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September 4, 2014

Oklahoma releases extensive report concerning problems with Lockett execution

As reported in this lengthy Tulsa World article, headlined "IV errors, lack of training cited in Oklahoma botched execution report," the Oklahoma Department of Public Safety released today this lengthy official report concerning the seemingly ugly execution of Clayton Lockett by the state back in April. Here is a rough summary of the report's findings via the news report:

Despite some problems, the execution drugs did what they were supposed to do, the Department of Public Safety said Thursday morning at a news conference on a report into Clayton Lockett's execution....

Lockett died April 29 at the Oklahoma State Penitentiary 43 minutes after his execution began. Witnesses watched as he writhed, strained and mumbled on the gurney inside the execution chamber....

The stress of two planned executions in one day, a lack of proper equipment and no backup plan hampered Clayton Lockett's execution, according to the DPS report released earlier today.  The report also found that the Department of Corrections lacked a longer needle and other equipment that medical professionals requested to insert the IV.  It also states that officials took no steps to revive Lockett after his execution went awry and the blinds were closed....

Gov. Mary Fallin’s staff began preparing a stay of execution for Lockett, but he died before it could be issued, the report states. “There was conversation inside the chamber about administering life-saving measures to Lockett, including transporting him to the emergency room, but no order was given,” the report states.

A paramedic who assisted in the execution also said he felt “stressed” because two executions had been scheduled on the same day.  “It was apparent the stress level at OSP was raised because two executions had been scheduled on the same day,” the report states....

The report makes 10 recommendations for changes in the state’s execution process, including more training requirements and better communication between executioners and officials in the death chamber.  “The current processes, including the use of color pencils and hand signals, could be used as a contingency if other modern methods fail,” the report states.

Executions should also not be scheduled within seven days of each other due to manpower limitations, the report recommends.  DPS investigators interviewed more than 100 witnesses as part of the investigation, including a Tulsa World reporter who witnessed the execution....

The report states that problems with Lockett’s IV were the main reason the lethal drugs were not properly delivered into his bloodstream.  “This investigation concluded the viability of the IV access point was the single greatest factor that contributed to the difficulty in administering the execution drugs,” the report concludes.

An autopsy cites evidence on Lockett’s body that the execution team had difficulty starting his IV, taking about 45 minutes.  It notes at least 14 needle marks and incisions showing multiple attempts to start an IV in his elbows, groin, neck, jugular and foot.

Needles requested by the physician were not available at the prison, the report states. “The physician requested a longer needle/catheter for the femoral access … but none were readily available.  The physician also asked for an intraosseous infusion needle, but was told the prison did not have those either,” the report states....

The execution was the first in Oklahoma to use midazolam, a sedative that has been linked to several botched executions in other states.  Officials resorted to the drug after running out of pentobarbital, which had been used in previous executions.  “This investigation could not make a determination as to the effectiveness of the drugs at the specified concentration and volume,” the report states.  “They were independently tested and found to be the appropriate potency as prescribed.  The IV failure complicated the ability to determine the effectiveness of the drugs.”...

Despite DOC claims that Lockett had “purposefully dehydrated himself,” an autopsy by the Dallas County Medical Examiner’s Office did not find that Lockett was dehydrated, the report notes.

The paramedic assisting with the execution had participated in nearly every Oklahoma execution, the report states.  It does not explain why DOC documents repeatedly referred to the person as a phlebotomist, an occupation not required to be licensed in Oklahoma.

The physician overseeing the execution had only participated in one execution before Lockett’s, the report states. “This was his second execution with the first being four to five years earlier. The physician understood his duties were to assess Lockett to determine if he was unconscious and ultimately to pronounce his death,” the report states. “He was contacted two days prior to the execution date and asked to fill in for another physician that had a scheduling conflict.”...

