When Cell Door Opens, Tough Tactics and Risk

nytimes.com/2014/07/29/us/when-cell-door-opens-tough-tactics-and-risk.html

July 29, 2014

NASHVILLE — The August night was hot, but Charles Jason Toll wrapped himself in a coat
and covered his mouth to protect against the electrical shocks and gas he thought might
come his way.

Outside the door of his solitary confinement cell at Riverbend Maximum Security Institution
here, five corrections officers in riot gear lined up, tensely awaiting the order to go in. When
it came, they rushed into the small enclosure, pushing Mr. Toll to the floor and pinning him
down with an electrified shield while they handcuffed him and shackled his legs.

Mr. Toll, 33, a heavyset man who suffered from diabetes and mental illness, said, “I can’t
breathe” — a complaint he would repeat, with increasing urgency, at least 12 times that night.

“You’re not going to be able to breathe,” an officer, Capt. James Horton, can be heard telling
him on a prison video. And then, “You wanted this.”

The officers carried him, face down, to a dark outdoor recreation yard to search him. A short
while later, Mr. Toll was dead.

In the insular world of correctional institutions, it is known as cell extraction, the forcible
removal of a prisoner from a cell by a tactical team armed with less-lethal weapons like
Tasers, pepper spray and stun shields.

Did you know you can share 10 gift articles a month, even with nonsubscribers?

Share this article.

Jails and prisons routinely make use of the tactic in response to threatening behavior or
disciplinary infractions. Mr. Toll, who was in prison on a parole violation and whose death in
2010 the state medical examiner ruled a homicide, had been accused of splashing an
“unknown liquid” at a guard through the doorjamb.

While cell extractions are not new, a series of lawsuits and cases around the country are
demonstrating the dangers of their widespread use, especially with mentally ill inmates like
Mr. Toll, who represent an increasing segment of the jailed population and who are
disproportionately the targets of force, statistics from several states indicate.

Videos made public in California last fall showed corrections officers at state prisons dousing
severely psychotic inmates with large amounts of pepper spray before forcibly removing
them from their cells, images that a federal district judge, Lawrence K. Karlton, who ordered
the release of the videos, termed “horrific.” And in Florida in May, an inmate who was
reportedly mentally ill died during a cell extraction at the Charlotte Correctional Institution.

1/15
Even when scrupulously conducted, cell extractions carry risks. Officers suit up in Kevlar
vests and kneepads to protect themselves from assaults with homemade weapons or other
objects. Injuries to inmates — from bruises and lacerations to concussions and broken bones
— are common, though no government agency tracks them. In some cases, prisoners have
died as a direct result of extractions, like Mr. Toll, whose death was caused by “asphyxia and
suffocation” from force applied while he was in restraints, the medical examiner found.

Image

Images taken from a video at Riverbend prison show a team led by Capt. James Horton entering
Charles Jason Toll’s cell. The time stamp is an hour later than the actual events.

Yet despite the frequent use and inherent dangers of cell extractions, states and localities
vary widely in when and how they are carried out and in the level of training required of
officers who conduct them. Many corrections experts say they believe that extractions are
vastly overused.

In some institutions, extraction is viewed as a last resort. Training emphasizes the need to
defuse the situation in other ways if possible, and extractions are tightly supervised. Special
care is taken when mentally ill inmates are involved.

But in many facilities, training is minimal, supervision is lax and forcible removals are
conducted reflexively, with little or no attempt at alternate solutions. Corrections officers
who are so inclined can easily turn the process into a vehicle for beatings or other prisoner

2/15
abuse.

“It can move from a proper tactical exercise to a punitive and retaliatory exercise,” said Steve
J. Martin, a lawyer and corrections consultant who has served as a federal monitor and is an
expert on the use of force in prisons and jails.

