Some six hours before he died on the morning of March 12, 2013, Daniel Linsinbigler, a short, boyish-faced 19-year-old with a self-reported history of bipolar disorder and schizophrenia, caused a ruckus in his Clay County Jail cell, shouting and pounding and kicking its solid metal door to get the attention of his jailers.

It was obvious he’d been suffering from delusions and was likely in the midst of a psychotic break — on March 2, a naked Linsinbigler was arrested after he ran around outside an Orange Park motel, shouting Bible verses at guests and proclaiming himself God. During his 10-day lockup in solitary confinement, he’d repeated to deputies and nurses that he was Jesus or, toward the end, that he had Satan inside him.

At about 8 a.m., a nurse in the jail recommended that he be restrained. At 8:07, Clay County Sheriff’s deputies entered his cell, pepper-sprayed him when he didn’t comply with their orders, and strapped him by the wrists, ankles and chest into a restraint chair on the cellblock. Snot and spit poured from Linsinbigler’s nose and mouth, a reaction to the pepper spray, so at 8:17, to shield themselves from his bodily fluids, deputies draped a TranZport Spit Hood over Linsinbigler’s head.

An hour later he was dead.

Linsinbigler suffocated to death in that chair, about 10 feet from an observation desk where a deputy was monitoring him, making notes on his condition every 15 minutes. He died wearing the green quilted smock the jail gives to inmates on suicide watch. He died with pepper spray still on his face, with the spit hood still covering his head.

Pepper spray swells a person’s airways and gives the sensation of not being able to breathe. In rare cases, it has also been linked to respiratory arrest and pulmonary edema, or a buildup of fluid in the lungs, according to a 1999 report in the North Carolina Medical Journal. (An autopsy found fluid in Linsinbigler’s lungs, though the report doesn’t say what caused it.) Instructions for the TranZport Spit Hood, meanwhile, say the hood should not be placed on someone who is having difficulty breathing.

For the first half-hour while he was in the restraint chair, Linsinbigler thrashed and yelled. In later interviews with investigators, the deputies and nurses on duty that morning described him as screaming out profanities or unintelligible gibberish. Four inmates, however, said they heard Linsinbigler pleading for help, shouting to anyone within earshot that he couldn’t breathe and begging deputies to remove the hood.

By 8:45, according to investigative records, Linsinbigler was no longer vocal. By 8:52, he’d stopped thrashing. By 9:06, deputies realized that he was no longer breathing. After they tried to resuscitate him, paramedics took him to the Orange Park Medical Center, where he was pronounced dead at 10:14.

The medical examiner ruled his death a homicide — a technical term meaning it was not a natural occurrence.

No one has been disciplined for his death, and no one has been held criminally responsible. An administrative review found that deputies at the jail followed Clay County Sheriff’s Office protocols. And based on an investigation by the Florida Department of Law Enforcement, Stephen Nelson, director of the Fourth Judicial District’s Clay County State Attorney’s Office, wrote in an opinion dated Aug. 23, 2013, “that the death of Daniel Linsinbigler involves no criminal wrongdoing or intent to do bodily harm to him, but is the result of an accidental unintended death.”