Early in the morning on Aug. 21, 2022, Atlanta police officers held Ricardo Dorado Jr. down on his stomach for 17 minutes before his heart stopped beating.

During the arrest, Dorado moaned and called out for help while officers struggled to get control and pressed their knees into his back, legs and arms, police body camera video shows. “I can’t breathe,” he gasped three times as another police officer held Dorado’s bloodied face against the floor.

“Let him wear himself out,” Officer Aaron Hayes said as he pressed Dorado’s ankles toward his back as Dorado continued to squirm. “He ain’t going nowhere. He’s just a little fish.”

Dorado would soon become unresponsive and go into cardiac arrest. He was pronounced dead 12 hours later in the hospital, according to the autopsy.

About a year later, the city of Atlanta paid $3.75 million to Dorado’s family. But his family says they are still waiting for justice.

Dorado and more than three dozen other deadly force cases reveal a failure by the city’s police oversight agency, the Atlanta Citizen Review Board, to investigate officer conduct, an investigation by The Atlanta Journal-Constitution has found.

The oversight agency was created to investigate citizen complaints about whether officers violated police department policies and to recommend reforms and training.

The City Council expanded the review board’s power in 2020 to investigate all deadly force cases in the wake of the fatal arrests of George Floyd in Minneapolis and Rayshard Brooks in Atlanta. Deadly force is “that amount or degree of force that is likely to cause or actually results in death or serious physical injury,” the police manual says.

The AJC identified 39 deadly force cases awaiting the board’s review. District Attorney Fani Willis decided between June 17, 2021, and July 1, 2024, not to prosecute the police officers in about half of the cases, including Dorado’s death.

The Citizen Review Board has not investigated or held public hearings on any of the cases since 2020.

“We haven’t started the process yet,” Executive Director Lee Reid said when asked about dozens of cases waiting for his investigators to probe.

At first Reid said he was following “industry standard” by waiting on the district attorney to complete the criminal investigations. In December the AJC showed him that there were 18 completed criminal cases ready for his investigators to work on. Reid then moved the bar and said he has to wait for police internal affairs to decide whether officers had violated department policy — a review, in many cases, that stretches on for years.

The process laid out by Reid does not appear in city policy or law.

Police oversight expert Jayson Wechter said he knows of no citizen board that has investigative power, as Atlanta’s does, that waits until after internal affairs to start investigating police conduct, and there is no one standard for when citizen investigations can begin. Best practice is to start an investigation “as quickly as possible” to collect evidence and speak to witnesses, he said.

Board Chairman Germaine Austin said he supports Reid’s position. “It’s very essential that we don’t meddle in current investigations,” Austin said.

But the police investigation of Dorado’s death is complete and officers were disciplined in 2023. The department released its internal affairs investigation on Jan. 9 at the request of the AJC. Two officers were suspended for using unnecessary force to restrain Dorado and five others for failing to intervene.

It’s unclear why the department waited over a year to share its decision with the public.

Protesters confront Interim Atlanta Police Chief Rodney Bryant on July 6, 2020, outside the Wendy's where Rayshard Brooks was killed by an Atlanta police officer. The City Council expanded the Atlanta Citizen Review Board's power to investigate all police shootings that same day in the wake of Brooks' death. (AJC 2020)

Credit: JOHN SPINK / AJC

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Credit: JOHN SPINK / AJC

Falling between the cracks

Dorado’s death isn’t the only one to be ignored for months or years by the watchdog agency.

More than three years ago, the district attorney decided not to prosecute an officer who shot dead a 28-year-old man armed with a gun during a domestic disturbance on Sept. 21, 2020.

A year ago, Willis closed a case involving another Atlanta officer who shot multiple times at a stolen black Lexus SUV being driven by a juvenile on Oct. 28, 2021. The SUV had hit and injured another officer at the scene. No one else was reported injured.

In July, Willis decided not to bring charges in the fatal shooting by an Atlanta plainclothes officer of James Wilborn, 35, who was involved in an argument with an ex-girlfriend on Oct. 25, 2022. Wilborn threw punches at the officer. Police internal affairs exonerated the officer for discharging his firearm and using force. Yet Reid’s agency has still not launched an investigation.

In two cases the civilian board took the step of assigning an investigator, but no review was done.

“They were just inadvertently assigned. There was nothing done with them,” said Deputy Director of Investigations Sheena Robertson on July 16.

