Summary of the Findings of the
Summary of the Findings of the
Department of Corrections’ Task Force Regarding the
James R. McDonough,
Secretary of the Florida Department of Corrections
Introduction: On December 13, 2006, Angel Diaz, convicted and sentenced for the crime of first degree murder, was executed by means of lethal injection, as provided by chapter 922, Florida Statutes. On the morning of December 14, 2006, in response to concerns regarding the circumstances surrounding the execution, the Secretary of the Department of Corrections, in consultation with the Office of the Governor, formed an investigatory task force to look into the events of the execution (hereinafter “Task Force.”) The Secretary appointed two members of the Department, Maximillian J. Changus, Assistant General Counsel and George B. Sapp, Assistant Secretary for Institutions who had familiarity with the execution process and two members not affiliated with the Department, Electra Bustle, Assistant Commissioner for the Florida Department of Law Enforcement and Bonita J. Sorensen, M.D., Deputy State Health Officer for the Department of Health. The described objective was to immediately conduct interviews with personnel involved with the execution process as carried out on the day in question, analyze the collected observations to determine if there were deviations from the written procedure, and prepare a prompt report.
Methodology: Early in the afternoon of
Task Force member Sapp interviewed the executioners himself, to protect the statutorily mandated anonymity of those individuals. Task Force member Sapp also interviewed the execution team member that actually placed the IV line, who was not available at the time of the initial interviews. The independent observer from the Florida Department of Law Enforcement that witnessed the execution was also interviewed. After the interviews, the members consulted and began preparation of this report.
Definitions: The Lethal Injection Procedure identifies various persons involved in the administration of the execution. They include the Warden of Florida State Prison, the executioners who actually initiate the flow of lethal chemicals into the inmate and the execution team which refers to correctional officers and other persons, including those with medical training who assist with the administration of the execution. This report will utilize these terms throughout so as not to identify specific individuals who are entitled to anonymity pursuant to Section 945.10, Florida Statutes.
General findings: There are a multitude of actions involved in preparing for and carrying out an execution, including institutional security, visitation, and inmate care concerns. A complete description of the responsibilities of the warden and the execution team are too numerous to detail in a report of this nature. However, it was determined from interviews that that these preliminary matters were attended to by the Warden. This report will only address issues beyond the preliminary preparations of the inmate.
Factual findings from interviews:
Experience, training and preparation: Pursuant to the Lethal Injection Procedure, the Warden verified the training and qualifications of all execution team members. The execution team participated in several training events and walk-throughs prior to the day of the execution. It should be noted that the prison had carried out three executions in the prior three months, so that the execution team had numerous opportunities to prepare for the day of execution.
Use of checklist: Compliance with the Lethal Injection Procedure is required to be documented by use of a checklist. The Warden has complied with this requirement. A copy of the completed checklist is attached to this report as Exhibit “B.”
Limited Examination: The Lethal Injection Procedure requires that the Warden designate one or more members of the execution team to conduct a limited medical examination to determine whether there are any medical issues that could potentially interfere with the administration of the lethal injection process. According to members of the execution team, the primary reason for undertaking this examination is to determine whether venous access could be a problem. These findings are to be reported to the Warden as soon as is practicable. It was confirmed that an examination of the inmate, in conjunction with a routine medical visit, was completed at the appropriate time and a discussion with the Warden promptly followed.
Preparation of the lethal chemicals: The Lethal Injection Procedure currently requires that the lethal chemicals be mixed according to a very specific regimen. Two members of the execution team reported that the chemicals were mixed according to the established regimen. Based on the information collected including the description on how the chemicals were mixed, it appears that the chemicals were mixed properly. However, it should be noted that the Lethal Injection Procedure requires that the independent observer from the Florida Department of Law Enforcement witness the mixing of these chemicals. This was not done so, which is a deviation from the written procedure. According to the statements of the execution team members, the chemicals were properly transported and secured in the executioners’ room; it appears this requirement was completed in accordance with the Lethal Injection Procedure.
Presumptive drug and alcohol testing: The procedure directs that, approximately one hour prior to execution, all members of the execution team will be tested for the presence of drugs or alcohol to prevent a team member’s impairment from impacting his or her ability to carry out the necessary functions. All execution team members, the executioners and the Warden were tested and all tested negative. However, it is noted that the members were tested at various times during the afternoon prior to the execution, but all individuals remained within the prison boundaries post-testing.
Preparation of the inmate: After reading of the execution warrant, and at the appropriate time as detailed in the Lethal Injection Procedure, the inmate was placed on the gurney and restraints were applied. Heart monitor leads were applied to the inmate and the monitors were checked to ensure that they were operational. At that point, an execution team member inserted intravenous (IV) lines into both arms of the inmate. The left arm IV line was completed on the first try, although it was noted that it took some effort to thread the catheter into the vein, due to resistance or “dragging.” When the right arm IV line was initially attempted, insertion was successful but the catheter would not thread into the vein. Therefore, the execution team member reattempted another site further up the arm. The catheter again met with resistance but at least one-half to three quarters of the catheter threaded into the vein. A check of the IV solution drip and the presence of a flash of blood evidenced, to the satisfaction of two execution team members, that venous access had been satisfactorily completed in both arms.