A few months before Mr. Toll died, another inmate at Riverbend was kicked, beaten and
slammed into a concrete wall while handcuffed and shackled, splitting open his forehead,
according to a lawsuit filed in the case. And in Los Angeles in 2008, deputies at the county
jail — armed with Tasers, rubber bullets and rubber ball grenades — systematically moved
down a tier extracting one inmate after another. Prisoners were choked, beaten unconscious
and then shocked back into awareness, court documents show. More than 100 broken bones
and other injuries resulted. One inmate required a metal plate in his right eye after multiple
fractures to the eye socket; another received Taser shocks to his testicles and buttocks.

Jeffrey Schwartz, a correctional consultant who has worked with a large number of jails and
prisons around the country, said that in his view, only about 20 percent of the cell extractions
carried out in the United States were necessary.

Inmates, he said, often feel compelled to fight back during an extraction so as to not lose face
in front of other prisoners. Officers, too, gear up, like soldiers preparing for battle.

“Once they put on those heavy pads and the adrenaline is flowing, they want to go in,” Dr.
Schwartz said.

An Inmate’s Past

He was 14 when things began to go wrong.

His stepfather died. He started experimenting with drugs. He was arrested for setting fire to
a trash can with a cigarette and then for stealing his father’s car. When he was 18, a series of
house burglaries and an escape from a county jail work crew sent Mr. Toll to state prison.

Medical records from his years behind bars show his mental and physical health slowly
declining. He developed diabetes and high blood pressure. He made suicide attempts.

At various times in prison, he received diagnoses of schizoaffective disorder, bipolar disorder,

drug abuse and depression. He carried the scars of self-inflicted injuries, including a deep
slash on his right forearm from 2006, after he reported that two other inmates had raped
him. A tattoo on each arm depicted a demon’s head — to ward off voices that told him to
harm himself, he told people.

Mr. Toll had more than 50 disciplinary infractions, many of them minor. But in one instance,
in 2009, when he was off his psychiatric medication, Mr. Toll was accused of throwing
scalding water on an officer, which led to his placement in solitary confinement at Riverbend.

3/15
A few weeks before he died, he swallowed 97 Tylenol pills, landing him in the hospital for a
few days. When he returned to Riverbend, he got into an acrimonious dispute with a guard
who had a reputation for taunting inmates, according to former employees of the prison and
depositions taken as part of a lawsuit brought by Jane Luna, Mr. Toll’s mother, after his
death.

“He was real anxious,” Ms. Luna said of her son, recalling a phone conversation she had with
him the Sunday before his death.

Shortly after 9 p.m. that Tuesday, Aug. 17, 2010, Captain Horton assembled a cell extraction
team to pull Mr. Toll out so that it could confiscate any containers he could use to throw
liquid.

A prison videotape shows how the cell extraction unfolded. (Most prisons and jails monitor
extractions by videotaping them, although prison videographers have been known to point
cameras at ceilings and floors when they want to hide what is taking place. In this case, the
cameras were trained on Mr. Toll, but much was obscured by the bodies of the officers and
the darkness of the recreation yard.)

At 9:24 p.m. on the video, Captain Horton can be heard ordering Mr. Toll, who had jammed
the cell door, to unblock it.

When he did not — “Let’s get it on, goddamn it,” Mr. Toll said — the team members, dressed
in body armor, black jumpsuits and black helmets, moved in, led by Gaelan Doss, a guard
weighing more than 450 pounds and carrying a curved stun shield.

As the officers carried Mr. Toll out of the cell — face down, hands cuffed behind his back —
Captain Horton threatened to shock him with a Taser if he did not stop moving. The
extraction team took Mr. Toll to the farthest cage in the outdoor recreation yard, where they
placed him face down on the ground and began to search him, working in the dark with only
a single flashlight.

“Please, please. I can’t breathe,” Mr. Toll said.

“Quit resisting, Mr. Toll,” Captain Horton responded.

At 9:33 p.m., Mr. Toll began making snoring noises that a medical expert later said indicated
that he had slipped into a coma and was near death. The officers continued to search him.

At 9:38 p.m., Marina Tucker, a nurse who accompanied the extraction team, was called to
check on Mr. Toll. When she found that his lips were blue and he did not respond to his
name, she began cardiopulmonary resuscitation.

An ambulance was summoned. At 10:32 p.m., Mr. Toll was declared dead.

