The Governor`s Commission on the Department of Corrections own incompetence in carrying out the execution of Mr. Diaz

^{Representations by DOC personnel that the problems with the Diaz execution was caused by his liver disease B and that there were not any problems anyway -- were conclusively refuted by the autopsy findings and all of the expert witnesses who have testified about the matter.}

^{The Governor=s Commission found that:}

^{1. The execution team failed to ensure that a successful IV access was maintained throughout the execution of Angel Diaz.}

^{2. Failure of the execution team to follow the existing protocols in the delivery of the chemicals. 41}

^{3. The protocols as written are insufficient to properly carry out an execution when complications arise.}

^{4. Failure of the training of the execution team members.}

^{5. Failure of the training to provide adequate guidelines when complications occur.}

^{6. There was a failure of leadership as to how to proceed when a complication arose in the execution process.}

^{7. There was inadequate communication between the execution team members and the warden who was not informed of the problem and the changes implemented.}

^{PC-W Vol. VI 1013.}