The Oklahoma Department of Public Safety released today a 29-page report summarizing its investigation of the execution of Clayton Lockett.
"The Department of Corrections has been very open. They've allowed us — they've had no influence on the outcome of this investigation," said DPS Commissioner Michael Thompson at a news conference about the report. "And I'm very confident that the Department of Corrections will look at our recommendations and give them due consideration."
The report details problems with Lockett's IV line, notes inadequate training among those involved in the execution process and makes several recommendations to the Department of Corrections for improving its protocols.
Six DPS investigators were assigned to the case full time, with nine more and an analyst working on it part time. Hundreds of pieces of evidence were gathered and more than 100 people connected to the execution were interviewed.
IV Problems
An unidentified paramedic with more than 20 years of experience was responsible for placing Lockett's IV. Several vein checks performed prior to the execution indicated Lockett's veins were good.
According to the report, the paramedic and eventually the doctor on hand worked to place the IV from 5:27 p.m. to 6:18 p.m. The paramedic initially established an IV line in Lockett's left arm but didn't have tape to hold it in place. The line became "unviable" before the paramedic was able to get tape. He or she then attempted to establish a line in Lockett's left arm two more times but was unsuccessful.
The doctor stepped in to help at that point, using a larger needle to access the jugular vein on the left side of Lockett's neck. Although a small amount of blood flowed back into the line, indicating successful placement, that vein became unviable too. The paramedic simultaneously tried to place a line in Lockett's right arm three times.
The doctor moved on to the vein running under Lockett's left collarbone but was unsuccessful. In an interview with DPS investigators, he said he didn't have access during an ultrasound machine, which would have helped in the process. Meanwhile, the paramedic tried and failed twice to insert a line into veins in Lockett's right foot.
The doctor decided to try running the line through one of Lockett's femoral veins; however, the prison didn't have supplies he preferred to use. Rather than use a 2- or 2.5-inch needle or one that could be inserted into a bone, which is comparable to IV delivery, he had to use a 1.25-inch needle.
The prison did have a kit to place a central line, which can be used for veins in the neck, chest or groin, but the doctor didn't think about using it for the femoral vein.
Execution personnel cut Lockett's pants and underwear to give the doctor access to Lockett's groin. The doctor placed the line, and the paramedic taped it down. The report said the doctor thought the catheter was "bending because of its length," but he and the paramedic said they were comfortable with the line.
Warden Anita Trammell had Lockett covered with a sheet to "maintain Lockett's dignity," but that prevented her from her normal duty of watching the IV for problems. It wasn't until Lockett began moving after being declared unconscious and while the second round of drugs was being delivered that the line was checked.
The report notes swelling under the skin "smaller than a tennis ball, but larger than a golf ball" that the doctor believed would have been noticed had the IV access point been monitored. That swelling indicated fluid had leaked from the IV into surrounding tissues.
Lockett's autopsy noted a high amount of midazolam, the sedative used first in the execution protocol, in the tissue near where the IV was inserted. The report concludes the IV failed as early as that drug was administered.
Inadequate training
The DPS investigation found DOC training followed protocol but still has areas that need to be addressed.
There's no formal training for the paramedic, doctor or three executioners — the people who actually push the drugs through the IV lines. Those personnel received briefings just before the execution, and the paramedic trained the executioners on the same day.
Trammell and DOC Director Robert Patton told DPS investigators training was inadequate. Trammell said her only execution training was on-the-job training and DOC lacked formal training procedures. Patton and Trammell said the department has no training or contingency plans for executions that go wrong.
One situation personnel were prepared for was difficulty with the initial IV line. In that case, the doctor may step in to assist; however, once problems arose during the execution, no one was sure how to proceed. The report says the only step taken inside the chamber was the doctor attempting to find Lockett's left femoral vein.
Recommendations
DPS investigators made several recommendations for DOC ahead of any future executions, including monitoring the IV site and improving communication methods.
The report calls for the IV insertion point to be visible and continuously observed throughout the execution. It also recommends contacting the governor to possibly request a postponement after an hour of unsuccessful attempts to place the IV.
Not only should DOC have an additional set of the execution drugs on hand, but it should also work with "appropriate medical personnel" about necessary supplies.
The report says DOC should create formal training for anyone involved in the execution process, and DOC should look at other states' programs.
Investigators determined several situations DOC should prepare contingency plans for, including issues with equipment or supplies, difficulty with IV access, ineffective drugs and unanticipated medical issues.
The findings also call for updates to the DOC's communication methods during the execution. Current methods involve the use of colored pencils and hand signals, which DPS recommends using only if a modern system fails.
The report recommends DOC look at a system that would "allow direct, constant contact" between execution personnel and the governor's office. The DOC currently relies on telephones.
