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 Members
James 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 Boards 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
i
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
ii

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 Recommendations
1. 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.
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.
iii

1.1.4 Use of Force Review
Boards should include a
detailed review into the
totality of circumstances,
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.
iv

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.
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
highest standards and
practice for objective and
independent investigative
practice in officer-involved
death cases.
consider following the
practice of leading police
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.
provide training and special
bulletins describing health
risks in severe heat
conditions, including
prevention and mitigation
procedures.
review tactical procedures
during high heat times and
include options for arrest
tactics and use of force to
control for these risk
factors.
v

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
in this incident was the
difficulty in controlling and
restraining a large,
especially strong, and
aggressive suspect.
4.4.1 Review current BPD
Defensive Tactics Training
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.
vi

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
officers 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.
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.
vii

5.2 The BPD does not have
a specially trained team to
conduct complex officer-
involved homicide
investigations.
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.
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 OCMEs
requirement for outside
expertise delayed the
OCMEs 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
victims family were
insufficient and not
transparent.
adopt communications and
transparency guidelines
that emulate other leading
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.
viii

focus on delivering high-
quality investigations in the
most transparent manner
possible.
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 States
Attorney, should release
the full homicide
investigation to the public
(appropriately protecting
the names and identities of
persons) as an example of
transparency.
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.
ix

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. Wests 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.

x

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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1
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 BPDs
policies, training, rules of operations, and the overall goals of the Department.
1

The Commissioners 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 period
2
.
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 Commissioners 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
2

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 units 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 vehicles 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 Ruizdressed 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 chestapproached
the drivers side of the vehicle. Officer Chapmandressed in blue jeans, a brown short-
sleeved tee-shirt, and a ballistic vest identical to that of Officer Ruizapproached the
passenger side of the parked vehicle. Officer Ruiz asked the driver for his drivers
license and registration. The driver produced a Maryland drivers 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 Ruizs
request, and they stepped over to the curbside. Officer Chapman maintained a cover
position nearby Officer Ruiz. Officer Ruiz noticed the drivers 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
3

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. Wests 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. Wests 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. Wests legs but was unable to restrain
them, due to the strength of Mr. Wests 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 backupSignal 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
4

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, its 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. Wests 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 effect
3
. 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.
4
Officer Ruiz reportedly said, Let him go; we will get him later. Mr. West then took an
aggressive boxers 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.
5

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.
Wests 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. Wests 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

5
Time estimates are reconstructed from BPD radio logs and transmission from the scene.
6

back and lower extremities that were consistent with the information provided from the
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.

7

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)
8

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 Andersons 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

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)
9

the chest. The unit was assigned to stop street level drug sales and street crime.
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.

10

Summary of IRB Findings and Recommendations:
The IRBs 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 BPDs 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 members
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:
11

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. Wests 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 positionbacking up
Officer Ruizto 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.
12

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. Wests identification, the vehicle, and the
passenger, plus they could maintain loose contact and direct the responding
officers the location of Mr. Wests 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 scenariossuch as the Tyrone West Incident
and stress the potential opportunities for tactical disengagement.
13

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 BPDs 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
14

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.
15

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 supervisors 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. Wests sock. According to Officers Ruiz and
16

Chapman, as well as the female passenger in Mr. Wests 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. Wests legs. As a result of Mr. Wests kicking and
thrashing, Officer Chapman was unable to gain control. Mr. West then stood up with
Officer Ruiz, who maintained a hold around Mr. Wests trunk. Officer Ruiz then released
his hold around Mr. Wests 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 officers 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 boxers 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.
17

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.
Wests arm (to reduce his active resistance to handcuffing), and arm holds. Eventually,
the officers were able to overcome Mr. Wests 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.
18

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 departments 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 91
o
Fahrenheit, with a heat index in the 100s) 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 Sprays Effects on a Suspects
Ability to Breathe, National Institute of Justice Research in Brief, page 1.
19

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
20

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
trainingincluding the various defense tactics in the academyduring 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 officers knee (upper
right quadrant of suspects back) avoiding the centerline placement or putting weight
21

over the suspects thoracic cavity to avoid injury or suffocation.
10
Supervisors should
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 subjects 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. Wests 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 officers 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.

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).
22

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.
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 BPDs 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 BPDs 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
23

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 cant be
used in a criminal investigation.
11
The CIRT Team function can streamline the complex
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 BPDs 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. Wests 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

11
Garrity v. New Jersey, 385 U.S. 493 (1967): Police Officer rights.
24

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
o No petechial hemorrhages, no tracheal or hyoid bone injuries, no asphyxia
12

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 OCMEs requirement for outside expertise delayed the OCMEs
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 States Attorney, and the deceaseds 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 victims 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

12
Classic signs of asphyxia are visceral congestion, petechiae, cyanosis, and fluidity of blood.
DiMaio/DiMaio. . Forensic Pathology, 2
nd
Edition. (Chapter 8 on Asphyxia.)

25

significant delays by the other independent agencies (States Attorney and OCME)
worsened the familys 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
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 publics 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 68 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
26

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 7.1.5 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 communitys 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
27

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 States 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
transparency. For example, the Las Vegas District Attorneys Office provides a detailed
letter to the public setting out the reasoning for the District Attorneys decision. The
Prosecutors 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 OCMEs 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 OCMEs
report and announcement of the cause of death lessened the familys 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 States 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 Attorneys Office provides a detailed
letter to the public of the District Attorneys 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 OCMEs decision to reach outside for specialized
28

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 OCMEs report and announcement of the
cause of death lessened the familys 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.

29

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 Examiners 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.
30

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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