Protocols and Dangers

4/15
 Image

A family photograph of Mr. Toll when he was 28, about five years before he died during a cell
extraction at Riverbend Maximum Security Institution in Nashville.

Removing a recalcitrant inmate from a cell was once achieved by brute force. Guards in
regular uniforms went in and did whatever they needed to subdue a prisoner. But with the
rise of super-maximum-security prisons in the 1980s and 1990s, steel and concrete fortresses
designed to hold inmates whom politicians called “the worst of the worst,” prison officials
codified the procedure to make it safer for officers, using specially trained teams equipped
with body armor and less-lethal weapons.

5/15
In most jails and prisons, extraction teams are called when an inmate poses an immediate
danger — holding a homemade knife or other weapon, for example. Acts of defiance, such as
covering the window of a cell, refusing to return a food tray or barricading the door, can also
result in an extraction.

Yet despite the addition of formal protocols and protective clothing, the process remains
dangerous.

“It’s always violent, and it’s always unsafe for staff. It’s unsafe for inmates,” said Brad
Hansen, emergency management supervisor for the Department of Correctional Services in
Nebraska.

Officers have been stabbed with homemade knives. They have slipped on cell floors slick with
water or shampoo. They have been spit on or bitten by prisoners with H.I.V. or hepatitis C
and sustained cuts and bruises from wrestling prisoners to the floor. Dr. Schwartz, the
corrections consultant, recalled an officer whose leg was badly cut during the making of a
training film on cell extractions.

The highest risk, however, is for prisoners, who wear no body armor and are greatly
outnumbered.

Mr. Toll, who had been forcibly removed from a cell once before, described to his mother
feeling “like a rag doll.” Todd White, the inmate at Riverbend whose head was slammed into
a wall by guards after he was in restraints, said: “You feel helpless. They just come in there
and beat the hell out of you and do what they want to do.”

In most jails and prisons, policies on the use of force specify in some detail how an extraction
should unfold: An officer, for example, is assigned an inmate’s arm or leg and told to keep
that limb under control. But once the team goes in, the reality often bears little resemblance
to the paper directives, looking more like a barroom brawl than a tightly orchestrated
exercise, said Joseph Garcia, a security consultant.

“It’s chaos,” Mr. Garcia said.

His own method, which has been adopted by some jails and prisons, uses only two officers,
and they do not enter the cell. The officers use weapons like Tasers and 12-gauge shotguns
that fire less-lethal ammunition to subdue an inmate, and then restrain him. The method is
not free of controversy, but Mr. Garcia said that the mother of an inmate might prefer that
her son receive a bad bruise on a leg or a Taser shock to having him suffer a broken bone,
concussion or worse from a traditional extraction.

As jails and prisons become more populated with mentally ill inmates — in some institutions,
40 percent or more of inmates suffer from mental illness — the situations that provoke
extractions have increased. In a system ill equipped to handle psychiatric symptoms, the
behavior of inmates is often treated as a disciplinary problem.

6/15
Yet for an inmate who is severely mentally ill, the arrival of a cell extraction team is more
likely to instill terror than compliance, mental health experts say.

“It’s demeaning, it’s degrading, it’s frightening,” said Dr. Edward Kaufman, a psychiatrist
who has worked extensively in prison settings and served as an expert witness in the
California lawsuit. He noted that one psychotic inmate in the California case, shown in a
video being pepper sprayed multiple times, had delusions that the guards were trying to rape
him. The corrections officers kept ordering him to back up to the cell door and place his
hands through the port for the handcuffs, increasing the inmate’s fears.

7/15
Image

8/15
9/15
 Mr. Toll's mother, Jane Luna, brought a civil rights lawsuit, but a jury found last year that prison
officials were not liable for the death. “I can’t see a future,” Ms. Luna said. “He was my only
child.”Credit...Joe Buglewicz for The New York Times

“The guy keeps screaming, ‘Don’t rape me,’ ” Dr. Kaufman said.