Anita Trammell, warden at the Oklahoma State Penitentiary, and Patton told investigators that DOC employees received “inadequate” training before the execution. “Warden Trammell stated the only training she received was on-the-job training and that DOC had no formalized training procedures or processes concerning the duties of each specific position’s responsibility,” the report states.

“The warden and director both indicated DOC had no training protocols or contingency plans on how to proceed with an execution if complications occur during the process.” The report states that DOC lacks training requirements for medical professionals and executioners taking part in executions.  “It was noted there was no formal training process involving the paramedic, the physician or the executioners and their specific roles. They were not involved in any pre-execution training or exercises to ensure they understood the overall process,” it states.

Notably, as the Tulsa World article highlights, this report and its recomendations could surely have some impact on Oklahoma's significant upcoming execution plans:

The state plans to review its protocols before the three executions it has scheduled. The execution of a second inmate, Warner, scheduled to be executed two hours after Lockett was stayed until Nov. 13.

Two additional executions have been scheduled after Warner’s execution.  State officials have not said whether they will have enough time to implement any recommended changes in protocol in time for the next scheduled execution.

Legal challenges to the state’s process could also delay upcoming executions. Claiming the state is experimenting on “captive and unwilling human subjects,” 21 Oklahoma death-row prisoners filed a federal lawsuit in June challenging the state’s execution protocols.

September 4, 2014 at 02:08 PM | Permalink


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Most adverse events have a dozen factors clustering. They had doctors involved, why not ask the doctor to help insert the needle after third try? Why not send the guards to phlebotomy school before, have them moonlight in the hosptial inserting IV's?

Imagine if the person had been resuscitated and needed coma care for another 50 yesar due to anoxia of the brain, becoming literally, the mascot fo abolition. OK. Put your fingers in your groin, or on the side of your throat, move tehm in a line. Do you come upon a gigantic pipeline like pusing artery. An equally huge vein is next to it. If you hit the artery, go ahead and push it in. A little blood may squirt out, like a water fountain of blod, and get on Youtube.

Why does the murderer require a perferect death when 90% of us will go slowly, painfully, and fully humiliated by our losses of function? Why because these arguments are pretextual, and no perfection will ever satistfy the lawyer abolitionists on the bench.

Posted by: Supremacy Claus | Sep 4, 2014 4:09:17 PM

"the execution drugs did what they were supposed to do"

You mean kill the person? Hitting him with a stick a bunch of times will too. The report is useful but doesn't seem to address if he felt some extra degree of pain because of the screw-ups. Perhaps this is not possible to determine. If I missed something, ok.

The drugs are not supposed to work in this fashion. Simply killing the person isn't the idea here, I'd think.

"Why does the murderer require a perfect death when 90% of us will go slowly, painfully, and fully humiliated by our losses of function? Why because these arguments are pretextual, and no perfection will ever satisfy the lawyer abolitionists on the bench."

I think this is a general enough comment to deem it useful to answer.

There is some ground between "perfect" and the process going much better here. A person dying in a hospital room shouldn't be handled this way. Perfection won't satisfy abolitionists to the extent that they are opposed to the death penalty. But, John McCain isn't an abolitionist, and he wasn't satisfied. When conservative death penalty supporters find it wrong, at least prudentially, the state should be concern with comments like:

"Warden Trammell and Director Patton both acknowledged the training DOC personnel received prior to the execution was inadequate."

Anyway, yes, when the state kills people, they might be put to a somewhat higher test than benefits given to the general public. But, basic rules should be in place even in a hospital room. Not met here. I realize some figure he's a heinous murder so doesn't deserve such concern, but ultimately he is still a "person" and our treatment of others is also a matter of our one, to speak metaphorically, soul.

Posted by: Joe | Sep 5, 2014 10:25:07 AM

ETA: Yes, after the execution started, it was basically a point of no return.

Stopping it in media res after the drug(s) entered his body was probably realistically impossible. By the time his lawyer talked to the judge, it was a lost cause.

Posted by: Joe | Sep 5, 2014 10:26:51 AM

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