Kerrie Hirte, the mother of Cilivea Thyrion, looks over autopsy reports sent by the medical examiner. (Photo | Isiah Holmes)

On a recent chilly November evening, Kerrie Hirte confronted a piece of mail she’d both anticipated and dreaded. Sitting at her kitchen table, beneath a picture of her late daughter Cilivea Thyrion, 20, Hirte examined the contents of an orange envelope from the Milwaukee County Medical Examiner’s Office. Inside were unredacted autopsy reports, with details that raised new questions about her daughter’s death in the Milwaukee County Jail nearly two years ago. 

Hirte invited the Wisconsin Examiner to her Green Bay home to accompany her when she first viewed the unredacted autopsy reports. They show that correctional officers were aware that Thyrion, who died after eating pieces of an adult diaper while on suicide watch, had a previous history of eating the very item she was given the day she died. In autopsy protocol records, the medical examiner also noted evidence of blunt force injuries to Thyrion, including injuries to her head, lower extremities, liver, and ribs. 

The reports described the scene of Thyrion’s death on Dec. 16, 2022. By then, Thyrion had been in the jail just two days short of 10 months. Thyrion was arrested by the Wauwatosa Police Department in February, after getting in a fight at her residence and charged with felony suffocation/strangulation and misdemeanor battery. Thyrion died before she was sentenced for the charges. 

According to the records later mailed to Hirte, medical examiner investigators found Thyrion “lying on a bare metal slate” with her arm “resting on a green mattress pad on the floor.” The green mattress was one of the only items in the cell besides a toilet, sink, a paperback book and intercom. Thyrion had been housed in the jail’s Special Needs Unit, where she’d been on suicide watch since Dec. 11. “It is unknown at this time what [led] to her needing this type of cell and supervision,” the medical examiner’s investigation report states.

On the morning of Dec. 16, Thyrion pushed the assistance button inside her cell to call guards for help. When correctional officers arrived, they saw Thyrion gesturing towards her neck. After gathering other correctional staff, they called 911 as it was apparent that the 20-year-old was suffocating. The medical examiner’s report states that correctional officers performed a Heimlich maneuver to help Thyrion clear whatever she was choking on. The report states that correctional officers called 911 three times, but Thyrion was unconscious by the time medics arrived. 

An investigation by the Waukesha County Sheriff’s Department found that Thyrion had ingested an adult diaper, which correctional officers gave her while she was on suicide watch. Although why the diaper was provided is redacted in Waukesha’s reports, interviews with correctional officers strongly imply that it was to help Thyrion deal with her menstrual cycle. In a letter stating that no charges would be filed for Thyrion’s death, the Milwaukee County District Attorney’s Office wrote that the guards tried unsuccessfully to find underwear made specifically to limit self-harm risks, but could only find an adult diaper. The district attorney’s letter states that “they wanted to meet a basic need for Ms. Thyrion and did not consider that the diaper could be used in a way to self-harm.”

What correctional officers knew about Thryion’s self-harm risks is woven in and out of the redactions in the Waukesha sheriff’s investigation. One interview of a correctional officer noted that the guard “was aware of Thyrion’s history and had conversations with her about [redacted]”, and that the guard was “very sad about the situation because nobody thought that Thryion would hurt herself by [redacted] and they were just trying to make her ‘feel like a woman.’” 

Yet, the medical examiner’s scene report states that “according to Correctional Officers (CO) and jail staff, [Cilivea] had a history of trying to swallow inedible objections (sic) including plastic forks and diapers. She was seen trying to swallow unspecified objects today around 1030 hours and it is believed that she was unsuccessful at actually swallowing anything.” After reading that section of the report Hirte wondered why her daughter would be given a diaper if jail staff were aware of the risk. “They make it sound like they just gave her diapers all the time,” Hirte told Wisconsin Examiner. 

After reading a portion of the reports stating that Thyrion had no next of kin, but that detectives were aware that she’d called an unknown female, Hirte began to weep. While Thyrion was incarcerated, Hirte recalled talking to jail health care staff “several times about Cilivea.” She told Wisconsin Examiner that her daughter had signed “a release of information so that I could find out what was happening to her in there. And when you’re reading that [the medical examiner reports] it makes it sound like they had no idea who she was talking to. When they know darn well it was me.”

According to the medical examiner report, jail staff “stated they were not aware of any triggers, upcoming court proceedings, or recent events that would make Cilivea want [to] harm herself today or for any of the past self harm attempts.” 

Hirte wonders if jail staff knew that Thyrion had swallowed plastic forks and diapers before, and if so,  “why would you give her anything then?”

In late 2023, among Thyrion’s belongings released to Hirte by the jail was a handwritten note from Thyrion requesting to see a nurse. “I think I need a med adjustment,” Thyrion wrote. Electronic messages Thyrion sent jail staff throughout her incarceration also show that she regularly communicated her needs, without many results. The messages were obtained by Wisconsin Examiner through open records requests. 