Administration of the lethal chemicals: Both executioners reported that they had received adequate training and have participated in prior executions. After confirmation by the Governor’s Office that there were no last-minute legal stays, the Warden signaled to the executioners that they were to proceed. As directed in the Lethal Injection Procedure, the primary executioner began the delivery of
sodium pentothal from Stand “A” into line “A” (left arm.) The primary executioner noted that the pushing of the chemicals was more difficult and took two to three times longer than normal. Both executioners had been advised to push slowly because of concerns over the inmate’s veins. After dispensing the first two syringes of sodium pentothal, the saline flush, and the first half of the first syringe of pancuronium bromide, the executioner advised the assisting member of the execution team that he could no longer push the syringe. A decision was made by the execution team to switch to line “B” (right arm.) The remainder of the chemicals in Stand “A” was dispensed in proper sequence into line “B.” With the administration of the potassium chloride, there was no corresponding decline in heart rate. As directed in the Lethal Injection Procedure, the primary executioner began the flow of lethal chemicals from Stand “B.” The primary executioner started with the sodium pentothal from Stand “B” into line “B.” During this administration, with guidance from the assisting execution team members, the secondary executioner started with a saline flush from Stand “B” into line “A” and then administered the syringes of potassium chloride from Stand “B” into line “A.” The primary executioner continued with the sequential flow of lethal chemicals and completed the pushing of the first syringe of pancuronium bromide from Stand “B.” At that point, the heart monitors evidenced that the heart had begun to cease functioning. The executioners stopped the administration of lethal chemicals and waited for the cessation of cardiac activity. The execution members did a physical check to ensure that the inmate had expired. Pronouncement was then made.
Observations of the execution team during the execution: All of the execution team members present in the chamber indicated that they were not primarily focused on observing the inmate during this time, for various reasons including respect for the process. The execution team also indicated that the inmate’s head was turned towards the witnesses. Based on the placement of the execution tam members within the chamber, a few of them were able to observe the inmate’s facial expressions. There were reports of some facial movements, including squinting and limited bodily movements. Many of the execution team members noted that the inmate twice asked, “What’s happening?” during the initial part of the administration of the lethal chemicals. They all reported that they heard snoring, which was believed to have started abut eight to ten minutes into the administration. None related seeing or hearing any evidence of pain.
Independent observer from FDLE: The observer, Inspector Tim Westveer, was able to see the inmate from his vantage point. He noted the inmate making several facial expressions approximately five minutes into the procedure and that subsequently he observed the inmate snoring and breathing deeply.
Post-execution matters: Although this was not a primary focus of the Task Force, the interviews indicate that the normal series of events occurred, including the removal of the inmate’s body. A limited debriefing was held the next morning, which is a minor deviation from the written procedure that indicates that it will be held immediately after the inmate’s body was removed.
Limitations: The Task Force members are currently aware of the preliminary autopsy findings released by Dr. William Hamilton. However, this information was not in the possession of the Task Force members at the time of their interviews completed on
Since the Governor has, in response to the events of this particular execution, created the Commission on Administration of Lethal Injection, the Task Force believes the Commission will incorporate the completed autopsy information in its process at the appropriate time.
Pre-execution limited medical examination: The Lethal Injection Procedure requires a limited examination of the inmate to determine whether there were issues that would interfere with the execution. In this case, there were no indications reported to the Warden that the condition of the inmate’s veins might pose difficulty in ensuring that venous access was adequate to complete the process.
Preparation of the lethal chemicals: The evidence gathered supports the conclusion that the lethal chemicals were mixed in accordance with the Lethal Injection Procedure. However, the Lethal Injection Procedure requires the presence of an independent observer from the Florida Department of Law Enforcement. The FDLE observer was not present at the time of the preparation of the chemicals.
Administration of the lethal chemicals: There were deviations from the established procedure.
First, when the executioners encountered difficulty in pushing the lethal chemicals during the administration of the first stand of lethal chemicals, the execution team made the decision to direct the primary executioner to switch from line “A” to line “B,” without an assessment of the primary access site, as called for in the Lethal Injection Procedure.
Second, a decision was made for the secondary executioner to administer a saline flush and the potassium chloride from Stand “B” into line “A” simultaneously with the primary executioner pushing the sodium pentothal from Stand “B” into line “B.” Neither of these decisions is described as an option within the confines of the Lethal Injection Procedure.
Next steps: The Governor’s creation of the Commission on the Administration of Lethal Injection will be able to examine the execution process and conduct a more thorough review of this area and incorporate the findings of the medical examiner in its deliberations. The Task Force will be available to assist the Commission in its endeavor.
Final Comment: The Task Force would like to thank Warden Bryant, the members of the execution team, and the executioners for their cooperation with this review process. All parties integral to the execution process made themselves available for interview at the convenience of the Task Force and were open in their discussion of events.
Miximillian J. Changus Electra Bustle
Assistant General Counsel Assistant Commissioner
Florida Department of Corrections Florida Department of Law Enforcement
Bonita J. Sorensen, M.D. George B. Sapp
Deputy State Health Officer Assistant Secretary for Institutions
Florida Department of Health Florida Department of Corrections