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.