DPS Report On Clayton Lockett Execution Finds Problems With Process

The Oklahoma Department of Public Safety released the findings of its investigation into the execution of Clayton Lockett. The investigation cites a lack of written protocols for handling contingencies and deficiencies in formal training for Department of Corrections employees and others involved in executions at the Oklahoma State Penitentiary in McAlester.

At a news conference Thursday morning, DPS Commissioner Michael Thompson said better training would have prevented the problems that happened during Lockett's execution.

He said the Department of Corrections did not have a detailed protocol for dealing with problems that they may encounter during an execution. He said DOC had carried out 110 executions without a problem before the Lockett execution.

According to the report, Lockett's cause of death was Judicial Execution by Lethal Injection. The manner of death was listed as Judicially Ordered Execution.

5/31/2014: Related Story: Oklahoma DPS Commissioner: Execution Probe Close To Wrapping Up

Following is a summary of the findings made by Southwestern Institute of Forensics Science (SWIFS) in Dallas, during their examination of Lockett's body and additional information obtained by the investigation team from SWIFS or through the investigation:

Judicial execution with:

a. Execution protocol medications used: midazolam, vecuronium and potassium chloride.

b. History of difficulty finding intravenous access sites resulting in numerous attempts to start an IV.

c. Attempts in both antecubital fossa, both inguinal regions, left subclavian region, right foot and right jugular region.

2. Superficial incised wounds of the upper extremities consistent with history of self-inflicted incised wounds with a safety razor.

3. Contusions and abrasions of extremities.

4. Cardiac hypertrophy (480 grams)

5. Mild coronary artery atherosclerosis.

6. Hydroxyzine detected.

a. Lockett was prescribed hydroxyzine, but the prescription had ended March 3. There were emails from DOC personnel alleging Lockett had been hoarding medication. SWIFS personnel stated there were higher than therapeutic levels of hydroxyzine present in Lockett's system and hydroxyzine should not have interfered with the execution drugs administered. They also could not determine when or how much of the hydroxyzine was taken.

7. No evidence of dehydration.

8. No Taser marks on the body.

9. Toxicology indicated elevated concentrations of midazolam in the tissue near the insertion site in the right groin area, which is indicative of it not being administered into the vein as prescribed in execution protocols. The presence of midazolam in the psoas muscle indicates midazolam was distributed 14 throughout Lockett's body during the execution. According to SWIFS pathologists, the concentration of midazolam located in Lockett's blood was greater than the therapeutic level necessary to render an average person unconscious.

10. Vecuronium bromide was found in the femoral blood sample taken from Lockett's body. The presence of vecuronium bromide in the psoas muscle indicates vecuronium bromide was distributed throughout Lockett's body during the execution.

11. Potassium was found in the femoral blood sample taken from Lockett's body.

Read the complete report here.

Regarding whether DOC correctly followed their current execution protocols, authorities determined there were minor deviations from specific requirements outlined in the protocol in effect on April 29. Despite those deviations, it was determined the protocol was substantially and correctly complied with throughout the entire process. None of the identified deviations contributed to the complications encountered during the execution.

According to the document, the physician and paramedic made several attempts to start a viable IV access point. They both believed the IV access was the major issue with this execution. This investigation concluded the viability of the IV access point was the single greatest factor that contributed to the difficulty in administering the execution drugs.

According to the findings, during the execution Warden Anita Trammell decided to cover Lockett's body with a sheet, including the IV insertion area, which, according to her, was normal in all executions. Another reason for her decision was to maintain Lockett's dignity and keep his genital area covered.

From that time, no one had visual observation of the IV insertion point until it was determined there was an issue and the physician raised the sheet. Warden Trammell acknowledged it would be her normal duty to observe an IV insertion point for problems. She believed if the IV insertion point had been viewed, the issue would have been detected earlier.

The physician added that an IV would normally be monitored by watching the flow of the IV line and the area around the insertion point for any signs of infiltration. This investigation found that neither of these observations occurred, which led to the issue being discovered several minutes after the execution began.

The autopsy indicated elevated concentrations of midazolam in the tissue near the insertion site in the right groin area, which was indicative of the drugs not being administered into the vein as intended. Thus, the IV access was not viable as early as the administration of the midazolam.

8/28/14 Related Story: Autopsy: Clayton Lockett Died From Lethal Drugs, Not Heart Attack

According to the document, the investigation could not make a determination as to the effectiveness of the drugs at the specified concentration and volume. They were independently tested and found to be the appropriate potency as prescribed. The IV failure complicated the ability to determine the effectiveness of the drugs.

The Department of Public Safety made several recommendations to the Department of Corrections for future executions:

After the Warden admitted a problem with the IV could have been detected earlier the Department of Public Safety recommended:

The IV catheter insertion point(s) should remain visible during all phases of the execution and continuously observed by a person with proper medical training in assessing the ongoing viability of an IV. This person should remain inside the execution chamber during the entire process.

Due to the lack of training and keeping of logs prior to the execution, the Department of Safety recommended:

The information to be recorded on execution logs should include, but not be limited to:

a. all statements or behaviors that could be detrimental to completing an execution;

b. all meals provided to an offender and what portions of the meals the offender consumed or refused.

c. all medication provided to an offender and the observations made by personnel as to whether the offender ingested the medication as prescribed;

d. all liquids consumed by the offender

The Department of Safety also recommended additional execution supplies:

DOC should obtain from the selected pharmacist, one complete, additional set of each execution drug being utilized for an execution to be used in the event an issue arises with the primary set.

2. DOC should consult with appropriate medical personnel to determine any and all supplies or equipment necessary including, but not limited to the following:

a. Heart monitoring equipment;

b. Venous ultrasound equipment;

c. Appropriate needle/catheters to coincide with th

e IV access options listed in protocol.

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