Medical Staff at Notorious Atlanta Jail Let Autistic Teen Waste Away and Die, Lawsuit Says

During the last years of his life, Shane Kendall, an autistic teenager, was locked up inside Atlanta’s notoriously dangerous Fulton County Jail. In an interview, his parents told The Appeal that when Shane turned 18, he was sent to the adult unit—“big boy jail,” as he called it.

He wouldn’t survive the year.

On Jan. 31, 2021—roughly a month before his 19th birthday—officers found Shane curled up in a ball on the floor of his cell, according to a wrongful death suit his father, Harold Joseph Kendall, who goes by Joe, filed earlier this year.

The suit alleges that Shane asked to be placed in a different cell. But, when the officers denied Shane’s request, he assaulted his cellmate, who later reported that Shane told him he’d started a fight because he wanted to get out of the cell. Guards then gave Shane a notice that he was facing 48 days of disciplinary lock-down—essentially 24-hour a day solitary confinement, according to the complaint.

The next morning, officers found Shane unresponsive from an apparent suicide attempt. Joe’s suit alleges that the jail’s medical providers—employed by the for-profit company NaphCare—failed to render lifesaving care and neglected his medical needs throughout his incarceration. The suit names NaphCare, two medical providers, several Sheriff’s Office employees, Fulton County, and its sheriff, Patrick Labat, as defendants.

When the nurse arrived at his cell, she refused to perform CPR, saying she had a bad knee, according to officers’ reports, with one officer noting that he was “alarmed” by the nurse’s refusal. The physician’s assistant, who arrived more than 10 minutes after staff discovered Shane’s body, was described as “disorientated” in one supervisor’s report. Unlike the nurse, he brought an Automated External Defibrillator, which recommended “no shock,” according to the complaint.

NaphCare has faced similar accusations of neglect from incarcerated patients and their loved ones. In the last five years, the company has been sued more than 300 times in federal court. But despite the ongoing controversies surrounding the for-profit company, Fulton County commissioners on Nov. 15 voted to renew NaphCare’s contract through the end of 2024. From Jan. 1 through Dec. 31, 2024, Fulton County will pay NaphCare more than $33 million.

The County also recently recognized the “NaphCare team of healthcare heroes for going above and beyond to save lives during a serious incident at the jail,” Fulton County Chairman Robb Pitts said in a press release posted on NaphCare’s website. The medical providers were awarded the Fulton County Chairman’s Award for Outstanding Endeavors for the Benefit of Fulton County Citizens.

In court filings, NaphCare has denied all wrongdoing in Shane’s case and asked the court to dismiss the complaint. The sheriff and County have also filed motions to dismiss. The court has not yet ruled on their motions. The Fulton County Sheriff’s Office, which operates the jail, told The Appeal in an email that it does not comment on pending litigation and would not say if the medical providers were still employed at the jail. The Office of the Fulton County Attorney emailed that the municipality had no comment in response to questions sent by The Appeal. Attorneys for NaphCare did not respond to requests for comment.

Shane’s parents hope their lawsuit will help protect others at the jail.

“It’s not just about Shane. There are so many lives in there,” Shane’s stepmom, Margie Thorpe, told The Appeal. “The fact that we still contract with this medical company to take care of these people or not take care of them is a crime.”

Shane’s criminal defense attorney, Rachel Kaufman, who also represents Shane’s dad in the civil suit, told The Appeal that the teen should never have been sent to the Fulton County Jail. In addition to autism, a developmental disability, Shane had been diagnosed with bipolar disorder, schizophrenia, ADHD, and intellectual impairment, according to medical and court records.

Kaufman’s co-counsel in the criminal case, Daniel Kane, told the court during Shane’s first competency hearing that Shane was hallucinating during one of their initial meetings. Kane testified that during his 40-plus-year career, he’d only raised concerns about clients’ competency in three cases. At the Fulton County Jail, Shane reported to medical staff that he experienced visual hallucinations when in closed spaces.