In late March 2022, Thyrion messaged jail staff asking to be moved to another part of the facility because activity going on in her pod was “mentally upsetting.” The following month in April, Thyrion wrote complaints about jail staff mocking her with “fat jokes” and being rude. In June, Thyrion was denied access to the gym, and made multiple requests for a Bible and hygiene products. 

Redactions in the messages obscure crucial details about Thryion’s needs. Anything related to Thyrion’s mental health history, including the word “suicide” is redacted in most reports. “I have not been [getting] my [redacted] and I don’t know why. I really need it. I have been getting really bad [redacted],” she wrote on June 29, 2022. In August, she reported being verbally threatened by a correctional officer, and asked why she wasn’t getting her mail. When she asked to speak with friendlier and familiar jail staffer, Thyrion was denied. “I promise to be better,” Thyrion wrote in the electronic messages. “I Just need to talk to her please she’s a good friend she’s great to talk to please she was in cell four please I’m sorry.” 

On Dec. 2, 2022, court records show that Thyrion’s sentencing had been scheduled for January 2023. In her last message sent on Dec. 12 to jail staff, just four days before her death on Dec. 16, Thyrion reported that jail staff had used her cell’s intercom system to call her fat, pathetic, and that “no one in my family should have raised an inmate” and that “it all started because I threw up my food and she said that maybe if I stopped eating everything I would not be throwing up.”

Records from the Milwaukee County Jail showing correspondences between Cilivea Thyrion and jail staff during her time at the jail, obtained through open records requests.

Thyrion’s messages to jail staff about harassment and neglect, her note asking for “a med adjustment,” the medical examiner’s note that correctional staff knew about her history of ingesting objects like diapers (seemingly at odds with the district attorney’s letter mentioning that jail staff didn’t consider the diaper to be a self-harm risk), and their subsequent decision to furnish an ordinary diaper rather than one designed to prevent self-harm, raise serious questions about the lack of accountability in her case. Hirte feels what happened to her daughter was intentional, “because they gave her something and then walked away.” 

With many crucial details about Thyrion’s medical history at the jail hidden behind black inked redactions, these various pieces form a picture of what her life inside the jail was like. Normally, the Milwaukee County Medical Examiner’s Office does not release autopsy protocols. As Thyrion’s mother, however, Hirte was sent an unredacted copy which was also reviewed by Wisconsin Examiner. The report notes “blunt force injury” including an abrasion to Thyrion’s head, fractures to four ribs, and contusions or abrasions to her abdomen, liver, left hand, and “lower extremities and the bottom of the right foot.” Instead of food, plastic fragments were found in Thyrion’s stomach, and “a crumpled piece of cloth fabric” in her large intestine. 

“To me,” Hirte told Wisconsin Examiner,  “it’s like, should she have been in the hospital if she had that towel in her large intestines?” A few days after viewing the autopsy reports, Hirte traveled from Green Bay to Milwaukee, to speak before a Milwaukee County committee reviewing an audit of the Milwaukee County Jail. The audit revealed “systemic issues ranging from dangerous suicide watch practices and a mental health challenge to critical staffing shortages and occupant overcrowding.” 

Auditors noticed “unsafe restraining of occupants” on suicide watch, including being handcuffed to benches for hours at a time. Although the jail places an average of 36 people in suicide watch on a weekly basis, mental health assessments were inconsistent. While auditors were visiting the jail, staff realized that someone on suicide watch had not been logged on a white board. “This discrepancy highlights a critical breakdown in communication and procedure,” the auditors wrote. There was also a backlog of 51 people awaiting competency evaluations. Despite there being a high number of pre-trial jail occupants taking psychotropic drugs, suggesting “a significant mental health burden within the jail” according to the audit, medications are distributed in bulk stock, meaning they’re not individually prescribed or even properly labeled with instructions on how to take the drugs. 

The auditors also found a lack of supervision and clear duties for correctional staff in the jail’s restrictive housing units, and found that the jail’s suicide prevention policies — while complying with Department of Corrections (DOC) regulations — lacked “specificity and clarity.” The auditors warned that “this vagueness hinders consistent and effective implementation of critical procedures, particularly those related to suicide watch.” Throughout the audior’s visit, the auditors recommended that the Milwaukee County Sheriffs Office and its contracted jail health care provider Wellpath emphasis suicide prevention training and address staffing shortages, lack of supervison, and the various nonfunctioning light fixtures, graffiti, and damaged windows which create an unfavorable atmosphere within the jail.

Thyrion’s death came as part of a string of six deaths within the jail over a 14-month period. During the audit committee hearing on Dec. 2, Milwaukee County Sheriff Denita Ball said that after each death, the office does a review to see what could be done better. As a result, Ball said before a committee of county supervisors, there hasn’t been a suicide at the jail since January 2023. “We’re putting things in place that is helping,” said Ball. “One death is one too many.” 

