baltimore police independent report into tyrone west death

In-Custody Fatality Independent Review Board for the Death of Tyrone West

Findings and Recommendations

August 8, 2014

Independent Review Board MembersJames K Stewart, Chair,

Professor Amy Dillard, JD, Professor Patrick L. Finley, PhD,Chief Barney Melekian, DPPD, Dr. Hamin Shabazz, PhD and Dr. Shirley Thompson-Richard, M.D.

This report presents the Independent Review Board’s assessment of the official homicide investigation report, States Attorney Report, legal records, documents, evidence, photographs, audio statements, scene diagrams, and medical reports and documents pertaining to the in-custody death of Mr. Tyrone West at the Baltimore Police Department on July 18, 2013. The Independent Review Board is not an investigative body empowered to call witnesses, its resources are limited to volunteer assistance from Board members, and it is without professional analytic support. The Board consists of citizens with expertise in Constitutional Policing, Law Enforcement Best Practices, Police Accountability, Homicide Investigations, Forensic Analysis, Community Policing, Authority of Law, Defensive Tactics, Arrest and Control Techniques, Policing Theory, Laws of Arrest, Use of Force Policies and Practice, Internal Medicine, and Investigative Best Practices. The Independent Review Board is separate from the Baltimore Police Department and has no direct relationship with the police agency or the City of Baltimore, other than as citizen-volunteers and, in some cases, as residents.

In-Custody Fatality Independent Review Board Report on the Death of Tyrone West

Executive Summary:

The sudden death of Mr. Tyrone West on July 18, 2013 during an arrest by Baltimore Police Department officers was unexpected and produced some controversy among his family, community activists and the media. Soon after the death, the Police Commissioner convened an independent board of respected professionals from law enforcement, academia, and medical and legal professions to review the circumstances surrounding the incident and make, where appropriate, recommendations for improvement to prevent a similar recurrence. The Independent Review Board (hereafter referred to as the “IRB” or “Board”) reviewed all reports, evidence, statements, and Baltimore Police Department (BPD) policies and training, in addition to requesting further information from BPD. The IRB conferred several times during the past four months and reached unanimous agreement on the incident findings and recommendations for improvement, all of which are presented in this report.

The IRB concludes that Mr. West died suddenly while engaged in an extended period of resisting a lawful arrest by BPD. The postmortem examination report concluded that Mr. West “died of Cardiac Arrhythmia due to Cardiac Conduction System Abnormality complicated by Dehydration during Police Restraint.” According to the Medical Examiner, another factor that may have “contributed to his death was the extreme environmental temperatures, which were reported in the high 90s, with a heat index in the low 100s (degrees Fahrenheit).” The Autopsy revealed “neither signs of asphyxia, nor significant injury to vital structures or vital areas of the body.”

Whenever physical force is employed in police-citizen encounters, there is always a risk of serious injury and, potentially, death. The law authorizes police officers to use only that force necessary to overcome resistance, to defend themselves, and to affect a lawful arrest. The IRB finds that the officers did not employ force beyond that which was necessary and reasonable to subdue an exceptionally strong and well-muscled suspect who was resisting a lawful arrest. The officers involved used less than lethal weapons and defensive tactics to attempt to control, restrain, and arrest Mr. West. The IRB noted, with concern, that the officers involved departed from some BPD policies and training and made several tactical errors that may have extended the length of the physical encounter, compromised officer safety, and potentially aggravated the situation.

After extensive review, the IRB reports 18 findings, which are broken into seven issue areas:

1. Officer Judgment/Decision-Making

2. Transfer Criteria for Specialized High-Discretion Units (i.e., Northeast Operations Unit)

3. Use of Force Policies

4. Officer Tactical Procedures and Techniques

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5. Professional and Objective Investigative Protocols

6. Care of Life and Emergency Lifesaving Protocols

7. Communications/Transparency

The IRB findings indicate that the arresting officers did not follow BPD guidelines during several aspects of this incident; there were also several tactical errors in their attempts to control the situation.

The report also offers 34 recommendations to improve BPD training, investigations, supervision, officer accountability and communication with the community.

Table 1: Summary of Issue Areas, Findings and Recommendations

Issue Areas Findings Recommendations1. Officer Judgment/Decision Making

1.1 The officers’ tactical decisions did not follow BPD procedures

1.1.1 The BPD should better supervise officers in the Northeast Operations Unit (especially when working in non-uniform assignments) and provide them with specific directions that more carefully focus their activities on high-probability evidence-based stops, searches, and arrests.1.1.2 The BPD should conduct a full review of the tactics and decisions made in future incidents that led up to the use of force and retrain the officers involved (and other patrol officers) to be alert for lapses in practice that can threaten officer safety.1.1.3 BPD training should include de-escalation methods and tactical disengagement defensive tactics.1.1.4 Use of Force Review Boards should include a detailed review into the totality of circumstances,

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including the reasons for the initial contact with a subject.

1.2 Motor vehicle traffic stops by unmarked police vehicles involve inherent risk and the possibility that the subject may not acknowledge the authority of law enforcement personnel to make traffic stops.

1.2.1 BPD leadership should consider refresher training and the need for a comprehensive training plan regarding the risks and tactical mitigation involved in traffic stops by unmarked police vehicles.

1.3 There was scant probable cause or justification in this case to request consent to search the vehicle trunk for weapons.

1.3.1 Refresher training in the current case law (federal and state courts) restricting police ability to search and seize evidence of a crime and contraband absent a search warrant should be provided as a training bulletin that can be offered immediately to patrol unit during roll call training, and also used in the annual in-service training.

2. Transfer Criteria for Specialized High-Discretion Units (i.e., Northeast Operations Unit)

2.1 The two officers in this case assigned to the Northeast Operations Unit (NOU) were inexperienced, with only two and three years of BPD service, respectively.

2.1.1 BPD should create a policy that details the requirements for candidates wishing to serve in this specialized unit.

3. Use of Force Policies 3.1 The written BPD Use of Force Policies are consistent with standard accepted practice but were not be consistently applied in this case.

3.1.1 The BPD should provide additional supervisor and command training in best methods for conducting performance audits to ensure supervisor accountability for officer performance and officer compliance with written Use of Force policies.

3.2 The post-incident homicide investigation in this case did not reflect the

3.2.1 The BPD should consider following the practice of leading police

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highest standards and practice for objective and independent investigative practice in officer-involved death cases.

agencies in contracting with independent, competent, objective investigators for all Officer-Involved Shootings or Death in Custody Investigations.

4. Officer Tactical Procedures and Techniques

4.1 Medical research reports that vigorous physical exertion during high humidity and heat (conditions present in this case) can have deleterious physical consequences for both police officers and citizens, and note that parties should be aware of the factors that might be related to a health emergency.

4.1.1 The BPD should provide training and special bulletins describing health risks in severe heat conditions, including prevention and mitigation procedures.4.1.2 The BPD should review tactical procedures during high heat times and include options for arrest tactics and use of force to control for these risk factors.

4.2 Critical incidents such as this one provide important insights and information for improved training in tactical procedures and techniques.

4.2.1 The BPD collects arrest and use of force data annually, which should be included in an annual report including a detailed analysis of the frequency, circumstances, types, and outcomes of use of force for different categories of crimes. This use of force data report should be reviewed by police leadership, to update training, defensive tactics, contacts with the public and to inform internal affairs investigators

4.3 The use of Oleoresin Capsicum (OC) Spray in this case resulted in significant cross-contamination of both Officers Chapman and Ruiz.

4.3.1 Reinforce through review, retraining and better monitoring current BPD OC Spray policies and guidelines.

4.4 The primary issue experienced by the officers

4.4.1 Review current BPD Defensive Tactics Training

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in this incident was the difficulty in controlling and restraining a large, especially strong, and aggressive suspect.

and align with the best practices used by leading agencies.4.4.2 Examine BPD restraint procedures to determine if there are tactically, technically, and strategically more efficient methods available when multiple officers are involved in restraint procedures. If more efficient measures are available and not used in incidents like this one, revise policy, training, and accountability mechanisms. 4.4.3 Use linked pairs of handcuffs when attempting to arrest large, muscular, and/or resistive suspects.4.4.4 Provide information annually on defense tactics during in-service reviews and training.4.4.5 Provide BPD officers with additional non-lethal restraint tools, such as Electronic Control Devices (e.g., “Tasers”).

4.5 Violently-resisting subjects need to be handcuffed for their own protection and the safety of the officers and bystanders.

4.5.1 The BPD should issue an updated training bulletin to alert officers to this potential danger.

5. Professional and Objective Investigative Protocols

5.1 The BPD homicide investigation in this case did not meet professional best practices for objectivity and thoroughness.

5.1.1 Critical use of force incidents require sophisticated investigations and an understanding of the legal complexities associated with a police officer’s authority, tactical decisions and conduct during the totality of circumstances surrounding the incident. The IRB

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recommends that BPD contract such review tasks to outside experts, consistent with state laws, to conduct an independent and objective investigation.5.1.2 Homicide investigators should video and audio record all statements from officers, witnesses, and experts as part of an officer-involved investigation of an incident.