Some states, concerned about injuries and aware that mentally ill inmates are more
vulnerable, have begun to provide prison staff members with special training. Officers are
encouraged to use what Mr. Martin, the corrections consultant, calls “time and distance,”
waiting out a situation or negotiating with a prisoner rather than rushing in with a team.

“The use of force, to a certain degree, means you’ve lost,” said Dan J. Pacholke, deputy
secretary for operations for the Department of Corrections in Washington, one of several
states that have taken steps to try to minimize cell extractions. He added that his department
makes extensive use of crisis negotiators and gives staff members special training. Having
national standards for how and when cell extractions should be done would help, he said.

Mr. Pacholke noted that most extractions take place in solitary confinement units, where
inmates are kept under tight control and have extensive idle time, conditions that exacerbate
problematic behaviors. To address this, the department has increased activities for
maximum-security prisoners and reduced the number of inmates in isolation. At most, 10 to
12 extractions a month are carried out across the state, he said.

Nebraska’s Department of Correctional Services has also taken steps to reduce the use of
extractions.

“We got to the point where we thought that there had to be some other way to do it,” said Mr.
Hansen, the Nebraska official. The number of cell extractions carried out in state prisons
dropped to 98 in 2013 from a high of 232 in 2008, he said.

Mr. Hansen added that a mental health negotiator is summoned when a disturbed inmate is
causing problems, and the department’s policy now dictates that three attempts must be
made to talk the prisoner into submitting to restraints before a more aggressive step is taken.

If more severe tactics are required, pepper spray, pumped in from outside the cell, is viewed
as preferable to sending in a team of officers, because inmates are more likely to capitulate
quickly and no physical combat is involved.

“Cell extractions are the last resort,” Mr. Hansen said.

Examining the Events

Ricky J. Bell, the warden at the time of Mr. Toll’s death, said in a telephone interview that his
officers did nothing wrong that night.

10/15
“It’s unfortunate that Mr. Toll died in that extraction,” said Mr. Bell, who is now retired. “But
I feel the staff did exactly what they should.”

No criminal or disciplinary charges were brought against the officers involved. Last year, a
jury in the civil rights lawsuit brought by Ms. Luna found that Mr. Bell, Captain Horton and
Mr. Doss were not liable for the death.

“At the end of the day we found 12 jurors who said: ‘He’s an inmate. He’s a criminal. So
what?’ ” said David Weissman, one of the two lawyers who argued the case for Ms. Luna.

Image

Riverbend Maximum Security Institution in Nashville. A few months before Mr. Toll died,
another Riverbend inmate claimed he had been kicked, beaten and slammed into a wall during a
cell extraction.Credit...Joe Buglewicz for The New York Times

But former employees of Riverbend who were present that night, as well as three
independent corrections consultants and a forensic medical expert who reviewed the
videotape of the cell extraction, the autopsy report and other documents at the request of The
New York Times, said that Mr. Toll should not have died that night and blamed the way the
cell extraction was conducted.

“This was such a needless — clearly, objectively needless — death,” said Mr. Martin, who has
testified in use-of-force cases on behalf of both corrections officials who were defendants and
inmates who were plaintiffs.

11/15
During the course of the extraction, the officers violated training guidelines, applied force in
a dangerous manner, ignored clear signs that Mr. Toll was in distress and failed to provide
competent emergency care, the former employees and corrections experts said.

Training at the prison was also inadequate, Mr. Weissman said. Mr. Bell, the warden,
discontinued refresher courses in cell extraction at Riverbend for budgetary reasons about
three years before Mr. Toll’s death, he said in a deposition. Only one officer involved was up-
to-date in training, and two had never participated in an extraction before.

A former employee of the prison who was present that night said that the extraction had been
mishandled from its start.

“Wrong is wrong,” said the former employee, who spoke on the condition of anonymity for
fear of endangering his current job. “It’s wrong in the light and it’s wrong in the dark, and
that whole deal was wrong.”

He said that the officers placed far too much pressure on Mr. Toll’s back and upper body,
something that training courses routinely warn increases the risk of suffocation.

“I could see they put their knees against him, against the shield on top of him,” the former
employee said, adding that it was hot and that Mr. Toll was wearing several layers of
clothing, which may have increased his respiratory distress.

