The Governor's Commission findings were that the Department of Corrections was neither "capable nor prepared to carry out" an execution in accordance within the dictates of the Eighth Amendment.
In the six years between the Sims decision and the Diaz execution we have learned that the DOC never trained the primary or secondary executioners, that the execution team was never trained on the effects of the lethal chemicals, nor did it train (or tell) the execution team which chemicals they were injecting at any time during the execution process.
The DOC was never trained as to the proper and necessary injection sequence, a sequence now known to be necessary under the Eighth Amendment. The DOC personnel were never properly trained to assess the patency of the IV lines, never trained to properly monitor the IV lines, let alone trained to insert them correctly (see GCALI testimony of Dr. Hamilton). The DOC personnel were never properly trained to identify a problem with the IV lines when there was substantial resistance during the injection process.
Furthermore, the execution team members testified that on at least seven prior occasions they felt similar resistance but were never trained to realize that this was due to an improper IV insertion.
Had the DOC been "capable and prepared" in establishing the second of the two IV lines, Diaz would have immediately felt the immense pain of the potassium chloride because the poorly trained DOC personnel ignored the protocols and skipped the injection of the sodium pentothal into the second line.