Joe testified that he never expected Shane to be able to live independently. He said the teen had received therapeutic services since he was a toddler.

“​​He had a list of mental problems as long as your arm, and they had been documented since birth,” Joe told The Appeal. When Shane was less than a week old, he was placed in foster care and went to live with Joe and his ex-wife; they adopted him a couple of years later, Joe said.

“If there’s ever anyone who should have been treated as a mentally ill person rather than a criminal, then it’s Shane Kendall,” Joe said.

At 15, Shane allegedly picked up a loaded gun left out at his adoptive mother’s house—she and Joe had split up years earlier—and fatally shot her, said Kaufman. Joe did not receive his medication when he stayed at his mother’s house, according to Joe’s complaint. Despite his well-documented history of psychiatric and developmental disabilities, the Fulton County District Attorney’s Office charged him as an adult with murder and other offenses.

Kaufman told The Appeal she “begged and pleaded” with the prosecutors, then under the leadership of former Fulton County District Attorney Paul Howard, to agree to have him placed in a psychiatric hospital, but they “fought me every step of the way.”

At the first competency hearing, Assistant District Attorney Adriane Love accused Kane and Shane’s father of lying about Shane’s disabilities, which prompted Kane to file a motion for the court to find her in contempt. Kane told The Appeal that Love’s accusations were “completely unethical.”

During her closing arguments at Shane’s first competency hearing, Love said that Shane’s legal team was “trying to get you to feel sorry for Shane Kendall.”

“He’s had all of these problems,” Love said. “I’m not saying he hasn’t had a hard life. I’m saying that he’s competent to stand trial and they haven’t proven otherwise.”

She told the jury that his medical history and diagnoses were “irrelevant in proving” whether or not he was competent to stand trial and that he was only at the psychiatric facility “because his parents have lobbied to keep him there and the State hasn’t objected.”

However, the 2018 Court order that sent Shane to the facility states that a psychiatrist found Shane incompetent.

“Both counsel for the Defendant and counsel for the State agree that Defendant should be transferred to the [facility] for psychiatric treatment to see whether restoration of competency can occur,” the order states.

At the end of Love’s closing, she said she’d like to “add a little levity” into the proceedings and told the jury she liked cartoons and comic books. She then played an excerpt from one of the Spiderman movies in an apparent attempt to underscore her argument that Shane was malingering.

Kaufman did not make similar attempts at “levity” in her closing remarks.

“I’m boiling with anger and frustration,” she told the jury. “How low are we going to go? And the state is willing to go pretty low. The state’s default position has been to win at all costs, to ignore ethics, morality.”

That hearing ended in a hung jury. Kaufman said she hoped the prosecutors would change course and not retry the case. Instead, they took Shane to trial again. This time, the jury found him competent to stand trial.

Kane said he warned Love what would happen if Shane went to jail.

“I told Adriane, I told her, this guy is not going to make it, he will not live,” he said. “And damned if I wasn’t right. If he goes to jail, I said, something will happen.”

Shane’s case “breaks my heart every day,” Kane said. “I wake up with it in the middle of the night.”

Love, who stayed in the prosecutor’s office after Fani Willis defeated Howard in 2020, is now the Chief Deputy District Attorney for the High Profile Cases and Difficult Witness Division. She did not respond to requests for comment.

While Willis has become a darling of some Democratic circles for using the state’s racketeering law to prosecute former President Donald Trump and several of his associates, she’s also drawn fierce criticism for using that same law against musicians.

Last year, Willis’s office filed charges against musician Young Thug and more than two dozen others affiliated with his record label, Young Stoner Life (YSL) Records, accusing them of conspiracy to violate the state’s Racketeer Influenced and Corrupt Organizations (RICO) Act. Young Thug (A.K.A Jeffery Williams) was also charged with participation in criminal street gang activity.

Love is prosecuting the case against Young Thug, who has maintained his innocence on all charges. In court, Love has argued that the rapper’s lyrics—which she has read to the jury— indicate his guilt. One of Williams’ co-defendants was recently stabbed at the Fulton County Jail.