5.2 The BPD does not have a specially trained team to conduct complex officer-involved homicide investigations.

5.2.1 The BPD should formalize the requirements for training and maintaining high-level investigative competence and objectivity to investigate officer-involved incidents that may result in death.

5.3 The Internal Affairs investigations take too long to be closed and to reach a finding to be of real service to the police department, its personnel, or the community.

5.3.1 The BPD should establish an internal expert panel of specially trained investigators in a Critical Incident Review Team (CIRT).

6. Care of Life and Emergency Lifesaving Protocols

6.1 The Office of the Chief Medical Examiner (OCME) operates under strict protocols and professional standards established by the state licensing board.

No recommendation

6.2 The OCME’s requirement for outside expertise delayed the OCME’s report by several months, and this was not communicated to the families or to the community.

6.2.1 Where specialized expertise is needed that may cause significant delays, the information should be presented to the family and the public to keep them updated.

7. Communications/ Transparency

7.1 The BPD communications with the victim’s family were insufficient and not

7.1.1 The BPD should adopt communications and transparency guidelines that emulate other leading

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transparent. police agencies.7.1.2 The BPD Commissioner should provide public presentations on high-interest incidents.7.1.3 Public presentations of critical incident investigative reviews need to be timely and conducted without delay once all the facts are known.7.1.4 The BPD should focus on delivering high-quality investigations in the most transparent manner possible.7.1.5 The BPD should develop ways to inform the public of investigative findings in both criminal and administrative investigations.7.1.6 Building community trust should be a priority within the BPD, through procedural justice training and practice.7.1.7 BPD collects data on reported use of force incidents, and this data and the trends and patterns should be tracked, analyzed and released to the public annually.7.1.8 The BPD, in consultation with the State’s Attorney, should release the full homicide investigation to the public (appropriately protecting the names and identities of persons) as an example of transparency.

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7.2 The OCME sought independent expert advice and consultation regarding the cause of death. This resulted in a delay, and the reason for the delay was not communicated to the family or the public.

7.2.1 When specialized death investigation expertise is required but not available “in house,” the OCME should develop an expedited process to contract and acquire the necessary expertise without delay.7.2.2 OCME should consider notifying the police, family members and the public when extraordinary delays in releasing their autopsy findings are expected.

Overall, the BPD is working to improve the quality of use of force and in-custody death investigations, including bringing in leaders from outside agencies and providing more transparency to the community. However, more work remains to be done to maintain and improve community trust following controversial use of force incidents. For example, BPD communications with Mr. West’s family and the larger community were not well coordinated and did not respond in a reasonable time to numerous questions surrounding the incident. The BPD should accelerate the timetable regarding informing the public of the facts and circumstances surrounding the death of a person in police custody.

To address such issues that may arise in future incidents, the IRB recommends that BPD implement a timely Board of Review process, examining the totality of circumstances surrounding every use of force incident that results in death or serious injury. The review must include an assessment of whether the actions, decisions, and tactics complied with administrative rules, regulations, training, and BPD goals. To do so, many leading law enforcement agencies are contracting with professional experts in high-profile use of force cases to conduct such independent and objective investigations. This practice provides greater transparency for the community and, ultimately, helps build and maintain trust and confidence in an agency.

The BPD Commissioner charged the IRB to conduct a review of all aspects of this incident and to make recommendations for improvements. The BPD Commissioner has committed to developing a plan to implement the recommendations, will present to the IRB a six month progress report, and will make a public statement to ensure that future situations like this one can be prevented.

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Contents

Executive Summary.......................................................................................................... i

Incident Summary............................................................................................................2

General Background Questions Raised by the IRB.........................................................7

Summary of IRB Findings and Recommendations........................................................10

Issue Area 1: Officer Judgment/Decision-Making.......................................................10

Issue Area 2: Transfer Criteria for Specialized High-Discretion Units (i.e., Northeast Operations Unit)..........................................................................................................14

Issue Area 3: Use of Force Policies............................................................................15

Issue Area 4: Officer Tactical Procedures and Techniques........................................15

Issue Area 5: Professional and Objective Investigative Protocols..............................21

Issue Area 6: Care of Life and Emergency Lifesaving Protocols................................23

Issue Area 7: Communications/Transparency............................................................24

Conclusion...................................................................................................................299

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Introduction:

Following the sudden death of Mr. Tyrone West in July 2013, Baltimore Police Commissioner Batts convened an independent board of respected professionals from law enforcement, academia, and medical and legal fields. He stated that this Independent Review Board (IRB, or “Board”) is “not an investigative body and does not have subpoena powers.” Instead, the Board members were “asked to utilize [their] expertise to evaluate the events, examine the actual case, and review the Baltimore Police Department (BPD) policies and procedures, as well as the actions and decisions of the Baltimore Police Department Officers.” The board members agreed to conduct the review as a public service and to objectively examine whether or not the police performed according to legal and professional standards of conduct and to BPD’s policies, training, rules of operations, and the overall goals of the Department.1

The Commissioner’s letter also stated that “the Independent Review Board will compile a report and share it with the media and that the members be available to attend the media presentation.” Commissioner Batts, his staff, and BPD personnel limited their contact with Board members as appropriate for an independent review.

The BPD Internal Affairs Bureau staff did provide the incident reports, as well as copies of departmental procedures, policies, rules, accountability mechanisms, and training content. The Homicide investigators and commanders prepared a full briefing on the investigation and provided dozens of extra documents and reports that the Board requested. The Board read dozens of orders, rules , procedures, and training documents, and the Board heard and interviewed both Homicide and Internal Affairs investigators who were on-scene and intimately familiar with the details of the incident. Board members listened to the audio recordings of the officers’ statements; reviewed forensic evidence and crime scene diagrams; and requested additional materials, information, and forensic examinations. The Board met in person and via conference calls on numerous occasions over a four-month review period2.

What follows is the report of the Independent Board of Review for the Tyrone West Death In-Custody.

1 This is the report called for in the Commissioner’s letter and the report is being released to the public and the media on August 8, 2014.2 The IRB convened on January 23, 2014 and completed its work on August 8, 2014

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Incident Summary:

On July 18, 2013, at approximately 7:00 p.m. Eastern Daylight Time, the sun was shining and providing good illumination for observation. Weather officials described conditions as hot and humid; temperatures were reported in the high 90s, with a heat index in the low 100s (degrees Fahrenheit). Baltimore police officers Nicholas Chapman (three years of BPD experience) and Jorge Bernardez-Ruiz (two years of BPD experience) were patrolling in an unmarked police vehicle. The officers were wearing non-uniform casual attire as part of the Northeast Operations Unit. This unit’s special mission is to prevent violent crime and street drug dealing.

While on duty, the officers observed a dark green Mercedes Benz unsafely backing down the street into an intersection and then turning, proceeding eastbound onto Kitmore Road at well below the posted speed limit. The officers observing this unusual activity turned their unmarked vehicle around and began following and observing the conduct of the vehicle’s two occupants. They watched the male driver and the female passenger looking back at the officers’ unmarked vehicle and then dropping their heads and arms below view, which the officers interpreted as possibly associated with attempting to conceal a firearm or contraband (i.e., illegal drugs). The officers decided to stop the vehicle but did not notify BPD Dispatchers that they were stopping a suspicious vehicle that may contain weapons and contraband. The officers activated the blue emergency dashboard lights (these unmarked vehicles have no sirens) to effect a vehicle stop.

The vehicle continued moving down Kitmore Road and turned right onto Kelway Road, where the driver pulled to the curb and stopped. Officer Ruiz—dressed in blue jeans, a black short-sleeved tee-shirt, and a black ballistic vest with a BPD Badge displayed on the left side and POLICE displayed in large white letters across the chest—approached the driver’s side of the vehicle. Officer Chapman—dressed in blue jeans, a brown short-sleeved tee-shirt, and a ballistic vest identical to that of Officer Ruiz—approached the passenger side of the parked vehicle. Officer Ruiz asked the driver for his driver’s license and registration. The driver produced a Maryland driver’s license identifying him as Tyrone West, as well as the vehicle registration. The license identified Mr. West as 6 feet tall and weighing 237 pounds.

After a brief discussion between Officer Ruiz and the vehicle passengers, both the driver and passenger were asked to exit the vehicle. They complied with Officer Ruiz’s request, and they stepped over to the curbside. Officer Chapman maintained a cover position nearby Officer Ruiz. Officer Ruiz noticed the driver’s size and exceptional physical development and requested that Mr. West sit down on the curb, as a precaution for both the driver and the officer. Mr. West and the passenger both complied. While standing in front of them, Officer Ruiz further asked Mr. West for

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permission to search inside the vehicle and the trunk, which was granted. It is unclear why the officer asked for permission to search the vehicle trunk, which was not accessible to the driver or passenger during the unusual activity noted inside the vehicle. Officer Chapman then asked the female passenger if she would agree to be searched by a female officer, which was also granted. Officer Chapman then radioed for the assistance of a female officer to conduct the search (approximately 7:10 p.m.; according to the radio logs, this is the first transmission associated with the traffic stop). Both the driver and the passenger were cooperative and complied with all of the officers’ requests.