Dr. Michael M. Baden, a former chief medical examiner for New York City who reviewed
videotape of the extraction, as well as the autopsy report and photographs from the autopsy,
said that bruising over Mr. Toll’s windpipe appeared to be from “pressure from hands or an
arm squeezing on the neck.”

Other marks on Mr. Toll’s nose, face and forehead, he said, “are typical for an altercation
where force is applied to the face.”

The way the extraction team transported Mr. Toll was also problematic, the corrections
experts said, running contrary to what is taught in most training courses, which advise
against carrying inmates face down by the arms and legs except in an emergency. And
although the officers said in legal proceedings that they did not hear Mr. Toll say that he
could not breathe, the former employee said that all the officers present that night heard the
complaints and ignored them.

12/15
 Image

Cell extractions, said Steve J. Martin, a corrections consultant, “can move from a proper tactical
exercise to a punitive and retaliatory exercise.” He said waiting out a situation can yield a better
result.Credit...Ilana Panich-Linsman for The New York Times

Perhaps most troubling, the extraction team took Mr. Toll to the dark recreation yard instead
of a well-lighted multipurpose room or another cell, an option prescribed by training
procedures. Prison officials said the decision was made to get him away from the other
inmates. But the lights in the yard had been broken for three years, the former employee
said, and the darkness made it impossible to monitor Mr. Toll’s safety.

“It was a recipe for disaster,” he said.

13/15
Even the attempts to provide emergency aid were bungled.

Ms. Tucker, the nurse, placed a piece of medical gauze over Mr. Toll’s mouth when she began
rescue breathing, further obstructing his airway. And compressions were not started until
well after rescue breathing began, although the current protocol for CPR advises that
compressions should be applied first.

In a telephone interview, Ms. Tucker said that her training in CPR predated the current
protocol.

She said she had been worried about the way that the officers were carrying Mr. Toll. “They
kind of had him upside down, and I thought they were putting strain on his arms and legs,”
she said.

Neysa Taylor, a spokeswoman for the Tennessee Department of Correction, declined requests
to interview department officials or officers about Mr. Toll’s death. Captain Horton did not
respond to interview requests left with his lawyer and the department. Mr. Doss, reached by
telephone, refused to comment, and messages left on voice mail and social media for other
officers who participated in the extraction were not returned.

Unanswered Questions

After Mr. Toll died, internal-affairs investigators at the prison concluded in their report,
obtained by The Times, that Mr. Toll’s death was “in no way caused by the actions of staff.”

But the investigators, corrections experts who reviewed the report said, failed to interview
crucial witnesses, did not ask basic questions in the interviews they did conduct and failed to
preserve relevant evidence from the scene.

“It was the most incompetent investigation I’ve ever seen,” said Ron McAndrew, a
corrections consultant and former warden at the Florida State Prison, who served as an
expert witness for the plaintiff in the Toll case.

At least one officer involved in the cell extraction quit his job in part because of the way the
investigation was handled.

In a resignation letter sent to Mr. Bell, a copy of which was obtained by The Times, the
officer, William Amonette, wrote that he had been treated badly at the prison “ever since I
asked questions in your office about the witnesses in the Charles Toll case that were not
spoken to by Internal Affairs.”

“I cannot work somewhere where asking questions or trying to do what is right is punished,”
he wrote.

14/15
The morning after Mr. Toll died, the phone rang at Ms. Luna’s house at 5:30. A man who
identified himself as the prison chaplain told Ms. Luna that her son had been found dead in
his cell during the night, the cause an apparent heart attack. Nothing was said about the cell
extraction.

Since her son’s death, Ms. Luna said, she has found it difficult to move on with her life. She
has been too depressed to work. The house she shares with a friend is cluttered with boxes,
some filled with legal documents, others with mementos from her son.

“I can’t see a future,” she said. “He was my only child. He was my life, and I can’t seem to find
my next step to go on.”

Join a subscriber-only event. Connect with our journalists. See the lineup.
SEE THE LINEUP

15/15