After a psychiatrist found Shane incompetent, the court sent him to an inpatient program that attempts to make children ready to stand trial after they’ve been deemed unfit.

According to program records, staff provided Shane with a crash course in courtroom procedures. One staff member testified at the first competency hearing that Shane and the other clients did crossword puzzles, word searches, coloring books, and a game called “competency football,” where they tossed a football as they were quizzed on different vocabulary words.

Kaufman told the jury the program was akin to “obedience training.” Thorpe said the staff treated Shane like a “Pavlovian dog” and gave him cookies when he answered questions correctly, but at least they knew he was safe.

“We got to visit him in person,” said Joe. “We got to hug one another.”

By the time he completed the program, he was 17 years old. The court then sent him to the Fulton County Jail, where he stayed until his death. (As of last month, twenty-one 17-year-olds were detained at the jail, according to the sheriff’s office.)

His medical records show that NaphCare staff were aware of his diagnoses and his stay at the psychiatric facility. However, workers placed him in the general population unit, according to a housing assignment form completed by a registered nurse at the jail. (In its court filing, NaphCare claims their staff did not assign Shane to general population housing.)

“There was so much evidence that he was not fit for that jail,” Kaufman said.

During the 2020 campaign for sheriff, Joe and Thorpe spoke to Sheriff Labat, who was running to unseat the incumbent, on several occasions about their concerns for Shane, according to Joe’s lawsuit. The complaint states that because the pair believed Labat would help mentally ill detainees at the jail, they campaigned for him and donated to his election campaign. After Labat took office in January 2021, he visited Shane at the jail. Thorpe texted Labat to thank him, according to the complaint.

“Shane sounded like a life vest was just thrown to him,” she texted.

A few weeks later, Shane was dead.

Joe and Thorpe relied on video calls to stay connected while Shane was at the Fulton County Jail. Sometimes, Shane asked them to play music on their calls.

“He liked that song, ‘Happy,’” Joe said. “And he said, ‘Put ‘Happy’ on. Y’all dance.’”

Joe and Thorpe feared for their son’s safety—and for good reason. The complaint says other detainees physically assaulted and bullied Shane because of his “perceived sexual orientation.”

Joe said his son never went to the exercise yard because he was afraid.

“Not a breath of fresh air, not sunlight,” Joe said.

While at the jail, Shane lost a significant amount of weight even though he was on psychiatric medications that typically cause weight gain, according to the complaint. His health records from the jail show he lost 57 pounds in less than a year. But mental health clinicians rarely mention his weight loss in their notes.

Thorpe says the jail’s meals couldn’t sustain him. Shane had told her that breakfast was delivered at about 1 AM and shoved under the door. By the time he went to eat it, he said bugs had crawled into his food.

His parents said they bought him as much as they could from the commissary, but he kept losing weight, and they worried that other detainees were pressuring him to give them his food.

“At every turn, they failed to keep him safe,” said Joe, who suspects his son may not have died by suicide. Guards say Shane was found with a ligature around his neck. But at the first competency hearing, Joe said that at 15—the last time Shane was free—the State of Georgia had paid for an occupational therapist to teach Shane how to tie his shoes and complete other tasks, such as brushing his teeth and bathing.

“He was in grave danger every second,” Joe said of Shane’s time at the jail.

Shane’s medical records also reveal that he repeatedly refused his mental health medication, was physically assaulted by another detainee, and, on several occasions, wore dirty uniforms and appeared unkempt.

“I don’t take a shower,” he told one mental health professional. “I take a bird bath. I’ve seen things happen to people in the shower.”

Joe said he spoke to Shane the night before his body was found.

“He said, ‘I gotta go. I got into kind of an emergency I got to take care of,’ and so he hung up,” Joe told The Appeal.

Less than 12 hours later, Shane was pronounced dead. The jail’s incident reports list a contradictory timeline for that morning and raise significant concerns about the medical assistance—or lack thereof—that he received.

