When Aundrea Milnes was arrested for refusing to leave an Omaha hospital early in the morning of Nov. 3, 2022, police officers gave her a choice: She could be taken to a homeless shelter, or she could go to jail.
Milnes, according to grand jury transcripts, chose the Douglas County Correctional Center. As she sat in her jail cell, Milnes was “irate” as she was “screaming and yelling that she was in pain,” a former corrections officer told a grand jury last September.
Less than 10 hours after Milnes, 47, was arrested, she died in a jail cell of complications of an abdominal and intestinal condition.
A Douglas County grand jury scrutinized Milnes’ death and 13 others — six at the Douglas County Correctional Center, two at the state-operated Omaha Correctional Center, and six at the hands of or in the presence of law enforcement. The grand jury listened to a presentation from Douglas County Attorney Don Kleine and heard testimony from investigators, corrections officials and medical personnel.
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By the end of the proceedings, the 19 Douglas County residents impaneled on the grand jury — 16 jurors and three alternates — finding no criminal conduct on the part of police or corrections officers.
But the grand jury also took the rare step of issuing a recommendation: “The Grand Jury recommends that in all deaths in correctional facilities, both county and state, that there be an independent review of those deaths.”
The recommendation, which is nonbinding and does not appear to have been widely shared with the public or corrections officials, strikes some legal observers as eyebrow-raising given that it came from a body that is meant to be a mechanism for independent oversight.
“Technically, (the grand jury) should be that independent arbiter who’s looking into the death,” Creighton University School of Law Professor Leigh Ellis said.
Since 1988, Nebraska state statute has required a grand jury be convened to review the circumstances of all deaths that occur in the presence of law enforcement or detention personnel. Jurors are presented with testimony from investigators and witnesses to the death, and they have subpoena power to call witnesses and examine documents.
After being presented with each case, the jurors deliberate and return a criminal indictment against those involved or a “no true bill.” Jurors also have the option of creating reports to explain their findings and issue recommendations, though they are not required to do so — and, in most cases, do not.
The process is highly secretive: The public is not made aware of a grand jury convening until their work is finished and the identities of grand jurors are never revealed. Because of that, it’s impossible to know what led the grand jury to issue this particular recommendation or what it meant by independent oversight. World-Herald reporters discovered the September recommendation while reviewing grand jury transcripts at the Douglas County Courthouse.
Since 2016, when , Douglas County grand juries have issued at least four recommendations. Grand juries in other counties have also made recommendations: A Lincoln Journal Star investigation from 2020 identified additional recommendations from Hall and Sarpy Counties.
All of those recommendations were related to specific aspects of police or jail operations — unlike the September recommendation, which appears to target a broader issue of oversight.
County officials say they don’t oppose more scrutiny of in-custody deaths
Public officials on the county level said they were open to the idea of more independent oversight.
Kleine, who led the September grand jury along with dozens of others dating back to the 1990s, said he’s not opposed to further scrutiny of deaths that occur in custody.
“Anything we can do to make things better from an investigative standpoint is fine by me,” Kleine said. “I don’t think there would be a problem with having an even closer look at what happens, particularly if (the grand jury) sees a pattern, or if they see a lack of something at corrections.”
Michael Myers, the director of corrections for Douglas County, said he believes the review systems in place — which include an internal investigation, external investigation by the Douglas County Sheriff’s Office and grand jury review — are exhaustive and sufficient. And while he’s not opposed to further oversight, he said, Myers is unsure what that would look like.
“There’s no perfect system, but I don’t have any recommendations,” Myers said. “We try to learn something from every death. Sometimes there’s nothing to learn, but a couple of times we have made real changes as a result of our review.”
For example, Myers said, after an inmate with a background in corrections died by suicide shortly after he was booked, the facility began placing anyone with a law enforcement or corrections background on an automatic behavior or suicide watch. And after a woman jumped to her death from the second-floor balcony of a housing unit at the jail in 2020, safety netting was installed in all two-story units.
Those changes were the result of internal reviews, Myers said, not grand jury recommendations.
A spokesperson for the Nebraska Department of Correctional Services, which has been the subject of grand jury recommendations in multiple counties, did not respond to questions about the procedure for receiving and reviewing these recommendations in time for publication.
Officials not always informed of grand jury recommendations
As part of the grand jury process, jurors have broad discretion to make “any recommendations (they) determine to be appropriate.” But state statute provides little insight on what should happen to the recommendations once they are made.
