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Oklahoma investigation into botched execution finds problems with IV insertion, training of execution team

A 2011 photo of Clayton Lockett. (Oklahoma Department of Corrections via AP)

During Oklahoma’s botched execution of Clayton Lockett, the execution team did not know how to react when it discovered problems during the lethal injection. The chaotic, uncertain response was exemplified by what happened when it became apparent that things were going awry: Inside the execution chamber, people were discussing whether to try to save Lockett’s life; outside the chamber, talks touched on “whether to continue or how to stop the execution,” according to an official state review.

Lockett’s botched lethal injection on April 29 drew worldwide criticism and sparked a debate over the death penalty in the United States. A review, ordered by Gov. Mary Fallin (R) after the execution and released by the Oklahoma Department of Public Safety on Thursday, found that the execution team failed to properly monitor the IV and outlined problems with the execution team’s training.

The review, which was conducted by investigators with the Oklahoma Highway Patrol, with medical guidance from an unidentified doctor), found that because there were not many contingency plans outlined in the state’s execution protocols, “personnel involved with the execution were unaware of how to proceed” once problems emerged.

And no one involved in carrying out the execution realized there were problems involving the IV that was meant to deliver the lethal injection drugs until “several minutes” after the execution began, because the area where the IV had been inserted was covered.

“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,” the review said.

Dale Baich, an attorney for Lockett said that the state’s review “raises more questions than it answers,” and argued that independent inquiry is needed.

“Once the execution was clearly going wrong, it should have been stopped, but it wasn’t,” Baich said in a statement Thursday. “Whoever allowed the execution to continue needs to be held accountable.”

Lockett had been sentenced to death after being convicted of murder and other charges after he and accomplices attacked and sexually assaulted two teenage women, one of whom witnesses said Lockett shot twice before she was buried alive. During his execution, Lockett grimaced and writhed on the gurney, clenching his jaw and appearing to be in pain, witnesses said later. The execution was called off when problems with the IV were discovered, and Lockett was declared dead a short time later.

Both the physician and the paramedic involved in the execution “believed the IV access was the major issue with this execution,” according to the review. After several unsuccessful attempts to insert the IV — including on his left arm, his right arm, his left jugular vein and two locations on Lockett’s foot — the paramedic and physician believed the vein was properly inserted into Lockett’s femoral vein about five minutes before the first dose of drugs (midazolam) were administered at 6:23 p.m.

Lockett was declared unconscious about 10 minutes later, at which point the other execution drugs (vecuronium bromide and potassium chloride) were also administered.

“At some point during the administration of these two drugs, Lockett began to move and the physician recognized there was a problem,” the report states. That is when the physician looked under the sheet and realized that the IV had leaked, with clear liquid and blood visible on Lockett’s skin near his groin.

This is when the blinds were lowered, blocking witnesses from seeing what happened next. The Guardian’s U.S. news operation and the American Civil Liberties Union, along with other organizations, filed a lawsuit last week saying that this violated the First Amendment and arguing that journalists and other witnesses should be allowed to see everything that happens from the moment the inmate enters the execution chamber.

Anita Trammel, the warden, had covered Lockett’s body with a sheet when it was believed that the IV was inserted because of a desire “to maintain Lockett’s dignity and keep his genital area covered,” the report states. However, as a result, no witnesses were able to see where the needle went and no one looked at where the IV was inserted until after the problem was discovered.

The review released by the Department of Public Safety recommends that the place where the IV is inserted should be visible during the entire execution and observed by a person with medical training throughout the process. In addition, the review recommends that the Department of Corrections should establish better training and set up guidelines for what should happen if unexpected things occur.

Trammel told investigators that she would normally monitor the place where the IV was inserted to keep an eye out for any problems, saying that the problem could have been discovered earlier if the IV’s insertion point was visible. The physician and paramedic, meanwhile, said that they did not know when the catheter became dislodged and weren’t sure how much of the drugs were delivered into Lockett’s vein.

But the review notes that IV access “was not viable as early as the administration” of the first drug, midazolam, because the state’s autopsy found higher levels of midazolam in the tissue near his groin.

An independent autopsy found that the execution team failed to properly place the IV, despite the “excellent integrity” of Lockett’s veins at the time of his death. While Department of Corrections employees said they believed that Lockett had dehydrated himself on purpose, the independent autopsy and the state-ordered autopsy found that there were no indications that Lockett was dehydrated. The official review also notes that medical personnel with the Department of Corrections said that Lockett’s veins were deemed suitable for an IV on the day of his execution.

The state-ordered autopsy determined that lethal injection was the cause of Lockett’s death, rather than a heart attack, which is what officials had said the day he died.

Both Trammel and Robert Patton, director of the Oklahoma Department of Corrections, acknowledged to investigators that training before the execution “was inadequate.” The state’s review noted that the physician, paramedic and three executioners in the chamber were not included in training the day before Lockett’s lethal injection. And there are only minimal training requirements for these individuals, the investigation found.

Once problems with the IV were discovered and the blinds lowered, the people inside the chamber and outside of it were having two separate conversations. Outside the chamber, Patton and several state officials determined that the execution would be halted and a stay would be ordered by Brewer. Meanwhile, inside the chamber, personnel discussed trying to save Lockett’s life or take him to an emergency room. Lockett died before the order for the stay was relayed to the people inside the execution chamber.

The review also found that additional problems were caused by the fact that Lockett’s execution was one of two scheduled to take place in the Oklahoma State Prison that night. Lockett’s execution was scheduled for 6 p.m., while Charles Warner was set to be killed at 8 p.m. Warner’s execution was stayed after the botched lethal injection and Oklahoma has not carried out any executions while the review was conducted. The warden and the paramedic described a feeling of extra stress and urgency owing to this scheduling.

This botched execution in April was one of three so far this year that have gone awry. Most recently, an execution in Arizona took nearly two hours and required 15 doses of lethal injection drugs. These problematic executions have drawn additional attention to the ongoing shortage of lethal injection drugs, which has caused states to scramble to obtain the drugs needed to carry out executions. Oklahoma was using a new lethal injection combination for the first time during Lockett’s execution. The state used a three-drug protocol involving midazolam, rather than pentobarbital, which the state had used during its two other executions earlier this year.

Related: Everything you need to know about executions in the United States.

This post has been updated.