Officer Ruiz was talking to both the driver and passenger, who were sitting on the curb together. Officer Chapman left the tactical cover position and began searching the vehicle for weapons and contraband. Officer Chapman observed an open bag of fast food, including some that was partially eaten, as well as associated items on top of the passenger console where the suspicious activity had been observed. Officer Ruiz asked Mr. West, for safety reasons, to cross his legs, which he did while sitting on the curb. As Mr. West crossed his legs, his pant legs rose a few inches and revealed a large bulge in Mr. West’s sock. Officer Ruiz assumed that the partially exposed plastic baggie probably contained dangerous drugs or narcotics, similar to the manner in which street drug dealers carry drugs in Baltimore. When Officer Ruiz bent over to inspect and retrieve the plastic bag partially hidden in Mr. West’s sock, Mr. West shoved the officer backwards and attempted to get to his feet. Officer Ruiz recovered and immediately placed Mr. West in a “bear hug” hold and pushed him against the vehicle, to prevent his escape. As they struggled, both fell to the ground, with Officer Ruiz on top. Officer Ruiz repeatedly commanded Mr. West to stop resisting, and the two exchanged blows (confirmed by the female passenger). Officer Chapman, who had been searching the vehicle, heard the commands to stop resisting and ran over to assist in the arrest of Mr. West. Officer Chapman attempted to control Mr. West’s legs but was unable to restrain them, due to the strength of Mr. West’s kicks. Mr. West, who was large in stature, then stood upright, with Officer Ruiz once again clinging to him in a “Bear Hug” restraint hold.

Officer Chapman realized that the situation was becoming dangerous and called for emergency backup—“Signal 13” (Officer Needs Help). This call notifies all personnel to respond immediately because an officer is in need of urgent assistance, due to a serious threat. This call took place approximately 1 minute and 9 seconds after Officer Chapman had called for a female officer to help search the female passenger.

Both of the on-scene officers commanded Mr. West to stop resisting and to place his hands behind his back. Suddenly, Mr. West relaxed and stopped resisting. Officer Chapman and Officer Ruiz again ordered him to place his hands behind his back to be handcuffed. Mr. West then pushed away from the car he was leaning against and

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lunged at Officer Ruiz. According to Officer Ruiz, he thought Mr. West was attempting to grab his BPD service weapon.

Both officers were trying to hold and contain Mr. West. They struggled with Mr. West in close contact, with the officers applying defensive tactics and Mr. West resisting their attempts at control. Mr. West again relaxed and raised his hands in what the Officers interpreted as a sign that he would submit to arrest. The officers ordered Mr. West to put his hands behind his back. Mr. West then started punching the officers again. The situation was described by the officers as “chaotic and lots of punching by Mr. West.” According to the female passenger, she observed Mr. West say during the physical resistance to the officers, “it’s only a measly four 4 bags…” Officers later recovered from the crime scene a single glassine bag containing 13 smaller glassine bags of cocaine.

Mr. West continued to resist arrest. At this point, the officers deployed BPD-issued OC Spray, in close physical contact as the struggle continued, and the officers themselves were contaminated by the OC Spray and were handicapped by the effects. The OC Spray did not appear to reduce Mr. West’s resistance, and he continued to “punch, kick and push” the officers. Officer Chapman then escalated to a higher level of force by using a baton, and he struck Mr. West several times on the legs (on the thigh muscle), in a manner and location trained by the BPD. The baton strikes on the thighs appeared to be delivered without effect3. Mr. West was able to break free from the officers while they were suffering from the effects of the OC Spray and from physical exhaustion. Mr. West ran across Kitmore Road and into an alley, then stopped and looked back at the officers and to where the vehicle was parked.

The officers pursued Mr. West and observed him “reach down and throw something.” 4Officer Ruiz reportedly said, “Let him go; we will get him later.” Mr. West then took an aggressive boxer’s stance with his fists raised and facing the officers. The two officers continued to attempt to restrain Mr. West. Civilian witnesses confirmed that Mr. West continued to strike at the officers and that the officers responded with both punches and kicks as the episode continued.

Mr. West then ran to a parked vehicle and used it to separate himself from the officers. As the officers came around opposite sides of the parked car, Mr. West charged forward and, with a karate-type jab, poked Officer Chapman in the eye, further injuring him. At this point, the female passenger, according to her statement to the police investigators, was imploring Mr. West “just to lie down and stop fighting,” but he ignored her. By this

3 Both the use of OC Spray and the baton were deployed appropriately within BPD policies, procedures, and training; however, the manner in which the OC Spray was delivered will be reviewed in the “Summary of IRB Findings and Recommendations” section of this report.)4 According to the BPD Homicide report and officer statements.

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point, Officer Chapman had called three times for a “Signal 13” (Officer Needs Help) as Mr. West assaulted the two officers and refused to submit to their orders.

Approximately 1 minute after the last Signal 13 Call was made responding officers began arriving on scene. A total of six additional officers then engaged Mr. West and forced him to the ground. Officer Chapman and Officer Ruiz were exhausted in the unusual heat and humidity and disengaged because of the effects of the OC Spray. Mr. West was placed into a face-down, prone position, and the officers struggled with Mr. West as he resisted the handcuffs, which were eventually placed on his wrists. Although his arms were now restrained, Mr. West continued to kick violently and struggled against the officers who attempted to control his legs. One officer placed a knee on Mr. West’s back to keep him from getting up. At approximately 7:14 p.m. the suspect was in-custody after a struggle that lasted an estimated 4 minutes in duration.5

Approximately 34 seconds after Mr. West was handcuffed a medic was requested for the suspect in-custody and about a minute later the on-scene officers called for a medic for officers exposed to OC Pepper Spray. Then a supervisor was called and quickly arrived on scene since he was responding to the Signal 13 and the supervisor immediately checked on Mr. West’s condition. The supervisor observed that Mr. West did not appear to be breathing. The officer removed the handcuffs, rolled Mr. West over onto his back, and attempts were immediately started to resuscitate him, Medics were called again at 7:16 p.m. to respond ASAP. The supervisor took over the lifesaving efforts. At approximately 7:18 p.m., a second call for medics and Emergency Medical Technicians (EMTs) went out. The EMT personnel arrived and transported Mr. West, while continuing lifesaving assistance until Emergency Room (ER) physicians at Good Samaritan Hospital took charge (see Finding 4.1and Recommendation 4.1 and 4.2 for more information on EMT and ER procedures). Mr. West was pronounced dead by the doctors at the hospital after sometime.

According to BPD investigators and reconstruction of the incident from eye witnesses, officers at the scene, and radio logs, the elapsed time of active resistance was approximately 4 minutes. It is estimated, using radio logs, eye witness testimony, and officer statements that Officers Ruiz and Chapman were engaged for approximately 3 minutes and 32 seconds, and the other responding officers’ involvement lasted 1 minute and 21 seconds. The time from the actual stop to custody was estimated to be 4 minutes and 53 seconds.

An autopsy was performed on the body of Mr. West at the Office of the Chief Medical Examiner for the State of Maryland on July 19, 2013. The Medical Examiner reported that Mr. West had superficial abrasions on his face and abrasions and contusions on his back and lower extremities that were consistent with the information provided from the

5 Time estimates are reconstructed from BPD radio logs and transmission from the scene.

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scene investigation. There was no evidence of “any significant injury to vital structures or vital areas of the body” that may have been consistent with a beating or other physical harm. There were no marks indicating that Mr. West had been subjected to a Taser (Electric Conduction Device). Furthermore, it was noted that there were no broken bones or major organ damage and no petechial hemorrhages. The Office of the Chief Medical Examiner completed the autopsy and determined that Mr. West died because his heart suddenly stopped beating (i.e., Cardiac Arrhythmia) due to Cardiac Conduction System Abnormality, which was complicated by dehydration and the exertion and physical excitement during the engagement with the police. The report concludes, “in the absence of significant injury and signs of asphyxia, all prevailing factors in this case increased his potential for sudden death.”

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General Background Questions Raised by the IRB:

The death of a human being is a tragedy. It is a tragedy felt by family and friends, the Baltimore community, and the Baltimore Police Department. When an in-custody death occurs, it should raise questions as to how widespread the use of force is within the context of policing in Baltimore.

1. The Board asked BPD officials for data on the number of physical arrests made in 2013 and the percentage of those arrests in which the use of force was reported. The BPD had the raw numbers, and the IRB conducted calculations.

The BPD reported that they made a total of 48,423 arrests for all of 2013. The BPD reported that uses of force during these arrests occurred in 471 cases, accounting for less than 1 percent (.97 percent) of all arrests. This calculation of less-than-one percent is not an anomaly, but rather consistent with the arrest data Baltimore has collected each year since 2009.