After the sheriff spoke, the floor was opened up for public comment. “From what I see from this audit shows all my concerns,” said Hirte. “It shows more. There’s stuff I didn’t even know that I now know. And I hope it opens everybody’s eyes as to why I came back here to fight for my 20-year-old daughter. The only daughter I have died, who died in the Milwaukee County Jail, they say while she was on suicide watch. This basically says how unequipped they were to handle her.” 

In November, days before the jail audit report was sent to Milwaukee County Audit Committee officials, the jail’s contracted health care provider Wellpath filed for bankruptcy.  The Milwaukee County Medical Examiner’s Office declined to comment, and the Milwaukee County Sheriff’s Office also did not respond to multiple requests for comment for this story. 

A new report tallies deaths in Wisconsin from gun violence, including murders and suicides, and makes recommendations for prevention. (Photo by Ethan Miller/Getty Images)

Guns claimed the lives of 830 Wisconsin residents in 2022 according to Gun Death in Wisconsin, a new joint report by the Wisconsin Anti-Violence Effort (WAVE) Educational Fund, the state’s leading gun violence prevention organization, and the Violence Policy Center (VPC), a national research and advocacy organization working to stop gun death and injury.

The study was released as part of the Emergency Gun Violence Summit being held Thursday at the Baird Center in Milwaukee. It analyzes data from the federal Centers for Disease Control and Prevention (CDC) and the Federal Bureau of Investigation (FBI) on lethal gun violence in the state and compares Wisconsin firearm death data to other Great Lakes states.

The study offers year-over-year trend analyses by sex, age, race, and ethnicity for firearm suicide and firearm homicide. 

It also examines gun suicide and homicide deaths in urban and rural areas and presents firearm criminal trace data from the federal Bureau of Alcohol, Tobacco, Firearms and Explosives (ATF). 

The report also presents personal stories of Wisconsin residents affected by lethal gun violence.

“This report highlights the toll of gun violence on Wisconsin communities and the disparities that must be addressed,” said Nick Matuszewski, director of policy and program at WAVE Educational Fund. “WAVE is committed to advocating for necessary changes to protect every Wisconsinite. Research shows that policies like universal background checks and extreme risk laws effectively reduce gun violence. By prioritizing these measures, we can create safer environments and protect our communities from the impacts of gun-related incidents.”

“Effective public policy relies on comprehensive, reliable data not only to recognize public health threats but also identify effective solutions,” said Josh Sugarmann, executive director of the Violence Policy Center. “This annual study is one more tool for advocates, organizations, and policymakers working to reduce gun violence in Wisconsin.”

Wisconsin gun death findings:

• Guns claimed the lives of 830 Wisconsin residents in 2022, including 529 firearm suicides and 277 firearm homicides. In 2022, guns were used in 57.3% (529 of 924) of suicides and 84.7% (277 of 327) of homicides. For both suicides and homicides, the majority of victims were male. While the state’s overall suicide and firearm suicide rates were similar to national rates, both its homicide and firearm homicide rates were lower than national rates.
• Black Wisconsin residents are disproportionately affected by lethal gun violence. While Black residents comprise only 6.3% of Wisconsin’s population, 75.5% of firearm homicide victims were Black, with the Black firearm homicide victimization rate more than doubling from 23.0 per 100,000 in 2019 to 55.9 per 100,000 in 2022. Black Wisconsin residents were almost 70 times more likely to die from firearm homicide than white residents. And while the white population in Wisconsin has historically had the highest rate of suicide by firearm in the state, the Black population surpassed this disturbing metric in 2022. Between 2018 and 2022 the firearm suicide rate for Black Wisconsin residents more than tripled — from 3.0 per 100,000 to 9.4 per 100,000.
• Most gun deaths in rural Wisconsin are suicides, not homicides. Suicides increased from 81% of all rural gun deaths in 2018 to 91% of all rural gun deaths in 2022. For that same period, the rural firearm suicide rate increased from 8.1 per 100,000 to 11.4 per 100,000.
• Since 2020, gun deaths have outpaced motor vehicle deaths across the state, a shocking fact recognizing most people’s daily exposure to motor vehicles as opposed to firearms.
• For homicides in which the victim to offender relationship could be identified, 76.8%  of Wisconsin homicide victims were killed by someone they knew (162 of 211).
• For homicides in which the circumstances were known, 80% (184 out of 230) were not related to the commission of any other felony –  41.3% (76 homicides) involved an argument between the victim and offender.
• According to ATF, in 2022 more than 8,000 firearms were recovered in Wisconsin and traced. Almost all of the guns recovered and traced were handguns – 79.8% were pistols and 6% were revolvers. In addition, the vast majority of firearms recovered in Wisconsin (84.5%) were originally sourced in-state.

The report also cites WAVE’s recommended gun violence prevention policies for the state as well as its recent policy successes. 

The Violence Policy Center is a national educational organization working to stop gun death and injury. 

Wisconsin Anti-Violence Effort Educational Fund (WAVE) is a statewide grassroots organization dedicated to preventing gun violence, injuries and deaths through education and advocacy.