According to Kleine, who said his office has communicated some recommendations to key stakeholders in the past, there is no formal procedure nor requirement for grand jury recommendations to be disseminated.
Ellis, the Creighton professor, said she questioned the purpose of allowing grand juries to make recommendations if there’s no mechanism for sharing them with the public or lawmakers.
“Grand juries were created as a tool to give people confidence in the objectivity and the fairness of investigations in the legal system and it just feels like a facade when there are all these supposed checks and balances in place, but yet there’s no one actually checking the recommendations,” she said.
Perhaps the most consequential grand jury recommendation in Douglas County was issued in 2007 — before the word “recommendation” even appeared in state statute — when jurors called for the closure of the Omaha City Jail. In December 2007, a grand jury indicted four jail officials after an inmate at the detention facility formerly located at Omaha police headquarters died in custody after days of pleading for medical attention.
In addition to the indictments, the grand jury issued a scathing four-paragraph report that recommended the jail be closed. The jail was closed and merged with the Douglas County Correctional Center within seven months of the grand jury’s recommendation.
“That was a very good thing,” Kleine, who led the 2007 grand jury, said of the city jail’s closure. “It shows that there’s something that can happen from (the grand jury) process.”
Since 2016, Douglas County grand juries have made at least four recommendations, including the one in September 2023.
- In 2017, a grand jury proposed additional mental health training for Omaha police in the wake of Zachary Bear Heels’ death. Bear Heels, who was experiencing a mental health crisis, died after Omaha police shocked him with a stun gun in 2017. That recommendation was communicated to the Omaha Police Department, .
- after a 2018 Douglas County grand jury reviewed the death of Susan Kiscoan. She died of Addison’s disease, an affliction that attacks the adrenal glands and can lead to fatigue and rapid weight loss, in the Douglas County Correctional Center after she was arrested for trespassing at a hospital. An investigation revealed that Kiscoan, who was also diagnosed with schizophrenia, had not been given medication for Addison’s disease for three days before her death. That jury made four specific recommendations, mostly about medical documentation and training for staff. The jurors also wrote in their report that they were generally “concerned about the lack of medical and mental health resources” at the jail.
- A Douglas County grand jury in 2021 recommended that all state inmates receive a full medical assessment before being placed in protective custody.
Myers said he did not know of any grand jury recommendations made since he took over the top job at the jail in 2018. The recommendations related to the Kiscoan case were made before Myers’ first day.
As for the September recommendation, Myers said he wasn’t aware of the request for more independent oversight until a World-Herald reporter told him about it.
Aside from grand jury, little oversight exists for county jail deaths
Between 2020 and 2023, at least 135 people died behind bars in Nebraska, according to .
The majority of the reported deaths — 105, or about 76% — occurred in state correctional facilities. The remaining 33 deaths occurred in the custody of county jails in Cherry, Douglas, Hall and Lancaster Counties. Twenty of those 33 deaths occurred in the custody of the Douglas County Correctional Center, the jail facility in downtown Omaha that housed an average of 1,046 people daily in March 2024.
When someone dies in a state correctional facility, that death is subject to an additional layer of scrutiny through the Office of the Inspector General for Corrections — a position created by the Nebraska Legislature in 2015 that is required by law to investigate all deaths and serious injuries that occur within Nebraska’s nine state prisons.
About a month before the September grand jury wrote its recommendation, Nebraska Attorney General Mike Hilgers concluding that the inspector general positions were unconstitutional. Despite the opinion carrying no legal authority, the Department of Correctional Services to case management systems and in-person visits at state institutions.
Earlier this year, about six months after Hilgers’ opinion, to pass a resolution to create a legislative committee to review how the Legislature exercises its oversight of state government.
The resolution also enacted a memorandum of understanding between the Legislature and Gov. Jim Pillen that allowed the inspector general of corrections to again get information from executive branch agencies and to resume visits to prisons.
There’s no similar layer of scrutiny for the deaths that occur in the state’s 63 county jails, where the grand jury process is the only independent oversight mechanism beyond a law enforcement investigation.
The State Ombudsman’s Office, which has existed to take complaints regarding state agencies and employees since the 1960s, has some oversight authority over county jails. State Ombudsman Julie Rogers, who was appointed to the post in 2020, said her office takes a lot of complaints from inmates housed in county jails — but the office is not required to investigate deaths of inmates in county custody.
Ellis, the law professor, said she sees a major flaw with a complaint-based system in death investigations.
“Who issues the complaint? The person who dies?”