2. How does Reported Use of Force Compare Nationally or with Comparable Agencies? Getting national trend data on police use of force (PUF) can be challenging. However, a study by Hickman, et al (2008) Toward a National Estimate of Police Use of Force, reported that 19.2% of the arrestees reported that police used force against them. 6 In the Survey of Jailed Inmates (2002) 21% reported that police used force against them. In the Hickman, Garner (2006) study of six cities, they reported that the Montgomery County Police, a comparable jurisdiction in Maryland, documented that in 6.2% of arrests made police use of force was reported. Using this standard the BPD has a low number of reported use of force incidents given the high volume of arrests made each year.

3. How many complaints for excessive force, rude conduct, or improper procedures had been filed against the principle officers involved in this tragic incident? The BPD Internal Affairs Division Chief responded to this IRB question with the following:

“In response to the IRB's request for the involved officers disciplinary records, please be advised that the information you request falls within the definition of personnel records and cannot be released pursuant to Maryland statute.

6 Police Supplement Public Contact to the National Crime Victims Survey (2002, Bureau of Justice Statistics)

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The Maryland State Government Article 10-616 (Required Denials) states that unless otherwise provided by law, a custodian shall deny inspection of a public record under this section. Subsection 10-616 (i) states a custodian shall deny inspection of a personnel record of an individual, including an application, performance rating, or scholastic achievement information.

Maryland Case Law defines disciplinary records as personnel records, see Montgomery County v. Shropshire, 420 Md. 362, 381 (2011) (police internal affairs records related to administrative violations and employee discipline are personnel records and not accessible to the County Inspector General under the MPIA); Baltimore City Police Department v. State, 15 Md. App. 274, 282-83 (2004)(investigation of employee misconduct is personnel record); and 78 Opinions of the Attorney General 291 (1993)(information about a complaint filed against an employee is not disclosable)”7.

4. Were the principal officers in the Tyrone West Incident involved, associated with or present at the crime scene of Anderson’s Death in-custody as alleged by Tyrone West family members? The Internal Affairs Division Chief responded to this Background Question from the IRB:

“Regarding the allegations by the Tyrone West family that the same officers were involved in the Anthony Anderson in-custody deaththat simply is incorrect. The incident involving Mr. Anthony Anderson occurred on September 21, 2012. The names of the involved officers are in the public domain and can be verified by a Google search (search: Anthony Anderson Baltimore). The Baltimore Sun has done extensive reporting on that case and they list the three involved officers, Strohman, Vodarick and Boyd. You can see that those three were not involved in the Tyrone West incident.”8

The IRB did follow up and independently verify that the names of the principal officers (in the public domain) were completely different from those involved in the Tyrone West incident. There were some general similarities, however - the detectives in the Anderson case were in an unmarked vehicle, wearing non-uniform attire and black ballistic vests with POLICE in large white letters across the chest. The unit was assigned to stop street level drug sales and street crime.

7 Chief Rodney Hill, Internal Affairs Division, Baltimore Police Department, July 28,2014 (e-mail)8 Chief Rodney Hill, Internal Affairs Division, Baltimore Police Department, July 28, 2014 (separate e-mail)

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The unit has reportedly been disbanded. There was no association by the officers involved with the West Incident with the previous incident and there is no basis to suggest that the officers were present.

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Summary of IRB Findings and Recommendations:

The IRB’s assessment of the Tyrone West incident considered the totality of circumstances and not just the specific use of force. We also examined the decisions leading up to the officers’ need to use force and subsequent restraint of Mr. West. The IRB reviewed the quality of the judgments and how effective the BPD policies, procedures, training, and supervision were in identifying any points along the timeline of this incident where there may have been opportunities to change the engagement, de-escalate the situation, or employ other options to control the incident.

The IRB did not have a team of independent analysts to review all of BPD’s data on officer use of force, circumstances involved with the decisions to use force, the characteristics (e.g., age, gender, residence) of the subjects stopped, the times of day when incidents occurred, the numbers of officers involved and level of force used, errors and mistakes made, and the accountability mechanisms and discipline. Furthermore, we were unable to read all the training, policies, and procedures and investigative requirements. The IRB cannot reach a conclusion of how well the primary mechanisms through which the department establishes and reinforces professional standards of conduct and the organizational culture are performing.

However, there are a continuing number of critical incidents that seem to reveal lapses in tactical decision-making, compromises in officer safety, departures from BPD policies, and lack of respect for both youth and adults who are stopped by the police. These critical incidents may indicate underlying patterns and practices that must be addressed. The BPD should evaluate their quality of supervision, training, and accountability mechanisms to address these lapses and ensure that police-initiated encounters with the public are constitutional, align with professional standards and are appropriate.

The IRB has identified seven issue areas where improvements ought to be made. We have made specific recommendations for each of the associated findings, but, again, these are not the results of an extensive survey of leading agencies or exhaustive research on best practices. The recommendations rely on each Board member’s expertise, experience, personal knowledge or research, and understanding of the professional code of conduct.

Issue Area 1: Officer Judgment/Decision-Making:

Finding 1.1 – The officers’ tactical decisions did not follow BPD procedures.

The officers did not follow BPD guidelines during several aspects of this incident. Specifically:

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BPD guidelines state that officers should call for a backup/cover uniformed officer when making a car stop in an unmarked vehicle.

BPD guidelines state that officers making a car stop notify the dispatcher of the location, tag numbers, and the reason for the traffic stop.

The officers, in accordance with BPD training, ought to have made a records check; they then would have been alerted to Mr. West’s long history of resisting authority, violence, and drug sales. But, in this case, the officers did not follow the guidelines and compromised officer safety with serious consequences.

There were also several tactical errors when attempting to control the subjects. These errors were committed during the initial traffic stop of Mr. West and contributed to the subsequent deterioration and loss of tactical control of the situation. They include the following:

o The decision by Officer Chapman, to leave his cover position—backing up

Officer Ruiz—to search the parked, unoccupied vehicle then exposed Officer Ruiz to being assaulted and overwhelmed by Mr. West and potentially the female companion.

o The Officers failed to pat-search either person to determine if they were

armed, which would have been reasonable given the suspicious behavior by the driver and passenger observed while following the vehicle.

o Officer Chapman appears to have departed from basic tactical training. These

decisions (i.e., not to call for uniform cover officers, not to notify BPD Dispatch Operator of the traffic stop of a vehicle possibly involved with illegal drugs and weapons, not to maintain a cover position to protect officer Ruiz, to search an unoccupied vehicle leaving a single officer to control two subjects, not to “pat” or “frisk” search the subjects for weapons) contributed to the deterioration of the car stop from a controlled situation into a chaotic one that escalated into dangerous chaos and increased the risk to officer safety.

Additional tactical errors were made during the physical assault by Mr. West, during attempts to arrest West, and during the subsequent foot pursuit:

The decision to deploy the OC Spray was appropriate as a less-than-lethal option; however, it was not within the proscribed distance for safe use. BPD Orders call for the officer to be a minimum of three feet from the intended OC Spray target. In this case, the officers were in physical contact with the intended OC Spray target. Departing from the BPD guidelines had incapacitating consequences and created a situation where the officers were unable to adequately defend or protect themselves.

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The decision to continue to physically engage Mr. West and pursue him even though additional officers were en route in response to several Signal 13s was not the only option available, but it appeared to be the only possibility the officers considered. The officers had Mr. West’s identification, the vehicle, and the passenger, plus they could maintain loose contact and direct the responding officers the location of Mr. West’s flight. Discretion, especially at the point where both officers were suffering the effects from improperly deployed OC Spray, is better than continuing engagement.

Recommendation 1.1.1 – The BPD should better supervise officers in the Northeast Operations Unit (especially when working in non-uniform assignments) and provide them with specific directions that more carefully focuses their activities on high-probability evidence-based stops, searches, and arrests. Research demonstrates that directed patrol into “hot spots” (i.e., narrowly defined geographical locations that generate disproportionate drug sales and serious crime) is far more efficacious than general patrol in larger areas. However, this incident reveals possible problems by officers in these special units regarding decision-making, departing from established policy and training, and officer safety. Strict supervision is required in high-discretion plain-clothes assignments and is essential to ensure that officers comply with policy. The assignments of special details in unmarked police cars and plain street clothes need to be better informed by both crime and intelligence analysis. The BPD needs to have focused supervision of officers in non-uniform assignments. The supervisors need better training in identifying non-compliant actions and effective accountability mechanisms.

Recommendation 1.1.2 – The BPD should conduct a full review of the tactics and decisions made in this incident that led up to the use of force and retrain the officers involved (and other patrol officers) to be alert for lapses in officer safety. The BPD should develop a much more effective and systematic process of incident review. There are numerous leading law enforcement agencies which provide high level critical incident and use of force reviews (e.g., the Los Angeles Police Department, the Las Vegas Metropolitan Police Department.). The IRB reviewed BPD policies and the training curriculum, and recommends that the BPD employ a more effective training curriculum on force and tactical decision-making.

Recommendation 1.1.3 – BPD training should to include de-escalation methods and tactical disengagement defensive tactics. The BPD should review the continuing Officer and Supervisory annual training, and update it to include examples of real incidents and tactical decision making scenarios—such as the Tyrone West Incident—and stress the potential opportunities for tactical disengagement.

