Attendants did not properly monitor the intravenous line inserted into the groin of an Oklahoma inmate who writhed and groaned – and finally died almost an hour after his execution began – according to a state report released Thursday. The report also recommended more training for prison officials and medical personnel.
The report on the botched execution of convicted murderer and rapist Clayton Lockett, 38, comes as death-penalty states across the country try to adapt to shortages of execution drugs by using different chemicals whose health effects and humaneness remain in question. Death penalty opponents have called on states to release the names of the companies making the drugs, but authorities have refused, citing the companies' need for privacy.
The Oklahoma review, released by the state's Department of Public Safety (DPS), cited problems with the IV inserted into Lockett that caused swelling larger than the size of a golf ball.
Lockett's execution was to be the first of two executions held back-to-back on April 29, but the second execution, of inmate Charles Warner, was postponed that night and is now set for Nov. 13.
The state placed additional pressure on prison officials to complete the April execution of Lockett by making the unusual decision to carry out another execution just after Lockett's procedure was to be finished, the report said. The DPS report recommended that the state hold executions at least seven days apart, noting that the prison warden believed that the planned double execution caused "extra stress" for staff members.
Lockett died behind a closed curtain 43 minutes after his execution began, after state prisons director Robert Patton halted the process 15 minutes after the drugs started to flow. Patton said the cause of death was a heart attack, but autopsy results released last week said he died from the drugs: midazolam, vercuronium bromide and potassium chloride. The autopsy did not explain why the execution took so long or why Lockett writhed.
A paramedic and physician inserted the intravenous line in Lockett's groin after failing to find suitable veins in his arms, legs, neck and feet. The report said the IV site was covered with a sheet and not monitored until Lockett began moving unexpectedly after receiving two doses of drugs.
The medical workers had tried nearly a dozen times to place an IV in the Oklahoma inmate's limbs, but were unprepared for how to proceed once the line they secured to deliver a lethal injection began leaking drugs.
"The physician observed an area of swelling underneath the skin and described it as smaller than a tennis ball, but larger than a golf ball. The physician believed the swelling would have been noticeable if the access point had been viewed during the process," the report said.
Lockett's troubled execution prompted Gov. Mary Fallin to halt all upcoming executions until a review that she had ordered was completed.
"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 DPS report. The agency's commissioner was appointed by Fallin.
Fallin had no immediate comment on the report, nor did a corrections department spokesman.
Oklahoma used the sedative midazolam for the first time in Lockett's execution. That drug was also used in lengthy attempts to execute an Ohio inmate in January, and an Arizona prisoner last month. Each time, witnesses said the inmates appeared to gasp after their executions began and continued to labor for air before being pronounced dead.
But Oklahoma's review did not find fault with midazolam or other drugs, instead noting that the IV troubles made it difficult to determine the drugs' effectiveness.
Prison officials previously said that Lockett was combative in his cell on the morning of his execution, and that he may have been intentionally dehydrated himself to make it more difficult for the IV to be placed. But the report said that Lockett had no signs of dehydration at the time of his death, and that self-inflicted cuts on his arms should not have affected IV access.
The report also noted that medical personnel examined Lockett's veins and determined they were good or acceptable for IV access.
Lockett had been convicted of shooting Stephanie Nieman, 19, with a sawed-off shotgun and watching as two accomplices buried her alive in 1999. Three executions have been set in Oklahoma for November and December.
One of the inmates is Warner, who was supposed to die the same day as Lockett. Warner was convicted of raping and killing his roommate's 11-month-old daughter in Oklahoma City in 1997.
Al Jazeera wire services