The agency has a budget of $1.6 million to investigate complaints involving the Atlanta Police Department’s 1,684 officers. One investigator and a manager are handling more than 100 citizen complaint investigations about lower-level allegations of officer misconduct. The board should have four investigators, but two jobs were vacant for nearly a year. The agency hired one investigator in December.

There is no dedicated staff person to work on deadly force cases. Reid said they need at least six investigators and to increase the salary range – currently $50,000 to $54,000 – to attract investigators with more skills.

“We don’t have the resources to do it, and the officer-involved shooting investigations take a lot of time,” Robertson said.

After publication, a spokesperson for Mayor Andre Dickens released a statement: “The ACRB (the board) rightfully operates as an independent entity, and any specific questions about their investigations should be directed to them. That said, we will review the information presented and work with the Atlanta City Council to evaluate any changes that would expedite the conclusion of investigations. The Dickens Administration is committed to transparency, due process and justice for all who call Atlanta home.”

The Atlanta Police Department declined multiple requests to interview Chief Darin Schierbaum and his subordinates. The department didn’t respond to questions about how it handles deadly force cases and how it shares information with the review board. In a statement, the department said it supports the board and the “vital role” it has in building community trust. The department said it will review the AJC’s findings.

The Atlanta police union objects to how long it has taken the review board to start its investigations, said Vincent Champion, the southeast regional director of the International Brotherhood of Police Officers. Cases already get reviewed by the district attorney and internal affairs, he noted.

“Our biggest concern as a union is that we don’t want this hanging over our members while they’re trying to do their jobs,” Champion said.

These delays are stressful and keep officers from being promoted or hired for new jobs. The police union represents more than 800 of Atlanta’s officers.

Shootings not reported to board

City law says that the board must investigate “all incidents, including ... an officer’s discharge of a firearm.”

The AJC’s review of cases over the past four years found seven cases that the Atlanta Police Department did not report to the board that involved an officer’s discharge of a firearm. These cases are in addition to the 39 deadly force cases that the board has not yet investigated.

Reid confirmed the board had no record of the firearms cases, but he said that unless it involves a serious injury or death it “may not qualify under our ordinance” for the board to review.

The police department did not answer questions about why they did not report these cases to the board.

One officer was involved in two different shootings. On Nov. 15, 2020, the officer discharged his gun during a gunfight while working security at a restaurant. One man was killed and two security guards were injured. Police records do not indicate who fired the fatal shot.

On Aug. 9, 2022, the same officer shot a man in the face after the man pulled a gun on the officer as he approached the vehicle to investigate a reported sexual assault. Death records show the man died weeks later from his injuries. The board was only notified of the second shooting.

The district attorney didn’t prosecute the officer for either shooting.

City fined $2 million

The Atlanta Police Department has its own long history of failing to investigate its officers in a timely manner even after citizens complain.

Atlanta was recently fined $2 million by a federal judge for repeatedly violating the judge’s prior orders relating to the handling of citizen complaints. The fine followed numerous instances where the city had provided false information about when complaints were made and how long it took to investigate them, court records show.

“This dishonesty is negligent at best, deceitful at worst,” Chief U.S. District Judge Timothy C. Batten Sr. warned the city of Atlanta in an October 2023 court order.

The fine stems from a lengthy civil lawsuit by attorney Daniel Grossman, who has served as a court-appointed monitor of the city’s police since 2018.

Sheena Robertson, left, deputy director of investigations for the Atlanta Citizen Review Board, listens during a board meeting in December at Atlanta City Hall. (Christina Matacotta for the AJC)
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In essence, Grossman has been a watchdog but without the powers of the review board to evaluate police policies and procedures or recommend discipline.

The Atlanta Citizen Review Board was supposed to improve civilian trust in the police. The current board was born out of community frustration of years of unchecked police misconduct that culminated in the death of 92-year-old Kathryn Johnston during an illegal raid by Atlanta police at her home in 2006. Four Atlanta officers were later convicted and sentenced to federal prison for conspiring to violate Johnston’s civil rights.

In the future, Reid said, he would like his agency to investigate all citizen complaints against the police. That’s despite the AJC’s finding that his agency has a record of not investigating the most serious deadly force cases.

“That’s a lot of cases that we’re missing out on,” Reid said.

‘They’re supposed to be there to protect you’

Dorado had struggled for years with an addiction to methamphetamines and routinely heard voices that threatened to hurt him, said his sister Arcelia Beltran. Getting treatment was a challenge in rural Lexington, Nebraska, where his family lived since 1994. Their parents had immigrated from Mexico in 1978.

