OKLAHOMA CITY - Saying there was no one specifically to blame for the botched execution of inmate Clayton Lockett in McAlester five months ago, Oklahoma Department of Public Safety (DPS) Commissioner Michael Thompson released a detailed investigative report Thursday entitled "The Execution of Clayton D. Lockett."
At a press conference at DPS Headquarters, Thompson addressed the issues that prompted the Department Of Corrections (DOC) to stop Lockett's execution after a lethal injection caused his body to convulse April 29th.
It took nearly 40 minutes for Lockett to die - much longer than during previous state executions.
A Texas medical examiner's autopsy found Lockett died by lethal injection, not a heart attack as previously suspected.
The report concluded the "viability of the IV access point was the single greatest factor that contributed to the difficulty in administering the execution drugs."
During an interview, a physician stated he did not have access to an ultrasound machine, which is a commonly used tool to locate and penetrate veins.
It took several attempts to find a vein that could be used on Lockett's body.
Officials finally decided to inject the drugs into Lockett's right groin area.
The report said the physician and paramedic requested a longer needle/catheter for the femoral access... "but none were readily available."
"The physician had never attempted femoral vein access with a 1 1/4 inch needle/catheter; however, it was the longest DOC had readily available."
Oklahoma State Penitentiary 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 told the paramedic the catheter dislodged. The paramedic observed the catheter was tilted to one side and believed it was no longer penetrating the vein.
Thompson said the lack of monitoring the IV insertion point in Lockett's groin led to the improper insertion issue being discovered several minutes after the execution began.
The report said "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."
In the end, however, Thompson said "the drugs worked."
DPS recommendations to avoid similar problems include:
- The IV catheter insertion point(s) should remain visible during all phases of the execution.
- After one hour of unsuccessful IV attempts, DOC should contact the Governor to advise the status and potentially request a postponement of the execution.
- DOC should maintain and provide their own equipment and supplies ensuring their operability prior to each execution.
- DOC should evaluate and establish protocols and training for possible contingencies if an issue arises during the execution procedure.
- DOC should establish formal and continual training programs for all personnel
involved in the execution process.
- Due to manpower and facility concerns, executions should not be scheduled within seven calendar days of each other.
- Communication between the execution chamber and executioners' room. DOC should research and implement modern methods that allow personnel in these two areas to communicate clearly.
Charles Warner, who was scheduled to be executed that same night, is now awaiting execution in November.
DOC Director Robert Patton issued a statement Thursday saying "(DOC) began rewriting the execution protocol in the days immediately following the execution. We will continue that work taking into consideration the recommendations in the investigative report."
Joe Dorman, Democratic nominee for Governor, released a statement, saying "Once again, Mary Fallin has succeeded in creating a biased report in her continued efforts to keep Oklahomans from knowing the full truth. This report was led by Fallin's Cabinet Secretary of Safety and Security, Mike Thompson, who can be fired by Fallin and witnessed the botched execution. I question his ability to conduct an unbiased investigation. Further, until recently her office kept the official execution logs and autopsy report under lock and key, leaving us all to wonder what Mary is hiding."