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Recommendation 1.1.4 – BPD Use of Force Review Boards should include a detailed review of the totality of circumstances, including the reasons for the initial contact with a subject. Use of Force Reviews ought to specifically identify points where de-escalation or tactical disengagement would have been a better tactical decision. When opportunities to de-escalate are noted during the review process, these should be included in formal training and provided in bulletins and during roll call to ensure that de-escalation techniques can be reinforced with the line officers, their supervisors, and command officers. BPD Leadership should notify all supervisors that all post-incident use of force reviews will include an analysis of when disengagement or de-escalation tactics could and should have been employed. The supervisors should be held responsible for ensuring that these practices are understood and used by officers assigned to their units.

Finding 1.2 – Motor vehicle traffic stops by unmarked police vehicles involve inherent risk and the possibility that the subject may not acknowledge the authority of law enforcement personnel to make traffic stops. Traffic stops by unmarked police vehicles are risky because drivers may not acknowledge plain clothes and unmarked vehicles as law enforcement personnel. In the West case, the officers stated that they saw suspicious activity inside the moving vehicle that they believed may be related with hiding weapons or drugs. The possible presence of firearms or drugs in a vehicle ought to cause the officers to notify BPD dispatch prior to the stop. The potential for a high-risk incident is justification for the officer(s) to call for a marked unit for assistance. According to BPD’s Operating Manual, a section on officer safety guidelines (p. 145) clearly states, “Before stopping a vehicle or as you stop it, give your location and the tag number to the communications section. If you are stopping the vehicle because of suspicious circumstances or actions of the occupants, advise the dispatcher of this by using a code 10-25.” In this incident, the officers could have followed the policy but did not. Therefore, they did not comply with the policy as written.

Recommendation 1.2.1 – BPD leadership should consider refresher training and the need for a comprehensive training plan regarding the risks and tactical mitigation involved in traffic stops by unmarked police vehicles. The BPD Operating Manual does not have a detailed procedure for traffic stops by an unmarked vehicle. The manual should be updated to include plain-clothes officers about to make a traffic stop, requiring them to notify dispatch and request a marked unit to respond.

Finding 1.3 – There was scant probable cause or justification in this case to request consent to search the vehicle trunk for weapons. The IRB finds that there was neither need nor probable cause to conduct a search of the trunk of the vehicle if the officers were indeed concerned about their safety and were only looking for weapons associated with the unusual movements by the driver and passenger during the period the officers followed the vehicle, as indicated in their statements. The officers

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had no reason to ask the driver for consent to search the vehicle trunk based on their observations.

Recommendation 1.3.1 – Refresher training in the current case law (federal and state courts) restricting police ability to search and seize evidence of a crime and contraband absent a search warrant should be provided as a training bulletin that can be offered immediately to patrol unit during roll call training and also used in the annual in-service training. There are courses provided by the U.S. Department of Justice, Office of Justice Programs and the Bureau of Justice Assistance - available at no cost - that have well tested curricula on constitutional policing that help officers and supervisors better understand the complexities associated with current search and seizure law. In addition, a course in proprietary policing can help officers build trust in the community and prevent crime and drug sales.

Issue Area 2: Transfer Criteria for Specialized High-Discretion Units (i.e., Northeast Operations Unit):

Finding 2.1 – The two officers in this case assigned to the Northeast Operations Unit (NOU) were inexperienced, with only two and three years of BPD service, respectively. The NOU is a highly discretionary assignment with a focus on preventing major crimes and illegal drug related activities. The officers assigned frequently work wearing casual attire and drive unmarked police vehicles. In addition, this unit does not respond to the routine calls that are dispatched to marked units. These officers in non-uniform assignments also are not subject to public attention or informal supervision during the period of assignments so they are unlikely to serve as a deterrent to criminal conduct or reassure the public that police are actively protecting them.

General Orders 32 and 33 of the BPD Operating Manual outline the procedures for recruiting members for the NOU. Neither of these Orders mention police experience, aptitude, specialized training, or temperament requirements for officers to be selected for this unit.

Recommendation 2.1.1 – The BPD should create a policy that details the requirements for candidates wishing to serve in this specialized unit. The IRB recommends that officers transferring into a specialized, non-uniform enforcement unit be paired with a supervisor or an experienced officer and tested on the current laws governing search and seizure, special tactics, goals of the BPD and officer safety protocols. Because of the risks and the need for discretion and mature judgment, some reasonable years of service should be written into the policy as a transfer requirement—probably between three to five years of experience as a police officer. Once selected and reviewed, a newly assigned officer should be assigned with a more senior officer for a period of six months or until the new officer has mastered the requirements of the specialized unit.

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Issue Area 3: Use of Force Policies:

Finding 3.1 – The written BPD Use of Force Policies are consistent with standard accepted practice but were not be consistently applied in this case. The IRB finds that BPD commanders and supervisors do not conduct routine compliance audits of the patterns and practices employed by specialized, non-uniform enforcement units to ensure that sworn personnel are complying with the stated procedures and policies. However, there is evidence in this case that officers may have departed from BPD-approved policies.

Recommendation 3.1.1 – The BPD should provide additional supervisor and command training in best methods for conducting performance audits to ensure supervisor accountability for officer performance and officer compliance with written Use of Force policies. Commanders and supervisors should conduct regular audits and spot checks to ensure policy compliance to protect officers and maintain high professional standards. These compliance audits need to be documented and noted during the supervisor’s own performance review.

Finding 3.2 – The post-incident homicide investigation in this case did not reflect the highest standards and practice for objective and independent investigative practice in officer-involved death cases. The homicide investigation in this case had gaps in the evidence chain, scene photos and officer condition photos, canvass and statements from potential witnesses and the crime scene management. The quality of the investigation does not reflect professional best practices.

Recommendation 3.2.1 – The BPD should follow the practice of leading police agencies in contracting with independent, competent, objective investigators for all Officer-Involved Shootings or Death in Custody Investigations. Any time there is an in-custody death, officer-involved use of deadly force, or critical injury associated with an arrest, the BPD should conduct an automatic and independent review, similar to the Office of Independent Reviews conducted by the Los Angeles Police Department and other leading agencies.

Issue Area 4: Officer Tactical Procedures and Techniques:

Five physical engagements occurred during the arrest of Mr. West. The first four involved Mr. West and Officers Ruiz and Chapman. The fifth engagement involved five additional officers (Beasley, Lee, Cioffi, Hinton, and Hashagen) and one trainee (Lewis). Officers Ruiz and Chapman retreated from the final (fifth) engagement once fellow officers arrived and began to assist in the control and restraint of Mr. West.

After the initial car stop, Mr. West was asked to exit the car and sit on the curb. The initial engagement between Mr. West and Officer Ruiz began when Officer Ruiz attempted to examine a bulge in Mr. West’s sock. According to Officers Ruiz and

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Chapman, as well as the female passenger in Mr. West’s car who witnessed the event, Mr. West then began to swing at the officer, and the two fell to the ground. Mr. West and Officer Ruiz continued struggling and exchanging blows. Officer Chapman attempted to assist Officer Ruiz by controlling Mr. West’s legs. As a result of Mr. West’s kicking and thrashing, Officer Chapman was unable to gain control. Mr. West then stood up with Officer Ruiz, who maintained a hold around Mr. West’s trunk. Officer Ruiz then released his hold around Mr. West’s trunk, and the officer and Mr. West disengaged.

At that time, the second physical engagement occurred after the officers’ requested that Mr. West place his hands behind his back. Mr. West then resisted the officers’ attempt to handcuff him. Mr. West eventually relaxed his resistance, and the officers once more requested that he place his hands behind his back. At this time, the officers were still unable to restrain and control Mr. West, and a call for help was made.

The third engagement occurred immediately after the officers’ second request for Mr. West to put his hands behind his back. Mr. West again resisted and, as Officer Ruiz attempted to gain control of Mr. West, Officer Chapman deployed pepper spray. The discharge aimed to assist in the restraint and control of Mr. West by Officer Ruiz. However, at the time of the discharge, both Officers Chapman and Ruiz were within three feet of Mr. West. With both officers feeling the effects of pepper spray exposure, Mr. West continued to actively resist the attempts at restraint, control, and arrest by the two officers, even after being exposed to the pepper spray. During this engagement, Mr. West was repeatedly struck in the legs with a baton by Officer Chapman in a continued attempt to further assist in control and restraint. The officer’s use of the baton was consistent with his BPD education and training and followed the BPD use of force, policies, and guidelines. Neither the pepper spray nor the baton strikes appeared to have an effect on Mr. West.

The fourth engagement began when the two officers were able to catch up to Mr. West, who assumed a physically aggressive, crouched boxer’s position. During the initial part of this engagement, blows continued to be exchanged between Mr. West and the officers. During this engagement, Mr. West fell to the ground but was able to regain his standing position, again disengaging from the officers and attempting to escape once again.