Dorado left Nebraska and was sometimes homeless. On Aug. 21, 2022, the 33-year-old was passing through Georgia on a bus to visit his four children, who were living with his ex-wife in New Hampshire. When the bus stopped in Atlanta, Dorado panicked and acted out. He was kicked off the bus.

Arcelia Beltran, seen here in 2021 with her brother Ricardo Dorado Jr., says that on the night her brother died, he had wanted to call the police for help. She discouraged him out of fear for his safety. (Courtesy of Arcelia Beltran)

Credit: Contributed by Arcelia Beltran

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Credit: Contributed by Arcelia Beltran

Around midnight in Nebraska, Beltran answered a phone call from Dorado. He believed someone was out to get him.

He wanted to call the police for help.

“Ever since we were little we were taught that the police are all good. They’re supposed to be there to protect you,” Beltran said.

But she had seen news reports of police shooting people in crisis and worried about his safety. She told him not to call.

Later, Beltran received a phone call from her mother frantically asking her in Spanish to speak to a police officer at the family’s door in Nebraska.

He delivered the devastating news: Dorado was dead.

Beltran collapsed to the floor and wailed in shock and disbelief. She had always feared getting this call about her youngest brother.

No one told the family how Dorado had died.

They arranged for Dorado’s body to come home and were horrified to see long purple bruises and a gash on his forehead. They first learned police contributed to Dorado’s death months later when they read the autopsy report, in which the medical examiner stated: “It is my opinion that Ricardo Dorado Jr. died of cardiac arrest while being restrained by law enforcement in the prone position.”

A promise to transform local policing

Dorado’s death was the kind of police encounter that city leaders had promised would be independently investigated when they voted to expand the power of the Atlanta Citizen Review Board in 2020.

Protests broke out nationwide over the killing of George Floyd after a Minneapolis officer held him down by kneeling on his neck for nine minutes and 29 seconds and three other officers failed to provide Floyd medical care. All were convicted of criminal charges and sentenced to prison.

In June 2020, an Atlanta officer fatally shot Rayshard Brooks outside a Wendy’s and the city erupted in protest. (Officer Garrett Rolfe was charged with murder, but a special prosecutor later found Rolfe’s use of force was “objectively reasonable” and dropped the criminal charges in August 2022. He remains on the force.)

Facing intense public pressure, city leaders vowed to transform local policing. Keisha Lance Bottoms, the mayor at the time, signed an order three days after Brooks died directing Atlanta police to report to the review board every time officers used deadly force. The order does not say when the review board should start its investigation.

The City Council granted the Citizen Review Board greater powers on July 6, 2020, almost a month after an Atlanta police officer fatally shot Rayshard Brooks. (AJC archive)

Credit: AJC archive

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Credit: AJC archive

Protesters marched to City Hall in 2015 to rally against police brutality. Among their demands was expanded power for the Atlanta Citizen Review Board.  (AJC 2015)

Credit: bsanderlin@ajc.com

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Credit: bsanderlin@ajc.com

Officers can use deadly force only when a person is suspected of committing a felony with a weapon or is an immediate physical threat to the officers or the public. Police officers must first try to de-escalate the situation, according to the police manual.

Mayor Andre Dickens was a City Council member in 2020 and sponsored the legislation to expand the board’s powers. Four years later, in July, he told the Citizen Review Board that he continues to support its role as a truth-teller for the city.

“We strive to get it right as much as we can, but when we do not get it right you guys, your team, helps to make sure that any reported mistakes, any missteps are brought to light and that justice can be served on behalf of the people of Atlanta,” Dickens said.

What went unspoken is that the city had made an empty promise in 2020. No deadly force cases have been reviewed by the board in the four years since Brooks was shot by police.

A Dickens spokesman on Dec. 18 said the mayor wanted to talk about this issue but the mayor has not responded to repeated requests for an interview.

Wechter, who serves on the board of a national civilian oversight group, said cases should be promptly investigated so remedial action is taken. Officers also shouldn’t have the shadow of an administrative investigation hanging over them if they have been cleared of criminal wrongdoing, he said.

17 minutes

Gary Bailey calls 911 around 3:20 a.m. on Aug. 21, 2022.

He’s the security guard at a BP station on Windsor Street and is watching while Dorado vandalizes gas pumps, beats on vehicles and runs into the road.

“I need the police ma’am,” Bailey tells the emergency dispatcher. “I need to get somebody before somebody shoot him.”