In their reports, officers provide different times for when Shane’s body was discovered, ranging from about 6:00 AM to 6:10 AM. Their times also vary for when they called for medical assistance—from about 6:12 AM to 6:17 AM. One officer said that he called for medical aid after staff entered the cell, removed the ligature, handcuffed Shane (“due to officer safety precautions”), and began CPR.

The medical providers’ reports are brief—each less than 10 sentences. They say that officers called for medical assistance at about 6:10 AM but make no mention of their arrival times or whether the nurse refused to perform CPR.

Surveillance video captured the corridor outside Shane’s cell that morning. Two staff members appear to discover Shane’s body at 6:10 AM, according to footage viewed by The Appeal. Over the next several minutes, staff members can be seen walking away and toward Shane’s cell with no apparent sense of urgency. At about 6:20 AM, a staff member wheels a stretcher toward the cell with another person walking several steps behind.

About two minutes later, a person in a lab coat can be seen walking toward the cell. At 6:36, people who appear to be emergency medical workers walk toward the cell. About 13 minutes later, Shane was pronounced dead, according to a supervisor’s report.

NaphCare has been accused of providing dangerously inadequate care to other detainees in Fulton County. In August, a man detained at the jail sued NaphCare, Labat, and others.

When he first arrived at the jail in May 2023, he spent three days in a holding cell covered with urine and feces with about 30 other detainees, he wrote. He alleged that he was then placed with the general population instead of in the “alternative lifestyle” dorm, even after he disclosed to officers that he was gay.

While in the general population wing, a detainee sexually assaulted him, and he was extorted for commissary items, according to his hand-written complaint. He alleged that food is “often served half cooked, raw, and always cold,” locks on the doors are broken, and there was a bedbug infestation in September.

On the medical side, he said that he had to wait a month before receiving his HIV medications and that even after three months at the jail, he had not yet received all his mental health medications.

“Filed multiple grievances,” he wrote. “Process is a complete sham, waste of time.”

The man filed the lawsuit pro se, meaning he does not have an attorney. The federal magistrate judge recommended denying the plaintiff’s request for appointed counsel and dismissing NaphCare as a defendant because the complaint did not clearly state why their care had violated the law.

In another case, a detained person named Lashawn Thompson did not receive his medications for schizophrenia for more than a month before his death at the jail in September 2022, according to an independent autopsy commissioned by his family. Photos of his filthy cell and bug-bitten body, which were released several months after his death, set off widespread condemnation and triggered a Department of Justice investigation into the jail.

At the time of Thompson’s death, more than 90 percent of detainees in his unit, which housed people with mental illness, were so malnourished they had developed a wasting syndrome typically found in people with advanced-stage cancer, according to a report by NaphCare. That document also stated that most people in the unit had not received “essential medications” or completed “activities of daily living,” typically defined as showering, dressing, using the toilet, and eating.

A few months after Thompson’s death, in December 2022, a 29-year-old detainee told the jail’s Physician’s Assistant—the same one named in Joe Kendall’s suit—that he had not had a bowel movement in almost a month and was having trouble walking, according to a jail incident report. (Out of respect for the privacy of the decedent’s family, The Appeal is not naming him.)

The Physician’s Assistant said he would give the man milk of magnesia and return him to his unit. While the man waited, he became increasingly disoriented, according to the incident report. An officer asked the medical provider to examine the man again. During the exam, the man lost consciousness and was taken to the hospital, where he was pronounced dead minutes after arriving.

According to his autopsy report, the man died of complications of ischemic bowel disease, which causes reduced blood flow to the intestines. He was also diagnosed with lower extremity cellulitis, a bacterial infection. That year, 15 detainees died—a five-fold increase over the previous year’s deaths.

So far this year, 10 detainees in the custody of the Fulton County Sheriff’s Office have died.

Joe says he hopes his lawsuit will help bring about change at the notorious jail.

“People go to jail,” said Joe. “It shouldn’t be a death sentence.”