The fifth and final engagement occurred across the street from where engagement four had transpired. Officers Ruiz and Chapman again attempted to regain control of Mr. West. It was during this final physical engagement that Officers Lewis, Beasley, Lee, Cioffi, Hinton, and Hashagen arrived. Mr. West continued to resist and exchange blows with various officers. Officers Chapman and Ruiz retreated from the engagement due to physical exhaustion, as well as the incapacitating effects of the earlier exposure to the pepper spray.

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The responding officers eventually grappled Mr. West to the ground in a prone position, first on his side, then on his stomach. Even while being restrained in the prone position, Mr. West continued to resist by kicking and through muscle tension. He refused to cooperate and obey the appropriate commands to stop resisting and allow the officers to execute their duty. Officers were unable to successfully handcuff Mr. West despite his continued resistance. Officers continued to apply department-approved procedures for controlling a resisting suspect, including leg holds, body pins, baton strikes to Mr. West’s arm (to reduce his active resistance to handcuffing), and arm holds. Eventually, the officers were able to overcome Mr. West’s resistance and complete the handcuffing procedures.

Finding 4.1 – Medical research reports that vigorous physical exertion during high humidity and heat (conditions present in this case) can have deleterious physical consequences for both police officers and citizens, and note that parties should be aware of the factors that might be related to a health emergency. Many law enforcement agencies in humid climates provide bottled water and reminders about how to check for proper hydration to their officers. Police officers are on the streets and may not have access to water for themselves or others suffering the effects from the heat and humidity.

Recommendation 4.1.1 – The BPD should provide training and special bulletins describing health risks in severe heat conditions, including prevention and mitigation procedures. New training should include information on safety risks during high heat and humidity, especially dehydration. Officers should be trained in ways to check their hydration levels and monitor the own physiology during these red alert days. The training should include the symptoms of others who may come into contact with law enforcement.

Recommendation 4.1.2 – The BPD should review tactical procedures during high heat times and include options for arrest tactics and use of force to control for these risk factors. The Training Command should review research on the techniques and tactics to physically restrain, control, and arrest violently resisting subjects during exceptionally hot conditions.

Finding 4.2 Critical incidents such as this one provide important insights and information for improved training in tactical procedures and techniques. Data for critical incidents should be collected routinely and analyzed to understand the patterns and practice of use of force by BPD personnel. Seemingly isolated incidents, when viewed as part of the totality of the use of force, may reveal new insights where use of force may be emerging as a problem, and the analysis may alert police leadership to a potential problem in policy or training.

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Recommendation 4.2.1: The BPD collects arrest and use of force data annually, which should be included in an annual report including a detailed analysis of the frequency, circumstances and types and outcomes of use of force for different categories of crimes. This use of force data report should be reviewed by police leadership, to update training, defensive tactics, contacts with the public and to inform internal affairs investigators. Many agencies have a policy of annually sharing the use of force data with the public and they also post it on the department’s official website to ensure that this data is available to their communities.

Finding 4.3 – The use of Oleoresin Capsicum (OC) Spray in this case resulted in significant cross-contamination of both Officers Chapman and Ruiz.

The effects of the pepper spray disabled the officers during their attempt to restrain and control Mr. West.

The intent of pepper spray use by a police officer is as an assist to control and restrain a suspect. The National Institute of Justice identifies OC Pepper Spray as a less-than-lethal restraint:

“Pepper spray is a use-of-force option to subdue and control dangerous, combative, or violent subjects in the field. OC, with its ability to temporarily incapacitate subjects, has been credited with decreasing injuries among officers and arrestees by reducing the need for more severe force options. Research findings suggested that inhalation of OC spray does not pose a significant risk to subjects in terms of respiratory and pulmonary function, even when it occurs with positional restraint.”9

OC Pepper spray represents a relatively non-violent and moderately aggressive method of inducing suspect compliance during restraint. When two or more officers are involved in the attempted control and restraint of a suspect and pepper spray is deployed, the risk of cross-contamination increases. Additionally, discharge of pepper spray in distances closer than the recommended minimum three-feet distance further increases the likelihood of cross-contamination. This was seen when Officer Chapman deployed his pepper spray against Mr. West, and both Officer Chapman and Officer Ruiz were exposed to the deleterious effects of the spray.

Additionally, the excessive heat and humidity (actual temperature at that time was approximately 91o Fahrenheit, with a heat index in the 100’s) may have increased both officers’ exposure to the pepper spray residue through exposure to contaminated sweat,

9 Chan, Theodore; Vilke, Gary; Clausen, Clark, et al, (Dec. 2001). “Pepper Spray’s Effects on a Suspects Ability to Breathe,” National Institute of Justice Research in Brief, page 1.

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either from Mr. West or possibly from each other. This exposure to the pepper spray may have impacted the officers’ ability to maintain control of Mr. West and significantly increased the danger to the officers, Mr. West, and community members nearby. Exposure to the pepper spray, either in part or in whole, was responsible for reducing the officers’ effectiveness, and Mr. West was able to break free. This cross-contamination may have extended and prolonged the incident by permitting Mr. West the opportunity to evade the physical arrest and handcuffing for a brief period.

Recommendation 4.3.1 Reinforce through review, retraining and better monitoring current BPD OC Spray policies and guidelines. The BPD should provide refresher training for all in-service personnel carrying OC Spray. This could be accomplished during in-service training and/or through other social media/marketing methods (e.g., inter-office memos, email reminders, bulletin board postings, posters).

Finding 4.4 – The primary issue experienced by the officers in this incident was the difficulty in controlling and restraining a large, especially strong, and aggressive suspect. Controlling and restraining a resisting suspect without serious injury is perhaps one of the most difficult physical requirements faced by law enforcement personnel. Large and especially strong individuals make this responsibility even more difficult. As was seen with Mr. West, his size, strength, and active resistance made his control and restraint exceedingly difficult.

Due to his significant muscularity and the associated tightness of his shoulder muscles, bringing both arms behind his back to the width that permitted handcuffing was problematic during the arrest process.

The presence of multiple assisting officers was vital to the eventual control and restraint of Mr. West. However, the large number of officers involved also created less-than-optimal efficiency for the restraint and control of Mr. West. With no coordinated strategy or plan, the multiple officers seemed to be unclear as to the most effective and efficient roles as they were attempting to arrest Mr. West.

Recommendation 4.4.1 – Review current BPD Defensive Tactics Training and align them with the best practices used by leading agencies.. A review of the tactics and techniques used by the officers in the restraint and control of Mr. West illustrate a need for a review of the defensive tactics and techniques currently in use by the BPD. The IRB recommends that current BPD Defensive Tactics Training be reviewed by independent, certified experts and brought into compliance with the best and most up-to-date practices.

Recommendation 4.4.2 – Examine BPD restraint procedures to determine if there are tactically, technically, and strategically more efficient methods available when multiple officers are involved in restraint procedures. If more efficient measures

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are available and not used in incidents like this one, revise policy, training, and accountability mechanisms. The BPD should examine the practices of other law enforcement agencies when multiple officers are involved in control and restraint. A more defined strategic and tactical approach would help to reduce the difficulty. Special new training should be provided for BPD officers and supervisors to recognize the physical challenge to handcuffing a well-muscled and exceptionally strong individual.

Recommendation 4.4.3 – Use linked pairs of handcuffs when attempting to arrest large, muscular, and/or resistive suspects. The BPD should establish the practice, when necessary, of linking two sets of handcuffs, colloquially known as “daisy-chaining, when attempting to restrain large or unusually muscular individuals.

Recommendation 4.4.4 – Provide information annually on defense tactics during in-service reviews and training. The BPD should incorporate the lessons learned from actual police encounters through exercise scenarios and in annual reviews and training—including the various defense tactics in the academy—during in-service training for officers’ use in the execution of their duties. Defensive tactics and arrest techniques, as with any psychomotor skill, are perishable over time and will atrophy (i.e., become less efficient and effective) without reinforcement. Reinforcement of officers’ skills through updated and regular training will ensure their efficacy and efficiency.

Recommendation 4.4.5 – Provide BPD officers with additional non-lethal restraint tools, such as Electronic Control Devices (e.g., “Tasers”). BPD should issue officers devices such as Tasers. This would provide each officer with an additional tool for non-lethal restraint and control. Such devices may have significantly shortened the period of extreme physical resistance and reduced the stress and danger to the officers and Mr. West.

Finding 4.5 – Violently-resisting subjects need to be handcuffed for their own protection and the safety of the officers and bystanders. Properly handcuffing and restraining a violently resisting subject can be difficult and challenging. It can also be dangerous for the suspect. Placing unusual pressure on the lower back may, in some cases, create a situation that could cause asphyxia.

Recommendation 4.5.1 – The BPD should issue an updated training bulletin to alert officers to this potential danger. The BPD Arrest and Control training bulletins and curriculum is written clearly and describes proper procedures. It describes “handcuffing from the prone position with proper placement of the officer’s knee (upper right quadrant of suspect’s back) avoiding the centerline placement or putting weight over the suspect’s thoracic cavity to avoid injury or suffocation.”10 Supervisors should

10 There are additional procedures that serve as guides for example in the U.K., The Kent Police, 109 postual asphyxia training memo, for a review on precautions for avoiding postural asphyxia).