Body camera video obtained by the AJC shows Sgt. Jerome Jones and Officer Quinn Green approaching Dorado, who is bare chested and walking on a lawn near the gas station. They order him to, “Get on the ground.” Green uses a Taser and chemical spray on Dorado, but neither stops him.

Dorado flees back to the gas station and briefly locks himself inside the bathroom. As he emerges, multiple officers hit Dorado’s arms and legs with batons as they chase him through the store. Dorado throws a plastic tote, knocks wine bottles from the shelves, and hits Jones in the head with a wine bottle.

The city of Atlanta paid $3.75 million to the family of Ricardo Dorado Jr. a year after his fatal arrest. His family (from left), brother, Humberto Dorado, father, Ricardo Dorado Sr., mother, Josefina Dorado, and sister, Arcelia Beltran, say they are still waiting for justice. (Sarah Mariel for the AJC)

Credit: Sarah Mariel for The Atlanta Jou

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Credit: Sarah Mariel for The Atlanta Jou

In less than five minutes, the chase ends with Dorado sitting on the floor, hugging his knees to his chest and knotting his fists into his boxers with blood oozing from his face.

Officers flip Dorado face down on the floor. Officer George Crenshaw kneels on Dorado’s back and hip while another officer, Aaron Hayes, grabs Dorado’s legs and presses both toward Dorado’s back, video shows. Officers struggle to handcuff Dorado’s wrists, but once they do Officer Kamari Woods kneels on an arm. As Dorado bangs his bloodied face against the floor, another officer holds Dorado’s head down to make him stop.

It takes four officers to control the 5-foot-11, 208-pound man.

As the arrest unfolds, at least eight more officers surround Dorado. During the 17 minutes Dorado is being held, no one suggests that officers sit Dorado up so he can breathe more easily, according to a police internal affairs investigation.

The department’s use of force policy requires an officer who observes another police officer using too much force to intervene and stop it. The policy also prohibits any officer from holding a person in a way that will restrict oxygen, “due to the potential for serious injury or death.”

As the minutes tick by, Dorado’s calls for help go quiet. By now he has been held down by four police officers for nearly a quarter of an hour.

“You good man?” Officer Daniel Fernandez asks as Dorado makes loud, ragged breathing sounds. Five minutes later, Fernandez puts two fingers to Dorado’s throat to check for a pulse: “I don’t feel s---.”

Officers roll Dorado onto his back and start chest compressions.

Then they administer three bottles of an opioid-reversal nasal spray, Narcan.

Dorado lies motionless on the floor.

Death deemed a homicide

Dorado was pronounced dead 12 hours later at an Atlanta hospital. The medical examiner ruled that Dorado’s cause of death was “prone restraint cardiac arrest following exertional apprehension of (an) agitated individual, complicated by methamphetamine toxicity, blunt head trauma and coronary artery disease.”

The medical examiner labeled the case a homicide which is a death that occurs at the hands of another person and does not imply criminal intent.

Dr. Alon Steinberg, a board-certified cardiologist, reviewed the autopsy at the request of the AJC. He agreed that Dorado died of “prone restraint cardiac arrest.” Steinberg, who has researched prone restraint, has testified in court and in depositions as an expert witness in approximately 20 civil lawsuits on police and corrections officers’ use of prone restraint and its role in cardiac arrests.

“If he had not been held in that position, he’d probably be alive,” Steinberg said. “Nobody should have to stay in that position for 17 minutes.”

Even without the weight of police officers on his body, Dorado would have had difficulty expanding his rib cage and diaphragm to breathe as he laid on his stomach. His heart would struggle to move blood, Steinberg said.

Dorado’s underlying heart disease is an “incidental finding,” Steinberg said. Similarly, George Floyd’s autopsy report showed a narrowing of an artery, he noted.

The medical examiner who conducted the autopsy of Ricardo Dorado Jr., concluded he died of cardiac arrest while being restrained by police in the prone position. (Fulton County Medical Examiner)

Credit: Fulton County Medical Examiner

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Credit: Fulton County Medical Examiner

“It’s interesting that even after George Floyd that a case like this, someone can be restrained for 17 minutes and not know there’s a problem,” Steinberg said. “It’s kind of shocking. You would think every cop in the United States would know not to restrain anyone for long in that position, but I guess they didn’t learn.”

Dorado should have been rolled onto his side after he was handcuffed and not left on his stomach for more than five minutes, according to a 49-page investigative report produced by the office of Fulton County District Attorney Fani Willis and obtained by the AJC.

In the police internal affairs investigation Sgt. Steven Stewart, an Atlanta police training academy instructor, concluded that officers acted “objectively reasonable under the totality of the circumstances” while arresting Dorado, but some did not follow training.

