but rather would likely point the outcome to a more definitive cause of death from a pre-existing medical condition,” the close-out memo said.
A secondary, private autopsy that was performed by a doctor outside of Broward County is mentioned in the federal lawsuit and in court records in a separate county lawsuit, which is seeking the public release of the jail video filed by the Florida Courier and the advocacy organization Chainless Change.
A brief in that separate lawsuit said the second doctor ruled Desir’s death a homicide, finding his neck and carotid arteries were compressed.
“That’s a huge gap to me,” Mikeco Desir said of the contradictory results.
The State Attorney’s Office said in an email Friday that prosecutors have not been provided with the second autopsy. In a statement after the second autopsy was performed, the State Attorney’s Office said, “In all cases in which prosecutors decline to file criminal charges, our prosecutors are always open to reviewing new evidence or information when it is provided.”
The federal monitoring of Broward County jails dates back to 1976, when three inmates handwrote a lawsuit detailing crowding and other mistreatment, which became a class-action lawsuit including all future inmates.
A settlement was reached in the case in 2019, a year after mental health care expert Dr. Kathryn Burns released an 88-page review of the conditions in the jails, calling them “absolutely inhumane.”
“Inmates with serious mental illness are suffering needlessly,” Burns wrote in her 2018 report. Some of the cases noted in Burns’ review were reported in a 2016 Sun Sentinel investigation of the county jails.
An ongoing review of the jails’ procedures is done as part of the settlement agreement, and Burns has released two reports since 2018, most recently in May 2023. Conditions and procedures have notably improved since the 2018 report, Burns said in her reports, and lauded Tony and the Sheriff’s Office’s for “their commitment and effort” in her most recent review.
Some improvements in the jails Burns noted in 2020 and 2023:
- Mental health bed space expanded.
- Increased number of deputies in mental health units.
- Increased number of Baker Act referrals to hospitals and admissions.
- A mental health unit for women.
- Continued Crisis Intervention Training for security personnel.
- Created a mental health call-in line for families of inmates.
The number of people in the jails put on the mental health caseload is increasing, Burns found this year. In the two recent reports, Burns detailed issues that still remain, one of them being the coordination of care between mental health staff and medical staff.
In the 2020 report, Burns wrote that “there are still indications that the physical conditions of inmates with serious mental illness are sometimes dismissed as symptoms of mental illness rather than investigated as a potential physical problem or illness.”
In the May 2023 report, Burns wrote that coordination of care between mental health and medical personnel “remains an area of serious concern: mental health staff respond timely to medical referrals and make timely referrals to medical, but the relationship does not appear reciprocal.”
In one example of the lack of coordination of care, Burns wrote that one inmate’s physical and mental health declined while held in the Main Jail for several weeks. He wasn’t medically assessed because he was lying in the fetal position in his cell and would not communicate for about two weeks, Burns’ report said.
One nurse recorded that the inmate was “alert and oriented,” though he was described as nonverbal by others’ assessments, Burns wrote. The inmate went to an intensive care unit the next day, where he was found to be suffering from severe dehydration and acute kidney damage.
“The nurse’s assessment on the previous day was at best cursory and inaccurate and at worst, a fabrication,” Burns wrote. “In any event, in spite of his being in the infirmary, medical staff was not engaged in his care and treatment.”
In another example, one inmate returned to the jail after a psychiatric hospitalization in April 2022. He was prescribed an oral medication and an injection for schizophrenia, though a nurse at the jail did not document his injection medication, and the man was given only the oral medication upon his return to the jail, Burns’ report said.
Mental health staff told medical staff he was nonverbal and struggling to move. “Medical did not evaluate him saying that the prisoner refused and/or wouldn’t answer questions,” Burns wrote. “Medical staff did not persist in efforts to examine him.”
He died inside North Broward Bureau in mid-June, Burns wrote. At the time of her report, his autopsy was not available and it was unclear how and why he died.
Desir is not discussed in Burns’ 2023 report.
The lawsuit mentions some of the same examples in Burns’ reports, in addition to other inmates. It mentions two women who gave birth in their cells at the North Broward Bureau — Tammy Jackson in April 2019 and Stephanie Bretas in September 2020. Tony fired two-top level jail administrators after Bretas gave birth in the cell.
In August 2021, a North Broward Bureau deputy was charged with battery for repeatedly hitting an inmate with his flashlight. A jury found Deputy Delroy Rose guilty last July, and he was ordered to pay $645 in fines.
Burns concluded in May that the Sheriff’s Office was not in compliance with about 12%, of the requirements of their settlement agreement. One of the areas that needed improvement was the coordination of care between medical staff and mental health staff.
She marked as non-compliant the requirement that medical and mental health staff “timely consult with one another.”
“Because the consequences are so dire, this area must be a focus of intensive quality improvement study and development of a corrective action plan,” she wrote.
Information from the Sun Sentinel archives was used in this report.