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ensure that prone subjects are raised to a sitting or standing position as soon as possible after handcuffing as is safe, to avoid any obstruction to the subject’s breathing.

Issue Area 5: Professional and Objective Investigative Protocols:

Finding 5.1 – The BPD homicide investigation in this case did not meet professional best practices for objectivity and thoroughness.

First, there were problems with crime scene evidence-collection, such as the recovered plastic bag containing Controlled Dangerous Substances (CDS). There were no specific locations detailed, and the bag was not forensically examined for fingerprints. The prints were needed to link with confidence the bag containing CDS to Mr. West.

Second, crime scene photos were not catalogued. There was no way to identify the reason for the photo , its relevance to the investigation and what the photo was documenting or its location or relationship to the incident.

Third, the canvass for witnesses was incomplete. A well-planned canvass could have been conducted. There were more witnesses that could have been contacted to secure more statements. There may have been cell phone videos of parts of the encounter that may have been informative.

Fourth, the Homicide investigation presentation to the IRB was not completely objective. There was evidence of Mr. West’s criminal record that dominated the presentation, rather than equal backgrounds of the officers’ history of internal reviews, complaints, and investigations. The presentation of the facts, the systematic investigation, and the complexities of investigating members of the same agency (BPD) was a hindrance to objectivity.

Recommendation 5.1.1 – Critical use of force incidents require sophisticated investigations and an understanding of the legal complexities associated with a police officer’s authority, tactical decisions and conduct during the totality of circumstances surrounding the incident. The IRB recommends that BPD contract such review tasks to outside experts, consistent with state laws, to conduct an independent and objective investigation. There are skilled law enforcement professionals, academics, medical experts, and legal firms that have this capability (e.g., the Office of Independent Review in Los Angeles). The benefit of outside reviewers is that they bring a level of objectivity without the apparent conflict of interest that is attached to investigating members of your own agency.

Recommendation 5.1.2 – Homicide investigators should video and audio record all statements from officers, witnesses, and experts as part of an officer-involved investigation of an incident. Many law enforcement agencies have instituted video and audio taping all statements as an emerging best practice, and BPD needs to ensure that this practice is adopted.

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Finding 5.2 – The BPD does not have a specially trained team to conduct complex officer-involved homicide investigations. In an effort to mitigate the complexities that arise from conducting an officer-involved homicide investigation, many professional law enforcement agencies have established a Force Investigation Team (FIT). These highly trained investigators provide a more accurate and thorough criminal investigation of officers’ uses of force that result in serious injury or death. Having such a team should be a priority and have separation from the regular homicide personnel.

Recommendation 5.2.1 – The BPD should formalize the requirements for training and maintaining high-level investigative competence and objectivity to investigate officer-involved incidents that may result in death. New, specialized FIT investigators should have the training, expertise, and legal and forensic support to enable objective rapid investigations.

Finding 5.3 – The Internal Affairs investigations take too long to be closed and to reach a finding to be of real service to the police department, its personnel, or the community. The requirements for expedition and expertise in police officer use of force cases demands a higher level of capabilities than are currently present in BPD’s Internal Affairs. For critical incidents, special teams of well-trained Critical Incident Review Teams (CIRT) (see below) should conduct the administrative investigations and prepare for the Use of Force Review Boards.

Recommendation 5.3.1 – The BPD should establish an internal expert panel of specially trained investigators in a Critical Incident Review Team (CIRT). These experts will review all instances of officer-involved-shootings, deadly force, or serious injury from an administrative and compliance with training, policies, departmental goals and tactical decision making best practice. This CIRT unit has an overarching goal of improving BPD’s capabilities to deal with incidents that escalate to deadly force. A CIRT unit examines the totality of circumstances, from initial contact through the use of deadly force. The results aim to improve training, policy, tactics, and decision-making associated with use of force and officer safety. It can be proactive by conducting thorough administrative investigations of critical incidents. These CIRT teams would report directly to the Commissioner regarding whether the decisions, actions, and use of force were in or out of compliance with BPD policies, the Constitution, and best professional practices. These teams would respond to the crime scene along with the recommended FIT teams. The detailed CIRT reports should be presented to the Use of Force Review Boards. The CIRT must be separated from the FIT Team because of the constitutional protections afforded to police officers (and citizens) and because of the Garrity decision, which permits the police department to compel testimony regarding officer conduct that may be criminal but notes that the compelled information can’t be used in a criminal investigation.11 The CIRT Team function can streamline the complex

11 Garrity v. New Jersey, 385 U.S. 493 (1967): Police Officer rights.

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and fragmented process since CIRT investigators only specialize in Police involved use of force and deadly force critical events. The CIRT Team also integrates the investigation of policy compliance with the accountability process. The CIRT function provides a comprehensive, rather than a fragmented approach to these challenging types of special cases.

Issue Area 6: Care of Life and Emergency Lifesaving Protocols:

The IRB reviewed the actions taken by the BPD officers, the EMTs, and the ER Physicians to resuscitate and care for Mr. West. As part of that task, they analyzed the report by the Office of Chief Medical Examiner (OCME), examined BPD’s use of force policies, and reviewed external communications involving the notification of the next of kin and information released to the public through the media.

Findings 6.1 – The OCME operates under strict protocols and professional standards established by the state licensing board.

The IRB review established that these protocols were followed and documented as required. The OCME was required to reach out for specialized expertise to examine the cause of death in this atypical case. The death in this case was not attributed definitively to a single cause but was listed as “Inconclusive cause of death.” Multiple factors contributed to Mr. West’s death, but no one factor could be stated as the sole or main cause of death. The factors are:

Cardiac Conduction System Abnormalities

o Sinoatrial and atrioventricular nodal arterial dysplasia, mild

o Intramural coronary arterial dysplasia, mild

o Fibrosis in ventricular septum and proximal left bundle branch

o Cytoplasmic vacuolization of purkinje fibers, distal left bundle branch, marked

Dehydration

o Elevated vitreous electrolytes

Altercation with the Police

o Police restraint resulted in multiple superficial injuries. As noted in the autopsy

report (and evidence photographs), there were abrasions and contusions of arms and thighs, but no internal organ damage.

o No fractures

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o No petechial hemorrhages, no tracheal or hyoid bone injuries, no asphyxia12

This was not a routine autopsy, as the OCME required the services of a Cardiac Forensic Pathologist to attempt to identify the cause of death in this exceptional case.

Finding 6.2: The OCME’s requirement for outside expertise delayed the OCME’s report by several months and this was not communicated to the families or to the community. The incident occurred on July 18, 2013 and the autopsy was conducted and completed on July 19, 2014. However, the results of lab tests and toxicology reports usual take another two weeks. In this case the final report was issued by the OCME on December 5, 2013 the delays provided the opportunity for unfounded speculation by some and prevented the BPD from issuing a public statement regarding the circumstances surrounding the sudden death of Mr. West.

Recommendation 6.2.1 – Where specialized expertise is needed that may cause significant delays, the information should be presented to the family and the public to keep them updated. The IRB reviewed the extensive documentation presented by the OCME; the only issue is the lack of timely communication to the police department, the State’s Attorney, and the deceased’s family as to how long it might reasonably take for completing a routine autopsy report.

Issue Area 7: Communications/Transparency:

The IRB reviewed the communications and transparency by the BPD from two important perspectives: (1) Communications with the West family/next of kin; and (2) Releasing information to the community and general public to inform them of facts and the investigative progress, and to assure them that a full, objective, and professional investigation was proceeding as a priority.

Finding 7.1 – The police department communications with the victim’s family were insufficient and not transparent. The lack of information regarding the complex investigative process required for an in-custody death, and the lack of any timeline for a conclusion as to the cause and responsibility of the death of Mr. West, caused the family, as reported in the media and by others, to doubt the integrity of the process. The significant delays by the other independent agencies (State’s Attorney and OCME) worsened the family’s discontent with the entire process. The combination of fragmented information, months of no response from official agencies, and the circulating rumors created an erosion of confidence and trust in the police and other official agencies among the family members and segments of the Baltimore community. The prolonged process without creditable updates of progress was reportedly frustrating 12 Classic signs of asphyxia are visceral congestion, petechiae, cyanosis, and fluidity of blood. DiMaio/DiMaio. . Forensic Pathology, 2nd Edition. (Chapter 8 on Asphyxia.)

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to the family members and the public. When the findings of the cause of death were released as “inconclusive,” the family felt it reflected a “cover-up” and further eroded their trust in the Baltimore Police Department.