The leg hold used by Hayes “is not a technique that is sanctioned,” Stewart said. Officers are taught to briefly use their knees while securing handcuffs but not to hold a person down on their stomach with the majority of their body weight, like Crenshaw did, Stewart said. Woods also didn’t follow training in how he used his body weight to restrain Dorado, according to Stewart. The three officers used “unnecessary force” on Dorado, internal affairs concluded.

Woods and Hayes were suspended for three days without pay. Crenshaw resigned from the department in 2022 before discipline could be imposed.

Dorado should have been sat up once he was no longer combative, internal affairs determined. Five officers, including Fernandez, Jones, Green and other officers present during the arrest, were suspended for three days without pay for not intervening, internal affairs concluded.

Crenshaw and Fernandez declined to comment and the other officers did not respond to attempts to contact them. The department declined to make any of the officers available for interviews.

The year following Dorado’s death, Atlanta police did a one-hour training session about the dangers of keeping a handcuffed person on their stomach. The department did not answer questions about the training and whether it was in response to Dorado’s death.

Ricardo Dorado Jr. had struggled for years with a drug addiction and mental illness. He routinely heard voices that threatened to hurt him, according to his sister. (Courtesy of Arcelia Beltran)

Credit: Obituary photo

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Credit: Obituary photo

The presentation warned that people under the influence of meth may be susceptible to sudden increases in heart rate that can cause cardiac arrest when they are held down. Officers were instructed that, “Once a person has been handcuffed, make sure that person is no longer positioned on his or her stomach.” The AJC obtained the visual presentation by filing a public records request.

It includes an illustration of three police officers holding a man face down on the ground by pressing his legs toward his back, holding his arm and holding down his head. The words “I can’t breathe” are written over the image.

In February 2023, Dorado’s family filed a notice of claim demanding $17.5 million from the city of Atlanta, 1 million dollars for each minute that police officers held him on the ground.

On Oct. 2, 2023, the Atlanta City Council agreed to pay Dorado’s children $3.75 million, which is the largest pre-litigation police settlement paid by the city of Atlanta in the prior decade.

‘Swept under the rug’

For more than two years, Dorado’s family waited to hear if any of the police officers who restrained him would be criminally charged for his death. Out of the blue this October, a victim advocate called to say Willis wanted to talk.

Dorado’s parents, Josefina and Ricardo Sr., and their three children logged onto the video call on Oct. 17 and waited anxiously to hear what prosecutors had found. Willis said her office considered charging officers with involuntary manslaughter, reckless conduct and violation of oath of office.

“The office decided not to bring charges based on all of the evidence looked at,” said Willis, according to the family’s recording of the meeting obtained by the AJC.

Willis assigned blame for Dorado’s death elsewhere. “Society has failed him,” she said.

Dorado’s death was tragic but the evidence did not meet the burden of proof necessary to establish that a crime was committed, an office statement said. Willis declined multiple requests for an interview about Dorado’s case and her decisions not to prosecute the officers in about half of 39 deadly force cases.

The office noted that Willis has indicted 20 officers since taking office in 2021. “Any allegation that this office is reluctant to seek charges against officers when appropriate is contradicted” by her record, the statement said.

“If he had not been held in that position, he'd probably be alive. Nobody should have to stay in that position for 17 minutes."

- Dr. Alon Steinberg, a board-certified cardiologist

Humberto Dorado spent two years after his brother’s death hoping that there would be a criminal trial. He was frustrated when Willis blamed society’s failure to provide drug and mental health treatment to his brother.

“It wasn’t society who killed him, it was those police officers that were there,” Humberto Dorado said. “... I don’t see how they cannot push forward or press any charges.”

A July 1 letter signed by Willis notified state investigators of her decision “that the evidence is insufficient to proceed with an indictment and criminal prosecution” of six officers involved in the arrest, but she didn’t tell the family until Oct. 17 after the AJC started asking her office questions.

Beltran said it was a slap in the face to be told the possible charges and then to have them ripped away. She no longer feels like she can trust the police.

The review board should still independently investigate Dorado’s death and the police officers involved, Beltran said.

“I can’t help but feel anger that he might be another one that is just swept under the rug,” Beltran said.

Ricardo Dorado Jr. is buried in Lexington, Nebraska, where his family has lived since 1994. (Courtesy of Arcelia Beltran)

Credit: Courtesy of Dorado family

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Credit: Courtesy of Dorado family