Recommendation 7.1.1 – The BPD should adopt communications and transparency guidelines that emulate other leading police agencies. For example, the Las Vegas Metropolitan Police Department has a crime scene briefing that informs the media of what happened and what is releasable to the public within hours of an incident. Then, in high-interest cases, the Chief or designee meets with the family and later with the media at approximately 72 hours post-incident. At that time, the Chief Executive announces what is known and what remains to be answered, a timeline for future releases and an expectation of when the findings will be released. This procedure is helping to restore community trust and confidence in the police among community residents and helping to set reasonable expectations regarding the release of new information and a final conclusion

Recommendation 7.1.2– The BPD Commissioner should provide public presentations on high-interest incidents. Many Chiefs have used public presentations in such high profile situations to build trust in the community and ensure that all factors have been considered and objectively assessed. Many State and District Attorneys have concerns about these public presentations, but the public’s right to know and the need to build community trust are overriding factors.

Recommendation 7.1.3 – Public presentations of critical incident investigative reviews need to be timely and conducted without delay once all the facts are known. Delays of six months or longer leave too much time for rumors and unrelated speculation to contaminate the community perception of an incident. The damage done by long delays in releasing pertinent information separates the communities from the police, which is not a good development. In high-interest cases, the Commissioner should consider being the spokesperson to the public at two essential points in time: (1) at 72 hours post-critical incident; and (2) when the objective investigation is complete (typically 6–8 weeks) or at least provide a full update on what the investigation has revealed so far, what remains to be done, and why more time is required.

Recommendation 7.1.4 The BPD should focus on delivering high-quality investigations in the most transparent manner possible. They must publicize their findings quickly and, when required, hold accountable the officers and supervisors for any incidents of non-compliance with BPD regulations. The BPD must improve the manner in which they inform the community as to what happened. In those cases where they are unable to immediately release information, they need to state why they cannot release the information and provide a specific point in time for such release. In the absence of information from police regarding a critical incident, rumors and false

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information will take root. All too often, such rumors will overshadow the actual facts of an incident.

Recommendation 7.1.5 The BPD should develop ways to inform the public of investigative findings in both criminal and administrative investigations. They must publicize their findings quickly and, when required, hold accountable the officers and supervisors for any incidents of non-compliance with BPD regulations. The BPD must improve the manner in which they inform the community as to what happened. In those cases where they are unable to immediately release information, they need to state why they cannot release the information and provide a specific point in time for such release. In the absence of information from police regarding a critical incident, rumors and false information will take root. All too often, such rumors will overshadow the actual facts of an incident.

Recommendation 7.1.6 Building community trust should be a priority within the BPD through procedural justice training and practice.. Research on procedural justice and community trust demonstrates that both youth and adults who encounter police and perceive that they are treated fairly and respectfully by the police report positive impressions of law enforcement, even when the interaction results in a sanction (e.g., traffic citation or criminal arrest). These positive impressions extend to people and communities who have not had any personal contact with law enforcement but are influenced by their understanding of people they know and by media reports. Officer safety may also be improved in communities where citizens and police share a commitment to mutual trust and fairness. Research suggests that public impressions of police actions are shaped by a few controversial and high-profile cases. Perceptions as to how such cases are investigated, the timing of the release of information, and what corrective actions are required and acted upon form a community’s perception of the legitimacy of its Police Department.

Recommendation 7.1.7 – BPD collects data on reported use of force incidents, and this data and the trends and patterns should be tracked, analyzed and released to the public annually. The agency needs to more completely understand the types and kinds of incidents that require the use of physical force and identify officers who are involved and track the frequency of these incidents. This information can reveal patterns and practices that need to be addressed through improved training, officer safety equipment, better supervision, counselling and , if appropriate, disciplinary action. Using objective data analysis the BPD can proactively address problems early rather than react to an incident, public complaints or civil litigation.

Recommendation 7.1.8 – The BPD, in consultation with the State’s Attorney, should release the full homicide investigation of this case to the public (appropriately protecting the names and identities of persons) as an example of

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transparency. For example, the Las Vegas District Attorney’s Office provides a detailed letter to the public setting out the reasoning for the District Attorney’s decision. The Prosecutor’s Office also attaches to the Decision Letter the full homicide investigation reports so the public can read and review the investigation conducted by the police and the evidence collected, analyzed and presented. This level of transparency is helping to build stronger trust with the community and reduces the speculation about why some action was taken or why there was a lack of action.

Finding 7.2 – The OCME sought independent expert advice and consultation regarding the cause of death. This resulted in a delay and the reason for the delay was not communicated to the family or the public. The OCME’s decision to reach outside for specialized expertise to a Cardiac Forensic Pathologist is recognized and commended by the IRB. It was the Cardiac Forensic Pathologist who gave evidence for Cardiac Conduction System Abnormality but, unfortunately, this actually doubled the delay and significantly extended the autopsy process. The family members and the public were not informed of the need for a forensic specialist or that additional time would be required to complete the additional examination. This delay in the OCME’s report and announcement of the cause of death lessened the family’s sense of trust even more that Justice was being done.

Recommendation 7.2.1 – When specialized death investigation expertise is required but not available “in house,” the OCME should develop an expedited process to contract and acquire the necessary expertise without delay The OCME has reached out to Forensic Pathologists and other medical experts in the past to provide special expertise. The process may be streamlined so that contracting required expertise will be seamless and there are no delays

Recommendation 7.2.2 – The BPD, in consultation with the State’s Attorney, should consider releasing the full homicide investigation to the public (appropriately protecting the names and identities of persons) as an example of transparency. For example, the Las Vegas District Attorney’s Office provides a detailed letter to the public of the District Attorney’s decision; attached to the letter is the full homicide investigation.

Finding 7.3 – The OCME sought independent expert advice and consultation regarding the cause of death. The OCME’s decision to reach outside for specialized expertise to a Cardiac Forensic Pathologist is recognized and commended by the IRB. It was the Cardiac Forensic Pathologist who gave evidence for Cardiac Conduction System Abnormality but, unfortunately, this actually doubled the delay and significantly extended the autopsy process. The family members and the public were not informed of the need for a forensic specialist or that additional time would be required to complete the additional examination. This delay in the OCME’s report and announcement of the

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cause of death lessened the family’s sense of trust even more that Justice was being done.

Recommendation 7.3.1 – When specialized death investigation expertise is required but not available “in house,” the OCME should develop an expedited process to contract and acquire the necessary expertise without delay The OCME has reached out to Forensic Pathologists and other medical experts in the past to provide special expertise. The process may be streamlined so that contracting required expertise will be seamless and there are fewer delays.

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Conclusion:

The Independent Review Board concludes that Mr. Tyrone West died suddenly while engaged in an extended period of resisting a lawful arrest by BPD officers. The Officer of the Chief Medical Examiner’s postmortem examination reported that Mr. West “died of Cardiac Arrhythmia due to Cardiac Conduction System Abnormality complicated by Dehydration during Police Restraint.” According to the Medical Examiner, another factor that may have “contributed to his death was the extreme environmental temperatures which were reported in the high 90s with a heat index in the low 100s (degrees Fahrenheit).” The investigation showed “that Mr. West fought with several police officers and resisted restraint for several minutes prior to becoming suddenly and unexpectedly unresponsive. This period was likely associated with a high output of adrenaline, leading to increased energy exertion and use of oxygen reserves that further increased the stress on his heart.” The autopsy revealed “neither signs of asphyxia, nor significant injury to vital structures or vital areas of the body.” The Post Mortem Examination Report concludes with the following statement: “What could not be determined from forensic investigation and autopsy findings was the absolute relative contribution of each factor in causing his [Tyrone West] death. Therefore, the manner of death is COULD NOT BE DETERMINED.”

Whenever physical force is employed in police-citizen encounters, there is always a risk of serious injury and, potentially, death. The law authorizes police officers to use only that force necessary to overcome resistance, defend themselves and others, and affect a lawful arrest. The IRB finds that the officers did not employ force beyond that which was necessary and reasonable to subdue an unusually strong and well-muscled suspect who was resisting a lawful arrest. The officers involved used less-than-lethal weapons and defensive tactics to attempt to control, restrain, and arrest Mr. West. The IRB noted, with concern, that the officers involved departed from some BPD policies and training and made several tactical errors that may have extended the length of the physical encounter, compromised officer safety, and potentially aggravated the situation.

The IRB recommends that BPD implement a timely Use of Deadly Force Review Board and specialized investigative support teams (e.g., FIT and CIRT teams or independent outside professionals) examining the totality of circumstances surrounding every use of force incident that results in death or serious injury. The review must include an assessment of whether the actions, decisions, and tactics complied with administrative rules, regulations, training, and the goals of the BPD. Many leading law enforcement agencies contract with professional experts in high-profile use of force cases to conduct an independent and objective investigation. This practice provides greater transparency for the community and can help maintain trust and confidence in an agency.

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The BPD communications with the family and the community were not well coordinated and did not respond in a reasonable time to numerous questions surrounding the incident. The BPD needs to accelerate the timetable regarding informing the public of the facts and circumstances surrounding the death of a person in police custody.

The BPD is working to improve the quality of use of force and in-custody death investigations, bringing in leaders from outside agencies and providing more transparency to the community. However, more work remains to be done to maintain and improve community trust in these controversial uses of force incidents by the BPD.

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baltimore police independent report into tyrone west death

Documents

custody death of

police accountability

police agency

police commissioner

police restraint

death of tyrone westfindings

sudden death of

states attorney report